Borderline Personality Disorder Demystified, Revised Edition

ONE

What Is Borderline Personality Disorder and How Is It Diagnosed?

THE CAUSES OF BORDERLINE PERSONALITY DISORDER OFTEN vary in type and degree from one person to another, so it makes sense that the symptoms also vary considerably in type and severity. In other words, there’s not a one-size-fits-all description for why any one person has BPD or how it causes them to feel, think, and act. Even so, once the basic symptoms are understood, it usually becomes apparent to the individual and family that borderline personality disorder (BPD) is present, and that it is a major contributor to the difficulties they are experiencing. Simply recognizing that you have BPD is the critical first step in gaining control over your life.

There is very good research evidence that borderline personality disorder (referred to as borderline disorder) is the result of physiological and chemical disturbances in certain pathways in the brain that control specific brain functions. You are born with these disturbances, and they usually are amplified by events that occurred after birth. According to the most recent survey conducted in the United States, borderline disorder affects approximately 6 percent of the population. It appears to be more common than schizophrenia and bipolar (also known as manic-depressive) disorders. Borderline disorder was once thought to occur more frequently in women than in men, but that data is now in question. Therefore, it may now be estimated that approximately one in every seventeen people in the United States suffers from borderline disorder.

THE SYMPTOMS OF BORDERLINE DISORDER

To be diagnosed with borderline disorder, you must experience and demonstrate a minimum of five of the nine symptoms listed in Table 1.2 here. These symptoms are separated into four different groups (Table 1.1), or as many experts in the field of personality disorders refer to them, behavioral dimensions or domains.

TABLE 1.1

THE FOUR BEHAVIORAL DOMAINS OF BORDERLINE DISORDER

Most people with borderline disorder don’t have all of the symptoms in each of the four domains of affected behaviors listed above, but most do have at least one symptom from each. Many of my patients find that the arrangement of the symptoms of the disorder into these four domains makes it easier for them to recognize and remember their symptoms and the consequences. Overall, individuals with borderline disorder may be characterized as appearing dramatic, hyperemotional, and erratic.

DOMAIN 1: POORLY REGULATED EMOTIONS

A number of experts in the field believe that an inherent difficulty in regulating emotions is the driving force behind many of the other symptoms of borderline disorder. If you have borderline disorder, your emotions may change quickly, and you may find it difficult to accurately perceive and express your emotional responses, especially to unpleasant events. You may often overreact emotionally to daily events. However, at other times your emotional responses may seem blunted, only to be followed by hyperemotional reactions at a later time. Descriptions of other major symptom indicators of poorly regulated emotions in borderline disorder follow.

Mood Swings and Emotional Lability

The emotions of people with borderline disorder are often very unstable and undergo rapid changes that are difficult to control. This is referred to as emotional lability. These labile emotions can include negative feelings of anxiety, anger, fear, loneliness, sadness, and depression. Less often, labile emotions can also include positive feelings such as happiness, joy, enthusiasm, and love. Your emotions may fluctuate quickly from feeling good to feeling bad, sometimes for reasons that are obvious to you but at other times for reasons that are not apparent. Because of these rapid fluctuations in mood, and because you are more likely to develop feelings of depression and episodes of major depressive disorder than individuals who do not have borderline disorder, at some point you may have been diagnosed as having bipolar disorder (which psychiatrists previously referred to as manic-depressive disorder).

Your feelings may also be hyperreactive; that is, you may significantly overreact to some situations. For example, you may become very upset over constructive criticisms, unavoidable separations, or disagreements that other people seem to take in stride. Such events may cause a wave of anxiety, sadness, anger, or desperation. In addition, you may find that you have great difficulty calming down your emotions and soothing yourself by focusing on reassuring thoughts or by engaging in usually pleasant and healthy activities. During these periods of severe hyperemotionality, or “emotional storms,” as they’re called, you may feel so desperate that you turn to alcohol or drugs for relief, lash out in anger or rage, or engage in other destructive behaviors such as cutting.

Recent research also suggests that people with borderline disorder have difficulty in accurately identifying their emotional responses and those of other people, cannot appropriately balance mixed feelings, and have intense responses to negative emotions. For example, you may find that you overidentify with the emotions of others and may become overly upset when they have negative experiences. You may even feel as if these events are occurring to you. In other words, you react too strongly to the plight of others, such as their living situation, their difficulties, or any negative situation they are experiencing.

