About Borderline Personality Disorder
Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders in the DSM-IV, ten of them to be specific (a number that will be reduced to six in the DSM-V), that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person’s subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships. It is noteworthy that the DSM-V description of personality disorders includes this emphasis on sense of self and relations with others more than the previous editions of the DSM did.
We explain that the ten different styles have many overlapping features and that most people have a mixture of those styles, but most importantly, that when people personify and live out any of those styles with a certain consistency, inflexibility, and in such a way that causes a certain level of distress in one’s emotional and interpersonal life, they meet criteria for a personality disorder. For patients with BPD, in reviewing the DSM-IV symptoms that the particular patient in question meets, we note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more “under the radar,” characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms. We also find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones).
Our view is that the problems in the patient’s identity, that interact with a propensity to intense emotional responses and lead to the associated difficulties in the patient’s interpersonal life and the other symptoms of BPD, are best explained by a “divided” or “split” sense of self and others. We refer to this as the “split psychological structure” in which different, contradictory ways of thinking about the self and others manifest themselves at different times, or in different ways, but rarely if ever, at the same time. For example, a patient may present as morally rigid, highly concerned about proper and respectful behavior, but at other times engage in questionable moral practices and behave in provocative and inappropriate ways. Or a patient may present as very quiet and meek, describing a history of poor treatment by others but may, at times, demonstrate hostile and contemptuous behavior toward others. Yet another patient may present as self-sufficient, arrogant, a “know-it-all”, rejecting all that the therapist has to offer, whereas the therapist knows from the history and referral source that the patient has recently suffered fleeting depressive and suicidal feelings pursuant to one in a string of occupational failures. None of these “self representations” are specifically listed as BPD criteria in the DSM. Nevertheless, they each can be viewed as part of a dyad – a specific internal mental representation of self in relation to another. A borderline patient’s particular set of mental dyads involves contradictory representations of self, each of which experienced as true and authentic parts at the time it is being experienced. This alternation across time between different experiences of self can lead to confusion, anxiety, depression, and a sense of emptiness that comes from not having a stable sense of the core self.
How does this “split” sense of identity emerge, and why? We understand personality a person’s habitual way of experiencing self and others and of interacting with the world around him. We see these habitual patterns of experiencing the self and others as built up from people’s prior experiences, particularly those emotionally-charged interactions between the infant/child and significant caregivers, which are repeated over time. These experiences of self-in-relation-to-others from early in life are part of the normal developmental process and result in a set of expectancies as to how the self will be treated or experienced by another, and vice-versa, in subsequent relationships. In early infant development, specific experiences lead to dyads that are associated with specific emotions – pleasure/satisfaction and pain/frustration. In early life, these dyads are not accurate or literal representations of what is actually happenig; rather, they tend to represent polarized, extreme images and affects which are affected by the individual’s particular temperament – intense or quiescent, which links this way of thinking about BPD to current neurobiological studies.
In the case of healthy psychological development, these early, extreme and disconnected representations gradually become integrated into more complex, subtle and realistic internal images of self and others. We come to realize that we, and others, have both good qualities and bad, that we can experience disappointments in ourselves or others while still appreciating the good qualities. We learn that experiencing negative emotions does not destroy the capacity for positive emotions and that our emotional state can be complex, with a variety of emotions of multiple valence (rather than only all positive or all negative) in relation to others. In the case of healthy identity, various representations or ways of experiencing the self can co-exist without a sense of tension, dissonance, or threat. One can see oneself in any given interaction as smart, yet with something still to learn; one can see oneself as driven, a bit aggressive, yet at the same time patient and forgiving; one can see oneself as one who is dependent upon others, but is capable of operating in various spheres, effectively, on one’s own.
