Borderline Personality Disorder
Borderline Personality Disorder Diagnosis: DSM IV Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1) Frantic efforts to avoid real or imagined abandonment.
2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior
5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6) Affective [mood] instability.
8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
*Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association
In-depth look at Borderline Personality Disorder – signs and symptoms, diagnosis, causes, and treatment
Borderline personality disorder is often a devastating mental condition, both for the people who have it and for those around them.
Perhaps shaped by harmful childhood experiences or brain dysfunctions, people diagnosed with borderline personality disorder live in a world of inner and outer turmoil. They have difficulty regulating their emotions and are often in a state of upheaval. They have distorted images of themselves, often feeling worthless and fundamentally bad or damaged.
And while they yearn for loving relationships, people with borderline personality disorder typically find that their anger, impulsivity, stormy attachments and frequent mood swings push others away.
With borderline personality disorder, there is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.
Over the last 10 years, increasing awareness and research are helping improve the treatment and understanding of borderline personality disorder. At the same time, it remains a controversial condition, particularly since so many more women than men are diagnosed with it, raising questions about gender bias. Although definitive data are lacking, it’s estimated that 1 percent to 2 percent of American adults have borderline personality disorder (BPD). It occurs in about one in every 33 women, compared with one in every 100 men, and is usually diagnosed in early adulthood.
Even though a very troubling personality disorder, with consistent help, many with BPD improve over time and are eventually able to lead productive lives.
Borderline Personality Disorder Signs and Symptoms
While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with borderline personality disorder view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.
Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments. In fact, suicide rates among people with BPD are very high, reaching 10 percent.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, self-injury (such as cutting and burning) and other personality disorders.
Because of their risky, impulsive behavior, people with BPD are also more vulnerable to unplanned pregnancies, sexually transmitted diseases, motor vehicle accidents and physical fights. They may also be involved in abusive relationships, either as the abuser or the abused.
Causes of Borderline Personality Disorder
What causes someone to develop Borderline Personality Disorder? Possible causes of BPD include:
- Genetics. Some studies of twins and families suggest that personality disorders may be inherited.
- Environmental factors. Many people with borderline personality disorder have a history of childhood abuse, neglect and separation from caregivers or loved ones.
- Brain abnormalities. Some research shows changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.
Most likely, a combination of these issues results in borderline personality disorder.
How is Borderline Personality Disorder Diagnosed?
Personality disorders are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with borderline personality disorder, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV): pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
- 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., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
- recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- affective instability 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)
- chronic feelings of emptiness
- inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- transient, stress-related paranoid ideation or severe dissociative symptoms
A diagnosis of BPD is usually made in adults, not children or adolescents. That’s because what appear to be signs and symptoms of BPD may go away with maturity.
Risk Factors for Borderline Personality Disorder
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children. Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments, as well as impulsivity and poor judgment in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion.
Treatment of Borderline Personality Disorder
Treatments for BPD have improved. Group and individual psychotherapy are at least partially effective for many patients. Peer reinforcement of appropriate behavior may be more successful than one-on-one counseling because difficulties with authority figures often prevent learning in such situations. Group therapy can also be helpful in modifying specific impulsive behaviors.
A relatively new psychosocial treatment termed dialectical behavior therapy (DBT) has been developed specifically to treat BPD, and this technique has looked promising in treatment studies.
Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and, or, labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.
Is There Self-Help for Borderline Personality Disorder?
Living with borderline personality disorder can be difficult. You may fully realize that your behaviors and thoughts are self-destructive or damaging yet feel unable to control them. Treatment can help you learn skills to manage and cope with your condition.
Other things you can do to help manage your condition and feel better about yourself include:
- Sticking to your treatment plan
- Attending therapy sessions as scheduled
- Practicing healthy ways to ease painful emotions, rather than inflicting self-injury
- Not blaming yourself for having the disorder but recognizing your responsibility to get it treated
- Learning what things may trigger angry outbursts or impulsive behavior
- Not being embarrassed by having this condition
- Getting treatment for related problems, such as substance abuse
- Educating yourself about the disorder so you understand its causes and treatments better
- Reaching out to others with the disorder to share insights and experiences
Remember, there’s no one right path to recovery from BPD. The condition seems to be worse in young adulthood and may gradually get better with age. Many people with the disorder find greater stability in their lives during their 30s and 40s. Their inner misery may lessen and they go on to sustain loving relationships and enjoy meaningful careers.
