However, a diagnosis of borderline personality disorder is a little more complicated than that and due to the complex nature of the condition, it is often underdiagnosed or misdiagnosed.
Diagnosing Borderline Personality Disorder
A mental health professional (such as a psychiatrist, psychologist, clinical social worker or psychiatric nurse), experienced in diagnosing and treating mental disorders, can detect borderline personality disorder based on a thorough interview and a discussion about symptoms. Based on the information provided they will consider whether you meet criteria relevant to the disorder.
In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), there are two key features of the condition:
- Pervasive patterns of instability of interpersonal relationships, self-image, and affects; and
- Marked impulsivity that begins by early adulthood and is present in a variety of contexts.
A Sense of Abandonment
There are a number of ways these key features can manifest. For example, individuals with borderline personality disorder are very sensitive to real or imagined abandonment, and make frantic efforts to avoid it.
A perceived separation or rejection can lead to profound changes in self-image, affect, cognition, and behaviour. Individuals can experience intense abandonment fears and inappropriate anger, even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (eg sudden despair in reaction to a partner’s having to go to work unexpectedly; panic or fury when someone important to them is just a few minutes late).
The abandonment fears often come with a fear of being alone, and thus individuals may feel that they need to always be with others. Their frantic efforts to avoid being alone can include impulsive actions such as self-mutilation and suicidal behaviours.
Individuals with borderline personality disorder usually have a history of unstable and intense relationships. People in their lives may be alternatively idealised and devalued, with the switch happening quite quickly. When the other is idealised, relationships can move quite fast, with demands to spend a lot of time together, and share the most intimate of details very early in the relationship, However, they may switch quickly from idealising to devaluing, if they feel that the other person does not care enough, does not give enough, or is not “there” enough.
Another common feature of BPD, is an identity disturbance characterised by markedly and persistently unstable self-image or sense of self. Often there is not a clear idea of one’s identity which can manifest in dramatic shifts in self-image, shifting goals, values, and vocational aspirations, sudden changes in opinions and plans about career, sexual identity, values, types of friends and roles. What does tend to be consistent in individuals with BPD however, is a sense of being bad or evil. It is also common for individuals with BPD to have feelings that they do not exist at all.
To meet the diagnostic criteria for BPD, individuals must display impulsivity in at least two areas that are potentially self-damaging such as: gambling; spending money irresponsibly; binge eating; abusing substances; engaging in unsafe sex; or driving recklessly. Individuals with this disorder tend to display recurrent suicidal behaviour, gestures, or threats, and/or self-mutilating behaviour. The recurrent suicidality is often the reason that people with BPD present for help at mental health services.
Another common characteristic of BPD is unstable and reactive episodes of mood such as intense episodic dysphoria (general unease and dissatisfaction with life), irritability, or anxiety, usually lasting a few hours and only rarely more than a few days. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses and reduced capacity to regulate their emotions. The person with borderline personality disorder often has a great deal of difficulty managing their anger, and may frequently express inappropriate, intense anger that easily gets out of control. This may manifest in extreme sarcasm, enduring bitterness, or verbal outbursts. Often, such expressions of anger are followed by shame and guilt and may be interpreted as evidence to themselves that they are indeed evil.
Those with BPD may experience transient paranoid ideation or dissociative symptoms (eg depersonalisation) during periods of extreme stress, especially in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived end of the abandonment and return of the other person may result in a remission of symptoms.
Other Associated Features that may Support a Diagnosis
- Self-sabotage – Individuals may undermine themselves at the moment a goal is about to be realised (eg dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last).
- Recurrent job losses, interrupted education, and separation or divorce are common.
- Psychotic-like symptoms (eg hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress.
- Individuals may feel more secure with transitional objects (ie a pet or inanimate possession) than in interpersonal relationships.
- Physical handicaps may result from self-inflicted abuse behaviours or failed suicide attempts.
- Personal histories of physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in those with borderline personality disorder.
- Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, eating disorders (notably bulimia nervosa), post traumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personality disorder also frequently co-occurs with the other personality disorders.
What if I do get diagnosed with Borderline Personality Disorder?
A diagnosis of BPD is not a life sentence of extreme instability and mental anguish. There are several interventions that have proven effective for treating borderline personality disorder, such as Dialectical Behaviour Therapy, Cognitive Behaviour Therapy and Schema Therapy.
Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention often show improvement, beginning sometime during the first year. As many of the interventions are based on learning skills and strategies to deal with overwhelming feelings, those involved in therapy gradually improve their functioning and belief in their ability to cope.
Following therapeutic intervention, most individuals with this disorder attain more stability in their relationships and improve their job performance. Follow-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behaviour that meets full criteria for borderline personality disorder.
Greta Neilsen is a Loganholme psychologist utilising DBT Informed Therapy in her integrative approach to therapy. She endeavours to provide her clients with a safe space to understand the challenges they face, as they develop ways to overcome their difficulties.
To make an appointment with Loganholme Psychologist Greta Neilsen, please call (07) 3067 9129 or you can book online today.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington; DC.
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