Borderline personality disorder or BPD seems to currently be the “go to” diagnosis for anyone with impulsive suicidal behaviours, who self-harms, and/or has extreme difficulties in managing their emotions, but a diagnosis of borderline personality disorder is a little more complicated. Unfortunately, due to the complex nature of the condition it is often underdiagnosed or misdiagnosed.
How is it Diagnosed?
A mental health professional experienced in diagnosing and treating mental health disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect borderline personality disorder based on a thorough interview and a discussion about symptoms. Based on the information provided they will consider whether criteria relevant to the disorder is met.
In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), there are two key features of Borderline Personality Disorder which are;
- Pervasive patterns of instability of interpersonal relationships, self-image, and affects, and
- Marked impulsivity that begins by early adulthood and is present in a variety of contexts.
Individuals with borderline personality disorder are very sensitive to real or imagined abandonment and make frantic efforts to avoid it. A perceived separation or rejection can lead to profound changes in self-image, affect, cognition, and behavior. They can 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 partner’s having to go to work unexpectedly; or panic or fury when someone important to them is just a few minutes late). The abandonment fears often come with a fear of being alone, and thus they may need to always be with others. Their frantic efforts to avoid being alone can include impulsive behaviours such as self-mutilation and suicidal behaviours.
Individuals with borderline personality disorder usually have a history of unstable and intense relationships. People in their lives may be alternatively idealized and devalued, with the switch happening quite quickly. When the other is idealized, relationships can move quite fast, with demands to spend a lot of time together, and share the most intimate of details very early in the relationship. However, they may switch quickly from idealizing to devaluing, if they feel that the other person does not care enough, does not give enough, or is not “there” enough.
Another common characteristic of BPD, is an identity disturbance characterized by a marked and persistently unstable self-image or sense of self. Often there is not a clear idea of one’s identity, which manifests in dramatic shifts in self-image, shifting goals, values, and vocational aspirations, sudden changes in opinions and plans about career, sexual identity, values, types of friends and roles. What is consistent in sense of self in individuals with BPD is a sense of being bad or evil. It is also common for individuals with BPD to have feelings that they do not exist at all.
To meet the diagnostic criteria for BPD individuals must display impulsivity in at least two areas that are potentially self-damaging such as; gambling, spending money irresponsibly, binge eating, abusing substances, engaging in unsafe sex, or driving recklessly. Individuals with this disorder also display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. The recurrent suicidality is often the reason that people with BPD present for help at mental health services.
Another common characteristic of BPD is unstable and reactive episodes of mood such as intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses and reduced capacity to regulate their emotions. They often have a great deal of difficulty managing their anger. They may frequently express inappropriate, intense anger that easily gets out of control. This may manifest in extreme sarcasm, enduring bitterness, or verbal outbursts. Often, such expressions of anger are followed by shame and guilt and may be interpreted as evidence that they are indeed evil.
Those with BPD may also experience transient paranoid ideation or dissociative symptoms (e.g., depersonalization) during periods of extreme stress, especially in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived end of the abandonment and return of the other may result in a remission of symptoms.
· Individuals may undermine themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last).
· Recurrent job losses, interrupted education, and separation or divorce are common.
· Psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress.
· Individuals may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships.
· Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring depressive disorders or substance use disorders.
· Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts.
· Personal histories of physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in those with borderline personality disorder.
· Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personality disorder also frequently co-occurs with the other personality disorders.
A diagnosis of BPD is not a life sentence of extreme instability and mental anguish. There are several interventions that have proven effective for treating borderline personality disorder. Several psychological therapies have evidence to support their effectiveness for BPD, including Dialectical Behaviour Therapy, Cognitive Behaviour Therapy and Schema Therapy. Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention often show improvement, beginning sometime during the first year. As many of the interventions are based on learning skills and strategies to deal with overwhelming feelings, those involved in therapy gradually improve their functioning and belief in their ability to cope. Following therapeutic intervention, most individuals with this disorder attain more stability in their relationships and improve their job performance. Follow-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behaviour that meets full criteria for borderline personality disorder.
By Greta Neilsen
Greta Neilsen is a clinical psychologist practicing in Bowen Hills in Brisbane who has a special interest in treating problems with emotional regulation such as Borderline Personality Disorder. For more information see the full site at www.gretaneilsenpsychology.com.