%20(1).jpg)
Borderline Personality Disorder (BPD) continues to be one of the most misunderstood and stigmatised mental health diagnoses. Even if a client meets the diagnostic criteria of BPD, many psychologists and psychiatrists in the field will not use the diagnosis, or at the very least will not write it down, because the stigma and mistreatment in the health care field that can follow is still that bad.
BPD is a diagnosis used to describe a pattern in which someone consistently experiences instability in the areas of:
As well as significant difficulty with impulsivity in a number of areas of life.
Individuals with BPD will have at least five of the following nine symptoms:
1. Chronic feelings of emptiness
Chronic emptiness is also commonly reported in clients with Treatment Resistant Depression. It is not just feeling lonely or sad, but instead can be understood to be a persistent feeling of hollow nothingness or pointlessness. Clients of ours have described it as being wrapped in cotton wool, but rather than feeling comforting, it keeps out the good and the bad to the point where everything feels eerie and utterly meaningless. Clients describe this symptom as extremely painful and causing intense despair.
2. Emotional instability in reaction to day-to-day events (also known as emotion dysregulation)
This describes the experience of having intense shifting mood states in reaction to daily occurrences. One minute the person might feel intense sadness, irritability, anxiety, or anger, only for it to seemingly resolve hours later. These shifting mood states can be triggered by things such as being disappointed, feeling dismissed or rejected, doing something well or skilfully, or having a nice surprise. Essentially, it is how everyone feels when something good or bad happens, but to the power of ten.
Unfortunately, healthcare professionals, friends, and family may struggle to believe that the intense shifting mood states part of BPD are genuine, legitimate, and authentic. If they see someone crying heavily one minute only to be laughing with friends soon after, they might conclude that the person couldn’t have been that distressed to begin with. They might wonder, “which is the real version of the person, the crying version, the happy version, or it is all one manipulative act?” In the case of BPD, the emotional extremes are real, the shifts rapid, and the results are just as confusing for the individual. It is an emotional rollercoaster, leaving the individual feeling exhausted.
In terms of why some people experience emotions so intensely (and can have such rapid shifts between them), the science is unclear, but the current best explanation we have is an interplay between nature and nurture.
The nature element can be a genetic propensity towards intense emotions and shifting mood states. The nurture element might look like not being consistently exposed to adequate emotional validation, emotion regulation skills, or modelling of coping strategies. These can influence each other in what is known as epigenetics.
For example, a child might have “big feelings”, which an anxious parent or teacher might be overwhelmed by or see as behavioural and dismiss or ignore, which in turn can lead the child to feel misunderstood and confused and so they may escalate their attempts to communicate their distress, which can in turn lead to them being reprimanded by the parent/teacher, which may lead the child to shut down, etc.
3. Frantic efforts to avoid real or imagined abandonment
People with BPD have a deep fear of being abandoned. This can be due to past experiences of being bullied, abused, or rejected, or can come from low self-esteem and a deep fear that one is unlovable.
As the self-hatred and or/ the fear of rejection is so intense, the hypervigilance around being rejected and the attempts to avoid it are likewise, intense. This can look like:
These attempts to avoid rejection are best understood as attempts to seek connection. People with BPD may feel misunderstood, dismissed, or ignored, and so they may communicate distress to others (verbally or through behaviours) as a way to connect and feel understood. Unfortunately, these gestures are often viewed as “manipulative”, “childish”, or “attention-seeking”, leading people to respond with ambivalence or in a harsh and punishing way, rather than with warmth and compassion. This sets up a cycle in which the person with BPD feels that they are not being taken seriously, and so their attempts to be taken seriously escalate, only leading them to be misunderstood further.
For people with BPD stuck in this cycle: The reason you are feeling misunderstood is not due to the intensity of the gestures, it’s the person’s willingness to understand you and see your pain. Try to avoid continually communicating distress to people who are not equipped to support you, and instead work on identifying people (or reaching out to new ones) who are willing and able to hear and validate your distress. You will also need to work hard on validating your own distress, as no one will understand you like you do.
