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Borderline Personality Disorder and Relationships
Tips for Surviving BPD
Borderline personality disorder, or BPD, literally makes life hell for both the person who has it and the people they love. Like all personality disorders, it's a pervasive, deeply-rooted way of relating to the world - so ingrained that a number of counselors sometimes claim that trying to treat the disorder is a futile attempt.
Part of the problem is that people with personality disorders typically do not believe there is anything wrong with them. They've "always" been the way they are, so it's hard for them to see their behaviors as contributing to the problems they have today. Another part of the problem is that the mental health community tends to stigmatize or see personality disorders as too big to handle, and in one sense, they're correct: we simply don't understand personality disorders sufficiently to treat them effectively and efficiently.
When I trained to be a drug and alcohol counselor and during the years I practiced, I rarely saw people with personality disorders, and received no formal training on how to treat them.
But if the experts in mental health can't handle people with borderline, narcissistic, or antisocial personality disorders, imagine how loved ones feel! People who love someone with BPD are often caught between feelings of tender protectiveness for their partner's vulnerable, fragile side and intense feelings of rage at they way they're being treated.
The good news is that the psychiatric community has a much better understanding of BPD and treatment today. A diagnosis of BPD isn't automatically rejected as an untreatable condition these days. Keep reading to learn more about BPD and how to cope with it if you or a loved one is suffering.
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- Borderline Personality Test - Psych Central
This free, online tool can let an individual evaluate whether they may have BPD. It's not a substitute for a diagnosis, but can help determine if getting help may be beneficial.
- Clinical Resource Directory | Behavioral Tech, LLC
Publications, materials and information about Dialectical Behavior Therapy and searchable index to locate DBT therapists in your state.
Many people believe that BPD patients are manipulative, but this is a mistaken assumption. In the video "Back from the Edge," shown later in this article, you'll discover why.
Signs and Symptoms of BPD
There are a couple of important things to understand about diagnosing personality disorders like BPD. The first thing to understand is that everybody has personality disorder traits. For instance, many people have experienced a fear of abandonment from time to time, and it doesn't mean they have BPD. In order to make a diagnosis, a clinician must consider whether a person has a sufficient number of traits, and how pervasive and enduring they are, to conclude that a disorder exists.
The psychologist or psychiatrist must also rule out other conditions that may have similar or shared traits, or figure out whether two or more conditions may exist at the same time. Usually, they rely upon the patient's reports about themselves, but may sometimes receive information from other people. Because the expert's exposure to the patient's behavior is limited, they may not get sufficient information to make a correct diagnosis.
On the other hand, many non-experts have plenty of exposure to their partner and try to make a diagnosis without understanding the proper way to use the Diagnostic and Statistical Manual. This often creates more problems than it solves. Although they are seeking to understand, they often discover that by attaching a label to their loved one's behaviors, they introduce new reasons to argue with their significant other, who now feels defensive, criticized, and possibly even ashamed.
If you believe your loved one may have BPD, it may be possible to guide them gently into treatment, but it would be wise to withhold an "armchair diagnosis" if you don't want to make your situation worse.
When locating a therapist, look for one that specializes in BPD or a technique called dialectical behavior therapy (DBT).
DSM-IV Diagnostic Criteria for BPD
The Diagnostic & Statistical Manual (Rev. IV) provides the psychiatric community with standardized guidelines for making diagnoses. According to the DSM-IV, borderline personality disorder may be present if at least five of the following nine conditions exist:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."
- 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). Note: Do not include suicidal or self-mutilating behavior covered in (5).
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- 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).
- 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.
Remember that only a qualified, trained provider can make an actual diagnosis!
Living with BPD
To get an idea of what it's like to have BPD, imagine yourself waking up in the morning and deciding to make some toast for breakfast. The toaster dial is broken. You must remove the bread before it turns into a blackened char. But you also need to use the restroom and get ready for work, so you're squeezing your legs together and maybe twisting painfully as you wait for your toast to finish. Your gaze shifts between the clock on the wall and the toaster. Your dog's watching you and wondering why you're dancing around and making those funny cursing noises. You're tempted to kick the pup for that judgmental stare he keeps giving you.
You decide you can eat the toast now, even though it's not quite as golden as you'd like, so you retrieve it and drop it on your plate to cool while you rush to use the toilet.
Crisis averted. You down your meal quickly and go to take a shower. Unfortunately, there is no temperature control on it, so you can choose only between scalding your skin and freezing your butt off. How do you decide? You know some people can take warm showers, but you've never experienced one yourself! You wish you knew how to fix it or to find someone who does, but alas, you don't know anyone and can't afford to hire someone. You've been told that yours cannot be fixed, in fact. You suffer through your shower and feel tremendous relief when you get a chance to dry off and dress.
