What is Borderline Personality Disorder?
CENTRE FOR ADDICTION AND MENTAL HEALTH – Tackling a treatment crisis
Personality disorder is a term used to describe personality traits when they have become extreme, inflexible, and maladaptive. Over 2% of the population have some degree of Borderline Personality Disorder (BPD). Of this population 8 to 10% commit suicide – this rate is more than 50 times the rate of suicide in the general population.
BPD is a severe, complex and highly stigmatised psychiatric illness that is a great mimicker of many other psychiatric illnesses. The public health impact and cost of BPD is significant as people with BPD are frequent users of emergency departments, crisis and primary care services. It is Australia’s third most costly mental disorder. In addition, there are substantial costs to quality of life associated with detrimental impact on employment, education, life in community, and relationships.
According to the Diagnostic and Statistical Manual 5 (DSM-5, 2013), BPD is impairment in personality (self and interpersonal) functioning and the presence of pathological personality traits that are pervasive and persistent across time and situations. BPD starts in adolescence and emerging adulthood but treatment is often late when problems in interpersonal relationships, education and employment are realised.
Typical features of BPD are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk-taking and/or hostility.
A. Moderate or greater impairment in personality functioning manifest by:
- Impairments in self functioning (a or b):
a. Identity: markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness; dissociative states under stress. Sometimes a positive sense of self, other times, negative or even evil. Such experiences usually occur in situations in which there is a lack of meaningful relationship, nurturing and support. When under such stress, may automatically become out of touch with reality – dissociation. This emotional detachment may result in feeling foggy, spaced out or feeling as if outside own body which may bring about self-harm to reaffirm the ability to feel.
b. Self-direction: Instability in goals, aspirations, values, or career plans. A lack of “personhood” and goals or sense of non-existence causes frequent change of jobs, friends, lovers, religion and values. This may be exacerbated in unstructured work or education situations.
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognise the feelings and needs of others associated with interpersonal hypersensitivity (i.e. prone to feeling slighted or insulted) perceptions of others selectively biased toward negative attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealisation and devaluation and alternating between over involvement and withdrawal. Intense and stormy relationships with a quick alternating pattern of seeing the other person as “all good” or “all bad”. Relationships may feel either perfect or horrible and never in between. This all-or-nothing approach to relationships may cause lovers, friends and family to feel emotional whiplash from the rapid swings between disillusionment with a caregiver whose nurturing qualities have been idealised and devaluation when rejection or abandonment is expected.
Frantic efforts to avoid real or imagined abandonment: Desperate efforts to avoid abandonment involve begging, clinging, fighting, jealousy, self-mutilating or alternatively, avoiding any closeness with others altogether. This push-pull behaviour may drive others away.
B. Pathological personality traits in the following domains:
- Negative Affectivity, characterised by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
Affective instability due to a marked reactivity of mood: These emotional surges are marked but also transient, lasting a few minutes or only rarely more than a few days. Regulating these unpredictable, affective emotions can be overwhelming and leaving the person feeling out of control. Often, self-stabilising involves deliberate self-harm to reduce the emotional dysregulation.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy. Very sensitive to signs of rejection and criticism. This fear could be triggered from something innocuous as a loved one getting home late from work.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
2. Disinhibition, characterised by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger. Such as spending sprees, binge eating, reckless driving, shoplifting, engaging in risky sex, drugs and alcohol use, and deliberate self-harm. Engagement in these harmful, sensation-seeking behaviours, especially when wanting to ease distress in the short-term, despite the possible serious negative consequences in the long-term.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults. Intense anger and irritability that may be difficult to control once started. This anger can be expressed as aggressive or destructive behaviour to interpersonal stress or directed inwards from chronic feelings of emptiness, often leading to self-harm. May display extreme sarcasm, enduring bitterness or verbal outbursts often elicited when caregiver or loved one are seen as neglectful, withholding, uncaring, or abandoning.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g. substances of abuse or medication) or a general medical condition (e.g. severe brain injury).
Read Headspace – BPD Assessment about the process of BPD diagnosis.
The change in BPD definition
Unlike the DSM-IV (2000), the DSM-5 diagnostic criteria for BPD does not require there to be at least five out of nine specific symptoms present. The DSM-5 included radical changes to the definition that fundamentally amended a traditional BPD definition which previously had minimal changes since it entered the DSM system 30 years ago. BPD in DSM-5 is based on a hybrid categorical-dimensional diagnostic model whereas before it was rendered in terms of core impairments in personality functioning and pathological personality traits with high fidelity. Hopefully, these changes diminish overlap with other personality disorders, allowing doctors to be more comfortable with diagnosing patients and therefore lead to creating more much needed training for therapists and appropriate services for people with BPD.
Causes of BPD
BPD, like many other mental disorders, is caused by a complex combination of genetic, social, and psychological factors. All modern theories agree that the cause of BPD is an interaction of all these factors in order for BPD to manifest in young adulthood.
The known risk factors for development of BPD include those present at birth, called temperaments; experiences occurring in childhood and sustained environmental influences.
The level of heritability for BPD is estimated to be 52-68%. Inherited biogenetic dispositions include temperaments, affective dysregulation, impulsivity, and interpersonal hypersensitivity. Environmental factors can significantly delimit or exacerbate these dispositions into BPD in adulthood. Neurological findings suggest that the amygdala, which is part of the “emotional brain”, is hyper-reactive in people with BPD.
Studies have shown that pre-borderline children fail to learn accurate ways to interpret feelings, desires, needs, beliefs and reasons or to accurately attribute motives in themselves and others (mentalisation). Hence, such children fail to develop basic thought processes that make up a stable sense of self and awareness of others. A child with such vulnerabilities growing up in an invalidating environment in which she is led to believe that her feelings, thoughts and perceptions are not real or do not matter has a high likelihood of failing to mentalise in the adulthood and manifesting into adult BPD.
About 70% of people with BPD report history of physical and/or sexual abuse. Childhood traumas can lead to alienations, desperate search for protective relationships and development of intense feeling that are BPD characteristics. Since not all people who experience childhood trauma and BPD can develop without such experiences, these traumas are not enough to be a source to BPD development. Approximately 30% of people with BPD experience early parental loss or prolonged separation from their parents which may contribute to patients’ fears of abandonment. BPD. People with BPD often report feeling alienation, neglect or disconnected from their families and often attribute to poor communication with their parents. However, this may be a result of individual’s dysfunctional thought processes to describe and communicate feelings, needs, desires, motives.
Social and Cultural Environment
Evidence shows that up to 10% of the population have some degree of borderline personality traits. In present society which is fast-paced, reliant on technology, highly mobile, and where family situations may be unstable due to divorce, economic factors or other pressures on the caregivers, these factors may contribute to variations of BPD prevalence.
Read more on aetiology of BPD at Australian Institute of Professional Counsellors.
RETHINK BPD – Myths surrounding BPD
For more information
The ACPARIAN: Borderline Personality Disorder This e-journal issue includes literature on BPD complexities and challenges, attachment and parenting, psychological interventions, self-harm, integrative model of care and medical considerations.
Personality crisis: Looking beyond the borderline
Headspace – Diagnosing BPD in Adolescence: What are the issues and what is the evidence?
National Health and Medical Research Council – Clinical practice guideline for the management of personality disorders
ABC News – Psychiatrist says BPD sufferers need targeted treatment
Personality crisis: Looking beyond the borderline