For health professionals/friends/family/carers stuck in this cycle: The key to breaking this cycle lies not in how you respond when the gestures are occurring, but how you respond when the gestures are not occurring. If you can consistently offer compassion and understanding (with a big emphasis on believing the person’s distress and letting them know that you believe them and take them seriously), the gestures will become unnecessary. Encourage the person to use their words, and respond exactly the same if they tell you they need support or show you (consistently showing compassion - neither increasing nor descreasing care/support).
4. Identity disturbance with extreme or persistant unstable self-image or sense of self
Identity disturbance can be understood as a profound lack of sense of self. In psychology, having a sense of self means being connected to and identifying with your thoughts, feelings, and your body. People with identity disturbance may experience:
A persistent unstable self-image describes an identity that fluctuates significantly rather than being consistent. This can look like:
Why do people with a BPD have such poor, shifting self-image? One theory as to why people with BPD have such a poor sense of self is due to numbness and emptiness that comes from chronically suppressing or detaching from painful emotions. It would be very difficult to have a fully developed, coherent sense of self if you feel you have to push down and numb highly distressing emotions on a day to day basis.
Another theory is that it arises from living with such shifting mood states, with the individual leaping from one moment to the next without the continuity of a coherent narrative identity.
5. Impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
Impulsive, risk-taking behaviours can be understood as serving a number functions. They can be:
The reason why people with BPD may use such behavioural extremes to regulate their emotions is because the emotions themselves are extreme. Practicing mindfulness, engaging in gentle exercise, and talking to a friend, are all effective in managing challenging emotions that are mild to moderate. Unfortunately, when someone is experiencing distress that is an 8/10 on the pain scale, mindfulness might not cut it - hence they are driven to extremes to regulate/distract. The more intense the emotion, the more intense the coping behaviour will be.
It is worth noting that Dialectical Behaviour Therapy (DBT) has specific skills designed for intense emotions, such as Distract with Sensations, Opposite Action, Urge Surfing, etc.
6. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
One of the intense painful emotions many people with BPD have is overwhelming anger. This anger can catch them off guard and leave them feeling out of control and overwhelmed. Below are some potential reasons why people with BPD may experience intense anger:
Suppression/Repression
One possible reason is that like with all other emotions, people with BPD experience anger to the extreme. Due to their fears of rejection and abandonment, they might suppress (consciously) or repress (unconsciously) feelings of annoyance or anger they have towards others, leading to accumulative built up anger. Eventually, this can come out in aggression (overt anger) or passive aggression (saying that everything is “fine” while communicating anger through non-verbals). Such an outburst typically leads to intense shame, and so the person “stuffs” down all the feelings, starting the cycle all over again.
Self-Hate
Clinically, we have observed that clients who have such constant, unbearable self-hate can have it come out in the form of rage toward those around them. Perhaps this is due the constant fatigue of having to mask feelings, being surrounded by people who are (or seem to be) ok, and the exhaustion of being constantly misunderstood and knowing that it is not socially acceptable to communicate the intensity of their pain.
Secondary Emotion
For some individuals, anger or rage has become a secondary emotion for them. According to DBT, primary emotions are your real emotions - your response to your internal experience or to the world around you. Secondary emotions are your emotional response to your primary emotion. Secondary emotions come about when we judge or do not accept and make room for our primary emotions.
For example, someone might feel anxious (their primary emotion). If that person struggles to accept or tolerate that anxiety, they might feel anxious about their anxiety, angry about their anxiety, ashamed about their anxiety, etc. These are all secondary emotions.
For people with BPD, persistent emotional distress might lead them to feel vulnerable and overwhelmed and result in a chronic state of rage - essentially ongoing anger towards themselves, others, or the world, in regards to their suffering and their situation.
Angry Child Mode
Another way to conceptualise intense anger in the context of BPD is through the Angry Child mode in Schema Therapy. The Angry Child mode is triggered when we feel that our needs are not being respected and we do not have the skills or confidence to make that happen. Feeling both misunderstood and ill-equipped as to how to manage being misunderstood is a common BPD experience.
