Borderline personality disorder is often characterized by “splitting,” or black-or-white, all-or-nothing thinking. (Credit: TalkSpace)
This post contains discussion of abuse, self-harm, eating disorders, and suicidal ideation. The subject’s surname has been omitted for privacy. She has not been treated at Penn Medicine. If you or someone you know is in crisis, call the 24/7 toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Kristen is stuck on a roller coaster. It’s not a gentle, kid-friendly coaster with smiling animal cars and a 30-second runtime, but an intense, seemingly endless stretch of extreme hills and terrifying drops, with a safety harness that keeps threatening to snap off. The ride occasionally comes to a jarring (though much appreciated) halt, allowing her to catch her breath and take in her surroundings, but no park staff come to her rescue, and soon enough, she’s hurtling full tilt towards the next loop. Sometimes the car goes full Final Destination 3 and flies off the tracks altogether. She blacks out or dissociates, removing herself entirely from the experience – but when she opens her eyes, there’s no ride operator hustling her onto the exit platform. She’s just ascending that first hill again. And again. And again. It’s exhausting.
At 22, Kristen was diagnosed with borderline personality disorder (BPD), but as draining as her daily emotional roller coaster is, she’s equally tired of battling the stigma and the misinformation surrounding her diagnosis. Given that the U.S. House of Representatives unanimously passed a resolution back in 2008 designating May as “Borderline Personality Disorder Awareness Month,” now seems the perfect time to shed some light on this often misunderstood, yet very common mental illness.
Borderline personality disorder is characterized by a pattern of intense moods, unstable relationships, and dramatic self-image shifts. Individuals with BPD – including an estimated 1.6 percent of the adult population in the United States – often struggle with abandonment (real or imagined) and will frantically try to stave off separation or rejection, and their relationships tend to feature alternating periods of idealization (all good! best friend ever!) and devaluation (all bad! this ‘friend’ is a traitor!). Poor impulse control often leads to risky behaviors such as substance abuse and eating disorders, and recurring suicidal ideation and self-harm are very common; an estimated 10 percent of people with BPD ultimately complete a suicide attempt. Individuals’ generally dysphoric moods are punctuated by sudden, short-lived episodes of anger and other extreme emotions that can prove difficult to control, and while there are occasional periods of calm, people with BPD are often left wrangling chronic feelings of emptiness, boredom, and confusion over who they are (interests, values, plans for the future).
Those not living with BPD may be tempted to reduce these episodes of anger to “temper tantrums” or insist that everyone occasionally feels unsure of whether their friends really like them, but as Kristen summarizes, “Living with BPD is like having two states of mind: everything is perfect, or everything is horrible. I feel everything – good and bad – much more intensely and for longer periods than people without BPD, and my mood can drastically change within seconds. I feel like a light switch sometimes. In situations where there’s conflict, miscommunication, or anything I could perceive as failure – especially constructive criticism – or if I feel left out or abandoned, I immediately go into panic mode.”
Initially named because it delineated the fuzzy “border” between psychosis and neurosis, BPD is one of ten distinct personality disorders recognized by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These disorders are grouped into three separate clusters sharing similar attributes, with BPD fitting into Cluster B: Dramatic, Emotional, and Erratic Disorders – but that wasn’t always the case.
Until the DSM-5 was published in 2013, “Personality disorders and other mental illnesses weren’t kept in the same ‘bin,’ so that contributed to the perception that personality disorders were perhaps not as real or as serious – that the symptoms could be attributed to something else, or they were being exaggerated,” said Michael E. Thase, MD, a professor of Psychiatry and director of the Penn Medicine Mood and Anxiety Program. This perception spread through both the public and (regrettably) the field, perpetuating the belief that patients struggling with personality disorders were essentially “untreatable” ticking time bombs.
The DSM-5’s dismantling of its multi-axis system marked a big change, Thase noted, and now all mental illnesses, including personality disorders, have been placed in the same, equally important “bin.” However while BPD is now “one of the most well-researched disorders,” varying levels of stigma still remain, partially because of BPD’s challenging diagnosis history, and partially because its presentation in media is hardly flattering.
