Borderline Personality Disorder

There are a lot of places on the Internet to find information on BPD. Some appear to be helpful and some do not. You must use your judgment.

Following is a partial list of criteria for Borderline Personality Disorder from The DSM IV (Diagnostic and Statistical Manuel of Mental Disorders, Fourth Addition):

Borderline Personality Disorder is distinguishable by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  6. 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).
  7. chronic feelings of emptiness
  8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  9. transient, stress-related paranoid ideation or severe dissociative symptoms

The DSM IV goes on to say:

The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

Individuals with Borderline Personality Disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). 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. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g. sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.

Individuals with Borderline Personality Disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not "there" enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will "be there" in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations.

Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with Borderline Personality Disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil.

Individuals with Borderline Personality Disorder may display affective instability that is 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) (Criterion 6). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.

Associated Features and Disorders

Individuals with Borderline Personality Disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnotic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring Mood Disorders or Substance-Related Disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and broken marriages are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with Borderline Personality Disorder. Common co-occurring Axis I disorders include Mood Disorders, Substance-Related Disorders, Eating Disorders (notably Bulimia), Post-Traumatic Stress Disorder, and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also frequently co-occurs with the other Personality Disorders.

Specific Culture, Age, and Gender Features

The pattern of behavior seen in Borderline Personality Disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance abuse) may transiently display behaviors that misleadingly give the impression of Borderline Personality Disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers. Borderline Personality Disorder is diagnosed predominantly (about 75%) in females.

Prevalence

The prevalence of Borderline Personality Disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. In ranges from 30% to 60% among clinical populations with Personality Disorders.

Course

There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning.

Familial Pattern

Borderline Personality Disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders, Antisocial Personality Disorder, and Mood Disorders.

Differential Diagnosis

Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the clinician should avoid giving an additional diagnosis of Borderline Personality Disorder based only on cross-sectional presentation without having documented that the pattern of behavior has an early onset and a long-standing course.

Other Personality Disorders may be confused with Borderline Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Although Histrionic Personality Disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, Borderline Personality Disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both Borderline Personality Disorder and Schizotypal Personality Disorder, but these symptoms are more transient, inter-personally reactive, and responsive to external structuring in Borderline Personality Disorder. Although Paranoid Personality Disorder and Narcissistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from Borderline Personality Disorder. Although Antisocial Personality Disorder and Borderline Personality Disorder are both characterized by manipulative behavior, individuals with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in Borderline Personality Disorder is directed more toward gaining the concern of caretakers. Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment, however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide care giving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by the typical pattern of unstable and intense relationships.

Borderline Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Borderline Personality Disorder should be distinguished from Identity Problem...which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.*

BPD and Alex Moser

Does Alex Moser suffer from Borderline Personality Disorder?

The DSM says she does if she finds herself in five or more of the following criteria.

When Alex begins therapy, she sees herself in all nine criteria described in the DSM:

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

Alex has a very active imagination and feels terrified when by herself. She fears for her physical safety, but far more deeply, she is terrified of being left alone. Being alone is her worst nightmare. She likens it to feeling as though she is in a one-man space capsule, far from Earth, with no mechanism for returning, and no ability to communicate with anyone. Alex will stay at a pub or party far longer than she wishes to in an effort to avoid being alone.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

Alex tends to "fall in love" easily. She has no understanding of patterns from one relationship to the next. Each new "love" is perfect, and subsequently life will be perfect if only she can have this relationship. Secure in her belief that "this is the one" she quickly engages in physical and emotional intimacy, well before a deeply meaningful relationship has been established. She often chooses men who base their self-identity on being in a relationship, and Alex often feels trapped before the relationship has an opportunity to develop.

Due to Alex's fear of being alone (and a potential victim of a violent attack) she often begins relationships with men whom she would be better off staying away from. But her immediate imagined need for protection leads her to be less than discriminating in some of her choices. More often, Alex chooses men who genuinely enjoy her company and who have a lot to offer in a relationship. But the more a partner shows interest and concern, the more Alex feels trapped and finds excuses for ending the relationship.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

Alex imagines that she knows who she is, but she has very little awareness of how people perceive her. She vacillates between extreme feelings of unworthiness and self-righteousness, with a heavy helping of self-loathing.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

Alex says she never has enough money for bare survival, but she never seems to remember the myriad ways she divests herself of any potential "extra" money. She regularly hands ten dollar bills to homeless people, she tends to go out to restaurants and bars with friends on a regular basis. When she goes out she usually drinks too much alcohol to make rational choices, and will often leave outrageously disproportionate tips, justifying the high tip because the waiter or bartender has given her several drinks at no charge. It is not uncommon for Alex to work an evening shift with Eileen, and earn $100 in tips, and then turn around and go with Eileen to another pub and drop $50 (a ten dollar bar bill and a forty dollar tip) followed by a visit to an after-hours restaurant in Chinatown, where she'll drop another $20 on a five dollar tab with fifteen dollar tip. If she didn't drink so much, she would still find ways to get rid of her money. A part of her spending habits are directly related to her mother, who hoards money. Alex does not wish to see herself as anything like her mother. Another part of her spending habits has to do with her subconscious need to keep life unstable.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

Alex has regularly cut her arms and legs with razor blades since she was twelve. She got the idea from a book her mother gave her about a teenage girl who was a self-mutilator.

