Borderline Personality Disorder (BPD)
What is BPD?
Borderline personality disorder (ie BPD) is a mental health condition. Research shows that around 1.6% of the general population and 20% of the inpatient psychiatric population suffer from this condition.
However, do note that BPD is constantly misdiagnosed due to a lack of awareness and social stigma.
For example, recent studies showed that nearly 40% of people who were diagnosed with BPD were previously misdiagnosed at some point in their lifetime.
People with BPD often have intense feelings of abandonment and struggle to manage their emotions. The emotional symptoms can manifest in impulsive behaviours, such as rash decisions, maladaptive behaviours, or self-harming tendencies.
BPD falls under the “Cluster B” category of personality disorders. Disorders under this cluster are commonly characterised by unpredictable and dramatic behaviours.
Personality disorders are patterns of behaviour that are rigid and pervasive and can lead to societal challenges and personal distress.
Many with BPD may be unaware of their condition. In addition, it is also often misdiagnosed as CPTSD (complex post-traumatic stress disorder) or depression.
This article has information on the signs and symptoms of BPD, its causes, and how to manage it with professional support.
Signs and Symptoms of Borderline Personality Disorder
Borderline Personality Disorder (BPD) is complex and can manifest in various ways.
Therapists and counsellors categorise the symptoms into nine primary groups for diagnostic purposes.
To be diagnosed with BPD, an individual must exhibit at least five of these symptoms. Moreover, these symptoms should be persistent, typically starting in adolescence and affecting multiple areas of one’s life.
The 9 Symptoms of BPD
1. Fear of Rejection
Fear of rejection could manifest in several different ways. For example, some of the common sub-signs include:
- Overwhelming fear of being abandoned
- Fear of being left alone by loved ones
Common and regular situations, such as a partner or family member returning late from work or temporarily staying away from a loved one (eg work trip), can trigger intense anxiety.
This anxiety (also known as ‘separation anxiety’) may lead to desperate attempts to maintain physical proximity to the person.
The attempts could include behaviours like:
- Pleading
- Clinging
- Initiating conflicts
- Physically preventing the person from leaving
2. Unstable Relationships
Rather than a main symptom, having unhealthy or unstable relationships is usually a consequence of emotional symptoms such as lack of trust and fear of abandonment.
Due to the emotional distress, people with BPD frequently stay in relationships that are either too intense or last for a very short duration.
For example, the person might fall in love quickly and believe every new acquaintance is their soulmate or that they’re meant to be together.
People with BPD may also perceive relationships as either a ‘perfect’ one or a ‘disastrous’ relationship. The black and white thinking often leaves them emotionally disoriented due to their abrupt shifts between admiration and lack of interest.
3. Identity Disturbance
People with BPD frequently struggle with a weak sense of self (ie they may not know who they are and what they like).
Due to a blurred self-perception, the person may commonly experience feelings of guilt or shame and perceive themselves as inherently flawed or ‘wrong.’
The unstable self-perception can lead to sudden and intense shifts in their self-image. Drastic changes to self-image often manifest as:
- Low self-esteem
- Abrupt changes in their aspirations, beliefs, work, or social circles
- Poor social skills
- Lack of self-awareness
Moreover, due to the emotional distress, the person may also undervalue their own achievements and progress.
For example, scoring a high grade would make the person think that it was luck or that the teacher favoured them – rather than thinking that they received the results due to their best effort.
The self-sabotaging behaviour further complicates their journey to creating a stable identity.
A weak sense of self usually occurs because of past traumas or unpleasant experiences in life.
4. Impulsive and Self-Destructive Behaviours
People with BPD might indulge in harmful, thrill-seeking experiences in moments of distress.
This could include reckless spending, overeating, driving dangerously fast, or substance abuse.
While these behaviours might offer temporary relief, they often harm oneself and others long-term.
5. Self-Harm
Two of the most common concerns and symptoms of BPD include:
- Suicidal tendencies
- Self-harm
Both the above signs could include passive suicidal thoughts such as contemplating suicide, thinking about suicidal methods, or making threats of dying.
Self-harm (also called self-mutilation) can include actions like
- Cutting
- Burning
- Severe scratching
The above actions are also known as non-suicidal self-injury (NSSI ).
However, active self-harm and suicidal thoughts could also occur. These include:
- Reckless behaviour (eg rash driving)
- Intentionally putting oneself in situations where one knows injury or harm might be possible
6. Extreme Mood Swings
People with BPD often experience abrupt and drastic changes in their emotions. For example, perception of others, self-worth, and views of the environment or society could change rapidly.
Moreover, the person may constantly shift between intense feelings of anger, fear, anxiety, disdain, sorrow, and affection. The emotional changes, although intense and genuine, typically last only for a short while.
Note: Anger management can help you understand, manage, and regulate your emotions.
The emotional fluctuations usually differ from prolonged mood swings in conditions like depression or bipolar disorder.
7. Chronic Feelings of Emptiness
People with BPD often have a sense of emptiness that is chronic and present constantly.
