Borderline Personality Disorder: A Summary

This is a summary of what I have learned over the past two years, after my first direct encounter with what is called Borderline Personality Disorder (BPD). Whilst I do not have BPD (although everyone is a little bit on every mental health continuum), I do endeavour to be a loyal and committed ally of people with BPD (pwBPD). In a very real sense, I wish I knew then what I do now; but at least I have made the effort to learn. I hope that these notes are useful to others. For anyone who wishes to be a sincere ally (a catch-all term that should include partners, family, and friends) of a person with BPD it is absolutely necessary to make the effort to listen to the pwBPD and to educate yourself using scholarly sources. Not making the effort means that you're not an ally, regardless of how close you think you are to the person, and not using scholarly sources will cause more harm and prejudice than good.

This document was initially written at the end of BPD Awareness Week 2022 in Australia and for World Mental Health Day, and will be updated as new information comes to hand. Throughout all the content here it is emphasised that (a) quantifiers are always required (many, most, some, etc) and every BPD person is unique and will not show all characteristics and (b) always see the person. Please note that I am not a psychologist, although I am a student of the subject and have completed most of a Graduate Diploma of Applied Psychology at the University of Auckland. I encourage people to donate to the Australian BPD Foundation.

Warning: This article mentions suicide, self-harm, and abuse.

Definition and Prevalence

"Borderline Personality Disorder" is a mental health condition marked by a long-term pattern of intense emotional reactions, divergent moods, unstable interpersonal relations, impulsivity, and issues in self-identity and self-direction. The term itself was coined when the condition of behaviours was deemed to be on the borderline of psychosis (difficulty in determining what is real) and neuroticism (disorders that cause constant distress), where a neurotic person in a time of stress would show signs of psychosis. Whilst neither 'psychosis' nor 'neuroticism' are used as formal mental health descriptors, the term "borderline" has stuck. The term was included in DSM-III (1980) where it remains to the current edition. An alternative, and more intuitive term, is "Emotionally unstable personality disorder" (EUPD).

The median prevalence of BPD is c1% (Ellison et al, 2018). In clinical settings, BPD prevalence is around 10-12% in outpatient psychiatric clinics and 20-22% among inpatient clinics. Prevalence is notably higher among incarcerated individuals and notably lower among the elderly. There is a pronounced gender distinction with women diagnosed over men at a 3:1 ratio (Skodol, Bender, 2003). Underdiagnosis and misdiagnosis are unfortunately common, with over 40% of pwBPD had been previously misdiagnosed with other disorders like bipolar disorder or major depressive disorder (Ruggero et al, 2010).

Diagnosis and Symptoms

The DSM-5 (p663, 2013) gives the following as diagnostic criteria. Formal diagnosis requires satisfication of five or more of the criteria.

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)
2. A pattern of unstable and intense interpersonal relationships characterised by alternating
between extremes of idealisation 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) (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
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

There are similar criteria for the International Classification of Diseases (11th Revision) which describes "the borderline pattern descriptor" as follows:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by many of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships
3. Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self
4. A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours
5. Recurrent episodes of self-harm
6. Emotional instability due to marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty controlling anger
9. Transient dissociative symptoms or psychotic-like features in situations of high affective arousal

If one thinks that they fit the criteria for BPD it is essential to seek a professional diagnosis. Without professional treatment, one is taking an enormous risk of harm to themselves and others. Likewise, if one thinks that another person fits the criteria, raise the matter very gently and delicately with a motivation of care and with recognition and self-awareness that you are not a professional.

Causes and Neurology

Borderline personality disorder often begins in adolescence or early adulthood. It is characterized by problems with interpersonal relationships (they are intense, alternating between idealization and devaluation), mood (depression and especially inappropriate, intense anger), and unstable self-image. Current estimates of the general population prevalence of borderline personality disorder range up to 5.9 percent, and recent studies of college students suggest that up to 17 percent struggle with significant borderline traits. Borderline personality disorder is associated with psychiatric disability, substance abuse, eating disorders, and medical problems.

