Life on the Line – what is Borderline Personality Disorder?

What is it like to have Borderline Personality Disorder?

Just a few hours ago, Charlene had felt like she was on top of the world. She had been out shopping with her best friend, Jenny, and they were both having a great time. Charlene made quite a few purchases. She’d spent more than she intended but they were such great value, she couldn’t resist. Plus, she recently got a new job, which pays well, so she’d felt confident that she would be able to manage the expense.

Then everything changed. While leaving the shopping centre Charlene suggested to Jenny that they should meet up again next weekend. Jenny hesitated, then said she already had other plans. Charlene felt immediately disappointed. As she was driving home afterwards she found herself unable to stop thinking about Jenny’s response. The more she thought about it, the more certain she began to feel that Jenny had just been making an excuse, and really didn’t want to spend time with Charlene again. Charlene felt growing feelings of having been rejected, and a growing certainty that Jenny wanted to distance herself from Charlene and end their friendship.

Feelings of being rejected and abandoned by Jenny were quickly followed by feelings of intense anger. How could Jenny treat her this way? Why did Jenny hate her – after everything Charlene had done for her? Soon all of the past disputes and misunderstandings that had ever happened in their friendship were filling Charlene’s mind. With every passing minute Charlene felt increasingly furious at Jenny and a growing hatred for her. How could she have been so blind to think Jenny was a friend after all the times she had hurt her? Charlene hated Jenny. There was no way she would ever speak to her again.

Right on the heels of hatred began feelings of self-loathing. Why did Charlene’s friends always end up hurting her like this? She concluded that it was because she is a vile, detestable person. Nobody could possibly care for someone so obviously defective.

Feelings of self-loathing spawned feelings of despair and hopelessness. The whole world, and the whole of Charlene’s life – which mere hours ago had seemed bright and full of promise – were now a pervasive, inescapable blackness.

This is Charlene’s state of mind now, She cannot bear these feelings and can see no possibility of relief. She is certain she will feel this way forever, that there is nothing she can do to make this pain stop. The feelings seem unbearable, so Charlene needs them to stop. There is only one way she can escape this pain…

What is Borderline Personality Disorder?

The above vignette tries to capture a small slice of the experience of Borderline Personality Disorder. The characteristic feature of Borderline Personality Disorder is highly variable and intense moods. Many of the other features of Borderline Personality Disorder function as strategies to manage these intense and rapid changes in mood. Other characteristics of Borderline Personality, such as intense and unstable relationships, disturbed sense of self, impulsivity (such as impulsive spending or drug use), inappropriate intense anger are illustrated in the above scenario.

The scenario ends with Charlene thinking of “only one way she can escape”. There are several possible behaviours that might typically follow this line of thinking in individuals with Borderline Personality Disorder:

• suicide attempt;
• substance use;
• self-injury;
• reckless behaviours, such as gambling or promiscuous sex, that may serve to numb feelings.

Note that these behaviours function as a means of escape or coping with intense distress, and are not attention-seeking.

Other features of Borderline Personality Disorder not captured in the above vignette include:

• desperate efforts to avoid abandonment;
• paranoia;
• dissociation (mentally “blanking out”, regression to a child-like state, or manifesting an altered persona);
• chronic feelings of emptiness;
• hallucinations (relatively rare).

Borderline Personality Disorder is one of many recognised Personality Disorders in the DSM-IV and ICD-10. Personality refers to patterns of thinking and behaviour that are stable over time in an individual. For example, if John is a person who throughout his life has consistently liked to see the humorous side of stressful situations, we would consider that a feature of his personality. If Louise is a person who has always been irritated when people like John make light of a serious situation, then we would consider that a feature of her personality.

“Personality disorder” refers to particular clusters of enduring patterns of thought and behaviour that fall well outside the distribution of personality traits that is usually seen within the general population. Additionally, to be considered a “disorder” it is necessary that those traits cause significant distress for the individual or those around them and impact on functioning.

A “personality disorder” does not merely represent the most extreme end of a normal distribution – it is not like saying people who are very tall have a disorder simply because they fall at the upper end of a natural range. People can be naturally tall, but if a person is unusually tall and there is also an unusual pattern of growth, this can indicate a growth disorder. Likewise, if a person shows unusual extremes of personality and there is significant impact on their functioning and a characteristic cluster of symptoms and history, then this can indicate a personality disorder.

Borderline Personality Disorder is confusingly named. The name originates with the idea that individuals with these traits fall somewhere between (borderline) neurosis (anxiety disorders) and psychosis. The ICD-10 name for the condition – Emotionally Unstable Personality Disorder, Borderline Type – doesn’t exactly roll off the tongue, but is at least more descriptive.

