Borderline Personality Disorder Resources

by Aunt Becky | Jul 18, 2019

What Is Personality?

Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.

While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behavior.

What Is A Personality Disorder?

A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time.

Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.

What is Borderline Personality Disorder?

Borderline Personality Disorder is a personality disorder marked by a pervasive pattern of unstable personal relationships, self-image, and affects along with excessive impulsiveness beginning in early adulthood. This instability can cause significant problems in personal relationships, long-term planning, and careers.

BPD is a serious psychological condition that’s characterized by unstable moods and emotions, relationships, and behavior. It’s one of several personality disorders recognized by the American Psychiatric Association (APA).

Personality disorders are psychological conditions that begin in adolescence or early adulthood, continue over many years, and, when left untreated, can cause a great deal of distress. Thankfully, treatment that’s targeted specifically to BPD may help those who struggle with this disorder significantly.

Unfortunately, BPD often remains undetected (and therefore untreated) for many, many years because it often exists with another mental illness (comorbidity) like depression, drug abuse or anxiety. This personality disorder is also commonly misdiagnosed as something else altogether, as it shares traits with other personality disorders.

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD)  is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self and unstable emotions; and people who have BPD often engage in dangerous behavior and self-harm. People may also struggle with a feeling of emptiness and a fear of abandonment, and the hallmark symptoms may be brought on by innocuous events. Symptoms of borderline PD usually begins by early adulthood and occurs across a variety of situations: love life, relationships, work, friendships, family.

Substance abuse, depression, and eating disorders are commonly associated with BPD. Up to 10% of people affected die by suicide.

BPD’s causes are unclear but seem to involve genetic, brain, environmental and social factors, as BPD occurs about five times more often in a person who has an affected close relative with the same disorder. Additionally, adverse life events also appear to play a role in the development of this and other personality disorders. BPD is recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a personality disorder, and a diagnosis is based on the symptoms as well as a medical exam to rule out other problems.

BPD is a complex disorder that has historically been difficult to treat for a number of reasons, including poor treatment plans and inadequate insurance coverage.

Thanks to developments in the last twenty-five years, a diagnosis of borderline personality disorder is no longer the grim fate it once was.

Prevalence of Borderline Personality Disorder:

It’s estimated that 1.6% of the adult U.S. population has BPD, but that number may be as high as 5.9%. Borderline personality disorder (BPD) is prevalent and this incidence rises as high as 15% to 20% in psychiatric setting. BPD is associated with high rates of suicide – nearly all people who have BPD have experienced suicidal ideation and almost 10% die by suicide by adulthood.

Nearly 75% of people diagnosed with BPD are women. Recent research suggests that men may be equally affected by BPD but are commonly misdiagnosed with PTSD or depression.

Although psychosocial causes of BPD have been explored in many studies, relatively little data exists in locating biological causes. The neurological and genetic factors of BPD have not yet been fully explored, perhaps because it is difficult to find BPD subjects to participate or because the technologies used are relatively new. The study of such factors may help create new insights into the causes, comorbidities, and treatments of BPD.

People affected by BPD generally use a high amount of healthcare resources. There is an ongoing debate about the naming of the disorder, especially the word borderline. The disorder, like the other Cluster B personality disorders, is often stigmatized in both the media and the psychiatric field.

Borderline Personality Disorder And Stigma:

When psychologists talk about “personality,” they’re discussing the patterns of thinking, feeling, and behaving that make each of us unique. No one acts exactly the same all the time, but we do tend to interact and engage with the world in fairly consistent ways. This is why people are often described as “shy,” “outgoing,” “meticulous,” “fun-loving,” and so on. These are all elements of personality.

Because personality is so intrinsically connected to identity, the term “personality disorder” might leave people who’ve been diagnosed with one feeling like there’s something fundamentally wrong with who they are. It’s important to remember that having a personality disorder is not a character judgment. In clinical terms, “personality disorder” means that the pattern of relating to the world is significantly different from the norm. (In other words, people with PD’s don’t act in ways that most people expect). This causes consistent problems in many areas of life, such as relationships, career, and feelings about themselves, and others.

While mental health advocates actively fight stigma associated with mental illness, Borderline Personality Disorder (BPD) remains one of the field’s most misunderstood, misdiagnosed and stigmatized conditions. Studies show that even some mental health professionals have more stigmatizing views about BPD than any other mental health condition; some even choose to limit the amount of BPD patients they’re “willing” to see or refuse to treat people with BPD altogether.

For the mental health professionals who do treat BPD, they often do so without the proper training, making therapies frustrating and uncomfortable for everyone. People who have BPD may leave feeling misunderstood and judged while providers may feel ineffective and inadequate.

People who have BPD are frequently labeled as “treatment resistant” and dropped as patients by those who should be helping this, When this happens, it reinforces the common misconception that reaching out for help is hopeless, which further intensify the symptoms that caused the person to seek help in the first place. When someone who has an intense fear of abandonment –  common symptom of BPD – is “abandoned” by a person who should be helping them, these people may stop seeking treatment due to a heightened fear of abandonment.

The features of BPD include emotional instability; intense, unstable interpersonal relationships; a need for intimacy; and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as “difficult,” “treatment-resistant,” “manipulative,” “demanding,” and “attention-seeking,” are often used and may become a self-fulfilling prophecy, as the negative treatment triggers further self-destructive behaviors.

Causes of Borderline Personality Disorder:

As is the case with other mental disorders, the causes of BPD are complex and not fully agreed upon, though new evidence suggests that BPD and post-traumatic stress disorder (PTSD) may be related in some way. Most researchers agree that a history of childhood trauma can be a contributing factor, but historically, less attention has been paid to investigating the causal roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.

These different factors suggest that there are multiple factors that may contribute to the disorder.

Genetics:

Studies of BPD in families show that first-degree relatives — meaning siblings, children, or parents — of people treated for BPD are ten times more likely to have been treated for BPD themselves than the relatives of people with schizophrenia or bipolar disorder. People who 

People who have first degree relatives with BPD are 40% more likely to inherited this disorder. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment. Nonetheless, researchers have concluded that personality disorders seem to be more strongly influenced by genetic effects than almost any axis I disorder (such as bipolar disorder, depression, and eating disorders).

