Borderline Personality Disorder (BPD) is a complex diagnosis. It can be confusing to understand, I think because its traits can be observed at one time or another within the general population. The diagnosis is controversial because some people hold the belief that the feelings and behaviours associated with it are a reasonable, human reaction to difficult life experiences. Indeed emotional experiences like loneliness, fear of abandonment, excessive self-criticism and pessimism about the future have the potential to affect us all – especially so during difficult life events, such as romantic break-ups, bereavement or job loss.
Having said that, the mental health conditions known as personality disorders are some of the most stigmatised. BPD is a serious and debilitating condition that, unfortunately, still receives a lot of negative attention based on misinformation and inaccuracies. It is important to remember that for a diagnostic decision to be reached the criteria must be persistent (occurring within a substantial time frame), pervasive (spanning several life areas) and problematic (severe enough to cause significant difficulties). Some people find that getting the diagnosis helps them to name and understand their experiences and get access to treatment and support they otherwise might not. Recovery is possible, especially with the right treatment. These problems need not persist for a whole lifetime.
This is my summary of the Stronger Minds Podcast episode Understanding Borderline Personality Disorder. The host is Kimberley Wilson, a Chartered Psychologist and author of the book How to Build a Healthy Brain. In the episode she addresses misrepresentations of BPD through an expert appraisal, challenging the rhetoric that sufferers of the condition are deliberately manipulative or attention-seeking. This includes an excellent explanation of black-and-white thinking, also known as “splitting” – an often misunderstood term, even by professionals. Before you read on, it is worth noting that the diagnostic criteria discussed in the episode is from the DSM-5 – a diagnostic tool that is highly contested (which Wilson does touch upon). The ICD-11, which will eventually replace the ICD-10 (the diagnostic manual used by clinicians in the UK currently, in which Emotionally Unstable Personality Disorder [borderline type] is one of the categories) will instead classify personality disorders along three levels of severity (mild, moderate and severe), with the option of specifying one or more prominent traits. Whether this will have much impact on destigmatising the label is yet to be seen – but the more stigma is reduced, the sooner people will learn about personality disorders and seek treatment.
With these technicalities about diagnosis now out of the way (no wonder it is confusing!), all that remains to be said is how valuable this episode is. It is the clearest, most comprehensive explanation of BPD/EUPD I’ve heard from a professional. Every point made is succinct, substantiated and well-illustrated, so I would encourage you to listen to it in its entirety.
In the meantime, here is my summary (all content is Wilson’s own).
BPD/EUPD: what is it?
BPD is a diagnostic label given to a group of overlapping symptoms that relate to a person’s ability to form relationships, manage emotions and behave in predictable or socially acceptable ways.
The name refers to living at the “borderline” between neurosis and psychosis. Some prefer to use the term Emotionally Unstable Personality Disorder (EUPD), as it is currently known in the UK.
A BPD diagnosis can feel fixed or condemning due to the name alone. The diagnosing professional must be very careful to explain the condition so the person does not leave the assessment room thinking there is something wrong with them, or that their personality is broken.
BPD diagnosis is more prevalent in women. Why?
In the general population the gender split seems to be about equal. But epidemiological studies from the early 2000s suggested that 75% of people diagnosed with BPD are women.
There may be a bias in diagnosis. Since society largely expects men to be more impulsive and engage in more risk-taking behaviours, these traits are seen in the context of “normal” behaviour – leading to under-diagnosis of BPD in men, or anti-social personality disorder diagnoses.
There is an element of sampling bias too because women are more likely than men to contact a doctor or therapist for help.
It could be something to do with the invalidating environment, specifically the greater tendency of girls to internalise their distress, combined with the social expectation for women to be compliant.
People with this diagnosis are disproportionately ending up in prisons.
It is rare for someone to fit neatly into the diagnostic criteria for one disorder.
People with a BPD diagnosis also present with mood disorders 80-96% of the time. In addition:
- 88% present with anxiety disorders.
- 64% present with substance use disorders.
- 53% also have eating disorders.
- ADHD is present in one third of people.
- 1 in 10 people have co-occurring somatoform disorders (emotional distress manifesting as physical illness).
The criteria describe problems with one’s own sense of identity combined with problems relating with others. We would expect these two things to be connected. After all, it would be incredibly difficult to interact with others in a consistent way without a clear sense of who you are, or your own value. Let’s go into this in more detail.
