PERSONALITY DISORDERS

What is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a type of personality disorder, typically arising in early adulthood. Individuals with BPD often experience intense episodes of emotional dysregulation, have an extreme fear of being abandoned, and may often engage in impulsive behaviours. These behaviours are often chronic dysfunctional patterns that lead to inflexible and prevalent distress and social issues.

An individual with BPD may exhibit some of the following symptoms:

Ψ Frantic efforts to avoid real or imagined abandonment
Ψ A pattern of unstable and intense interpersonal relationships that alternates between extremes of idealization and devaluation
Ψ Identity disturbance: markedly and persistently unstable self-image or sense of self
Ψ Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, substance abuse, reckless driving, binge eating)
Ψ Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Ψ 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).
Ψ Chronic feelings of emptiness
Ψ Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
Ψ Transient, stress-related paranoid ideation or severe dissociative symptoms

Many individuals with BPD do not realise they suffer from it and therefore are unaware that there are healthier and more adaptive ways of behaving and relating to others.

What is the Difference Between BPD and Bipolar Disorder?

BPD and bipolar disorder share quite a number of similar symptoms, such as extreme changes in behaviour and mood. However, there are significant differences across both conditions. For BPD, behaviour and mood change quickly as a result of high stress, especially during interactions with other people. On the other hand, moods are less reactive to situations and more sustained in bipolar disorders, usually occurring in cycles that could last weeks or months. Also, unlike BPD, individuals with bipolar disorder experience drastic changes in activity and energy.

What Does the ‘Borderline’ in BPD Mean?

People often undermine the gravity of BPD when the ‘borderline’ in BPD is misconstrued as a condition that is bordering on the edge of real mental illness. The term is used to illustrate BPD patients who border between two key categories of personality disorder commonly classified in conventional literature: 

Ψ Psychosis: the individual loses touch with reality and experiences hallucinations and/or delusions due to psychological disorders

Ψ Neurosis: the individual goes through chronic distress despite remaining in contact with reality.

In BPD, the individual may experience common symptoms triggered by what others perceive as ordinary events, such as brief separation from family members. However, depending on the symptoms that surface, the individual might not necessarily fit either of the two categories.

What Causes BPD?

The three main causes thought to be responsible for the development of Borderline Personality Disorder are:

Ψ Genetics has been shown to be an indicator of BPD. Having a family history of BPD increases one’s risk of developing BPD in their early adulthood.

Ψ Childhood trauma and abuse, such as physical, emotional, or sexual abuse, have also been found to be associated with the development of BPD. Other issues include inappropriate family boundaries, poor maternal attachment or separation, or parental substance use.

Ψ Brain changes: Malfunctioning neurotransmitters can also lead to the development of BPD. In individuals with BPD, certain regions of their brain that controls behaviours and emotions do not communicate properly.

A majority of personality disorders develop in their teenage years as an individual matures and develops their personality. An individual must be over the age of 18 to be diagnosed with BPD as one’s personality and identity are usually still in the process of formation and stabilisation in teenage years. While anybody can develop BPD, individuals with existing mental conditions, such as depression, eating, and anxiety disorders, are at a higher risk of also developing it.

Comorbidities with BPD

Comorbidities occur when two or more disorders exist within an individual concurrently. An individual with BPD is also predisposed to a higher chance of developing comorbid disorders such as:

Ψ Mood disorders
Ψ Substance abuse disorders
Ψ Anxiety disorders
Ψ Bipolar disorders
Ψ Eating disorders
Ψ Somatoform disorders

Myths of Borderline Personality Disorder

There are some common myths lingering around BPD. Now’s the time to separate fact from fiction!

MYTH #1: People with BPD are attention-seeking and manipulative.

Contrary to popular beliefs, the purpose of engaging in self-injurious and suicidal behaviour is NOT to get attention. In fact, they have learnt to engage in those behaviours as a way to cope with difficult and intense emotions that they experience within, regardless of their level of awareness of the harmful consequences of those maladaptive coping strategies. Individuals with BPD experience deep-seated fear of abandonment and rejection.

A cancellation of a meet-up with friends may be a small matter to us, but to someone with BPD, it may trigger intense anxiety about being left alone. While an act of manipulation requires preplanning to influence someone else’s behaviour, the behaviours of individuals with BPD, though maladaptive, would most likely be a way to soothe themselves and to signal to those around them that they are not coping well on their own, and would benefit from some support.

MYTH #2: Only women can develop BPD.

Men may be as likely as women to develop BPD. Although it is true that there are more women than men diagnosed with BPD in clinical samples (3:1), there is no discrepancy across gender in community samples. This may be an indication of greater help-seeking behaviours among women.