Moreover, the study found that BPD was estimated to be the third most-heritable personality disorder out of the other personality disorders reviewed. Twin, sibling, and other family studies indicate partial heritability for impulsive aggression, but studies of serotonin-related genes have suggested only mild contributions to behavior.

However, while this suggests that BPD runs in families, unfortunately these studies cannot tell us exactly how much of BPD is due to genetics. That’s because first-degree relatives share not just genes, but also environments in most situations. For example, siblings may be raised together by the same parents. This means that these studies may reflect, in part, any environmental causes of BPD as well.

Research collaborators found that genetic material on chromosome 9 was linked to BPD features, concluding that genetic factors play a major role in individual differences of borderline personality disorder symptoms. Research had earlier concluded that 42 percent of variation in BPD features was attributable to genetic influences and 58 percent was attributable to environmental influences.

Brain Abnormalities

A number of CT scans and MRIs studies performed on people who have BPD that have found abnormalities in ares of the brain responsible for the regulation of stress responses and emotion. These areas include the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas.

Hippocampus:

The hippocampus is a small, curved formation in the brain that plays an important role in the limbic system. The hippocampus is involved in the formation of new memories and is also associated with learning and emotions. Because the brain is lateralized and symmetrical, we actually have two hippocampi.

The hippocampus tends to be smaller in people with BPD, as it is in people with post-traumatic stress disorder (PTSD).

Amygdala:

The amygdala (Latin, corpus amygdaloideum) is an almond-shape set of neurons located deep in the brain’s medial temporal lobe. This are plays a important role in processing of emotions; thus, the amygdala forms part of the limbic system.

However, in BPD, unlike PTSD, the amygdala also tends to be smaller.

The amygdalae tend to be smaller and more active in people with BPD. One study found unusually strong activity in the left amygdalae of people with BPD when they experience and view displays of negative emotions. This unusually strong activity may explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.

Prefrontal Cortex:

The prefrontal cortex is a region associated with planning complex cognitive behaviors like executive function and expression of appropriate social behavior.

The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment. Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties people who have borderline PD experience in regulating their emotions and responses to stress.

Hypothalamic-Pituitary-Adrenal Axis:

The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production tends to be elevated in people with BPD, indicating a hyperactive HPA axis in these people, which causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability.

As traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average activity in the HPA axis of people with BPD, may simply be a reflection of the higher than average prevalence of traumatic childhood and maturational events among people with BPD. Another possibility is that, by heightening their sensitivity to stressful events, increased cortisol production may predispose those with BPD to experience stressful childhood and maturational events as traumatic.

Increased cortisol production is also associated with an increased risk of suicidal behavior.

Neurobiological factors:

Estrogen:

Differences in women’s estrogen cycles may be related to the expression of BPD symptoms in female patients.  A 2003 study found that women’s BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative behaviors.

Developmental factors:

Childhood Trauma:

There is believed to be a strong correlation between child abuse, especially child sexual abuse, and development of BPD as well as many other mental illnesses.

Many people who have BPD report a history of abuse and neglect as young children; those who have BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, or sexually abused by caregivers of either gender. They also report a high incidence of incest and loss of caregivers in early childhood. People who have BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings.

Caregivers were also reported to have failed to provide needed protection and to have neglected their child’s physical care. Parents of both sexes were typically reported to have withdrawn from the child emotionally and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were significantly more likely to have experienced sexual abuse by a non-caregiver.

It has been thought that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.

Neurological Patterns:

That said, the intensity and reactivity of a person’s tendency to feel negative emotions predicts BPD symptoms more strongly than does childhood sexual abuse.This finding, differences in brain structure, and the fact that some patients with BPD do not report a traumatic history, suggest that BPD is distinct from the post-traumatic stress disorder which frequently accompanies it.

Thus, researchers are examining developmental causes in addition to childhood trauma.

Mediating And Moderating Factors:

Executive Function:

A group of cognitive processes that include planning, working memory, attention, and problem-solving might be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the relationship between a person’s sensitivity to abandonment and BPD symptoms were stronger when executive function was lower.This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.

A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.

Family Environment:

Family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment predicts a lower risk. One possible explanation is that a stable environment buffers against its development.

Symptoms of Borderline Personality Disorder:

Borderline personality disorder (BPD) manifests in many different ways, but for the purposes of diagnosis, mental health professionals group the symptoms into nine major categories. In order to be diagnosed with BPD, you must show signs of at least five of these symptoms.

Furthermore, the symptoms must be long-standing (usually beginning in adolescence) and impact many areas of your life.

Chronic feelings of emptiness. People with BPD often speak about feeling empty, as if there’s a hole or a void inside them. At the extreme, you may feel as if you’re “nothing” or “nobody.” This feeling is uncomfortable, so you may try to fill the void with things like drugs, food, or sex. But nothing feels truly satisfying.

Explosive anger. If you have BPD, you may struggle with intense anger and a short temper. You may also have trouble controlling yourself once the fuse is lit – yelling, throwing things, or becoming completely consumed by rage. It’s important to note that this anger isn’t always directed outwards: you may spend a lot of time feeling angry at yourself.

Extreme mood swings. Unstable emotions and moods are common with BPD. One moment, you may feel happy, and the next, despondent. Little things that other people brush off can send you into an emotional tailspin. These mood swings are intense, but they tend to pass fairly quickly (unlike the emotional swings of depression or bipolar disorder), usually lasting just a few minutes or hours.

Fear of abandonment. People with BPD are often terrified of being abandoned or left alone. Even something as innocuous as a loved one arriving home late from work or going away for the weekend may trigger intense fear. This can prompt frantic efforts to keep the other person close. You may beg, cling, start fights, track your loved one’s movements, or even physically block the person from leaving. Unfortunately, this behavior tends to have the opposite effect – it drives people away.

Feeling suspicious or out of touch with reality. People with BPD often struggle with paranoia or suspicious thoughts about others’ motives. When under stress, you may even lose touch with reality – which is known as dissociation. You may feel foggy, spaced out, or as if you’re outside your own body.

Impulsive, self-destructive behaviors. If you have BPD, you may engage in harmful, sensation-seeking behaviors, especially when you’re upset. You may impulsively spend money you can’t afford to spend, binge eat, drive recklessly, shoplift, engage in risky sex, or overdo it with drugs or alcohol. These risky behaviors may help you feel better in the moment, but they hurt you and those around you over the long-term.

