A borderline writes:
"Being a borderline feels like eternal hell. Nothing less. Pain, anger, confusion, hurt, never knowing how I'm gonna feel from one minute to the next. Hurting because I hurt those who I love. Feeling misunderstood. Analyzing everything. Nothing gives me pleasure. Once in a great while I will get "too happy" and then anxious because of that. Then I self-medicate with alcohol. Then I physically hurt myself. Then I feel guilty because of that. Shame. Wanting to die but not being able to kill myself because I'd feel too much guilt for those I'd hurt, and then feeling angry about that so I cut myself or O.D. to make all the feelings go away. Stress!"

Therapists use a book called "Diagnostic and Statistical Manual" (DSM) to make mental health diagnoses. They've outlined nine traits that borderlines seem to have in common; the presence of five or more of them may indicate BPD.

However, please note the following:

• Everyone has all these traits to a certain extent. Especially teenagers. These traits must be long-standing (lasting years) and persistent. And they must be intense.
• Be very careful about diagnosing yourself or others. In fact, don't do it. Top researchers guide patients through several days of testing before they make a diagnosis. Don't make your own diagnosis on the basis of a WWW site or a book!
• Many people who have BPD also have other concerns, such as depression, eating disorders, substance abuse even multiple personality disorder or attention deficit disorder. It can be difficult to isolate what is BPD and what might be something else. Again, you need to talk to a qualified professional. 

DSM-IV Definition of BPD

1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 
2. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5). 
3. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."

Following is a definition of splitting from the book I Hate You, Don't Leave Me by Jerry Kreisman, M.D. From page 10: 

The world of a BP, like that of a child, is split into heroes and villains. A child emotionally, the BP cannot tolerate human inconsistencies and ambiguities; he cannot reconcile anther is good and bad qualities into a constant coherent understanding of another person. At any particular moment, one is either Good or EVIL. There is no in-between; no gray area....people are idolized one day; totally devalued and dismissed the next.

Normal people are ambivalent and can experience two contradictory states atone time; BPs shift back and forth, entirely unaware of one feeling state while in the other. 

When the idealized person finally disappoints (as we all do, sooner or later) the borderline must drastically restructure his one-dimensional conceptionalization. Either the idol is banished to the dungeon, or the borderline banishes himself in other to preserve the all-good image of the other person.

Splitting is intended to shield the BP from a barrage of contradictory feelings and images and from the anxiety of trying to reconcile those images. But splitting often achieves the opposite effect. The frays in the BP's personality become rips, and the sense of his own identity and the identity of others shifts even more dramatically and frequently.

4. Identity disturbance: markedly and persistently unstable self-image or sense of self. 
5. 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). 
6. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 
7. 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). 
8. Chronic feelings of emptiness. 
9. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 
10. Transient, stress-related paranoid ideation or severe dissociative symptoms. 

Dissociation is the state in which, on some level or another, one becomes somewhat removed from "reality," whether this be daydreaming, performing actions without being fully connected to their performance ("running on automatic"), or other, more disconnected actions. It is the opposite of "association" and involves the lack of association, usually of one's identity, with the rest of the world.

There is no "pure" BPD; it coexists with other illnesses. These are the most common. BPD may coexist with:

• Post traumatic stress disorder 
• Mood disorders 
• Panic/anxiety disorders 
• Substance abuse (54% of BPs also have a problem with substance abuse) 
• Gender identity disorder 
• Attention deficit disorder 
• Eating disorders 
• Multiple personality disorder 
• Obsessive-compulsive disorder 

Statistics about BPD

BPs comprise: 

• 2% of the general population
• 10% of all mental health outpatients
• 20% of psychiatric inpatients
• 75% of those diagnosed are women
• 75% have been physically or sexually abused.

Types of BPD

High Functioning, Low Functioning

People with BPD vary a great deal in their functionality: that is, in their ability to live a normal lifestyle, work inside or outside the home, cope with everyday problems, interact with others, and so on.

