Understanding Borderline Personality Disorder

Borderline Personality Disorder (BPD) can be very confusing. If you or a loved one have been diagnosed with this disorder, you may have lots of questions about what BPD is, how it's treated, and what to expect.

What do they mean by Borderline?

Many people are (understandably) confused by the name of this disorder. Does "borderline" mean it’s almost a disorder, or does it mean something else? As it turns out, the word borderline is an artifact from an older way of thinking about mental illness.

Psychiatry originally focused on treating a category of disorders called neurosis (from the Greek words for “nerve” and “disorder”), an term used to describe things like depression, anxiety, phobias, and obsessive-compulsive tendencies. To really simplify things, we might think of neurosis as being on the lighter end of mental health issues. These disorders mostly have to do with specific problems that (generally speaking) respond well to treatment.

If neurosis is at the lighter end of the mental health spectrum, then psychosis is at the more severe end. Psychosis (from the Greek words for “mind” and “disorder”) describes a mental break from reality. Again, without getting too technical, people suffering from psychosis typically experience things like hallucinations, delusions, or paranoia.

Around the 1930’s, analysts began to identify a third group of patients who fell somewhere in between neurosis and psychosis. These patients struggled with complex issues but didn't usually lose contact with reality. Because they were deemed to be somewhere in the middle, the term borderline was used. Although much has changed in our understanding and treatment of mental illness, the name lives on.

So what is BPD?

BPD is a personality disorder.  Personality describes a person’s typical way of dealing with the world. Things like your general worldview, how you treat yourself and the people in your life, and the strategies you typically use to solve problems all fall under the heading of personality. So, when psychologists say personality disorder, what they are really saying is that a person’s typical way of dealing with the world is causing problems. Usually, the problems affect both the person and the people around them.

What are the symptoms of BPD?

BPD is usually diagnosed based on a history of problems in three main areas: relationships, self-image, and emotions. In addition, many people with BPD have a tendency to act impulsively (i.e. without thinking things through).

Instability in relationships: People with BPD often have difficulty maintaining stable relationships. Relationship problems can stem from poor boundaries, sudden mood swings, difficulties with trust and communication, and being easily triggered to extreme anger or extreme sadness by certain thoughts or situations. Many people with BPD have extreme reactions to feeling misunderstood, rejected, or abandoned. They may lash out angrily and do or say abusive things. In times of crisis, they may threaten or attempt suicide. Although they usually feel terrible about doing or saying hurtful things after they have had a chance to calm down, people with BPD often feel unable to control themselves when triggered emotionally.

Instability in self-image: Having a stable self-image is an important part of mental health. Whether we are facing good times or bad, we want our sense of self to be balanced. People with BPD have a self-image that is highly reactive to certain situations. They may feel on top of the world when things are going well, but then completely worthless when things don't work out the way they'd hoped. People with BPD may lose the ability to see themselves as worth anything at all when they feel disliked, unwanted, or abandoned by someone important to them. Many people with BPD describe feeling "empty" inside at times. When combined with impulsive behavior, a reactive self-image can lead to self-harm or even suicide. It can also lead to things like substance abuse when the person attempts to use drugs or alcohol to regulate self-image.

Instability of emotions: Another word for emotions is affect. Affect (from the Latin word meaning “to act upon”) describes a person’s emotional reaction to internal or external events, such as thoughts, actions, or situations. People with BPD often have problems with affect regulation, meaning that their emotional reactions tend to be extreme and difficult to control.  It is not uncommon for people with BPD to experience intense emotional reactions that are so quick and overpowering that they feel completely out of control. When combined with impulsive behavior, intense emotions can result in harm to oneself and/or others, recklessness, or destruction of property. Sometimes, people with BPD may cut or burn themselves in an attempt to regulate their powerful emotions. Because of this, helping the person to find less harmful ways of expressing emotions is often a major focus of early treatment.

What causes BPD?

That’s a question that hasn’t really been answered yet. There are lots of theories about how BPD develops, and exploring them would require far more space than I have in this article. Suffice it to say that nobody really knows how a person develops BPD.

How is BPD treated?

People with BPD often experience problems in multiple areas of life. In addition to the BPD, they may struggle with anxiety, depression, substance abuse, or eating disorders.  There is often a history of trauma. Because it can be complicated, BPD takes time to treat effectively. Treatment is often a long-term process, and change comes slowly. This makes treatment difficult because many people seek therapy for BPD when they are in the midst of a crisis. They may be focused only on short-term relief and have difficulty understanding that they are dealing with a long-term problem. As a general rule, effective methods for treating BPD take at least a full year to begin to see lasting improvement. Sometimes, successful remission can take multiple years of treatment. Medication may be used to help with co-occurring conditions, but BPD itself will not typically respond to medication. The only effective treatment is some form of therapy.

One commonly used treatment approach for BPD is Dialectical Behavioral Therapy (DBT), a skills-based treatment model that uses a combination of group instruction and individual therapy. Another effective treatment approach is long-term talk therapy with a therapist who is trained to treat BPD.

Don’t be discouraged!

With treatment, many people with BPD are able to find relief. If you or someone you love has been diagnosed with BPD, the most important thing is to stick with treatment! Recovery takes time. It is often a frustrating and difficult process, but well worth it when you consider the possibility of having more stability and more satisfying relationships with yourself and the people that you care about.

For more information about a related personality disorder, please see my post What is Narcissism?

People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”

― Marsha Linehan