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Do You Love Someone With BPD?

It’s the “I hate you; don’t leave me” syndrome. Borderline personality disorder relationships are fraught with intensive highs and extreme lows. People with borderline personality disorder (BPD) are on a rollercoaster of unpredictable mood shifts, engulfing feelings of insecurity and self-destructive behaviors — and all too often, they take loved ones along for the ride.

Borderline Personality Disorder Relationships – The Experience

Relationships affected by borderline personality disorder are taxing. Loved ones never know who will show up — the affable, affectionate individual they fell in love with or the insecure, sometimes rage-filled person waiting in the shadows. While borderline personality disorder differs from bipolar disorder in that “borderlines” don’t switch between extreme mania and deep depression, similar to bipolar disorder, people with BPD keep those they love on edge with hot-and-cold interactions and erratic moods.

Borderline personality disorder relationships can be rocky and intense and cause you to feel:

Invalidated – People with BPD often don’t see their behaviors as problematic. This is the nature of personality disorders and one of the characteristics that make them so difficult to treat. Your loved one may brush you off when you bring up concerns about their behavior. You might get responses like, “So, I got a little angry at you? That’s normal. Every couple fights.”

Trapped – Your loved one’s intense insecurity can drive them to desperate acts in an effort to keep you around, making you feel like a hostage in your relationship. It’s not uncommon for people with BPD to threaten or attempt suicide or other self-harm. Data shows that 60% to 70% of borderlines attempt suicide but only 8% to 10% succeed.

Anxious – Mood swings and impulsivity are common symptoms in people with BPD. Not knowing what to expect from your loved one can leave you feeling anxious. You may be nervous and antsy, trying to anticipate their next mood or move.

Villainized – It’s common for people with BPD to blame those closest to them for everything that goes wrong in their lives. You’re “all good” or “all bad.” There’s rarely room for anything in between.

Idolized – They hate you one day and love you the next. As quickly as you’re the villain, your loved one puts you on a pedestal. You can do no wrong — for the time being.

Misunderstood – Borderlines can be “crazymakers.” You may feel you’re constantly having to explain yourself and blamed for even the smallest grievances. Your BPD loved one has a knack for twisting your words around and recreating history. For them, all difficulties begin and end with you. Studies confirm that people with borderline personality disorder struggle with trustworthiness perception, and especially trusting their partner during challenging situations. This is the case even when the partner has proven themselves trustworthy.

Befuddled – Loved ones of people with BPD often find themselves running in circles trying to keep the peace. Perhaps you keep a mental checklist of circumstances that have set your partner off in the past and have become hypervigilant about making sure those situations don’t repeat themselves. The problem is, people with BPD keep upping the ante, constantly changing their preferences and dislikes so you’re always having to “prove” you love them. You may often feel you’re damned if you do, and damned if you don’t.

Causes of Borderline Personality Disorder

Like many personality disorders, psychologists believe that underlying causes lie at the intersection of environmental and biological factors. Research on borderline personality disorder is still new, but has pointed to the following contributors:

Brain differences – An imbalance of brain chemicals such as norepinephrine, acetylcholine and serotonin may play a role in BPD. Those chemicals help regulate emotions that people with BPD have trouble controlling such as sadness, irritability, anxiety and anger.

Emotional dysregulation – Along the same line as imbalanced neurotransmitters, brain scans of people with borderline personality disorder show overactive activity in areas associated with emotional responses. “Borderlines” feel emotions intensely and often have knee-jerk reactions to them.

Trauma – People with borderline personality disorder sometimes have past trauma stemming from emotional abuse or neglect and attachment issues. A history of sexual abuse is also common. Some studies show around 40 to 71% of BPD patients have experienced sexual abuse. Stress and neglect have also been shown to contribute to the onset of BPD, especially in young adults.

