The Faces of Borderline Personality Disorder: A Misunderstood and Crippling Disorder
Borderline Personality Disorder (BPD) according to the DSMIV (Diagnostic tool to diagnose mental disorders) is characterized by a pervasive pattern of instability of interpersonal relationships and self-image. It is characteristic of marked impulsivity beginning by early adulthood and presents in a variety of contexts. We at Harley Street Psychology have been working with sufferers of BPD since the start of the clinic and it is always fascinating how many therapists stay well clear of dealing with BPD. BPD is one of the most difficult of disorders within the personality disordered spectrum to treat, because once it has developed (and we don’t know the primary causes) it becomes engrained in the individual usually from a very early age and becomes further reconditioned for many years where it feels near impossible to get rid of the symptoms.
At Harley Street Psychology we view BPD as a “relational disorder” rather than following the specific criteria in diagnostic manuals. Many people don’t realize that in therapy the therapeutic relationship is key to assisting the individual through any difficult process and is vital in the overall effectiveness of the therapy. Think about it this way… if you didn’t like someone you wouldn’t want to open up to them right? The same applies to the therapeutic relationship. However, like any relationship there will always be issues that arise and these need to be ironed out with the therapist. By doing so a greater understanding of BPD can be achieved which is a transferable quality to other relationships.
Here is a list of some of the pervasive difficulties that someone with BPD may experience. The reason for which is to highlight the lived experience of such an individual to explain the severity of what one goes through-largely without assistance, unless privately funded.
There are extreme and frantic efforts to avoid real or imagined abandonment. Individuals with BPD have an acute fear of abandonment-this can develop in various forms, such as fear of rejection, not being good enough, real abandonment, and even playing the potential abandonment out in ones head.
There is a historic pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation-this suggests that one second you may be idealized and the next second you may be rejected and devalued, and often made to feel devalued. This process of devaluation is often a good indicator of how devastated the BPD sufferer is on an emotional level and is a very extreme way of illustrating what it feels like to be them. Think about this as a means for the BPD sufferer to transfer their feelings onto you so you can get a glimpse of their suffering.
A debilitating experience in itself is developing an identity disturbance, such as the significant and persistent unstable self-image or sense of self. This forms a core to BPD, in that there is a drastic instability in self-image or sense of self that this may come across as being a severe experience of insecurity or sensitivity. However on an internal level, there is a sense of constant self-denigration and disgust with the self, where the person may desperately need reassurance but yet be suspicious of its deliverer.
According to diagnostic methods, impulsivity is noted in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). These experiences need to be seen as brief methods of self-soothing for the individual, however to the outsider, this is seen as erratic behavior which can be criticized rendering the BPD sufferer even more ashamed as a result.
In many cases of BPD, there is recurrent suicidal behavior, ideation, gestures, or threats, or self-mutilating behavior. The level of emotional pain and turmoil experienced is often transferred to such feelings, behaviors and thought processes as there is a desperation for some sense of soothing. Even the thought of suicide may be soothing but not necessarily wanting to be achieved ‘forever’, but often feeling that there is no other way out.
Emotional instability becomes a cornerstone to BPD; this is due to a significant reactivity of mood (i.e., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). The emotional element of BPD is often a primary factor that may trigger various episodes and cause a great deal of distress for the individual. A tool I often use is to draw up a mood chart, and do this for a minimum of two months to see the relevant patterns within ones mood. By doing this, there is a preemptive response to mood, which may help in remaining one step ahead at all times.
Chronic feelings of emptiness shroud BPD. This is rooted in childhood development and the lack of a secure base to understand the process of self-soothing and emotional connectedness. Words like love, containments, happiness and emotional connectedness may all seem far removed from the mind of the individual with BPD. Largely this is because they do not trust that the person delivering these actions and words are genuine. This is one aspect within the therapeutic relationship that is addressed immediately and it is vital to look at the sabotages that the individual will create out of being uncomfortable when they experience the above wonderful emotions.
Inappropriate intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights). Anger, has become a particularly anti-social method of expressing oneself in society. Unfortunately, societal reactions are often focused on the individuals with “anger problems” seeking out assistance, whereas I believe that general society should also learn how to deal with anger and assisting the individual in diffusing the experience.
Anger provides us insight into the depth of pain an individual is experiencing at the point of eruption. The second we can identify with the depth of pain, within ourselves we are able to rationalize and feel less burdened by the person experiencing the angry outburst. In these situations, our fight or flight response is triggered and we tend to either react by mirroring the angry response, or running away from the acute confrontation. Learn to endure someone who displays angry outbursts and no doubt they will appreciate your attempts at doing so.
Transient, stress related paranoid thoughts or severe dissociative symptoms. Unfortunately, due to the high level of sensitivity the BPD sufferer experiences, these dissociative symptoms may at many times cause the individual to cut off from the extreme emotional pain and resemble someone that has “switched off” the ignition and may become unaware of what is happening in their body and mind. This is why it is vital that Mindfulness practice is used as often as possible to maintain a centeredness and presentness.
