National Borderline Personality Disorder Awareness Month

Borderline Personality Disorder is a serious, impairing mental illness.  One out of every 50 people in the general population and one out of every five psychiatric inpatients suffer from this disorder [1].  One out of every ten people with BPD commits suicide [2].

I have collected some more specific information about this illness below.  I caution you against self-diagnosing, however if you have any concern about these symptoms and your mental health, please see a specialist, whether it be a psychologist, psychiatrist, social worker, or your primary doctor.  Your emotional and mental health is invaluable and it never hurts to get a professional evaluation.  No matter what troubles you, you are not alone.

The American Psychiatric Association’s guide––the Diagnostic and Statistical Manual of Mental Disorders, fourth revision (DSM-IV)––defines this disorder and lays out criteria for diagnosis.  “A personality disorder,” according to the DSM-IV, “is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” BPD in particular is marked by “a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.”  Below are the diagnostic features of BPD:

Individuals with Borderline Personality Disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this “abandonment” implies they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.

Individuals with Borderline Personality Disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations.

Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with Borderline Personality Disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Completed suicide occurs in 8%–10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil.

Individuals with Borderline Personality Disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses. Individuals with Borderline Personality Disorder may be troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.”

One psychiatrist I spoke with advocates replacing the troubled term with “Emotional dysregulation disorder.”  Emotional dysregulation is the inability to properly modulate emotional responses, causing many problems, principle among them volatile interpersonal relationships, black and white thinking, and self-harm.  He argued that the stigma around the term “borderline” is not only hurtful to patients but that it inspires hopelessness in clinicians (BPD was long viewed as untreatable). When first labeled, psychologists viewed BPD as a disorder on the “border” between neurosis and psychosis, although this viewpoint is somewhat inaccurate, and more importantly, misses the primary feature of this disorder, namely the difficulty in modulating emotions.  I’ve heard that the DSM-V may introduce a new name however the current proposal still uses the old term.[3]

[1] Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision), Ch. 16

[2] Johnson, P. et al. “Understanding Emotion Regulation in Borderline Personality Disorder: Contributions of Neuroimaging” http://neuro.psychiatryonline.org/article.aspx?articleID=101828.

[3] http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=17#

Note: The World Health Organization is the only other major institution to attempt to define this disorder.  I personally find their description inadequate, but I include it here for further reading.

The World Health Organization defines BPD as a subtype of “Emotionally unstable personality disorder.”  The tenth revision of theInternational Classification of Diseases (ICD-10) defines EUPD as “a personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others.”“  In addition, those diagnosed as borderline may experience further symptoms: “…[T]he patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).”