If you have a loved one with borderline personality disorder (BPD), life can be fraught with crises and conflict. Here is what you should know.
Misunderstood, fearing abandonment, on an emotional rollercoaster and often suicidal – this is life for many people with borderline personality disorder, but there is treatment that offers hope and restored quality of life.
BPD is less well-known, than other mental health conditions such as depression and anxiety, but it comes with debilitating symptoms that cause significant distress and unstable relationships, for both those diagnosed and their families and loved ones.
Up to 10% of BPD patients die by suicide,[i] and at least 40% will make multiple attempts to take their own lives,[ii] while self-harming behaviour such as cutting is a common means to release their intense emotional pain.
However, psychiatrist and South African Society of Psychiatrists (SASOP) member, Dr Aneshree Moodley said long-term therapy together with the right medication, offered a lifeline for people living with borderline personality disorder. Appropriate treatment can assist BPD patients to regulate their moods, emotions and behaviour, she said.
And for those living closely with a BPD patient, there are coping strategies that can be learned, resources for information and networks for support.
One of several types of personality disorders, BPD is characterised by rigid and unhealthy patterns of thinking and behaving. Individuals with BPD have difficulty interpreting emotions and relating to people and life experiences, leading to unstable interpersonal relationships and difficulty in functioning at work and in social situations, Dr Moodley explained.
She said, as with many mental health disorders, the cause of BPD was “a combination of nature and nurture”.
“There are strong hereditary factors in the causes of most personality disorders. In terms of nurture, the individual’s early childhood environment, the form of parenting they experienced, and their early childhood development all play a significant causative role. A lot of emphasis also falls on the person’s attachment style, based on the nature of their childhood bond or connection with their primary caregiver.
“We commonly see a real or perceived sense of abandonment or rejection triggered, for example, by the death of a parent or a divorce during the person’s early childhood, which leads to the pervasive feelings of rejection or abandonment experienced in borderline personality disorder,” she said.
For people with borderline personality disorder, the fear of abandonment is deep-seated and chronic, and they will respond with intense emotion and behaviour to real or perceived rejection, she said.
Dr Moodley said it was important to distinguish between the feelings of rejection that many people experience occasionally, and the BPD patient’s “constant stream of thoughts of being rejected and abandoned” in response to everyday events.
“The BPD patient’s response is not like a once-off reaction which could be explained or contextualised by a person being under more stress than usual, for example. This is a deep fear, a regular, frequent pattern of interpreting some small incident – such as a partner being a few minutes late for a date – as utter abandonment, resulting in accusations and angry outbursts that are disproportionate to the situation.
“The person with BPD may threaten to block the other person or end the relationship, and in extreme cases make threats to self-harm or commit suicide.
“Meanwhile, the other person is often left completely befuddled because the reaction is out of all proportion. This is one of the aspects that makes it difficult to live with someone who has BPD,” Dr Moodley said.
She said feelings of rejection for individuals with BPD were a daily, if not hourly, occurrence.
“It’s constant and it’s disruptive emotionally, socially and in their work lives. They feel a constant, intense psychological sense of being emotionally tortured.”
The other core characteristics of BPD are instability in moods and emotions. The person with BPD is unable to regulate their thoughts and feelings, and many describe a sense of emptiness, hollowness or numbness.
They also display impulsive and reckless behaviour such as impulsive eating or abuse of alcohol and/or drugs, reckless driving, impulse buying, out-of-control gambling or impulsive, disinhibited sexual behaviour.
She Dr Moodley said this impulsive behaviour may be seen as an attempt to “fill the hole”, and similarly their tendency to latch onto one person and form co-dependent relationships may also be a strategy to soothe the emptiness or numbness, she said.
People with BPD tend to struggle with their sense of identity and sense of where they fit in in the world, expressing these “chronic internal battles” in frequent and often dramatic external changes, she said.
“This often an insatiable desire – they are not satisfied with just one tattoo or a hair colour change, for example. However, it is important that all factors are taken into account before making a diagnosis – just because a person changes their hairstyle often does not by itself indicate a personality disorder,” she said.
Dr Moodley said due to their fear of abandonment and emotional instability, people with BPD tended to have “rollercoaster relationships” – highly intense and extremely unstable personal, family and work relationships.
“They move from euphoric highs of idolising the other person, describing them as the ‘best friend ever’ or the ‘dream partner’. But within few hours or days, their mood may rapidly plummet to extreme lows where the other person is now the ‘worst friend ever’, the new partner is ‘the absolute pits’.”
People with BPD display “an exquisite sensitivity” in interactions with other people, she said, coming across as thin-skinned and hypersensitive to any perceived slight. At times, their response to interpersonal conflict can appear to be paranoid.
“A comment which others might disregard, may be latched on and fixated on by the BPD patient, eventually snowballing into an intense emotional response or angry outburst,” Dr Moodley said.
Unlike other personality disorders, such as narcissism, individuals with BPD do feel intense remorse, guilt and shame, deepening their fear that their behaviour will lead to further rejection or abandonment.