Causes of BPD:
Although we have a diagnostic tool to diagnose someone with BPD, there is no substantial research into what causes BPD. There are a number of theories about what the causes may be, however many professionals subscribe to the biopsychosocial model of causation, in which they see the causes of BPD to be closely tied to biological, genetic, and social factors, and psychological factors. This suggests that there is no direct cause from any of the above mentioned factors, instead it is a complex and intertwined amalgam of all three factors.
BPD in our experience has often been misdiagnosed. We have had patients I’ve worked with arriving with a diagnosis of schizophrenia, Bipolar disorder all the way through to suggesting nothing was wrong.
Nonetheless, we have found that the greatest difficulty for people with BPD to overcome is creating a new relationship with themselves, where they do not sabotage every new good thing that comes into their lives because there is a deep-set core belief that they don’t deserve anything good in their lives.
This core belief can change, but what we have noticed is that there is a constant sense of not being good enough and fearing failure, and because they have been in this cycle of constant destruction, pain and heartache grow to become common sense and in a strange way a safety net of certainty. Many of us develop such strategies of coping with the uncertainty of life, but for people with BPD, uncertainty is filled with terror and panic and such high levels of anxiety that they can either crash into periods of depression or severe anxiety and panic attacks.
A key ingredient to overcoming BPD is by firstly establishing a good relationship with a therapist. Our advice is to find someone who fits the way you are and get a good feel for them. They need to be able to contain you enough in any phase or mood you find yourself in.
This is the responsibility of your therapist to work through this process with you and to help you overcome feelings and fears of abandonment.
We have had the privilege of working with some of the severest forms of BPD at Harley Street Psychology and observe the immense changes that a person goes through when they want to change their behavior and thinking. This is very much possible even though many professionals believe that if you have BPD there is no way of maintaining a sense of control and live a full and enriching life.
Statements like that go against everything we believe in, and if I had to accept that as gospel then that is like suggesting that some headaches can be treated whereas others cannot. At the end of the day it is a headache and yes some headaches can be worse than others, but there is always a way to get to the root of the problem and address core beliefs and ways or relating and functioning.
Not only is BPD difficult for others to relate to, but first and foremost, it is incredibly difficult for the person diagnosed with BPD to fully accept that this is what is wrong with them. There is initially a phase of fighting against this diagnosis, especially if it has been adequately diagnosed and not misdiagnosed, as is the case in many other situations.
In saying this, that is why it vital to find someone who has expertise in dealing with BPD and who is strong enough to contain ruptures and outbursts so that a solid structure can be achieved and maintained.
Besides being terrified of the actual BPD diagnosis, we can only imagine how terrifying it must be to work with a professional who feels incapable of ‘holding’ the person while they’re going through such emotional and cognitive turmoil. Please bear in mind that the therapist you will be working with is still a human being and is one who has flaws, so it is essential to work through any ruptures that may occur within the therapeutic relationship.
Learning to be authentic with ones feelings and thinking is a vital combination in adapting oneself to having BPD and face up to the many faces it can have present.
Mindfulness, a philosophy or mode of living life arose during the beginning of the 21st century in western minds, and is derived from Zen Buddhism often found in most eastern philosophies dating back centuries.
The practice is simple. By allowing thoughts to enter the mind, not judging them, and allowing them to exit as quickly as they came in. However, still a practice, and a practice means PRACTICE! The only way this process can become beneficial for us is to embrace the teachings and techniques and apply them on a daily basis with consistency. At Harley Street Psychology, we always speak about conditioning the mind in the same fashion as we do our muscles, and if we don’t allow these new ways to become habit to us, we become complacent and revert to old ways of being.
There are a number of very helpful mindfulness practices that are available, however what we instruct anyone attempting at taking up mindfulness is find a technique that is suitable and helpful to you-don’t follow every guru that has “the cure it all solution”, instead build on your own philosophy in life and test out many. Additional approaches which are especially helpful are: Schema therapy, Acceptance and commitment therapy, Existential therapy.
Cognitive Analytic Therapy:
Cognitive Analytic Therapy (CAT) was first developed by Anthony Rile, and in my opinion is one of the most collaborative and embracing therapy models available to us. Founded on the given that everything in life has a beginning, middle and end, the structure of the therapy follows the same process.
CAT was primarily designed to deal with BPD and its challenges and besides there being a secure and agreed framework in which to practice it, it is very forgiving and collaborative with many other approaches.
A technique we use often and this can apply to anyone wanting to observe themselves closer is using a mood graph. The intention is noting twice a day (morning and evening) your mood and rating it (1-10) and identifying the precipitating event contributing to the mood. The intention of which is to be constantly checking in with yourself so that you are actively aware of your internal emotional state. This is often difficult for BPD sufferers, in that they often dissociate (almost like a day dream like state and feel detached from themselves) and are not conscious of their emotional and cognitive state.
Within BPD, there is often resentment towards a family member or someone close. In psychotherapy we call it the narcissistic wound carried by the individual. This is an emotional wound so painful that it is near impossible to reach the person on an emotional level, because when things become too painful the BPD sufferer will most often resort to deviating or avoiding the cause of emotional pain. In order for a beneficial relationship to develop for the patient there needs to be a close connection with explicit boundaries and clear expectations of ones needs and desires-this should be achieved and maintained on both