A Borderline Personality Disorder Primer by Kiera Van Gelder, MFA

Borderline Personality Disorder 101

Kiera Van Gelder, MFA

Kiera Van Gelder © 2009

is an ILLNESS of impulsivity and dysregulation.

Borderline Personality Disorder

It influences how a person perceives, relates to, and thinks about the

environment and oneself.

It is considered a personality disorder

because


BPD is highly stigmatized and misunderstood. The typical portrayal of BPD is Glen Close as Alex Forrest in “Fatal

Attraction”


Chaotic

Childish

Clingy

Cranky

Demanding

Desultory

Going to Extremes

Adoring and Contemptuous

Fickle

Flighty

Fragile

Hostile

Importunate

Inconstant

Irritable

Manipulative

Mercurial

Moody

Possessive

Reckless

Seductive

Shallow

Unpredictable

Unreasonable

Vehement

Volatile

Clinicians historically have describe BPD traits as being willfully

imposed on others, rather than symptoms of an illness

--Michael H. Stone, MD


Helpless

Unlovable

Alone

A failure

Defective

Misunderstood

Incompetent

Hopeless

Out of control

Unsafe

However, this is how people with BPD see themselves:

Neglected

We need to understand the extreme pain of having BPD in order to make sense of why people behave as they do:

“Feeling overwhelmed, worthless, very angry, empty, abandoned, furious, enraged”

“Feeling misunderstood, thinking that no one cares about them or that they are bad, thinking about killing themselves, believing they are evil, feeling like a small child, and believing they are damaged.”

“the overall ‘amplitude’ of this pain may be a particularly good marker for the borderline diagnosis.”

Zanarini, et al. Harv Rev Psychiatry. 1998 Nov-Dec;6(4):201-7.

Dr. Mary Zanarini and colleagues identified “BPD Pain” as involving:

1. Frantic efforts to avoid real and imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance, persistently and markedly unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self damaging (e.g. substance abuse, sex, binge eating, spending, reckless driving).

5. Recurrent suicidal behavior, gestures or threats; or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or lack of control of anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).

9. Transient stress related paranoid ideation or severe dissociative symptoms.”

“A pervasive pattern of instability of interpersonal relationships, self-image, affects and control over impulses beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following

criteria: (5 out of 9)

The American Psychiatric Association’s manual of diagnoses (the

DSM IV TR) defines nine BPD symptoms. These symptoms, you’ll note, are also basic human experiences, and so, the disorder is best

defined by the severity of symptoms and their duration.

American Psychiatric Association Dialogistic and Statistic Manual IV TR


How to make sense of BPD when everyone experiences the symptoms to one degree or

another?

Clinicians and researchers continue to struggle with refining the diagnosis to accurately reflect the experience of those who suffer from it. The variety of forms it takes, and the way it borders on average human experience, makes understanding the disorder difficult.

And there are so many of them!

Additionally, since you only need 5 out of 9 symptoms to qualify, there are a total of 256 different combinations of BPD. Valarie Porr, MA, often uses the parable of the blind man touching an elephant when showing people in her workshops how many ways BPD can be perceived. Here are just some of

the ways clinicians explain the core symptoms:

• Dr. John Gunderson: “Phenotypes” that can be traced to

genetic markers

• Dr. Aaron Beck: “Schema”

•Dr. Judith Herman: Complex Post Traumatic Stress Disorder

• Dr. Marsha Linehan: Multiple areas of “Dysregualtion”

• Dr. Otto Kernberg: Disordered “Attachments” and “Defence

Mechanisms”


Emotion Dysregulation Disorder

Chemical Imbalance

Willful Asshole…

Just needs to change

Reactive Attachment

Disorder

I’m screwedComplex Post Traumatic

Stress Disorder

Faulty Schema

Primitive defenses

As you can see, doctors have many theories and ways of defining BPD

No! Screw you! Thanks to Valarie Porr for

the inspirationfor this slide!

Bipolar & Bipolar II

Generalized AnxietyDisorder

Substance Abuse

PTSD

Eating Disorders

Depression

Obsessive Compulsive Disorder

Kleptomania

Additionally, many clinicians cannot see the disorder because they focus on the many “Co-Occuring”

diagnosis, as BPD “borders” on and combines with numerous other struggles….

Co-dependence

Agoraphobia

Sex Addiction

Often, people with BPD will be given other diagnosis and treated specifically for those, but ultimately the core of our suffering is never healed. This can go on for decades, leading to the conclusion that there are people who are

untreatable and incurable. When, in fact, they have not received the right education and treatment.

“Ragaholic”

Panic DisorderPersonality Disorder Not Otherwise Specified

Is there anything I

don’t have?

I’m certain you don’t

have BPD!


So what is BPD (minus the confusion, stigma, denial, misinformation and horrible media

portrayals?


