A note about DBT programs in the area:
Seattle Anxiety Specialists, PLLC does not currently provide treatment for Borderline Personality Disorder, as we do not currently have a DBT program. If you are looking for treatment for Borderline Personality Disorder, or related symptoms, please consult this list of options for DBT programs in the Seattle area:
Borderline Personality Disorder (BPD)
OVERVIEW
Borderline Personality Disorder (BPD), also known as Emotionally Unstable Personality Disorder (EUPD)[1], is a condition that impairs emotional regulation.[2] This results in impulsivity, intense mood swings, and consequently, unstable relationships.[3] People with this condition generally have a severe fear of abandonment, issues controlling anger, and an altered perception of themselves, as well as others.[4,5] This condition causes emotions to be more intense and long-lasting, making it more difficult to return to a neutral emotional state.[6]
The behavioral and emotional irregularities caused by BPD can affect multiple aspects of one’s life, such as personal relationships, professional and academic success, social life, and self-esteem.[7] These changes result in increased risk for reckless behavior, self-harm, and suicidal tendencies.[8] Additionally, BPD is frequently present alongside other mental health conditions such as Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Eating Disorders, and other Personality Disorders.[9,10]
BPD is classified as a Cluster B personality disorder, along with conditions such as Antisocial Personality Disorder and Histrionic Personality Disorder. Disorders in this group are grouped together as they tend to involve volatile emotions and turbulent behavior.[11] It is estimated that BPD affects about 1.6 to 5.9% of the global population.[12] BPD is chronic, as are other personality disorders, thus making its resultant behavioral patterns long-term and relatively unyielding. However, treatment can help with management of behaviors and symptoms to facilitate a healthier way of life.[13]
SYMPTOMS & DIAGNOSIS
The main characteristic features of BPD are instability and volatility across various aspects of life, such as interpersonal relationships, mood and affect, self-image, and behavior. The primary symptoms reflect this to include:[14]
Intense fear of abandonment and frantic efforts to avoid it, even without cause
A tendency to swing between extreme idealizing and extreme downgrading, resulting in unstable and passionate relationships
Unstable self-image and sense of identity
Self-sabotaging impulsive behavior, such as overspending, substance abuse, engaging in unsafe sexual practices, etc.
Suicidal tendencies and self-harm
Extreme emotional reactivity resulting in intense emotional episodes that are generally short-lived, persisting for a few minutes or hours and occasionally, for a few days
Long-lasting, recurrent feelings of emptiness
Short temper that flares up intensely and inappropriately along with difficulties in controlling anger
Short-term paranoia or dissociation brought upon by stress
According to the DSM-5, an individual is diagnosed with BPD if they display five or more of the aforementioned symptoms. Some other additional patterns that individuals with BPD may display are:[15]
Self-sabotaging immediately prior to the completion of a goal
Higher sense of security with pets or inanimate objects than within interpersonal relationships
Frequent interruptions in jobs, education, and relationships
The unstable self-image caused by BPD results in large shifts in how one perceives major aspects of their lives, such as their career, friends or sexuality. It also results in extreme sensitivity towards the external environment, making individuals more susceptible to being impacted severely by people and occurrences around them. For example, unwarranted and intense feelings of anger or abandonment in response to events are common, occurring in quotidian situations such as a friend being late to a meet-up or a clinician ending an appointment. This constant fear of abandonment stems from an inability to be alone and a necessity to constantly be around other people, which is also a consequence of identity disturbance.[16]
Extreme emotional volatility in the face of interpersonal stressors is a consequence of the ever-present fear of abandonment in BPD. Individuals often have trouble controlling their anger when they believe someone close to them is being neglectful, resulting in vocal outbursts that are exceptionally bitter or sarcastic in nature. Feelings of guilt and perceptions of being evil often follow these outbursts. Additionally, chronic feelings of emptiness can result in boredom and the constant seeking for something to do. All of these culminate into the observed pattern of unstable interpersonal relationships in individuals with BPD.[17]
RISK FACTORS
Genetics: BPD is about five times more prevalent among individuals who have a close relative with the disorder, such as a parent or sibling. The presence of BPD in family history leads to increased risk for substance use disorders, anti-social personality disorder, and depressive or bipolar disorders within the lineage.[18]
Physiology: Structural and functional changes have been observed in the brains of people with BPD, particularly in regions associated with regulation of impulses and emotions. However, it is unclear whether this physiology increases the risk of developing BPD or if having the disorder results in physiological changes.[19]
Environmental factors: Reports of trauma are common among those with BPD, with many reporting instances of abuse, abandonment, or other hardships during childhood. Later instability and conflicts in interpersonal relationships are also commonly reported and act as risk factors.[20]
DIAGNOSTIC ISSUES & OVERLAPS
Sociocultural Issues: The behaviors associated with BPD have been observed in multiple different contexts across the world and these can often lead to misdiagnosis. Identity issues prevail in youths due to conflicts and pressures in choosing a career, exploring sexuality, and uncertainties in other aspects of life. As a result, adolescents and young adults can often display BPD-like behaviors— such as anxiety, emotional turmoil, and existential crises— which are not necessarily a result of actually having the disorder.[21]
