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Understanding Borderline Personality Disorder

By Caroline Miller, Editorial Director of The Child Mind Institute


Harold Koplewicz, M.D., Founder and President of the Child Mind Institute
Harold Koplewicz, M.D., Founder and President of the Child Mind Institute

Borderline personality disorder (BPD) is a diagnosis that has historically been difficult to understand, and even more difficult to treat successfully. The symptoms associated with it are a painful mix of emotional turmoil, unstable relationships and self-destructive behavior, including suicide attempts.

But new insights into the disorder, leading to new, more effective treatments, have made the prognosis for someone with BPD much more promising. With the right support, most people with BPD can successfully learn to regulate their overwhelming emotions, stop self-destructive behavior and improve their lives.

“It used to be that receiving a BPD diagnosis felt like a life sentence of misery,” said Dr. Alec Miller, an expert in treating adolescents with BPD. “But research now shows that the chances of functioning better and even dropping the diagnostic label are very high.”

Another important change is that BPD is now diagnosed and treated in teenagers. Until recently mental health professionals were reluctant to give the diagnosis to anyone under 18, despite the fact that symptoms become prominent in adolescence, or even earlier. Now experts stress that treating BPD as early as possible leads to better long-term outcomes, as well as lowering the risk of dangerous or suicidal behavior.

What is BPD?

Experts call BPD a biosocial disorder, meaning that it starts with a biological (or temperamental) inclination which is exacerbated by the social environment. People who develop BPD are by temperament highly emotionally sensitive and reactive, feeling things more immediately and more intensely than most people. And once a powerful emotion is triggered, it takes them longer to return to their emotional baseline.

BPD develops when one of these emotionally vulnerable people is confronted with an environment that doesn’t validate her feelings — that is, acknowledge them, make her feel understood, and respond appropriately. In many cases, kids who develop BPD have been abused or neglected. But the disorder can also come about in children whose ordinary, well-meaning parents minimize or discount their emotional reactions, which they find exaggerated or inappropriate.

The chronic sense of not feeling understood or supported leads people with BPD to feel painfully alone and disconnected, explains Dr. Blaise Aguirre, the founding medical director of 3East, a continuum of care using dialectical behavior therapy (DBT) to treat borderline personality disorder at Boston’s McLean Hospital. Friends and family members don’t understand why people with BPD have huge reactions to small things. For Dr. Aguirre, author of Borderline Personality Disorder in Adolescents, BPD is something like a peanut allergy; the reaction may not be typical of most people, but it’s no less real.

Emotional dysregulation

When a child’s powerful feelings aren’t validated by the adults in her life, it becomes difficult for her to learn to manage them in a healthy way. Adults help us name and identify what we’re feeling; by soothing us they teach us how to soothe and calm ourselves down.

“Take a person with extremely strong, intense emotions, who is constantly told that she’s overreacting, she shouldn’t feel the ways she feels,” explains Dr. Jill Emanuele, clinical psychologist and director of the Mood Disorders Center at the Child Mind Institute. “As a result, she doesn’t learn how to regulate and modulate her emotions. “

People with BPD are often overwhelmed by intense anger and feelings of abandonment, emptiness, shame and self-loathing.

These feelings tend to destabilize relationships for people with BPD, who are hypersensitive to social cues from others, and more likely than others to interpret things negatively. Minor slights — or things misinterpreted as slights — are taken as evidence of abandonment, and the reaction can be swift and intense, causing rifts with friends, parents, partners. They go from “I love you” to “I hate you” in a heartbeat, Dr. Aguirre explains. Or they become so frantic asking for reassurance that they are loved — incessant texting, calling, begging, clinging —that they drive partners away.

Rifts with friends or breakups with partners are often the trigger for self-harm or suicide attempts, he notes.

Why does BPD lead to self-destructive behavior?

Without the skills to manage painful feelings in a more effective way, people with BPD often find unhealthy alternatives, including substance abuse, risky sex, reckless thrill-seeking.

Self-injury is very often one of these behaviors: Teenagers use things like cutting, scratching and opening wounds to alleviate emotions they find intolerable. “In fact it can work as an emotional regulation strategy,” notes Dr. Miller, cofounder and clinical director of Cognitive and Behavioral Consultants in Westchester and New York City. “The problem is that if it works, they’re more likely to use it again to cope with negative emotions. To reduce self-harm we need to acknowledge what it’s doing for them, and try to give them some safer replacement strategies.”

One dangerous misunderstanding about BPD is that the emotional drama and the self-destructive behaviors, including suicide attempts, are manipulative pleas for attention.

“Historically, people with BPD have been viewed as purposely manipulative,” explains Dr. Emanuele, “using extreme measures to get things, gaming people around them. But that’s not it at all. These people are in intense pain, and feel they can’t get what they need.”

In fact, Dr. Aguirre notes, suicidal feelings are almost universal in people with BPD, and reflect a desperate need to escape extreme emotional distress.

