Understanding Borderline Personality Disorder

If someone you know or love is diagnosed with borderline personality disorder or BPD, you probably have a lot of unanswered questions going through your mind. How could this happen, you might ask yourself? What’s to become of your friend or loved one? Will they ever have a chance at a normal life? Is there anything that can be done to treat this individual? More importantly, perhaps, is what can you do, if anything, to help?

The good news is that there are many advances in the treatment of BPD today that can spell a far different future for individuals diagnosed with the condition than in years past.

First, however, let’s take a look at just what borderline personality disorder is.

BPD – What It is

Borderline personality disorder (BPD) is a serious mental illness. It can not only cause a great deal of suffering, but it also carries a high risk of suicide. Anyone diagnosed with BPD needs specifically targeted treatment.

Why is it called “borderline,” and what does that really mean, anyway? According to the literature, for years the condition was considered to be somewhere between psychosis and neurosis – on the borderline. The name, although it didn’t really apply or describe the actual condition, stuck. So, here we are today with the name of Borderline Personality Disorder, or BPD, for short.

What’s key to know is that BPD isn’t just a personality disorder. BPD is a serious mental illness. But it was only officially recognized as a psychiatric illness by the American Psychiatric Association (APA) in 1980, making it a relative newcomer in the field of mental illness. There is still a great deal of research that needs to be done, as well as development in the areas of medication, treatment, and programs of family support.

The APA currently classifies BPD as a personality disorder. The official definition of “personality” is “a cluster of traits, unique to each person, which determines how one relates to oneself, other people, and the world.” The term “personality disorder,” then, has come to mean “a regular pattern of relating to oneself and others that is troubled.”

There are imaging studies that have been done on people with BPD that show changes in brain structure and chemistry. This seems to indicate that there may be a biological component to BPD, leading some experts in the field of mental illness to conclude that the disorder should be classified similar to other serious conditions such as bipolar disorder, and not as a personality disorder.

Bottom line: There is still much research that remains to be done on BPD, learning more about the condition, how best to treat it, and how to help family members and loved ones cope with an individual diagnosed with it.

What Does BPD Look Like?

Because BPD has what can be described as many challenging aspects, it can be tough for the layperson to discern. That’s why an accurate diagnosis is required. Still, however, there are certain things that you can see in an individual who actually has BPD.

When a person is suffering from BPD, they often have a pattern of very stormy relationships, some of which may become violent at any given moment. These individuals may change jobs frequently, or be unable to hold onto a job for very long due to their impulsiveness and intense and frequent mood changes. In fact, a hallmark characteristic of individuals with BPD is their severe difficulty in regulating their emotions, called emotional dysregulation.

It is estimated that about one to two percent of Americans are affected by BPD, affecting more females than males by a ratio of about three-to-one. Some clinicians, however, believe that males with the condition are underdiagnosed.

How BPD is Diagnosed

The clinical criteria used to diagnose BPD are those published by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual (DSM) IV:

“A pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity beginning in early adulthood and presenting in a variety of contexts as indicated by five or more of the following:

  • Frantic efforts to avoid real or imagined abandonment
  • A pattern of unstable and intense interpersonal relationships
  • Identity disturbance
  • Impulsivity in at least two areas that are self-damaging
  • Recurrent suicidal behavior, suicidal gestures, threats or self-mutilating behavior
  • Affective [mood] instability
  • Chronic feelings of emptiness
  • Inappropriate, intense anger
  • Transient, stress-related paranoid ideation or severe dissociative symptoms”

The National Alliance on Mental Illness (NAMI) clarifies this last symptom, saying that individuals with BPD only have paranoid thinking when they’re under severe stress, and not on a regular basis. Furthermore, the NAMI says that dissociative symptoms are when consciousness “splits off.” NAMI gives the example of a trauma survivor driving down a one-way street without realizing it.

Note that the next version of the APA’s DSM is projected to be published in 2012 and the above-mentioned criteria for diagnosing BPD are being reviewed, and may be changed.

