By Alexandra Wilson (AMHSW; CSW; MAASW; BSW Usyd)
Borderline Personality Disorder (BPD) is an often misunderstood and highly stigmatised mental health disorder. However it is not a rare condition, approximately 1–4% of the population are thought to have BPD, which is more than bipolar disorder and schizophrenia combined.
BPD unfortunately has one of the highest rates of death of any mental health condition, with an estimated 10% of sufferers ending their own lives. This is an unacceptable statistic and shows we need to do more to provide those with BPD support and effective treatment.
Diagnosis and Symptoms
A personality disorder is defined in DSM 5 (Diagnostic & Statistical Manual of Mental Disorders, 2013), as, ‘…an enduring pattern of inner experience and behaviours that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.’ (DSM 5, 2013; pp. 645).
In other words, it’s part of somebody’s personality. In basic terms, BPD leads to difficulties regulating one’s emotions and emotional responses, and these difficulties have a significant impact on the person’s life and relationships.
A diagnosis of BPD can only be made in adults, however traits of the disorder can be seen emerging in adolescence.
The diagnosis criteria for BPD requires 5 or more of the following apply for the person over time:
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships, characterised by alternating between extremes of idealisation and devaluation
- Identity disturbance: markedly and persistently unstable self–image or sense of self
- Impulsivity in at least 2 areas that are potentially damaging (e.g. substance abuse, reckless driving etc)
- Recurrent suicidal behaviour, gestures, threats or self–mutilating behaviour
- Affective instability due to marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress–related paranoid ideation or severe dissociative symptoms.
(DSM 5, 2013; pp. 663)
As you can see, BPD may have many different combinations of these symptoms. Therefore, there is not one standard form of BPD, there are many variations.
A diagnosis of BPD is often a diagnosis of exclusion. That means it is made when other diagnosis have been dismissed. It is common for people diagnosed with BPD to have had previous diagnoses of depression, anxiety, or other mental health conditions. People with BPD can also have co–existing mental health issues as well as BPD. For example, it is not uncommon for people to have depression or anxiety, as well as BPD.
The most widely accepted theory of what causes BPD is a bio–social explanation. This means a person has a biological disposition towards the disorder (so they are born with a biological or genetic disposition), plus experience of an ‘invalidating environment’.
An invalidating environment is defined as any experiences that result in emotional invalidation. This can be severe, such in the case of childhood abuse. It could also be something less obvious, such as parents who dismiss and invalidate the display of emotions in a child.
Trauma–related mental health conditions, such as post traumatic stress disorder (PTSD) can display very similar symptoms to BPD. Many people with BPD have a history of trauma, but not all.
The results of childhood trauma are very similar to BPD symptoms, such as difficulties regulating emotions, difficulties with attachment and relationships, and an unstable sense of identity. It is important to recognise the role of trauma in anyone diagnosed with BPD, however it may not change the recommended treatment plan for recovery.
People with BPD often try lots of different forms of mental health treatment in their journey towards wellness, but often have limited effectiveness from these treatment. Common forms of therapy, such as cognitive behavioural therapy (CBT), are often ineffective for BPD. It is not uncommon for people with BPD to have had lots of contact with mental health services and professionals in the past.
There is significant stigma associated with BPD, even within health services. BPD behaviours are often misunderstood as ‘attention–seeking’, or ‘manipulative’ in nature. These labels are not only incorrect, they are harmful and can stand in the way of effective treatment.
There is however, significant research to indicate that people with BPD benefit from a specialised treatment approach, and that risk issues be managed slightly differently from other diagnostic groups.
Research into BPD has demonstrated best outcomes for people who engage in Dialectical Behavioural Therapy (DBT). DBT has been extensively researched, and shown to be the best form of treatment for BPD. Research has also shown DBT can be highly beneficial for other conditions, such as drug and alcohol addiction, eating disorders, and any condition resulting in difficulties regulating emotional states.
DBT targets emotion regulation and distress tolerance as core components of the therapy. Interpersonal effectiveness skills and mindfulness are also core aspects. DBT is traditionally offered in a group and individual therapy framework. The groups focus on teaching psychological skills. The individual therapy sessions are focused on individual issues, monitoring of mood, behaviour change, as well as forming a therapeutic relationship. DBT therapy also allows contact between client and therapist between sessions, which is highly effective in producing positive change.
If You or Someone You Love Has BPD (or is suspected to have)
It’s important to realise there is effective treatment available for BPD. As with all mental health conditions, early intervention is preferable.
Whilst children and adolescents cannot formally be diagnoses with BPD, behaviours such as self harm and emotional instability can and should be addressed before adulthood. Families and parents may also benefit from education and support if their child is suspected to have emerging traits of BPD.
If you are worried about yourself or someone else’s mental health, seek help and advice. Talk to your GP or mental health professionals, and consider trying a DBT program near you.
Most importantly, if you have tried treatment before and not had a good experience, don’t give up! It often takes time to find the right treatment approach and the right therapist– but your mental health is important!
Hopefully in the future BPD will become less misunderstood and stigmatised, and seeking help will be a common thing to do.
Mental Health Access Line (Central Coast) 1800 011 511 Lifeline 13 14 24 Mindful Recovery Services www.mindfulrecovery.com.au or (02) 4660 0100
Alexandra (Alex) Wilson holds a Bachelor of Social Work from the University of Sydney (2003) and is the owner of Mindful Recovery Services. Mindful Recovery Services is a private practice providing psychological treatment and support for adolescents and adults. Alex is passionate about dispelling myths about mental illness and is highly skilled in dialectical behavioural therapy. She is an experienced public speaker and provides consultation to other professionals on managing difficult behaviours in teens. Alex lives on the NSW Central Coast with her partner, 2 young boys, and a cheeky puppy named Axel.