First, an understanding of what we call “Psychiatric Disorders”

The diagnosis (i.e. depression, addiction, PTSD) acts as a map that allows us to

understand symptoms that cause misery and get in the way of good living.

A psychiatric condition is not WHO we are: no matter if it’s biologically-based or involves

our personality!

However, our language and thinking often reinforces that concept.

ie “He is a schizophrenic; I am an alcoholic; she is a borderline.”

Mental illness or psychiatric disorder refers to difficulties (impairments) a person

experiences with thoughts, emotions, behaviors, perceptions and relationships.

Why is BPD called a “Personality” Disorder?

Personality Development involves the interaction of

Biological pre-dispositions (nature) External Environments (nurture)

A Personality Disorder

occurs when personality traits are

inflexible and maladaptive and cause

functional impairment or

subjective distress.

Unlike many mood disorders, a personality disorder involves one’s sense of self and perception of the world. For some of us, our experience of self and other, our ways of behaving and reacting, become harmful and rigid. It takes great courage and insight to go beyond our habitual ways to grasp that our personality might be impaired. Of course, everyone’s personality is disordered to some extent. But with “Personality Disorder,” it is sever, destructive, incapacitating and often hellish for ourselves and those who know us.


1) High emotional sensitivity

2) High emotional reactivity

3) A Slow return to emotional baseline

Quick to heat up

Slow to cool down

= Symptoms of Impulsivity and Dysregulation

Dr. Marsha Linehan suggests that people develop BPD due to a “biological vulnerability” in combination with a specific environment:

Those with BPD typically have three vulnerabilities


A little Acronym for BPD: RISEREACTIVITY

impulsive, out-of-control, overly aggressive, acting without thinking

INTENSITY psychic bleeding, hemorrhaging pain, unable to calm

down

SENSITIVITY emotional burn victims; thin-skinned; easily disturbed by

small slights

EMOTIONALITY Overwhelmed by feelings / dissociated from feelings;

thoughts easily distorted; difficulty seeing beyond present emotional state


Cognition

Behavior

Relationships

Emotions

Self-Image

Before looking at the more “intra-psychic” aspects of BPD (like attachment, rejection sensitivity, and fear of abandonment) let’s focus on the areas of dysregulation Dr. Marsha Linehan lists as

being central to BPD.

5 Areas of Dysregulation:


Emotions

Chronic anxiety

Rapidly changing emotions

Overwhelming passion / desire

Extreme sensitivity

Rages

Dissociation, being “shut down”

People with BPD have been described as “emotional burn victims” due to extreme sensitivity. Their interior world is constantly shifting,

unpredictable and difficult to express to others or understand.

Low tolerance to stress

Easily frustrated

Boredom

Despair

Loneliness


People with BPD typically use impulsive, self-destructive behaviors as a way to regulate intense,

negative emotions and cope with life.

Behavior

Self- harm: cutting & burning

Suicide Attempts and threats

Drug & Alcohol Abuse

Impulsive Spending

Unsafe Sex

Vandalism

Thrill-seeking

Picking fights

Shoplifting

Binging and purging

Geographical cures


Relationships

Intolerance ofRejection

Unstable “Stormy” Relationships

Intense Fear of Abandonment

Frantic Attempts to Avoid Being Left

Other person becomes focal point for self

Conflicts with othersdifficult to tolerate

Need for constant assurance

Trust is given indiscriminately or

not at all

Need for closeness pushes others’ boundaries

People with BPD have difficulty tolerating separation or perceived rejection from those they are closest too, and can live in constant fear of abandonment.

Difficulty internalizing love or remembering positive connections


Cognition

Overly Jealous or Suspicious

Black and White Thinking

Alternately see others as all good or all bad

Difficulty holding onto positives

Paranoia when under stress

People with BPD can have impaired and distorted thinking, especially under stress or when triggered.

Inability to recognize consequences of behavior

Hyper-vigilant to possible threats

Interprets neutral faces as hostile

“Emotional information processing” impairment


People with BPD have a fragile and shifting sense of self. A sudden change, even a good one, can destabilize a person’s sense of

themselves and their place in the world.

Self-Image

Rapidly ChangingIdentity

Deep Insecurity

Depersonalization / feeling unreal

Emptiness

Confused sexual orientation

Sense of self dependant on others

Annihilation of self by others through abandonment or engulfment

Environment determines self-worth

Sense of being bad or wrong

Shifting and contradictory goals or values

Common beliefs researchers discovered those with BPD have about themselves and the world,

in addition to “dysregulation”

I am endangered

I am like a small child

I am uncared forZanarini, (1988)

The world is dangerous and malevolent

I am powerless and vulnerable

I am inherently unacceptableBeck and Freeman (1990)

These very much contribute to our personality and how we interact with

ourselves and the world!

