What Makes Borderline Personality Disorder So Challenging?

Battle lines are drawn in her head each side ready to attack the other at a moment’s notice.  On one side, her inner critic waits not-so-patiently to judge. Her inner critic judges harshly when she ridicules her best friend or takes a stranger home from the bar, when she cuts or quits yet another job after a month.  To the inner critic in her head, the list to be judged is seemingly endless. 

On the other side, the impatient teenage part of her argues “you can’t tell me what to do” or “I’ll show you” or “I want what I want when I want it.”  But underneath the bravado, the rebellious teen cowers at the criticism, wondering what’s wrong with me.  “Why can’t I do anything right?” or “Why am I so stupid?” or “Why am I unlovable?”

All the while, the wounded inner child deep in her being hides, trying to avoid getting caught in the middle of yet another argument.   Frequently, she checks out, dissociating to keep out reminders of past pain. More than anything, she fears abandonment.

She is frequently out of her window of tolerance with wild swings between the hyper-aroused rebellious teenager and the hypo-aroused, sometimes dissociated, wounded inner child.  Her inner critic keeps the cycle going.  She has borderline personality disorder (BPD).

A Different Lens on Borderline

An article on the website HelpGuide.org describes life with Borderline Personality Disorder (BPD).  She lives on “shifting sands – the ground beneath her feet constantlychanging and throwing her off balance, leaving her scared and defensive.” This same article explains she“probably feels like she’s on a rollercoaster—and not just with her emotions or relationships, but her sense of who she is.” She is “extremely sensitive.” Her emotions feel like an “exposed nerve ending … small things trigger intense reactions.” Once upset, she has a hard time calming herself. The emotional volatility and inability to self-soothe lead to relationship problems and impulsive, reckless behavior.  Shame and guilt follow.    

She has a nascent wise mind that has the potential to begin the healing process but doesn’t yet have the awareness and skills to tolerate distress, regulate emotions or interact effectively with others.  DBT offers the opportunity to learn and practice healing awareness and practical skills.  Research on treating borderline personality disorder with DBT has shown dropout rates improve, hospitalizations and emergency room visits decrease, suicidal and self-harming behaviors decrease, substance abuse and other addictive behaviors decrease and quality of life indexes improve.  While DBT is not effective for all clients with BPD, it helps most participants move closer to a life worth living.  

Estimates of BPD Prevalence in the St Louis Area

NAMI reports the prevalence of BPD is between 1.6 and 5.9 percent. At six percent, that’s an estimated 129,000 adults in the St. Louis metropolitan area with BPD.  At two percent, more than 40,000 adults in the metro area are living with the misery of BPD.

BPD Under-Treated

At the 1stInternational Congress on Borderline Personality Disorder in 2010 in Berlin, it was reported 40 percent of clients with BPD received no treatment while 50 percent were treated only by their primary care physician in the last 12 months. Just nine percent were in therapy. Less than one percent were hospitalized. 

Assuming two percent prevalence in the St. Louis metropolitan area, an estimated 17,000 adults with BPD likely had no treatment in the last 12 months.  Some 21,000 adults were treated only by their primary care physician. Adults with BPD most likely to seek therapy had significant co-morbidities. BPD accounts for about one in ten outpatient therapy clients and one in five inpatient hospitalizations.

Diagnostic Criteria for BPD

While significant changes were proposed, DSM-5 left diagnostic criteria for BPD essentially unchanged from DSM-IV-TR.  People with BPD exhibit four types of behavioral disturbances: (1) poorly regulated and excessive emotional responses; (2) harmful impulsive actions; (3) distorted perceptions and impaired reasoning; and (4) markedly disturbed relationships.  To diagnose BPD, there must be apervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulth ood and present in a variety of contexts, as indicated by five (or more) of the following:

• frantic efforts to avoid real or imagined abandonment 

• a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

• identity disturbance: markedly and persistently unstable self image or sense of self

• impulsivity in at least two areas that are potentially self-damaging (e.g., excessive spending, substances of abuse, sex, reckless driving, binge eating). 

• recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

• affective instability due to a marked reactivity of mood (e.g. intense episodic state of unease or generalized dissatisfaction with life, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

• chronic feelings of emptiness

• inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper tantrums, constant anger and reoccurring fights).

• transient, stress-related paranoid ideation or severe dissociative symptoms

A Challenging Diagnosis

BPD is difficult to diagnose.  BPD symptoms overlap with other illnesses and high rates of co-occurring disorders create challenges for proper diagnosis and treatment. According to data from the NIMH-funded National Comorbidity Survey Replication, about 85 percent of people with BPD also meet the diagnostic criteria for another mental disorder, including:

61 percent also have at least one anxiety disorder, most commonly a specific phobia, or social phobia

49 percent have an impulse-control disorder, most commonly intermittent explosive disorder

38 percent have a substance abuse or dependence disorder, most commonly alcohol abuse or dependence

34 percent have a mood disorder, most commonly mild chronic depression or major depression.