6. 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).

Alex has a knee-jerk negative reaction to anything that even remotely seems to threaten her precarious existence. She does not need to find real stimulus for anxiety, she can work herself into an emotional maelstrom with a simple thought, e.g. it might occur to her that possibly someone she depends on might leave, and she reacts to the thought as though it were a fact. Alex is often irritable, but she never recognizes it. She's generally exhausted, as she doesn't get anywhere nearly enough sleep, and this contributes to her irritability. Alex regularly snaps acerbically at people, and is baffled about why they respond in kind. She has no understanding of how she sounds to others.

7. chronic feelings of emptiness

Alex often feels like she could not be more alone, and her feelings of isolation cause her to feel empty, unloved, and unlovable.

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

Alex regularly imagines slights and responds with rapidly rising fury. She has a very hard time controlling this response, but she minimizes it in her view of who she is and how she behaves. If asked, she will say -- and wholeheartedly believe -- that she has a very low key response to the world and rarely gets angry. In reality, she can "go off" at the drop of a hat. But her temper tantrums disappear as quickly as they appear, and her denial is such that she literally doesn't remember blowing up only minutes after she's stopped screaming.

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Whenever Alex's existence is threatened, e.g. facing possible eviction, feeling fearful that someone is trying to break into her apartment, when she feels her job is at risk, etc., she first becomes paranoid, imagining horrific scenarios where she is a victim, and then she loses her sense of self, swallowed up in a dissociative black out.

After Therapy

In entering a therapeutic relationship with Dr. Frank, Alex has agreed that life has become altogether unmanageable. She has reached an all-time low and is now willing to try therapy in earnest.

After six years of therapy, and ten years after her suicide attempt, does she still fit the (minimum five out of nine) DSM criteria for BPD?

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

In therapy, Dr. Frank has created boundaries and within those boundaries, Alex eventually comes to feel both safe and well loved. It is through this relationship with Dr. Frank that Alex learns to be more responsible in developing friendships and romantic relationships with reliable people, and she learns how to relax and not worry about being abandoned. Alex learns that even if someone does leave her, her world is still in place and she will not be swallowed up in the loss.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

Alex stops putting people on pedestals when she meets them. In allowing others to be human from the start, disappointments are not disproportionately enormous. She allows herself more time to get to know people, and no longer throws herself into new relationships with no thoughts about the efficacy of any given relationship.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

After Alex has been in therapy with Dr. Frank for a couple of years, her self-image becomes one of understanding and acceptance of who she is. She develops an appreciation of her positive characteristics while beginning to determine which characteristics are undesirable and potentially destructive or self-destructive. She actively works to eliminate undesirable characteristics as she becomes aware of them.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

Occasionally Alex will behave spontaneously, but after several years of practicing Aikido, Alex has learned patience and she has learned to question impulsivity with a skeptical eye.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

After Dr. Frank required Alex to sign contracts stating she would call him prior to hurting herself, Alex grew tired of (and embarrassed about) calling Dr. Frank so frequently -- and sometimes in the middle of the night. She forced herself to begin to control when she called him, and then she forced herself to stop calling him so frequently. Alex never wished to violate the contracts she made with Dr. Frank, so she had to call rather than cut. When the situation became untenable, when she felt she had to cut, but she didn't dare call Dr. Frank again, she began holding ice cubes against her skin in an attempt to create something similar to the shock she felt when she cut her skin. Although ice didn't bring about exactly the result she had come to rely on, it did jolt her enough that she was able to wait until an appropriate time to talk with Dr. Frank.

If Dr. Frank had not made himself accessible to Alex when she felt incapable of controlling her self-mutilating, she probably would not have stopped, or would not have stopped as quickly as she did. The fact that Dr. Frank cared enough about Alex to be willing to accept phone calls from her at three in the morning if need be meant a great deal to Alex. Dr. Frank proved to her that he cared and this was the underlying reason she was able to stop hurting herself.

6. 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).

Alex never overcame her irritable nature or her feelings of acute anxiety when faced with monetary difficulties. But she did learn to manage those unpleasant feelings in an appropriate way, i.e. she no longer dissociated, or became robot-like, nor did she feel that any given situation defined her entire world.

7. chronic feelings of emptiness

As Alex began to interact with the world and her friends in a more meaningful way, her feelings of emptiness naturally dissipated.

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

Alex is never fully able to control her anger. The best she is able to achieve is a determination to try to bring it under control more quickly. She can’t quite find ways to see her anger as irrational until after she has expressed it. She does learn to control herself in situations in which a display of temper might lose her her job, or destroy a friendship. By the end of The Existence Game, Alex is still working on managing her fiery temper.

9. transient, stress-related paranoid ideation or severe dissociative symptoms

After several years in therapy, Alex was no longer troubled by paranoia or dissociation.

Alex Moser recovered through her willingness to step away from what was familiar to her, and to take a leap of faith and trust Dr. Frank. Dr. Frank was a tremendously talented therapist who understood the power of love and commitment in turning a life around.

* Proposed revisions on Borderline Personality Disorder definition from the American Psychiatric Association's developmental DSM-5 can be found here