Some people with BPD are so incapacitated by their illness that they are unable to work. They may spend a great deal of time in the hospital because of self-mutilation, severe eating disorders, substance abuse, or suicide attempts. BPD makes it very hard for them to form relationships, so they may have a weak support system. They may be so incapable of dealing with money that they have no cash for food or a place to live.

People who are close to low-functioning borderlines often find themselves living from crisis to crisis. They often feel manipulated by self-mutilation and suicide attempts. However, because the borderline is obviously ill, non-BPs usually receive understanding and support from family and friends.

High-functioning borderlines act perfectly normal most of the time.  Successful, outgoing, and well-liked, they may show their other side only to people they know very well. Although these borderlines may feel the same way inside as their less-functional counterparts, they have covered it up very well-so well, in fact, that they may be strangers unto themselves. 

Non-borderlines involved with this type of BP need to have their perceptions and feelings confirmed. Friends and family members who don't know the borderline as well may not believe stories of rage and verbal abuse. Many non-BPs told us that even their therapists refused to believe them when they described the BP's out-of-control behavior. 

Of course, there's a lot of room in between high-functioning (sometimes referred to as the "borderline" borderline) and low- functioning BPs.  Stressful life events are most likely to trigger dysfunctional coping mechanisms.

Acting In, Acting Out

Most borderline behavior is about one thing: trying to cope with internal anguish. However, people with BPD may do this in different ways. In our experience, the behavior of people with BPD tends to fall into two general categories: "acting out" and "acting in." These are not official, empirically researched categories. Rather, they are a convenient, real-world way of looking at differences.

Acting-out behaviors are attempts to alleviate pain by dumping it onto someone else-for example, by raging, blaming, criticizing, making  accusations, becoming physically violent, and engaging in verbal abuse. Acting-out behaviors cause direct anguish for friends, family members, and partners. For example, one borderline woman, Kiesha, became very angry when she felt that her husband was ignoring her at an office Christmas party. So she went up to him, threw her drink in his face, and stalked out.

Acting-in behaviors mostly hurt the person with BPD, although non-BPs are also affected. Someone with BPD who mostly acts in may feel extremely guilty over imagined transgressions. They may mutilate themselves, try to hold in their anger, and blame themselves for problems that are not their fault.  Suicide is also a possibility.

Some BPs seem to mainly act in. Some mainly act out. And some both act in and act out. Take Kiesha, for example; after she embarrassed her husband at the Christmas party, she felt very guilty. She walked home from the party, a distance of several miles. When she arrived home, she grabbed several ornaments from the tree and crushed them with her hands, causing a great deal  of bleeding.

Assumptions held by BPD sufferers

When you're interacting with someone with BPD, it's crucial to understand that their unconscious assumptions may be very different from yours.

Their assumptions may include:

• I must be loved by all the important people in my life at all times or else I am worthless. I must be completely competent in all ways to be a worthwhile person.
• Some people are good and everything about them is perfect. Other people are thoroughly bad and should be severely blamed and punished for it.
• My feelings are always caused by external events. I have no control over my emotions or the things I do in reaction to them.
• Nobody cares about me as much as I care about them, so I always lose everyone I care about-despite the desperate things I try to do to stop them from leaving me.
• If someone treats me badly, then I become bad.
• When I am alone, I become nobody and nothing.
• I will be happy only when I can find an all-giving, perfect person to love me and take care of me no matter what. But if someone close to this loves me, then something must be wrong with them.
• I can't stand the frustration that I feel when I need something from someone and I can't get it. I've got to do something to make it go away.

Keep in mind that these do not reflect the thinking of every person with BPD. You must judge what is pertinent in your individual circumstances.

Myths and Realities about BPD

Myth 1:  People with BPD never get better.

Reality: Many people with BPD report success with proper treatment.