Self-harm. Suicidal behavior and deliberate self-harm is common in people with BPD. Suicidal behavior includes thinking about suicide, making suicidal gestures or threats, or actually carrying out a suicide attempt. Self-harm encompasses all other attempts to hurt yourself without suicidal intent. Common forms of self-harm include cutting and burning.

Unclear or shifting self-image. When you have BPD, your sense of self is typically unstable. Sometimes you may feel good about yourself, but other times you hate yourself, or even view yourself as evil. You probably don’t have a clear idea of who you are or what you want in life. As a result, you may frequently change jobs, friends, lovers, religion, values, goals, or even sexual identity.

Unstable relationships. People with BPD tend to have relationships that are intense and short-lived. You may fall in love quickly, believing that each new person is the one who will make you feel whole, only to be quickly disappointed. Your relationships either seem perfect or horrible, without any middle ground. Your lovers, friends, or family members may feel like they have emotional whiplash as a result of your rapid swings from idealization to devaluation, anger, and hate.

Wait! Do I Have Borderline Personality Disorder?

Do you identify with the following statements?

I often feel “empty.”

My emotions shift very quickly, and I often experience extreme sadness, anger, and anxiety.

I’m constantly afraid that the people I care about will abandon me or leave me.

I would describe most of my romantic relationships as intense, but unstable.

The way I feel about the people in my life can dramatically change from one moment to the next—and I don’t always understand why.

I often do things that I know are dangerous or unhealthy, such as driving recklessly, having unsafe sex, binge drinking, using drugs, or going on spending sprees.

I’ve attempted to hurt myself, engaged in self-harm behaviors such as cutting, or threatened suicide.

When I’m feeling insecure in a relationship, I tend to lash out or make impulsive gestures to keep the other person close.

If you do identify with some of these statements, it’s time to get checked out by a doctor – not because you necessarily have BPD, but to rule it out.

Wait! Does My Loved One Have Borderline Personality Disorder?

In your relationship:

Do you feel like you have to tiptoe around your loved one, watching every little thing you say or do for fear of setting them off? Do you often hide what you think or feel in order to avoid fights and hurt feelings?

Does your loved one shift almost instantaneously between emotional extremes (calm one moment, raging the next, then suddenly sad?) Are these rapid mood swings unpredictable and (seemingly) irrational?

Does your loved one tend to view you as all good or bad, with no middle ground? For example, either you’re “perfect,” and the only one they can count on, or you’re “selfish” and “unfeeling” and never truly loved them.

Do you feel like you can’t win: that anything you say or do will be twisted and used against you? Does it feel as if your loved one’s expectations are constantly changing, so you’re never sure how to keep the peace?

Is everything always your fault? Do you feel constantly criticized and blamed for things that don’t even make sense? Does the person accuse you of doing and saying things you never did? Do you feel misunderstood whenever you try to explain or reassure your partner?

Do you feel manipulated by fear, guilt, or outrageous behavior? Does your loved one make threats, fly into violent rages, make dramatic declarations, or do dangerous things when they think you’re unhappy or may leave?

If you answer “yes” to most of these questions, your partner or family member might have borderline personality disorder.

Diagnosis of Borderline Personality Disorder:

Anyone who receives a diagnosis of a personality disorder, must also meet the general criteria for all personality disorders.

The essential features of a personality disorder include impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, according to the DSM-V following criteria must be met:

• A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
• B. One or more pathological personality trait domains or trait facets.
• C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
• D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or sociocultural environment.
• E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication)

Diagnosis of borderline personality disorder is based on a clinical assessment by a mental health professional. The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them. Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it. Although some clinicians prefer not to tell people with BPD what their diagnosis is – from concern about the stigma attached to this condition or because BPD was once considered to be untreatable – it’s usually helpful for the person with BPD to know their diagnosis, as this helps them know that others have had similar experiences and can point them toward more effective treatments.

In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient’s quality of life.

Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others. Diagnosis is based both on the person’s report of their symptoms and on the clinician’s own observations. Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or substance abuse.The ICD-10 manual refers to the disorder as emotionally unstable personality disorder and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in the previous editions.

Diagnostic and Statistical Manual (DSM-5)

A person must meet 5 of 9 criteria to receive a diagnosis of borderline personality disorder. The DSM-5 defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as markedly impulsive behavior. In addition, the DSM-5 proposes alternative diagnostic criteria for BPD in section III, “Alternative DSM-5 Model for Personality Disorders”. These alternative criteria are based on trait research and include specifying at least four of seven maladaptive traits.

According to Marsha Linehan, many mental health professionals find it challenging to diagnose BPD using the DSM criteria, since these criteria describe such a wide variety of behaviors.

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits.

To diagnose borderline personality disorder, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:

1. Impairments in self-functioning (a or b):

a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self criticism; chronic feelings of emptiness; dissociative states under stress.

b. Self-direction: Instability in goals, aspirations, values, or career plans.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity ( such as being prone to feeling slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:

1. Negative Affectivity, characterized by:

a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide, and suicidal behavior.

2. Disinhibition, characterized by:

a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

b. Risk-taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one‟s limitations and denial of the reality of personal danger.

3. Antagonism, characterized by:

a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head injury)

World Health Organizations International Classification of Disease ICD-10:

The ICD-10 defines a disorder that is conceptually similar to BPD, called (F60.3):

Emotionally Unstable Personality Disorder. 

Two Subtypes of Emotionally Unstable Personality Disorder:

F60.30 Impulsive Type

At least three of the following must be present:

• marked tendency to act unexpectedly and without consideration of the consequences
• marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized
• liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions
• difficulty in maintaining any course of action that offers no immediate reward
• unstable and capricious (impulsive, whimsical) mood

F60.31 Borderline Type

At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:

• disturbances in and uncertainty about self-image, aims, and internal preferences
• liability to become involved in intense and unstable relationships, often leading to emotional crises
• excessive efforts to avoid abandonment
• recurrent threats or acts of self-harm
• chronic feelings of emptiness
• demonstrates impulsive behavior, e.g., speeding in a car or substance abuse

The ICD-10 also describes some general criteria that define what is considered a personality disorder.

