Borderline Personality Disorder (BPD) is an issue that is close to my heart. BPD was my first big diagnosis. I was a “perfect fit” for it. I met all the criteria. Unfortunately, some of my other symptoms were thrown by the wayside in the interest of me fitting neatly into a box; But that is a conversation for a different day. At this point I am not sure if I aged out of the diagnosis, or was just completely misdiagnosed (as I have different diagnoses now and am far from being neuro-typical). I want to share with you the ins and outs of BPD
So, let’s dive in
A Tidbit of History
The first thing to learn about the ins and outs of BPD is its history. In the ol’ days of 1938, the term “borderline personality disorder’ was proposed by Adolph Stern. Stern described a group of patients who “fit frankly neither into the psychotic nor into the psychoneurotic group” and introduced the term “borderline” to describe this observation because, you see, it “bordered” on the cusp of psychotic and neurotic but was neither on its own.
Years and not nearly enough understanding later, the term “borderline personality organization” was introduced by a cool dude with a cool name—Otto Kernberg. Whatever the supposed underlying psychological functioning, the cluster of symptoms and behavior associated with borderline personality were becoming more widely recognized
Aaah, Otto. It’s fun to say; but I digress.
Ol’ Otto described a group of patients with a consistent pattern of functioning and behavior characterized by instability and reflecting a disturbed psychological self-organization. This included significant fluctuations from periods of confidence to times of absolute despair, (did someone say black and white thinking?), inconsistent self-image, rapid changes in mood with those oh-so-familiar fears of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Other psychotic symptoms, including brief delusions and hallucinations, can also be present.
The characteristics that now define borderline personality disorder were described by Gunderson and Kolb in 1978 and have since been incorporated into more contemporary psychiatric classifications.
But… But why?
So why, oh why, does BPD happen? The real answer is that we aren’t sure yet, but we have a few good ideas about the ins and outs of BPD involving a little nature here and a little nurture there.
Biological Components of BPD
Bear with me while I say some science stuff then explain a bit.
People with borderline personality disorder show increased activity in the dorsolateral prefrontal cortex and in the cuneus, and a reduction in activity in the right anterior cingulate cortex (a part of the brain that is important in attention, cognitive processing, emotion and possibly consciousness.) The right anterior cingulate cortex combines emotional, attentional, and bodily information to bring about the conscious emotional experience
First, let me explain that mess of brain stuff.
That dorsolateral prefrontal cortex beep-bop-boop is the place in the brain that acts as a kind of “filter.” The Prefrontal cortex is the final destination for much of the brain’s information about emotion before action is taken.
Just imagine all your emotions going through a sifter before you act. It separates the rational from the purely emotional so that an appropriate response goes past your lips. Because this area has some damage, the filter is damaged. This attributes to the, sometimes, unreasonable anger.
With a neuro-typical mind—a stimulus occurs, the brain processes this event as it does. It goes through the filter, one reacts appropriately.
With BPD, a stimulus occurs, the brain processes it, and it goes through a damaged filter, and the super angry, rageful reactions happen.
Now, the right anterior yada-yada is where stuff like your amygdala is located. This area of the brain is an integral part of creating the emotional experience. It also is an integral part in handling our aggression.
So, let’s put it together:
Stimulus –>> The right anterior cingulate processes this experience and makes it mean something –>> the aggressive meaning passes through the prefrontal cortex, but, like, without the filter –>> The expression is then all that anger that was brewing.
The next thing you know, you’re telling off a coworker for using your favorite pen, or maybe throwing your own phone at a wall. I know… these are my experiences. Like I said ins and outs of BPD.
Second thing—if anyone says its “mind over matter” you can tell them to shove it because this does, indeed, have a biological component. Yeah, SCIENCE!
Social Components of BPD
Trauma history is a central feature of both BPD and PTSD. The neurobiological impairments associated with the development of PTSD can be seen as the predisposing factor for BPD. Both environmental and neurobiological factors contribute to the development of BPD. Genetic predisposition becomes activated during environmental experiences of trauma history. This is sometimes called a precipitating experience. It has been reported that trauma and neglect might exacerbate both biological and behavioral tendencies.
Part of the ins and outs of BPD include evidence for a strong association between traumatic events and dissociative symptoms in BPD. According to past studies, borderline patients have high rates of childhood abuse and dissociative symptoms. Depersonalization and derealization are leading symptoms of BPD, and dissociation can be a prominent feature in some individuals. Research of the dissociative cousins, PTSD and depersonalization suggested that dissociation might be a form of emotional dysfunction, promoting trauma-related stressful emotions. Dissociation severity is correlated to the childhood traumas such as inconsistent caretaking, sexual abuse, adult rape, and emotional neglect.
While some people with borderline personality disorder come from stable and caring families, deprivation and instability in relationships are likely to promote borderline personality development.
Signs and Symptoms of BPD
It is common that people with borderline personality disorder may engage in destructive and impulsive behaviors such as self- harm, eating disorders, and excessive use of alcohol and illicit substances. Self-harming behavior in borderline personality disorder is common and associated with a variety of different meanings for the person, such as relief from incredible amounts of distress and feelings, such as emptiness and anger, and to reconnect with feelings after a period of dissociation. As a result of the frequency with which they self-harm, people with borderline personality disorder are at increased risk of suicide.
