Borderline Personality Disorder in Adults
All humans are social, and one of our deepest needs is to attach, or feel connected to others. After all, we cannot survive without others. When we are young, our most important attachments are to parents and adult caregivers. As we become older, our attachments change to include friends and peers. In adulthood, it changes to focus on romantic partners.
Because one of our deepest needs is to attach, it is natural then, that one of our deepest fears is lack of attachment, or rejection, or abandonment. For people with borderline personality disorder, these fears become overwhelming and extreme.
Individuals with borderline personality disorder are very emotionally sensitive. They are especially sensitive to rejection, where they can feel rejected by others, even when the other person did not intend to reject them. This can cause problems in relationships.
When things are going well, individuals with borderline personality traits can be exciting and fun to be with. They can be very appreciative, and ‘idealize’ friends and loved ones. This can make friends and loved ones feel very important and valued.
But it’s a different story if things are not going well. If an individual with borderline personality disorder feels rejected (perhaps because of a disagreement), their feelings can change very quickly. For example:
Feelings of happiness may suddenly shift to feeling depressed and suicidal.
Appreciation may suddenly shift to anger and hatred of others.
Unfortunately, the fears of abandonment and rejection can be a self-fulfilling prophecy. Individuals with borderline personality traits fear abandonment or rejection. This leads to negative behaviours (like excessive clinginess and jealousy) that can make it difficult for to be with them..
Individuals who have symptoms of Borderline Personality Disorder tend to:
- Be very afraid of being rejected or abandoned. Because of this, they can become very clingy in relationships. They may need a lot of reassurance, which can be hard for others to understand.
- Have trouble regulating their emotions(for example, controlling intense emotions and anger). It’s natural to care about our relationships. It’s important for us to get upset if we have stresses in our relationships, because this reminds us to work out the problem. For those with borderline personality traits, their extreme emotions cause problems.
- Have impulsive and harmful behaviour. Those with borderline personality traits may turn to negative behaviours (like self-harm, or self-medicating with drugs and alchohol) to control their intense emotions. But in the long run, these negative behaviours end up causing more problems.
Symptoms seen in Borderline Personality Disorder include:
- Intense and frequent mood swings;
- Trouble managing anger;
- Feeling alone and empty inside;
- Fears of being alone, rejected or abandoned to the point where your teen makes frantic efforts to avoid being alone, rejected or abandoned;
- Relationships that go from one extreme to the other (alternating between powerful love and hate for the same person);
- Problems from impulsive behaviour (acting before thinking);
- Repeated thoughts of suicide or self-harm behaviours (like cutting).
Families of those with borderline personality traits may feel that they are ‘walking on eggshells’ much of the time.
There are many theories, but it’s likely caused by several things working together, like:
- Family history. Those with Borderline Personality Disorder seem to be born or “hard-wired” with a very intense emotional system, or temperament. This tends to run in families. For those with these traits, up to half of their family members will also have a very intense emotional system. Having just enough sensitivity in relationships is a good thing. But being extremely sensitive causes problems.
- Life events. Many individuals with borderline personality disorder have experienced some form of abuse or trauma.
People with Borderline Personality Disorder often have other conditions, like:
- Anxiety disorders;
- Substance abuse;
- Mood disorders (like depression);
- Eating disorders, (usually binge eating or bulemia, but sometimes anorexia nervosa).
It’s important to get help for these conditions as well.
It is estimated that 1-2 out of every 100 adults have Borderline Personality Disorder (BPD), with a similar number of men and women. More women see professionals for treatment, through.
If you think that you, or a loved one has many of the symptoms of Borderline Personality Disorder outlined above, then consider an assessment by a psychologist or a psychiatrist. It is better to do this as early as possible, instead of waiting for problems to get worse. Professional help can give a person the support and strategies that will help them (and their families!) to cope.
Most individuals who receive appropriate treatment will benefit and show improvement. Compared to those that do receive treatment, those who don’t get treatment are at higher risk for aggression, criminal behaviour, ongoing mental health problems, suicide, homelessness and problems in their relationships.
In adults, the symptoms of Borderline Personality Disorder (BPD) are worse in early adulthood and the young adult years. But most have more stable lives and emotions in their 30’s and 40’s.
1. Dialectical Behaviour Therapy (DBT)
In DBT, people learn to accept themselves without judgment. At the same time, they learn to find ways to change problem behaviours in ways that bring them closer to their own ultimate goals. This therapy includes education for family members. In DBT, people learn many skills to help them handle their intense emotional system including:
- Interpersonal effectiveness;
- Distress tolerance;
- Emotional regulation.
2. Psychodynamic and interpersonal therapies
It can be hard to find a therapist who is trained in DBT. But there are other types of therapy that can be helpful for those with borderline personality traits. In practice, most therapists will use a combination of therapies depending on their training, and specific situation.