Gender Issues: BPD is diagnosed far more frequently in women than in men, at a rate of about 75%.[22] The discrepancy is likely the result of sampling bias in studies, attempting to find the prevalence of BPD in genders. As a result, the actual prevalence rates in each gender are currently unknown.[23] Biological and sociocultural factors may also play a part in creating this gender gap by increasing the number of risk factors for women: factors such as higher rates of childhood sexual abuse and socialization that promotes internalizing problems put women at a higher risk of developing BPD.[24]
Differential Diagnoses:
Depressive and Bipolar Disorders: Depressive and Bipolar Disorders often co-occur with BPD and can be diagnosed alongside each other when all the diagnostic criteria are met. However, symptoms of depressive and bipolar disorders can often resemble BPD behaviors in the short-term, potentially misleading the diagnosis.[25]
Other Personality Disorders: BPD and other personality disorders may be diagnosed interchangeably due to certain shared characteristics. However, these can be distinguished by looking at the differences in their main diagnostic features. For example, BPD is differentiated from Histrionic Personality Disorder in that it involves self-sabotage, outbursts of anger in relationships, and feelings of emptiness. While both BPD and Schizotypal Personality Disorder share similar symptoms of paranoia, the manifestation of this in BPD is far more short-lived and dependent on externalities. Fear of abandonment, self-destructive tendencies, and impulsivity distinguish BPD from Paranoid Personality Disorder and Narcissistic Personality Disorder. Differentiations between BPD and other personality disorders can be understood from comparing diagnostic criteria in this way and identifying the specific differences.[26]
Substance Use Disorders: Consistent substance use may result in behavioral changes that misleadingly mimic BPD.[27]
Identity Problems: Issues in identity often accompany certain developmental phases, such as adolescence, resulting in BPD-like behaviors.[28]
Other Medical Conditions: Sometimes, other medical conditions can result in personality changes that resemble BPD via impacts on the central nervous system.[29] It is therefore important to have a full evaluation from a licensed mental health provider, such as a clinical psychologist or psychiatrist, to determine what condition someone may have.
PROGNOSIS & TREATMENT
Despite large variation amongst individuals in the prognosis of BPD, one pattern is observed most frequently: a peak in symptoms in early adulthood and a gradual reduction as one gets older. Symptoms of volatility, lack of affective control, and impulsivity tend to follow this trend, whereas relationship instability is usually lifelong.[30]
Treatment can help alleviate symptoms and suffering in individuals with BPD. Generally, talk therapy is the primary treatment method instead of medication. Symptoms vary in how easy they are to treat: relationship instability, fear of abandonment, and feelings of emptiness tend to be the most difficult to treat, while treatment most effectively ameliorates anger, suicidal tendencies, and social adjustment.[31]
Multiple treatment methods are used to treat BPD, such as:[32]
Dialectical Behavior Therapy (DBT): A treatment method specifically designed to treat BPD, DBT helps individuals develop skills to manage their symptoms.[33] It helps with emotional regulation, reduction in self-harming tendencies, stress management, and stability in relationships.[34] The behavioral skills that are taught include: mindfulness, interpersonal skills, emotion control, and distress tolerance. As of now, this is the only treatment for BPD with empirical support.[35]
Mentalization-Based Therapy (MBT): MBT is a form of talk therapy specific to developing interpersonal skills— specifically, the skill of better understanding of how other people may think or feel.[36] Mentalizing— the process which this treatment method aims to invigorate— is the way in which people make sense of themselves, but more importantly, the people around them and their mental states.[37] An impaired mentalization ability is one of the causes of relationship instability and emotional reactivity in interpersonal contexts in BPD. MBT works to alleviate these symptoms by enhancing both the sense of self as well as mentalization.[38]
Transference-Focused Therapy (TFP): This treatment method focuses on the relationship between therapist and patient to help improve understanding about interpersonal problems and emotions.[39] Transference involves the way the patient feels about the therapist, which is influenced by the patient’s general relationship patterns. In TFP, the patient experiences the growth of their relationship with their therapist and learns how to navigate other relationships in the process.[40,41] TFP aims to not only address BPD behaviors, but also the disturbances in identity and self-image.[42]
Medication: Medication can often help manage symptoms and other co-occurring conditions by alleviating impulsivity, depression, and anxiety. However, although many BPD patients are prescribed multiple medications, this approach is most likely neither effective nor requisite.[43] Antidepressants, antipsychotics, and mood-stabilizers are the medications often used in BPD treatment.[44]
Those who seek treatment often show improvements within the first year and most individuals begin to find stability in relationships and work style at 30-40 years old. Additionally, in follow-up studies it has been found that up to half of the affected individuals no longer met the diagnostic criteria for BPD after 10 years.[45] Moreover, it is unlikely that the full spectrum of symptoms will completely return after remission.[46]
Contributed by: Sanjana Bakre
Editor: Jennifer (Ghahari) Smith, Ph.D.
