Author’s Note: Each person with borderline personality disorder (BPD) is different and an individual person, just as each person without BPD is different and an individual, hence the variety of examples.
Those of us with disorders, disabilities and chronic illnesses constantly face an array of hurtful comments, microaggressions, harassment and inaccessibility.
The first time I decided to disclose my borderline personality disorder to a close friend, she interrupted me about two minutes into the conversation. “Wow, I think I have BPD now like you, too! This is so scary cool!”
In another instance, it was a particularly stressful week, and someone I once considered a close friend witnessed my stress and anger. I was not violent, rude or hurtful, but I was still called “an immature child who needs to learn to control herself.”
In yet another instance, I received an anonymous threat for “being borderline human.”
These themes are too familiar to those of us who struggle with a disability or disorder. Depression disorders are minimized as brief sadness or bipolar disorder as typical mood swings. Our experiences and disorders are often minimized by others as nonexistent or a fabrication. Others may minimize it into a trendy label they can assign to themselves. We attempt to express our human differences, needs and symptoms out of intimate trust and accessibility, but the conversation and representation often follows a similar theme of invalidation, fear, microaggressions, harassment or ignorance.
These personal conversations and instances are part of a larger problem: stigma and inaccessible mental health care which is fueled by this stigma and misunderstanding. Plus, it is not uncommon for people with BPD to be refused treatment.
Borderline personality disorder in particular, as described in the article here, has a
“surplus stigma” and often lacks treatment accessibility. It is also often confused with other mental disorders or behaviors. We need to be careful and improve the way we describe and frame the language of mental health and mental disorders. A substantial portion of this confusion may come from vague, stigmatized or shorthand descriptions of the disorder typically found on the internet, media and a lack of accurate awareness.
My symptoms have been frequently overlooked, minimized, blamed on insignificant day-to-day
events and turned into a joke. As a result, I have not taken myself seriously or trusted myself, have not received the proper college accommodations in time nor did I fully acknowledge the importance of treatment. Clearly, a lack of treatment and fear to reach out may result in worsening symptoms and contribute to suicide rates. Additionally, research to help shed light on the BPD stigma shows these attitudes may hinder the progress made in treatment and damage the doctor-patient relationship. If disorders are not taken seriously, accurately understood and destigmatized, then the treatment accessibility will not improve. I only just recently started a dialectical behavior therapy treatment program after searching for accessible treatment for over six years.
When initially attempting to understand my disorder and experiences, I could not find information that was easy to understand, accurate and accessible. It was easy to find the shorthand descriptions, “someone who struggles with anger” or “someone who fears abandonment,” but to most people, these vague and abstract bullet-pointed lists describe little to nothing and are misused.
These descriptions and stigma offer very little lived experience of the disorder, little research and little actual understanding of these symptoms. For example, I often receive the response, “Well, it’s not a disorder because of course people have a fear of abandonment. No one likes abandonment.” Based on these descriptions of the disorder and lack of awareness, I cannot entirely blame people for these misunderstandings and responses. I was quick to ignore it when I was first told I have BPD because of the vague and limited descriptions.
As someone with BPD who is a psychology student, after encountering this lack of information, I was motivated to elaborate on the nine hallmark symptoms, reality and treatment of this disorder. I remember wanting access to this information to better understand myself, others and to manage my symptoms. I needed to “radically accept” it to seek out treatment. I was always an incredibly sensitive toddler, and many more symptoms were evident from age 10. I initially ignored the warning signs because of my own misunderstanding. I then felt further alone, misunderstood and “evil” from most of the resources I had quick access to.
Hopefully, this helps shed light on some of the main symptoms of BPD, while simultaneously dispelling some misunderstandings for both those of us with BPD and our loved ones who may not understand yet.
A BPD Model and Causes
Dr. Marsha Linehan explains BPD is characterized by three emotional elements that help explain and connect the nine symptoms, which include innate hypersensitivity, intense emotional reactivity and a slow return to emotional baseline.
Hypersensitivity means emotions are easily aroused and may occur from ordinary circumstances that do not typically bother someone without the disorder. According to Linehan, people with BPD have hypersensitivity present from birth. As a result, it leads to a tendency to experience heightened negative emotions across various contexts and situations. This hypersensitivity then makes it difficult to learn appropriate emotion regulation strategies, which reinforces the sensitivity. For example, some studies show that people with BPD have a biased perception of emotion recognition, which helps explain the difficulties with social interactions. People with BPD attributed negative emotions to neutral facial expressions or a more negative emotion than depicted. Other studies have shown a heightened emotion vigilance in certain performance tasks or a heightened responses to high valence words.