There are no medications that treat borderline personality disorder specifically. But medications may be helpful for anxiety or depression that is not getting better with talk therapy.
Individuals with borderline personality traits can become “stuck” in their intense and distressing emotions, “I feel terrible; I’m such a bad person for feeling this way.”
Mindfulness meditation can help a person get “unstuck”. It can help them cope with these feelings, and give more options on how to cope, “I’m feeling terrible. Anyone would feel terrible in this situation. This is what I’m going to do about it…”
Mindfulness is one of the core strategies in DBT. It is a kind of meditation where
- Practice being in the present moment, instead of thinking or worrying about the past or future. Focusing on the body (sights, sounds, body sensations, breathing) while letting other thoughts go, can help a lot with worries.
- Learn to look at themselves and the world in a way that helps them to accept themselves, without being critical or judgmental.
For those with borderline personality traits, everyday conflicts and problems can feel like life or death situations. In these situations, individuals may tend to react quickly in ways that reduce their emotional distress. Unfortunately, these reactions don’t usually help to solve these problems in the long run.
With support, an individual can learn to tolerate intense emotional responses without doing things that will make the situation worse.
Emotional regulation is about:
- Working with emotions
- Being able to keep feelings in balance and not let them become overwhelming. This allows a person to stay calm and rational, even when faced with emotionally difficult situations.
Emotional regulation includes:
Recognizing your feelings
- E.g. “I’m feeling upset… I’m angry that my sister didn’t say hi to me in front of the other family members.”
Accepting your emotions
- E.g. "Its natural to feel upset in a situation like this."
Being able to calm down if you're too upset
- E.g. "I'm too upset to deal with this right now. I'm going to go to the bathroom and calm down before I do anything rash."
Choosing how to respond appropriately
- E.g. “Maybe she’s upset with me, or just too busy with the other guests? Either way, the safest thing to do is to be nice. When things are quieter, we can talk alone and see what’s up. Even if she is pissed off now, if I’m kind and helpful, she’ll apologize later. It won't help to get angry and upset at her."
Types of emotional regulation strategies that are taught in DBT:
- Keeping a healthy ‘emotional bank account’ by doing things that make people less susceptible to intense and negative emotions (for example, eating well and getting enough sleep).
- Thinking about whether or not feelings “make perfect sense” for the situation at hand. If they do, the person should act on these feelings. But if the feelings aren’t justified by the facts of the situation, the person can learn how to change their feelings by adopting an opposite emotion.
Individuals can learn many different ways to handle challenges and problems more positively.
- What’s the problem?
- What would I like to see happen (goals)?
- What are possible solutions to reach that goal?
- What are the pros and cons of each possible solution?
- Did it work? Should I try something else?
- Connecting to the present moment.
- “What day is it? Its Saturday."
- "Where am I? I’m in the living room."
- "What’s in the room? I see the couch, the coffee table, and my cup of coffee.”
Keeping busy (behavioural activation)
- Being passive and obsessing about stresses doesn’t help. Keeping busy with an activity can be a really positive way to handle stress.
- Deep breathing
- Progressive relaxation
- Mindfulness meditation.
Getting social support
- Spending time with family and friends.
- Reaching out to talk with people close to you during rough times.
Do understand those with borderline personality traits experience emotions (especially anger and anxiety), differently than most people. For these individuals, conflict with a loved one can feel like a life and death situation. Understand that even mild rejection, criticism or 'abandonment' can ‘trigger’ these individuals.
Do reassure your loved one about your connection when there are breaks in your connection.
- If you are close enough, then reassure your loved one often that you are and always will be ‘there’ for him/her.
Bridge any separations by talking about the reunion.
- If you have a physical separation (i.e. you have to leave), talk about the next time that you’ll be together (“I have to go now. But I'll be thinking about you, and I'll see you tomorrow.")
If you have an emotional separation (i.e. a disagreement, conflict, misunderstanding), talk about how you will get over this. ("I know you're upset at me now, and I'm sorry if I'm a bit upset too. But we'll get over this.")
Do validate your loved one's feelings. This means recognizing the feelings, and not criticizing or ridiculing your loved one for having them. You don’t have to agree with your loved one's feelings and response to a situation. You just need to show that you can see how they feel. For example, “I can see you are very worried about this”.
Do set clear expectations with your loved one about what you can and cannot do. It is important that you set limits to avoid burn out. For example, you may need to make it clear that you need a little time to yourself to recharge. Your loved one might see this as rejection. Make sure that when you talk about the separation (the times when you’re away), always talk about the reunion as well. You might say, “I’m starting a yoga class on Wednesday evenings. I need to take care of myself and stay healthy, so that I can be there for you. I’ll be away from 7-9 pm. I’ll be back home by 9:30 pm so we can spend time together then. How does that sound?”
