Indicators of BPD
Is someone you care about causing you a great deal of pain?
Do you find yourself concealing what you think or feel because you're afraid of the other person's reaction or because it just doesn't seem worth the horrible fight or hurt feelings that will follow?
Do you feel that anything you say or do will be twisted and used against you? Are you blamed and criticized for everything wrong in the relationship-even when it makes no logical sense?
Are you the focus of intense, violent, and irrational rages, alternating with periods when the other person acts perfectly normal and loving? Does no one believe you when you explain that this is going on?
Do you feel manipulated, controlled, or even lied to sometimes? Do you feel like you're the victim of emotional blackmail?
Do you feel like the person you care about sees you as either all good or all bad, with nothing in between? Is there sometimes no rational reason for the switch?
Are you afraid to ask for things in the relationship because you will be told that you're too demanding or that there is something wrong with you? Are you told that your needs are not important?
Is the person always denigrating or denying your point of view? Do you feel that their expectations of you are constantly changing, so you can never do anything right?
Are you accused of doing things you never did and saying things you never said? Do you feel misunderstood a great deal of the time, and when you try to explain do you find that the other person doesn't believe you?
Are you constantly being put down? When you try to leave the relationship does the other person try to prevent you from leaving in a variety of ways (anything from declarations of love and promises to change to implicit or explicit threats)?
Do you have a hard time planning anything (social engagements, etc.) because of the other person's moodiness, impulsiveness, or unpredictability? Do you make excuses for their behavior or try to convince yourself that everything is okay?
Right now, are you thinking, "I had no idea that anyone else was going through this?"
Thoughts that may indicate BPD
Does this person:
- Alternate between seeing people as either flawless or evil? Have difficulty remembering the good things about a person they're casting in the role of villain?
- Find it impossible to recall anything negative about this person when they become the hero?
- Alternate between seeing others as completely for them or against them?
- Alternate between seeing situations as either disastrous or ideal?
- Alternate between seeing themselves as either worthless or flawless?
- Have a hard time recalling someone's love for them when they're not around?
- Believe that others are either completely right or totally wrong?
- Change their opinions depending upon who they're with?
- Alternate between idealizing people and devaluing them?
- Remember situations very differently than other people, or find themselves unable to recall them at all?
- Believe that others are responsible for their actions-or take too much responsibility for the actions of others?
- Seem unwilling to admit to a mistake-or feel that everything that they do is a mistake?
- Base their beliefs on feelings rather than facts?
- Not realize the effects of their behavior on others?
Feelings that may indicate BPD
Does this person:
- Feel abandoned at the slightest provocation?
- Have extreme moodiness that cycles very quickly (in minutes or hours)?
- Have difficulty managing their emotions?
- Feel emotions so intensely that it's difficult to put others' needs-even those of their own children-ahead of their own?
- Feel distrustful and suspicious a great deal of the time?
- Feel anxious or irritable a great deal of the time?
- Feel empty or like they have no self a great deal of the time?
- Feel ignored when they are not the focus of attention?
- Express anger inappropriately or have difficulty expressing anger at all?
- Feel that they never can get enough love, affection, or attention?
- Frequently feel spacey, unreal, or out of it?
Behaviors that may indicate BPD
Does this person:
- Have trouble observing others' personal limits?
- Have trouble defining their own personal limits?
- Act impulsively in ways that are potentially self-damaging, such as spending too much, engaging in dangerous sex, fighting, gambling, abusing drugs or alcohol, reckless driving, shoplifting, or disordered eating?
- Mutilate themselves-for example, purposely cutting or burning their skin?
- Threaten to kill themselves-or make actual suicide attempts?
- Rush into relationships based on idealized fantasies of what they would like the other person or the relationship to be?
- Change their expectations in such a way that the other person feels they can never do anything right?
- Have frightening, unpredictable rages that make no logical sense-or have trouble expressing anger at all?
- Physically abuse others, such as slapping, kicking, and scratching them?
- Needlessly create crises or live a chaotic lifestyle?
- Act inconsistently or unpredictably?
- Alternately want to be close to others, then distance themselves?
(Examples include picking fights when things are going well or alternately ending relationships and then trying to get back together.)
- Cut people out of their life over issues that seem trivial or overblown?
- Act competent and controlled in some situations but extremely out of control in others?
- Verbally abuse others, criticizing and blaming them to the point where it feels brutal?
- Act verbally abusive toward people they know very well, while putting on a charming front for others? Can they switch from one mode to the other in seconds?
- Act in what seems like extreme or controlling ways to get their own needs met?
- Do or say something inappropriate to focus the attention on them when they feel ignored?
- Accuse others of doing things they did not do, having feelings they do not feel, or believing things they do not believe?
Additional Traits Common to People with BPD
People with BPD may have other attributes that are not part of the DSM definition but that researchers believe are common to the disorder. Many of these may be related to sexual or physical abuse if the BP has experienced abuse earlier in life.
Pervasive Shame: The all-pervasive sense that I am flawed and defective as a human being. It is no longer an emotion that signals our limits; it is a state of being, a core identity. Toxic shame gives you a sense of worthlessness, the feeling of being isolated, empty, and alone in a complete sense. Non-BPs share this characteristic.
People with BPD have difficulty with personal limits-both their own and those of others. Non-BPs share this characteristic.
