What is Borderline Personality Disorder (BPD)? Part 1: The Science & Development Part 2: Presentation & Treatment
What Is Borderline Personality Disorder (BPD)? Part 2:
The next section is repeated from Part 1 so this blog can be stand alone. If you read Part 1, please skip it. Here is a basic BPD symptom list to ensure memory.
Basic Symptom List-
Fear of Abandonment, Unstable Relationships, Identity Disturbance, Impulsive Behaviour, Self-harm or Suicidiality, Affective Instability, Chronic Emptiness, Intense Anger, Stress-related Paranoia or Dissociation
Borderline Personality Disorder (BPD): Definition
The Diagnostic and Statistical Manual (DSM) that is used to diagnosis mental health concerns defines Borderline Personality Disorder as:
The 9 Diagnostic Criteria
Fear of Abandonment: Frantic efforts to avoid real or imagined abandonment.
Unstable Relationships: A pattern of intense, turbulent relationships that shift between extremes of idealization and devaluation (often called "splitting)
Identity Disturbance: A markedly and persistently unstable self-image or sense of self.
Impulsive Behavior: Engaging in self-damaging acts in at least two areas, such as reckless driving, unsafe sex, substance abuse, binge eating, or overspending.
Self-Harm or Suicidality: Recurrent suicidal behavior, threats, gestures, or self-mutilating behavior.
Affective Instability: Rapid and intense mood swings or emotional reactivity, with episodes typically lasting a few hours and rarely more than a few days.
Chronic Emptiness: Persistent, deep feelings of emptiness or worthlessness.
Intense Anger: Inappropriate, intense anger or trouble controlling temper, including frequent physical fights or constant bitterness
Stress-Related Paranoia or Dissociation: Transient, stress-induced paranoid thoughts or severe feelings of unreality and detachment.
What stands out for me, as a clinician, is affect regulation and abandonment fears, including how abandonment fears impact relationships.
For those of you who have read about Attachment Styles, this may sound similar to Anxious Attachment Style and there certainly is overlap. However, think of BPD as far further along of the continuum, abandonment fears more extreme as well as only one of other symptoms, seen above. See BPD Part 1
Borderline Personality Disorder: Presentation or How It Shows Up
I recently posted some videos about BPD on social media that got some controversial responses. Borderline Personality Disorder (BPD) often gets a strong response by those who feel they have been hurt and abused by a person with the disorder. However, the personal presentation is extremely varied.
I feel one of my many roles is to bring compassion and understanding to mental health struggles, and of course, please stay safe and expect good treatment from others.
The stereotype simply does not always hold up. Many people who struggle with BPD internalize and isolate their emotions and anxious attachment fears, masking really well.
There are sufferers that are extremely high functioning. They may be a charismatic colleague. They may be overly concerned with their physical appearance. There are those that have well-managed symptoms and have extensive self-insight into their triggers.
Triggers can be very specific and only show up in very close relationships where the anxieties are intense and seemingly uncontrollable.
This can be a partner that is anxious, jealous, demanding and even seem to “make up” situations that you don’t feel are in any way accurate, they almost seem paranoid. There can be intense fear of loss and related intense mood swings.
Men with BPD are more likely to have a more criminal or anti-social presentation. They may be dangerous.
What is important to remember is the variability of this presentation. I have met people that complain of feeling completely out of control with intense affect and related behavior (ex. Self-harm) including demands on others that are very hard on their closest people. There can be a victimized stance or an aggressive one, vacillating between the two.
Yes, there are extreme cases with both intense affect and strategic, manipulative behaviour, including various forms of abuse. There are those that largely live in a combative cycle, constantly attacking/fighting with really low vulnerability tolerance, and therefore, seem easily triggered to anger or upset.
What stands out for me is that most people with BPD need help with affect regulation. Their feelings feel huge. If these are managed, other behaviours and symptoms are as well.
There is also an attachment piece where fears escalate as they get close to other people and they need to work hard to manage these fears of loss and exposure (feel vulnerable in connection). The emotional intensity can be a lot to witness in another person.
This varied presentation is due, in apart, to whether a person has managed or unmanaged BPD. It often develops in the teenage years due to biological development. Our brains completely mature by the age of 25. As we get older, we learn to manage symptoms. All of these above factors help change the presentation over time.
So how can we manage it? How can we heal the trauma from childhood and even the traumas of living with BPD?
Borderline Personality Disorder: Treatment and Management
It is best to have a circle of care, a varied plan to treat Borderline Personality Disorder, optimally.
If it is unmanaged initially, a psychiatric assessment may be needed to begin creating a window of tolerance with medication. This would create enough emotional stability to allow for learning new things.
The next step may be vulnerability tolerance in a therapy setting. Simply learning to sit in closeness and work through what comes up. Ex. Anger and discomfort due to over-sensitivity, fear. It may feel like nothing will help.
Dialectical Behavioural Therapy groups are really effective to learn affect regulation techniques. This will continue the management of symptoms. This is a technique-based therapy that controls a big feeling(s) enough to bring the neocortex back online. This calmer state allows for making new, healthier choices and getting needs met in a way to facilitate further intimacy. DBT Group
As this symptom management becomes a new, healthy pattern, healthier intimate relationships are also possible. Every new social/intimate situation that is navigated successfully allows the brain to rewire and restructure. As this happens, change becomes easier.
Once stabilization is attained it is possible to begin the deeper healing of the trauma(s) that helped the development of BPD in the formative years.
This begins with creating a strong working relationship with a therapist that is both trauma-specialized and treats personality disorders. Personality Disorders
The identification of traumatic memories, situations &/or relationships that will need to be processed from the amygdala through the neocortex is a necessary step.
Why? This manages trauma symptoms link blog and ensures further, deeper affect regulation of triggered feelings.
A few things are important to note. I want you to choose the right therapist so you trust them and the therapeutic process. Therapy is hard and you both need someone who gets that and knows how to pace it for you. You have to trust they will be consistent and reliable, this is where healing happens. You also need to be able to tell them when you are upset or triggered so you can work it through together.
I also want to see your therapeutic work include bodywork. When memories and feelings get stuck in the amygdala, they wreak havoc on your visual centres’ and central nervous system. Figure out what works for you during this powerful time.
What about free movement dance?
Can meditation begin a lifelong taking care of your CNS?
Would you consider immersing your hands in clay and learn to make pottery?
A daily yoga practice?
Somatic techniques can be incorporated into you therapy sessions. Your therapist can use somatic exercises to connect you to your body and the sensations that come up. Art and drawing can access different pieces that are frozen as well. Sandtray therapy is a gentle, powerful way to access the unconscious. There are myriad ways to heal this important piece. Want more on specifics on therapy techniques and what one is right for you? Trauma & Treatment Blog
Healing trauma is a long-term process as it includes rewiring and restructuring the brain to expect different narratives in your life. This takes time. It is also worth it to get the life and relationship you deserve. Want more information on trauma therapy treatment options? Trauma Treatment Blog
The perfect circle? In no particular order:
A Psychiatrist
A supportive Family Doctor GP
A Psychotherapist/Social Worker
Great friends that get mental health struggles
Healthy relationships with family, even if that means distance.
A partner that sees you and works on insecurities with you, but expects to be treated well too.
A DBT group that is working the program together.
Time alone to self-reflect and practice the ongoing emotional processing of big feelings.
In Conclusion:
There is help. It is not hopeless. BPD can be managed and managed well. Find a careplan that works for you.
Lisa S.
