Borderline Personality Disorder (BPD)

It is not clear why some people suffer from BPD, but it is likely that there are multiple factors at play, including having experienced a very difficult childhood – comprising experiences of neglect, and physical and/or sexual abuse – and a genetic predisposition. The condition is much more common in people who have family members with BPD than among the general population. Research suggests that people with BPD can have morphological differences in their brains that impact on their ability to regulate emotions, and with their sense of self. It may be more common among women than men, but men with BPD are much more likely than women to experience severe suicidal ideation and completed suicide, while women with BPD appear to be more likely to seek professional help for their symptoms.

It can be very difficult to live with BPD – and it can also be difficult for close family members and loved ones to cope, as the symptoms can be extremely challenging in the context of a group dynamic. In fact, perhaps the most painful aspect of having BPD is that if often causes huge problems in people’s relationships with those they love and esteem most, as it can lead to exaggerated responses to minor difficulties or issues in the relationship, causing significant interpersonal problems.

According to the criteria of the DSM-5-TR, those affected display a pattern of unstable, intense interpersonal relationships, and alternate between idealising and devaluing the same, while also having a persistent, markedly unstable self-image or sense of self.

The ICD-11 has a primary focus on core personality dysfunction, and also subdivides BPD into three levels of severity: mild, moderate, and severe. It also allows a mental health caregiver to diagnose one or more prominent traits, such as detachment or disinhibition.

BPD is sometimes treated in the short term with medications, such as selective serotonin reuptake inhibitors (SSRIs) and antidepressants, although their usefulness is not entirely clear. However, a range of therapeutic approaches has been clinically proven to help, and with time, the vast majority of people get much better, experiencing great improvement in their symptoms when they engage in psychotherapy, particularly if they attend therapy for a significant amount of time. NICE guidelines state that people with BPD should be treated with an explicit, integrated theoretical approach that is explained to the patient, and shared across any team involved in their treatment, with frequent (for example, twice weekly) sessions that can be adapted to their needs.

 A range of therapeutic modalities is indicated for the treatment of BPD, and has been clinically proven to help, including the following:

• Cognitive Behavioral Therapy (CBT) helps you to understand what triggers your more extreme emotions and responses, and to develop more effective management techniques for these triggers. Over time, you will find that you become less anxious and experience fewer negative moods, and fewer damaging behaviours, in response to the things that you find distressing. Gradually, you will learn how to respond to negative stimuli in your environment in a more productive way.
• Dialectical Behaviour Therapy (DBT) involves working on developing communication skills, learning how to tolerate and manage negative emotions more effectively, better regulation of emotions, and mindfulness skills that will help you to deal with the extreme emotions that you feel. All of this contributes to developing better communication skills and can help you to foster more positive relationships with other people.
• Psychodynamic Therapy (PT) focuses on helping you to understand how events and associated emotions from the past have impacted on how you operate in the world today, in terms of your general behaviour, how you make decisions, and how you interact with other people. By understanding yourself better, you will gradually become better-equipped to behave in a different, more useful way, mitigating against the negative impacts of BPD and incrementally improving your quality of life.
• Dynamic Deconstructive Psychotherapy (DDP) is a time-limited form of therapy that aims to provide people with BPD with the tools they need to improve their quality of life quite quickly. It helps them to explore their emotions and how they are interacting with others, and to develop new ways of understanding and responding to the things that have, in the past, triggered negative responses. DDP is typically indicated if you are in an urgent crisis situation, and need immediate help. Most people having DDP will benefit from progressing – once their situation has stabilised – to a more long-term psychotherapeutic approach aimed at the remission of their symptoms.
• Mentalisation-based Treatment (MBT) helps you to explore how and why you think, feel, and believe certain things, and how these thoughts, feelings, and beliefs impact on what you say and do. This is a skill that is often more challenging for people with BPD than others, but with appropriate support from your therapist, you can learn how to understand both yourself and others better, and how to interact with the various people in your life in a much more positive way.
• Schema-focused Therapy (SFT) focuses on the schemas, or behavioural patterns, which have emerged in your life in response to experiences, memories, sensations, and so forth. Schemas that are maladaptive, such as extreme feelings of anger and abandonment, when not warranted by the situation, do not foster healthy relationships with the self or with others. Through therapy, you can learn new schemas based on more positive responses, while building healthier relationships with the other people in your life.

Because everyone is different, and because people with BPD often also have other psychological and/or psychiatric issues, your psychotherapist will work with you to tailor-make a therapeutic approach that meets your needs, and that may combine two or more of the modalities described above. You will both also work together to form a positive therapeutic relationship, as one of the most important indicators of a good outcome is the trusting relationship that has been formed. Additional approaches that your psychotherapist may suggest are:

• Group Therapy, referring to a form of therapy that is carried out with a group of people with the same or a similar mental health issue, typically with one therapist. Particularly in cases where crises and urgent situations have been dealt with, this can be a positive way to engage with therapy in an ongoing, long-term manner, while also experiencing the support and insight of your peers, who live with similar difficulties.
• Couples Therapy is often useful for people with BPD, as BPD can cause or contribute to many issues in an intimate relationship. By engaging in couples therapy – while also having therapy for the BPD itself – you can explore how your condition and its various symptoms impact on the relationship, and how you both can learn better ways to relate to one another.
• Family Therapy can also be very useful, as BPD often relates to dynamics within the wider family, while people with BPD are often very concerned about how their condition may impact on their own children. Therapy that explores the dynamics of the whole family in a safe, honest, and controlled setting can be enormously helpful in terms of mitigating the impact of BDP and developing a more positive family relationship in general.

