Borderline Personality Disorder (BPD) is a complex mental illness that is both historically and presently met with widespread misunderstanding among the general population. Due to the distinctive nature and high intensity of symptoms associated with the diagnosis, those who suffer with BPD are often stigmatized and judged even within medical and mental health settings. The intensity of an individual with BPD’s emotional experience is often difficult for people to understand, resulting in interactions based on judgment and emphasis on behaviors exhibited, often missing the pain the individual is trying desperately to cope with.
Along with this confusion, there are numerous and intricate ways BPD presents itself. This disorder also rarely stands alone since research indicates a high rate of co-occurrence with other mental health disorders including major depression, bipolar, PTSD, anxiety, eating and substance use disorders which make misdiagnosis common.
Too often, the enormous strength and resiliency these individuals bring to their daily struggle of coping with the disruptive and painful symptoms is missed. My goal with this article is to shed light on the many complexities of this challenging mental health struggle that impacts close to two percent of the world population (about 140 million people).
What is Borderline Personality Disorder?
A person who struggles with BPD commonly exhibits five areas of dysregulation:
- Emotion dysregulation
- Behavioral dysregulation
- Cognitive dysregulation
- Interpersonal dysregulation
This means that the individual struggles to understand and manage their automatic emotional reactions which in turn leads to negative thought distortions, feelings of disconnect and mood-dependent behaviors that inadvertently negatively impact their sense of self and those around them causing relationships to become intense, chaotic and unstable.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), BPD is diagnosed based on (1) a pervasive pattern of instability of interpersonal relationships, self-image, and mood affects, and (2) marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following for a minimum of 6 months:
- A pattern of intense and unstable interpersonal relationships
- Frantic efforts to avoid real or imagined abandonment
- Identity disturbance or problems with sense of self
- Impulsivity that is potentially self-damaging
- Recurrent suicidal or self-injurious behavior
- Affective instability
- Chronic feelings of emptiness
- inappropriate, intense or uncontrollable anger
- Transient stress-related paranoid ideation or severe dissociative symptoms
How Does BPD Develop?
The biosocial theory defines BPD as primarily the dysfunction of an individual’s emotion regulation system which results from a combination of two distinct components: A predisposed biological sensitivity to emotion AND a consistent invalidating environment. This combination is transactional therefore occurs repeatedly within the person’s life which ultimately triggers development of BPD.
Simply put, some individuals are born with their brain wired to respond with heightened reactivity when experiencing emotions.
Such individuals feel emotions more strongly than the average person and have extreme difficulty calming emotions down. Contrary to the neurotypical brain, these individuals are born with a small or underactive anterior cingulate in the frontal cortex. This portion of the brain is what assists in regulating or “pumping the brakes” on emotions, and it is less functional in a person with BPD. Due to this, the person with BPD is often flooded by emotion even if they “know” the situation does not make sense. The experience is very real to them. Within this confusing emotional state, they often look to others, rather than themselves, for an accurate reflection of reality. Those around them do not understand this natural vulnerability therefore unintentionally (and occasionally intentionally) lead to patterns of invalidation over time.
An invalidating environment isn’t necessarily one in which the individual is the subject of abuse, neglect or trauma which is a common misconception about BPD. Even the most well-intentioned families and environmental groups can be invalidating by ignoring, ridiculing, denying, or judging a person’s feelings, especially because they do not understand the individual’s predisposed biological vulnerability to emotion. The environment sees the individual’s emotional reactions as socially unacceptable characteristics or personality traits, such as “dramatic”, “too much” or “crazy”. Therefore, those who grow up in an invalidating environment learn to believe that their actions, thoughts, and feelings don’t matter or don’t make sense due to the reaction of those around them.
An environment of invalidation maintains and may exacerbate the biological sensitivity of the individual which leads to a self-fulfilling prophecy (BPD individual amps up emotions and behaviors in order to be taken seriously leading to increased invalidation from environment due to perceived “overreaction” or, at times, “manipulation”).
This environment also may intermittently reinforce the escalation of such emotional displays leading to heightened confusion and an inability for the BPD individual to build their own inner compass and skills to manage emotions and connect with others.
For example, an individual may yell at the top of their lungs to be heard. Some times the environment responds with concern and comfort, and at other times it responds by withholding warmth and over-simplifies the ease of problem solving, (ex: “Just get over it,” pr “It’s not that big of a deal.”)
How Do You Treat BPD?
Dialectical Behavior Therapy (DBT) is an intensive outpatient treatment program developed by Dr. Marsha Linehan and is considered the gold standard of treatment for those diagnosed with BPD and/or struggling with BPD traits among other diagnoses. DBT focuses on teaching skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
A year-long structured program under the umbrella of cognitive behavioral treatment, DBT uses a combination of weekly individual therapy, weekly group skills-training and crisis phone coaching to help develop a life where emotions do not rule thoughts and behavior. These components work together to teach behavioral skills that target common symptoms of BPD, including an unstable sense of self, chaotic relationships, fear of abandonment, emotional lability, and impulsivity such as self-injurious or suicidal behaviors. Many of the treatment interventions are focused on a combination of behavior change and acceptance.
Pine Rest is home to three fantastic DBT teams. The teams at the Northwest Clinic (located in Walker) and the Traverse City Clinic serve both adolescents and adults. The Caledonia Clinic team provides an adult program.
Hope for Those Who Struggle with BPD
Dialectical Behavior Therapy (DBT) has been empirically proven time and time again to be effective for individuals and families struggling with BPD. It has the power to transform lives for not only for those struggling with BPD but also for those who love and support them. Through psychoeducation and skill-building, individuals can grow in understanding, find self-compassion and gain access to choose and have control over their thoughts and behaviors, ultimately leading to a decrease in suffering and working towards goals of building a life worth living.