Borderline Personality Disorder (BPD) is a disorder of instability or chaos. BPD is a pervasive pattern of instability across contexts of self, emotions, relationships and world view. For those suffering BPD, little in life is stable and predictable, and managing daily emotions can become an overwhelming experience. BPD typically begins development in adolescence and has been considered a life-long condition. BPD is notoriously difficult to treat and has required regular, long-term therapy to reduce the chaos and bring normal functioning. BPD is an incredibly difficult disorder to live with, for the sufferer and loved ones.
Symptoms of BPD can include:
- Impulsivity: in relationships, spending, substance use, driving or eating for example
- Strong fears of abandonment and efforts to avoid it: this may include pushing away those closest in an effort to end the relationship before it can be ended, or becoming obsessional, clinging and jealous in efforts to keep the relationship
- Identity disturbance: an unstable self-image which may shift as regularly as several times within an hour, and even regress to a more childlike state of helpless
- Suicidal behaviour: such as gestures, threats or self-harming behaviour
- Emotional instability: strong reactivity in mood, sensitivity to criticism, irritability and shifts in mood frequently
- Chronic feelings of emptiness
- Anger issues: intense, inappropriate anger with lashing out
- Temporary paranoia or dissociation
For those living with BPD, life can be unbearable. While there are occasions of intense happiness, there are many times of intense lows. BPD can be characterised as uncontrollability, while others may be able to manage emotions and relationships with effort, for those with BPD, control over the self is not achievable. Insight into the self and our thoughts and behaviours is needed in order to contain and manage behaviours which may hurt others or drive them away, for those with BPD, this insight is lacking or difficult to come by.
Reputation
BPD as a disorder has developed a strong, negative reputation. Typically, BPD sufferers present more to emergency wards than other mental health disorders, and receive little benefit from mental health wards. BPD sufferers will often present to hospitals for self-harm and suicidal ideation, and as a result, hospitals are typically harder on BPD patients, discharging them from hospitals as soon as possible. People with BPD require more empathy and understanding from those around them, and so are usually left with bad experiences and feelings of being misheard or misunderstood from these hospital experiences. If you have BPD or know of someone with BPD, it is important to understand this experience and minimise hospitalisation where possible as these bad experiences may worsen BPD symptoms and lead to more self-harm or suicidal behaviour.
I will typically ask clients who have received a diagnosis of BPD to not google the disorder as it can be very confronting or traumatising to read the bad press on the condition, and is not helpful to recovery. I would prefer clients come and speak to me about it in person so the negative reputation can be minimised, and understanding and empathy be the focus.
Emotions
Empathy is a skill taken for granted by most, while those with BPD can have empathy, the internal struggle and instability of self and environment is so overwhelming it becomes incredibly difficult to consistently consider others and the impact of behaviour on them. Projection will often get in the way of true empathy for sufferers of BPD, whereby their own, avoided emotions (such as anger) will become projected onto the other person, and they will respond as if the other person is displaying their emotion (such as becoming hostile or helpless to perceived anger). This projection makes it hard for others to get close, as any attempts to bypass projected emotions will increase projection.
Relationships
Speaking of others, relationships with sufferers of BPD are difficult for everyone involved. The sufferer of BPD is battling internal thoughts and feelings constantly vigilant for abandonment, while the attachment figure must also manage possible paranoia, projection and efforts to push/pull them. For friends of the BPD sufferer, similar issues apply, while it may be easier to manage boundaries in the friendship than a romantic or parental relationship, the friendship may also become drained due to the chaotic emotions and problems which will continuously present. Breakdowns in relationships will unfortunately only further beliefs of abandonment, issues in trust and further instability in views of self, relationships and the world.
Treatment of BPD
Treatment of BPD is typically long-term. The instability present in the disorder means
sufferers will often struggle to manage regular appointments, and treatment may be focused on crises which present at the time rather than coping skills which are needed for the emotional struggle. The most effective treatments for BPD are Dialectical Skills Therapy (DBT) which focuses on training specific skills in addition to individual therapy. DBT is traditionally delivered as a group treatment for skills, alternating between modules of mindfulness skills training which assists coping, and modules of distress tolerance, emotion regulation and interpersonal skills. The group is delivered in conjunction with weekly individual therapy which focuses on individual issues and skills coaching.
Intensive Short-Term Dynamic Psychotherapy (ISTDP) has also been shown to be effective with BPD, focusing on the emotional experience of the sufferer and restructuring their experiences, thoughts and behaviours in a graduated format. In this manner the sufferer is gradually able to cope with stronger emotional experiences, as well as reflect internally and gain conscious control over behaviours through isolating affect (thinking about feeling) so they do not become “ruled” by the feelings. ISTDP directly works with defensive behaviours such as projection which can lead to relationship and treatment breakdown, and offers a neutral approach which emphasises understanding and appreciation of difficulties.
If you believe you or a loved on suffers from BPD and would like further information on the disorder, or would like treatment for BPD, please consider making an appointment to discuss it with myself. I have experience working with BPD and have seen significant progress with my clients suffering BPD over treatment.
References:
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Publishing, Inc.
- Linehan, M. (2015). DBT skills training manual. New York, NY: The Guilford Press.