Individuals with Borderline Personality Disoder will often describe “feeling great one minute and deeply depressed the next”. This feature of dramatic fluctuations between positive and negative mood states leads to frequent confusion and misdiagnosis as Bipolar Affective Disorder. However, there are significant differences between these two conditions, particularly with regard to treatment. Some confusion can also result from abbreviations of the two disorders – Borderline Personality Disorder may be shortened to BPD, and Bipolar Affective Disorder is commonly abbreviated as either BPD or, more correctly, BPAD. While this might seem trivial, it can have significant consequences in time-pressured settings such as Emergency Departments and Acute Mental Health Units.

How does Borderline Personality Disorder develop?

While there is some evidence of a genetic influence on development of Borderline Personality Disorder, and research has also identified differences in brain structure and hormones (both of which could be consequences, not causes, of the condition), the overwhelming evidence for why Borderline Personality traits develop relates to a variety of childhood experiences. Topping the list of risk factors for development is childhood sexual abuse. However, Borderline Personality Disorder regularly presents in individuals with no history of sexual abuse. Traumatic childhood experiences generally are a risk factor, as are unstable family environments, dramatic inconsistency in parenting and invalidating parenting.

In my experience of working with clients with Borderline Personality traits the common denominator in their developmental histories seems to be what I will call “catastrophic violations of caregiver trust”: a person, or people, in the child’s developmental environment who the child has understood to be in a position of authority and protection has failed to perform that role (often repeatedly) such that the child can no longer assume they have a safe and nurturing environment. The child learns it is necessary to be vigilant to danger and adopt sometimes extreme behaviour to prevent significant harm to themselves either physically or psychologically.

Because these experiences begin in childhood and usually persist over an extended period of time, the person’s understanding of how the world operates (“the world is dangerous, people can’t be trusted and are likely to abandon me”), themselves (“I am bad/defective”) and survival (“I must do whatever it takes to survive; If I don’t act fast to protect myself it will be too late”) become somewhat cemented as the person matures, brain plasticity slows and neural connections associated with this thinking become more “fixed” (see my post on neuroplasticity for a little more information on how thinking patterns can become “hardwired”). Entering adulthood, the threats that characterised childhood are usually no longer present, but threat-based processing and protective patterns of behaviour persist. These can then become the problem, rather than the solution they once were.

For Charlene, hating people who showed signs of negative feelings towards her may have been protective in childhood – causing her to avoid people who might have posed a genuine risk of harm. Now, however, it causes her to periodically distance herself from the positive social supports of her friends.

Can Borderline Personality Disorder be treated?

Personality Disorders have traditionally been thought of as difficult to treat. However, long-term studies tracking individuals with Borderline Personality Disorder suggest that a majority of people (more than 80%) treated for Borderline Personality Disorder show a stable recovery from symptoms at a ten year follow-up. Certainly there are treatments that have been shown to be effective at reducing symptoms. The therapy with the most research evidence for efficacy is Dialectical Behaviour Therapy (DBT), which was developed by psychology researcher Marsha Linehan who was herself diagnosed with Borderline Personality Disorder.

Important components of DBT include the development of skills of distress tolerance and emotion regulation. People with Borderline Personality Disorder often make dramatic attempts to avoid experiences that they believe they will be unable to cope with. Developing distress tolerance and capacity to regulate emotions reduces the perceived need for such avoidance.

One of the many components of distress tolerance is using pleasant activities as a distraction at times of increased distress. At Thrive Wellness we provide a customisable Pleasant Activities list as a free resource that may be useful for generating ideas for activities that can be used for distraction.

Medication is sometimes prescribed by psychiatrists to help reduce the intensity of symptoms in people with Borderline Personality Disorder. Antidepressants, mood stabilisers (such as sodium valproate) and antipsychotics may be prescribed, often in low doses, according to the symptoms of concern. These treatments are for symptom relief and are not considered to treat the underlying condition.

What if I know someone with Borderline Personality traits?

Interestingly, the characteristics of intense and unstable relationships among individuals with Borderline Personality Disorder creates corresponding characteristics in the people they encounter: people typically fall between one of two extremes of being either “rescuing” or “rejecting”. Neither of these are particularly effective in the long-term. Rejection will exacerbate distress, while rescuing will undermine self-efficacy. If you know someone who has Borderline Personality Disorder it is useful to develop an awareness of how you respond to them and position your own behaviour between these two extremes: Instead of saving him you remind him of his strengths and how he has coped in the past. Instead of rejecting her you try to empathise with what she feels.

It is also useful to understand that the behaviour of a person with Borderline Personality Disorder is not attention-seeking or deliberately dramatising. It is often perceived this way by others because the person can appear to be regularly over-reacting to small things. The reality is that the experience of an individual with Borderline Personality Disorder is dramatic, intense and painful; the reactions are valid when one understands the whole picture of that person’s life experience.

Finally, encourage your friend to seek professional help – be a support, but do not attempt to be a therapist. To act as therapist is to adopt a saving role, and will eventually backfire.