Some people have a certain set of difficulties that affects their sense of self, their emotions, and their relationships that can be diagnosed as Borderline Personality Disorder (BPD). The diagnosis of BPD is based on an assessment of these difficulties over time and across a range of situations.
Experiences of BPD include difficulties with:
Emotions and overwhelming feelings
People with BPD describe having intense and often very painful feelings that overwhelm them. “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” Marsha Linehan. People can feel very empty and alone; as though they shouldn’t feel the way they feel and that they have to hide their true feelings behind a mask. Sometimes there can be a feeling of unreality, dissociation or a strong sense of not deserving anything good, not knowing who you really are or hating yourself. With such powerful emotions people may turn to self-harm, substances or compulsive behaviours to change unbearable experiences into more manageable ones.
Relationships
People can experience strong and changeable feelings of closeness and trust, and betrayal and anger. Often for very good reasons, people may be vigilant and highly sensitive to any sign of rejection or criticism. Sometimes people will try to be what someone else wants them to be especially if they need that person. They may feel that they have to try and keep everyone else happy but they don’t matter or are not entitled to their own life or their own feelings. Sometimes the anticipation of being rejected can be unbearable and it might feel safer to reject someone before they reject you. People are often highly critical of themselves and maybe of others which may make relationships volatile. It can be really hard to trust people and difficult to cope with losses and separations.
Impulsive behaviours
Sometimes in desperate need to change something that feels unbearable people will do something that they wouldn’t choose to do if they hadn’t been so overwhelmed by their feelings. These feelings could include shame, anger, self-hate or despair or a feeling of disconnection or numbness. Sometimes people try to take their own lives. Sometimes people hurt themselves (self-harm), use drugs or alcohol, or take risks with their safety to try to cope, to punish, or to feel better, for a while at least, even if what they are doing causes other problems. Some people might judge these behaviours but they can be ways of validating feelings, proving something to yourself or someone else or simply the best way you know to cope.
Fragile sense of self
People may feel they don’t know who they are, or that who they are changes with who they are with. They may feel empty, disconnected and not real at times, or for prolonged periods. People might have a voice in their head that tells them they don’t have real problems, and that they don’t matter. That voice may be very unkind. When particularly overwhelmed some people can withdraw, leaving them feeling vulnerable and alone.
More about Borderline Personality Disorder
Trauma and BPD
BPD is something that affects people’s emotional stability and relationships. Many people had insecure, disrupted or losses of attachment relationships in childhood which is when we usually learn to regulate our emotions, so it makes sense that emotional regulation would be very difficult for people who had difficult relationships with a parent. Some people also have experienced complex trauma, being betrayed, emotionally or physically neglected, or emotionally, sexually or physically abused. Many people have post-traumatic symptoms, such as nightmares, flashbacks, dissociative states (spacing out), panic symptoms and feelings of unreality. For some people the negative, very critical experiences they have had can come back as internal, punishing self- talk or sometimes as voices. The internal voice may make judgemental, scornful or contemptuous comments that may make people feel worse.
How common is BPD?
It is estimated that at any point in time, 1.8% of the general population experience BPD. About 75% of these are females (males are more likely to be diagnosed with other disorders).
Will things get better?
BPD used to be thought of as untreatable by some people but this is not true. BPD is the good prognosis diagnosis but people need help. BPD is a terribly painful and long struggle and isn’t something that can be fixed quickly or in isolation. Remember you are not alone, others have felt like you and life is much better for them now.
What can you do?
No advice works for everyone but here are some suggestions to consider.
Attitude
- Do what you can for yourself when you can.
- Discover what works for you, trust yourself.
- When you can, be kind to yourself. Healing is harder work than people think.
- When you feel okay to, celebrate your little wins, validate yourself.
- Acceptance and compassion help us change more than punishment and threat.
Relationships and support from others
- Seek people and supports who you feel safe with and build trust slowly.
- Repair your relationships, say you are sorry if you have something to apologise for.
- Learn to be assertive…stick up for yourself.
- Learn how to communicate better e.g. non-violent communication.