As BDP is a complex condition that requires considerable support, and typically does not affect just the person involved, but also anyone they are in a relationship with, it can also be a good idea to engage in therapies and practical approaches specifically designed to address these issues. Firstly, and most importantly, having a balanced lifestyle that incorporates self-care in the form of healthy eating, a reasonable amount of exercise, and the avoidance of harmful substances, along with nurturing positive relationships and friendships that minimise conflict and stress, really helps.

When it comes to complementary therapies, many approaches can be useful, but with a caveat: therapies of this sort should never be seen as a replacement for professional psychotherapy, and care should be taken in locating professionals who have appropriate qualifications, and who will work alongside your psychotherapist or psychologist. Don’t be afraid to ask about their training and qualifications, how long they have been practicing, and what ethical code they observe. Unless you receive satisfactory answers to these questions, it is best to stay away.

Useful complementary therapies may include:

• Mindfulness Meditation, which is a practice that involves deliberately disengaging from conscious thought and learning how to be in the moment, focused on the here and now. During periods of mindfulness, you can feel and acknowledge difficult emotions and thoughts, but also decide not to engage with them. Over time, you can use mindfulness in a range of settings to help you to slow down, see your emotions in a more objective, relaxed way, and control how to respond to the triggers in your environment.
• Sound healing, breathwork, music therapy, and psychedelic-assisted therapies, when offered by a suitably-qualified professional, can all assist in healing traumas and address the issues that may underlie or exacerbate BPD.
• Parenting skills courses can be very helpful for people with BDP, who are much more likely than average to have had negative experiences during their own childhoods, and who may be very anxious to avoid causing any psychological harm to their own children. People with BPD may struggle with some of the challenges that come with parenting, while also experiencing distress if they feel that they are not parenting well, or that they risk inadvertently causing harm to their children, who may be exposed to anger or other negative moods. Attending a programme focusing on fostering better parenting skills, typically in parallel with psychotherapy that works to mitigate the symptoms of BPD, can impact positively on the person with BPD while also minimising the risk of intergenerational harm.
• Support groups for alcohol abuse and other substance abuse issues, or for eating disorders or other disorders involving self-harm, can be very helpful for many people with BPD, who may have been self-medicating or self-managing this challenging condition for years. In parallel with attending therapy, a specialised support group will show you that you are not alone, and also help by providing concrete advice and help with any issues you may have in these areas.
• Yoga or another guided exercise programme can be very helpful in supporting your mental health generally. Yoga, which often combines exercise with guided meditations, has been clinically proven to be useful not just in terms of supporting your physical health, but also in teaching mindfulness and other techniques that will help you to feel more in control of your emotions. All forms of exercise are known to support good mental as well as physical health.

It can be scary learning that you have BPD, but having this condition does not mean that you do not deserve to be happy, or that you can never learn how to manage it. With time, patience, and appropriate treatment and support, the vast majority of people with BPD can see a dramatic improvement in their symptoms, with huge positive benefits not just for them, but for all the people who care about them.

BPD is considered a significant mental health disorder, so it is important to be properly diagnosed by a mental health professional, who will typically be a psychiatrist, who will explore your clinical records, and also refer to medical records and reports from people close to you.

If you are diagnosed with having BPD, you might feel taken aback at first. Even if you have long suspected that something is wrong, it can be difficult to accept, perhaps partly because the condition is still, unfortunately, rather stigmatised in society. But a diagnosis is good news, not bad, because now you know what the issue is, and by working closely with mental health professionals who have your best interests at heart, you can start taking meaningful steps towards a much higher quality of living.

It is uncommon for BPD to present itself alone, and often there are other co-morbid conditions. These range from depression, anxiety, trauma, and substance abuse to neurological disorders such as ADHD. As a consequence, the assessment of BPD symptoms must be considered as part of a comprehensive assessment process.

As part of this diagnostic evaluation: the clinician should be able to document that the patient meets the criteria for a diagnosis of BPD, being aware of possible other conditions. At the Private Therapy Clinic, we use psychometric screening tools, in combination with a semi-structured clinical interview that explores the patient’s interactions and behaviour in various areas of their life, including: social adaptation, patterns of impulses and actions, symptoms that might be viewed as psychotic, and interpersonal relationships. It is a non-judgemental, gentle exploration to ascertain what your difficulties are and whether, together, they constitute BPD. By exploring these crucial areas of life, our Psychologist or Psychiatrist acquires the information necessary to make a clear diagnosis.

If you would like to talk to someone about a BDP assessment, or about treatment, either in the Ireland or online, please get in touch with the Private Therapy Clinic on Whatsapp message at: 7511116565 email, chat bot or book online to arrange an appointment.

Carpenter, R. W., & Trull, T. J. “Components of Emotion Dysregulation in Borderline Personality Disorder: a Review,” Current Psychiatry Reports, 2013, 15(1), 335. Link

Cattane, N., Rossi, R., Lanfredi, M., & Cattaneo, A. “Borderline Personality Disorder and Childhood Trauma: Exploring the Affected Biological Systems and Mechanisms,” BMC Psychiatry, 2017, 17(1), 221. Link

Chapman AL. “Borderline Personality Disorder and Emotion Dysregulation,” Development and Psychopathology, 2019, 31(3):1143-1156 Link

Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P, “Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis,” JAMA Psychiatry, 2017, 74 (4): 319–328. Link

Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. “Time to Attainment of Recovery from Borderline Personality Disorder and Stability of Recovery: A 10-year Prospective Follow-up Study,” The American Journal of Psychiatry, 2001, 167 (6), 663–667. Link