Parenting styles – Research shows that certain parenting styles can contribute to the onset of borderline personality disorder. This may include a hostile environment, over-controlling parents or aloof parents. Children of mothers with BPD are at a higher risk for developing the disorder.

Hope for Borderline Personality Disorder Relationships

Understanding the causes of borderline personality disorder can give you more empathy for your loved one, but it’s important you don’t take responsibility for their behaviors. There are effective treatments for borderline personality disorder that can help your loved one, and in turn, your relationship. These include:

• Inpatient borderline personality disorder treatment – A recent study showed inpatient borderline personality disorder treatment helps decrease symptoms of depression, anxiety and suicidal thoughts in BPD patients and improve their ability to function in a healthy manner.
• Dialectical behavior therapy (DBT) – A therapeutic approach that focuses on emotional regulation and distress tolerance and draws heavily on mindfulness, DBT can help BPD patients manage their behaviors and emotions. In fact, one study found that 77% of participants with borderline personality disorder no longer met BPD diagnosis criteria after 12 months of DBT.
• Trauma therapies – Because people with borderline personality disorder sometimes have a history of trauma, it’s not surprising that specialized trauma therapies show promise. Trauma therapies like EMDR can help people with BPD address the root causes of some of their symptoms.
• Medications – Traditional antidepressants have shown limited success in borderline personality disorder treatment with monoamine oxidase inhibitor (MAOIs) and fluvoxamines yielding the most benefits. Research has shown promising results in decreasing BPD symptoms with atypical antipsychotics and anticonvulsants.

Borderline personality disorder relationships are exhausting. It’s tempting to let loved ones “off the hook” for their behaviors in order to keep the peace. That’s why it’s a good idea to seek treatment for yourself. A mental health professional can help you develop resiliency, learn not to enable your loved one’s behaviors, and determine if the relationship is salvageable should your loved one refuse to get help.

Many people pick at imperfections on their skin or become preoccupied with removing some unwanted hair from time to time. People with trichotillomania and dermatillomania, or hair-pulling disorder and skin-pulling disorder, experience these behaviors to such extremes that it disrupts their lives, causes them distress and shame, and sometimes alters their appearance.

Symptoms of Trichotillomania and Dermatillomania

Trichotillomania and dermatillomania are both body-focused repetitive behaviors (BFRBs) categorized under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). “Though there are similar patterns, what people are aiming for with these disorders is a little different than disorders like OCD,” says Kerrie Armstrong, PhD, a clinical psychologist at The Anxiety Treatment Center of Greater Chicago. “While both have repetitive behaviors, there is not always a thought or obsession with BFRBs.”

Hair-Pulling Disorder Symptoms

Diagnostic criteria for trichotillomania include:

• Hair pulling that causes significant distress or impairment in at least one important area of functioning
• Repeated hair removal from any area on the body for cosmetic or non-cosmetic purposes
• Noticeable hair pulling in one or multiple sites (some people concentrate on one area causing bald spots while others pull over larger areas, resulting in hair thinning)
• Unsuccessful attempts to decrease or stop hair pulling
• Hair pulling and loss that can’t be attributed to another medical condition or mental health disorder

People with hair-pulling disorder pull hair from their scalp, eyebrows, eyelashes and other areas. They may have rituals around hair-pulling like biting, chewing, hiding or eating it.

Skin-Pulling Disorder Symptoms

Diagnostic criteria for dermatillomania include:

• Skin picking that causes significant distress or impairment in one important area of functioning
• Recurring skin picking that results in lesions
• Repeated attempts to decrease or quit skin picking
• Skin picking and sores that can’t be attributed to a substance, medical condition or another mental health disorder

People with skin-pulling disorder may see skin imperfections that others don’t consider flaws. They may pick at their skin in an attempt to make the perceived imperfection look better. They may touch, rub, scratch or pinch skin until it bleeds and scabs.

