Over the course of my career, I have often worked with clients diagnosed with Borderline Personality Disorder (BPD).
How to understand and help those affected by depression, anxiety and other mental health concerns is often shared and discussed on social media, but there tends to be far less information circulated about BPD.
I wanted to share some factors which are helpful to recognise, to avoid misunderstandings and conflict and support those affected.
The current Diagnostic Statistical Manual (DSM-5) defines the main features of BPD as “a pervasive pattern of instability in interpersonal relationships, self-image, and effect, as well as markedly impulsive behaviour, beginning by early adulthood and present in a variety of contexts”.
BPD is indicated by the presence of five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment. (not including suicidal or self-mutilating behaviour covered in Criterion 5)
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealisation and devaluation
- Identity disturbance: markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (not including suicidal or self-mutilating behaviour covered in Criterion 5)
- Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
- 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)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
BPD is found in around 0.7% of the general population, with a far higher prevalence among those in mental healthcare and forensic settings. There is conflicting data as to gender differences in the prevalence of BPD: it is sometimes found to be more common among women, with other studies indicating no difference.
There is little research focussing on BPD among those with non-binary gender identities.
Causes are not clear, though developmental trauma and abuse have been found to be high among those diagnosed, with neurobiological, genetic and psychosocial factors all viewed as playing a role in the onset of BPD.
For those with BPD, relationships can be very difficult. There can be a powerful fear of being abandoned, paired with a real struggle to make and keep friends, despite trying very hard to do so. Others are inadvertently driven away, as behaviour swings from clinging and idolising to hateful anger.
Loneliness and rejection are often experienced, but difficult to tolerate and express. This quote from Mind is illustrative: “The worst part of my BPD is the insecure relationships … when I am attached to someone, they are my whole world and it is crippling”.
Intense, labile emotions last from hours to days. Those with BPD can have an underdeveloped sense of identity, mirroring those admired and often changing and shifting image.
Feelings of emptiness and impulsivity can lead to extensive drug and alcohol use and other risk-taking behaviours, which can be alarming and concerning to those supporting them.
As a practitioner, working with someone with BPD can be challenging. A therapeutic alliance can appear to be blossoming well, when suddenly an action is perceived as a slight, a comment interpreted as an insult, or a distressing mood is experienced by the client, and the relationship completely shifts.
Accusations can be made, communication withdrawn, hostile emotions can erupt. The therapist can be left wondering what they have done wrong and how they can regain the former dynamic.
Friends, family members and partners supporting someone with BPD can have similarly bewildering experiences.
While it can seem impossible at times, it is essential to remember that people with BPD can heal and achieve balance and that research increasingly evidences that the condition is not as resistant to change as previously thought.
The role of validation is important. In common parlance this word is often used as a negative term, applied when someone is perceived to be agreeing with, excusing, permitting or minimising inappropriate conduct.
However, validation is the act of communicating to another person that you recognise and acknowledge their emotions, thoughts and experiences, even if you disagree or are upset by their words or actions.
Explaining to the loved one or client with BPD that you are present, listening, trying to understand and remain aware that historical and recent experiences might be impacting how they are thinking, acting and feeling in the moment can help to avoid communication breakdowns.
For an extensive exploration on Marsha Lineman’s six stages of validation, please see here.
Setting and maintaining boundaries is a particularly challenging aspect of supporting someone with BPD. Clear and consistent boundaries ensure a sense of comfort, safety and respect in a personal or professional relationship, but those with BPD can, consciously or unconsciously, be inclined to test the boundaries of others.
This may be in the form of demands and requests, timekeeping issues such as arriving late, missing sessions or wanting to remain in session after the designated time has elapsed, overfamiliarity, aggression or intimidating use of language and tone.
Succumbing to the temptation to permit or tolerate boundary transgressions leads to a sense of confusion for both parties, as what is acceptable and unacceptable becomes less clear and more difficult to vocalise.
Honesty, clarity, assertiveness and the willingness to respectfully challenge is important in establishing a predictable routine. For those with BPD, this sense of stability and trust can be pivotal.
A strengths-based approach is beneficial. To the person with BPD, conflict and a focus on problems may feel all too familiar. Highlighting areas of proficiency, genuine interest and progress helps cultivate an internal locus of self-worth, esteem and identity.
Finally, patience is key. As stated above, those with BPD can take time to settle into relationships and can find establishing clear lines of communication with others difficult at times. It is therefore important to allow time and space for an alliance to grow.