Part One: Identity
Unstable self-image/identify issues: excessive self-criticism; chronic feelings of emptiness; and dissociative states during distress, experienced as a “checking out” psychologically and considered to be a protective mechanism of the mind (often in response to trauma).
Problems with self-direction: instability in goals, aspirations, values or career plans.
Part Two: Relationships
Difficulties in empathy, interpersonal hypersensitivity and perceptions of others selectively biased towards negative attributes or vulnerabilities.
Intimacy issues: intense, unstable and conflicted close relationships marked by mistrust, neediness and anxious preoccupation with real or imagined abandonment, often viewed in extremes of idealisation and devaluation and alternating between over-involvement and withdrawal.
This is experienced as not knowing what distance is safe or healthy. Sometimes close feels too close and sometimes separate seems isolating, to the point of feeling left and abandoned.
There may also be fears of rejection by and/or separation from significant others associated with fears of excessive dependency or complete loss of autonomy. This is sometimes described or experienced as a “push/pull” dynamic in relationships.
These difficulties can express themselves in the following ways:
- Negative affectivity characterised by unstable emotions and frequent mood changes.
- Emotions that are easily aroused, intense and/or disproportionate to circumstances.
- Anxiousness: nervousness; tenseness; or panic – often in reaction to things that come up in relationships.
- Worrying that the bad things that have happened to you in the past have tainted or corrupted your opportunities in the future.
- Feeling fearful and apprehensive about, or threatened by, uncertainty.
- Pessimism about the future.
- Fears of falling apart or losing control.
- Frequent feelings of being down, miserable and/or hopelessness and difficulty recovering from such moods.
- Feelings of inferior self-worth and pervasive shame.
- Thoughts of suicide and suicidal behaviour.
- Impulsivity in response to immediate stimuli.
- Difficulty establishing or following plans.
- Self-harming behaviour and/or sense of urgency under emotional distress.
- Risk-taking engagement in dangerous and potentially self-damaging activities
- Hostility: persistent or frequent angry feelings; or anger/irritability in response to minor slights.
BPD and brain development
Brain imaging studies indicate that people with BPD have different patterns of activation in the amgydala – the threat recognition area of the brain – that could contribute to symptoms.
Trials have shown that people with BPD are more likely to see hostile emotions (anger/disgust/condemnation) in neutral faces, suggesting that they both anticipate and see more hostility in the world around them (known as hyper-vigilance). Wilson goes on to explain it like this: “the more you look for something the more likely you are to find it.”
There can be a history of extreme or prolonged emotional distress in childhood. This includes serious parental psychopathology, including extreme emotional abuse. Such interpersonal abuse and terror is not uncommon for people with BPD.
These environments are described as “emotionally invalidating”. In other words, children who grow up in such environments are made to question the reality or the validity of their emotions. For example, they may have been consistently told that they deserved the abuse or neglect they were receiving, or that their emotional reactions were silly or stupid (known as emotional dismissal).
Black-and-white thinking or “splitting”
Abuse coming from someone who is supposed to play a caring or protective role for a child is particularly harmful. This is because it forces the child to question or actively distort their reality in order to help them survive and create some semblance of a sense of safety.
When faced with the dilemma of parental abuse the child (whose psychological apparatus is not yet developed fully enough to comprehend that the problem lies in the adult and not the child) has to come up with some other solution for why this is happening to them.
That solution is often a process called “splitting” or black-and-white thinking. The child is forced to separate the good from the bad, for example: “my parent is good and I am the cause of all the problems”.
This black-and-white thinking, arising out of this conflict between dependence and fear, has potential knock-on effects for self-identity that continue to cause problems for the individual later in life. People with this diagnosis can behave as if their internal thoughts and beliefs are external objective truths, due to the inflexible nature of their thinking.
This all-or-nothing approach to the self and to the world becomes a template for all significant relationships and social interactions.
For example, someone with BPD may be constantly worried that any negative thing they do will cause the other person to leave them – an experience known as fear of abandonment. They may engage in a pattern of idealisation/devaluation in close relationships.
It can be very hard for someone on the outside to see how a small disagreement about something tiny or seemingly meaningless can lead to self-harm or suicidal ideation.