- Therapy can be a way of protecting your personal and work relationships.
Treatment/therapy
- Do your research into therapies, they are very different.
- The relationship with your therapist is more important for your recovery than the type of therapy you are doing.
- There are many opportunities for therapeutic activities and self-development in the community, explore what appeals to you.
What can friends and families do?
- Adopt a non-judgmental, interested, warm position (this doesn’t mean you have to agree).
- Set limits (i.e. say “no” when you need to), but don’t abandon the person with BPD.
- Accept that this is the way your loved one feels although you may not understand.
- Seek support for themselves - either one-on-one or or family counselling attending support groups
- Learn about BPD – some helpful websites are listed on our resources page.
There are several treatments that are most often used to manage BPD:
- Dialectical behaviour therapy (DBT) focuses on the concept of mindfulness, or paying attention to the present emotion. DBT teaches skills to control intense emotions, reduce self-destructive behaviour, manage distress, and improve relationships. It seeks a balance between accepting and changing behaviours. This proactive, problem-solving approach was designed specifically to treat BPD. Treatment includes individual therapy sessions, skills training in a group setting, and phone coaching as needed. DBT is the most studied treatment for BPD and the one with the greatest research.
- Schema-focused therapy ( SFT) - Schemas are rigid core beliefs that we may hold about ourselves. BPD symptoms can arise due to a pattern of maladaptive schemas that develop in early life. SFT addresses these schemas and the associated emotional, cognitive, and behavioural difficulties.
- Cognitive analytic therapy (CAT) - looks at the ways a person thinks, feels and acts, and the events and relationships that underlie these experiences (often from childhood or earlier in life).
- Mentalization-based therapy (MBT) is a talk therapy that helps people identify and understand what others might be thinking and feeling.
- Transference-focused therapy (TFP) is designed to help patients understand their emotions and interpersonal problems through the relationship between the patient and therapist. Patients then apply the insights they learn to other situations.
- Good Psychiatric Management: GPM provides mental health professionals an easy-to-adopt “tool box” for patients with severe personality disorders.
- Medication does not treat BPD. It may help people to manage some of the symptoms and treat other mental illness such as depression, impulsivity, and anxiety that people may be experiencing at the same time. Often patients are treated with several medications, but there is little evidence that this approach is necessary or effective. People with BPD are encouraged to talk with their prescribing doctor about what to expect from each medication and its side effects.
- Self-Care activities include: regular exercise, good sleep habits, a nutritious diet, taking medications as prescribed, and healthy stress management. Good self-care can help to reduce common symptoms of BPD such as mood changes, impulsive behaviour, and irritability.
Diagnostic Criteria
Clinical criteria as published by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM 5)^ used to make a diagnosis of BPD are:
A pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity beginning in early adulthood and presenting in a variety of contexts as indicated by five or more of the following:
- frantic efforts to avoid real or imagined abandonment;
- a pattern of unstable and intense interpersonal relationships;
- identity disturbance;
- impulsivity in at least two areas that are self–damaging;
- recurrent suicidal behaviour, suicidal gestures, threats or self-mutilating behaviour;
- affective [mood] instability;
- chronic feelings of emptiness;
- inappropriate, intense anger; and
- transient stress-related paranoid ideation or severe dissociative symptoms.
The ICD-10# published by the World Health Organization includes diagnostic criteria for unstable personality disorder, borderline type (F60.3)
Emotionally unstable personality disorder is characterised by:
- a definite tendency to act impulsively and without consideration of the consequence
- unpredictable and capricious mood
- liability to outbursts of emotion and an incapacity to control the behavioural explosions
- tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored.
Two types may be distinguished: impulsive type and borderline type.
The borderline type is characterised by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicidal gestures and suicide attempts.
International Statistical Classification of Diseases and Related Health Problems 10th Revision
^ DSM-5 p663
# In an appendix (p 766-7) the DSM-5 lists Proposed Diagnostic Criteria for BPD which mentions "the typical features of BPD as instability of self-image, personal goals, interpersonal relationships, and affect, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition"
#International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version 2016