Borderline Personality Disorder

No desire to lose a toenail...

Therapists everywhere let out a collective sigh when we recognize borderline traits in a patient. As an undergrad, I had a fabulous professor for my abnormal psychology class. Prior to working at our humble university, she specialized in borderline personality disorder (BPD) at a group clinic out-of-state. I couldn't for the life of me, understand why she would give up such an impressive and needed specialty. That is, until I got a few years of practice under my belt. I don't pretend to specialize in personality disorders, as that's a long-term therapeutic relationship that has yet to entice me. Think of me as a runner (I'm SO not). There are casual runners that say, "I know what I'll do today, I'll go for a run!" Then there are intense athletes that train for marathons, choking down nutrient rich sweet goo, and barely realize they just lost a toenail. In this humble metaphor, the latter are the therapists that relish an opportunity to work personality disorders. I admire these folks, yet have no desire desire of my own, to lose a toenail. 

Before I get myself in too deep, I better share a little something about what BPD actually is. I know you're thinking, gosh- I hope I don't have it! Like all personality disorders, BPD often stems from experiences that may have been traumatic for the individual, often in childhood. This is something I like to point out, as interacting with someone who struggles with borderline traits can be challenging to say the least. Finding understanding and compassion can be very helpful, while maintaining a safe distance, (a.k.a. boundaries). Here are the characteristics of BPD as defined by the DSM-V diagnostic criteria manual:

Criteria for Borderline Personality...

A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following...

  1. Frantic efforts to avoid real or imagined abandonment.
  2.  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self image or sense of self.
  4.  Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). 
  5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms. 

My girl Kari Morton breaks it down for you...

I have a little bone to pick with this criteria. When you read this, you're wondering if that applies to about a dozen people in your life, or even you. BPD is a big umbrella over a very large population that has a lot of different faces. For example, someone with BPD could be:

  • An explosive inmate serving life in prison for stabbing someone in the gut- because they called him a derogatory name one day.
  • A teen girl binging and purging, desperate to perfect her dance routine for state competition.
  • An elderly woman that cries about how everyone hates her, and she doesn't know why her children never visit.
  • A young man that burns himself with cigars to feel something, because he's so empty inside.
  • A mother that beats her children at the drop of the hat, because they don't meet her expectations of perfect cherubs. 

Flailing for some kind of control...

As you can see, these pictures I've painted are so versatile, that it's hard to put your finger on it. In my humble opinion, the common thread for all individuals with BPD, is that they are flailing for some kind of control in their life, and when they don't get it, there is is little ability to maintain composure, or emotional regulation. This is a hallmark of BPD. When you see people overreacting out of nowhere, when they have gone from one extreme to the other without warning, BPD may be what you're dealing with. This can manifest as an explosion of anger outward, or inward. What does that mean?

1) Anger outward: Rage, violence, threats, passive aggressive rants, manipulation, text bombing, non-stop calling etc...

2) Anger inward: Binging/purging, starving, cutting, self-harm of any kind, obsessing, negative self-talk, perfectionism etc...

Both of these are harmful behaviors that result from the fear of abandonment, or loss of control. Let me paint you a picture. Say you are feeling like you're not-so-much into your honey anymore- thinking it's time to call it quits. You sit her down, say it's been great and all, but you don't see the relationship going anywhere and you would like to end it. She explodes. 

You what? You know what's wrong with you? You are afraid of commitment! You're a horrible partner. How can I be expected to make you happy when you are (insert vicious insults here)!!!!!

She storms off, and proceeds to text you all night with a slew of insults, historical montage of your infinite flaws, and belittles you, using all your known insecurities. But wait, we aren't done! Come 3 a.m., you get a call saying:

If I can't be with you, I won't be with anyone. I don't want to live anymore. 

Until one of the two dies inside...

Of course this cry for help results in a desperate outreach to make sure she's OK. Don't worry, she likely is. This gesture was an attention getter, and a successful one. The unfortunate cycle that starts here, is the partner's fear she will hurt herself if they break up, so they continue this dance for an unspecified amount of time until one of the two dies inside. In this example, the partner becomes codependent on keeping the other safe, while the person with BPD gets the control they are desperate for. It's a perfect recipe for unhappiness, but a common one.

Walking on eggshells...