Subtypes of Borderline PD:

Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or more of the following:

Treating Borderline Personality Disorder:

There is a significant difference between the number of people who would benefit from treatment and the number who are treated. The so-called “treatment gap” is a function of the disinclination of the afflicted to submit for treatment, an under-diagnosing of the disorder by healthcare providers, and the limited availability and access to state-of-the-art treatments. Nonetheless, individuals with BPD accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of individuals with BPD who are in treatment continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.

Psychotherapy is the primary treatment for borderline personality disorder Treatments should be based on the needs of the individual, rather than upon the general diagnosis of borderline PD. Medications are useful for treating co-morbid disorders, such as depression and/or anxiety. Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD, though if someone who has BPD is engaging in self-harm, thoughts of suicide, and/or feelings of hurting someone else, short-term hospitalization is a must.

Psychotherapy

Long-term psychotherapy, in particular, dialectical behavioral therapy (DBT) and using psychodynamic approaches is currently the treatment of choice for BPD.

There are six such treatments available: dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy. While DBT is the therapy that has been studied the most, all these treatments appear effective for treating BPD, long-term therapy of any kind, including schema-focused therapy, is better than no treatment, especially in reducing urges to self-injure.

Transference-Focused Therapy aims to break away from absolute, “all or nothing” thinking as it provides people who have BPD a way to articulate their social interpretations and emotions in order to turn their views into less rigid beliefs. The therapist addresses the person’s feelings and goes over situations, real or realistic, that could happen as well as how to approach them. TFT views the person with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

Cognitive behavioral therapy, or CBT, is a short-term therapy technique that can help people find new ways to behave by changing their thought patterns. Engaging with CBT can help people reduce stress, cope with complicated relationships, deal with grief, and face many other common life challenges.

Mentalization-based therapy (MBT) is a talk therapy that helps people identify and understand what others might be thinking and feeling.

General Psychiatric Management combines the core principles from each of these treatments and it is considered easier to learn and less intensive. Randomized controlled trials have shown that DBT and MBT may be the most effective, and the two share many similarities. Researchers are interested in developing shorter versions of these therapies to increase accessibility, to relieve the financial burden on patients, and to relieve the resource burden on treatment providers.

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat Borderline Personality Disorder. DBT has been proven useful in treating mood disorders, suicidal ideation, and for change in behavioral patterns such as self-harm, and substance abuse. DBT includes:

• Distress tolerance: Most approaches to mental health treatment focus on changing distressing events and circumstance but with little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully. Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness.
• Emotional Regulation: Learning to properly identify and label emotions, Identifying obstacles to changing emotions Reducing vulnerability to “emotion mind” Increasing positive emotional events Increasing mindfulness to current emotions Taking opposite actions.
• Interpersonal Effectiveness: The interpersonal response patterns –how you interact with the people around you and in your personal relationships. These skills include effective strategies for asking for what one needs, how to assertively say ‘no,’ and learning to cope with inevitable interpersonal conflict
• Mindfulness: a mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations, used as a therapeutic technique.

Group Therapy:

Two types of group therapy may help some people with BPD, even though those with borderline personality disorder can be resistant to disclosure; a group setting allows them to learn from others who’ve had similar life experiences.

• Group therapy lead by a professional with selected members, the most beneficial of which is considered to be Dialectical Behavior Therapy (DBT)
• Self-help groups (such as AA) provide support and a network of peers and can be used with other treatments for BPD, but shouldn’t be the sole treatment for people with borderline personality disorder.

Medications And Borderline PD:

A 2010 review by the Cochrane collaboration found that no medications show promise for “the core BPD symptoms of chronic feelings of emptiness, identity disturbance, and abandonment.” However, the authors found that some medications may impact isolated symptoms associated with BPD or the symptoms of co-morbid conditions.

Although many people with BPD take medication, the fact is that there is very little research showing that it is helpful. What’s more, in the U.S., the Food and Drug Administration (FDA) has not approved any medications for the treatment of BPD. This doesn’t mean that medication is never helpful but it is not a cure for BPD itself. When it comes to BPD, therapy is much more effective. However, the doctor may consider medication if:

• Dual diagnosis of BPD and depression or bipolar disorder
• Panic attacks or severe anxiety
• Hallucinating or having bizarre, paranoid thoughts
• Feeling suicidal or at risk of hurting yourself or others

Because of weak evidence and the potential for serious side effects from some of these medications, the UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends: “Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behavior associated with the disorder.” However, “drug treatment may be considered in the overall treatment of comorbid conditions.”

As of 2017, trials with these medications had not been replicated and the effect of long-term use had not been assessed:

Typical antipsychotics studied in relation to BPD:

• Haloperidol may reduce anger
• Flupenthixol may reduce the likelihood of suicidal behavior.

Atypical antipsychotics studied:

• Aripiprazole may reduce interpersonal problems and impulsivity.
• Olanzapine, and quetiapine, may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety

Mood Stabilizers Studied:

• Valproate semisodium may ameliorate depression, impulsivity, interpersonal problems, and anger.
• Lamotrigine may reduce impulsivity and anger
• Topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger, and general psychiatric pathology.
• The effect of carbamazepine was not significant.

Antidepressants Studied:

• Amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate showed no effect.

Coping With Borderline Personality Disorder:

If you have borderline personality disorder (BPD), you probably feel like you’re on a rollercoaster – and not just because of your unstable emotions or relationships, but also the changing sense of who you are. Your self-image, goals, and even your likes and dislikes may change frequently in ways that feel confusing and unclear.

People with BPD tend to be extremely sensitive. Some describe it as like having an exposed nerve ending. Small things can trigger intense reactions. And once upset, you have trouble calming down. It’s easy to understand how this emotional volatility and inability to self-soothe leads to relationship turmoil and impulsive—even reckless—behavior. When you’re in the throes of overwhelming emotions, you’re unable to think straight or stay grounded. You may say hurtful things or act out in dangerous or inappropriate ways that make you feel guilty or ashamed afterwards. It’s a painful cycle that can feel impossible to escape. But it’s not.

Learn To Calm Yourself Down:

As someone with BPD, you’ve probably spent a lot of time fighting your impulses and emotions, so acceptance can be a hard thing to wrap your mind around. But accepting your emotions doesn’t mean approving of them or resigning yourself to suffering. All it means is that you stop trying to fight, avoid, suppress, or deny what you’re feeling.