The Ten Forms of Twisted Thinking
From “The Feeling Good Handbook” by David D. Burns, M.D. © 1989
As you work through your recovery and become more skilled at using The Four Agreements and The Five Steps, you will find yourself becoming more aware of twisted thinking as part of your Borderline view of the world around you. These guidelines of twisted thinking from Dr. David Burns are invaluable to help you as your proceed on your journey of healthy, happy living.
1. All-or-nothing thinking – You see things in black-or-white categories. If a situation falls short of perfect, you see it as a total failure. When a young woman on a diet ate a spoonful of ice cream, she told herself, “I’ve blown my diet completely.” This thought upset her so much that she gobbled down an entire quart of ice cream.
2. Overgeneralization – You see a single negative event, such as a romantic rejection or a career reversal, as a never-ending pattern of defeat by using words such as “always” or “never” when you think about it. A depressed salesman became terribly upset when he noticed bird dung on the window of his car. He told himself, “Just my luck! Birds are always crapping on my car!”
3. Mental Filter – You pick out a single negative detail and dwell on it exclusively, so that your vision of reality becomes darkened, like the drop of ink that discolors a beaker of water. Example: You receive many positive comments about your presentation to a group of associates at work, but one of them says something mildly critical. You obsess about his reaction for days and ignore all the positive feedback.
4. Discounting the positive – You reject positive experiences by insisting that they “don’t count.” If you do a good job, you may tell yourself that it wasn’t good enough or that anyone could have done as well. Discounting the positives takes the joy out of life and makes you feel inadequate and unrewarded.
5. Jumping to conclusions – You interpret things negatively when there are no facts to support your conclusion.
Mind Reading : Without checking it out, you arbitrarily conclude that someone is reacting negatively to you.
Fortune-telling : You predict that things will turn out badly. Before a test you may tell yourself, “I’m really going to blow it. What if I flunk?” If you’re depressed you may tell yourself, “I’ll never get better.”
6. Magnification – You exaggerate the importance of your problems and shortcomings, or you minimize the importance of your desirable qualities. This is also called the “binocular trick.”
7. Emotional Reasoning – You assume that your negative emotions necessarily reflect the way things really are: “I feel terrified about going on airplanes. It must be very dangerous to fly.” Or, “I feel guilty. I must be a rotten person.” Or, “I feel angry. This proves that I’m being treated unfairly.” Or, “I feel so inferior. This means I’m a second rate person.” Or, “I feel hopeless. I must really be hopeless.”
8. “Should” statements – You tell yourself that things should be the way you hoped or expected them to be. After playing a difficult piece on the piano, a gifted pianist told herself, “I shouldn’t have made so many mistakes.” This made her feel so disgusted that she quit practicing for several days. “Musts,” “oughts” and “have tos” are similar offenders.
“Should statements” that are directed against yourself lead to guilt and frustration. Should statements that are directed against other people or the world in general, lead to anger and frustration: “He shouldn’t be so stubborn and argumentative!”
Many people try to motivate themselves with shoulds and shouldn’ts, as if they were delinquents who had to be punished before they could be expected to do anything. “I shouldn’t eat that doughnut.” This usually doesn’t work because all these shoulds and musts make you feel rebellious and you get the urge to do just the opposite. Dr. Albert Ellis has called this ” must erbation.” I call it the “shouldy” approach to life.
9. Labeling – Labeling is an extreme form of all-or-nothing thinking. Instead of saying “I made a mistake,” you attach a negative label to yourself: “I’m a loser.” You might also label yourself “a fool” or “a failure” or “a jerk.” Labeling is quite irrational because you are not the same as what you do. Human beings exist, but “fools,” “losers” and “jerks” do not. These labels are just useless abstractions that lead to anger, anxiety, frustration and low self-esteem.
You may also label others. When someone does something that rubs you the wrong way, you may tell yourself: “He’s an S.O.B.” Then you feel that the problem is with that person’s “character” or “essence” instead of with their thinking or behavior. You see them as totally bad. This makes you feel hostile and hopeless about improving things and leaves very little room for constructive communication.
10. Personalization and Blame – Personalization comes when you hold yourself personally responsible for an event that isn’t entirely under your control. When a woman received a note that her child was having difficulty in school, she told herself, “This shows what a bad mother I am,” instead of trying to pinpoint the cause of the problem so that she could be helpful to her child. When another woman’s husband beat her, she told herself, “If only I was better in bed, he wouldn’t beat me.” Personalization leads to guilt, shame and feelings of inadequacy.
