Ask the Clinician: Borderline Personality Disorder

A short discussion of one of our most misunderstood mental health

conditions

Who Am I?

• R. Cecilia Jefferson, MD, a final-year psychiatry resident at UW-Madison

• A woman with a medical and psychiatric training background• A person who genuinely enjoys taking care of people with

borderline personality disorder• A person who thinks words are very important!• A person who is pretty uncomfortable with the term “Expert.”

– Words are important! “Expert” is not the right word for me. I’m just a person with a particular kind of background and experience.

– I prefer to call myself a clinician.

What is A Personality Disorder?

• Again, words are important! • Layperson terms vs Clinical terms• To a layperson:– “Personality Disorder” might sound like I’m saying,

“There’s something wrong with who this person is, as a person.”

– That’s a common, unfortunate misunderstanding! • To a clinician: – “Personality Disorder” has a very specific definition:

Clinical Term: Personality Disorder

• DSM-5: – “A personality disorder is an enduring pattern of

inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”

Clinical Term: Personality Disorder

• Basically, when we say Personality Disorder, we mean:– A stable, enduring, long-term pattern of struggles,

pervasive over multiple areas of a person’s life, that causes inner suffering and/or observable problems

– The areas of suffering and trouble are most often found in interpersonal relationships.

Bottom Line:

• These are people who struggle with consistently relating to other people in a way that is healthy, helpful, and effective for them.

• Their way of relating may have worked in the past, or may work in certain situations, but it’s inflexible!– They find it hard, or haven’t learned to relate in a different

way, even when their usual way causes suffering, both for them, and for others

• The relational pattern is what causes the suffering. – In personality disorders, we don’t really treat the person, as

much as we treat the pattern.

Borderline Personality Disorder

• What is it?– Misunderstood– Stigmatized– A clinical term that’s sometimes misapplied (even by some

doctors!), and misused as a descriptive word, or even as an insult!

– Often confused with Bipolar Disorder– It is both the result of suffering, and a cause of suffering– The relational pattern is the cause of the suffering, both for

the person and those who love and care for them• We don’t really treat the person – We treat the pattern!

How did it get that name?

• Bit of history! – The term “Borderline” comes from old-school Freudian

psychoanalysis• First used by Stern in 1938

– Originally trying to describe “unstable” people who were on the “borderline” between neurosis and psychosis

– These are antiquated psychological terms that either aren’t used anymore, or have drastically changed their meaning!

• It’s a really outdated name, that does a pretty bad job of describing what we’re talking about

• But for some reason, it stuck!

Borderline Personality Disorder: Facts

• We’re bad at estimating how common it is!– Affects anywhere from 1.6%-5.9% of the US population

• More commonly diagnosed in women:– A ratio of about 4:1 women over men

• High risk of completed suicide compared to the general population– Lifetime risk of around 7% in BPD– General population risk is around 1%

• Very commonly associated with a history of abuse – Especially childhood sexual abuse

What causes BPD?

• We don’t really know. • Thought to be a combination of genetic and

environmental factors• Genetic:

– High rate of heritability in studies of identical twins– More likely in people with a 1st degree relative with the

disorder• Environment:

– Commonly associated with childhood abuse and neglect– Associated with growing up in an environment where the

person’s feelings were dismissed, ignored, or invalidated

DSM 5: Borderline Personality Disorder

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

1. Frantic efforts to avoid real or imagined abandonment. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation.3. Identity disturbance: markedly and persistently unstable self-image or sense of self.4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,

irritability, or anxiety usually lasting a few hours and only rarely more than a few days).7. Chronic feelings of emptiness.8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of

temper, constant anger, recurrent physical fights).9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Breaking It Down

• A pervasive pattern of • Unstable interpersonal relationships, • Unstable self-image (sense of self), • Unstable affects (moods), and • Marked impulsivity, • Beginning by early adulthood (teens-20s) and • Present in a variety of life situations

Unstable Relationships

• Criteria 1 & 2 describe what this means:1. Frantic efforts to avoid real or imagined abandonment.

(Imagined=It looks like abandonment to them, but might not be intended that way. “Perceived” is a better word.)

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (Sometimes called “splitting.”)