The manifestation of BPD symptoms also varies between males and females. Men are more likely to exhibit externalising behaviours (e.g. impulsivity, aggressiveness, self-destructive behaviour), while women are more likely to exhibit internalising behaviours (e.g. anxiety, depression, mood fluctuations). As the symptoms typically exhibited in males with BPD are less commonly known, clinical psychologists may end up misdiagnosing or underdiagnosing them.

MYTH #3: BPD is here to stay.

As personalities are very ingrained, BPD can be challenging to address. However, it can definitely be managed. There are a range of effective therapies available that are substantiated by research. Research supports that patients who have undergone Dialectical Behavioural Therapy (DBT) for a year demonstrated significant improvement in self-injurious behaviours, number of hospitalisations, and symptom severity. 77% of them no longer met full criteria for diagnosis.

It is paramount for us to clarify the misconceptions and overcome the stigma surrounding BPD so that individuals with BPD can feel empowered to seek therapy for the disorder.

Caring for Someone with BPD

Even with the best intentions, living with someone or dating someone with BPD can be very challenging. Nonetheless, there are ways in which you can learn to manage this.

Ψ Educate yourself on BPD to empathise with your loved one.

With greater awareness, we are better equipped to understand that their impulsive and self-damaging behaviours may not be coherent with their internal needs.

Ψ Offer emotional support by listening actively and staying calm

When communicating with your loved one with BPD, it is crucial to provide your full attention in a non-judgemental manner. Individuals with BPD may hurl hurtful and irrational words when they are triggered, but do avoid invalidating their feelings and getting defensive. Focus on the emotions beneath their words to understand what they are trying to express. In the event that the conversation escalates, set healthy boundaries. An example would be to make it clear to them that you will walk away from the conversation if there are profanities or personal attacks involved.

Ψ Take care of yourself.

Prioritise your self-care by engaging in activities that spark joy in you (e.g., exercising, listening to music). It is not selfish to have a life outside of the relationship with your loved one with BPD. You may even join a support group for BPD caregivers or seek help if you’re experiencing significant distress. You can only support your loved one if you are taken care of yourself.

Ψ Encourage your loved one to seek therapy
If you suspect that a loved one might have BPD, it is best to encourage them to seek therapy early. The earlier that therapy is sought, the better the therapy outcomes. Individuals with BPD can lead very fulfilling lives too!

For more detailed information and resources on caregiver support groups for BPD, click here.

How is BPD Addressed?

Addressing Borderline Personality Disorder (BPD) requires patience, commitment, and time.

Individuals with BPD are highly recommended to attend therapy to learn psychological skills, process any childhood trauma, and to learn healthy coping strategies. Types of evidence-based therapy for BPD include:

Ψ Dialectical Behaviour Therapy (DBT)

DBT was initially developed for the managing of BPD. However, in recent years, it has also been used to manage other mental health conditions, like substance use disorders, eating disorders, and bipolar disorder. DBT can be practised in individual and group settings.

The DBT skills group sessions in our clinic focus on equipping you with skills on being mindful of what’s happening within yourself and in the present situation, how to regulate and manage your emotions, increasing your ability to tolerate distress in difficult situations, and developing healthy communication styles. Individual DBT sessions allow the client and their therapist to identify and understand the triggers leading up to the maladaptive recurrent behavioural patterns. The therapist would also remind the client about strategies learnt from the skills group to apply in relevant situations, eventually replacing the maladaptive patterns with healthier, more adaptive ones.

Ψ Schema Therapy

A longer-term therapy that focuses on identifying and changing maladaptive thinking and behaviour patterns, typically learnt from childhood. Techniques include emotional regulation strategies and experiential techniques (e.g., role play, chair work, imagery).

Ψ Mentalization-Based Therapy (MBT)

MBT uses a psychoanalytic therapeutic framework that aims to improve an individual's ability to understand their own thoughts and feelings, as well as those of others. The therapist helps the individual explore and reflect on their inner experiences and mental states of others, with the goal of strengthening their mentalizing abilities. By improving mentalizing skills, MBT helps individuals with BPD develop more stable and compassionate relationships, regulate emotions more effectively, and reduce impulsive and self-destructive behaviours.

Ψ Transference-Focused Therapy (TFT)

TFT uses a psychoanalytic therapeutic framework that concentrates on the therapeutic relationship between the individual and the therapist, and the transference reactions that arise within the therapeutic relationship.

The objective of TFT is to help individuals with BPD understand and manage intense and often complex emotions towards the therapist, which may reflect patterns of interpersonal difficulties in their lives outside of therapy. By exploring and working through these transference reactions, TFT can help individuals gain insight into their relational patterns, develop healthier ways of relating, to improve their social functioning and overall well-being.

While these therapies have been found to be effective, it is important that therapy should be tailored to the individual's specific needs and preferences. Like other mental health conditions, getting professional help as soon as possible leads to improved outcomes and prognosis.