The heritability of BPD is between 37% to 69%, a rather wide range (Gunderson et al, 2011), with indications that is one of the most heritable disorders (Torgersen et al, 2000). However, even when researchers do note specific linkages to genetics variation between genetic and environmental factors are balanced at 42%/58% (Distel et al, 2008). These environmental factors are commonly associated with the result of childhood trauma such as neglect and abuse; there is little doubt that a person who has experienced childhood trauma is at an increased risk for developing BPD and PTSD (Cattane et al 2017).

Real-time brain imaging scans have established that pwBPD are physically unable to regulate emotions (Nauret, 2017). Neuroimaging shows that pwBPD typically has a reduction in the brain's regions that regulate stress responses, emotions, and decision-making including the amygdala, the hippocampus, and the orbitofrontal cortex (O'Neill, Frodl, 2012). There is dysregulation of the hypothalamic-pituitary-adrenal axis, responsible for the production of cortisol, released during times of stress; pwBPD have abnormal levels of cortisol production (Cattane, et al 2017), reflected in damage erosion of the very areas of the brain responsible for stress regulation and decision-making. Amygdala damage is associated with impulsive behaviour, a lessens aversion to risk and loss (Gupta et al 2011), and also with hypervigilance (Terburg et al, 2012). Damage to the amygdala (emotional processing) and the hippocampus (declarative of episodic recollection) also reduces the capacity for memory (Yang, Wang, 2017).

Comorbidities

There are a number of comorbidities with BPD. The following are a few words on the most common, including Eating Disorders, Attention Deficit Hyperactivity Disorder, (complex and chronic) Post-Traumatic Stress Disorder, Narcissistic Personality Disorder, and Bipolar Disorders

Eating disorders and BPD are co-morbid, with some 53.8% co-occurrence from one extensive study (Zanarini, et al 2010), compared to 24.6% of patients with other personality disorders and more specifically, 21.7% of patients with BPD met criteria for anorexia nervosa and 24.1% for bulimia nervosa. Like other co-morbidities, an association has been drawn between eating disorders, BPD, and the environmental factor of childhood trauma, whether in the form of neglect or abuse (Sansone, Sansone, 2017).

Attention deficit hyperactivity disorder (ADHD) and BPD, is another frequent comorbidity, in a clinical setting, ranging from 16.1 to 38% of BPD patients (Weiner et al, 2019). This comorbidity questions whether it is appropriate to view either as an entirely early-onset neurological disorder (ADHD) or a later-onset environmental disorder (BPD). As with many other comorbidities, the expression of characteristics is more severe, hence people with ADHD and BPD are even more impulsive than those with BPD alone, and with a higher level of emotional dysregulation than those with ADHD alone.

Post-traumatic stress disorder (PTSD) including complex PTSD, and borderline personality disorder commonly co-occur, approximately 25-30% (Pagura et al 2010, Frías and Palma, 2015) of the time. Whilst PTSD is characterised by (a) a sense of threat, (b) avoidance, and (c) re-experiencing. complex PTSD has, in addition, (d) interpersonal avoidance and difficult interpersonal relationships (e) negative self-concept, and (f) affective instability. BPD does not have (a), (b), and (c), but does have (d), (e), (f) and, in addition, (g) anger, (h) chronic emptiness, (i) self-injury behaviours (j) transient psychotic and dissociation and (k) fear of abandonment. Individuals with comorbid PTSD-BPD have a poorer quality of life on average, with higher levels of self-harm.

Narcissistic Personality Disorder (NPD) and Borderline Personality Disorder (BPD) are both "cluster B" disorders, characterised by dramatic and intense behaviour (at least to observers), and impulsive behaviour. This cluster includes NPD, BPD, anti-social personality disorder, histrionic personality disorder, etc In addition to this general overlap the co-occurrence of BPD and NPD has been assessed from a range of 13% (Hörz-Sagstetter et al 2018) to 39% (Grant et al, 2008). There is a possibility that it is particularly associated with "vulnerable narcissism", whose traits include hypersensitivity, defensiveness, and low self-esteem. People with NPD and BPD are less likely to see a remission of BPD as NPD people have a lower motivation to seek therapy, and NPD is very difficult to treat (Caligor et al, 2015).

