Borderline Personality Disorder
Borderline personality disorder (BPD) is a common but highly stigmatized mental health disorder. Unfortunately, there is a large amount of misinformation available online and even many therapists are undereducated in diagnosing and treating BPD. If you or someone you love is suffering from BPD, I hope this article can help you better understand what BPD is and what can be done to heal. Many of the topics touched on in this article are very complex and I tend towards simplification in order to illustrate a point. I will provide links to resources for those interested in learning more in the additional information section.
What is Borderline?
I’ll start by listing the 9 traits of BPD (of which at least 5 are required for diagnosis) as listed in the DSM. After that, I’ll offer a framing on what drives these traits and how they are formed.
Desperate attempts to avoid real or imagined abandonment.
A pattern of unstable and intense relationships, alternating between experiencing a relationship partner as completely perfect or deeply flawed.
Unstable self-image or sense of self.
Suicidal behavior, gestures, or threats. Self-mutilating behavior such as cutting.
Intense emotional reactivity and mood swings typically over short durations of time.
Feelings of emptiness.
Stress-related paranoid ideation, typically as relates to interpersonal relationships. Dissociation.
The above traits can be helpful in identifying BPD, but not so much for understanding and treating BPD. BPD is a specific pattern of personality development in response to trauma, particularly sustained childhood trauma involving interpersonal relationships with key attachment figures.
At the core of BPD is a deep sense of attachment insecurity and fear or even expectation of abandonment. It is normal for all of us to at times feel like our relationships are at risk, like someone is lying to us, cheating on us, or doesn’t actually love us. For those with more secure attachment styles, these thoughts and fears are relatively transitory or are based on the reality of the situation. For those with BPD, these feelings are almost constant and are not necessarily grounded in the reality of the relationship. For example, someone with BPD can have a relationship with someone who genuinely loves and cares for them and has no thought of leaving the relationship, but the BPD person can be fully convinced that the person is about to leave. The traits of BPD begin to make more sense when seen through this lens. If you constantly expect that all of your relationships are on the verge of abandonment, of course you will have intense emotional reactivity. It makes sense that those with BPD would turn to impulsive behaviors to help regulate their intense emotional states.
The other lens that, in combination with attachment insecurity, helps to understand the core of BPD is related to the concept of “self”. When we are first born, we have no concept of the self as distinct from the outside world. As we develop, we learn to make this distinction and also begin to reflect on our own experience and identity. If all goes well, we enter adulthood with a relatively clear sense of who we are, what we care about, what our preferences are, and what our worth is. So what happens with BPD? It turns out that this development of “self” is a process that occurs within and relies upon our attachment experiences. As developing humans, we need adults to attune to our emotional states and help us reflect upon them. Our relationship with adults is the secure base through which we develop a sense of self. Because those with BPD typically experiences abuse or neglect by their caregivers, this developmental process goes awry. Hence the chronic feelings of emptiness that those with BPD experience. One of the key things to understand is that those with BPD are desperately searching for attachment relationships that will help them feel like a “real” person. The stakes are much higher for those with BPD because to them, the end of a relationship can feel like the end of their very identity. This is what fuels the intensity of the emotional reactivity those with BPD suffer from.
I hope this perspective I’ve offered helps to humanize those with BPD. People with BPD are commonly cast as manipulative, abusive, or even evil. While it is true that people with BPD can hurt and harm the people around them, it is important to understand that this is not because they want to hurt people.
How is BPD Treated?
BPD is typically treated with a combination of medication and therapy. Medication for BPD is generally understood to not treat the underlying condition, but instead can help manage some of the symptoms of BPD. For example, depression is a very common co-occurring condition with BPD. Medication can help lift that person out of their depression such that they can participate in therapy to address their core issues.
Part of the stigma around BPD is that it is not responsive to therapy. This is simply not supported by the evidence. It is true that general therapy offered by a clinician who is not trained in treating BPD tends to be ineffective or even harmful. However, there are a host of specialized approaches to therapy that have been proven to be effective at improving the lives of those with BPD. The most common approach is dialectical behavior therapy (DBT). Other common approaches are mentalization based therapy (MBT), transference-based therapy (TBT), and schema therapy. My personal approach as a therapist draws most strongly from psychodynamics and schema therapy so that is what I will describe here in a brief way.
In my view, BPD develops in response to a set of traumatic interpersonal experiences, typically with primary caregivers. As such, BPD also heals through interpersonal experiences, called corrective emotional experiences. Due to their constant fear of abandonment, those with BPD have highly volatile relationships and often express intense anger, fear, and sadness in response to their perception of abandonment. The therapeutic relationship is a relationship too, and the BPD client will eventually begin to play out similar patterns with the therapist. It is the therapist’s job to recognize that what underlies this is a fear of losing the relationship and a deep sense of unworthiness and unlovability. The therapist stays grounded, does not abandon the client, and attends to the clients underlying emotional need in that moment. As the BPD client experiences this corrective response over and over, they begin to develop real trust in the relationship as well as a real sense that they are genuinely loveable. This becomes the foundation through which they can begin to experience their relationships outside of therapy in a new way. Therapy for those with BPD is obviously much more involved than this but this captures the essence of how it works.
It is worth taking a moment to talk about what reasonable expectations are for treatment. BPD isn’t something you either have or don’t have and once it is “treated” you never have to deal with it again. Let’s imagine there is a continuum of BPD of 0-100. At 0, a person has no borderline traits whatsoever. At 100, a person maximally experiences all BPD traits. Imagine that around 75 is when a person qualifies for the diagnosis of BPD. If someone enters therapy and their borderline traits are at 85, it is not reasonable to expect to ever get down to 0. But could that person get down to 50? Yes, that is possible. At this level, a person might not qualify for the technical diagnosis of BPD, but they may still experience many of the symptoms in either a less frequent or less intense way. This can be the difference between life and death. This can be the difference between maintaining close interpersonal relationships with friends, family, and romantic partners as opposed to an endless string of ruptured relationships. If you or someone you love is suffering from BPD, this is something worth fighting for.
https://www.patreon.com/posts/borderline-deep-68834672 - Psychology In Seattle Podcast – Borderline Personality Disorder (Deep Dive). In order to listen to the full episode, you have to subscribe to the Patreon for $5. If this topic is of interest to you, it is well worth the money spent. I am not affiliated with the podcast in any way.
About the Author
Brad Schlosser is a therapist and Registered Clinical Social Worker Intern based in St. Petersburg, FL. If you are a Florida resident and are interested in booking a session for in-person or telehealth counseling, please see the Contact Us page.