Borderline Personality Disorder 

Overview and Prevalence

Borderline Personality Disorder (BPD) is a complex mental health disorder which can severely affect how a person sees themselves, relates to others, and makes sense of the world around them. It is marked by an ongoing pattern of intense mood swings, unstable self-image, feelings of emptiness, difficulties managing anger, and impulsive, reckless behaviours.

Typically manifesting in mid to late teens or early adulthood, such symptoms can be extremely emotionally distressing for both the patient and their loved ones. It is estimated that between 250,000 to 1,000,000 Australians are affected by BPD at some stage in their lives. Indeed, while personality disorders tend to be pervasive and present life-long challenges, recovery is possible – particularly with early diagnosis and appropriate treatment.

Symptoms – what does it look like?

While every BPD patient may look slightly different, there are some key characteristics across those suffering from this disorder. People with borderline are often terrified of the thought of rejection or abandonment and as a result, may make frantic efforts towards avoiding this. Unstable and intense interpersonal relationships are also common, as BPD patients alternate between viewing someone with immense positivity (idealisation) and with extreme negativity (devaluation). For example, a romantic partner may be viewed as wonderful one day and the BPD patient may sing their praises (idealisation); whereas the next, that same partner may commit a minor transgression that is perceived as a major betrayal by the borderline patient, leading them to drastically change their view of them to the other extreme (devaluation).

Not everyone with BPD will experience every single symptom described above; some patients experience only some, while others experience many, or all. Moreover, different symptoms can be triggered by different things in the environment. For example, having a loved one unexpectedly cancel dinner plans may be perceived as rejection – however, one person with BPD may cope with this perceived abandonment by devaluating their loved one and cutting communication (“beating them to the punch” so to speak, when it comes to doing the rejecting). Another BPD patient may respond also by devaluating, however, the accompanying behaviour may be more impulsive in nature, for example by indulging in their own dinner plans, binge-eating and/or engaging in substance abuse. In any case, it is quite rare for individuals with BPD to maintain consistent, stable feelings and views towards important people in their lives.

Mood swings – e.g. unstable self-perception (individuals may change how they view themselves and their place in the world) – as a result, their interests and values may appear to change dramatically. Such perceptions may also appear ‘extreme’ in that individuals may display ‘black and white’ thinking where situations are either viewed as either all good, or all bad. Similarly, the views an individual with BPD holds about the people in their life (e.g. family and friends) can also vary greatly, shifting between all good and all bad.

A key theme across many of BPD symptoms is instability – whether of the self/identity, of relationships and their role within them, of views and beliefs, held about the world, of emotions such as anger, worthlessness, insecurity, anxiety or emptiness. Another key feature of BPD is that it is an ongoing and relational mental health problem.

Do you experience these symptoms (DSM V)?

  1. Fear of, and efforts to avoid abandonment (real or imagined)
  2. Patterns of unstable and intense interpersonal relationships (often characterised by alternating between either idealisation OR devaluation of another person)
  3. Identity disturbance (unstable self-image or sense of self)
  4. Self-destructive, impulsive behaviours across different life domains such as spending, substance abuse, binge-eating, reckless driving
  5. Recurrent suicidal behaviour, gestures or threats; or self-harm
  6. Affective instability/mood swings – e.g. ‘intense’ episodic dysphoria, irritability or anxiety that usually lasts a few hours, rarely more than a few days.
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger or difficulty controlling anger – anger management
  9. Stress-related paranoid ideation or severe dissociative symptoms

Aetiology – why does it happen?

Although the specific cause of borderline personality disorder is not established, research indicates that it likely involves a combination of genetics, neurology (brain structure and function) and environmental, social, and cultural factors. Additionally, many people with BPD report experiencing various trauma, particularly in early development. This can refer to traumatic life events such as physical, sexual, or emotional abuse, abandonment/neglect and other instances of adversity; as well as exposure to unstable, invalidating or hostile relationships, and/or too stressful incidents such as witnessing conflict or violence.

Indeed, the exact nature of trauma is not so much of concern as the impact of the trauma on the individual, and the behaviours that they subsequently and consequently adopt in response. Many of the symptoms of BPD are thought to be defence mechanisms learned via experiencing trauma early in life while undergoing the developmental phase. Instead of learning things that an average, healthy child might learn (such as how to invite other children to play, how to use your manners and share toys, exploring their imagination), a child who experiences trauma or does not receive appropriate support or nurturing from their caregiver is less likely to have the capacity to indulge in their childhood. Rather, the child’s resources are redirected to dealing with whatever trauma is in front of them, to the detriment of their normal psychological development. And, having learned and maintained these behaviours from a young age, the accompanying thought processes and supporting beliefs are ingrained in the BPD patient, who continues to apply these behaviours and sustain these beliefs systems into adulthood. However, as people carry these maladaptive behaviours into their adult relationships,

Indeed, the patterns of interpersonal behaviour and emotions developed about people around them such as the caregiver, remain and are simply transferred to other prevalent social relationships; from friendships in school to romantic relationships in adulthood.

Treatment – how do we manage it?

Considering that the main difficulties of a person with BPD are relational in nature, the client will reproduce in therapy prior approaches of relating with other significant people in their life. The therapist is then able to reflect these patterns of relating to the client aiming to enhance new learnings out of their therapeutic relationship. Therapy may not work until trust in therapy is reached, which may take months or years of regular counselling. In summary, the client’s adverse perceptions of others are transferred to the therapist (e.g. mistrust), reducing the therapist’s ability to have a real, positive impact on the patient’s recovery.