Many psychiatric terms have become part of the popular lexicon. Terms such as “bipolar” and “OCD” are thrown around to describe a moody family member or an organized friend. Other examples: “manic,” “ADHD,” and “schizophrenic.” The widespread misuse of these terms can be harmful, distorting their meaning and increasing stigma. Words matter.
Borderline personality disorder (BPD) is another syndrome frequently invoked but poorly understood and heavily stigmatized. Since many people live with BPD, it’s important to combat some of the misperceptions. Effective treatment starts with a thorough diagnostic assessment and then an open conversation about the diagnosis. Reducing the existing stigma and intense shame surrounding BPD can be life changing. And lifesaving.
History
In some ways, “borderline” is an unfortunate name. In the 1890s, an American psychiatrist, J.C. Ross, originated the term “borderline insanity” to describe a group of patients with unstable moods and impulsivity. “Borderline personality disorder” as a syndrome was first described in the 1930s by American psychoanalyst Adolph Stern. These patients didn’t fit into the categories of “neurosis” or “psychosis,” thus were on the “borderline.” Dr. Stern correctly understood that this syndrome was often (but not always) associated with a history of early trauma, characterized by emotional hypersensitivity, and needed a different approach to treatment; traditional psychoanalysis was not working.
What is a Personality Disorder?
According to the American Psychiatric Association’s diagnostic manual (DSM-5-TR), a personality disorder is “an enduring pattern of experience and behavior” which is “pervasive and inflexible, has an onset in adolescence or early adulthood” and “leads to distress or impairment.” The DSM currently lists 10 specific personality disorders (including Narcissistic Personality).
Key Features of BPD:
The syndrome is described best by Dr. John Gunderson, an exceptionally empathic Harvard psychiatrist who devoted his career to understanding and treating people with BPD. His YouTube videos on the topic are well worth watching (*see link to one below). Through decades of clinical work and teaching, Dr. Gunderson helped de-stigmatize and demystify BPD for untold numbers of patients, family members and mental health providers, instilling hope and reducing despair.
The features of BPD generally manifest by adolescence/early adulthood. People with BPD experience high degrees of distress and isolation. The risk of suicide is elevated. It is also very difficult for families, who often feel helpless in the face of the emotional intensity, anger, conflict and risky behaviors.
- Fear of abandonment (“rejection sensitivity”): frantic efforts to avoid feeling alone; for example, repeatedly texting a loved one or threatening self-harm
- Pattern of intense and unstable relationships: a tendency to swing suddenly from idealizing to demonizing someone, from intense love to intense hate, to view people as all good or all bad; difficulty maintaining friendships
- Emotional reactivity and extreme mood swings, including intense anger; sudden mood changes (often in response to interpersonal interactions); difficulty controlling emotions
- Unstable sense of self; identity disturbance; changing self-concept; may include negative view of self (worthlessness, shame)
- Feelings of emptiness; easily bored; unfulfilled
- Self-harm and suicidality: cutting; suicidal thoughts, threats, and/or attempts
- Impulsive and risky behaviors: can include substance use, risky sexual behaviors, reckless driving
- Dissociation: feelings of detachment, out-of-body sensations, gaps in memory
Causes of BPD
BPD, as with most mental illness, involves a complex interplay between genetic predisposition and environmental influences (especially early life experiences). The role of genetics is strong, estimated to be as high as 40-60%. People who have a close relative with BPD are five times more likely to develop it. Epigenetic factors are also involved; gene expression can be altered by childhood neglect or abuse (physical or emotional).
Also supporting a strong biologic component: many people with BPD have been emotionally hypersensitive since very early childhood, even infancy. And functional neuroimaging has demonstrated an overly reactive limbic system (our emotional “alarm system”). In contrast, the prefrontal cortex (emotional regulation, reasoning, impulse control) appears under-reactive. The resulting imbalance contributes to symptoms such as hypervigilance (scanning for threats), difficulty calming down, and misinterpreting neutral cues as threats. (For example, assuming someone dislikes you if they don’t immediately reply to your text).
Developmentally, early attachment patterns between the child and caregiver play a role in the development of BPD. In the past, the blame was placed on parents, contributing to the shame surrounding this disorder. As we’ve learned more about the heritability of the disorder, it’s better understood as a dynamic 2-way interaction. With an overly sensitive, easily distressed infant who is harder to soothe, the caregiver may respond with more frustration, irritability, a sense of helplessness, even withdrawal. The caretaker’s distress and inability to soothe the infant then worsens the emotional escalation. As Dr. Gunderson says, “the child helps create the parenting as much as the parenting creates the child.”
Stigma
Features of BPD (intense and rapidly changing moods, anger, impulsiveness, recurrent suicidal threats, and intense fear of rejection) often induce negative feelings in others. Relationships are stormy. People with the disorder may be labelled as “difficult” by family, friends, and even, unfortunately, by their treatment providers. People may understandably respond with anger or by distancing themselves, which then intensifies the negative emotional cycle, as abandonment is one of the biggest fears. Maladaptive and troubling behaviors increase, further isolating the person in distress.
People suffering from BPD may be viewed as willfully “manipulative” and “attention seeking,” when they are doing their best to manage their intense emotional distress and shame, and to avoid abandonment.
With improved understanding of BPD as a “real” neurobiological disorder with effective treatment options, hopefully the stigma will continue to decrease. Education about BPD, along with peer support networks, can be very validating in this regard.
Treatment of BPD
Adding to the stigma surrounding BPD is a sense of hopelessness, the myth that it is not treatable. In fact, there are several effective treatments, the most prominent being DBT (Dialectical Behavioral Therapy). DBT, developed by psychologist Marsha Linehan in the 1980’s, involves building skills in several key areas:
- Tolerating distress: learning to handle painful feelings without acting out in harmful ways
- Understanding and regulating emotions
- Healthier interpersonal relationships
- Mindfulness: being present in the moment, observing one’s thoughts and feelings without judgement
Psychotherapy, such as DBT and other approaches, is the mainstay of treatment. This may include individual therapy, group therapy and/or family therapy. Family work can be extremely helpful in interrupting a vicious cycle of emotional escalation and frustration. For patients and families, learning effective strategies to manage the emotional intensity and behavioral dysregulation of BPD strengthens self-efficacy and hope.
While not the primary treatment modality, psychiatric medications may be useful in addressing specific symptoms and additional diagnoses, such as anxiety, depression, and mood dysregulation.
With good treatment, people with BPD can experience a rapid decline in symptoms over the first few years, along with significantly improved social relationships and overall stability and well-being.
Resources:
John Gunderson: youtu.be/h15OnmUqFj8
National Educational Alliance for Borderline Personality Disorder: dev.borderlinepersonalitydisorder.org/list-of-recommended-bpd- resources/
If you or someone you love needs mental health support or is contemplating suicide, seek help immediately. For help 24/7, call or text 988 for the Suicide and Crisis Lifeline or go to the nearest emergency room.
