DR. ESSLIN TERRIGHENA busts myths around Borderline Personality Disorder.
The instability, unpredictability, and emotional intensity associated with Borderline Personality Disorder (BPD) has made it subject to much criticism. Individuals suffering from BPD are often stigmatized as dramatic, attention-seeking, abusive, or manipulative. It is crucial to address the pervasive myths that surround this mental health disorder to de-vilify people with BPD, remove barriers for seeking support and enhance understanding of the general public of what BPD actually is.
Myth #1: Borderline Personality Disorder is an excuse for a character flaw.
Fact: BPD is a diagnosable mental health condition influenced by genetic and environmental factors.
Based on extensive research, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) identifies BPD as a mental health disorder and outlines nine symptoms [LINK MB article] along which BPD can be diagnosed if certain criteria are met. These symptoms pertain to emotional, cognitive, and interpersonal instability, leading to high levels of internal distress and interpersonal conflict.
BPD has been found to affect around 1.6% of the general population, and up to 20% of the psychiatric population. Studies indicate that genetics and environment interact in the development and expression of BPD, with an estimated 40% heritability of the disorder based on familial and twin studies. Early environmental factors play a crucial role. It has been estimated that people with BPD are 13 times more likely to have experienced childhood trauma than the general population and that up to 70% of the BPD population report childhood abuse. While one of the criteria of BPD excludes diagnosis before the age of 18, research shows that symptoms are often experienced before then.
Myth #2: Only women have BPD.
Fact: BPD is likely to be under-diagnosed in men.
Currently, BPD is more likely to be diagnosed in women with a 3:1 female-male ratio of diagnosis. However, research suggests that this may be due to a gender bias in the diagnostic process, rather than a true gender difference. Women are still stereotyped as more emotional than men, are more likely to internalize overwhelming feelings, and are more likely to seek mental health support. As a result, men may express a different behavioural pattern of BPD symptoms that is often misdiagnosed with other disorders more focused on anger dysregulation, addiction, or manic-depressive episodes. For example, when fear of abandonment is triggered, by prevailing stereotype, this may lead women to desperately cling to their partners to stop them from leaving, while men may rather withdraw and avoid commitment to prevent a situation in which they are left.
Myth #3: People with BPD are crazy and unpredictable.
Fact: The extreme behaviours people with BPD may engage in to cope with distress, which can seem unpredictable or over-reactive, are actually based on relatively stable mechanisms.
When triggered, people with BPD can experience intense feelings of distress, fear or anger, cognitive distortions, and instability in their self-image. As a result, they may express unusual, extreme, or impulsive behaviours which might come out of nowhere for the people around them. This can make it feel unstable or unpredictable for others.
However, the pattern underlying these reactions are actually quite stable. There is a trigger in the environment that leads to the experience that certain core needs are violated or not met. Such core needs can include safety, stability, attachment security, validation, positive regard, nurture, connection, belonging, or acceptance. This then activates a network of negative thoughts, feelings, and physical sensations which can quickly become overwhelming.
To cope with the arising distress, the person may then automatically resort to behaviours that helped them survive in the past, even if they are not applicable or appropriate in the current context. It is crucial for both the person with BPD and their loved ones to understand what the triggers are, what thoughts and feelings are activated, what needs are un-met, how to meet these needs, and how to soothe distress in healthier ways, and . This can help to start engaging in healthier coping and resilience strategies that reduce the expression and destructive impact of extreme behaviours.
Myth #4: People with BPD are manipulative, abusive, and dangerous.
Fact: Manipulative, abusive, and dangerous behaviours are not synonymous with BPD.
People with BPD may engage in unhealthy behaviours when they are emotionally triggered and feeling overwhelmed. These behaviours can be manipulative, abusive, and dangerous, the same way any person has the capacity to act in such ways. There can be a lower threshold to engage in unhealthy behaviours due to the intensity of the emotional distress often experienced in BPD. However, people with BPD are capable of regulating or learning to regulate their reactions, just like everyone else. BPD is not an excuse for toxic behaviours. Notably, research shows that only 3-5% of reported violent acts are linked to serious mental health disorders, and instead people suffering from mental illness are actually over 10 times more likely to be victims of violent acts than the general population.
It is important to understand what is going on for a person with BPD when they are experiencing a state of intense distress. People with BPD often have a history of feeling unsafe, threatened, and having their emotions dismissed or punished. There are likely to be struggles with self-worth, identity, and abandonment fears. When these things are triggered in the present, this may evoke a trauma response with overwhelming emotion. Often, people then engage in automatic behaviours that they learned from a young age to protect themselves or in an attempt to get their needs met, which can include anger outbursts, manipulation and push-and-pull responses. Some of these behaviours may have been the only viable coping mechanism for survival in the environment they grew up in.
For example, someone who fears abandonment may get highly anxious when their partner goes out with friends. To deal with that anxiety, they may engage in reassurance-seeking behaviours, start sending lots of text messages, and demanding photographic proof of where their partner is. These actions, which can seem manipulative and controlling, are driven by overwhelm, despair, and frequently an incapability of effectively soothing anxiety in different ways. Ironically, actions to reduce the fear of abandonment, often lead to abandonment.
Such behaviours are not healthy, and often contribute to the interpersonal instability seen in BPD as they damage relationships and push people away. However, with enhanced awareness of the process leading to emotional outbursts and unhelpful or destructive behaviours, people with BPD are able to create change in their actions, just like everybody else.
Myth #5: People with BPD are unsuitable for intimate relationships.
Fact: People with BPD have many positive things to contribute to fulfilling relationships.