Bipolar Disorders and BPD also occur, in approximately 20% of cases (Zimmerman, 2019) and there is an ongoing discussion on whether BPD should be part of the bipolar spectrum, although most recent literature suggests that they are distinct, and the debate has actually sidetracked from the substantive issue. Like other comorbid states, people with "borderpolar" have higher levels of impaired functioning, substance abuse disorders, and self-harm (Patel et al, 2019). Further, people with BPD and a Bipolar Disorder are more likely to have PTSD as well, generating an especially challenging combination that has been insufficiently researched and is likely underdiagnosed.

Prognosis

BPD conditions remain throughout the lifespan, although with variations in symptoms (Biskin, 2015). In some cases BPD symptoms can be observed in childhood, however, there is an absence of evidence regarding the course of development of those who do not meet the full criteria. Adolescence is usually when BPD is recognised, although there is evidence of remission in follow-up studies ranging from 40% to 65%, although residual symptoms are not always predictable. Adult BPD longitudinal studies also suggest a gradual decline in symptoms, with periods of remission of recurrence. The decline of symptoms was mainly in the behavioural aspects of impulsivity; self-harm and suicide remained a factor with one large study indicating a 10% suicide rate after 27 years of follow-up, mainly patients in their 30s with multiple failed treatments. Even with a decline in symptoms over time functional recovery - defined as remission along with full-time vocational or educational activity and at least one stable and supportive relationship with a close friend or partner - occurred in only just more than 50% of patients (Zanarini et al, 2012).

People with BPD have a reduced life expectancy ranging from 14 to 27.5 years, with a median value of 20 (Castle, 2019). Most of the early mortality is largely due to cardiovascular deaths with major risk factors (e.g., obesity, smoking, poor diet, and lack of exercise) significantly greater among people with BPD. Other notable risk factors include arteriosclerosis, hypertension, hepatic disease, arthritis, gastrointestinal disease, cardiovascular disease, and sexually transmitted diseases. These can be attributed to maladaptive lifestyle choices (smoking, drugs, alcohol, diet) as well as iatrogenic (prescription medicines). The problems are often compounded with a person with BPD having comorbidity, and also by the stigma attached by BPD even in the responses of health professionals. Suicide rates vary from up to 10% of cases from follow-back research, or from 3-6% in prospectively followed cohorts, and most occur later in life (mean age of 37, standard deviation of 10) (Paris, 2019)

Treatment

There is no cure for BPD, but recovery and management are possible. There have only been very modest evidence of neurogenesis of the amygdala (Jhaveri, 2018) and mood disorders are known to weaken the prospect of neurogenesis of the hippocampus. In other words, the very experience of having BPD reduces the possibility of recovery from BPD (Toda et al, 2019). There is evidence that deep brain stimulation can help relieve some psychological and behavioral side effects, such as hypervigilance (Langevin, 2012).

There are some regularly prescribed medications for pwBPD, typically antipsychotics (Grootens, Verkes, 2005) and mood stabilisers (Lieb et al, 2010). Usually, psychotherapy has been shown to be particularly beneficial, with Dialectical Behaviour Therapy (DBT) offering the greatest rates of success (Choi-Kain, 2017). It is, of course, not something that necessarily works for everybody with BPD, and other therapies may be more appropriate depending on the individual (e.g., schema therapy, mentalisation-based treatment, transference-focussed psychotherapy). A particular warning is raised for matters of misdiagnosis, especially with common co-morbidities such as PTSD. In many cases, a treatment that is very effective for PTSD can aggravate BPD and vice-versa e.g., trauma history, mood swings, and alienation from others (Hammond, 2020)

Community

The BPD Community consists of people with lived experience of Borderline Personality Disorder. This can include people with the illness (diagnosed, undiagnosed, treated, and in remission), their close friends, family, partners, and allies. The following are a few short comments on the lived experiences of both pwBPD and those in their life. This section of the summary is somewhat more informal than what has preceded.