Some people do the opposite. They blame other people or their circumstances for their problems, and they overlook ways they might be contributing to the problem: “The reason my marriage is so lousy is because my spouse is totally unreasonable.” Blame usually doesn’t work very well because other people will resent being scapegoated and they will just toss the blame right back in your lap. It’s like the game of hot potato–no one wants to get stuck with it.
Ten Ways to Untwist Your Thinking
From “The Feeling Good Handbook” by David D. Burns, M.D. © 1989
Now that you’ve identified your twisted thinking, use the suggestions of Dr. David Burns to help you untwist those thoughts.
1. Identify The Distortion: Write down your negative thoughts so you can see which of the ten cognitive distortions you’re involved in. This will make it easier to think about the problem in a more positive and realistic way.
2. Examine The Evidence: Instead of assuming that your negative thought is true, examine the actual evidence for it. For example, if you feel that you never do anything right, you could list several things you have done successfully.
3. The Double-Standard Method: Instead of putting yourself down in a harsh, condemning way, talk to yourself in the same compassionate way you would talk to a friend with a similar problem.
4. The Experimental Technique: Do an experiment to test the validity of your negative thought. For example, if during an episode of panic, you become terrified that you’re about to die of a heart attack, you could jog or run up and down several flights of stairs. This will prove that your heart is healthy and strong.
5. Thinking In Shades Of Grey: Although this method may sound drab, the effects can be illuminating. Instead of thinking about your problems in all-or-nothing extremes, evaluate things on a scale of 0 to 100. When things don’t work out as well as you hoped, think about the experience as a partial success rather than a complete failure. See what you can learn from the situation.
6. The Survey Method: Ask people questions to find out if your thoughts and attitudes are realistic. For example, if you feel that public speaking anxiety is abnormal and shameful, ask several friends if they ever felt nervous before they gave a talk.
7. Define Terms: When you label yourself ‘inferior’ or ‘a fool’ or ‘a loser,’ ask, “What is the definition of ‘a fool’?” You will feel better when you realize that there is no such thing as ‘a fool’ or ‘a loser.’
8. The Semantic Method: Simply substitute language that is less colorful and emotionally loaded. This method is helpful for ‘should statements.’ Instead of telling yourself, “I shouldn’t have made that mistake,” you can say, “It would be better if I hadn’t made that mistake.”
9. Re-attribution: Instead of automatically assuming that you are “bad” and blaming yourself entirely for a problem, think about the many factors that may have contributed to it. Focus on solving the problem instead of using up all your energy blaming yourself and feeling guilty.
10. Cost-Benefit Analysis: List the advantages and disadvantages of a feeling (like getting angry when your plane is late), a negative thought (like “No matter how hard I try, I always screw up”), or a behavior pattern (like overeating and lying around in bed when you’re depressed). You can also use the cost benefit analysis to modify a self-defeating belief such as, “I must always try to be perfect.”
How to help someone with Borderline Personality Disorder
Those who have a family member, significant other, or friend with a serious mental disorder often ask
how they can be helpful to that Person. Despite their desire to help, family and friends may find
themselves experiencing feelings of frustration, helplessness, resentment, and anger. The following
suggestions have come from talking with patients about the ways that people in their support system can
Be patient! Changing behavior patterns can be a long process and is very hard work. Like conditions
such as diabetes, many mental disorders are chronic (life-long), and a reasonable goal is improved
management, not a cure.
Point out positive qualities. Everyone has things he/she does well. Having a mental disorder often
undermines the person’s confidence, and they may focus their attention on the things they cannot do.
Notice small changes, rather than focusing on how far the person has to go, or how much they were
able to do in the past. Do compliment efforts to use new skills and coping strategies, or to try new
medications despite side-effects.
Expect setbacks. Managing a chronic illness is hard work, and sometimes the course of the illness
is an up and down one. Remember – a lapse is not necessarily a relapse. Setbacks are often expected and
temporary, and even helpful at times as patients recognize the need to continue actively managing their
disorder. Don’t induce guilt when there is a setback. It is often hard for persons with a mental illness to
accept their limitations and adding guilt increases feelings of alienation from those who want to help.
Support the person’s decision to seek help and follow treatment recommendations, but give
responsibility for treatment to the patient. You cannot force someone to get treatment or stay in treatment.
You cannot control another person’s disorder and you cannot cure it.
Direct your anger at the disorder, not the person with the disorder. The person who has the disorder
hates it more than you do. Don’t blame the person for having a disorder. He or she did not choose to have
a mental disorder. Try to think of the person as having a disorder, not being a disorder.