Giving yourself permission to feel your feelings can take away a lot of their power.

Try to experience your feelings without judgment or criticism. Let go of the past and the future and focus exclusively on the present moment. Mindfulness techniques can be very effective in this regard.

• Start by observing your emotions, as if from the outside.
• Watch the waves of emotion as they come and go
• Focus in on the physical sensations that accompany your emotions
• Accept what you’re feeling right now

Remember that just because you’re feeling something doesn’t mean it’s reality. Feelings aren’t facts.

Engaging your senses is one of the quickest and easiest ways to quickly self-soothe. You will need to experiment to find out which sensory-based stimulation works best for you and you’ll need different strategies for different moods. What may help when you’re angry or agitated is very different from what may help when you’re numb or depressed:

Touch:

If you feel nothing or not enough, try running cold or hot (but not scalding hot) water over your hands; hold a piece of ice; or grip an object or the edge of a piece of furniture as tightly as you can.

If you’re feeling too much, and need to calm down, try taking a hot bath or shower; snuggling under the bed covers, or cuddling with a pillow.

Taste:

If you’re feeling empty and numb, try sucking on strong-flavored mints or candies, or slowly eat something with an intense flavor, such as salt-and-vinegar chips.

If you want to calm down, try something soothing such as hot tea or soup.

Smell:

Light a candle, smell the flowers, try aromatherapy, spritz your favorite perfume, or whip up something in the kitchen that smells good. You may find that you respond best to strong smells, such as citrus, spices, and incense.

Sight:

Focus on an image that captures your attention; something in your immediate environment (a beautiful view, a beautiful flower arrangement, a favorite photo) or something in your imagination that you visualize.

Sound:

Listen to loud music, ringing a buzzer, or blow a whistle when you need a jolt

To calm down, turn on soothing music or listen to the soothing sounds of nature, such as wind, birds, or the ocean. A sound machine works well if you can’t hear the real thing.

Helping Yourself When You’re Overwhelmed:

What do you do when you’re feeling overwhelmed by difficult feelings? This is where the impulsivity of borderline personality disorder (BPD) comes in. In the heat of the moment, you’re so desperate for relief that you’ll do anything, including things you know you shouldn’t—such as cutting, reckless sex, dangerous driving, and binge drinking. It may even feel like you don’t have a choice.

Once the fight-or-flight response is triggered, there is no way to “think yourself” calm. Instead of focusing on your thoughts, focus on what you’re feeling in your body. The following grounding exercise is a simple, quick way to put the brakes on impulsivity, calm down, and regain control. It can make a big difference in just a few short minutes.

Find a quiet spot and sit in a comfortable position.

Focus on what you’re experiencing in your body. Feel the surface you’re sitting on. Feel your feet on the floor. Feel your hands in your lap.

Concentrate on your breathing, taking slow, deep breaths. Breathe in slowly. Pause for a count of three. Then slowly breathe out, once more pausing for a count of three. Continue to do this for several minutes.

Fighting Impulsivity:

It’s important to recognize that these impulsive behaviors serve a purpose. They’re coping mechanisms for dealing with distress. They make you feel better, even if just for a brief moment. But the long-term costs are extremely high and ultimately not worth it.

Regaining control of your behavior starts with learning to tolerate distress; it’s the key to changing the destructive patterns of BPD. The ability to tolerate distress will help you press pause when you have the urge to act out. Instead of reacting to challenging emotions with self-destructive behaviors, you will learn to ride them out while remaining in control of the experience.

If your attempts to calm down aren’t working and you’re starting to feel overwhelmed by destructive urges, distracting yourself may help. All you need is something to capture your focus long enough for the negative impulse to go away. Anything that draws your attention can work, but distraction is most effective when the activity is also soothing. In addition to the sensory-based strategies mentioned previously, here are some things you might try:

Hobbies: This could be anything: gardening, painting, playing an instrument, knitting, reading a book, playing a computer game, doing a Sudoku, or playing on your phone.

Move around: Vigorous exercise is a healthy way to get your adrenaline pumping and let off steam. If you’re feeling stressed, you may want try more relaxing activities such as yoga or a walk around your neighborhood.

Talk to a friend: Talking to someone you trust can be a quick and highly effective way to distract yourself, feel better, and gain some perspective.

Watch TV: Choose something that’s the opposite of what you’re feeling: a comedy, if you’re feeling sad, or something relaxing if you’re angry or agitated.

Work Hard: You can distract yourself with chores and errands: cleaning your house, doing yard work, going grocery shopping, grooming your pet, or doing the laundry.

Work On Your Relationships:

If you have borderline personality disorder, you’ve probably struggled with maintaining stable, satisfying relationships with lovers, co-workers, and friends. This is because you have trouble stepping back and seeing things from other people’s perspective. You tend to misread the thoughts and feelings of others, misunderstand how others see you, and overlook how they’re affected by your behavior. It’s not that you don’t care, but when it comes to other people, you have a big blind spot.

Recognizing that you have an interpersonal blind spot is the first step. When you learn to stop blaming others, you can start taking steps to improve your relationships and your social skills.

Fighting Assumptions:

When you’re derailed by stress and negativity, as people with BPD often are, it’s easy to misread the intentions of others. If you’re aware of this tendency, check your assumptions. Remember, you’re not a mind reader! Instead of jumping to (usually negative) conclusions, consider alternative motivations. As an example, let’s say that your partner was abrupt with you on the phone and now you’re feeling insecure and afraid they’ve lost interest in you.

Before you act on those feelings:

Ask For Clarification: One of the simplest ways to check your assumptions is to ask the other person what they’re thinking or feeling. Double check what they meant by their words or actions. Instead of asking in an accusatory manner, try a softer approach: “I could be wrong, but it feels like…” or “Maybe I’m being overly sensitive, but I get the sense that…”

Consider Other Possibilities: Maybe your partner is under pressure at work. Maybe he’s having a stressful day. Maybe he hasn’t had his coffee yet. There are many alternative explanations for his behavior.

Projection:

Do you have a tendency to take your negative feelings and project them on to other people? Do you lash out at others when you’re feeling bad about yourself? Does feedback or constructive criticism feel like a personal attack?