5 Misconceptions About Trichotillomania and Dermatillomania

There are many misconceptions about skin-picking disorder and hair-pulling disorder. Some of these include:

#1 It’s a bad habit – People with skin-picking disorder or hair-pulling disorder feel urges well beyond the desire for everyday cosmetic fixes that many people feel. “They see things as imperfections that others don’t, and have difficulty stopping,” says Dr. Armstrong. “They know they’ve done damage and can’t leave it alone. There’s lots of embarrassment and shame.”

#2 They can “just stop” – Simply deciding to stop pulling their hair or picking their skin isn’t an option for people with these conditions. “Most of us could walk away if we started picking and drew blood or pull one hair, and it’s done,” says Dr. Armstrong. “[People with these disorders] go above and beyond what’s just a typical act for appearance’s sake.” They may have bald spots on their head or scabs and scars on their body. Discontinuing the behavior is complicated by the fact that in some cases, people don’t realize they’re engaging in the behavior until they’re in the middle of it.

#3 It’s a self-harming behavior – There’s often a misconception that people are picking or pulling for attention or as a self-harming activity like cutting. “Many of the parents of adolescents I see are very concerned they’re self-harming like someone who would self-injure, and it’s not the same thing,” says Dr. Armstrong. “Both acts can cause damage and scars, but the motivations are different.” In some cases, they’re aware of the behavior, like trying to fix a blemish. Other times, they’re not necessarily aware of what’s happening and really want to stop.

#4 It’s a form of OCD – Though trichotillomania and dermatillomania are classified under the umbrella of Obsessive-Compulsive and Related Disorders, they’re different than OCD. Unlike people with OCD, those with skin-picking disorder and hair-pulling disorder don’t always experience obsessive thoughts around the behavior. “They’re not necessarily aware of the skin picking or hair pulling, at least immediately,” says Dr. Armstrong. “It can happen automatically, and they don’t recognize it right away.” Also, unlike people with OCD who feel a sense of relief once they’ve engaged in the compulsive behavior, people with trichotillomania and dermatillomania typically feel shame and embarrassment.

#5 It’s a rare condition – Some data estimates that up to 4% of the population experience trichotillomania at some point in their lives. That translates into millions of people. Skin-picking disorder is also common, affecting about 1 in 20 people, according to the OCD Foundation. However, researchers believe that these statistics underestimate the prevalence of the disorder. They presume many people suffering from these disorders don’t seek treatment because of embarrassment or lack of available resources. “It’s only in the last eight or nine years things really started picking up with more advocacy,” says Dr. Armstrong. “Even though there’s all that info out there, patients still struggle to find people who know what it is and are willing to treat it.”

Possible Causes of Trichotillomania and Dermatillomania

Research on hair-pulling disorder and skin-pulling disorder is still in its infancy, but so far, studies have shown contributing factors that include:

Brain abnormalities – Some research has found neurological abnormalities in people with skin-picking disorder. Research has also shown changes in areas of the brain associated with cognition, affect regulation and habit learning in animals and people with hair-pulling disorder.

Genetics – Some studies have found genetic indicators in people with these disorders such as the same gene mutation in first-degree family members diagnosed with trichotillomania.

Co-occurring disorders – People with trichotillomania and/or dermatillomania are often diagnosed with one or more co-occurring mental health disorders. Some of these include body dysmorphic disorder, anxiety, mood disorders, OCD and eating disorders. “The biggest thing I see is anxiety in general and anything that falls within it,” says Dr. Armstrong. “I have several patients with mood disorders. When you have a patient with skin-picking disorder you also have to be aware of the possible presence of body dysmorphic disorder.”

Emotional regulation issues – Some data indicates people with body-focused repetitive behaviors have less tolerance for strong emotions and stress than those without these disorders.