Availability, Understanding, Solutions

A common error by allies have when a pwBPD is having an episode of extreme emotions (anger, sadness, anxiety, etc) is that they seek to provide rational solutions to what is a perceived problem. This may be a genuine response motivated by care and love, but it is not the appropriate approach. A person in such a situation is experiencing an emotional disturbance and the experience must also be dealt with emotionally. The following steps - availability, understanding, and solutions - must be carried out in order with each step depending on the preceding. An alternative name for these is "SET theory" (Kreisman, 2018), standing for "Support, Empathy, Truth", although that will get confusing for people with an interest in discrete mathematics (such as the author).

Availability: One should recall that a pwBPD suffers a chronic fear of abandonment; thus availability must be of the first priority. Simply being present can help alleviate the fear. Statements of support and engagement are also valuable: "I am here for you", "I care about you", "I want to help", etc.

Understanding: Once availability is established, the pwBPD is likely to express their feelings. Their ally must display empathy and understanding at this point. The pwBPD may seek to ground their feelings in events or interpretations that might be completely erroneous, conflated, etc. The ally should not seek to correct them or downplay the real or imagined causes, but rather validate the emotions. This requires some attention on the behalf of the ally to listen to the feelings as well as the words being used. Feelings are ALWAYS valid, even if the reasons are not and the pwBPD feels their feelings more viscerely than anyone else. The ally should give statements that validate the feelings: "This must be very frustrating for you".

Solutions: Only once the pwBPD has an assurance of an ally's availability, and the empathic rapport of understanding and validating their emotional state is established, should potential solutions be offered. These need to be factual or based on the ally's commitments (and the ally had better follow through): "This is what I can do to help", "If you do x, then y will happen. Perhaps consider z", etc.

Shame, Guilt, and Remorse

It is virtually a given that pwBPD will engage in words or actions that are very hurtful and damaging to those close to them. Unlike people who have limited emotional range or capacity, a pwBPD feels emotions, including shame and guilt, intensely. The coping mechanisms and responses of pwBPD however are typically very poor and they will often hold on to shame and guilt in a manner that is damaging to their self-esteem (through self-loathing), despair (avoiding establishing commitment through fear of hurting people in the future), or even various of self-harm. For pwBPD it is essential that they learn to turn shame into guilt and guilt into remorse, otherwise the pain will be ongoing.

Shame is more prevalent among pwBPD than guilt (Peters, Geiger 2016). Shame reflects the individual's negative self-concept and self-loathing, and represents the accumulated negative beliefs that the individual has toward themselves. With pwBPD it is an important contributor to anger, unstable mood, instability of interpersonal relationships, externalisation of blame, and self-harm. When a pwBPD is triggered by events that generate shame, including the results of their own impulsivity and other behaviours. However, it is necessary for a pwBPD to develop guilt about actions rather than accumulating further shame about them. Guilt at least focuses on the event and identifies the need to change behaviour, rather than adding to the negative self-image of shame which is an interrnalised and private pain.

The difference between guilt and remorse involves taking ownership of what a person has done that has hurt another. Contact, even indirect contact if necessary, of those that have been impacted is suggested. Informing the wronged party that one feels that they have wronged them and that one is changing themself so it doesn't happen again, is required. Further, asking if there's anything that can be done to make amends is a full acceptance of responsibility. There is no onus on the wronged party to give forgiveness or to accept any offer of amends. However, in most cases, people are forgiving when they see a genuine attempt in a person to change.

Mirroring, Splitting, Discarding, Reconnection

Borderline
Feels like I'm going to lose my mind
You just keep on pushing my love
Over the borderline
-- Madonna, Borderline (1983)

The famous Madonna song, for what it's worth, actually is not about BPD, but for those in a close relationship with a pwBPD, they experience of having one's love "pushed" and that the close ally may lose their own mind is a very common experience. A common descriptor used by both pwBPD and their loved ones is that the experience is like being on an emotional roller-coaster. Many of those who have experienced a relationship with a pwBPD describe a cycle of behaviour that, if consciously carried out, would constitute manipulative abuse (Brüne, 2016). Instead, the actions carried out by a pwBPD are unconsciously driven as they desperately fear abandonment whilst at the same time having high levels of chronic mistrust and a belief that they are unlovable.