One patient told me that at such times “it is like someone is putting a dagger in my heart.” This person also told me that the situation did not even have to be happening to real people; it could affect her if she were watching a movie or even a television commercial. She knew the situation was not real, but she felt as if it were and that it was happening to her. She added that at these times, the pain from her emotional involvement in these situations lasted for quite some time. This is another characteristic of emotional dyscontrol in borderline disorder. In addition, you may find that once upset your emotions do not return to their normal level as quickly as they do in people who don’t have the disorder.

You may also be hypersensitive to the real or perceived negative behaviors of others toward you: you’re always on the lookout for the slight frown, raised eyebrow, or minor change in a person’s tone of voice that indicates that they are irritated or angry with you. When you believe you detect such critical reactions, no matter how subtle, your response may often be considerably out of proportion to the situation. You may feel anxiety, self-recrimination, and anger that are simply not warranted under the circumstances. While you may be vaguely aware that you are overreacting, the feelings are just too real and too strong to ignore.

Anxiety

Episodes of severe anxiety are common symptoms of borderline disorder. One of the first psychiatrists to write in detail about borderline disorder believed that “anxiety is the motor” that drives the other emotional symptoms of the disorder, such as anger, and behavioral symptoms such as impulsivity. Anxiety can produce tension-related physical symptoms, including a migraine headache, backache, stomach pain, irritable bowel, rapid heartbeat, cold hands, hot flashes, and excessive sweating.

Anxiety may even reach the level of the massive and disabling symptoms referred to as panic attacks that are so severe you feel you are dying and may go to the emergency room for immediate care. When less severe than a panic attack, the anxiety may be more pervasive and last for a longer duration. Or the anxiety may evolve into anger, despair, and physical symptoms. You may also attempt to relieve the anxiety by engaging in impulsive behaviors that I discuss below.

Intense Anger or Difficulty Controlling Anger

Poorly controlled anger is one of the most common and destructive symptoms of borderline disorder—so much so that it occurs in two of the nine diagnostic criteria of the disorder. You may feel irritable and angry much of the time, and you often can be argumentative, quick-tempered, and sarcastic. You may even become furious, or sometimes enraged, in circumstances that do not warrant such responses. The slightest event or exchange can result in an angry outburst. You may then say and do things that are quite destructive and later regret that you did so. Individuals with borderline disorder have more numerous and intense episodes of anger and depression than other individuals, and their emotions may fluctuate between anger, anxiety, and other emotions more readily as well.

You may realize in the midst of these outbursts of anger that you are overreacting, but seem unable to control the strong emotions sweeping over you. As one patient put it, “I know my husband does not deserve all of the anger and abuse that I heap upon him, but he’s the one around most of the time and I’m fairly sure he won’t leave me. I don’t seem to be able to control the anger. At the time, I think he deserves it—so he gets it.” Your family, your spouse or partner, and others close to you have learned that they must be very careful about what they say or do. Many comment, “It’s like I’m walking on eggshells all the time. I never know what I will do to cause her [or him] to blow up.” This apprehensiveness on the part of your family can result in a persistent, elevated level of tension in your home. Because you are very sensitive to the negative feelings of others, this can make an already tense living situation even worse.

Chronic Feelings of Emptiness

Another strong feeling you may experience is a sense of persistent emptiness. This sense of emptiness is often accompanied by feelings of boredom and loneliness. In turn, these feelings may lead to dissatisfaction with the people in your life and with your life in general. Dissatisfied with your life, you may be prone to change friends and jobs frequently, and even to engage in brief affairs. For a time, these changes can feel very exciting and temporarily relieve the emptiness, loneliness, and boredom. But the feelings return after a while, and the life patterns of inconstancy repeat themselves.

During our initial meeting, one young patient told me that these feelings of emptiness and boredom were so strong that she felt as if she had a big hole inside her that wouldn’t go away. It did diminish when she was involved in a relationship with a young man, at least for a while, but then would return in full force when they fought or when he left her. She added that, when severe, this feeling was so emotionally painful she would do almost anything to relieve it, even cut or burn herself, although the emotional pain always returned shortly thereafter.