There are recognized biological components to BPD

Research shows abnormalities in the neural systems that

regulate emotions, impulsivity and thinking

Emotions Regulation is

impaired

Amygdala system

Impulsivity control problems

Anterior Cingulate

Orbitomedial Prefrontal Systems

Perception and

Reasoning disortions Dorsolateral prefrontal system

The Best and Most Up to Date information on this is found in Valarie Porr’s Book: Overcoming Borderline Personality Disorder: A Family Guide for Healing and

Change


How biological vulnerabilities and environment interact: Linehan’s Bio-social model of BPD Development

1. High emotional sensitivity

2. High emotional reactivity

3. Slow return to emotional baseline

1. Indiscriminately rejects private experience

2. Punishes emotional displays while

intermittently reinforcing emotional escalation

3. Oversimplifies ease of problem solving and

meeting goals

Invalidating Environment:

Biological Vulnerability

Dr. Marsha Linehan proposes that it’s within a specific “person/environment”

interaction that BPD develops


Negates

Dismisses

Disregards

Criticizes

Punishes

So what is an Invalidating Environment?

An Invalidating Environment

A person’s communication and behavior

(Feelings, thoughts, preferences, beliefs,

sensations) *

* Linehan, 1991

An invalidating environment can be anything from highly abusive to a simple mismatch between caretakers and the

person who is vulnerable.

Being with and needing others brings up:

Emotional reactivity

Sense of being threatened

Paranoia and jealousy (especially perception of betrayal)

Difficulty negotiating boundaries (taking on others emotions, issues)

Heightened sensitivity to judgment and criticism

Polarized thinking / perceptions

Difficulty seeing others’ perspectives

Taking desperate actions in order to manage pain of conflicts and to express feelings.

People with BPD and those in relationship to them will encounter challenges specific

to the disorder

We all need to see these behaviors as “maladaptive” rather than “bad”: those with BPD can be triggered constantly by those they are closest to , therefore it may seem impossible to interact with

them without getting hurt yourself.

For example, intimate and close relationships are triggering to a person with BPD


Despite all this, we now know BPD is treatable!

2 years = 40% Remission6 years = 68% Remission 10 years = 85% Remission

(Zanarini, 2005, 2006)

Remission is defined as “no longer meeting 5 of 9

criteria”However, we must also be aware that remission does not mean “recovery” or having a good quality of life:

Recovery involves more than the absence of symptoms.

DBT : Dialectical Behavior Therapy (Marsha Linehan, WA)www.behavioraltech.org

CBT: Cognitive Therapy (Aaron Beck, PA)www.academyofct.org

SFT: Schema-Focsued Therapy (Jeffrey Young, NY) www.schematherapy.com

Mentalization (Andrew Bateman and Peter Fonagey, UK) www.menninger.edu

TFP: Transference-focused Psychotherapy (Otto Kernberg, NY)

www.borderlinedisorders.com

STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO)

www.uihealthcare.com/topics/medicaldepartments/psychiatry/stepps/index.html

Treatment for Borderline Personality Disorder is now proven effective and available in many places

Stage 4: “Incompleteness” Capacity for Joy and Freedom:

Love as inter-dependence, internalized mastery, “having perspective”, self-management, sense of self is evolving.

Dr. Marsha Linehan specifies 4 Stages of Recovery from Borderline Personality Disorder

Stage 1: Severe Behavioral Dyscontrol

Behavioral Control: Reducing self-harm, addictions, dissociation, rage,

suicide attempts, chronic despair.

Stage 2: “Overcoming Quiet Desperation” Emotional Experiencing:

Dealing with PTSD and trauma, fear of emotions, understanding triggers.

Behavioral

Emotional & Cognitive

Interpersonal

Sense of Self

* Adopted from M.M Linehan, 2004

Stage 3: “Problems in Everyday Living” Ordinary Happiness and Unhappiness:

Rebuilding a life, generalizing skills to relationships and work, involved with life.

Mindfulness: Developing awareness of body, feelings, thoughts, reactions, & surrounding

environment

No matter what kind of treatment is done, healing from BPD involves the cultivation of the

following qualities for ALL involved

Non-judgment: Not imposing our own viewpoint but

focusing on facts

Validation: Recognize what each person is

saying and experiencing,

even if you disagree.

Pausing and imagining what others are

feeling: The pause allows us to respond rather than react

Openness: A willingness to experience the symptoms without shutting down or

defending ourselves unnecessarily

Giving the Benefit of the Doubt: Not jumping to conclusions about other

people’s behavior

Curiosity: Asking “what is going on” rather than making

judgments and assumptions

Patience: Allowing ourselves and others to go through the

process and accept it won’t be on our schedule

Hope:

Believing that recovery is possible


“Abandon what is unskillful…. Cultivate

what is good.”

--The Buddha

A Borderline Personality Disorder Primer by Kiera Van Gelder, MFA

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Transcript of A Borderline Personality Disorder Primer by Kiera Van Gelder, MFA