Rushing out the door so you won't be late, you get into your car, where you discover that somehow, your gas pedal and brakes have both stopped working. You cannot stop at red lights, and you're racing down the streets barely able to steer around corners. You have no idea how in the world you'll come to a stop!
Is it hard to envision how you would feel if you experienced such a bizarre morning? Would you be anxious, afraid, frustrated, angry? All of the above? A BPDer's brain has no dials to adjust the temperature and speed of their thoughts, so much so that simple, everyday events can seem like unendurable crises to them - at least until something happens that their perceptions of what's affecting them shifts again, such as a loved one declaring to leave or the police knocking at the door.
This is what it may be like to have the serious mental illness known as Borderline Personality Disorder. Although people newly diagnosed with BPD may think that the name implies that they're on a fine line between sanity and insanity, the name originated when psychiatrists couldn't classify people exhibiting BPD as clearly "neurotic" or "psychotic," the only two categories that existed when BPD was first characterized as a particular cluster of traits.
As it turns out, borderline personality disorder is far from insane, though a BPDer's behavior might lead people to believe otherwise. In a nutshell, they are extremely sensitive people who don't know how to regulate their overpowering emotions. This often leads to over-the-top reactions that are often made worse by people who try to help them.
Examples of how BPD people respond to their overwhelming strong emotions include the diagnostic traits above. Friends and family may see several of these:
- Acting out (such as cutting or burning themselves, reckless driving, or outbursts of anger)
- Threats to leave
- Suicidal thoughts, gestures, or attempts
- Extreme rage over seemingly minor triggering events
- Extreme anxiety over real or imagined criticisms
- Quickly changing moods - sometimes from one extreme to another within minutes
- Acting hostile or withdrawn after periods of intimacy or connection (pushing away before he or she can be rejected.)
To outsiders, a person with BPD may seem perfectly normal. They can't see the inner turmoil of a person who literally feels like they do not exist or fit in anywhere.
This in-depth video consists of three BPD patients as they review their own thought processes and behaviors, with commentary from their loved ones and their doctors, to explain what it's like to cope with borderline personality disorder as an afflicted person or as a loved one. Although the video's statistic that BPD affects 1% of the population may be incorrect (further studies sponsored by the National Institute of Mental Health show that up to 6% of people meet the diagnostic criteria), you'll discover that BPDers are not "crazy" but that their methods are actually quite effective ways of responding to what their brains are doing.
BPD and the Brain
At least one study using magnetic resonance imaging (MRI) indicated that the brain functions differently in people with BPD. They do not process emotions the same way - possibly due to having different density of gray matter.
BPD is a complex illness. Treatment may include:
- Talk therapy (DBT, mentioned earlier, is considered the "gold standard" of BPD treatment)
- Group therapy
It is expected that treatment will take at least a year, and the quality of therapist-to-patient relationship is extremely important. Because it is challenging to treat, many insurance companies don't want to see this diagnosis!
Instead of simply accepting in insurance company's refusal, research your policy and remind them that they'll pay for treatment one way or another: Many BPD people end up in emergency rooms for suicide gestures or for accidents resulting from risk-taking, and then get referred to in-patient treatment anyway. Wouldn't it be better to prevent that?
Compassion is an Important Key for Coping with BPD
The book and workbook (below) are best used together. People who love someone with BPD rave about how helpful Mason & Krieger's books have been for them.
This outstanding resource can be helpful for both BPD and bipolar disorder if your loved one is receptive to using it. It can be used independently or in conjunction with therapy. It provides an online therapy program that can be used when local treatment may be difficult to find.
BPD Over Time
By the time a person reaches their 40s, BPD symptoms often fade on their own, but they may never disappear completely. Both BPDers and loved ones should understand that emotional stability can still be extremely hard to achieve even if symptoms improve. That's why it's so important to find the kind of treatment that can work best for learning emotional management.
Dealing with Borderline Personality
Although science cannot point to a definitive cause of BPD, it has been proven that people with BPD have different responses in their brain to perceived rejection or criticism. Studies have shown that a childhood history of abuse or neglect is frequently present, but many people with BPD grew up in stable homes. A recent study suggests that certain chromosonal influences can influence whether a person develops BPD, but most experts believe it's a combination of genetics and environment.
One study points to a link between gray matter density and emotion regulation in people with BPD. The brain is literally constructed somewhat differently than it is in people who have better control over their emotions.
The one element that is universally persistent in people with BPD is a feeling of being invalidated. In order to help a person with BPD manage their emotional state, both therapists and loved ones must recognize this critical fact.
Ironically, that same element is what makes treatment challenging!
How do you tell an unreasonable person that their viewpoint is valid, especially when you may be feeling defensive against an unfair, targeted attack against you? Sometimes a loved one tries to cope by keeping the peace and validating the attacker, and this backfires by rewarding the BPDer's unreasonable behaviors - teaching him or her that their out-of-control behavior is an effective way to cope with their overwhelming emotions.
