Borderline Personality Disorder

What is BPD?

Borderline Personality Disorder is a form of mental illness that is often found in survivors of childhood sexual, physical and emotional abuse. Some abused parties develop BPD and some do not for reasons that are unclear. BPD seems to run in families, but it is not yet known if this is due to genetic or environmental factors.   BPD is very common but frequently undiagnosed or misdiagnosed as Bipolar Disorder.

DSM Definition of BPD  (My notes are bracketed by parenthesis.)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects (mood swings), 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. Note: Do not include suicidal or self-mutilating behavior covered in (5). (Desperation / rage if they think they are being abandoned, intense feelings of sadness, loss and fear when their partner is away, a need to have access to the partner at all times, inability to allow their partner their own life and friends, a belief that healthy independence in their partner is a threat to them.)    

2.A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (The partner of the person with BPD, friends, coworkers or the person with BPD themself  is seen as wonderful or perfect, or as evil and rotten. People and things are seen as rigidly black and white by people with BPD – there is no normal middle ground.) People with BPD are highly intolerant of / unable to deal with the gray areas in life. This is called “splitting.” 

3.Identity disturbance: markedly and persistently unstable self-image or sense of self. (Confusion about goals, career, life choices, sexuality or sexual orientation. Persistent questions and discomfort with their perceived role in life. Pervasive issues related to “who am I” and “what is my role in the world”.  Many people with BPD change careers frequently or enter careers that give them a clearly defined framework and sense of identity, like large corporations or the military. Others fall prey to cults or fundamentalist religions that control all aspects of their life. Fundamentalism can be comforting for people with BPD since the “black and white” nature of these religions give them a framework that fits their world view.)  See *Author’s Note

4.Impulsivity in at least two areas that are potentially self-damaging
e.g., uncontrolled spending,  reckless driving, substance abuse, dangerous sexual acts or unsafe sex, binge eating, thrill seeking or risk taking behaviors. Note: Do not include suicidal or self-mutilating behavior covered in (5).

5.Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. This can be manifested as overt suicide attempts, drug or alcohol abuse, unsafe sexual behavior, or as a pattern of “living dangerously”; this also includes cutting, burning, piercing, and sexual self mutilation.  

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. (People with BPD are intensely moody and volatile emotionally – mood swings and huge shifts occur seemingly “out of nowhere”. This is why people with BPD are often misdiagnosed as having Bipolar disorder, and therefore improperly medicated.)

7.Chronic feelings of emptiness. (Generally manifested as sadness, loneliness, isolation, aimlessness, feeling empty without a project or relationship to distract them.  People with BPD’s low self esteem is often masked by public displays of ego, feelings of superiority or an intense need to  control themselves, other people, places and events.)  

8.Inappropriate, intense anger or difficulty controlling anger
e.g., frequent displays of temper, uncontrolled anger, violent rages,  recurrent physical fights, threats, sexualized expression of anger through violent or abusive sex.

9.Transient, stress-related paranoid ideation or severe dissociative symptoms.
(BPD may manifest as a belief that those who love them wish to hurt, control or destroy them. This is especially common in times of stress. Ongoing belief that they are being followed, threatened, observed or are always at risk. BPD’s see the world as a dangerous and frightening place and remain constantly on guard, even in safe environments and with safe people.)    

Though BPD affects nearly as many people as schizophrenia and bipolar COMBINED; it is greatly misunderstood by lay people and therapists alike. Few mental health professionals receive enough preparation in school to be effective in treating patients with this disorder. Few clinicians are aware of non-BP issues. (The issues of the Person with BPD’s partner.)  People who work in the legal system and other institutions desperately need to be better educated about BPD.

People with BPD often “mask” well - meaning that they present a “I have it all together” face to the world, at work and to their therapists.  People with BPD are often very charming, funny and engaging when they are not suicidal or raging.  They work hard at covering their tracks; generally only those who are very close to them are aware of the emotional roller coaster going on inside. People with BPD frequently project their issues onto others. (“I don’t have a problem – YOU have a problem.”)   As a result, people with BPD often live lives of misery, remaining undiagnosed or misdiagnosed. (and therefore improperly treated.)   Borderline personality disorder is very painful for both the person with BP and the people in their life. 

Borderline Personality Disorder is treatable with conventional therapy, geared toward impulse control, anger management and behavior modification, and also responds well to proper medication. (The misdiagnoses of BPD as Bipolar Disorder is very common – and generally leads to improper medication.)

Sadly – the overwhelming internal chaos, fear and shame often result in People with BPD refusing treatment.  Treatment for BPD is a long term process, but can lead to a much better quality of life for the Person with BPD and their partners and families. 

“The features associated with a good outcome were likableness, orderliness, high intelligence, and musical or artistic talent.

Poor outcome was associated with  antisocial tendencies, chronic irascibility, extreme shyness, chaotic impulsiveness, and refusal of treatment for drug or alcohol abuse.”

- By Michael H. Stone “The Fate of Borderline Patients“
The Harvard Mental Health Letter, March 1992

BPD seems to be highly  triggered by entering a relationship, possibly because a greater feeling of safety allows them to let down their guard and drop the mask with their partners.  (Note that I say “greater feeling of safety” – People with BP tend to be  hypervigilant and NEVER feel safe, remaining on guard at all times.)  Relationships bring intimacy issues and fears bubbling to the surface in all people, this seems to trigger the BPD symptoms and acting out. People with BPD are often highly abusive in relationships, yet do not see or fail to recognize / take responsibility for their behavior. (The person with BPD’s behavior is a defense mechanism against overwhelming internal pain and chaos; it therefore seems normal and justified to them.)  

People with BPD tend to have a repetitive series of short, intense, drama driven relationships. They typically worship and adore their partner in the beginning, then shift to seeing the partner as the source of their problems and the “root of all evil”. They frequently fail to see their role in the cycle, and often project their issues onto the partner.  People with BPD often have relationships which collapse in rage, bitterness and chaos once the devaluation part of the splitting cycle kicks in.

BPD generally coexists with other illnesses. These are the most common. 

• Post traumatic stress disorder
• Mood disorders (Bipolar Disorder, Unipolar Depression, other Affective Disorders.)  
• Panic/anxiety disorders
• Substance abuse (54% of people with BPD also have a problem with substance abuse)
• Gender identity disorder
• Attention deficit disorder
• Eating disorders
• Multiple personality disorder or Dissociative Identity Disorder. 
• Obsessive-compulsive disorder

Statistics about BPD

2% of the general population
10% of all mental health outpatients
20% of psychiatric inpatients
75% of those diagnosed are women (Note that this does not mean 75 % of people with BPD are women!)
75% have been physically or sexually abused

More about BPD – by Richard Corelli, MD.

*Author’s Note – I theorize that Religious and Political Fundamentalism are cultural manifestations of BPD, in effect a collective mental illness.    These political and religious movements are characterized by many of the definitive symptoms of BPD, but manifested at a group level. (Rigidity, intense need for control, black and white world view, splitting into all good and all bad, demonization of perceived enemies, and the punitive nature of these political / religious movements all strike me as being highly characteristic of the symptoms of BPD.) [Back to DSM]