We’re going to hit up the DSM-5-TR and explore the criteria for BPD.
There’s a lot of stigma around borderline personality disorder, or BPD, which may discourage those suffering from seeking treatment. In this episode, learn the criteria for BPD and effective treatments for it.
Savvy Psychologist is hosted by Dr. Monica Johnson. A transcript is available at Simplecast.
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Whenever you hear about Borderline Personality Disorder, it’s almost always in the worst or most extreme of situations. This leads to a lot of stigma surrounding the diagnosis. If you’re curious about the actual criteria for BPD and if there are effective treatments for it, you’ll want to listen to this episode.
Welcome back to Savvy Psychologist. I'm your host, Dr. Monica Johnson. Every week on this show, I'll help you face life's challenges with evidence-based approaches, a sympathetic ear, and zero judgment.
I have spent a lot of my career working with folks that have diagnosed personality disorders and I can tell you firsthand that there is a range of severity. There are people with personality disorders that you would never guess and it affects people from all walks of life. I have worked with individuals who are incarcerated, homeless, wealthy, and famous, and regardless of your station in life, untreated mental illness can steal joy and peace from you. As always, if anything I speak about here sounds familiar to you, seek professional services.
Now we’re going to hit up the DSM-5-TR and explore the criteria for BPD.
The first criteria is frantic efforts to avoid real or imagined abandonment. Individuals with BPD often experience intense fears of being abandoned or rejected, leading to desperate attempts to prevent it. These abandonment fears are related to an intolerance of being alone and a need to
have other people with them. They may go to extreme lengths to maintain relationships, even when they are unhealthy or detrimental. In popular culture, we most often think of Glenn Close in Fatal Attraction or recent celebrity news. These behaviors can also present themselves as extreme people pleasing. Many of the folks I’ve worked with that have BPD will put up with more unhealthy behaviors from partners, friends, and family members than anyone would ever suggest. What’s worse is that those with BPD often look at abandonment or being mistreated as being deserved because they are inherently “bad” or “unloveable.”
The second criteria is a pattern of unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation. Individuals with BPD may have difficulty maintaining stable and healthy relationships. They may idealize others initially, viewing them as perfect, but later devalue them, perceiving them as entirely negative or unworthy. In other words, they struggle with extremes and can vacillate between seeing someone as an angel or a demon. In the community, there is a term called favorite person, or FP for short. A favorite person is firmly situated on the idealized side of the spectrum. Most of us have identified people in our lives that we prefer to spend time with like our partners, close friends, and family members; however, with an FP, the experience is that you can’t live without this person. You may feel like you want or need to spend all your time with this person and have difficulty with boundaries. Not everyone with BPD will have a favorite person, but it is not uncommon. At times, the FP can even be the therapist and I have been in that position before.
The next sign is identity disturbance. This is defined as markedly and persistently unstable self-image or sense of self. Individuals with BPD often struggle with a consistent and coherent sense of self. They may experience frequent shifts in their self-perception, values, goals, and interests, leading to confusion and a lack of stable identity. Much of the long term work that I do with folks with BPD relates to helping them to define who they are, what is important to them, and their boundaries.
The fourth sign is impulsivity in at least two potentially self-damaging areas. BPD is associated with impulsive behaviors that may have harmful consequences, such as excessive spending, substance abuse, reckless driving, binge eating, self-harm, or risky sexual behaviors. For some, it is easy to hide these behaviors from others, particularly in unhealthy environments. For instance, I’ve worked with lawyers with BPD in the past who didn’t realize that some of their behaviors were impulsive because they were seen as normal within their communities. However, these folks were routinely drinking 5 to 7 alcoholic beverages a night and in massive credit card debt despite having six-figure salaries.
The fifth criteria is recurrent suicidal behavior, gestures, threats, or self-harming behaviors. Individuals with BPD often struggle with intense emotional pain and may engage in self-destructive behaviors, such as self-harm or suicidal behaviors. These actions are often a response to overwhelming emotions and a desperate attempt to alleviate distress.
The next criteria is affective instability due to marked reactivity of mood. Individuals with BPD experience significant emotional dysregulation. Their moods can fluctuate rapidly and unpredictably, leading to intense and unstable emotional states. They may experience intense periods of dysphoria, irritability, or anxiety, often triggered by external events. When you have BPD, you can feel like a raw nerve and even a gentle breeze can set you ablaze with sensory overload.
If you have BPD, you may also experience chronic feelings of emptiness. Individuals with BPD frequently experience a deep and persistent sense of inner emptiness. They may feel a profound void or loneliness, even in the presence of others. This feeling of emptiness can contribute to their difficulties in forming and maintaining stable relationships. When working with one patient, I described it like a sink hole in your soul. You keep hurling things into the void hoping to hear a clink at the bottom, but all you’re given is a searing silence.
The next criteria is inappropriate, intense anger, or difficulty controlling anger. Individuals with BPD may exhibit frequent and intense episodes of anger, which may be triggered by minor events. Their anger may be disproportionate to the situation and lead to impulsive or aggressive behaviors.
Lastly, BPD can be characterized by transient, stress-related paranoid ideation or severe dissociative symptoms. Individuals with BPD may experience brief periods of paranoid thoughts or severe dissociative symptoms, particularly during times of stress. These experiences can lead to distorted perceptions of reality or a feeling of detachment from oneself or the surrounding environment.
There are effective treatments for BPD and I’ll provide examples of some in just a minute, but please remember to get assessed and discuss an appropriate treatment plan for yourself if you experience these or any other mental health symptoms.
The first treatment I’m going to talk about is Dialectical Behavior Therapy (DBT). I know I talk about it a lot, but DBT is the most widely researched and effective treatment for BPD. It combines individual therapy, skills training, and phone coaching. DBT aims to enhance emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills. For many this would be the first line treatment if you have a BPD diagnosis.
Another effective treatment is Schema Therapy. Schema Therapy focuses on addressing maladaptive cognitive schemas and core beliefs underlying BPD symptoms. This long-term therapy helps individuals identify and modify dysfunctional patterns, enhance self-awareness, and develop healthier coping strategies. SFT has demonstrated effectiveness in reducing BPD symptoms and improving overall functioning.
Mentalization-Based Therapy (MBT) is another effective treatment. MBT focuses on improving individuals' ability to understand their own and others' mental states, leading to more accurate interpretation of social cues and healthier interpersonal relationships.
The last therapy I will mention today is Transference-Focused Psychotherapy. TFP emphasizes the exploration and resolution of internal conflicts and difficulties in relationships. It aims to enhance the individual's understanding of their own and others' emotions, thoughts, and intentions.
Medications are often used as adjunctive treatments for BPD, targeting specific symptoms such as mood instability, impulsivity, and anxiety. Selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, and antipsychotics are some medications that may be prescribed. However, medication should be integrated with therapy as medication alone is not typically an effective treatment for personality disorders.
Did any of the criteria for BPD surprise you? Let me know on Instagram @kindmindpsych. You can also reach out to me via my email at psychologist@quickanddirtytips.com, or leave a voicemail at (929) 256-2191.