The sensitive reactions are also noticeably intense. Linehan describes the emotional reactions may include grief instead of sadness, humiliation instead of embarrassment, rage instead of annoyance, panic instead of nervousness, and great joy and passion. Studies reveal that people with BPD may experience more intense negative affect at both a self-reported experience and physiological level. It is commonly self-reported that those of us with BPD experience extreme physiological reactions in response to certain triggers. At times, I will visibly shake with the minor perception of a slight — I accidentally dropped and spilled my water bottle once because I was visibly shaking in the middle of my college class.
Lastly, the slow return to baseline means it may take longer to “level out” from an emotion. That is, people with BPD show “delayed recovery” from an emotional response. One study demonstrated this occurrence, where people with BPD not only sustained the magnitude of an emotional reaction, but they also demonstrated greater startle reactivity. Non-BPD controls demonstrated a linear emotional trend and less reactivity.
Overall, BPD is a disorder of emotional dysregulation, leading to extreme emotional reactivity, regardless of how mundane the situation or thought seems. This symptom can contribute to the minimization and invalidation people with BPD face.
This hypersensitivity can be seen in childhood and show over time to be more apparent BPD. Although commonly assumed, early trauma alone does not lead to BPD and is not the only cause of BPD. I have personally not experienced a trauma contributing to my BPD. With this in mind, it is important to understand a common environmental factor of BPD does include childhood abuse and trauma.
Early separation, loss and insecure attachment patterns are also common and play a role in BPD. Invalidation is also a particularly common environmental factor that reinforces symptoms. For example, a child who is already hypersensitivity and displays some BPD symptoms may repeatedly get told growing up to, “Just get over it,” or, “What’s the big deal?” or, “Stop crying already!” Improper responses from parents that do not encourage proper management and emotion regulation may unintentionally reinforce the difficulty with emotions and behaviors.
Nine Main Symptoms
1. Frantic efforts to avoid real or imagined abandonment.
Misunderstanding: Abandonment and rejection, perhaps from jobs, relationships or peers, are negative experiences that are particularly memorable and painful. Additionally, it can be understandably difficult to be separated from close friends, relatives or a partner for long periods of time, perhaps due to business trips or travel. Depression or anxiety disorders may be exacerbated from these experiences, too. Separation anxiety must also be differentiated from BPD to be diagnosed.
BPD: The abandonment symptoms from BPD expand beyond this shorthand criteria. This symptom can be understood as a pattern of reactions to abandonment, rejection and criticism/slights, whether real or perceived. This symptom is elaborated on in the DSM and research. Some people may have more pronounced symptoms in one context than another. For example, the DSM states, “The perception of impending separation or rejection or the loss of external structure can lead to profound changes in self-image, affect, cognition and behavior. These individuals are very sensitive to environmental circumstances.” Another specified component includes the effort (action) to avoid abandonment.
Examples include recurrent begging, repeatedly asking for confirmation, repeated phone calls, physically clinging to or blocking the person from leaving or attempting to find the person. Other expressions of this symptom include intense and frequent preoccupations with abandonment, which may include panic and sudden depressive states such as isolating oneself in their house for days, nightmares of abandonment, self-injury or other symptoms. Mundane circumstances in which someone with BPD feels socially rejected or slighted, abandoned, a brief separation and threat to this structure may immediately exacerbate symptoms. People with BPD can be said to struggle with a form of “emotional permanence,” similar to the object permanence, which is the understanding that objects continue to persist, even when they cannot be observed through the senses.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (splitting).
Misunderstanding: Splitting can happen to anyone to an extent, just as anyone can experience low moods without a depressive disorder. Symptoms of disorders range on a spectrum. For example, when people are upset with someone, it’s not uncommon to ignore all the good characteristics about that person and magnify the negative characteristics and focus on why they are upset. It can be generally hard sometimes to view someone as a “good person who made a mistake” instead of writing them off as a “bad or mean person who intentionally hurt me.”