Folks with BPD can be quick to anger with responses often inappropriate for the situation at hand. There can be confusion about identity, and black-and-white thinking, i.e., things being all good or all bad, or all right or all wrong, with nothing in between. People with BPD may struggle with close relationships with others, especially romantically. The emotions of one with BPD are often tumultuous.
Borderline personality disorder is defined by the DSM-V (2013) as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked by impulsivity, beginning by early adulthood and present in a variety of contexts as indicated by 5 (or more) of 9 criteria.
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilation behavior
- Affective instability due to marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights.)
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
The use of antidepressants, mood stabilizers, and antipsychotics is common practice in treating BPD. One large study of prescribing practice in the US found that 10% of people with borderline personality disorder had been prescribed an antipsychotic at some point during their contact with services, 27% a mood stabilizer, 35% an anxiolytic and 61% an antidepressant. The lifetime prescribing rate for antidepressants was double that for patients with major depression.
Since patients with BPD suffer considerably with co-occurring disorders, BPD causes a therapeutic challenge for clinicians. First-line treatment for BPD is psychotherapy—like cognitive behavioral therapy or dialectical behavioral therapy. Symptom targeted medications right alongside therapy have also been found to be greatly effective.
Many people who have at one time been given the diagnosis of borderline personality disorder move on to live whole, fulfilling lives. In fact, about 50% of people diagnosed with BPD can be expected to overcome the diagnosis all together over time with proper treatment and support; however, during the course of the disorder, folks can have significant problems which mean that they require a large amount of support from services—like a medical team and in- patient treatment, and from those around them.
More ins and outs of BPD include comorbidity. It is a weird word. It means that BPD can occur with other diagnoses. Its symptoms very often overlap with depressive, schizophrenic, impulsive, dissociative, and identity disorders
Either because of its position on the ‘border’ of other conditions, or as a result of some conceptual and diagnostic confusion, borderline personality disorder often occurs alongside depression and anxiety, eating disorders such as bulimia and anorexia, post-traumatic stress disorder (PTSD), substance abuse disorders, and bipolar disorder (with which it is also sometimes clinically confused). It can also overlap with psychotic disorders considerably.
Borderline personality disorder (BPD) and bipolar disorder can occur together in 10%–20% of cases, and since symptoms of these disorders are quite similar, many patients with BPD have been mistakenly diagnosed with bipolar.
Borderline personality disorder is incredibly complex, but does not elude the scope of treatability. Therapy mixed with medication is an excellent course of action. Many people with BPD can overcome the diagnosis, or in the meantime, learn to live and function with the diagnosis to live happy and fulfilling lives.
Understanding the ins and outs of BPD, is understanding that it is not just a matter of the mind, but of the body as well. One may even consider it more damage to the brain than characterizing it as simply a “disorder.”
There are many misconceptions about BPD. With my own experience and with being very close to others with the diagnosis, we have been made to feel “broken” or unlovable.
This is so far from the truth. I have seen some pretty aggressive messages shared by strangers to individuals who have the BPD diagnosis from others who judge saying some very mean and ignorant things. Like “stay out of relationships”; Or “you’ll ruin the lives of others around you.” These messages are hurtful and damaging and should not be listened to.
If you have been diagnosed with BPD and are seeking treatment, good for you! That is the first step. Don’t let what the ignorant say impede your recovery. Don’t listen to the nay-sayers. Listen to your body, mind, and support team.
Having BPD is no joke, and it is incredibly difficult to live with, especially in the beginning. It is a long and well worth it journey. You are not a broken thing that needs to be fixed, you are just on the mend.
For people who may know someone who has this disorder, now you hopefully have a bit more insight into what it is. Be gentle and patient with your friends and loved ones in treatment and, of course, be supportive in a healthy way.
For those who know nothing about BPD, I hope you have learned something; And, for those who know little to nothing about BPD and still want to say mean things, shove off—you’re not helping anyone and are part of the problem of ignorance and misunderstanding of mental illness. Educate yourselves.
I hope this post has been helpful, and I hope those in the struggle that are reading this know you are most definitely not alone, even though the diagnosis itself can make loneliness seem cosmic.
I am with you, and I support you and your efforts. You have worth, you can overcome, and you are deserving of love—no matter what. Everyone needs to know that, and you, reader, if you have BPD, please do not forget it.
Below you can find my references if you would like to learn more about BPD. I have also left a link to a great informational video series for families who are affected by the diagnosis.
National Collaborating Centre for Mental Health (UK). Borderline Personality
Disorder: Treatment and Management. Leicester (UK): British
Psychological Society; 2009. (NICE Clinical Guidelines, No. 78.) 2,
BORDERLINE PERSONALITY DISORDER. Available from:
Herpertz SC, Dietrich TM, Wenning B, et al. Evidence of abnormal amygdala
functioning in borderline personality disorder: a functional MRI study. Biological
Kulacaoglu, F., & Kose, S. (2018). Borderline Personality Disorder (BPD): In the Midst of
Chaos, and Awe. Brain sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
Garrett, B. (2011). In Brain & behavior: an introduction to biological psychology (Vol. 3, pp. 228–228). essay, Sage.