Treatment for Trichotillomania and Dermatillomania

Treatment for skin-pulling disorder and hair-pulling disorder aims to increase the individual’s awareness of the behavior and target strategies to decrease it. “We could probably come up with the root cause, but a lot of times that doesn’t do enough,” says Dr. Armstrong. “Generally they need a very focused behavioral piece.” She compares it to people in addiction recovery. Effective drug and alcohol rehab addresses the underlying issues. Another critical component is making environmental changes that lessen exposure to triggers as well as developing tactics for dealing with those triggers when the individual encounters them.

Most hair-pulling disorder and skin-picking disorder approaches have a cognitive behavioral therapy component and include:

Functional assessment – Therapist and client dissect the experience before, during and after skin picking or hair pulling to try to “slow down” the behavior. For instance, Dr. Armstrong will ask clients to think about a specific hair-pulling or skin-picking incident – where they were, what they were feeling, what they were thinking, what they did prior to and following, and if they did anything with the skin or hair after they picked or pulled. This process can help her determine what therapeutic tools to use.

Habit-reversal training (HRT) – HRT helps clients become aware of destructive behaviors before they take place and then counter them with a “competing response.” For example, people with skin-picking disorder might make a fist or play with a fidget toy when they feel the urge to pick their skin coming on.

Stimulus control – In this technique, people try to change the environmental components of their behaviors. For instance, if they always pull their hair or pick their skin in bright lights with a mirror, they’d cover the mirror and keep lights low. Dr. Armstrong says this approach can be useful with clients that don’t necessarily feel the urge coming on but rather become aware of their behavior while in the midst of it.

Dialectical behavior therapy (DBT) – The mindfulness and distress tolerance aspects of DBT can be especially helpful with hair-pulling disorder and skin-picking disorder. These skills help people better tolerate their emotions and remain present in the moment so they’re aware of urges before it’s too late. “Having pieces of mindfulness so they are better able to be in the present moment and aware of urges that happen can help them ride those [urges] out without having to do anything about it,” says Dr. Armstrong.

Medication – Pharmacology outcomes are mixed for these disorders and large, double-blind studies are needed. One study showed N-acetylcisteine, a glutamate modulator often used for asthma, rashes and other skin conditions, has been effective in treating trichotillomania. Treatment with fluoxetine (Prozac) has shown some positive results for people with skin-picking disorder. However, the general consensus of researchers is that any pharmacology should be used in combination with behavioral therapy.

Usually treatment involves a combination of techniques; what works is different for each individual. “Very rarely is it one thing that is going to work,” says Dr. Armstrong. “What we’re working toward is not necessarily a cure but ways to manage and decrease the behavior so the individual can feel that they are the one in control.”

A country divided by ideology over slavery and the federal government’s role in prohibiting it led to America’s Civil War of 1861-1865 and a devastating loss of 625,000-750,000 lives. Long after rain washed away the blood of thousands of fallen soldiers at Gettysburg, Shiloh, Chancellorsville, Antietam and dozens of other battlefields, the nation was left with maimed veterans suffering from horrific injuries, amputations and chronic pain. Although the Civil War sparked an opioid epidemic rivaling the one America is currently experiencing, the use of morphine to treat sick and wounded soldiers harkens back to the American Revolution. As Alexander Hamilton lay dying from fatal wounds incurred in his duel with Aaron Burr, his doctor prescribed laudanum, a tincture of opium (codeine and morphine) mixed with alcohol.

The 19th Century Opioid Epidemic

The Union Army alone issued nearly 10 million opium pills to its soldiers in addition to 2.8 million ounces of opium powders and tinctures. The hypodermic syringe was introduced in the U.S. five years prior to the onset of the Civil War, in 1856. Thousands of Civil War soldiers wounded during combat or fallen ill in camps, were prescribed opium or morphine for the first time in field hospitals during the war. Many soldiers returned home from the war with gruesome amputations and narcotic addictions.