Don’t criticize. Those who have a mental disorder are often extremely critical of themselves. Negative
comments contribute to further lowering of self-esteem and feelings of worthlessness.
Be informed. Read as much as you can about your loved one’s disorder, but do not try to be your family
member or friend’s therapist or psychiatrist.
Identify family patterns that may contribute to problems. Try to notice and improve interactions
between you that trigger arguments or conflict. Seek family therapy or couple counseling if there has been
a long history of communication problems.
Take care of yourself. If a member of the family has had a mental disorder for many years, family life
has often been disrupted and family members may have given up activities they formerly enjoyed. Family
members and friends are entitled to time for themselves to pursue enjoyable activities.
Look for support. There are often support groups available for family and concerned friends. If you are
not aware of resources in your area, contact local hospitals, mental health centers, or national
organizations such as the National Alliance for the Mentally Ill. Numerous resources are now available on
Borderline Personality Disorder (BPD) Facts Sheet
WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)? BPD is an Axis II personality disorder characterized by a pervasive inability to regulate emotions and control behaviors linked to emotions. Intense negative emotions commonly include depression, anger, self-hatred, and hopelessness.
PREVALENCE OF BPD. BPD occurs in 0.2 to 1.8% of the general population, in 8 to 11% of psychiatric outpatients1 2 and 14 to 20% of inpatients. 3 4
SUICIDAL BEHAVIORS ARE VERY COMMON AMONG INDIVIDUALS WITH BPD. Suicide is among the top ten causes of death in the United States and in the world. Up to 40% of those committing suicide meet clinical criteria for a personality disorder at the time of their death. An even higher percentage of those attempting suicide have a personality disorder. The personality disorder most associated with both completed and attempted suicide is BPD.
BPD is the only DSM-IV diagnosis for which parasuicide (i.e., suicide attempts and/or other intentional, non-fatal, self-injurious behaviors) is a criterion and parasuicide is thus considered a “hallmark” of BPD. Rates of parasuicide among patients diagnosed with BPD range from 69 to 80%.5 6 7 Rates of suicide among all individuals meeting criteria for BPD (including those with no parasuicide) is 5 to 10% and double that when only those with a history of parasuicide are included.8
BPD INDIVIDUALS ARE HIGH UTILIZERS OF SERVICES AT COMMUNITY MENTAL HEALTH AGENCIES. Between 6 to 18% of all persons admitted to inpatient psychiatric treatment account for 20 to 42% of all admissions.9 10 11 12 13 14 Seventy-five to 80% of inpatient treatment dollars are spent on 30 to 35% of patients receiving inpatient treatment services.
People with BPD are commonly among the highest utilizers of inpatient psychiatric services. Between 9 to 40% of high utilizers of inpatient psychiatric services are diagnosed with BPD.15 16 17 18 19 BPD IS A CHRONIC DEBILITATING PROBLEM. Follow-up studies consistently indicate the diagnosis of BPD is a chronic condition, although the number of individuals who continue to meet diagnostic criteria slowly decreases over the life span. Two to three years after index assessment, 60 to 70% of patients continued to meet criteria.20 Other follow-up studies found little change in level of functioning and consistently high rates of psychiatric hospitalization over two to five years.21 22 Four to seven years after index assessment, 57 to 67% of patients continued to meet criteria.23 24 An average of 15 years after index assessment, 25 to 44% continued to meet criteria.25 26
ACHIEVING TREATMENT SUCCESS WITH BPD HAS BEEN NOTORIOUSLY DIFFICULT. BPD has been associated with worse outcome in treatments of Axis I disorders including major depression,27 OCD,28 bulimia,29 30 and substance abuse.31 Follow-up studies of BPD individuals who have received standard community-based inpatient and outpatient psychiatric treatment demonstrate that traditional approaches are marginally effective at best when outcomes are measured two to three years following treatment. In studies investigating pharmacotherapy for BPD, drop out rates are commonly very high32 33 and medication compliance has been problematic, with upwards of 50% of clients34 and 87% of therapists reporting medication misuse, including use of overdose as a method of attempting suicide.35
- Social Judgement in Borderline Personality Disorder (plosone.org)
- Boundaries and Borderline Personality Disorder (makebpdstigmafree.wordpress.com)
- 10 Things You Discover About Yourself When You’re Diagnosed With Borderline Personality Disorder (astralthunder.wordpress.com)
- Males with Borderline Personality Disorder (borderlinepersonalitygrrl.wordpress.com)