Do arrange regular, one on one time alone with your loved one. Go for a walk, take in a movie, play a board game, bake or build something together. When you make a plan for regular ‘special time’ together with just you and your loved one, you are showing that person that you value them.
Do ask your loved one how they would like to be supported. You might say: “I’m here for you. How can I support you?” Your teen might respond in many ways, for example, “I just need someone to listen to me”, or “Let’s go out for a walk” or “I need a hug…” or “I need your advice…”.The key is to follow your loved one's lead. If your loved one can’t tell you what support would help, then you might make a make a suggestion.
Do keep regular routines as much as possible (like wake up times, mealtimes, bedtimes).
Do support your loved one's treatment. Family and friends can play an essential role to effective treatment. Help your loved one get to appointments, and take part in family education and group sessions. If your loved one gets upset:
Be there for him/her. If you can’t be there in person, connect by phone.
Let your loved one know that you can see that he’s upset, “I can see you’re having a tough time. It’s hard to be upset.”
Stay close, but don’t try to problem solve until he or she has had the time to calm down.
Once he or she is settled down, find the 'kernel of truth’ in his/her upset. Even though the other person's response was intense, it was likely not completely ‘out of the blue’. There is probably an issue that needs to be worked out.
Do give positive feedback. It is good to praise positives that you notice. At the same time, note that praise is conditional acceptance. It is also important to show unconditional acceptance, by letting the other person know that even if some things are better, it doesn’t mean that you expect everything will go well all the time.
Do remember that you are not a therapist (even if you happen to be a therapist, your role is to be a supportive family or friend in this situation). Avoid trying to ‘analyze’ your loved one. And if you’re asked for advice, just share some suggestions. Don’t be too forceful in telling your loved one what to do.
Don't give advice unless you’re asked. All of us need to be accepted and validated, and this is especially true for those with borderline personality disorder. When you give someone advice without being asked, they get the message that you don’t accept them and want them to change. If you really feel you need to give advice, then ask for permission: “I am worried about you. Can I give you some advice?” If you absolutely feel you must give advice, at least first try to figure out how your loved one is feeling, and then validate those feelings.
Don't take it personally if your loved one has an outburst or tantrum. Understand that this is part of the condition. Be patient, and stay calm. You might say things like: “I can see you’re upset.” “What’s making you so upset?” Empathize by saying things like, “Yeah, I’d be upset if that happened to me too… That’s frustrating…” Empathy is one of the most powerful ways to support an individual with borderline personality traits.
Those with borderline personality disorder often ‘self injure’, and they often do this by cutting themselves. This can be very stressful for parents and families.
Do remember that those with borderline personality traits self-injure because they are trying to cope with intense emotional pain.
Do ‘connect before directing’. You might be tempted to start with giving your loved one advice, like "You shouldn't cut, try your coping strategies instead", but it is better to connect first. Connect by asking how your loved one teen is feeling. You could also observe out loud that your loved one must be in a lot of emotional pain and are trying to cope (“I see that you’re hurting and trying to cope”).
Do understand that while it’s ideal if your loved one can confide in you, s/he may not always be able or ready to.If your loved one just can’t share thoughts or feelings with you, do remind him/her about other family/friends, professionals (e.g. therapists) or a crisis line.
If your loved one has self-injured and needs requires medical attention for the injuries (like stitches for self-cutting), then bring your loved one to medical attention, such as an emergency department.
Let your loved one know that you care and that you will be there to help with the problem when she’s ready. When your loved one is self-injuring, focus on what is causing the most immediate stress. For example, “What’s causing you to feel upset?” “What stresses are you under?” You can then help resolve some of those stresses.
Don't simply tell your loved one to stop self-injuring, or make them feel guilty about it. This doesn’t help, and will probably make things worse in the long run, because your loved one may will feel worse, and will be less likely to turn to you or share feelings with you. Besides, if your loved one could simply stop injuring him or herself, then s/he would have done so by now.
Don't take it personally. Don't say things like, “How can you do this to me?”, because it’s not about you.
Behavioural Tech is the website for Marsha Linehan, founder of Dialectical Behaviour Therapy (DBT).
NEA-BPD National Education Alliance for Borderline Personality Disorder
Written by Dr’s Deanna Mercer (Ottawa Hospital); Dr. Marjorie Robb (CHEO), Dr. Michael Cheng (CHEO) and CHEO’s Mental Health Information Committee. Special acknowledgements to the Ottawa BPD Network for their comments and suggestions.
Under a Creative Commons License. You are free to share, copy and distribute this work as in its entirety, with no alterations. This work may not be used for commercial purposes. View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/
Information in this fact sheet may or may not apply to your child.
Date of Last Revision: Oct 8, 2016