Here are steps you can take to de-escalate arguments and help your loved one while protecting yourself and specific things to avoid:
WHAT TO DO
1. First, be aware that you're the target of the attack, but you're not the reason for it.
2. Hear them out. Let them vent all the bile and anger that's seething in them Recognize that their attacks are a way of trying to figure out who they are and how they are supposed to be, and that their attack is a sign that they trust you enough to come to you for that guidance.
3. Understand that the BPDer is driven by a need to be accepted, but expects to be rejected or invalidated. You have to find a way to show acceptance without invalidating them, but also without rewarding the things that should not be validated.
4. To do this, find one or two points that are valid about your loved one's complaints and acknowledge them out loud. Use specific words instead of vague ideas. "I would feel angry too, if I believed someone was trying to control me" is better than "I get what you're saying."
5. Avoid discussing the issues for now. Simply use the validation technique and say something like, "You are important to me and I'd like to think about what you've said for a while. Can we talk about this in a day or two?" If you believe suicidal or self-harming thoughts may be present, ask! If the person admits they're thinking about it, ask them to promise you that they will not act on those thoughts for the next thirty days. If they will not promise, consider calling the police.
6. Even though raising the subject again is probably the last thing you want to do, prepare yourself to follow through. Your BPDer is obsessing over things right now, and the next 24 or 48 hours will give them time to develop doubts about what they said. By the time you sit down to talk again, their views will be less extreme.
7. Revisit the subject after a day or two, when your loved one is not out of control, so that your BPDer knows you meant it when you said you care. When you resume the conversation, continue to use validation and affection. Provide reassurance that you love him/her and would like to see a happy resolution even if you cannot get into complete agreement. Many times, a couple of days will let the BPD person recognize where he or she was out of control and they will feel remorseful. When they realize that they didn't mean what they said, recognize that they are telling the truth as they experience it.
8. Be prepared to repeat the entire process if your loved one escalates out of control again. It can take several years to overcome BPD with proper treatment and a highly motivated patient. If your loved one is not highly motivated (which is true of most BPDers), is not in therapy, or hasn't progressed sufficiently with a therapist, it can take longer.
WHAT TO AVOID
1. When your BPDer threatens suicide or self harm, do not reward their behavior by giving them extra attention and care. Take their threats seriously, but do not allow those threats to control your responses in any way that rewards this behavior. Go ahead and remove anything that you believe might be used for such a purpose, but don't cancel your workday to stay nearby.
2. Avoid telling your BPDer that he or she is "wrong," "crazy," "out of control," or irrational. Even if you think you're being comforting, such as telling her she's beautiful when she has just said she feels fat, invalidating her perceptions can contribute to her perceptions that her opinions don't count. Try to find a way to validate her AND confront her belief at the same time, such as "I know you don't like the way your butt looks, but I think you have the sexiest legs imaginable!"
Irrational Thought Patterns in BPD - Simplified Examples
How She Interprets It
I feel ugly.
"No! You are beautiful."
"He ignores what I think."
"Well, why not start working out?"
"It's true: I'm horribly ugly."
I'm a failure.
"But you just got a promotion!"
"He doesn't pay attention to what I say."
"Well, why not go back to school?"
See? I am a failure! He never accepts me!"
Words to Live By
A gentleman who calls himself "Uptown" describes what it's like trying to meet the needs of a person with borderline personality:
"It's like trying to fill the Grand Canyon with a squirt gun."
He would know. He spent 14 years pulling the trigger. He has studied extensively on borderline personality disorder and shares his wisdom with participants in the online Talk About Marriage forum.
Coping with Suicide Threats
- Suicide Assessment Checklist
Learn how to help a suicidal friend before you ever find yourself in this dilemma. Thousands of people are affected every year by suicides. Learn how to evaluate risk and take practical steps to help the people you care about.
General Lifestyle Considerations
Because a person with borderline personality literally doesn't know where they fit in this world, it's important for them to find ways to instill meaning into their lives. An active lifestyle that exposes them to other people is especially valuable. Consider doing some of these activities together to ensure that your lives are filled with meaning and avoid the nagging doubts that haunt the BPDer:
- Group sports
- Social club memberships
- Mentoring others
Also, because people with BPD struggle to keep their emotions stable in the first place, introduce as much routine as possible in your lives with regular mealtimes and bedtimes, and comforting rituals like pet names for each other or daily "together" time - even if it's just five or ten minutes devoted completely to one another.
Living with BPD is not easy. Leaving may be the best choice for you. You are not ultimately responsible for anyone else, especially if that person isn't working on being responsible for themselves. However, if you have reason not to leave, putting these techniques into practice is likely to make your life easier.