Have you ever felt the fear and insecurity of living with someone, knowing that at some moment they would be very affectionate at you and at other times they would be so furious, you wish you were never born? That is what I feel living with a person diagnosed with BPD and one of the reasons I’m writing about it.

The term was first coined by Adolph Stern in 1938 to describe the personality in the borders of psychotic (hallucinations and delusions) and neurotic (negative mood states and anxieties). The disorder has only recently gained attention. However countless people are living with this. It does not only affect the person with the disease but the immediate surrounding people living with them. I describe it as “taking a stroll on a minefield,” one misstep and all hell’s breaking loose. Yet despite the pain, the person itself is not the ones to blame.

Personality disorders like BPD are just an awful way a person relate and interact with the world around them. It does not reduce the person into a mere diagnosis, and it also does not diminish our responsibility (their outbreak may be triggered by our mistakes), inside they are also struggling. I hope that this article can help both me and you navigate and understand BPD better. As our understanding and willingness to learn would help substantially both in their recovery and our own well-being.

What causes Borderline Personality Disorder?

The exact cause for BPD is unknown. However, research has suggested that interacting factors between the biological factors (genetics) and psychological factors (upbringing, parenting, abuse) are interacting to create the Borderline personality (Bateman & Krawitz, 2013).

Biologically people with BPD are more likely to have a smaller amygdala (Bateman & Krawitz, 2013). The amygdala is the brain’s gas pedal, and this region is overactive in individuals with BPD. Other biological factors that are suspected of contributing to BPD are genetics. One study has identified five times increased risk of developing BPD in identical twins compared to non-identical twins (Bateman & Krawitz, 2013).

Psychological factors in BPD are thought due to the upbringing during childhood or teenage years (Bateman & Krawitz, 2013). The evidence is inconclusive. However, it is without a doubt that environment that was abusive or neglectful will have a lasting impact on our psychological development, increasing our chance to develop insecure attachment, poor way of relating and low self-esteem and confidence.

How do you know that you or someone you love might have this condition?

If you suspect either yourself or your loved ones to have BPD, then this article might help to inform you more about this condition. However, BPD must be diagnosed by a qualified health care specialist as some of the symptoms may be found sporadically in the general population. Since the diagnosis also carries the stigma of mental health illness, a knowledgeable and understanding mental health professional is needed.

As with all personality disorder, the diagnosis of BPD consists of the person meeting several of the available criterions. The main feature in BPD is instability of creating and maintaining relationships, self-image, and feelings, combined with uncontrolled behaviors that begins at a young age and persist over time (American Psychiatric Association, 2013). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), five or more of the following behaviors need to be present to diagnose BPD.

Criteria 1. A distressing effort to escape abandonment

Consider the following, you and your partner are planning to watch a movie the next evening. Fifteen minutes before the time, your mom suddenly called you because she’s sick and needs your help to visit the nearest hospital. You called your partner to cancel your date, and suddenly they burst into tears and are furious. They continually probe you asking what’s wrong and are assuming that it’s because they have made a mistake. They are begging, trying to compensate and will “do anything” so that you wouldn’t abandon them. You try to explain your situations to your partner, but they just wouldn’t listen.

Seems familiar? This scenario is one example of what might happen to a person with BPD. It’s not because they’re a terrible person, its just that they genuinely fear separation and rejection. To another person, the changes in plans are entirely reasonable, sure they might feel some disappointment, but the turndown is not permanent, and they can still meet some other time. To a person with BPD, this kind of situation might trigger a type of life or death situation, with frantic efforts to undo their perceived separation and abandonment.

Criteria 2. A pattern of unpredictable and intense interpersonal relationships, switching between extreme affection, to outright hostility

For this criterion, you might have seen it often. People with BPD might start a relationship with an amorous start. After meeting for a few times, they suddenly assume that this person is “the one.” The relationship progresses quickly and may reach a depth not usually found in new relationships. However, they might alternate suddenly from intensely affectionate, to outright hostility.

For them, a simple slight, whether real or imagined, can trigger rage and hatred towards a person. It might be caused by the feeling that their partner / significant other does not care enough or does not give enough. Although it is not always their or their partner’s fault. A person with BPD can empathize and build a strong relationship with other people but by expecting that others will be there in return.

Criteria 3. An unstable self-image or sense of self

In individuals with BPD, the way they see themselves are subject to fluctuations. Their goals and values may suddenly shift. The role they played may also change sometimes from a victim of life’s cruelty to a righteous avenger of justice. Their self-image may alternate from being an awful person, to a blameless person, and perhaps to nothing at all. Their jobs may also reflect this instability. For example, choosing to be a teacher and after a while hating it, becoming an active member of a party and after a while switching to the opposite side, and so on. This unstable self-image is usually coupled with other criterions, for example, a sense of being an evil person after an anger outburst.