7. A pattern of unstable and intense interpersonal relationships characterised by extremes between idealisation and devaluation (also known as "splitting")
Individuals with BPD tend to have become mistrustful of others due to a history of being rejected, misunderstood, or abused. They also have a tendency towards black or white (or all or nothing) thinking. Given this, when they come across a person who seems like they might actually be a safe person, they might feel intense relief and an overwhelming desire to connect deeply with that person.
For example, let’s say that a person with BPD has found a therapist that they connect with. It can feel like they have finally found someone that understands them, and there can be unconscious psychological pressure for the therapist to be the person who can meet all their needs or live up to being the ultimate person (as a way to compensate for all the hurts and the fact that they don’t have multiple people that understand them and can meet their needs).
Inevitably, as with all relationships, the therapist eventually says or does something that’s not attuned to clients needs or values. Keep in mind that people with BPD are hypervigilant to signs of rejection and tend to have black and white thinking. With this in mind, it can be extremely crushing to a person with BPD who was relying on their therapist so heavily to give them hope for humanity. They may see this as a warning sign that therapist is unsafe, therefore leading to a sudden shift in how they see the therapist. Everything the therapist said or did that was helpful or caring, might now be viewed through a new lense of suspicion.
The difficulty individuals with BPD have in forming complex, integrated views of others (with both good and part parts) can be reflected in their difficulty forming complex, integrated views of themselves (with both good and bad parts).
Part of treating BPD is working through this tendency towards extremes and developing more realistic, integrated views of the self and others. When considering if someone is safe - the question shouldn’t be, “is the person good or bad” but instead should be, “is the person helpful for me the vast majority of the time or unhelpful for me?”
8. Recurrent suicidal behavior, gestures, threats, or self-harming behavior
As listed above, people with BPD experience chronic emptiness, intense self-hate, and have generally experienced a pervasive pattern of being misunderstood. It is no surprise then, that they tend to self-harm or present with suicidal ideation and suicidal gestures. Self-harm can have a very different function from person to person. It can be impulsive and public, or planned and private. Some common reasons for self-harm are:
One other function of self-harm is through unconscious repetition compulsion - where individuals compelled to re-enact abuse. For example, if someone has chronically been mistreated, they may have the overwhelming urge to hurt themselves, “it just feels right.” For others, it may be an unconconscious way to take back control.
It is important not to view self-harm and suicidal gestures as manipulative. The word manipulative has the following connotations - calculated, devious, cold, in control, and with an intent to manipulate for bad reasons. In our experience, when people with BPD engage in these behaviours it looks just like manipulation, but it is not. Instead of calculated attempts to get control, self-harm can be more accurately understood as frantic and desperate attempts to communicate deep distress and overwhelm when there is no other effective means of doing so. The person with BPD feels anything but in control.
9. Periodic paranoid ideation or severe dissociative symptoms in the context of immense stress
Paranoid Ideation is when people experience intense suspicion regarding the motives of or intentions of others. Given the common BPD experience of chronically misunderstood, rejected, and in some cases abused, it is not surprising that in times of stress those with BPD would have great difficulty trusting others.
Roughly 75-80% of people with BPD report having experienced stress related dissociation. Severe dissociation is when there is a noticeable disconnect between one’s thoughts, emotions, behaviours, perceptions, memories, and their identity. It is highly distressing and disorienting for the individual. To learn more about dissociation - go to our page on Dissociation and Dissociative Disorders.
In summary, BPD can be understood as chronic emptiness, emotion dysregulation, and compulsive urges (see table below). It is intended to describe an illness of manipulation and attention-seeking.
We do not offer a one size fits all but instead see each client as a whole person requiring an individualised approach.
View our servicesOur psychologists and dietitian are skilled in the areas of neurodivergence, eating disorders, & complex trauma.
Meet the teamOur approach is neurodiversity affirming, trauma-informed, weight neutral, and intersectional.
Book online