Category: Personality Disorders

Borderline Personality Disorder

Author: Keeley Joyce

WHAT IS BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder (BPD) is a condition in which individuals experience difficulties regulating emotions. Emotions in people with BPD are often felt intensely and for long periods of time. In addition, it takes longer to get back down to a regulated baseline of emotions after being emotionally triggered.  

Due to difficulties with emotional regulation BPD often causes, unstable relationships, impulsivity, negative self-image and intense responses to stresses that may result in dangerous behaviours such as self-harm. 

SIGNS AND SYMPTOMS

Borderline Personality Disorder affects how the person may feel about themselves, how they feel about other people as well as how they behave. People with BPD have a severe fear of abandonment and desperately attempt to avoid real or imagined rejection.  In individuals with BPD, they often have recurrent unstable relationships. Commonly switching from looking up to someone and adoring them to suddenly having negative feelings towards the person. Individuals with BPD often have frequent shifts in self-image, which may include negative feelings about oneself and feelings of worthlessness. Risky behaviour and impulsivity can also be noticed as a symptom of BPD, such behaviours may include, spending excessive amounts of money, drug use, reckless driving, self-sabotaging (may include quitting their job or cutting ties with someone who has a positive impact in their life). Individuals with BPD may have regular attempts at self-harm, suicide attempts, or threatening to do harmful things to themselves. Mood swings are often noticed in people who experience BPD. These mood swings can consist of extreme happiness to feelings of sadness, irritability, or shame, these polar extremes can last from a few hours to a few days.  An additional symptom of BPD is persistent feelings of emptiness. Individuals with BPD may also experience frequent intense anger in which they have trouble controlling.  Individuals with BPD may also experience short periods of psychotic symptoms or disassociations in the presence of stressors. These cognitive symptoms may look like paranoid thoughts or auditory hallucinations. Furthermore, additional cognitive symptoms are depersonalization (i.e., the individual or the person’s body feels unreal or altered) and derealization (i.e., feelings that the world around them is unreal).  

Causes

The cause of Borderline Personality Disorder are not fully understood, although research does indicate some evidence that genetic factors, adverse childhood experiences as well as brain abnormalities may be linked to BPD. Studies on twins and families have been done and suggest that genetics and heritability may influence the developments of BPD. A common history of adverse childhood events particularly, neglect and abuse are reported in BPD patients. Another important childhood factor that may be linked to BPD, is the inability to find stable attachments during childhood. Some research has also proposed the idea that there are changes in areas of the brain that are responsible for the regulation of emotions, impulsivity, and aggression.  Additionally, chemicals in the brain that are responsible for mood regulation such as serotonin may have an imbalances.  

Assessment & Diagnosis

Sometimes the diagnosis of OCD can be challenging because symptoms that are experienced often are noticed in other disorders such as anxiety disorder, depression, or other mental health disorders. The process of diagnosis starts off with a psychological evaluation which includes determining the individual’s thoughts, feelings, and behaviours to identify if the symptoms have interference with daily functioning. Criteria in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) published by the American Psychiatric Association may also be used for diagnosis. In addition, a physical exam can also be done to rule out any other problems or other complications that could be causing OCD like symptoms (i.e., neurological problems, traumatic brain injuries). 

Common Misdiagnosis

Individuals with BPD usually also meet the criteria for multiple diagnosis including:  

  • depression 
  • anxiety 
  • substance use disorders 
  • eating disorders 

Two conditions that commonly get misdiagnosed with BPD are, bipolar and complex PTSD. Bipolar Disorder and Borderline Personality disorder both present symptoms of, impulsive behaviour, intensive emotions, as well as suicidal thoughts. 

The similarity in presentation in complex PTSD and BPD can lead to misdiagnosis. Complex PTSD is a subset of PTSD and is a disorder deriving from the exposure of long-term trauma usually in childhood. cPTSD and BPD often get confused because they share similar behaviours and emotional patterns such as emotional distress, suicidal thoughts, anxiety, depression and disassociations. Although there are a few main differences in both BPD and cPTSD there is a noticed theme of fear of relationships. however, People with cptsd or BPD both have abandonment issue, but with BPD, this is more prevalent. People with cPTSD may choose to avoid intimate relationships while someone with BPD may have difficulties being alone and use an intimate relationship to prevent feelings of abandonment.  Individuals with BPD and cPTSD both struggle with emotional regulation. Although, individuals with BPD express more outbursts of anger such as crying or tantrum like behaviour more often, while irregulated emotions in cPTSD are typically presented as numbness, emptiness and detaching from emotions

Treatment 

While many individuals with BPD benefit from psychotropic medications, the gold standard treatment is treated through a form of psychotherapy, called Dialectical Behaviour Therapy (DBT). 

Dialectical Behaviour Therapy is a form of cognitive behavioural therapy (CBT). CBT tries to recognize and transform negative thinking patterns into positive behavioral changes. Additionally, DBT focuses on reassuring the patients and aiming to get them to be acceptant of the experience.  

A standard comprehensive DBT treatment includes five parts: 

  1. BT skills training Group 
  • mindfulness, distress tolerance, interpersonal effectiveness, emotion regulation 
  1. Individual therapy 
  • helps individuals apply the skills they have learnt to specific situations and discuss individual goals.  
  1. In-the-moment coaching  
  • telephone coaching in case the patient is in a crisis  
  1. Case management strategies 
  • teach the patients how to be autonomous and how to be their own case manager, take control of their own lives and care 
  1. DBT consultation team  
  • focuses on supporting those who are providing the DBT to ensure the best treatment possible is being provided to the patient 

DBT is completed in stages  

Stage 1: focuses on treating self-destructive behaviour i.e., suicide attempts, self-harm  

Stage 2: teaching quality of life skills: emotional regulation, distress tolerance & interpersonal effectiveness  

Stage 3: narrows in on improving relationships and self-esteem 

Stage 4: fosters additional joy and relationship connections 

Another effective treatment for BPD is Dr. Jeffrey Young’s schema therapy.  Schema-focused therapy helps an individual with BPD recognize any needs that have not been met which may be leading to negative patterns in life. This therapy focuses on allowing for all needs to be met promoting positive life patterns.  

Medications  

Although there are no medication treatments for borderline personality disorder, there are medications that can help with symptoms found within BPD such as anxiety, depression, aggression, and anxiety. 

These medications may be: 

  •  antidepressants (Celexa, Lexapro, Proxac ,Zoloft, Paxil) 
  • antipsychotics (Abilify, Cplyta, Geodon)  
  • mood stabilizing drugs (Tegretol, Lamictal, Trileptal)