It is true that ingrained personality traits are not easy for people to  change. But BPD behavior that has been learned can be unlearned. And many symptoms of BPD that are biological or chemical in nature can be treated effectively with medication.

Why is it, then, that this myth persists in spite of the fact that  researchers have demonstrated effective treatments? The problem is the stigma of BPD and the lack of awareness. The research on effective BPD treatment is so new that many seasoned clinicians weren't exposed to it during their training. In addition, clinicians are bombarded with contradictory research on BPD treatment, which may leave them confused about which treatment approaches are most effective. 

Since many mental health professionals find working with borderline patients arduous and exhausting, promising new studies often go unnoticed by clinicians who don't specialize in BPD. It becomes a vicious circle: clinicians don't read studies that could help them work with borderline patients because they believe that borderline patients are always going to be difficult to work with.

Another problem is that many insurance plans won't cover BPD treatment-again, because of the myth that treatment rarely works. This acts as a barrier for clinicians to learn about state-of-the-art BPD treatments. Clinicians then rely on outdated information, misleading statements, and false information about BPD they've heard from their associates. 

Myth 2:  BPD is a "wastebasket definition." Clinicians give patients this diagnosis when they can't figure out what's wrong with them.

Reality: BPD should be diagnosed only when patients meet the specific clinical criteria.

Janice Cauwels (1992) wrote: BPD is still a wastebasket diagnosis, a label slapped on patients by therapists trying to pretend that their illness is understood. It is also used to rationalize treatment mistakes or failures, to avoid prescribing drugs or other medical treatments, to defend against sexual issues that may have arisen in therapy, to express hatred of patients, and to justify behavior resulting from such emotional reactions. 

In other words, some clinicians use the word "borderline" like some schoolyard bullies use the word "cooties." But the fact that BPD is used as a wastebasket definition doesn't make it a wastebasket definition, any more  than calling grapefruit a fat burner makes it a fat burner. A patient should be diagnosed as borderline only if they meet the clinical criteria and only after a clinician has worked with the patient over time to verify that the BPD symptoms are persistent, extreme, and long standing.

Myth 3:  Women have BPD; men have Antisocial Personality Disorder.

Reality: Although BPD is diagnosed in women much more frequently, men have it as well. 

According to the DSM-IV, about 75 percent of those diagnosed with BPD are women and that most people diagnosed with Anti-social Personality Disorder (APD) are men. But although the personality disorders have some external similarities (i.e., difficulties with relationships, tendencies to blame others), their internal states are strikingly different. Borderlines feel shame, guilt, emotional distress, and emptiness; people with APD generally do not.

So why are more women diagnosed with BPD than men? No one knows, but several theories have arisen.

Theories of why BPD happens more often in women

• Sexual abuse, which is common in childhood histories of borderline patients, happens more often to women than men.
• Women experience more inconsistent and invalidating messages in this society.
• Women are more vulnerable to BPD because they are socialized to be more dependent on others and more sensitive to rejection.    
• Clinicians are biased. Studies have shown that mental health professionals tend to diagnose BPD more often in women than men, even when patient profiles are identical except for the gender of the patient. 
  
• Men seek psychiatric help less often.
• Men are more likely to be treated only for their alcoholism or substance abuse; their borderline symptoms go unnoticed because BPD is assumed to be a woman's disorder.
• Female borderlines are in the mental health system; male borderlines are in jail.
  

Myth 4: There is no such thing as BPD. 

Reality: More than three hundred research studies and three thousand clinical papers provide ample evidence that BPD is a valid, diagnosable psychiatric illness. 

Clinicians may claim that BPD doesn't exist for several reasons. They may not  have kept up-to-date with the research and are misinformed. They may believe that BPD is not a separate disorder, but part of another illness such as Bipolar Disorder or Post-Traumatic Stress Disorder. They may simply reject the idea of labeling anyone as "borderline" because they think it is too stigmatizing, or they may find nearly all psychiatric diagnoses limiting and misleading.