Borderline personality disorder is often accompanied by a fear of abandonment, unstable relationships (being head over heels in love one minute, idolising your lover and then hating them the next) BPD sufferers often have an unclear view of who they are and what they want in life, possibly accompanied by frequently changing friends, sexual partners, and jobs. BPD also often comes along with impulsive and self-harming behaviours and thoughts about suicide and is, not surprisingly, accompanied by emotional swings and awful feelings of emptiness, which sufferers may try to fill with booze, narcotics, or sex for examples. If you are suffering from BPD, you may also experience seemingly uncontrollable rage and not just at other people, but often, directed at yourself, frustration which can boil over into yelling and hurling objects in a rage. BPD is also accompanied, often by being suspicious of other people to the point of paranoia and finally, feelings of dissociation which are essentially feeling out of touch with reality: as if, at times, you are quite literally outside your own body. Clearly that is a lot of symptoms- one of these factors: unstable relationships, may have its roots in poor 'attachment' (https://www.counsellingwithdrtrevor.net/post/how-is-your-past-affecting-your-now-and-your-future) often caused by poor or inconsistent parenting. This could be manifested in feelings such as: ‘I want you, get away from me’ in your intimate relationships. In fact many of the potential causative factors in BPD point towards poor quality care-giving and neglect in childhood. Many of the other symptoms/factors involved are impulsive drives, anger, self-harm, alcohol and other drugs for examples can be impulsions which come and go rapidly with a BPD sufferers’ sudden and frequent changes of emotion.
So, what is the aetiology (origin) of this complex problem? BPD affects between 1 and 4% of the population according to the Australian BPD foundation and 10-25% of people presenting in clinical settings (Bradley et al, 2005). There is no one single cause of BPD but correlations exist between childhood sexual abuse, physical abuse, neglect, and BPD with childhood sexual abuse potentially being the strongest predictor (Bradley et al, 2005). An important point to note here is that the severity and age of onset of abuse may be important as a precursor to BPD. Also, an array of potential contributing factors, in a family where neglect and abuse have taken place, which are both complex and difficult to disentangle to from very clear predictive factors may underlie BPD. There does seem to be a consistent theme, however, that neglect and physical/sexual abuse are implicated in the origins of BPD. Another factor important in the development of BPD relates to family environment and psychopathology in parents. Although this is by no means an exhaustive investigation into the factors which underly BPD it seems reasonable to point out these three areas: abuse, poor/inconsistent family environment and psychopathology in a parent as at least being connected to the likelihood of developing BPD.
What is BPD like for sufferers?
I am reminded by a quote from the MIND website when I think of what clients tell me about their BPD experience:
"My experience is that I have to keep my emotions inside, because I get told I am overreacting. So, I end up feeling like I'm trapped inside my body screaming while no one can hear me."
Often, I will hear that people have been told they are over-sensitive and just a worrier or an over-thinker. People feel dismissed and subsequently often reveal that they are living with a problem they feel they can tell no one about. In a sense they are ‘over-sensitive’ i.e. they find it hard to emotionally regulate and that is a key concept within treatment: learning skills which help us emotionally regulate or calm down in the face of seemingly overwhelming distress. People who feel this distress and then go on to self-harm will tell you it is an immediately successful way of emotionally regulating, despite the fact that people feel shame, guilt and horror at what they’ve done to themselves. So partly, at least, the trick is to emotionally regulate without resorting to dangerous, damaging self-harm practices.
Effective treatment for BPD
Of primary importance for someone suffering from this problem and some, or even all, of its symptoms is the question: What can I do about it? Although the symptoms are, of course, truly horrible but there is at least some good news in that BPD is not necessarily a lifelong sentence and there are some effective treatment modalities for BPD sufferers. Some work suggests optimal treatment depends upon the background symptoms of the patients (Keefe et al, 2020) and chief amongst frontline treatment currently is DBT or Dialectical Behaviour Therapy. DBT has several core concepts including Mindfulness, distress tolerance interpersonal effectiveness, and emotional regulation which are often taught as a course of treatment and have an evidence base suggesting the approach works well (Linehan, et al 2015).
‘DBT demonstrates efficacy in stabilizing and controlling self-destructive behavior and improving patient compliance’. (Panos et al, 2014).
4 key treatment skills for BPD
#1 Mindfulness is of course, quite literally focussing on the present moment, not yesterday or tomorrow but right now often through focusing on one thing, for example, your breathing, and following this for a period of time whilst gently spotting the times you get distracted and bringing yourself back to the present moment. One way of achieving this is going for a mindful walk, where you notice all the sounds and sights and smells around you for a few minutes without judgement just noticing the feeling of your feet on the ground the wind in your face, the tweeting of birds the rumble of traffic and not focussing on other thoughts about problems or worries, and if you do, just gently coming back to the walk. Another example is square breathing breath in for four seconds, hold for four seconds, breath out for four seconds and repeat four times.
#2 Distress tolerance is about accepting that which you can’t change -whilst continuing to work on things that you can change. A great idea around this is defusion https://www.counsellingwithdrtrevor.net/post/do-you-suffer-from-unhelpful-thinking from Acceptance Commitment therapy, whereby you accept a feeling/set of thoughts as being present but also separate yourself from them by acknowledging these are just thoughts, they are not necessarily reality and you are not your thoughts, you are you. The central idea is around the notion that we all tend to have ‘sticky’ thoughts, i.e., ones that are uncomfortable and come without us asking for them to be there. At the same time many of us also tend to push unwanted thoughts away by trying to distract ourselves and yet this may ironically make them stronger. So, although brief distraction may get you through a tricky moment, long-term a better way could be ‘making room’ for thoughts, not agreeing with them but getting to a point where you note they are just thoughts they are not instructions you need to obey, they come and they go and some of them are true, some definitely false, some are mere fantasy and some reality and that is the way the mind works.