• “I love you! I hate you! Don’t leave me! I’ll die!” – Can feel all of these things, all at once.

• Relationships can look dramatic, and actually be very painful, confusing and exhausting for these folks, and the folks who love and care for them

Making Sense of It

• For a child, avoiding abandonment is a matter of survival! – Having a hair-trigger for the possibility of abandonment

might have developed as a result of real abandonment or neglect as a child!

– Many of these folks have never known what it’s like to feel safe in a relationship.

– The middle between love and hate, the grey area where most of us live, is a place of safety – And these people have never known that safety! They’re not sure how to find it, or how to keep it when they do find it.

Unstable Sense of Self

• Criteria 3 & 7 describe what this means :3. Identity disturbance: markedly and persistently unstable self-image or sense of self.7. Chronic feelings of emptiness.

• Criteria 5 & 9 can be symptoms of an unstable self:5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Making Sense of It – Unstable Self

• That inner feeling of emptiness comes from the absence of a sense of SELF

• Most folks develop a sense of who they are and how they feel through childhood and adolescence, by having their feelings validated and recognized by important people in their lives repeatedly over time– That’s an experience many people with BPD did not have!– As a result, it’s hard for them to define who they are and how they

feel outside of reacting to what other people are doing or saying. – So, other people’s reactions, no matter how small, become a

matter of life or death – Because those reactions from outside are what define who the BPD sufferer is, inside.

Making Sense of It – Self Harm

• A sense that the self is not real or valuable can also lead to the thoughts of self-harm and suicidal thoughts:– Cutting is dangerous, but it can also be a way that

borderline sufferers develop to feel real, like they’re in their bodies

– Feeling chronically empty, like you don’t count, can lead to feelings of worthlessness and thoughts of wanting to die (suicidal thoughts)• These thoughts often lead to suicidal behavior.

Making Sense of It – Dissociation and Paranoia

• A sense that the self is not real, valid or valuable can lead to distortions in a person’s perception of reality– Dissociative phenomena: Feeling like you’re floating

outside your body, like you’re separate from reality, “blacking out,” losing awareness; also includes intense flashbacks

– Paranoid thoughts, or over-reading the reactions of others– If you can’t trust your sense of who you are or how you

feel, how can you trust your perception of the world around you, and its people?

Unstable Affect and Marked Impulsivity

• Criteria 4, 6, & 8 detail what we mean here:4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Making Sense of It

• Mood reactivity, affective instability, and impulsivity are part of the reason that Borderline Personality Disorder is often confused with Bipolar Disorder– Sometimes people use the word “bipolar” to talk

about any kind of mood instability. – Using clinical terms as descriptive words in this

way can lead to a lot of confusion! Words are important!

• The affective instability of borderline personality disorder is just as real and potentially harmful as what happens in bipolar disorder. – It just comes from a different place and follows a

different pattern! • Yes, you can have both borderline personality

disorder and bipolar disorder! It’s not common, but some people do. – The distinction can be very difficult to make.

Making Sense of It – Unstable Affect

• Mood vs Affect– Mood: Means the internal sense of how you feel

emotionally (feeling sad, or euphoric, or angry)– Affect: Means the external sign of how someone is

feeling (crying, laughing, yelling)• In borderline personality disorder, both the

internal sense and the external sign of a person’s feelings are out of balance!– And sometimes, the external and internal don’t

match!

Making Sense of It – Unstable Affect

• Affective instability relates to an unstable sense of self:– Again: Most folks develop a sense of who they are

and how they feel during childhood and adolescence, by having their feelings validated and recognized by important people in their lives, repeatedly over time

– Without this validation, it’s hard to develop a sense of BOTH how you feel inside (your mood), and how you’re supposed to express those feelings (your affect)

• Again: Every perceived reaction of others, no matter how small it may seem, feels like a matter of life and death to those suffering from BPD, because the reactions of others are instrumental in determining not only how borderline sufferers feel, but in giving them a sense of who they are inside

Making Sense of It – Unstable Affect

• Not having a sense of how you feel and what feelings look like can make the world very confusing and frightening– Just as those with limited vision have an easier time

reading large print, it’s easier for borderline sufferers to “read” the language of big, dramatic feelings and reactions, and to write in that language, too