Criteria 4. Impulsive behavior in at least two areas (e.g., spending, sex, substance abuse, reckless driving, binge eating)

Impulsive behaviors are thought to be caused by extreme stress that may occur in people with BPD. They are trying to feel a little bit better or to escape from the burden even if it's just for a short while. However, this criterion is also shared with another type of mental health disorder (Bipolar Disorder) and therefore, should not be analyzed in isolation. The main problem with impulsivity is its potentially damaging behavior, not just for the person but also to their family support system. For example, gambling and reckless spending may lead to significant debts, unprotected sex, or another high-risk sexual behavior may lead to other long term consequences.

Criteria 5. Recurrent suicidal actions, gestures, or threats, or self-mutilating behavior

Arguably the most dangerous acts are the frequent harmful actions and behaviors that individuals with BPD may present. Complete suicide is common, ranging from 8-10% in individuals with BPD (American Psychiatric Association, 2013). Other dangerous behaviors such as suicide threats or gestures and self-mutilating act are even more prevalent. These acts are usually precipitated by separation or rejection (real or perceived), and they act to reduce the distress people with BPD may feel. To illustrate, these individuals sometimes use suicide threats to counteract denial. Other examples include the use of cutting, scratching, or burning both to decrease their emotional burden and indirectly to coerce people around them to do or act as they wanted.

Criteria 6. Unstable feelings due to a notably reactive mood

Individuals with BPD sometimes exhibit a volatile attitude ranging from irritability to anxiety. Couples with their incapability to handle interpersonal stresses, life with these individuals may be colored by periods of anger, panic, and hopelessness.

Criteria 7. Chronic feelings of emptiness

Persistent feelings of emptiness may manifest as boredom. Individuals may be easily bored and seek stimulation or things to do to relieve the feeling. Individuals with BPD may have difficulty in maintaining a lasting relationship and job which preclude a formidable source of meaning

Criteria 8. Inappropriate, intense, or difficulty controlling anger

A person with BPD might express verbal outburst (or physical) of rage when they see that the person close to them are leaving or neglecting them. Usually, the cause is due to their unrealistic expectation of the other person. However, both sides do have a responsibility to maintain boundaries in this kind of cases. After their anger outburst, these individuals typically fall into shame and guilt, which contributed to their unstable self-image. This inappropriate display of anger is one of the main reasons relationship with these individuals are difficult. Educating caregivers or lovers that these people do not mean what they said is vital since these individuals do show regret after the event.

Criteria 9. Short term, stress-related paranoid thinking.

During extreme stresses, the person might present paranoid ideas that are unrealistic, although only for a short while. Dissociative symptoms may occur, such as the feelings of being detached from one’s own body. Since the symptoms might not be noticeable, an evaluation by a mental health professional is needed.

Conclusion

Do you find a similarity with those criterions? If you do, then please seek help with a mental health professional. Although the conditions may endure and return to complete functioning is hard, two studies have shown that eight out of ten patients no longer meet the diagnostic criteria for BPD in 10 years, and once the symptoms are gone, it is rare for them to reappear (Gunderson, 2011; M. C. Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010; Mary C. Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). Therefore, with support from your health-care providers, family members, and significant other, this condition may be controlled just like any other chronic conditions.

To sum up, as you understand how BPD is caused and why the life of individuals with BPD are filled with crisis and intense emotional outburst, I implore you to reconsider your stance on your loved ones with BPD. They are humans, too, just like any of us. Their character is a collection of solutions (albeit, horrible solutions) to defend and solve external stress. It’s time to stop playing the blame game and to start the journey towards recovery.

References

American Psychiatric Association (Ed.). (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). Washington, D.C: American Psychiatric Association.

Bateman, A., & Krawitz, R. (2013). Borderline personality disorder: An evidence-based guide for generalist mental health professionals (First edition). Oxford: Oxford University Press.

Gunderson, J. G. (2011). Ten-Year Course of Borderline Personality Disorder: Psychopathology and Function From the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry, 68(8), 827. https://doi.org/10.1001/archgenpsychiatry.2011.37

Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2010). The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects: Psychosocial functioning of patients with BPD. Acta Psychiatrica Scandinavica, 122(2), 103–109. https://doi.org/10.1111/j.1600-0447.2010.01543.x

Zanarini, Mary C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2010). Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-year Prospective Follow-Up Study. American Journal of Psychiatry, 167(6), 663–667. https://doi.org/10.1176/appi.ajp.2009.09081130