Dr Moodley said it was important that a medical diagnosis of BPD – or any other personality disorder – be made by a professional such as a psychiatrist or clinical psychologist, as several different conditions could have similar outward symptoms but different causes, requiring different treatment strategies.
People with borderline personality disorder often have co-morbid conditions such as depression, anxiety, substance abuse or an eating disorder, and it is therefore important to have a professional and precise diagnosis and tailored treatment programme.
Patterns of self-harm such as cutting or burning, and the high risk of suicide, are of deep concern to the person with BPD and their loved ones.
There are several reasons for self-harm or self-mutilation, Dr Moodley said.
One theory is a deep sense or need to physically feel pain.
“The individual is not able to regulate their emotions, they don’t have the skills, and they struggle to identify their emotions accurately. They often describe very intense, deep emotional pain, a feeling of a tortured mind. These acts of self-harm are at times an attempt to substitute physical pain for the deeper inner pain, to distract the mind from the storm of emotions,” she said.
Another theory is that self-harming and suicidal threats or behaviour may stem from the fear of abandonment or as a desperate attempt to control a situation in order to avoid being abandoned.
Dr Moodley said treatment for borderline personality disorder was “a long road to walk”.
Long-term medication is likely to be part of a plan tailored to the individual’s specific needs, and the mainstay would be psychotherapy or “talk therapy”, which has the strongest evidence base of effectiveness.
She said dialectical behaviour therapy (DBT), one of the most strongly evidence-based therapies for borderline personality disorder, was a specialised form of cognitive behaviour therapy specifically tailored to treat emotional dysregulation.
DBT assists individuals to learn to identify and accurately name their emotions, and to communicate how they are feeling, accurately and frequently. It also incorporates techniques of mindfulness, meditation, relaxation therapy and “grounding behaviours”, Dr Moodley said.
“Therapy for all personality disorders is long-term. Because it’s a pervasive pattern of mood dysregulation and the fear of abandonment is chronic, one can’t realistically expect oneself or a loved one to change their behaviour after only a few sessions or months.
“These are behaviours that have to be unlearnt, very slowly and over time. The person has to learn new, healthy ways of behaving, thinking and relating to the world – and, most importantly, maintain the changes.”
Patients are encouraged to lead healthier lifestyles, which also aids in symptoms of depression and anxiety, and are taught skills to regulate their moods and set up daily schedules that include putting time aside for self-care.
She said medication should ideally be prescribed by a specialist such as a psychiatrist and treatment would be specific to the individual, aiming to treat symptoms such as impulsivity or anger, as well as comorbid disorders such as depression or anxiety.
“The ultimate aim of treatment is to help the individual improve their own quality of life.”
For families or others living with a person diagnosed with BPD, she advised becoming informed about the symptoms of the condition, acknowledging them and being supportive.
“Acknowledging that the person has a real illness rather than appearing to judge them for being over-dramatic may also go a long way. The repetitive pattern of behaviour and heated interactions can wear family members down, and this is why having your own support networks is important, people you can reach out to for emotional support and advice. Depending on the severity of the case, family members may look to counselling for themselves as well.”
Dr Moodley advised calmness – “as much as humanly possible” – in the face of angry outbursts or conflict, and to learn some of the basic skills of dialectical behaviour therapy so that they can help the individual in times of distress.
“Ask if they are feeling suicidal and help them to reach out for help, for example to a suicide hotline or an online or telephone counselling service. Contact their clinical psychologist or take them to an emergency room if it seems serious.
“Help them do the exercises they are learning in therapy or to take medication – when a person is in absolute crisis, bringing them back to the coping skills they are learning is a very helpful role for a family member to take.
“In calmer times, encourage and support their health-seeking behaviours – this could mean driving them to doctors’ appointments or taking them to fetch their medication. Check in with them after their therapy appointments and ask them how the process is going for them.”
She said people living with a BPD patient should also set their own healthy psychological boundaries, because the patient themself needs to learn how to maintain boundaries.
“If the family members themselves are taught how to keep healthy boundaries, then that makes a healthier family environment for all concerned.
“Living with someone with any sort of psychological or psychiatric illness is difficult and complex. Make sure you have the support you need to help your loved one to cope, and to improve your relationships,” she said.
Information and resources for people living with BPD and their families:
South African Depression and Anxiety Group (includes contact numbers for helplines, suicide hotline etc): https://www.sadag.org/index.php?option=com_content&view=article&id=965:how-to-help-a-loved-one-with-borderline-personality-disorder&catid=17&Itemid=184
American Psychiatric Association: https://www.psychiatry.org/patients-families/personality-disorders
Borderline Personality Disorder Demystified: http://www.bpddemystified.com/
Medscape (subscription required, free): https://www.medscape.com/answers/913575-165753/what-is-included-in-the-patient-education-about-borderline-personality-disorder-bpd
[i] Paris, J. Suicidality in Borderline Personality Disorder. 2019. Medicina. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6632023/