For example, the symptom is usually described as having an internal void or feeling of being inconsequential or ‘not enough’.
To cope with the emptiness, the person might reply with quick fixes such as:
- Consuming drugs
- Bingeing food
- Engaging in excessive physical intimacy
- Gambling or shopping excessively (ie retail therapy)
Although the above actions could give temporary relief, the emotional distress comes back.
Hence, the person may start to feel empty again after these short-lived and self-destructive coping mechanisms.
8. Explosive Anger
People with BPD frequently struggle with regulating their anger, leading to episodes of intense fury.
Their expressions of anger can manifest in various ways, from sharp, cutting sarcasm to prolonged outbursts filled with bitterness. Such vehement displays of emotion are distressing for those around them and the individuals themselves.
Following these episodes, they often experience profound feelings of shame and remorse. They then feel incompetent in their inability to manage their reactions effectively. This causes an internal conflict, and they end up in pain from their own response.
9. Dissociation
Dissociation is also linked with acute stress disorder and post-traumatic stress disorder (PTSD). Both these disorders can also coexist with BPD.
However, it is essential to clarify that dissociation is not a universal symptom among those with BPD. While some might not frequently experience severe dissociative episodes, most individuals may have, at some point, experienced milder forms of dissociation.
Milder forms of dissociation include:
- Becoming engrossed in daydreams.
- Immersing oneself so deeply in a book or film that one becomes oblivious to their surroundings.
- Experiencing moments of distraction, such as driving and suddenly realising you have missed an exit without any recollection of the preceding journey.
Through extensive research, experts have described the various experiences associated with dissociation. These include depersonalisation, derealisation, amnesia, identity confusion, and identity alteration.
Depersonalisation
Depersonalisation means having a sense of detachment from one’s own identity and body. In other words, it is like watching yourself from a third-person perspective.
People who experience depersonalisation often describe it as if they are observing their actions from an external perspective or feeling as though they are in a dreamlike state.
Derealisation
Derealisation is similar to depersonalisation. Common symptoms include:
- Feeling alienated from the external environment, including people and objects
- Finding familiar settings or items strange, surreal, or unrecognisable
It is not uncommon for individuals to experience both derealisation and depersonalisation at the same time.
However, some people may have only one type of dissociation.
According to research papers, the theory behind dissociative identity is the brain’s mechanism to distance itself from danger.
Danger could include traumatic events, memories, or people who may have hurt the person.
If a person used dissociation as a coping strategy during childhood traumas, it could influence their self-perception and their responses to stress in adulthood.
What Causes BPD
Borderline Personality Disorder (BPD) is a multifaceted condition, and its causes remain a topic of extensive research.
While there is no single cause for BPD, a combination of genetic, neurological, and environmental factors appears to play a role in its onset.
Neurological
Neurotransmitters, often known as the brain’s ‘messenger chemicals,’ facilitate communication between brain cells.
An imbalance, particularly in the neurotransmitter serotonin, is believed to be associated with BPD. Abnormal serotonin levels have connections to mood disorders, aggression, and challenges in controlling destructive impulses.
Brain Development Abnormalities
Advanced imaging techniques, such as MRI, have provided insights into the brain structures of individuals with BPD. These scans have highlighted an inconsistency in three critical brain regions:
- The Amygdala: This region is important in regulating emotions, especially those perceived as negative, like fear, aggression, and anxiety.
- The Hippocampus: This region is integral for behavioural regulation and self-control. Any dysfunction in this area can lead to erratic behaviours.
- The Orbitofrontal Cortex: This region is responsible for planning and decision-making. Abnormalities here can result in impulsive actions.
Early life experiences can influence the development and functioning of these brain regions. Given their role in mood regulation, these abnormalities in the brain can contribute to the relational challenges often faced by those with BPD.
Environmental
Common environmental factors that can cause BPD include:
- Emotional, physical, or sexual abuse
- Childhood trauma
- Neglect (From one or both parents during childhood)
- Family mental health history (eg growing up with family members with severe mental health conditions, such as bipolar disorder or substance misuse problems)
Genetics
The genetic makeup inherited from one’s parents can predispose an individual to BPD. Studies suggest that the likelihood of developing BPD can be passed down through generations.
While not everyone with a family history of BPD will develop the condition, it does increase the vulnerability.
Borderline Personality Disorder Diagnosis
As seen previously, BPD is a condition that is often misdiagnosed due to a lack of information and awareness.
Research shows that there is also a gender disparity in BPD diagnosis. Nearly 75% of those diagnosed are women.
BPD includes more emotional symptoms, which are mistakenly associated with gender. For example, there is often a societal belief that women are more ‘emotional’. However, this is entirely untrue.
It is common human nature to be emotional, but the way these emotions manifest in real life could differ among people. Due to these reasons, BPD in men may often be overlooked or misdiagnosed.
However, seeking professional support from the right Therapist can be greatly beneficial.