When trust and love has developed within a relationship, people with BPD can show high loyalty and trustworthiness. This can be partially driven by a fear of abandonment, but is also largely driven by the desire to not hurt, disappoint, or betray others and provide a stable, secure, and safe attachment space. In the sense of loyalty, there is an attempt to treat others the way they themselves want to be treated.
People with BPD often have more fine-tuned empathy and are sensitive to their own and other’s feelings, and needs. This can show up in high levels of care, compassion, and active listening for their loved ones. It also means that they may be quite intuitive and recognize someone else’s feelings very quickly without the other person having to explain things or even without the other person necessarily being aware of their own shift in mood. Research backs this up, showing that people with BPD show greater accuracy in interpreting eye cues in facial expressions than the general population.
Creativity and passion are also frequently associated with BPD. The intensity of emotions can be channelled into creative outlets – painting, music, dance, and poetry to name a few. It also means that while there can be intense emotional downs, there can also be intense and passionate emotional ups. When a person with BPD experiences joy, they feel it with every fibre of their being. When a person with BPD loves, they love whole-heartedly. This can also manifest in high levels of protectiveness to their loved ones.
Living with BPD requires high levels of self-awareness, and active coping strategies. As a result, people who have battled BPD and related struggles, such as trauma, abuse, addictions, self-harm, and suicidal ideation, are likely to have built an extensive resilience and support network. They often have invested immense efforts and strength to make the deliberate and difficult choice for change and healthier actions on a daily basis. Moreover, having gone through intense emotions and corresponding outbursts may also mean that they have had to engage and practice more elaborate problem-solving and social skills to maintain relationships and resolve complex issues. Dealing with a mental health issue can also foster high levels of courage and self-efficacy. People with BPD can be very direct and honest people, and while it does not always feel that way to them and others, they are often well equipped to handle challenges in life.
Myth #6: People with BPD are dramatic attention-seekers.
Fact: Emotional overwhelm and impulsivity can interact in BPD to contribute to extreme behaviours, including self-harm, risky actions and suicide threats.
Self-harm, suicidal ideation, impulsivity, and risk-seeking behaviours are core symptoms of BPD. For the most part, engaging in extreme behaviours is not to seek attention, but rather reflects desperate attempts to express pain, be heard and understood, or reduce overwhelming distress.
Intense emotional outbursts may feel like attention-seeking behaviours to others. However, this is often driven by intense emotional turmoil, and the need to be understood. Often, the more other people react with withdrawal or anger, the greater the sense of being misunderstood is, and the more the distress increases. This is how conflict can rapidly escalate.
When in a state of distress, rage, or overwhelm, people with BPD may make extreme threats trying to get their needs met and the intensity of their pain understood. When someone’s system is so overwhelmed with emotion, there can be a disconnect to more rational parts, which makes it difficult to return to a functional thought process and control behaviours. This is evidenced in neuroscience, whereby activity between the emotion centers and higher executive regions of the brain is significantly reduced in this time.
Frequently, self-harm, impulsivity and risk-seeking behaviours are coping attempts to manage and soothe negative thoughts, feelings, and physical sensations. They can induce adrenaline that can numb distress. These dysfunctional coping strategies have often developed at a time where there were no other clear options for coping, or there was no guidance, role-modeling or support for healthy emotional processing from adults, for example in cases of childhood abuse or neglect.
Impulsivity in BPD can make it particularly difficult to over-ride the compulsion to engage in damaging or risk-seeking actions, and can lead to subsequent feelings of guilt, and shame. This can reinforce a negative cycle of feelings of worthlessness and powerlessness for people with BPD. It is crucial for people with BPD and their loved ones to recognize the forces driving the unhealthy behaviours, and work toward reducing triggers and managing emotions, negative thought spirals, and uncomfortable physical sensations in healthier ways.
Myth #7: BPD cannot be cured.
Fact: BPD can be successfully treated.
Schema therapy has been shown to be particularly effective in treating BPD. Schema therapy rests on the premise that every human has needs, especially in developmental stages, and that these needs are not always met. When needs are consistently not met in childhood, this can create intense distress for the developing brain. Based on this, beliefs – so-called schemas – are built around how the world works, what to expect from other people, and what role the self plays. These schemas contain dysfunction beliefs and core fears. Later, the schemas can become blocks to getting the same needs met in adulthood that were denied in childhood. The wider network that is built around the schemas from a young age include negative thought structures and dysfunctional coping behaviours that can reinforce the dysfunctional patterns.
Identifying these schemas and various parts of the self that are triggered and expressed in various circumstances are a key part of schema therapy. It can be highly effective in helping individuals with BPD make sense of their feelings, reactions, and disentangle themselves from various parts. For example, when triggered I go into an angry child mode where I aggressively rant and push people away, even though my need is connection and stability – I am not my anger, it is just one part of me that gets activated. I can try to tap into a different, healthier part to meet my needs. This has been shown impactful in improving self-understanding, awareness, and emotion regulation.
Schema therapy has further been effective in shifting and reducing the intensity of feelings in the present by addressing and processing trauma from the past. EMDR Therapy can be very powerful as a trauma technique to enhance healthy trauma processing and resolve cognitive, emotional, and physical trauma symptoms.
Other therapeutic treatments that have shown consistent success in treatment of BPD include Cognitive Behavioural Therapy, and Dialectical Behaviour Therapy, which focus on reframing thoughts and mindset, engaging in healthier behaviours, and managing emotions.
If you are dealing with BPD and would like to find out more about how therapy can support you, please book a consultation with with Dr. Terrighena on (852) 2521 4668 or email@example.com.