Men Under-Diagnosed

About three-quarters of adults diagnosed with BPD currently are women.  There is growing evidence that men are under-diagnosed, most frequently misdiagnosed with PTSD or major depression.  Recent research suggests male and female late teens are diagnosed with BPD in roughly the same proportions.  Research is needed to determine if adult prevalence of BPD in men and women is similar.

Risk Factors for BPD

According to a 2010 blog by the director of the National Institute of Mental Health, the causes of BPD are not yet clear but research suggests genetic, brain disturbances and environmental factors are likely involved.

Genetics.BPD is about five times more likely to occur if a person has a close family member (first-degree biological relative) with the disorder.

Environmental and Social Factors.Many people with BPD report experiencing traumatic life events, such as abuse or abandonment during childhood. Others may have been exposed to unstable relationships and hostile conflicts. However, some people with BPD do not have a history of trauma. And, many people with a history of traumatic life events do not have BPD.

Brain Factors. Studies show that people with BPD have structural and functional changes in the brain, especially in the areas that control impulses and emotional regulation. However, some people with similar changes in the brain do not have BPD. More research is needed to understand the relationship between brain structure and function and BPD.

BPD Can Be Treated Effectively

Myths about people with BPD make it less likely people with BPD will seek treatment.  Perhaps, most harmful is the myth that BPD can’t be treated and that emotional dysregulation is a life sentence.  This simply is not true.  It is true that brief treatments do not work. Rather, long term treatments are needed to help people with BPD create a life worth living.  Developed in the 1970s by Marsha Linehan and colleagues, evidence-based DBT is generally considered the “gold-standard” of BPD treatments but other treatments can also be effective.  

There are other debilitating myths about people with BPD:  For example, their manipulation is mean-spirited; they self-harm and makes suicidal gestures to get attention; and they don’t want to get better. While it can be challenging for family, friends and professionals to deal with the mood swings and volatility of someone with BPD, the following assumptions underpinning DBT can make the challenge easier.  These assumptions also make treatment more likely to succeed.

DBT Assumptions Make Treatment More Likely to Be Effective

People with BPD are doing the best they can.  When family, friends and professionals validate people with BPD are doing the best they can, they feel heard and understood.  If the person with BPD still makes poor choices, then helping them make better choices involves coaching them through the chain of events to identify more effective ways to achieve their goals and generate natural consequences without further stigmatizing them. 

People with BPD want to improve.Assuming people with BPD want to improve makes it more likely they will be motivated to improve.  When family, friends and professionals assume they don’t want to improve, they invalidate their efforts to improve, sending the message that nothing they do is good enough.  An important way to reinforce their desire to improve is to validate what they do effectively rather than focusing on what they fail to do.  Validation motivates.  Validation also provides evidence of others’ willingness to see things from their perspective, thus strengthening trust.

People with BPD need to do better, try harder and be more motivated to change.If people with BPD want to improve, then they want to become more effective over time, learning from their poor choices.  In this context, expecting people with BPD will learn from their poor choices and try harder, do better and be more motivated next timeis only reasonable. That said, this is an area where it is important for others to follow the middle path, not pushing too hard or expecting too little.

People with BPD may not have caused all of their own problems, but they have to solve them anyway.  If the person with BPD was abused and abandoned as a child of there is a family history of BPD, it is understandable that they developed BPD.  As an adult, however, the person with BPD is the only person who can solve his or her own problems.  Blaming the abuser of family members will not solve the problems even if it is unfair.

The lives of people with BPD are painful as they are currently being lived.Having BPD, often with serious co-morbidities, is not something anyone would choose.  When someone with BPD says they are miserable, they are not trying to manipulate you; they are in pain.  That’s not to say they can’t improve their situation with nurturance and guidance but change starts by addressing the pain that they are currently living.

People with BPD must learn new behaviors in all important situations in their lives. Without lifelong learning, humans stagnate.  To flourish, people with BPD must be encouraged to learn from every situation they encounter.

There is no absolute truth.There are at least two sides to every story.  When family, friends and professionals assume they are (always) right, there is no room for give and take in the relationship and no room for learning how to make good choices.

People with BPD and their families, friends and professionals should start with the assumption that most people are well-meaning rather than assuming the worst.It’s hard to have a productive discussion if you assume the worst about the person with BPD or they assume the worst about you.  Everyone will save themselves a lot of misery by assuming others are well meaning.

People with BPD cannot fail DBT.DBT is about being more or less effective, not right or wrong.  DBT doesn’t have any tests; it is a set of skills that require practice, practice, practice.  Even after practicing a lifetime, there will still be room for improvement.

Sandra Miller, MSW, LCSW and sometimes blogger, sees clients at St. Louis DBT, LLC.