Another patient, whom I describe in more detail in Chapter 2, told me early in her treatment that when she felt empty and bored for a long period, she would leave her husband without notice and travel to another city. There she would see a former teacher for a brief two-or three-day affair, then fly home again. Although she temporarily felt excited, desired, and satisfied by these escapades, ultimately she was plagued by guilt and remorse for her behavior, and she dreaded having to deal with her husband about her absences. Nonetheless, the pattern continued until she was able to understand the nature of the feelings and the life situations that triggered this behavior, then take measures to gain control over it. Fortunately, her husband was able to tolerate the behavior until she was able to develop much more effective responses to the emptiness and boredom she often felt.

DOMAIN 2: IMPULSIVITY

The tendency toward impulsive, self-damaging behavior is so common and so strong in people with borderline disorder that some experts in the field consider it the most harmful symptom of the disorder. They believe it is more damaging than the symptoms of emotional instability and impaired reasoning. Impulsivity alone, as well as the overall severity of symptoms, appear to be the best predictors of the long-term outcome of the disorder. Untreated, people with borderline disorder who are very impulsive tend to have a worse prognosis than those who are not as impulsive. Research suggests that impulsivity in people with borderline disorder is the result of an imbalance between the neural systems (nerve cell pathways) of emotion and reasoning that regulate impulsive behavior (Chapter 6). Following are the major groups of symptoms of borderline disorder that are included in the category of impulsivity.

Impulsive Self-Harming Behaviors

If you have borderline disorder, there are many ways that you may behave impulsively, such as binge eating and spending money recklessly on clothes or other items. You may also engage in more harmful, impulsive acts like uncontrolled gambling; excessive drinking and drug abuse; unprotected sexual promiscuity; violent, aggressive acts or repetitious, illegal acts such as speeding, driving while intoxicated, and shoplifting.

For example, when one of my patients felt especially anxious and empty inside, she would go shopping at expensive stores and then steal clothing and other items, even though she could easily afford to buy them. Before these actions could be brought fully under her control, she was arrested for shoplifting and convicted of a felony. When another patient felt particularly neglected and abandoned, or was criticized by her husband, she would go to bars, drink excessively, and strike up conversations with men. She stated that she did this in an attempt to feel better about herself and to “get even” with her husband. These episodes would occasionally lead to brief sexual encounters that were very destructive to her self-esteem and to her relationship with her husband. These episodes also exposed her to a considerable risk of being seriously harmed, as she knew little about the men she picked up, and she did not protect herself properly from sexually transmitted diseases.

There is considerable research on the prevalence and consequences of impulsive behavior in people with borderline disorder. However, there is a scarcity of research on the events and warning signs that lead up to such behavior, and on why some people with borderline disorder are more impulsive than others. In general, impulsive behaviors often follow episodes of emotional storms and disrupted close relationships, especially real or threatened abandonment. They also appear to be more common in people with borderline disorder who have been physically or sexually abused as children. To meet this particular diagnostic criterion, you would exhibit a pattern of impulsive behaviors in at least two of the self-destructive ways that I mentioned above.

Recurrent Suicidal Behavior, Gestures, and Threats or Self-Mutilating Behavior

Recurrent suicidal behaviors, gestures, and threats or self-mutilating or injurious behaviors are a particularly striking group of impulsive symptoms that occur among many, but by no means all, individuals with borderline disorder. They are referred to as parasuicidal acts. The severity of these behaviors ranges from very serious acts that may inadvertently be life-threatening to less serious acts that are often attempts to control painful symptoms or a situation, gain attention, or seek help. You may physically hurt yourself by hitting yourself; cutting or scratching your wrists, arms, thighs, or other parts of your body; burning your skin with cigarettes; or taking overdoses of medications. At times, you may do these things in the desperate desire to have others take care of you, to “get even” with them, or to impose your way on them.

Most often, you may hurt yourself to help reduce the emotional pain you feel when it reaches an intolerable level. As one patient who frequently cut her thighs with a razor blade explained to me, “When I see the blood and feel the pain, somehow the pain and dead feelings inside go away for a while, and I’m again back in control and in contact with the world.” At these times, these acts may seem to alleviate, at least to a degree, the severe internal pain you are feeling.

For those of you who engage in one or more of these manifestations of borderline disorder, they are most likely very distressing to you, and to family members as well. It’s also such a striking type of behavior that, in its rare extreme, it has been dramatized in movies. For example, the character played by Glenn Close in the classic 1987 movie Fatal Attraction