If so, you, like many others, may have a problem with projection.

To fight projection, you’ll need to learn to apply the brakes – like curbing your impulsive behaviors. Tune in to your emotions and the physical sensations in your body. Take note of signs of stress, such as rapid heart rate, muscle tension, sweating, nausea, or light-headedness. When you’re feeling this way, you’re likely to go on the attack and say something you’ll regret later. Pause and take a few slow deep breaths. Then ask yourself the following three questions:

Am I upset with myself?

Am I feeling ashamed or afraid?

Am I worried about being abandoned?

If the answer is yes, take a conversation break. Tell the other person that you’re feeling emotional and would like some time to think before discussing things further.

Taking Responsibility For Yourself:

It’s extremely important that you begin to take responsibility for the role you play in your relationships. Figure out how your actions might contribute to problems. How do your words and behaviors make your loved ones feel? Are you seeing the other person as either all good or all bad? As you make an effort to put yourself in other people’s shoes, give them the benefit of the doubt, and reduce your defensiveness, and you’ll start to notice a difference in the quality of your relationships.

Concerns With Borderline Personality Disorder:

Suicide and Borderline Personality Disorder:

If you’re at immediate risk of committing suicide, you need to get help now. Call 911 if you’re in the United States or Canada, call the local police, or get yourself to your nearest emergency room.

If you’re not at immediate risk of suicide, but you’re having thoughts of suicide and need to get support, call a helpline to talk about how you’re feeling and to find resources near you. For example, in the United States, you can call the National Suicide Prevention Lifeline at 1-800-273-8255. It’s open 24/7, 365 days a week, and it’s free and confidential.

Suicidal behaviors and completed suicides are very common in people with borderline personality disorder (BPD). Research has shown that up to 80 percent of people with BPD will make at least one suicide attempt in their lifetime, and many will make multiple suicide attempts. People with BPD are also more likely to complete suicide than people with any other psychiatric disorders.

About 10 percent of people with BPD complete suicide, which is more than 50 times the rate of suicide in the general population.

There are several factors related to BPD that may explain why suicide, self-harm, and suicide attempts are so common, such as:

• Brain Abnormalities: Brain imaging has shown that compared to healthy people, individuals with BPD tend to have abnormalities involving the brain’s structure, metabolism, and function. These abnormalities appear to contribute to symptoms of BPD such as impulsivity and aggression, both of which are associated with suicidal behavior.
• Comorbidity: BPD tends to co-occur with other mental disorders, such as bipolar disorder, major depression, and schizoaffective disorder. When there are other mental disorders present, the risk of suicide increases.
• Duration: BPD is a chronic condition and usually lasts for years. Chronic conditions can lead to more risk for suicide since they don’t tend to get better quickly or without treatment. This may leave people with BPD feeling that there is no other way out, despite the fact that there are now effective treatments available.
• Impulsivity: BPD is associated with impulsivity, or a tendency to act quickly without thinking about consequences. Individuals with BPD may engage in suicidal behaviors in a moment of intense emotional pain without fully considering the consequences.
• Intense emotional pain: BPD is associated with very intense negative emotional experiences. These experiences are so painful that many people with BPD report that they would like to find a way to escape. They may use a number of different strategies to try to reduce their emotional pain, such as deliberate self-harm or substance use and even suicide.
• Substance Abuse: BPD often co-occurs with substance use and the use of drugs or alcohol is a risk factor for suicide all by itself. When substance use issues are combined with BPD, this may be a particularly lethal combination because substance use can lead to even greater impulsivity and people who are using substances have access to a means for overdose.

Family members of a person who is expressing suicidal thoughts, actions, or feelings, should immediately involve mental health professionals. Call 911, your local emergency number, and get help for your loved one right now.

Self-Injury and Borderline Personality Disorder:

Non-suicidal self-injury (NSSI), also called parasuidical acts, are a major concern in both clinical and non-clinical populations. It has been approximated that 65-80% of people who have with borderline personality disorder (BPD) engage in some form of NSSI. Despite such high co-morbidity, much still remains unknown about the relationship between NSSI and BPD symptomatology.

Self-mutilation can be a way to gain control of our feelings and emotions when we can’t seem to reel them in. We are able to determine the type and amount of pain we feel, instead of letting it emotionally take advantage of us. Since borderline personality disorder is characterized by emotional dysregulation, those with the illness may use self-injurious behavior in an attempt to regulate or gain some control of their emotional turbulence.

National Self-Injury Hotline:

1-800-DONT CUT (1-800-366-8288)

Self-injury often occurs without suicidal intent. Self-injury can involve cutting, burning, head-banging, hair-pulling, or hitting. Self-injury may also be classified as self-destructive behavior such as binging and purging, engaging in unsafe sex with multiple partners, and drug abuse Self-injury can be addictive and treatment for patients with borderline personality disorder is intended to help to break this cycle of addiction.

The motivations for self-injury in BPD patients vary and often occur during dissociative episodes; when numbness prevails. The physical pain of self-harm, patients have reported, causes a release of endorphins, naturally occurring opiates sent by the brain in response to pain. Self-harm may be used as a communication to others or an attempt to evoke a rescue.

Addiction and Borderline Personality Disorder:

People with borderline personality disorder represented 40 percent of people who sought buprenorphine to help with opioid addiction treatment. About 50 percent of people with BPD self-report a history of prescription drug abuse (about 9.2 percent).

A study found that over half of people with a lifetime diagnosis for BPD had a diagnosed substance use disorder in the past 12 months; similarly, the study found that 9.5 percent of people with a lifetime diagnosis of addiction also had BPD.

Yet another study found that 62 percent of people with BPD in the long-term study met the criteria for substance abuse when the study began; within 10 years of the study’s follow-up though, 90 percent of these people maintained sobriety for at least a two-year period, which is considered remission (or recovery) from the addiction.

