People with borderline personality disorder (BPD) seem to be forever pulling the petals from a daisy. Their black-and-white thinking can take them from “he loves me” to “he loves me not” almost as quickly as the adolescent girl, sitting forlorn in a field of flowers, can pluck the blossom clean. But this is no game for BPD sufferers. Their feelings run deep and are so painful, so frightening, that about 10% of BPD patients commit suicide. BPD is a mental illness that affects about 14 million Americans, or 5.9% of the adult population. People with BPD have a hard time figuring out who they are, often changing their habits and values to mimic whomever they’re with. Of all the personality disorders, BPD is the most common, most perplexing, and often has the most severe impact due to its tendency toward suicide. And despite its prevalence, BPD is difficult to diagnose and difficult to treat because its symptoms often overlap with other disorders such as depression, bipolar disorder, anxiety disorders, substance abuse and eating disorders (particularly bulimia). The name “borderline personality disorder” fails to capture the essence of this serious mental illness, says National Institute of Mental Health Director Thomas Insel. The term “borderline personality” was first proposed by Adolph Stern in 1938 to describe a group of patients who “fit frankly neither into the psychotic nor into the psycho-neurotic group.” Stern introduced the term borderline to describe what he observed because it “bordered” on other conditions. If you or someone you love is “borderline,” you know that something is dreadfully wrong with your behavior or that of a loved one but often do not know what to do about it. One moment the borderline person thinks someone is wonderful, the most amazing person they’ve ever known, and the next believes that same person is an evil, horrible human being. Even a minor disagreement or perceived slight can precipitate the shift from love to hate. There is no middle ground in the minds of those with borderline personality disorder, which can make living with them emotionally exhausting. People with BPD also tend to be extremely sensitive. Psychologist Marsha Linehan, best known for developing dialectical behavior therapy (DBT) to treat borderline patients, and who herself suffers from borderline personality disorder, told Time magazine, “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin.”
Brain Differences in Borderline Personality Disorder
Now, new research suggests an explanation for the relationship difficulties experienced by people with BPD. To assess the link between brain activity and empathy among people with borderline personality disorder, Brian Haas, PhD, and Joshua Miller, PhD, of the University of Georgia, asked study participants to take part in an empathetic-processing task in which they matched the emotion of faces to a situation’s context while a functional MRI measured their brain activity. “Our results showed that people with BPD traits had reduced activity in brain regions that support empathy,” Haas said. “This reduced activation may suggest that people with more BPD traits have a more difficult time understanding and/or predicting how others feel, at least compared to individuals with fewer BPD traits.” Haas said he hopes the study, published in the journal Personality Disorder: Theory, Research and Treatment, will spark new inquiries to assure people with BPD that there is a biological reason for what happens to them. Interestingly, other studies have found that people with BPD have increased activity in another part of the brain, the amygdala, which plays a key role in processing negative emotion and producing aggressive behavior.
What Causes BPD?
Linehan and others theorize that an “invalidating environment” — that in which children are taught to keep their thoughts and feelings to themselves and any emotion that is displayed is disregarded or trivialized — along with an innate tendency to react more intensely to lower levels of stress, are the key underpinnings of BPD. An invalidating environment causes children to distrust their emotions, which leads to mimicking behavior in adulthood. (Because of their distorted sense of self, BPD sufferers often take on the characteristics of another person with the goal of being liked and accepted.) Borderline personality disorder also occurs much more often in people who suffered trauma in childhood, particularly sexual abuse and incest.
Signs and Symptoms of Borderline Personality Disorder
Borderline personality disorder is ultimately characterized by the emotional turbulence it causes. Suicide threats and attempts and self-harming acts, such as cutting and burning, are all common in people with BPD. According to the National Alliance on Mental Illness, signs and symptoms include:
- Frantic efforts to avoid being abandoned by friends and family.
- Unstable personal relationships that alternate between idealization — “I’m so in love!” — and devaluation — “I hate her.” This is also sometimes known as “splitting.”
- Distorted and unstable self-image, which affects moods, values, opinions, goals and relationships.
- Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, substance abuse or reckless driving.
- Suicidal and self-harming behavior.
- Periods of intense depressed mood, irritability or anxiety lasting a few hours to a few days.
- Chronic feelings of boredom or emptiness.
- Inappropriate, intense or uncontrollable anger — often followed by shame and guilt.
- Dissociative feelings — disconnecting from your thoughts or sense of identity, or “out of body” type of feelings — and stress-related paranoid thoughts. Severe cases of stress can also lead to brief psychotic episodes.
Treatment for BPD
If you recognize any of these symptoms in yourself or a family member, it may be time to seek help. Borderline personality disorder is eminently treatable. In fact, BPD is termed the “good prognosis diagnosis” and that’s because people get better. “People with this disorder have a remission within a couple of years [of treatment] and when that happens, it’s sustained,” said Dr. John Gunderson, MD, of Harvard University in “Back From the Edge,” a documentary on BPD. “Relapses are not common.” In addition, when BPD is successfully treated, the other disorders often get better, too.
The Importance of Finding the Right Therapist
A qualified therapist will be familiar with BPD therapies such as dialectical behavior therapy, which focuses on helping individuals with BPD learn coping skills, manage their emotions and interact more successfully in their relationships, and schema-focused therapy, which helps people change self-defeating life patterns — or schemas — using cognitive, behavioral and emotion-focused techniques. The process of “limited re-parenting” is at the core of treatment in schema therapy and calls for the therapist to provide, within reason, what patients needed but did not receive from their parents in childhood. Some people with BPD take medication, particularly if they suffer from co-occurring disorders such as depression or anxiety — but it is not a cure for BPD. “It’s very important for patients and families to find clinicians who are knowledgeable about this, have experience with it and want to treat them,” Dr. Gunderson said. “To seek treatment from people who don’t have those qualifications is likely to make the patient worse.” By Laura Nott