On the APA site, in a section discussing the development of ASM-V, the development work group has recommended significant reformulation of the approach to the assessment and diagnosis of personality psychopathology, including revised general criteria for personality disorder.

The summary of changes for general diagnostic criteria for borderline personality disorder (from DSM-IV to proposed in DSM-V) are contained on pages 8-11 of this APA chart revised June 2011.

Living With the Symptoms

The individual with BPD may not have a clue that they have this serious mental illness. Often, they only know that they have a difficult time interacting with others, holding a job, keeping on an even keel emotionally. Those that live with or work closely with these individuals may be able to easily see that something is awry without knowing what it is or what to do to help the person.

While some articles and books appear to suggest that a person suffering from BPD is manipulative, hurtful to others and even bad, this is a short-sighted and inaccurate conclusion. Someone who has BPD may not be able to see how their own actions play a role in the tumultuous relationships and experiences of their day-to-day lives.

They’re not able to or find it difficult to tolerate strong feelings. Often they feel a deep sense of shame and cast blame on others as the cause of their problems. Blaming others can then lead to increased stress and subsequent loneliness.

It’s also important to know that individuals with BPD may often have other co-occurring mental and/or physical conditions that exacerbate their BPD. This may include having bipolar disorder, depression, anxiety, post-traumatic stress disorder (PTSD), eating disorders, and substance abuse.

BPD literature by Dr. Robert O. Friedel indicates that two-thirds of people with borderline disorder seriously abuse alcohol, street drugs and/or prescribed drugs. Dr. Friedel goes on to say that this is one of the most important factors contributing to the poor outcome of individuals with BPD.

Not every person with BPD is unable to hold down a job. Some can work productively, while their lives spiral out of control at home or in other areas. Others with BPD struggle every day just go be at work, let alone work productively. As with all mental illnesses and substance abuse, there is no one-size-fits-all scenario.

Treatment for BPD

Treating individuals with BPD requires first that a complete assessment be done. This is necessary so that a treatment plan can be created that takes into account all the individuals needs, including any other coinciding mental and/or physical conditions, and their strengths and weaknesses.

Treating BPD isn’t a hopeless endeavor. In fact, many people who receive appropriate treatment for BPD can go on to lead happy and productive lives.

The first step is to find the right kind of therapist to provide the evidence-based treatment, that is, treatment that has thus far proven effective in treating BPD. Keep in mind that finding therapists trained to provide evidence-based treatment may take a bit of research, but the eventual outcome is well worth whatever effort is expended.

There are also therapists that can provide treatment for family members and friends of individuals with BPD, thus helping them better cope with and be more supportive of the person with the illness.

Just as there is no one-size-fits-all scenario describing an individual with BPD, there is no single treatment that works for everyone with the illness. The therapist that treats the person with BPD may utilize a sort of menu-approach, applying parts of treatments or combining treatments.

Some of the evidence-based treatments for BPD include:

  • Psychotherapy – The individual with BPD needs to develop a trusting relationship with his or her therapist. There are many different branches of psychotherapy that can be useful in treating BPD, but they all share some of the same features. The focus is on relationships, there’s a clinical alliance, development of alternatives to self-destructive behaviors, and creation of a safe place for the individual to learn new behaviors and talk about their concerns. Cognitive Behavioral Therapy (CBT), is one of these branches of psychotherapy. CBT focuses on evaluating and changing a person’s thinking. This often helps the individual change his or her behavior. CBT has also been found to help with anxiety and depression, since both often co-occur in an individual with BPD.
  • Skills Training/Dialectical Behavioral Therapy – A relatively recent treatment, dialectical behavioral therapy (DBT) is perhaps the best-studied BPD intervention. DBT seeks to target, first and foremost, the reduction of out-of-control and life threatening behaviors, such as drug addiction, eating disorders, inability to regulate extreme emotions, and chaos in interpersonal relationships. Following that, DBT centers in on reducing the emotional dysregulation and distress that is so common with BPD. Finally, DBT hones in on solving problems that interfere with the individual’s quality of life. DBT teaches the individual self-regulation skills that he or she can then use to manage their strong feelings and impulsive urges independently. DBT involves individual and group sessions, homework, and telephone coaching and the hard work does pay off.  DBT has been shown to reduce anger, suicide risk, and the number of days in the hospital, as well as increase positive self-concept and help individuals function better in relationships.
  • Peer Support – There’s nothing like being around someone who’s been there, so to speak, someone who has had BPD and is now living a productive life following treatment. Listening to someone who has been able to develop alternative strategies for dealing with BPD successfully can be not only very inspiring but also provide excellent role modeling behavior. Being around these role models can also help reduce the feelings of shame and isolation that accompany BPD. While peer support isn’t a substitute for professional treatment, it certainly can augment such treatment. NAMI offers Peer-to-Peer and NAMI Connection to help individuals find peer support. There are also online forums devoted to helping people with BPD to feel a sense of community and recovery following treatment.
  • Medication – No single medication is used to treat BPD. But there are a number of medications that can help the effectiveness of therapy and to treat some of the symptoms of the condition. Research studies have shown that medication coupled with therapy can produce an improvement in people suffering with BPD. What medications may be useful? Keep in mind that any medications selected should be part of an overall treatment plan. For symptoms of anxiety and depression, antidepressants may help. For an individual having episodes where they break from reality, have paranoia and disordered thinking, antipsychotic medications can help. Similarly, impulse-control medications can help people with this often-typical area of concern of BPD. What is also important to remember is that it may take some time to determine the best combination and dosage of medications for the individual, and to allow time for the medication to take effect. Medication is useful in alleviating some of the symptoms of BPD, thus enabling the individual to better respond to and learn strategies beneficial to his or her recovery during psychotherapy.
  • Family Education – There’s no question that living with an individual with BPD is difficult and fairly exhausting. You might think that there’s nothing that can help you, but there are strategies that you can learn that can not only help you but also help you support your family member, loved one or friend with BPD. NAMI has a Family-to-Family program, for example, that may provide the kind of education that can be invaluable to you and other members of the family.
  • Issue-Specific Support Groups – Recovering from BPD is enhanced by the individual participating in issue-specific support groups. These include self-help groups such as Alcoholics Anonymous (for alcohol abuse), Narcotics Anonymous (for drug abuse), and recovery support groups included in NAMI Connection.

Finding Help and Resources

Finding the right therapist and treatment for the individual with BPD is critical. The best approach is to network and ask for referrals to clinicians where the individual with BPD lives or works. Checking the individual’s insurance program to see if the coverage requires it to provide the individual with qualified treatment is also paramount.

Resources are invaluable in helping your understanding of BPD as well as where to get help and support for yourself and other members of the family and close friends.

Ask the Doctor — This blog and video series provides insightful information from mental health professionals who study and treat BPD and other mental health disorders. This video clip features Dr. John Oldham discussing the latest research and treatments for BPD.

NAMI Peer-to-Peer — This is a free, nine-week course on recovery for anyone with a serious mental illness. The educational course is led by mentors who have themselves achieved recovery from mental illness. NAMI Peer-to-Peer provides comprehensive information, teaches awareness strategies, coping skills and self-care.

NAMI Family-to-Family – This is a free, 12-week course for family members of individuals (adults) with mental illness. The course is taught by trained NAMI family members who have relatives with mental illness. NAMI Family-to-Family provides communication and problem-solving techniques, coping mechanisms and self-care skills so that family members can better deal with their loved ones with mental illness and the impact on the family.

NAMI Connection – This is a recovery support group for adults with mental illness regardless of their diagnosis. NAMI Connection groups meet weekly for 90 minutes and the groups are free of charge to participants. These groups are led by trained individuals who are in recovery and understand the great challenges that people with mental illness face on a daily basis. This group also provides access to other groups and an unaffiliated online course for people with BPD.

BPD Family – This website includes support groups, live discussions and other resources for family members of individuals with BPD.

National Education Alliance Borderline Personality Disorder– This is an organization dedicated to raising public awareness, providing education, and promoting research on borderline personality disorder and to help enhance the quality of life of those affected by BPD.

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