In this article (part 2) and the subsequent article (part 3), I aim to improve your awareness and knowledge of BPD. Armed with your new awareness and knowledge, I encourage you to in turn help to improve the awareness and knowledge of others.
People’s lives depend on it.
BPD has an horrifyingly high suicide rate. Around 10% of people with BPD will commit suicide at some point1, and people with BPD commit suicide more often2 than the general population. However, BPD is one of the least known mental illnesses, not only in the general community but also among therapists.
Thinking back, my friend is highly unlikely to be the first person I’ve encountered who has BPD. For example, there was the work colleague who had the sudden mood swings and anger outbursts that are among the criteria for a BPD diagnosis. I didn’t interact with this colleague enough to know if they satisfied other BPD criteria, but I’m deeply concerned to think that I’ve known people who were at very high risk of suicide and did nothing because of my lack of awareness and knowledge.
What is borderline personality disorder (BPD)?
The US National Institute of Mental Health (NIMH) provides the following introduction to BPD:
Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of ongoing instability in moods, behavior, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships. A person with BPD may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days.
The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) has diagnostic criteria for BPD. DSM-IV, published in 2000, lists nine criteria, five (or more) of which a person must satisfy to be diagnosed with BPD. DSM-5, published in 2013, lists revised and more detailed criteria. The World Health Organization (WHO) International Classification of Diseases (ICD-10) also identifies the characteristics of a similarly described disorder.
As you read through these criteria, think about the behaviours of your family, friends and work colleagues.
DSM-IV Criteria (2000)
A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
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 only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
DSM-5 Criteria (2013)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative
attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma.
ICD-10 Criteria (2016)
F60.3 Emotionally unstable personality disorder
Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.
Do you recognise any of these criteria in your family, friends, or work colleagues?
While my friend has been unable to receive a formal diagnosis, we have exhaustively reviewed the diagnostic criteria for all mental and personality disorders, and I am personally left in little doubt that he has BPD. He satisfies eight of the nine DSM-IV criteria, and satisfies the criteria in DSM-5 and ICD-10. A feature article in the New England Journal of Medicine affirms our approach3, stating that “The diagnosis of BPD is most easily established by asking patients whether they believe that the criteria for the disorder characterize them.”
A formal diagnosis would still be desirable, especially as BPD can exist alongside or be confused with other disorders, but we don’t currently have that option. Here in China, the Chinese Classification of Mental Disorders (CCMD) does not currently identify BPD. A study4 has found that another personality disorder identified in CCMD-3, impulsive personality disorder (IPD), may have analogous diagnostic categories to BPD in the DSM, but ideally the CCMD should be updated to specifically identify BPD.
Can BPD be treated?
Yes, as a result of the incredible work of Marsha M. Linehan, a United States psychologist who committed herself to trying to do something about the biggest cause of suicide. Linehan is the creator of dialectical behavior therapy (DBT), a type of psychotherapy that combines behavioral science with Zen concepts like acceptance and mindfulness.
Systematic review by the Cochrane Collaboration has found that there is sufficient evidence for the effectiveness of DBT in treating BPD.
- DBT training, certification, and other resources for therapists
- therapist directories and other resources for patients and their families.
For people unable to access DBT-trained therapists, there are also DBT-inspired online programs, for example DBT Path.
What can be done to support BPD sufferers?
In the next article (part 3), I will discuss:
- how to effectively support a partner, family member of friend with BPD
- what society needs to do to provide better support for sufferers of BPD.
- Paris, J. (2006). Managing suicidality in patients with borderline personality disorder. Psychiatric Times, 23(8), 34-34. ↩
- Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: a meta-analysis. Nordic journal of psychiatry, 59(5), 319-324. ↩
- Gunderson , John G. (2011). Borderline Personality Disorder. New England Journal of Medicine, 364, 2037-2042. ↩
- Lai, C. M., Leung, F., You, J., & Cheung, F. (2012). Are DSM-IV-TR borderline personality disorder, ICD-10 emotionally unstable personality disorder, and CCMD-III impulsive personality disorder analogous diagnostic categories across psychiatric nomenclatures?. Journal of personality disorders, 26(4), 551-567. ↩