“If you look at movies or TV shows, individuals with borderline personality disorder are often presented as colorful, completely over-the-top characters, whose moods are all over the place, or who are inherently violent or manipulative or criminally dangerous when they’re angry,” Thase said. “One of the most famous examples is of course the ‘bunny boiler’ [played by Glenn Close] in Fatal Attraction. These very broad, prosaic portrayals should neither be seen as accurately capturing the reality of BPD, nor negate that this is a very real condition.”
Personality disorders often coexist with mood or anxiety disorders or other mental illnesses and may present overlapping symptoms, which can cause further confusion. Because Kristen presented a wide range of symptoms, it took until her third hospitalization for her symptoms to be narrowed down to BPD. A survivor of childhood abuse, Kristen often finds it “super difficult to describe my emotions; I never learned how to deal with or label different emotions. Since I was diagnosed with BPD, though, I definitely feel more at peace with myself – knowing there is an actual reason for why I think, feel, and act the way I do.”
Though Kristen’s experiences are not wholly representative of the entire BPD community, her struggles certainly provide a glimpse into the challenges associated with BPD.
“I think the most difficult part about living with BPD is the unpredictability of the disorder,” Kristen said. “I feel like Lucy [Drew Barrymore’s character from the film 50 First Dates] when she has to watch a video each morning to remind herself of her life. I will never know what kind of mood I’ll be in until I wake up.”
When she’s feeling positive, content, and structured, it’s almost as though any negatives she has experienced never happened; she doesn’t remember them in the moment. However, the same goes for volatile moods. She cannot draw from previous happy experiences to pull her out of a funk or an episode of anger because she can’t remember them while experiencing severe negative emotions. Depending on the intensity of the episode, she may develop physical symptoms like nausea, diarrhea, or vomiting, and she often feels urges to hit or punch “everything in sight – though never people,” self-harm by cutting, or restrict her food intake in order to focus on the “controlled” physical pain rather than mental pain.
Blackouts and terrifying out-of-body experiences have also occurred when her suicidal ideation reaches a critical point, and they have led to multiple hospitalizations. “It’s very scary when I lose sight of myself and no longer have control,” she said. “I spent almost a month of my life in the hospital last year because of the severity of my symptoms.”
However, though BPD is a chronic condition associated with a lifelong tendency to experience intense emotions and to behave impulsively, it’s certainly not “untreatable” despite the common misconception.
“Generally, patients with BPD are treated with a combination of coping-focused psychotherapy to help them better understand their emotions and develop strategies to manage them effectively, mindfulness, and perhaps cognitive behavioral therapy or long-term dynamic deconstructive psychotherapy,” Thase said. “Some patients may benefit from mood stabilizers, antidepressants, or antipsychotics so they can be in a more stable state for treatment. Those medications aren’t specifically for individuals with borderline, but they help to treat the coexisting conditions like depression or bipolar disorder. The hallmark of BPD is poor impulse control, so it’s also very important to work out a harm reduction plan with patients in order to help them live their best, safest lives.”
Kristen is still pushing herself to perceive the bumps in the road and the ruts she gets temporarily stuck in as learning opportunities. Struggling to comprehend and appropriately respond to complex, emotionally challenging situations can exacerbate her feelings of failure, but receiving the clarity of a diagnosis opened up doors to a treatment program that has helped her to at least more effectively strap herself into that emotional roller coaster car.
“I still worry about saying I have BPD because the stigma stresses me out. It feels like people don’t know how to interact with us. We’re often told to ‘grow up,’ but that invalidates our experiences because we can’t help the intensity of our emotions,” Kristen said. “Since the more severe symptoms tend to show around people I’m close to, it’s important for me to have people who understand the nature of the disorder and are patient. One of the most important things for me is just having people who will stay with me – through the good and bad. The more I talk about it, the more validated and free I feel.”
After all, roller coasters are much less scary when you ride with a friend.