A Closer Look At Borderline

Borderline Personality Disorder (BPD) is one of the most stigmatized and misunderstood mental health diagnosis. The harsh stereotypes with this diagnosis often interfere with the patient’s ability to get their treatment needs effectively met. BPD is largely characterized by pervasive instability in relationships, challenges in sense of self, rapid mood cycling, impulsivity and self-harming behaviors. The extent and intensity of these traits can often be frustrating and at times stressful for treating practitioners as well as the individual’s natural supports; however it is important to remember that individuals with BPD are truly feeling trapped in a cycle of overwhelming emotions which keeps them in survival mode and inhibits thriving.  

There are 9 criteria to BPD and an individual must meet at least 5 of the 9 criteria to qualify for the BPD diagnosis. BPD is often confused with Bipolar due to rapid mood cycling and impulsivity. While an estimated 20% of individuals diagnosed with BPD are also diagnosed with bipolar, BPD continues to be mistaken for Bipolar. While many individuals with BPD often have a comorbid diagnosis such as major depression, eating disorders, substance abuse or generalized anxiety, emotional distress resulting from BPD is more than a neurochemical imbalance, it is also rooted in pathology.

What Does BPD Look Like

To understand BPD we have to break-down the core characteristics. A major challenge of individuals with BPD that leads to excessive emotional dysregulation is an unstable image of self. Individuals with BPD struggle to have a consistent sense of self. Their self-image often swings from all positive to all negative. This all or nothing thinking pattern often transfers to seeing the world and others as all good or all bad. Challenges in cognitive rigidity contribute to extreme or intense emotional experiencing that individuals with BPD characteristically suffer from.  This cognitive rigidity not only interferes with emotional resiliency but also increases vulnerability to maladaptive behaviors that escalate or prolong emotional crisis. Individuals with BPD often have difficulty with nuanced thinking and the level they struggle to achieve cognitive flexibility suggests that their overly emotional thinking was born out of a highly stressful or chaotic environment in which their amygdala was frequently activated and frontal lobe access was inhibited.  

Maladaptive patterns of behavior and intense emotionally dysregulation are so often embodied in individual with BPD that we must look at the roots of the development. There is a large body of research that indicates individuals diagnosed with BPD have a high prevalence of trauma in their early development. A study by Bandelow and colleagues (2003) found that 96% of BPD patients reported some form of traumatic childhood experience, which was a statistically significant difference compared to the study’s  control group report of 38.5%. Studies on the relationship between trauma and BPD further illustrate that individual’s diagnosed with BPD specifically report higher rates of early interpersonal trauma such as physical and sexual abuse, family violence, bereavement and parental separation. As our understanding of attachment and trauma expands, BPD is increasingly being referred to as a disorder of attachment. Because attachment is what supports co-regulation and heavily influences the development of self-regulation in the face of stress, early disturbances in attachment are a significant barrier to establishing competency in an individual’s ability to regulate affect and a sense of safety or security in relationships.  

This is not to say that all individual’s exposed to trauma will develop BPD, but rather expose to childhood trauma, particularly relational trauma, increases an individual’s vulnerability to developing BPD symptomology. One of the leading psychologists in BPD research and treatment development, Marsha Linehan, theorized that the development BPD is dependent on an undetermined biological component that makes an individual’s nervous system more sensitive and chronically invalidating or abusive environment in childhood development.

Self-harm and Impulsivity

Individuals with BPD struggle with tolerating difficult emotions and often experience feelings at higher intensity levels. Overwhelming emotions and a frequent lack of support in developing emotional regulation skills often leads individuals with BPD to engage in extreme behaviors in a desperate attempt to change their emotional state. These behaviors often look like excessive spending, impulsive sex, binge eating, substance use and explicit self-harming behaviors like cutting. BPD is associated with high rates of suicidality and self-harming behavior. Studies have shown that up to 20% of patients in a psychiatric setting have a BPD diagnosis. Individuals with BPD often describe using self-harm like cutting to escape overwhelming hurt or dissociative states that often follow episodes of emotional crisis. These extreme methods of coping, particularly self-harm, often inhibit individuals from functioning and achieving important life goals. Long-term, it is impossible to be successful in life goals like parenting or career development when self-harming behaviors are used to manage stress and problem-solve difficult emotions.  Maladaptive behaviors like self-harm often keep individuals from achieving a satisfactory quality of life. Most individuals with BPD are well aware of this issue but feel helpless in the face of their overwhelming emotions and hopeless in the ability to adapt change while struggling so greatly with emotional tolerance. Many individuals with BPD often lack adequate support in improving their ability to cope with stress, however, with the right treatment change is certainly possible even for the most intense of cases.

Treatment

Dialectical Behavior Therapy was developed by Marsha Linehan for individuals with high-risk behavior with a focus on Borderline Personality Disorder. It has been shown to be effective in significantly reducing and even resolving BPD symptoms. DBT is a comprehensive treatment approach that is comprised of 4 modules including Mindfulness, Emotional Regulation, Distress Tolerance, and Interpersonal Effectiveness. At the foundation of many of the DBT tools is balancing acceptance with adapting change. This synthesis of opposites allows patients to directly work on emotions to improve the way they relate and respond to difficult emotional experiences. DBT integrates CBT principles with Mindfulness while emphasizing behavior modification that addresses the nervous system to reduce emotional dysregulation to bring sustainable change to maladaptive patterns that ultimately interfere with an individual’s quality of life or well-being. The Journal of Psychiatric Research has published multiple studies that suggest the implications of DBT can produce real changes in the brain. There is strong evidence that the practices of DBT reduce amygdala activation and increase frontal lobe activity, making us more capable of choosing effective behavior under stress.  If someone you know has BPD or you suspect has BPD and is feeling like their life is out of control, a certified DBT therapist or program can provide the tools and education needed to transition out of emotional chaos and achieve stability.