LukeNotes, Summer 2021
Instability in relationships, impulsive behaviors, and inability to manage emotions: these are just a few of the characteristics of borderline personality disorder (BPD). Borderline personality disorder is one of the cluster B types of personality disorders, which are those characterized by intense emotional expression, dramatic presentation, and unpredictable thinking or behavior.
The Roller Coaster
For those struggling with BPD, life and relationships can feel unstable, chaotic, and disorganized. The challenges that accompany BPD are often compared to riding a never-ending roller coaster. Life often feels confusing and uncontrollable to those living with the disorder. The wide range of symptoms may also make diagnosis difficult. While each person’s experience and expression of BPD is unique, common symptoms include (Diagnostic and Statistical Manual, 2013):
– Frantic efforts to avoid real or imagined abandonment by friends and family.
– Unstable personal relationships that alternate between idealization (“I’m so in love!”) and devaluation (“I hate her”). This is also known as “splitting.”
– Distorted and unstable self-image, which affects moods, values, opinions, goals, and relationships.
– Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, reckless driving, or misuse or overuse of substances.
– Self-harming behavior including suicidal threats or attempts.
– Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days.
– Chronic feelings of boredom or emptiness. • Inappropriate, intense or uncontrollable anger—often followed by shame and guilt.
– Dissociative feelings—disconnecting from your thoughts or sense of identity or “out of body” type of feelings—and stress-related paranoid thoughts. Severe cases of stress can also lead to brief psychotic episodes.
Emotional Regulation & Relationships
The practical presentation of borderline personality disorder may include inability to maintain stable employment due to consistent conflict with other employees or difficulty with authority figures. People with BPD may feel hurt or angry if it is perceived that others are receiving special treatment and they may incorrectly assume they are being mistreated.
People dealing with BPD are often extremely sensitive and react in a manner disproportionate to the situation. Seemingly small incidents prompt intense emotional and physical reactions, and once upset, they may be unable to calm down. This inability to self-soothe and poor emotional regulation often leads to relationship turmoil and impulsive, even reckless behavior.
Diagnosing Borderline Personality Disorder
A borderline personality disorder diagnosis is complex and should only be made by a trained mental health practitioner. The mental health provider will conduct a comprehensive clinical interview to gather information about the client’s background and history of the presenting symptoms. The client will undergo a psychological evaluation that may include questionnaires, medical history/exam and, if appropriate, interviews with family and friends.
Nearly 75 percent of people diagnosed with BPD are women. Recent research suggests that men may be equally affected by BPD but are commonly misdiagnosed with Post Traumatic Stress Disorder (PTSD) or depression instead (National Alliance on Mental Illness, 2021).
The cause of BPD is attributed to a combination of factors, including brain functioning and difference, genetics and external environmental factors (e.g. trauma). PTSD and BPD commonly co-occur, and about 50 percent of people with BPD also have PTSD. This rate is much higher than in the general population. For this reason, the diagnosis of BPD is controversial in the field, as some clinicians believe BPD is not a personality disorder but a complex response to trauma.
Borderline personality disorder is primarily treated using psychotherapy; however, medication may be prescribed if necessary, and hospitalization may be required if the client’s safety is at risk. Dialectical behavior therapy is one of several forms of therapy that is effective in treating BPD. Dialectical behavior therapy was designed specifically to treat borderline personality disorder and includes group and individual therapy. This therapy uses a skills-based approach to teach clients how to manage their emotions, improve relationships, and tolerate distress. For example, the S.T.O.P. skill (Stop and Take a step back, Observe what you are thinking/feeling, Proceed Mindfully) can be used to manage triggers or difficult situations.
It is critical that clients are active in their recovery process. Like most personality disorders, BPD tends to be a lifelong issue and involves a commitment to therapy and learning new tools. Depending on how early the interventions start, with time and age, people with borderline personality disorder are better able to manage their illness. In addition to professional treatment, clients should study the disorder, learn to recognize their triggers (e.g., certain dates, yelling), and follow the treatment plan (e.g., therapy, medications). Healing is centered on breaking the dysfunctional patterns of thinking, feeling, and behaving that contribute to distress.
It is necessary to identify and implement healthy means of coping, applying the tools learned in therapy. Most importantly, it will be beneficial for the client and those connected to them to be patient. It is not easy to change lifelong habits, and behavior change does not happen quickly.
A. Mechelle Haywood, Psy.D., is as a primary therapist at Saint Luke Institute in Silver Spring, Maryland.