But the symptoms of BPD become much more understandable when you get to know the psychological habits and environmental conditions in which they developed. And once you understand something you are in a much stronger position to intervene.
“Splitting” isn’t only seen in people with psychiatric diagnoses. We can all fall into the trap of black-and-white thinking. We even see this every day in two-party politics. Whenever you hear someone say “all of (group of people) are bad/evil”, this is an example of “splitting” by all-or-nothing thinking. We can think about splitting as positions you move in and out of rather than consistent states, which often happens when we are in unfamiliar or threatening situations. But rather than being an occasional trap to fall into, in BPD black-and-white thinking becomes one of the dominant ways of understanding the world and others.
The role of invalidating environments
Invalidating environments can be much more subtle than emotional abuse. The emotional dismissal may take the form of facial expressions, looks or behaviours that are designed to minimise the child’s emotional expression. Essentially the child gets the idea that their emotions are unwelcome or unbearable for the parent/teacher/friend – and that they have to deal with their emotional distress by themselves.
The cruel injustice of this situation is that we learn to manage our own emotions by initially having someone else help us to do it. It is the process of internalising repeated kindness and understanding that helps us to learn how to soothe ourselves later in life.
So there is this double whammy of not having your emotional needs attended to in the first place and therefore not learning how to take care of your emotions yourself later in life.
This is why we see a lot of the externalising behaviours in BPD, such as self-harm. With this developmental understanding, the risk-taking behaviours associated with BPD suggest someone who doesn’t know how (and perhaps never learnt) how to look after or protect themselves.
The function of self-harm is dependent on the individual person and their particular developmental history, but here are four common examples:
- Emotional pain may feel much harder to address than physical pain. Self-harm is a more manageable alternative that may even symbolise emotional pain and self-care.
- People who grew up in environments that were actively hostile to emotions come to (unconsciously) link deserving care only with having a physical illness or injury. Often the only “real” or acceptable pain or injury is a physical one. Self-harm may be an unconscious adaptation that emerges as a means of getting some care from an invalidating environment.
- Occasionally self-harm is a pathological form of control in the face of suffering. This includes abuse that is so inescapable it leads to a decision that sounds like: “if I’m going to suffer, then I might as well be in charge of what that suffering looks like.”
- Sometimes self-harm is a manifestation of self-hatred and this occurs when someone has taken in the idea that they are unwelcome, unwanted, a burden or a problem. People may be driven to punish themselves for not being a “better person”.
In all of these examples we’re talking about self-harm as a remedy for, an escape from, or as a management of emotional suffering.
This is why many patient groups and advocates campaign against the diagnosis of BPD as a disorder in itself, but rather an adaptive response to complex trauma.
Some anti-stigma campaigners say that what is being called an illness or disorder is really an understandable response to trauma experiences.
They argue that someone who has already been harmed in this way should not be further harmed by what can be a very stigmatising diagnostic label.
But – diagnosis is often the key to opening the door to treatment. In the UK this is Mentalisation-Based Therapy (MBT) and Dialectical Behaviour Therapy (DBT), which are group therapies developed specifically for people with BPD based on CBT and psychotherapy.
Coping with BPD: DBT and CBT skills to sooth the symptoms of Borderline Personality Disorder, by Blaise Aguirre and Gillian Galen. There are a few good self-help books out there, including DBT skills workbooks. This one is a practical, straightforward guide offering evidence-based solutions for adressing over 50 common problems experienced by people with BPD.
Borderliner Notes is a Youtube channel featuring short videos about BPD. Interviewees are people with lived experience of BPD and their families, as well as some clinicians – including psychologists Marsha Linehan (who developed DBT) and Peter Fonagy (co-founder of MBT).
Mind has some self-care ideas for Borderline Personality Disorder.
UK-based author Shehrina Rooney talks about living with BPD on her Youtube channel Recovery Mum. She was diagnosed at age 21.
Finally, there are two follow up episodes on Stronger Minds featuring talks with bloggers Rosie and Bryan about living with their BPD diagnosis.
Connecting with others who have similar experiences (such as through peer support) can be really helpful for people with BPD, especially for overcoming feelings of isolation and maintaining hope. If you cannot access peer support groups right now then hearing other people’s stories on podcasts or Youtube channels could be a helpful alternative.
Image: The Brooch / Eva Mudocci by Edvard Munch.