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Borderline Personality Disorder

The term “borderline” dates back to the early twentieth century when individuals with mental illness were categorized as either neurotic or psychotic. Early mental health professionals recognized that many patients did not fit well into either of these diagnostic categories. The expression “borderline” was introduced to cover those patients thought to be on the borderline between neuroses and psychoses. While this simplified neurosis/psychosis categorization of mental illness was abandoned long ago, the term “borderline,” despite being inaccurate, has endured. More accurate names have recently been suggested to take the place of the label “borderline personality disorder,” including emotional dysregulation and emotionally unstable personality disorder.




Characteristic Symptoms

Borderline Personality disorders are characterized by a long-lasting, rigid pattern of maladaptive thoughts, feelings, and behaviors. This enduring pattern of inner experience and behavior deviates markedly from the expectations of the individual’s culture. Because of the inflexibility and pervasiveness of these patterns, they cause serious relational problems and impairment of functioning for the afflicted individual. The characteristic symptoms of the personality disorders fall into four categories: distorted thinking, emotional dysregulation, impulse control problems, and interpersonal difficulties.

Distorted thinking is an extreme and inaccurate pattern of perceiving and interpreting one’s self, others, and the world around you. Examples of distorted thinking patterns include idealizing then devaluing other people or one’s self; extreme black-or-white thinking; distrustful, suspicious thoughts; unusual or odd beliefs that are contrary to cultural norms; and thoughts that include perceptual distortions and bodily illusions.

Emotional dysregulation is an inability to modulate the range, intensity, lability, and appropriateness of emotional responses. Some personality disorders are characterized by emotional sensitivity and a tendency to experience intense feelings.  Other disordered individuals show little or no emotional response, regardless of the circumstance or situation.  Still other personality disorders are characterized by emotional extremes; one moment overwhelmed with intense emotions, the next, numb and disconnected.

Impulse control problems are a third common characteristic symptom of personality disorders. Impulse control is the degree to which a person can regulate their internal drives or impulses to act. Much like the emotional regulation problems described above, personality disordered individuals have problems regulating their impulses. Some personality disorders are characterized by behavioral over-controlled (an inability to act), while others are characterized by a lack of behavioral control (acting spontaneously without forethought).

Interpersonal difficulties are common to all of the personality disorders. As would be expected, the three characteristic symptoms described above (i.e., distorted thinking, emotional dysregulation, and impulse control problems) make it difficult for personality disordered individuals to form and maintain healthy relationships.

 

Types of Personality Disorders

The DSM-5 lists borderline personality disorder as one of the dramatic-emotional (also called Cluster B) personality disorders. While each of these personality disorders is a distinct diagnosis, they all share a number of overlapping and related symptoms, including problems with emotional expression and difficulty forming stable, healthy relationships. In addition to borderline, the other dramatic-emotional personality disorders are antisocial, histrionic, and narcissistic.

Antisocial Personality Disorder 

Antisocial Personality Disorder (ASPD) is characterized by a pattern of behavior that involves the manipulation, exploitation, or violation of the rights of others. Individuals with ASPD are often deceitful, they lack remorse for their actions, and they show an unwillingness to conform to social norms and laws.

Borderline Personality Disorder

Borderline Personality Disorder (BPD), as mentioned above, is characterized by a persistent pattern of emotional instability, volatile interpersonal relationships, unstable self-image, and self-destructive impulsive behaviors.

Histrionic Personality Disorder 

Histrionic Personality Disorder (HPD) is characterized by a pattern of excessive emotional expression and attention seeking. Individuals with HPD often behave dramatically in situations that do not justify this type of reaction. They have an excessive need for approval and are often inappropriately sexually seductive or provocative.

Narcissistic Personality Disorder

Narcissistic Personality Disorder (NPD) is characterized by extreme feelings of self-importance, a high need for admiration, and a lack of empathy. Individuals with NPD often exploit others for their own gain and are overly sensitive to criticism, judgment, or defeat.


Prevalence and Age of Onset

The lifetime prevalence of personality disorders in the United States is estimated to be 9.1%-14.8% of the population. The prevalence of the specific personality disorder clusters varies with 1.5%-6.1% of the population meeting criteria for a dramatic-emotional personality disorder.

Personality disorders usually become recognizable during adolescence or early adulthood. Some dramatic-emotional personality disorders (antisocial and narcissistic) are diagnosed more frequently in males while others (borderline and histrionic) are more frequently diagnosed in females. Individuals with personality disorders are likely to have co-occurring major mental disorders, including anxiety disorders, depressive disorders, bipolar disorders, posttraumatic stress disorder, attention deficit / hyperactivity disorder, and substance use disorders.

 


Treatment & Support

Working with individuals suffering from borderline personality disorder is not easy. To complicate matters, there is no universally accepted or recommended approach to treating BPD. Some patients are helped by medication, others by therapy, still others by a combination of the two. What is known is that BPD is pervasive and ingrained, not an isolated set of troubling symptoms. Treatment is long term; and because of their high level of impulsiveness, many individuals with BPD drop out of therapy within a few months. For those who do stay in therapy, improvement usually comes slowly over the first year.