• “Mood reactivity” is the clinical term for the high sensitivity and mood fluctuations we’ve described

• “Affective instability” is the clinical term for the external evidence of those mood fluctuations

Making Sense of It - Anger

• Separated out from the “unstable affect” criterion because it can be present on its own, and it can cause so much suffering on its own – It is one type of reactivity, but a very important one

• Borderline sufferers often feel intense anger, and can react in anger to a degree out of proportion to what is happening around them– They can also have a “hair trigger” for an anger response– Explosive anger can often become their default response to

situations that would make anyone feel helpless or powerless

Making Sense of It - Anger

• Anger is a natural, human response to a sense that we are under threat– Anger is the way we defend our boundaries! It’s

how we let others know they’ve crossed a line that’s not okay

• Borderline sufferers are often people who have had their most basic, vulnerable lines crossed, when they were not in a position to defend themselves– Childhood abuse is the most common example

• As a result, their internal threat meter is poorly calibrated: Too sensitive in some situations, not sensitive enough in others, and prone to triggering big reactions

Always near the red zone!

• Anger is just one of many ways a borderline sufferer can react to the feelings of emptiness and helplessness they carry with them

Making Sense of It - Impulsivity

• Impulsivity: – Defined as a tendency to engage in behavior without much

forethought, usually behavior that might feel good in the moment, but has the potential to result in harm or danger

– Can be understood as another manifestation of the trouble borderline sufferers often have controlling their reactions• Getting “caught up” in a feeling or in a moment

– Can also be understood as the other end of the spectrum from self-harm or suicidal thinking – Also a result of not having a sense of the Self as real and valuable

Bringing It Back TogetherBorderline Personality Disorder is:A pervasive pattern of unstable interpersonal relationships, unstable self-image, unstable affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined (perceived) abandonment. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation.3. Identity disturbance: markedly and persistently unstable self-image or sense of self.4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,

irritability, or anxiety usually lasting a few hours and only rarely more than a few days).7. Chronic feelings of emptiness.8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,

constant anger, recurrent physical fights).9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

How is it treated?

• Psychotherapy is the cornerstone!– A trusting therapeutic relationship with clear and

consistent limits and boundaries is key– Dialectical Behavioral Therapy

• Invented by Marsha Linehan• Reduces self-harm and hospitalization• Teaches emotion regulation, distress tolerance, interpersonal

skills• Group and individual therapy are components

– DBT grew out of Cognitive Behavioral Therapy, mindfulness principles, and the psychodynamic concept of “re-parenting” – All are helpful approaches

Do we use medications?

• Yes! – But it’s important to realize that medications don’t treat the core

symptoms of emptiness and disrupted sense of self– There is no medication specifically designed to treat borderline

personality disorder• Medications can sometimes help with certain symptoms, but

they are used “off label,” and we have to be mindful of the side effects, which can be very serious! – SSRIs can help with low mood and anxiety– Mood stabilizers can help with fluctuating moods (these medications

can have serious side effects)– Antipsychotics can sometimes help with severe dissociation,

disorganized thinking or rage (can also have serious side effects)

About Medications…

• People who suffer from Borderline Personality Disorder often ALSO suffer from Major Depressive Disorder, other mood disorders, anxiety disorders, Post-Traumatic Stress Disorder, and eating disorders. – Often when we use medication, we are mainly treating

the symptoms of these other disorders, which affect and/or go along with Borderline Personality Disorder.

• Again for emphasis: The main treatment for Borderline Personality Disorder is psychotherapy!

Prognosis

• Actually, the prognosis for Borderline Personality Disorder is very good with treatment!– In studies that tracked patients for 6 or more years, as

many as 70-80% of the participants recovered with treatment• Meaning, their symptoms improved, they were able to do

some sort of work, engage in relationships, and stay out of the hospital

– Note the caveat: With treatment of some sort. Helping people get into treatment when they are ready is important.

In Summary

• Borderline Personality Disorder is complex, often stigmatized and not often understood

• It often develops from a background of suffering, and causes suffering for the person with the disorder, and the people who love and care for them

• It is treatable, and recovery is very possible!

Thank you!

Questions Please!