This doesn't just happen with intimate partners, but friendships, family members, coworkers etc... Here's a good gauge for you to know if you have someone with BPD in your life. Do you feel exhausted after being around this person? Does your psyche need a good cleaning after a short interaction? You you feel like you spend a lot of time walking on eggshells to keep him/her happy? You've got someone with BPD on your hands. So what now? This is one of the most complicated questions to answer. I'll say, it depends. If it's a friend or coworker, it's pretty easy to distance yourself from getting involved in the merry-go-round of drama once you actually identify what's going on. If it's a partner or family member? Not so easy. Let me answer a few common questions for you:

  1. Can BPD be cured? Yes and no. This isn't really something that can be medicated away. Sure, the anxiety and depression that can accompany BPD symptoms can be treated, but the core personality traits aren't so easy to fix. With the lack of emotional regulation, the therapeutic goal is to get the patient to identify when this is happening, what their emotion is, and find ways to decrease their distress through more productive means (other than exploding on others). This could be through journaling, listening to music, exercise, etc... This kind of therapy is called dialectical behavioral therapy, or DBT. The very nature of someone's inability to emotionally regulate, results in something called splitting, or black and white thinking. People with BPD usually see people/situations as all good or all bad. The reason therapists feel so challenged with BPD patients, is that they often put us on a pedestal and then stop showing up all together when they feel challenged with the therapeutic process. This is the reason that progress isn't always made in therapy. Both therapist and patient have to show up ready to work. 
  2. Is it bad that I don't want to be around them? Not at all. While our culture promotes self-sacrifice when it comes to family and friends, it's not appropriate if it's impacting your well-being. It's OK to distance yourself. In some cases, this can be done naturally over time , while others may be more challenging to back away from. It's typical for someone with BPD to act out when they feel they are losing their connection with you. Think of their verbal attacks as white noise. None of it is coming from a balanced place. This is literally a situation in which it's them, not you. If you are truly worried for their safety, enlist professional help, such as calling 9-11, or the police department for what's called a well-check. This is when a police officer goes to the person's house to check in and see that they are safe. I've used this several times for patients I have been concerned about. This is rarely necessary, and only appropriate if you feel a person is in imminent danger.
  3. Why are they like this? There are a lot of reasons. Like most mental illness, there is a genetic component. If one of your parents had BPD, you are more susceptible to those traits as well. In addition to this predisposition, environmental factors play a part in the development of this personality. There have been connections made between BPD and childhood abuse (physical, sexual, emotional), neglect, trauma (all sorts), bullying etc... There also appears to be a connection in borderline traits with people that have addiction problems. In fact, it's not easy to diagnose BPD unless someone has been sober for a period of time, as they share a lot of the same behavior. 
  4. If they have had such a hard time, shouldn't I be there for them? I feel bad. I get it. I tell you this person has likely had some horrible trauma in their history, but I also give you permission to back off from the relationship. This makes you feel bad. Of course. Just because they had a hard time, doesn't mean they get to put you through their drama. Engaging in the relationship at all is totally up to you, but I can promise you this: if nothing changes, nothing changes (my one and only Dr. Phil quote). It's true. Unless they get help for their struggles, and I'm talking intense therapeutic WORK, you have a lot more drama in your future. The only way to avoid this is to implement some strict boundaries. A fantastic resource to learn about boundaries is the book "Stop Walking on Eggshells." In addition to this book, I have also written a blog entirely on this topic! Boundaries. 

Completely miserable in their own skin...

I've spent the majority of this article discussing how challenging it is for people to navigate relationships with people who have BPD. One thing that is rarely discussed, is how hard things are for the person who has BPD. Yes, they are exhausting to be around. Yes, therapists can find working with borderline personalities to be challenging, and sometimes futile. However, that person who is experiencing big fat emotions, is completely miserable in their own skin. While they appear to be "overreacting" to everyone else, they do feel that real level of intensity. WOW. Not to mention the emptiness, lack of identity, and desperate desire to just be loved. For all you secure, well-adjusted people out there, it may be hard to imagine, but this is excruciating for the sufferer. Imagine if your biggest fear is abandonment, but because of your intense and seemingly irrational behavior, people keep abandoning you! Many borderlines ask, "what's wrong with me?" They actually can't help it. The coping skills just aren't there. Like I said, you have a right (and I encourage you) to distance yourself from drama. Just don't overlook a tiny shred of compassion for what they are also going through. Love is always better with boundaries if you ask me.

Boundaries...

While personality disorders are far from my specialty, I see them frequently. Likely a third of my patient load has struggled with (at least) a few of the traits of BPD, or the full kit and cabootle. One challenge with working in mental health, is the propensity to identify the patient as their condition. That borderline, that bipolar, that schizophrenic. First and foremost, these are people that love, laugh, fear, hurt, and cry. They have hopes and dreams that can be crushed. They wish for serenity in their own lives, and struggle to find it. When I sit across from a patient in this pain, I do have compassion and understanding for them. I own my puzzle piece of their story, and give my all to improving (if only) a small page of it. If your struggling with symptoms of BPD, you can get help for it. I encourage you to find a counselor in your area that specializes in DBT. Like I said, it takes work- but it's worth it in the end. If you're struggling with a loved one that has BPD...BOUNDARIES. I can't say it enough. Don't engage with them down the rabbit hole. It doesn't help either of you. Don't hesitate to find a counselor of your own to help you implement and electric fence around your emotional space. It's yours, and you have a right to say who you share it with. I give you permission. 

AM