Indeed, healthy identity is defined as integrated and coherent, stable across time, and as based on a realistic self assessment in which positive affects predominate over negative affects, and with resulting ego strength that is sufficient to navigate life’s challenges and disappointments. In the case of the personality disorders, and BPD in particular, however, there is a failure of integration of these self representations. Internalized dyads associated with sharply different affects (positive and negative) remain split off and continue to exist independently from one another so that the world is experienced in highly concrete/all-or-nothing terms, and with confusion and lack of continuity. Consequently, in response to triggers (life events), an individual experiences himself, and others, in terms of extreme and simplistic representations that are not coherently connected with the representations of self and other that might be triggered by a minor event (e.g., the individual may feel very happy and valued when a friend smiles at him, and may feel sad and worthless if the friend is late for meeting; the corresponding images of the friend would be a loving person in the first instance and a rejecting person in the second.)
Let us now extend this idea of the split sense of self, this sense of a dyad that is split, with part of the self being experienced at one time and another part at a second point in time, to the realm of interpersonal relationships. For the BPD patient, at each point in time he is experiencing only one self-representation, connected to one dyad; for example, the rigidly moralistic self at one moment, or the victimized self at another moment, or the nurtured self at a third moment. We find that each of these partial self-representations corresponds, at that moment, to a view of the other, who is experienced in the moment as the embodiment of the other side of the dyad. When a BPD patient is experiencing himself as moralistic, he tends to experience others as loose, slackers, unrighteous. Similarly, the patient experiencing herself as a meek, innocent victim tends to experience others as hostile, hurtful, and persecutory. The BPD individual who is experiences herself as nurtured and cared tends to experience the other as the perfect provider and caretaker. As life develops the situation is complicated by the fact that the patient may have populated his or her life with characters who actually, or at times, embody some of those tendencies. It is therefore very important, in the course of therapy, to sort out the degree to which the patient’s description of others is colored by the representations in his or her mind in contrast to the degree to which the patient is accurately describing others. This is one reason we find it very useful in therapy to focus on the transference – the patient’s perception of the relation with the therapist – so that we can compare the patient’s experience of what is happening with what appears to be happening on an objective level. As we get to know patients, what we tend to find is that patients need to experience others, including often their therapist, as embodying the opposite of side of the dyad. In sum, the patient’s experience of others is as divided, split, and unrealistic as is his or her sense of self.
The other BPD criteria tend to follow from this description of splits in the representation of self and other. When a person lives life with a need to avoid certain experiences of the self, positive or negative – loving or hating, because that self representation is too threatening (or perhaps too exciting), it results in a feeling of instability, of incompleteness, as the experience of the self shifts across situations and different interpersonal situations. Indeed, patients with BPD describe a subjective sense of instability, emptiness, and inner confusion. Other people then, come to play an important, albeit unrealistic role in the BPD patient’s life. They are not simply friends with whom to experience and share life, but crucial assistants in the patient’s self regulation (although usually unaware that they have been placed in this role). For example, if a patient needs to experience himself as smart or popular, and chooses associates that help mirror that feeling, then he needs to carefully control interactions: he can’t have others look smarter or more attractive than he is, because then his sense of inadequacy would come into awareness. Similarly, a patient can’t have the other leave him because then he’s on his own, to face his worst sense of self. In another example, if a patient can’t tolerate her own tendencies to be judgmental, contemptuous, and hostile, it stands to reason that she will often see in others those same tendencies, and will experience others as judging her, as being unreasonably cruel or angry with her, and at times may accuse them as such.
Although these processes do not operate consciously in the individuals with personality disorders, one can easily imagine the strains that this way of experiencing the self and the world places on one’s interpersonal relationships, and one can also see how some of the other BPD criteria would logically follow, namely the intense and unstable interpersonal relationships, the propensity towards intense, inappropriate anger, the fears of abandonment, and, one can imagine, the impulsivity, the transient suicidal feelings and parasuicidal behaviors that result when others fail to assume the roles the borderline patient has unconsciously assigned them, or when others actually reject or leave the patient, with a mix of confused, exasperated, angry, and/or frustrated feelings.