REFERENCES
1 Mind UK. (2022, September). What is borderline personality disorder (BPD)? Mind UK. Retrieved September 2022, from https://www.mind.org.uk/information-support/types-of-mental-health-problems/borderline-personality-disorder-bpd/about-bpd/#:~:text=Borderline%20personality%20disorder%20(BPD)%20is,unstable%20personality%20disorder%20(EUPD)
2 National Institute of Mental Health. (2022, April). Borderline personality disorder. National Institute of Mental Health. Retrieved September 15, 2022, from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder#part_10397
3 Cleveland Clinic. (2022, May). Borderline personality disorder: Causes, symptoms & treatment. Cleveland Clinic. Retrieved October 1, 2022, from https://my.clevelandclinic.org/health/diseases/9762-borderline-personality-disorder-bpd
4 Ibid.
5 National Institute of Mental Health (2022)
6 National Alliance on Mental Illness. (2017, December). Borderline personality disorder. NAMI National Alliance on Mental Illness. Retrieved September 10, 2022, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Borderline-Personality-Disorder
5 Mayo Clinic Staff. (2019, July 17). Borderline personality disorder. Mayo Clinic. Retrieved September 15, 2022, from https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237#:~:text=Borderline%20personality%20disorder%20is%20a,a%20pattern%20of%20unstable%20relationships
7 Cleveland Clinic (2022)
8 Mayo Clinic Staff (2019)
9 American Psychiatric Association. (2013). Borderline Personality Disorder. In Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed., pp. 663–666). essay, American Psychiatric Association.
10 Psychology Today Staff. (n.d.). Cluster B. Psychology Today. Retrieved September 16, 2022, from https://www.psychologytoday.com/us/basics/cluster-b#:~:text=There%20are%20four%20personality%20disorders,disorder%2C%20and%20narcissistic%20personality%20disorder
11 American Psychiatric Association (2013)
12 Cleveland Clinic (2022)
13 American Psychiatric Association (2013)
14 Ibid.
15 Ibid.
16 Ibid.
17 National Institute of Mental Health (2022)
18 Ibid.
19 American Psychiatric Association (2013)
20 Ibid.
21 Skodol, A.E., Bender, D.S. Why Are Women Diagnosed Borderline More Than Men?. Psychiatric Quarterly 74, 349–360 (2003). https://doi.org/10.1023/A:1026087410516
Ibid.
22 American Psychiatric Association (2013)
23 Ibid.
24 Ibid.
25 Ibid.
26 Ibid.
27 Ibid.
28 Nea.bpd, N. E. A. for B. P. D. (2014, February 1). Treating BPD. National Education Alliance for Borderline Personality Disorder. Retrieved September 28, 2022, from https://www.borderlinepersonalitydisorder.org/what-is-bpd/treating-bpd/
29 Ibid.
30 May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. Mental Health Clinician, 6(2), 62–67. https://doi.org/10.9740/mhc.2016.03.62
31 N.E.A (2014)
32 May et al. (2016)
33 N.E.A (2014)
34 Bateman, A., & Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9(1), 11–15. https://doi.org/10.1002/j.2051-5545.2010.tb00255.x
35 McLean Hospital. (2022, January 10). Mentalization-based treatment: Effective care for borderline personality disorder. A Guide to Mentalization-Based Treatment for BPD. Retrieved September 28, 2022, from https://www.mcleanhospital.org/essential/mbt
36 N.E.A (2014)
37 McLean Hospital. (2022, February 11). Understanding transference-focused psychotherapy. A Guide to Transference-Focused Psychotherapy. Retrieved September 29, 2022, from https://www.mcleanhospital.org/essential/tfp
38 N.E.A (2014)
39 McLean Hospital (2022)
40 N.E.A (2014)
41 Mayo Clinic Staff (2019)
42 American Psychiatric Association (2013)
43 N.E.A (2014)