When it comes to treating BPD and addiction concurrently, the similarities between addiction and borderline personality disorder make a proper diagnosis difficult. Treatment is particularly challenging in the case of BPD in which anti-social and manipulative tendencies make the difficult to work with. Further confusing matters is the fact that several signs of drug and alcohol addiction are very similar to symptoms of BPD:

• Both can be characterized by impulsive, self-destructive behaviors.
• Both may be characterized by mood swings ranging from severe depression to manic periods of intense energy.
• Both may be characterized by manipulative, deceitful actions.
• Both may be characterized by a lack of concern for one’s own health and safety and an insistence on pursuing dangerous behavior in spite of the risks.
• Both are often characterized by a pattern of instability in relationships, jobs, and finances

Treating comorbid BPD and substance abuse can be difficult. Because of the likelihood of polydrug (meaning: many drugs of) abuse, prescription drug abuse, and addiction, using pharmacotherapies like buprenorphine can be tricky and require intense oversight from medical professionals. Like all addiction treatment, detox and rehabilitation together are the best options.

It is highly important to treat both the substance use disorder and BPD concurrently.

Splitting and Borderline Personality Disorder:

Splitting is a maladaptive coping mechanism used by people with manipulative tendencies, such as those with narcissistic personality disorder and borderline personality disorder, in response to anxiety, stress or the perception of anxiety or stress. Splitting is the inability to integrate the good and bad parts of oneself or an object. Splitting means that it’s all good or all bad. Such objects can be anything – animate or inanimate – outside themselves (a lover, a sibling, a table) to which they are attached.

Splitting is considered a defense mechanism by which people with borderline personality disorder (BPD) can view people, events, or even themselves in all or nothing terms. Splitting allows them to readily discard things they have assigned as “bad” and to embrace things they consider “good,” even if those things are harmful or risky. Splitting is one of the nine criteria used to diagnose BPD.

Splitting can interfere with relationships and lead to intense and self-destructive behaviors. A person who splits will typically frame people or events in terms that are absolute with no middle ground for discussion. Examples include:

• Things are either “always” or “never”
• People can either be “evil” and “crooked” or “angels” and “perfect”
• Opportunities can either have “no risk” or be a “complete con”
• Science, history, or news is either a “complete fact” or a “complete lie”
• When things go wrong, a person will feel “cheated,” “ruined,” or “screwed”

What makes splitting all the more confusing is that the belief can sometimes be iron-clad or shift back-and-forth from one moment to the next. People who split are often seen to be overly dramatic or overwrought, especially when declaring that things have either “completely fallen apart” or “completely turned around.”

Such behavior can be exhausting to those around them.

Children And Borderline Personality Disorder:

It’s vital to understand that the impact of BPD is not limited to the person with the disorder. Symptoms merge into the lives of those around them and deeply shape the quality of interpersonal relationships. Often, the most seriously affected are the children of a parent with borderline personality disorder, as BPD interferes with normal, healthy parenting behaviors and changes the parent-child dynamics, while increasing the risk of environmental instability, drug and alcohol exposure, and poor family bonding.

The dynamics of the parent-child relationship are organized around the affected parent’s symptomatology; rather than understanding the child as an autonomous person with their own needs, desires, preferences, strengths, and weaknesses, the parent with BPD sees the child as a “need-gratifying object.” As a result, their parenting is driven by the desire to meet their own overwhelming need for validation, security, and love, rather than bestowing them upon their child.

Children of parents who have BPD are also at greater risk for having attention difficulties, aggressive behavior, and low self-esteem, in addition to major depression, anxiety, and the development of borderline personality disorder.

There are five groundbreaking empirical studies of children whose caregiver has BPD. Three of these assess children across a wide age span.

First, children aged 4-18 whose parent has BPD are more likely than are children of parents with other personality disorders to experience changes in household composition and schools attended, removal from the home, and exposure to parent drug or alcohol abuse, and parental suicide attempts.

Second, these children are diagnosed with more attention and disruptive behavior disorders than are comparisons.

Third, children aged 11-18 whose parent has BPD exhibit more problems with attention, delinquency, and aggression than do children whose parents have no psychiatric disorders; they also have more anxiety, depression, and low self-esteem than do children of depressed mothers, children of mothers with other personality disorders, and children of mothers with no disorder,

Fourth, when infants are 2 months, mothers with BPD demonstrate more intrusiveness and insensitivity, and their infants demonstrate more dazed looks, more looks away from mother, and less responsiveness than do infants of mothers without a disorder.

Fifth, when these infants are 13 months, 80% are disorganized in their attachment with their mothers which is the same percentage found in maltreated children. Disorganized attachment is thought to stem from fear of the mother or seeing the mother herself to be afraid.

if your partner has BPD:

Remove children if the person with BPD is being abusive. If the abuse is constant, consider your options.

Make sure your kids know that no one has the right to abuse them.

Don’t make excuses for abusive behavior. There are no excuses when it comes to your children’s mental health.

Help your kids by being there for them, supporting them, and following through on your promises.

Try to explain that the person with BPD isn’t lashing out because the child did something wrong.

Living With A Partner Who Has Borderline Personality Disorder:

If your loved one has borderline personality disorder, it’s important to recognize that he or she is suffering – and it’s not about you (even when it feels as though it is). The destructive and hurtful behaviors are a reaction to deep emotional pain. In other words, it’s not about you. When your loved one does or says something hurtful towards you, understand that the behavior is motivated by the desire to stop the pain they are experiencing; it’s rarely deliberate but it is still frustrating and upsetting.

Many friends or family members often feel guilty and blame themselves for the destructive behavior of the borderline person. You may wonder what you did to make the person so angry, think you somehow deserve the abuse, or feel responsible for any failure or relapse in treatment. But it’s important to remember that you’re not responsible for another person. The person with BPD is responsible for their own actions and behaviors.

Learning about BPD won’t automatically solve your relationship problems, but it will help you understand what you’re dealing with and handle difficulties in more constructive ways.

Remember the 3 C’s:

The 3 C’s are:

1. I didn’t cause it.
2. I can’t cure it.
3. I can’t control it.

First things first: take care of yourself.