One Union soldier who endured brutality at the infamous prison camp Andersonville wrote about opioid withdrawal symptoms when he tried to quit cold turkey. “No tongue or pen will ever describe … the depths of horror in which my life was plunged at this time; the days of humiliation and anguish, nights of terror and agony, through which I dragged my wretched being.” This soldier’s description is akin to the agonizing symptoms associated with what’s known today as acute withdrawal, which is often followed by post-acute withdrawal syndrome.

It wasn’t only soldiers who became addicted to opioids. Heartbroken families turned to drugs to cope with the devastating loss of husbands, sons, brothers and fathers, especially hitting southerners hard after defeat and the loss of wealth after the fall of the Confederacy.

In his book Dark Paradise: A History of Opiate Addiction in America, author David T. Courtwright wrote, “Even if a disabled soldier survived the war without becoming addicted, there was a good chance he would later meet up with a hypodermic-wielding physician.” Although morphine was not a cure, it was found to be an effective method for dulling all types of pain. In its most potent form, laudanum was widely used to treat lung diseases such as tuberculosis and in the Civil War to facilitate amputations. In its milder form, it was commonly prescribed for insomnia, colds and coughs in infants and adults. Alarmingly, laudanum was responsible for 236 infant deaths in a four-year time period in the late 1800s.

From the 1840s to 1890s, opiate usage in the U.S. rose by 538%. During the 1890s, the Sears & Roebuck catalog offered a syringe and a small amount of cocaine for $1.50. By 1895, the wide use of morphine and opium powders led to about one in every 200 Americans getting addicted to opioids, which equates to an estimated 344,500 people. It is estimated 60% of those addicted were women.

America’s War on Drugs

Most people associate America’s war on drugs with modern times, but it began in the late 19th to early 20th century. By the late 1890s, most medical school curriculums included education about the dangers of opiates. Bayer introduced heroin in 1898 to treat respiratory illness and it was often available without a prescription, which led to another upsurge in addiction. The following year they introduced aspirin commercially and many doctors realized it was the safer option for common aches and pains.

In 1909, a bill passed Congress to ban the import of opium, which by now was burgeoning due to the proliferation of opium smoking dens in most major cities and Western towns. The shift from a painkiller narcotic to a recreational drug played a part in changing the nation’s view on opioids. The Harrison Narcotics Tax Act of 1914, which went into effect in March 1915, was enacted to more strictly regulate the distribution of cocaine and opium-based drugs. According to Courtwright, the use of opioids had already been declining for about 20 years. And by 1920, the U.S. had succeeded in reducing the number of Americans addicted to opioids to less than two in every 1,000 people.

The Current Opioid Epidemic

The onset of the current opioid epidemic is blamed in part on Purdue Pharma launching aggressive targeted marketing campaigns starting in 1995, stating OxyContin (oxycodone) was not addictive. Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before evidence showed these medications were highly addictive.

The number of prescription opioids (e.g., oxycodone and hydrocodone) sold to pharmacies, hospitals and doctors’ offices nearly quadrupled from 1999 to 2010. By 2016, opioid overdoses reached a new high of more than 42,249 deaths, with an estimated 40% involving a prescription opioid. Of 948,000 people who used heroin in 2016, 170,000 were first time users and the drug was linked to 15,469 overdose deaths. On a positive note, misuse of all prescription opioids has been declining in 12th graders, with a 2017 prevalence of 4.2% versus 9.5% in 2004.

Unlike the early 19th century, today we are armed with sophisticated medicine, technology and science, robust clinical research, the knowledge addiction is a chronic disease and lessons from the past. Preventing overdose deaths, access to addiction treatment and preventing new addictions are only parts of the equation. While it’s essential to punish drug dealers, history tells us ostracizing and punishing users is not the solution. And it’s also unfair to cut off all prescription opioids from people suffering from severe, debilitating chronic pain syndromes. Developing less addictive, efficacious alternatives could help, but solutions to this problem need to address all of the contributing factors.

All parents of teens and even of younger children should know the facts about teen drinking and drug use. You may assume that your child would never drink or use drugs, but making that assumption is dangerous.