Criteria for diagnosing BPD

These are the criteria mental health professionals use to diagnose borderline personality disorder:

• Frantic efforts to avoid abandonment, real or imagined

• A pattern of unstable and intense relationships

• An unstable self-image or sense of self

• Dangerous impulsivity such as unsafe sexual encounters, substance abuse

• Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.

• Emotional instability due to high reactivity

• Chronic feelings of emptiness

• Inappropriate, intense anger or difficulty controlling anger

• Transient, stress-related paranoia or severe dissociative symptoms

Diagnosing teenagers

In the past, mental health professionals were reluctant to diagnose anyone under 18 with BPD, even though symptoms usually develop during the teen years. That was, in part, because emotional intensity and impulsive risk-taking are to some extent characteristic of adolescence itself. Typical teenage behavior, it was thought, could be confused with BPD.

But even if the behavior looks similar, the reasons for it are different in typical adolescents and those with BPD, Dr. Aguirre notes. Typical teens experiment with alcohol and sex out of curiosity and impulsivity, while people with BPD use them to escape acutely painful feelings. They may seek out sexual encounters, for instance, because they feel abandoned, and crave closeness, rather than sex itself. They may take dangerous risks because “in that moment of desperation the need to change how they feel makes the behaviors feel like the right thing to do.”

Another reason for not diagnosing BPD in teens was to avoid labeling them with a severe illness that didn’t respond well to treatment. But as the treatment picture has changed, so has the aversion to diagnosis in adolescence. One large study called the McLean Study of Adult Development, which followed BPD patients for 12 years, found that 74 percent of participants had no active symptoms after 6 years, and only 6 percent relapsed in the following 6 years.

The lead author of the study, Mary Zanarini, began to call borderline personality disorder a “good-prognosis diagnosis,” and those who are treated while they’re still teenagers have even more optimistic outcomes.

Why early diagnosis is crucial

If BPD is understood as a lack of emotional regulation skills, it’s crucial to get someone who develops symptoms into treatment as soon as possible, Dr. Aguirre says, “before patterns of maladaptive behavior have set in.”

This is particularly important as young people are developing their identity and sense of self, which is made incredibly difficult for young people with BPD symptoms. “When your environment doesn’t reflect back what your experience is,” Dr. Aguirre says, “it’s hard to know who you are, what your values are.”

Another reason experts urge earlier diagnosis of BPD is to lessen inaccurate diagnosis of more common disorders like ADHD, depression and bipolar disorder. Sometimes these are co-occurring disorders, but often they are misdiagnoses. As a result, these teenagers are given medications that aren’t effective, including mood stabilizers and antipsychotics.

“I’ve seen kids with BPD who were on extensive drug cocktails because the clinicians didn’t know what was happening,” adds Dr. Emanuele. “They’re just going after the symptoms. And no medication is going to correct the invalidation that these people feel.”

BPD patients who are admitted to Dr. Aguirre’s unit often come in “zombie-like,” he reports, because they are on so many medications. When they are discharged, he says, half are on no meds at all.

Treatment for BPD

There are a number of specialized psychotherapies that have been developed to treat BPD, but the gold standard treatment — the one with the most evidence for its effectiveness — is called dialectical behavioral therapy, or DBT. The reason it’s called “dialectical” is that it involves two things that might seem to be in opposition but are both important: the need for acceptance and the need for change.

First, a patient’s feelings need to be validated, or accepted without judgment, in order for her to learn more effective ways for her to manage and respond to them.

“It’s basically ‘I’m doing the best I can’ on the one hand,” explains Dr. Miller, “and at the same time ‘I need to do better’ on the other.”

Validation, which is the first step in DBT, means recognition and acceptance of another person’s feelings as being real. It doesn’t mean agreeing with the thoughts or feelings. When people feel accepted and understood, it has a calming effect and allows them to learn skills to regulate emotions and develop safer, more effective alternatives to the self-destructive behaviors they have been using.

“It’s essentially a skills-based approach which says that if our patients could do better, they would, but they’re lacking skills,” explains Dr. Miller, who is the author of Dialectical Behavioral Therapy with Suicidal Adolescents. “It’s so easy for us to tell people to stop problematic behaviors but it’s better to teach them new skills.”

DBT skills are very effective for getting patients to stop self-injury and suicidality, Dr. Aguirre notes. It’s tougher to change the self-loathing and self-hatred that can become fused with a borderline person’s identity.

He also notes that availability of DBT and other treatment for BPD is limited, which means that a lot of teenagers who should get treatment aren’t getting it. “The number of people with emotion regulation problems is outstripping the number of DBT providers,” he says, “and we know that because suicide rates in adolescents continue to go through the roof.”

Dr. Miller stresses the urgency of getting teens with BPD into treatment: “If you throw yourself into treatment, you can be a very successful, highly functional adult.”

Dr. Emanuel adds that she’s seen many patients dramatically improve their lives. “Over the years, I have repeatedly seen DBT give participants the hope and reality of a ‘life worth living,’ ” adds Dr. Emanuel. “And that’s something they had not been able to imagine or experience before.” #

Reprinted with permission from the Child Mind Institute.



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