Mental health experts who have the training and skills to diagnose BPD include:
- Psychiatrists
- Psychologists
- International or Singaporean Counsellors
- Clinical social workers
To diagnose BPD, a Therapist will:
- Conduct a comprehensive interview
- Focus on understanding the emotional and behavioural symptoms
- Inquire about the individual’s family medical history
If you suspect you have BPD, look for a Therapist with experience in BPD and related disorders.
Managing BPD
Borderline Personality Disorder (BPD) is a condition that, with time and appropriate intervention, many individuals can manage and even overcome.
It is not uncommon for symptoms to resurface, and in such instances, continued professional support becomes important.
Psychotherapy
The primary intervention for BPD is psychotherapy.
Psychotherapy (or Talk Therapy) could include approaches such as:
- Cognitive behavioural therapy (CBT)
- Schema therapy
- Dialectical behaviour therapy
- Acceptance and commitment therapy
- Mindfulness-based CBT
- Narrative therapy
During therapy, you may engage in a structured program where your therapist will provide you the space to:
- Openly talk about your emotions
- Share your thoughts in a non-judgmental space
- Talk about your past and current relationships
- Discuss your personal life goals and therapy goals
The main objective of psychotherapy is to help you become more self-reliant. Once you start to gain control over your emotions, you can manage them effectively even after therapy ends.
The type of therapy used for you could depend on several factors, such as:
- Your personal preference
- The intensity of your issue
- Your personality
- Therapist’s recommendations
- What the therapist thinks might be best fit for you
Therapy for BPD is usually a long-term process. However, through consistent support and intervention, you will start healing.
Dialectical Behaviour Therapy (DBT)
Dialectical Behaviour Therapy (DBT) is a therapeutic approach that was specifically created to treat symptoms of BPD.
DBT is created with two main aspects in focus:
- Many with BPD are emotionally sensitive. For example, even minor incidents, such as receiving feedback, can make them feel anxious.
- Many people with BPD have grown up in environments where their emotions were regularly invalidated.The negative childhood experiences, such as invalidation, make them believe their feelings were unjustified or trivial.
The above two factors can trap people in a harmful cycle:
Experiencing intense emotions -> feeling guilt for having them -> believing they are flawed or ‘wrong’ for feeling this way.
The goal of DBT is to break this cycle by focusing on two key concepts:
- Validation: Recognising and affirming that one’s emotions are genuine and acceptable.
- Dialectics: Embracing the idea that life is not merely black or white, and it is crucial to consider diverse perspectives, even those that challenge our own.
A DBT therapist uses these principles to create positive behavioural shifts. For example, a professional may validate that extreme mood swings or sadness can lead to self-harm instead of judging or labelling the person.
During DBT, you may either engage in weekly or biweekly sessions, depending on your availability and preference.
Schema-Focused Therapy
Schema therapy is a therapeutic approach that addresses and modifies maladaptive cognitive patterns.
This form of therapy integrates elements from cognitive-behavioural therapy (CBT) and other therapeutic approaches.
Roots in Childhood Experiences
Central to schema therapy is the idea that unmet childhood needs, such as the need for security, affirmation, and affection, can lead to the development of maladaptive schemas.
These schemas are deeply ingrained patterns of thought and behaviour that influence our self-perception and worldview.
The initial phase of the therapy focuses on identifying the clients’ schemas.
Once these schemas are identified, the next step is to associate them with past events that might have led to their formation and current symptoms manifesting in the person’s life.
The therapist and patient collaboratively delve into the emotions linked to these schemas. This involves understanding and processing feelings that arise from these ingrained beliefs.
Finally, the therapy aims to replace these schemas with healthier alternatives. For example, this might involve exercises to release pent-up anger and replace negative thought patterns.
Medication
While professionals do not use medications as the primary treatment for BPD, they sometimes prescribe medicines to help with specific symptoms.
For instance, some medications can help with anxiety, sadness, or sudden mood changes. Others might help reduce impulsive actions.
A few people with BPD benefit from antipsychotic medicines. Talking to a doctor about the best options for you is essential.
Frequently Answered Questions
Why do some people dislike the term 'borderline personality disorder'?
The term ‘borderline personality disorder’ has historical roots and suggests that individuals were on the borderline between psychosis and neurosis.
As understanding has evolved, many find the term problematic for several reasons:
- It may not accurately reflect the nuances of the condition.
- The label can inadvertently stigmatise the disorder.
- The name seems judgmental, hinting at a ‘defective personality’.
Many people advocate for more empathetic terms like ’emotionally unstable personality disorder’ (EUPD) or ’emotional intensity disorder’ (EID).
Is mentalisation-based therapy (MBT) effective for BPD?
Yes, mentalisation-based therapy (MBT) is an effective treatment for borderline personality disorder (BPD).
During MBT therapy, your therapist may encourage you to:
- Understand your psychological state
- Learn how your thoughts influences your behaviour
- Acquire skills to better understand others
- Gain an understanding of how the world works and how you can live healthily
MBT focuses more on the present experiences and avoids delving into the past. For example, you may focus on how to fix your current romantic relationships – rather than talking about why your previous relationship did not work.
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