#3 Interpersonal effectiveness is how you relate to others and put simply it is about how well we listen to, hear, and validate others in our communications whilst avoiding frustrating behaviour like (interrupting others when they speak). A really good technique is to talk to someone and really try to understand their point of view (you don’t have to agree with it to understand it) once you feel you’ve got it try saying it back to them ‘you feel…’ followed by what they feel- when we do this, and get it right, the other person feels heard, when we don’t get it right they can correct us and then we will have it right and so it’s a win/win situation. An excellent and relatively easy to understand model for learning some key factors for interpersonal effectiveness includes the Parent, Adult, Child model form transactional analysis. It really helps us understand where we and other are ‘coming from’ and in a nutshell spells out that as we talk to others (and ourselves) we are operating from one of three potential places: Parent, Adult and Child. To give a brief and clear example, if I am talking to you and you say to me: ‘I think we could make this house a lot tidier’ this may well be an adult communication if I then say ‘that’s true, when shall we get started?’ again I am making an adult response (note there is no hint of emotion we are just fact finding and sorting out something logically). If however, I say, ‘you are always criticising my messiness!’ this will be coming from a childlike place. In the same vein if I say to you ‘I’ve told you a thousand times before, you need to get organised!’ I am certainly coming from the place of critical parent (It doesn’t matter if I am an actual parent or not or young or old these ‘ego states’ are with us all from very early on). Understanding the model can really help clients get to grip with what is happening between them and other when the speak/communicate/argue/struggle etc.
#4 Whereas emotional regulation is about what you can do In the face of ever-changing emotions to help control or balance your emotions in a way that does not involve the extremes/risks of drugs, alcohol, risky sex, or other self-harm such as cutting yourself. One of the clear ways (and this is a set of ‘skills’ to learn in DBT) is via TIPP which stands for, Temperature, Intense exercise, Paced breathing and Paired muscle relaxation.
Temperature: This is about immediately changing your temperature. For example, by splashing cold water on your face, fill the sink up with very cold water, and preferably put ice cubes in. With the sink try to lean down and forward to immerse your face/head into the water, hold your breath and immerse yourself for as long as you can comfortably do so. NB never do this Temperature lowering technique without first talking to your doctor (especially if you have heart problems).
Intense exercise: This would ideally be aerobic type exercise for at least 20 minutes (brisk walk, stair climbing, jog, cycle, swim etc). If, however, you are in a tight spot and don’t have 20 minutes: do some star jumps, run on the spot, do some push-ups or just get out and do a brisk walk around the block (make it a fast walk!). The idea, and the evidence behind this, is that it is a great way to improve a low mood and/or lower frustration/anger.
Paced Breathing: The easiest way to achieve this is simply to breathe out longer than when you breathe in. One method is to use 'square' breathing, breathe in four 4, hold for 4 and breathe out for 4. There are other variations which achieve the same result: as we get emotionally upset our parasympathetic nervous system (as a response to what our body thinks is us being in danger, when we are not) kicks in and breathing becomes dysregulated, so by using a paced breathing technique we can counteract this response and tell the nervous system we are ok and that it can stand down.
Paired Muscle Relaxation: this is great way to relax when you are feeling anxious, say for example when you are in public. You work from head to toe picking body parts (e.g., start with the calves) you note the tension in the calves then tense them as hard as you can while you breathe in, next you breathe out and release the tension in the calves and then move up to thighs, bum muscles and so on. Each time you breath out relaxing the tensed muscle group and noting how much more relaxed the muscle/your body feels as a result.
This article is not designed or intended as a coverall for BPD its diagnosis and treatment, but may, of course, alert people to the possibility of symptoms and encourage them to connect to services for possible diagnosis and connection to practitioners trained to help with treatment. The Australian BPD Foundation is dedicated to education, treatment, support, and research around BPD, see https://www.bpdfoundation.org.au/mission.php for further information.
Further Useful support:
NB if you genuinely suspect you have correlating symptoms to those presented in this article head straight to your medical practitioner for referral/assessment for BPD. This article does not replace advice from a licensed medical practitioner or clinical psychologist.
Australian BPD Foundation Ltd. https://www.bpdfoundation.org.au/mission.php
Bradley, R., Jenei, J., & Westen, D. (2005). Etiology of borderline personality disorder: Disentangling the contributions of intercorrelated antecedents. The Journal of nervous and mental disease, 193(1), 24-31.
Keefe, J. R., Kim, T. T., DeRubeis, R. J., Streiner, D. L., Links, P. S., & McMain, S. F. (2021). Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management. Psychological Medicine, 51(11), 1829-1837.
Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., ... & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA psychiatry, 72(5), 475-482.
Morton, J., Snowdon, S., Gopold, M., & Guymer, E. (2012). Acceptance and commitment therapy group treatment for symptoms of borderline personality disorder: A public sector pilot study. Cognitive and Behavioral Practice, 19(4), 527-544.
Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014). Meta-analysis and systematic review assessing the efficacy of dialectical behavior therapy (DBT). Research on Social Work Practice, 24(2), 213-223.