Understanding Borderline Personality Disorder

By Laura Greenstein

Selfish. Manipulative. Untreatable. Clingy.

This is how people (even mental health professionals) describe those who live with Borderline Personality Disorder (BPD). But considering what a person experiencing BPD deals with daily, these labels aren’t fair.

“People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” That’s how BPD specialist Marsha Linehan describes the deeply misunderstood mental health condition.

That badly burned “emotional skin” means people living with BPD lack the ability to regulate their emotions, behaviors and thoughts. In fact, “Dysregulation Disorder” would be a more exact, less stigmatizing name for the condition according to NAMI’s Medical Director, Ken Duckworth.

What Does BPD Look Like?

Like other personality disorders, BPD is a long-term pattern of behavior that begins during adolescence or early adulthood. But what makes BPD unique from other personality disorders is that emotional, interpersonal, self, behavioral and cognitive dysregulation. What does that mean?

Well, put simply: Relationships can deeply affect a person with BPD’s self-image, behavior and ability to function. The possibility of facing separation or rejection can lead to self-destructive behaviors, self-harm or suicidal thinking. If they feel a lack of meaningful relationships and support, it damages their self-image. Sometimes, they may feel as though they do not exist at all.

When entering a new relationship, a person experiencing BPD may demand to spend a lot of time with their partner. They will share their most intimate details early on to quickly create a meaningful relationship. In the beginning, they will show immense love and admiration to their partner. But if they feel as though their lover doesn’t care enough, give enough or appreciate them enough in return, they will quickly switch to feelings of anger and hatred. In this space of devaluing their partner, a person living with BPD may show extreme or inappropriate anger, followed by intense feelings of shame and guilt. These feelings often contribute to a self-image of being bad or evil.

Possibly because of this, individuals who live with borderline personality disorder are among the highest risk population for suicide (along with anorexia nervosa, depression and bipolar disorder). Completed suicide occurs in 10% of people with BPD and 75% of individuals with BPD have cut, burned, hit or injured themselves. These self-destructive behaviors are usually in response to threats of separation or rejection, but may also occur to reaffirm the ability to feel.

Diagnosing BPD

The estimated prevalence of BPD diagnosis is 1.6%, but may be as high as 5.9%. The number is unclear because BPD is often misdiagnosed and underdiagnosed. In fact, one research study showed that 40% of participants with BPD were previously misdiagnosed. We need to do better.

There are nine criteria listed in the Diagnostic Statistic Manual (DSM-5) to determine whether someone has this condition. A person must present with five or more of the following:    

1. Desperate efforts to avoid real or imagined abandonment.
2. A pattern of unstable relationships switching between extremes of admiration and hatred.
3. Unstable self-image.
4. Impulsivity in at least two areas that are potentially self-damaging (such as spending, sex, substance abuse, reckless driving or binge-eating).
5. Repeated suicidal behavior and threats or self-harm.
6. Erratic mood swings.
7. Chronic feelings of emptiness.
8. Intense anger or difficulty controlling anger.
9. Temporary, stress-related paranoid ideation or dissociative symptoms.

BPD typically needs more observation than other mental health conditions to diagnose because the symptoms are often comorbid (paired) with illnesses such as depression, anxiety, eating disorders, post-traumatic stress disorder, substance abuse disorders and bipolar disorder. The book Borderline Personality Disorder: The NICE Guideline on Treatment and Management explains that the rate of comorbidity is so high that it’s rare to see an individual with solely borderline personality disorder.

While research hasn’t yet uncovered the exact cause of the condition, BPD is about five times more common among first-degree biological relatives of those with the disorder. Research also suggests that one of the major causes of the condition is trauma. In a study trying to treat 214 women with BPD, 75% of the participants had a documented history of childhood sexual abuse.

What Should I Do Now?

If you or someone you know was recently diagnosed with borderline personality disorder, here are a few first steps to take in managing this difficult condition:

Seek Treatment. Individuals who engage in treatment often show improvement within the first year. People with BPD are often treated with a combination of psychotherapy, peer and family support and medications.

Connect with Others. It can be incredibly helpful to have an emotional support system of people who know what you’re going through. It’s a reminder that you are not alone and you can recover. You can find others living with BPD through peer-support groups or online message boards or groups. For example, Healing From BPD includes a peer-hosted chat room.

Practice Self-Care. Part of healing is ensuring that no lifestyle choices are worsening symptoms and preventing recovery. Practicing healthy habits such as exercise, eating well and finding healthy ways to cope with stress and symptoms can be a key part of recovery. Also, it’s essential to avoid drugs and alcohol because these substances can worsen symptoms and disturb your emotional balance.

BPD should not come with a label of “manipulative” or “clingy.” It’s not a personality defect. It’s a serious personality condition that needs attention and care. If you experience this condition, keep in mind that these symptoms are not your fault. You are not behaving or thinking in a certain way because you are a bad or evil person: You are just a person who has a mental illness and you need support and treatment.