Borderline Personality Disorder (BPD) is a serious and prevalent psychiatric condition characterised by affective instability, marked impulsivity, and significant deficits in the capacity to work and maintain meaningful relationships. Patients with BPD struggle with a profound fear of abandonment, identity disturbances, and paranoid ideations. They are at risk for suicide, repetitive self-destructive behaviours, and comorbid mood, anxiety, and substance use disorders. Stern (1938) coined the term "borderline personality" to describe low-functioning, difficult-to-treat psychiatric patients whose symptoms lay between neurosis and psychosis. Thus, 'borderline' constituted a "broad category of patients whose psychology did not portray the chaos, disorganization, or defect in reality testing associated with psychotic patients, but also lacked the integration, stability of relationships, and regulation of affect associated with neurotic patients" (Kernberg and Michels 2009). Borderline personality disorder remains one of the most severe mental health problems in all of psychiatry.
Our understanding of borderline personality disorder began to take shape with the seminal work of Otto Kernberg (1967), who offered a perspective of 'borderline' as a syndrome and not as a default categorization of individuals that did not meet the neurotic or psychotic diagnosis. Following this breakthrough, Grinker and colleagues published the first empirical study of the Borderline Syndrome (Grinker et al. 1968). Subsequently, Gunderson and Singer (1975) provided the first clinical conceptualization of the disorder and attempted to define diagnostic criteria for BPD. By 1980, the construct of BPD was considered developed and validated to the extent that the disorder was included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980). Since then, the disorder has captured the attention of scores of researchers and clinicians and has become the most studied personality disorder.
Clinical Presentation and Diagnosis
BPD is a complex clinical syndrome that has three core features: emotional instability, impulsive behaviours, and interpersonal turmoil. These basic features, as well as cognitive symptoms, are captured by the DSM-IV-TR diagnostic criteria for BPD (American Psychiatric Association 2000). The DSM-IV-TR considers 9 diagnostic criteria in total, but only 5 are required to make a diagnosis of BPD. Below, we briefly describe each of the 9 criteria.
1) Avoidance of Abandonment
People with BPD have a strong fear of abandonment, and are thus very sensitive to any cue (real or perceived) that they are being rejected or abandoned. This can include strong reactions to seemingly minor rejections by others (e.g., becoming enraged when someone cancels plans). People with BPD will often engage in behaviours designed to reduce concerns that they are being abandoned (e.g., frequently calling someone they are in a relationship with to "make sure" that there are no signs of impending abandonment). Unfortunately, this type of behaviour may actually create the feared outcome, leading to failed relationships and even greater fears of being abandoned.
2) Unstable and Intense Interpersonal Relationships
Individuals with BPD attach rapidly and profoundly to others, even early on in relationships. Their perception of intimacy is greater than that of the other persons, and in many cases, it is inappropriate. Moreover, their perception of others often alternates between over-idealization and devaluation, which is also known as splitting. Splitting refers to difficulty holding opposing thoughts, feelings, or beliefs about one self or others. In other words, positive and negative attributes of a person are not joined together into a cohesive set of beliefs. For example, a person with BPD may view her boyfriend as "good" one minute, but shift to seeing him as all "bad" or even evil the next. Because of splitting, it is difficult for individuals with BPD to recognize that "good" people sometimes do things imperfectly or make mistakes.
3) Identity Disturbances
Unexpected and sudden changes in goals, interests, preferences, and values are portrayed by persons afflicted with BPD. These unanticipated changes can range from relatively minor things, such as changes in appearance, to aspects central to the life of the individual, such as career paths and goals. These sudden changes usually accompany interpersonal turmoil. Realistic or unrealistic perception of abandonment, feelings of loneliness, emptiness, and hopelessness are usually the specific triggers of these changes. Identity disturbances in individuals with BPD usually reflect efforts to preserve a sense of self-worth in the presence of interpersonal turmoil.
Impulsivity is a tendency to act quickly without thinking about the consequences of one's actions. Impulsive behaviour usually occurs in reaction to some event that has caused the person to have some kind of emotional response. Unprotected promiscuous sex, substance abuse, reckless driving, and binge eating are some examples of the impulsive behaviours seen in people with BPD. The impulsivity of individuals with BPD may be the consequence of their perception that they are not valued by others. As such, impulsive self-damaging behaviours are used to shield themselves from possible abandonment by a significant other. Alternatively, impulsivity in people with BPD may be caused by an inability to control motor responses (Nigg et al. 2005). These behaviours can increase the risk of suicide, and thus are of great concern.
