Unpacking Borderline Personality Disorder

Borderline personality disorder (BPD) is less well-known and less common than other mental health conditions such as depression and anxiety, but it comes with debilitating symptoms that cause significant distress and unstable relationships, for both those diagnosed and their families and loved ones.

Up to 10% of BPD patients die by suicide, and at least 40% will make multiple attempts to take their own lives, while self-harming behaviour such as cutting is a common means to release their intense emotional pain.

One of several types of personality disorders, BPD is characterised by rigid and unhealthy patterns of thinking and behaving. Individuals with BPD have difficulty interpreting emotions and relating to people and life experiences, leading to unstable interpersonal relationships and difficulty in functioning at work and in social situations, explains psychiatrist and South African Society of Psychiatrists (SASOP) member, Dr. Aneshree Moodley.

She notes that, as with many mental health disorders, the cause of BPD is “a combination of nature and nurture”.

“There are strong hereditary factors in the causes of most personality disorders. In terms of nurture, the individual’s early childhood environment, the form of parenting they experienced, and their early childhood development all play a significant causative role.

A lot of emphasis also falls on the person’s attachment style, based on the nature of their childhood bond or connection with their primary caregiver. “We commonly see a real or perceived sense of abandonment or rejection triggered, for example, by the death of a parent or a divorce during the person’s early childhood, which leads to the pervasive feelings of rejection or abandonment experienced in borderline personality disorder,” she adds.

For people with borderline personality disorder, the fear of abandonment is deep-seated and chronic, and they will respond with intense emotion and behaviour to real or perceived rejection, she says.

What is normal and what is not?

According to Dr Moodley, it is important to distinguish between the feelings of rejection that many people experience occasionally and the BPD patient’s “constant stream of thoughts of being rejected and abandoned” in response to everyday events.

“The BPD patient’s response is not like a once-off reaction which could be explained or contextualised by a person being under more stress than usual, for example. This is a deep fear, a regular, frequent pattern of interpreting some small incident – such as a partner being a few minutes late for a date – as utter abandonment, resulting in accusations and angry outbursts that are disproportionate to the situation.

“The person with BPD may threaten to block the other person or end the relationship, and in extreme cases make threats to self-harm or commit suicide.“Meanwhile, the other person is often left completely befuddled because the reaction is out of all proportion. This is one of the aspects that makes it difficult to live with someone who has BPD,” Dr Moodley explains.

She says feelings of rejection for individuals with BPD are a daily, if not hourly, occurrence.“It’s constant and it’s disruptive emotionally, socially and in their work lives. They feel a constant, intense psychological sense of being emotionally tortured.”

The other core characteristics of BPD are instability in moods and emotions. The person with BPD is unable to regulate their thoughts and feelings, and many describe a sense of emptiness, hollowness or numbness.

They also display impulsive and reckless behaviour such as impulsive eating or abuse of alcohol and/or drugs, reckless driving, impulse buying, out-of-control gambling or impulsive, disinhibited sexual behaviour.

According to Dr Moodley, this impulsive behaviour may be seen as an attempt to “fill the hole”, and similarly their tendency to latch onto one person and form co-dependent relationships may also be a strategy to soothe the emptiness or numbness.

People with BPD tend to struggle with their sense of identity and sense of where they fit in in the world, expressing these “chronic internal battles” in frequent and often dramatic external changes, Dr Moodley explains.

“They are not satisfied with just one tattoo or a hair colour change, for example. However, it is important that all factors are taken into account before making a diagnosis – just because a person changes their hairstyle often does not by itself indicate a personality disorder,” she notes.

Getting Help

Dr Moodley says it is important that a medical diagnosis of BPD – or any other personality disorder – be made by a professional such as a psychiatrist or clinical psychologist, as several different conditions could have similar outward symptoms but different causes, requiring different treatment strategies.

People with borderline personality disorder often have co-morbid conditions such as depression, anxiety, substance abuse or an eating disorder, and it is, therefore, important to have a professional and precise diagnosis and tailored treatment programme.

Treatment for borderline personality disorder is “a long road to walk” according to Dr Moodley. Long-term medication is likely to be part of a plan tailored to the individual’s specific needs, and the mainstay would be psychotherapy or “talk therapy”, which has the strongest evidence base of effectiveness.

She says dialectical behaviour therapy (DBT), one of the most strongly evidence-based therapies for borderline personality disorder, is a specialised form of cognitive behaviour therapy specifically tailored to treat emotional dysregulation.

DBT assists individuals to learn to identify and accurately name their emotions and to communicate how they are feeling, accurately and frequently. It also incorporates techniques of mindfulness, meditation, relaxation therapy and “grounding behaviours”.

“Therapy for all personality disorders is long-term. Because it’s a pervasive pattern of mood dysregulation and the fear of abandonment is chronic, one can’t realistically expect oneself or a loved one to change their behaviour after only a few sessions or months.

“These are behaviours that have to be unlearnt, very slowly and over time. The person has to learn new, healthy ways of behaving, thinking and relating to the world – and, most importantly, maintain the changes.”

Patients are encouraged to lead healthier lifestyles, which also aids in symptoms of depression and anxiety, and are taught skills to regulate their moods and set up daily schedules that include putting time aside for self-care.