Borderline personality disorder (BPD) is a complex mental illness that can cause emotional dysregulation and disrupt the lives of those who suffer from it and affect those around them. Not only is there little awareness about the disorder, but there is an abundance of stigmatizing information about it on the internet.
BPD develops over a period of time when someone with a pre-existing vulnerability (such as a genetic or biological temperament) faces multiple difficulties and trauma in their formative years. There are nine symptoms that are associated with BPD and a diagnosis requires the presentation of at least five of these symptoms:
These may sound like character traits that we all display to some degree but persons with BPD tend to present them in very specific ways. Their moods may fluctuate more frequently than others and they tend to feel their emotions very intensely whether it is happiness, sadness or anger. Their actions and behavior often come across as overreactions.
In an effort to resolve these intense feelings, they are likely to act impulsively since they are in a hurry to get past the emotional upheaval they are feeling. Similarly, when they are experiencing intense low moods, they behave in self-destructive manners which may include substance abuse, reckless driving, unsafe sex or careless spending. They may also engage in self-harm and have thoughts of suicide.
They suffer from low self-esteem and have a fragile sense of self that constantly changes. This tends to affect how they interact with people as they underestimate themselves and how they should be treated. This leads to unstable interpersonal relationships that have a lot of push-and-pull. They may feel that the person is great for them and get attached quickly. But when they sense that the attachment is getting stronger, they tend to feel exposed and back away. Some people with BPD may fear abandonment greatly and go to extreme lengths to keep people in their lives. This often stifles the other person and may result in a broken relationship.
They may also complain of feeling nothing or experiencing a void in themselves. This may lead to substance abuse that only worsens their condition. They may also employ a coping mechanism called dissociation, where they ‘zone out’ during an uncomfortable situation only to have no memory of it later.
Most people with BPD may not show all of these symptoms. Regardless, the symptoms that they do show feed one another and create a perpetual cycle of emotional distress. They may exhibit other symptoms of mental illness such as depression and anxiety that may be disruptive to their lives. The depression can occur from the rapid mood swings and low self-esteem while anxiety is a symptom that is common to all personality disorders. Treating only the depression and anxiety often results in temporary respite; making the diagnosis of BPD crucial for those who suffer from it.
Ideally, BPD is diagnosed after extended sessions with a psychiatrist who will conduct a thorough interview of the patient and may use diagnostic tools to arrive at a diagnosis. Family members, friends and other clinicians who know the patient are also consulted with the consent of the patient. If the patient is admitted in a hospital, they may be diagnosed after a few days of observation.
BPD is often misdiagnosed as well because its symptoms resemble so many other mental illnesses like bipolar disorder, post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). However, with bipolar disorder, periods of highs and lows tend to be longer and are evidently different from each other. PTSD and CPTSD are caused by trauma which is relevant to BPD but self-destructive behavior, which is a significant symptom of BPD is less prominent in PTSD and CPTSD. It is when slivers of information are used as diagnostic criteria instead of understanding the full nature of the presentation, a misdiagnosis could happen.
It is important to note that a diagnosis of BPD cannot be arrived at after one session. Additionally, a confirmed diagnosis of BPD cannot be made prior to the adolescent period as the personality is not fully formed by then. Similarly, a person cannot develop the disorder later in life since their personality has already developed by then.
Once a confirmed diagnosis is given, recovery can begin. The course of treatment for BPD is therapy and medication. Medication is prescribed according to the symptoms that they are experiencing at that moment; these may be antidepressants, anti-anxiety medication, mood stabilizers or even anti-psychotics. While the medication provides relief, its purpose is to stabilize the symptoms to a point where the patient can participate in therapy.
is considered to be the most effective treatment for BPD. Dialectical behavior therapy, mentalization based therapy, schema focused therapy and transference focused therapy are used to treat BPD. Time-bound therapy results in emotional regulation and high levels of functioning that can lead to improved quality of life.
People with BPD may struggle with the illness for years before a diagnosis can happen. But with a confirmed diagnosis, treatment can begin. The effects of sustained treatment can be seen as quick as within a year and tend to last a lifetime. Those who get better stay better.
This article is written with inputs from Dr Ashlesha Bagadia, psychiatrist and psychotherapist with Green Oak Initiative.
For more information on BPD, watch our video column ‘Understanding BPD with Dr Ashlesha Bagadia’.