BPD: Splitting in BPD can be understood as an extreme thought pattern symptom in which positive and negative dichotomies of the self and others are not integrated, which leads to a pattern of thinking in extremes. It often interferes with perceptions, social functioning and emotionality. Splitting in BPD is usually sudden, intense and longer lasting or quickly changeable. The trigger may be very minor. The two parts of splitting include idealization (positive qualities) and devaluation (negative qualities). For example, someone with BPD who is idealizing may attribute god-like qualities to their partner, constantly praise them, be dependent on them and spend lots of time with them, which may instantly switch to devaluation at the perception of a slight or abandonment. Devaluation may include suddenly hating them, feeling betrayed by them, or ignoring and avoiding them. This pattern may switch back and forth with the intense emotions. Generally, someone with BPD may alternate between over-involvement and withdrawal. Or, someone with BPD may struggle with one more than the other, or view the world and moment as “all good” or “all bad,” depending on the situation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
Misunderstanding: People’s thoughts and behaviors are constantly shaped by the real or perceived presence of other people and situations, often related to insecurity, social influences and decisions. Stress with school, jobs and social rejection are all components that commonly impact confidence and self-perception. Additionally, it is common to have a hard time picking a major/career. Low self-esteem and struggling with the sense of self can also be attributed to depression, anxiety and eating disorders.
BPD: I have repeatedly said this BPD symptom is the most difficult and complex symptom for me to explain. This other article I wrote entirely about this symptom might be a more helpful tool. This symptom may present itself in BPD in various ways. For example, this includes dramatic shifts in perceptions of who they are, their goals, jobs, aspirations, appearance or values. This symptom may include excessive self-criticism, intense dysphoria and dissatisfaction, feelings of worthlessness, extreme perfectionism and longing, struggles with self-image, self-hatred or the belief that they are inherently “bad.” These self-perceptions may constantly shift like criteria 2 or trigger as a result of criteria 1. Additionally, the DSM notes, “Such experiences usually occur in situations in which the individual feels a lack of meaningful relationship, nurturing or support. These individuals may show worse performance in unstructured work or school situations.” Understanding this symptom typically requires someone understands the rest of the symptoms, how they connect and influence each other.
4. Impulsiveness in areas that are potentially self-damaging.
Misunderstanding: It is not uncommon to confuse this criterion with ADHD, impulsiveness in adolescence, difficulty focusing or impulsiveness with PTSD, depression or bipolar disorder.
BPD: At the core of BPD, there are hyperactive emotions. As a result, this hyperactivity commonly contributes to impulsiveness in multiple areas, such as impulsively speaking, suddenly quitting a job (3), or self-injury (5). However, this criterion is specifically referring to instances in which the person engages in a particular pattern of behaviors, including substance use, gambling, binging, reckless driving, impulsive sex or overspending. This impulsiveness can be means to cope with the other symptoms, feel “alive” and break away from dissociation (9), self-punishment or stem from sudden rage, abandonment or a sense of urgency and intrusions for a relief of emotional turmoil. The current criterion states it must occur in at least two areas, although this is not always observed realistically. More broadly speaking, impulsiveness can technically occur in and from any one of these nine main symptoms, such as splitting, speaking and identity-based symptoms, but this single criterion refers to specific impulsive behaviors.
5. Recurrent suicidal behavior, gestures or self-injury.
Misunderstanding: A common misunderstanding is that self-injury (e.g., cutting) and suicide
attempts are the same; however, someone who engages in self-injury is not necessarily attempting suicide. Self-injury in BPD is often stigmatized as containing malicious intent, when it is usually done as an emotion regulation mechanism, to cope with emotional intensity, ground oneself from dissociation, self-punishment or as noted in the DSM, “expiate a sense of being evil.” It is also assumed sometimes that self-injury only occurs in BPD when it can also occur in depression, bipolar disorders, PTSD or other mental disorders.
BPD: This symptom specifically refers to reoccurring cutting, burning, bruising or other acts of self-injury to the body or suicidal thoughts and preoccupations, particularly suicidal behaviors. It has been estimated that up to one out of 10 of people with BPD die by suicide, and up to eight out of 10 attempt suicide an average of three times. Likewise, up to eight out of 10 engage in self-injury. To elucidate on this symptom, the DSM states, “Physical handicaps may result from self inflicted abuse behaviors or suicide attempts.” Although many people with BPD do struggle with what can be included under a self-harm spectrum, (self-sabotaging behavior, negative self-talk), that is not what this criterion in BPD is referring to alone.
6. Affective instability due to marked reactivity of mood (intense episodic dysphoria, irritability or anxiety usually lasting a few hours or rarely a few days).
Misunderstanding: This is often confused with someone who may be sensitive, dealing with stresses or with other mental illnesses, notably the changeability in PTSD and bipolar disorders.
BPD: This component can be easily captured by Dr. Marsha Linehan’s model of BPD explained earlier. This instability and sensitivity are better explained as a heightened emotional baseline across various contexts, often reacting to an occurrence, such as an interpersonal reaction or perceived failure. This contrasts with prolonged elevated or depressive episodes (mood states) in bipolar disorder or depression, where the episodes typically run their course and accompany a range of other symptoms at a single prolonged period, which qualify for either a (hypo)mania or depressive episode. The key here is that there is a difference between heightened emotional baseline and emotional reactivity in BPD and bipolar disorder mood states that deviate from someone’s more typical baseline mood state.