5) Recurrent Suicidal Behaviour, Gestures, or Threats, or Self-Mutilating Behaviours
Emotional instability, behavioural impulsivity, and fears of abandonment put individuals with BPD at a high risk for self-harming behaviours. It is believed that suicidal behaviours, gestures, or threats are meant to retain the attention and affection of significant others. Although these threats are usually regarded as manipulative tactics on the part of the individual with BPD, they are very difficult to ignore. Therefore, such behaviour is reinforced by the success of bringing the other person closer and eliminating the sense of abandonment. On the other hand, if the threat is ignored, an actual attempt at ending their lives might be carried out with a great probability of being successful.
Self-mutilating behaviour involves the direct and deliberate destruction or alteration of the body. This is also referred to as self harm or self injury. Examples of self harming behaviours include cutting, burning, needle sticking, and severe scratching. Self-mutilating behaviours are seen as coping mechanisms used to regulate negative emotions such as pain, loneliness, and extreme anger (Klonsky and Olino 2008). These behaviours are generally not conducted with the intent to commit suicide.
6) Affective Instability
A key feature of BPD is affective instability (also called emotional lability or affective dysregulation). People with BPD experience a lot of dramatic shifts in their emotional states. They may feel okay one moment but then feel angry, sad, lonely, afraid, jealous, or shameful moments later. These emotional shifts are intense and frequent. Changes in mood can last for hours and in rare cases for days. People with BPD experience changes in their affect more readily when confronted with interpersonal stress. This being said, it is rare that others can persuade these individuals out of their mood states. Instead, people with BPD may react with intense anger to the efforts of those attempting to provide some emotional relief.
7) Chronic Feelings of Emptiness
Persistent feelings of emptiness are often expressed by individuals with BPD. They are usually unable to express their aspirations and desires. To an outside observer, a person affected with BPD may appear as shallow and unmotivated. The feeling of emptiness and the inability to express what they desire in life brings upon feelings of anxiety and self-defeating behaviours. Individuals with BPD often believe that their feelings of emptiness will push significant others away, thus, increasing their fear of abandonment. This can elicit behaviours that are meant to attract others, while in reality these behaviours usually trigger interpersonal conflict.
8) Inappropriate, Intense, Uncontrollable Anger
Intense, inappropriate anger is one of the more troubling symptoms of BPD. Anger in BPD is deemed inappropriate because its level is usually more intense than is warranted by the situation or event that triggered it. For example, a person with BPD may react to an event that may seem small or unimportant to someone else (e.g., a misunderstanding) with very strong feelings and manifestations of anger (e.g., yelling or becoming physically violent). The stability of social relationships is constantly threatened due to the explosive nature of the anger.
9) Paranoid and Dissociative Symptoms
Paranoid thoughts and dissociative symptoms are common in BPD. They are typically transient and appear at times of extreme stress. Perceived abandonment from a significant other frequently serves as the cause of these symptoms. Paranoid thoughts of someone with BPD may involve unrealistic ideas about others trying to harm him/her, or that everyone around is purposefully abandoning him/her as part of a conspiracy plan. Dissociative symptoms reflect depersonalization experiences whereby the person feels as an observer in his or her own life, and able to observe his or her life from outside their own body. Generally, by taking away the trigger of the stress it is possible to end the paranoid or dissociative experiences. Consequently, the paranoid and dissociative episodes characteristic of BPD patients differ significantly from those experienced by patients with psychotic disorders whose symptoms are more stable.
People with BPD may experience these feelings in response to certain triggers. For example, they may see anger in someone else’s face, even though that person is not feeling that way, and have a stronger reaction to words with negative meanings than people who do not have BPD. Identifying and learning to respond to these triggers is a major step toward recovering from the illness.