• Don’t isolate yourself: Make it a priority to stay in touch with family and friends who make you feel good. You need the support of people who will listen to you, make you feel cared for, and offer reality checks when needed.
• Have your own life. Give yourself permission to have a life outside of your relationship with the person with BPD. It’s not selfish to carve out time for yourself to relax and have fun. In fact, when you return to your BPD relationship, you’ll both benefit from your improved perspective.
• Join a support group for BPD family members. Meeting with others who understand what you’re going through can go a long way. If you can’t find an in-person support group in your area, you may want to consider joining an online BPD community.
• Don’t neglect your physical health. Eating healthfully, exercising, and getting quality sleep can easily fall by the wayside when you’re caught up in relationship drama. Try to avoid this pitfall. When you’re healthy and well rested, you’re better able to handle stress and control your own emotions and behaviors.
• Learn to manage stress. Getting anxious or upset in response to problem behavior will only increase your loved one’s anger or agitation. By practicing with sensory input, you can learn to relieve stress as it’s happening and stay calm and relaxed when the pressure builds.

Communication Pointers:

Communication is a key part of any relationship but communicating with a borderline person can be especially challenging. People in a close relationship with a borderline adult often liken talking with their loved one to arguing with a small child. People with BPD have trouble reading body language or understanding the nonverbal content of a conversation. They may say things that are cruel, unfair, or irrational. Their fear of abandonment can cause them to overreact to any perceived slight, no matter how small, and their aggression can result in impulsive fits of rage, verbal abuse, or even violence.

• It’s important to recognize when it’s safe to start a conversation. If your loved one is raging, verbally abusive, or making physical threats, now is not the time to talk. Better to calmly postpone the conversation by saying something like, “Let’s talk later when we’re both calm. I want to give you my full attention but that’s too hard for me to do right now.”
• When things are calmer:Try to make the person with BPD feel heard. Don’t point out how you feel that they’re wrong, try to win the argument, or invalidate their feelings, even when what they’re saying is totally irrational.
• Listen actively and be sympathetic. Avoid distractions such as the TV, computer, or cell phone. Don’t to interrupt or redirect the conversation to your concerns. Set aside your judgment, withhold blame and criticism, and show your interest in what’s being said by nodding occasionally or making small verbal comments like “yes” or “uh huh.” You don’t have to agree with what the person is saying to make it clear that you’re listening and sympathetic.
• Focus on the emotions, not the words. The feelings of the person with BPD communicate much more than what the words he or she is using. People with BPD need validation and acknowledgement of the pain they’re struggling with. Listen to the emotion your loved one is trying to communicate without getting bogged down in attempting to reconcile the words being used.
• Do your best to stay calm, even when the person with BPD is acting out. Avoid getting defensive in the face of accusations and criticisms, no matter how unfair you feel they are. Defending yourself will only make your loved one angrier. Walk away if you need to give yourself time and space to cool down.
• Seek to distract your loved one when emotions rise. Anything that draws your loved one’s attention can work, but distraction is most effective when the activity is also soothing. Try exercising, sipping hot tea, listening to music, grooming a pet, painting, gardening, or completing household chores.
• Talk about things other than the disorder. You and your loved one’s lives aren’t solely defined by the disorder, so make the time to explore and discuss other interests. Discussions about light subjects can help to diffuse the conflict between you and may encourage your loved one to discover new interests or resume old hobbies.

Set – And Maintain – Boundaries:

One of the best ways to help a loved one with BPD gain control over their behavior is to set and enforce healthy limits or boundaries. Setting limits can help your loved one better handle the demands of the outside world, where schools, work, and the legal system, for example, all set and enforce strict limits on what constitutes acceptable behavior.

Establishing boundaries in your relationship can replace the chaos and instability of your current situation with an important sense of structure and provide you with more choices about how to react when confronted by negative behavior.

Talk to your loved one about boundaries at a time when you’re both calm, not in the heat of an argument. Decide what behavior you will and will not tolerate from the person and make those expectations clear. For example, you may tell your loved one, “If you can’t talk to me without screaming abuse at me, I will walk out.”

Do:

• Calmly reassure your loved one when setting limits. Say something like, “I love you and I want our relationship to work, but I can’t handle the stress from your behavior. I need you to make this change for me.”
• Make sure everyone in the family agrees on the boundaries – and how to enforce the consequences if they’re ignored.
• Think of setting boundaries as a process rather than a single event. Instead of hitting your loved one with a long list of boundaries all at once, introduce them gradually, one or two at a time.

But Don’t:

• Make threats and ultimatums that you can’t carry out. As is human nature, your loved one will inevitably test the limits you set. If you relent and don’t enforce the consequences, your loved one will know the boundary is meaningless and the negative behavior will continue. Ultimatums are a last resort (and again, you must be prepared to follow through).
• Tolerate abusive behavior. No one should have to put up with verbal abuse or physical violence. Just because your loved one’s behavior is the result of a personality disorder, it doesn’t make the behavior any less real or any less damaging to you or other family members.
• Enable the person with BPD by protecting them from the consequences of their actions. If your loved one won’t respect your boundaries and continues to make you feel unsafe, then you may need to leave. It doesn’t mean you don’t love them, but taking care of yourself should always take priority.

Supporting Your Loved One’s BPD Treatment:

Borderline personality disorder is highly treatable, yet it’s common for people with BPD to avoid treatment or deny that they have a problem. Even if this is the case with your loved one, you can still offer support, improve communication, and set boundaries while continuing to encourage your friend or family member to seek professional help.

While medication options are limited, the guidance of a qualified therapist can make a huge difference to your loved one’s recovery. BPD therapies, such as Dialectical Behavior Therapy (DBT) and schema-focused therapy, can help your loved one work through their relationship and trust issues and explore new coping techniques, learning how to calm the emotional storm and self-soothe in healthy ways.

Hotlines for Borderline Personality Disorder:

National Suicide Prevention Hotline: 1-800-273-8255

National Adolescent Suicide Hotline: 1-800-621-4000

National Self-Injury Hotline: 1-800-DONT CUT (1-800-366-8288)

Additional Resources for Borderline Personality Disorder:

National Education for Borderline Personality Disorder: website devoted to raising awareness, providing education, and promoting research for borderline personality disorder and those affected by it.

NAMI (National Alliance on Mental Health): website devoted to raising awareness and improving the lives of those afflicted with serious mental illness.

American Foundation for Suicide Prevention: AFSP raises awareness, funds scientific research and provides resources and aid to those affected by suicide.

• Call the National Suicide Prevention Lifeline: 1-800-273-8255
• Text TALK to 741741 to text with a trained crisis counselor from the Crisis Text Line for free, 24/7

BPD World has information, advice, education opportunities, and support for those with personality disorders.