Psychotherapy

While any therapeutic approach can be used for the treatment of BPD, the American Psychiatric Association recommends long-term psychodynamic therapy or dialectical behavior therapy. In the psychodynamic approach, the therapist attempts to link present feelings, thoughts, and symptoms to unconscious meanings derived from early life experiences (e.g., childhood sexual abuse). By linking the present to the past, BPD patients are given a new understanding that allows them to change their behavior.

Dialectical behavior therapy (DBT) is a psychosocial treatment developed specifically for BPD. DBT usually has individual and group therapy components. In the individual therapy sessions, the therapist develops an environment in which the patient’s feelings are recognized as legitimate and acceptable, combined with an insistence on the need to change. In the group sessions, the patient works on specific coping skills that are divided into four modules: core mindfulness (being aware of what is going on within one’s self), interpersonal effectiveness, distress tolerance, and emotion regulation.

Pharmacotherapy

Medications have been found to be only moderately effective in treating the symptoms of BPD. Presently no medication is available that acts specifically on the underlying pathology of BPD. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to help control depressive symptoms. Mood stabilizers such as lithium or certain anticonvulsant agents may be used to help control impulsiveness and explosive anger. Neuroleptic (antipsychotic) drugs may also be used when the individual shows distortions in thinking (e.g., paranoia) or psychotic symptoms. Medications have been shown to be most effective in BPD patients who have other co-occurring disorders (e.g., depression).

 

A Spiritual Perspective

BPD is a disorder built upon the hidden pain of past abuse or abandonment. The person feels unworthy, unwanted, and unlovable. She fears rejection and abandonment, yet she drives everyone away from her. Because she feels worthless, she unconsciously seeks to destroy herself through self-destructive, impulsive behaviors. The lack of self-worth and the history of sinful behavior in the person with BPD make forgiveness seem impossible, which can be a major roadblock to healing. When ministering to a person with BPD, the total and complete forgiveness of God that is available only through Jesus Christ (Ephesians 1:7–8; Colossians 1:13–14) is a great place to start. Understanding that God offers us forgiveness leads to a realization that God truly loves us (John 3:16); and if the Creator of the universe loves us, then we must have worth—despite our past or what we might think of ourselves.

  

Finding Care

The links and information below will provide you with a starting point in terms of finding mental health care providers, treatment facilities and support groups for those struggling with borderline personality disorder.

Mental Health Care Providers

When assisting an individual it is important to help them find the right type of mental health care provider. These links will assist you in beginning your provider search. Knowing and building relationships with providers in your area can prove invaluable. Both in aiding the individual in getting an appointment, as well as, being able to better support them once they begin receiving professional treatment.

An individual struggling with borderline personality disorder will most likely need to see both a clinical psychologist / therapist for psychotherapy (talk therapy) and a psychiatrist for medication.

By providing your zip code the following search engines will give you information about local mental health care providers.

Clinical Psychologists / Therapists Psychiatrists


Treatment Facilities

In some people, borderline personality disorder can become so severe that a hospital stay is needed. This may be necessary if the individuals seeking your care can’t take care of themselves properly or are in immediate danger of harming themselves or someone else. Psychiatric treatment at a hospital can help keep them calm and safe until their mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

By providing your zip code the following search engine will give you information about mental health treatment facilities in your area.

Substance Abuse and Mental Health Services Administration American Residential Treatment Association

Support Groups

Recognizing that community is one of the factors necessary for successful recovery, attending support groups can be a powerful and meaningful way to connect with others facing similar challenges. Support group experiences allow people affected by mental health difficulties and disorders to connect in a safe and supportive environment. Support groups are led by trained facilitators and teach coping skills, help reduce anxiety, build resiliency and provide a place for people to share common concerns and receive emotional support.

These links will give you information on support groups in your area.

National Alliance on Mental Illness Grace Alliance


Supporting the Family

Many times the family caring for an individual with a mental illness is overlooked. They are often the front line support for the individual. The responsibility of care can take a physical and psychological toll on caregivers. Many times the caregiver needs as much support as the individual that has the illness. Caregiver support groups are available for the families of those struggling with borderline personality disorders.

These links will give you information on caregiver (family) support groups in your area.

National Alliance on Mental Illness – Family Support Group National Alliance on Mental Illness – Family to Family Support GroupGrace Alliance




Educational Resources

Here are some links to aid you in learning more about borderline personality disorder. The more information you have, the better you will be able to help those seeking your guidance.

National Institute of Mental Health Mental Health America


Downloadable Resources 

First Step – What to do once a diagnosis has been made.

Daily Steps – Developing a holistic mental health care plan.

Difficult Steps – Navigating destructive behavior and legal issues.

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