7. Chronic feelings of emptiness.
Misunderstanding: This symptom may be confused with periods of stress or sadness. It is also not referring to major depressive disorder or persistent depressive disorder (dysthymia).
BPD: This symptom has been described as a constant empty void, longing, heaviness/grief, numbness or feelings of purposelessness. BPD can be understood as a disorder with changeable emotions and reactions, but this symptom tends to be enduring and constant. This may result in patterns of attempts to fill the void or distractions. People with BPD often describe that, even when they may be experiencing happiness or euphoria or are not directly experiencing a reaction, an emptiness or numbness still persists.
8. Intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Misunderstanding: This symptom is often confused with panic/anxiety or depression presenting itself as anger, ADHD and bipolar disorder, or it is confused with emotional hyperactivity in criterion 6.
BPD: This is considered separate from criterion 6 in that it specifies a more external symptom. Some people with BPD, although emotionally hypersensitive and may experience irritability and anger quickly and intensely, do not present with as many external based symptoms or have this display of anger as a main symptom. This symptom is specific in external displays of anger, perhaps in response to abandonment and devaluation. Physical altercations, verbal outbursts or throwing objects are a few examples.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Misunderstanding: Paranoid ideation is commonly confused with anxiety, particularly social anxiety. Likewise, hypervigilance and paranoia of PTSD is often confused as BPD paranoid ideation. On the other hand, dissociation can be confused with common daydreaming.
BPD: Paranoia is characterized by suspicions and distrust of the motives and actions of other people. Thought pattern symptoms of BPD may exacerbate to paranoid ideation under stress. For example, someone with BPD may think people are secretly plotting ways to slight, reject or abandon them. Or, someone with BPD may think someone has a plan to somehow berate them or that something was done intentionally to hurt them. For a personal example, in response to stress, I once panicked and thought someone was standing outside of my bedroom window and watching me. I closed my blinds and locked my bedroom door, turned my lights off, cried and hoped they would go away, even though I technically knew no one was there. My thoughts can easily and often become so jumbled, disconnected, distorted and race under stress, that it can be apparent in my difficulty forming a simple coherent sentence.
Dissociation is broadly referring to a disconnection and detachment from surroundings, emotions, thoughts and the body/identity. Daydreaming and zoning out sometimes can be considered a nonsymptomatic form of dissociation on the low end of the spectrum in response to fatigue or boredom. Symptomatic dissociation may continue despite efforts to stop it, be intrusive or unsettling and startling. It may occur to cope with the emotional intensity, paranoid ideation or in response to trauma/triggers. Someone dissociating may feel as if they are floating or watching themselves, like they are in a dream, looking through a veil/fog, may appear to be staring off into space, or as if their body and surroundings does not belong to them. Because this symptom has to do with identity, this symptom is related to the identity-based symptom in criterion 3.
Other Noted Symptoms and Features
The DSM specifically notes a few crucial characteristics of BPD:
- Real or perceived forms of support, structure and nurturance may result in temporary relief from symptoms.
- People with BPD tend to feel more comforted and secure with transitional objects and pets. So drawing from this fact, animal therapies and emotional support animals may be a particularly helpful supplement to treatment.
- An increase of stressors (like an extension to criterion 9) may include transient hallucinations, seeing body distortions and ideas of reference (believing that unrelated events, coincidences and occurrences are related or caused from each other, and that events have “hidden meanings/messages,” often related to paranoia and abandonment).
- To sum up, as noted by Jerold J. Kreisman, MD, and Hal Straus in “I Hate you- Don’t Leave Me, Understanding the Borderline Personality,“ “At first glance, these criteria may seem unconnected or only peripherally related. When explored in depth, however, the symptoms are seen to be intricately connected, interacting with each other so that one symptom sparks the rise of another […].”
Despite what the stigma may try to perpetuate, borderline personality disorder can be successfully treated, primarily with specific forms of psychotherapy, the hallmark treatment being dialectical behavior therapy, which was created by Dr. Linehan. Other treatments for BPD include mentalization based therapy, schema therapy, a specialized form of therapy called general psychiatric management, cognitive behavior therapy and medications. Research shows at least 80 percent manage symptoms from the proper treatment, though some functional impairments persist, such as some interpersonal and reactivity difficulties.
Note: This is not a diagnostic tool or checklist.
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Author: Kellyann Navarre