A typical cycle will consist of an initial and often incredible connection between the pwBPD and their loved one, their "favourite person" as described in the culture. The pwBPD will engage in "mirroring", elevating their loved one, affirming their beliefs, dreams, and activities, and will present themselves as exciting and adventurous in the process. For the loved one, they will often describe the experience in highly romantic terms, such as finally meeting their soulmate. This experience, however, does not last; the inevitable flaws of the loved one and the affective instability of the pwBPD will usually mean that the pwBPD will engage in "splitting" against their loved one. Where once they were exalted, they are now treated with equivalent disdain (often with rage and vitriol), and will soon be discarded. During the negative side of the split, the pwBPD, with far greater frequency than others, will establish a new love interest (Michael, 2021). "Splitting" itself is a malformed defense mechanism on the part of the person with BPD (Fetruck et al, 2018) where they convince themselves of the validity of the impending discard.

With the new love interest, the same process is very likely to repeat itself. Often enough, the pwBPD will then engage in the same process and re-establish connection with their original partner with a similar level of original elevation, and the cycle will repeat, or they will find an entirely new relationship; perhaps unsurprisingly, pwBPD tend to have a larger number of romantic relationships over their lifetime (Navarro-Gómez et al, 2017). Assuming a return to the original interest, it is not uncommon for loved ones of a pwBPD to describe how, over a number of years, their partners have discarded them several times and more. Whilst patience and commitment are admirable in any relationship, they will be insufficient in this situation. Therapy for pwBPD and couples therapy for the pwBPD and their partner is also required for success. Establishing clear boundaries and agreed consequences for particular actions should also assist.

Lying, Gaslighting, Lovebombing

The perception of reality for a pwBPD is driven by the current emotional state, which is subject to heightened levels of intensity and instability. As a direct consequence of this, a pwBPD engages in activities which, to an outsider, may seem like lying or gaslighting but are driven by these states rather than an act of conscious deception. For example, pwBPD often have a weakened level of promissory commitment to the expressions that they provide. Their reality is very much in the "here and now", rather than in the longer term, even when expressed in those terms. At the moment a pwBPD will quite sincerely and wholeheartedly believe what they are saying but will either forget the content entirely or have a radical change in affective orientation. Reminding the pwBPD of their prior commitments is important, but even more can be gained with a reminder of the emotional content of the commitment.

Another result of this emotional, rather than factual, perception is that pwBPD present statements that seem like gaslighting. Emotionally healthy people will develop feelings based on facts. However, pwBPD may unconsciously revise the facts to fit their current feelings or invent facts to fill in memory gaps. Tragically, this behaviour also weakens the ability of the pwBPD to develop a coherent autobiographical sense of self or firm memories. This can also be very confronting to an ally, whose immediate reaction will be to correct the factual error; this is a mistake and instead, the same SET principles described previously should be applied; the facts are secondary are actually secondary, empathy and understanding of the feeling must have priority.

Another experience that loved ones of a pwBPD experience is "lovebombing". This is overwhelming displays of affection and attachment. As the Oxford English Dictionary states: "the action or practice of lavishing someone with attention or affection, especially in order to influence or manipulate them". For a pwBPD the lavishing is real, at the moment. They are not consciously trying to manipulate their loved one. They are, in fact, both terrified of losing their loved one (thus the ovewhelming display of affection) and, at the same time, ready to engage in a "protective discard" on the assumption that their loved one will leave them.

Concluding Remarks

This summary is a compilation of my own notes and research over the past two years or so. It really is a personal essay, albeit written with my own tendency to an academic style, to make sense of what is a common and often debilitating mental illness. Despite the various difficulties, emphasis is again placed on the importance of individual variation with pwBPD, the legitimacy of their voice in explaining the lived experience of the condition, and the fact that the person who has BPD is also so much more than the illness that they carry. There are a terrible stigma (Aviram, et al, 2006) attached to pwBPD in popular culture and the media, and there are prejudices that abound and most surprisingly in the professions that should be the most helpful. Of course, pwBPD are just as prone to engaging in consciously hurtful acts toward others as anyone else, but in the main, they are incredibly empathic and caring although often unable to fully control their impulses. Genuine sympathy, understanding, and treatment all will help make life much better for them and us.

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