Borderlines may need to feel in control of other people because they feel so out of control with themselves. In addition, they may be trying to make their own world more predictable and manageable. People with BPD may unconsciously try to control others by putting them in no-win situations, creating chaos that no one else can figure out, or accusing others of trying to control them. Conversely, some people with BPD may cope with feeling out of control by giving up their own power; for example, they may choose a lifestyle where all choices are made for them, such as the military or a cult, or they may align themselves with abusive people who try to control them through fear. Non-BPs share this characteristic.
Lack of Object Constancy
When we're lonely, most of us can soothe ourselves by remembering the love that others have for us. This is very comforting even if these people are far away-sometimes, even if they're no longer living. This ability is known as object constancy. Some people with BPD, however, find it difficult to evoke an image of a loved one to soothe them when they feel upset or anxious. If that person is not physically present, they don't exist on an emotional level. The BP may call you frequently just to make sure you're still there and still care about them. (One non-BP told us that every time her boyfriend called her at work, he introduced himself using both his first and last name.)
Many individuals have noticed that some people with BPD have an amazing ability to read people and uncover their triggers and vulnerabilities. One clinician jokingly called people with BPD psychic.
Some people with BPD are competent and in control in some situations. For example, many perform very well at work and are high achievers. Many are very intelligent, creative, and artistic. This can be very confusing for family members who don't understand why the person can act so assuredly in one situation and fall apart in another.
Some people with BPD frequently bring the focus of attention back to themselves. They may react to most things based solely on how it affects them.
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
- 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:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
- 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.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- 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).
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- 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).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- 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
- 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.
Common "games" between BPs and Non-BPs
Feelings Create Facts
In general, emotionally healthy people base their feelings on facts. If your dad came home drunk every night (fact) you might feel worried or concerned (feeling). If your boss complimented you on a big project (fact) you would feel proud and happy (feeling).
People with BPD, however, may do the opposite. When their feelings don't fit the facts, they may unconsciously revise the facts to fit their
feelings. This may be one reason why their perception of events is so different from yours.
Splitting: (I Hate YouDon't Leave Me)
People with BPD may have a hard time seeing gray areas. To them, people and situations are all black or white, wonderful or evil. This process of splitting serves as another defense mechanism. Peter, who has BPD, explains: "Dividing the world into good or evil makes it easier to understand. When I feel evil, that explains why I am the way I am. When you are evil, that explains why I think bad things about you."
Tag, You're It : A Game of Projection
Some people with BPD who act out may use a more complicated type of defense mechanism we've named it "Tag, You're It"- to relieve their anxiety, pain, and feelings of shame. It's more complex because it combines shame, splitting, denial, and projection.
People with BPD usually lack a clear sense of who they are, and feel empty and inherently defective. Others seem to run away from them, which is lonely and excruciatingly painful. So borderlines cope by trying to "tag" or "put" these feelings onto someone else. This is called projection.
Projection is denying one's own unpleasant traits, behaviors, or feelings by attributing them (often in an accusing way) to someone else. In our interview with Elyce M. Benham, M.S., she explained that projection is like gazing at yourself in a hand-held mirror. When you think you look ugly, you turn the mirror around. Voila! Now the homely face in the mirror belongs to somebody else.
Sometimes the projection is an exaggeration of something that has a basis in reality. For example, the borderline may accuse you of "hating" them when you just feel irritated. Sometimes the projection may come entirely from their imagination: for example, they accuse you of flirting with a salesclerk when you were just asking for directions to the shoe department.
The BP's unconscious hope is that by projecting this unpleasant stuff onto another person-by tagging someone else and making them "it" like a game of Tag the person with BPD will feel better about themselves. And they do feel better, for a little while. But the pain comes back. So the game is played again and again.
Projection also has another purpose: your loved one unconsciously fears that if you find out they're not perfect, you will abandon them. Like in the Wizard of Oz, they live in constant terror that you'll discover the person behind the curtain. Projecting the negative traits and feelings onto you is a way to keep the curtain closed and redirect your attention on the perfect image they've tried to create for themselves.
How can people with BPD deny that they are projecting when it is so obvious to everyone else? The answer is that shame and splitting may combine with projection and denial to make the "Tag, You're It" defense mechanism a more powerful way of denying ownership of unpleasant thoughts and feelings.
Some adults who enter into relationships with borderlines feel brainwashed by the BP's accusations and criticisms. Says Benham: "The techniques of brainwashing are simple: isolate the victim, expose them to inconsistent messages, mix with sleep deprivation, add some form of abuse, get the person to doubt what they know and feel, keep them on their toes, wear them down, and stir well."
Everything Is Your Fault
Continual blame and criticism is another defense mechanism that some people with BPD who act out use as a survival tool. The criticism may be based on a real issue that the person with BPD has exaggerated, or it may be a pure fantasy on the borderline's part.
Family members we interviewed have been raged at and castigated for such things as carrying a grocery bag the wrong way, having bed sheets that weighed too heavily on the BP's toes, and reading a book the BP demanded they read.
One exasperated non-BP said that if by some chance he didn't make an unforgivable error one day, his wife would probably rage at him for being too perfect.
If you object to the criticism or try to defend yourself, your loved one may accuse you of being defensive, too sensitive, or unable to accept constructive criticism. Since their very survival seems to be at stake, they may defend themselves with the ferociousness of a mother bear protecting her cubs. When the crisis has passed and the person with BPD seems to have won, they may act surprised that you're still upset.