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Borderline Personality Disorder in Adults

Summary: All humans are social, and one of our deepest needs is to attach, or feel connected to others. It is natural then, that one of our deepest fears is lack of attachment, or rejection, or abandonment. For people with borderline personality traits, these fears become overwhelming and extreme.
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Introduction

All humans are social, and one of our deepest needs is to attach, or feel connected to others. In fact, we can’t survive without others. When we’re young, our most important attachments are to parents and adult caregivers. As we get 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.

Positives of being sensitive

  • Being sensitive may mean they can be very thoughtful and conscientious of other's feelings, which can help other's feel empathized, validated and good about themselves.
  • When in a good place, they can be extremely fun, exciting and passionate to be with.

It is normal for everyone to be sensitive from time to time.

However, in some people, their emotional sensitivity can be so extreme that it may be part of 'borderline personality disorder'.

Could My Loved One Have Borderline Personality Disorder?

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 stress 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 alcohol) 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. 

What Causes Borderline Personality Disorder? 

It is likely caused by several factors such as:

  • Genetics and temperament: Some people are simply born or “hard-wired” with a very intense emotional system, or temperament.
  • Life events. Many sensitive people have experienced situations that they have been overwhelming or stressful for them, contributing to their concerns of rejection or abandonment. This includes obviously stressful situations such as trauma or abuse. It can also include stresses such as parental separation or divorce. It can be bullying from peers. It may also simply be that the person's need for emotional validation / acceptance, was higher than that which the environment was able to provide. Some children simply have high emotional / attachment needs, and their well-meaning environment / parent(s) may simply have been unable to meet that need.

Other Conditions

People with Borderline Personality Disorder often have other conditions, like: 

  • Anxiety disorders; 
  • Substance abuse; 
  • Mood disorders (like depression); 
  • Eating disorders (usually binge eating or bulimia, but sometimes anorexia nervosa). 

It’s important to get help for these conditions as well. 

How Common is Borderline Personality Disorder (BPD)?

It is estimated that 1-2 out of every 100 adults meet the criteria for borderline personality disorder (BPD), with a similar number of men and women. However, more women than men actually seek help.  

How Is It Diagnosed?

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. 

Does It Get Better? 

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.  

How Can I Support My Loved One?

Is Your Loved One in a Calm, Logical, Rational State? (aka Green Zone)

When people are in the "green zone", they are able to reason, talk about things, and be rational (at least more than in other states). In this state, you can try some of the following things:

Do's

  • Do try to understand what helps your loved one be in a good place.
    • Physical needs include having regular routines and getting enough sleep, healthy nutrition, physical activity, outdoor time.
    • Higher needs include having people and activities in our routines that give purpose, belonging, hope and meaning.
  • Do schedule 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 you find that your loved one is expecting too much of you?
    • If so, gently set clear expectations with your loved one about what you can and cannot do, in order to avoid you from burning 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.
    • Start with loved one's perspective
      • You: "I know that you want me to spend time with you on Wednesday evenings. I enjoy those times very much."
      • You: "I'm starting on yoga class Wednesday evenings. I'll be away 6-8 PM. We can make sure we spend special time together before or after. What do you think?"
  • Do try to understand what triggers your loved one.
    • Typical triggers include times when our loved one might be wanting validation / acceptance, but we happen to give them invalidation, criticism, or non-acceptance.
      • Your loved one tries to do something nice for you (e.g. vacuum, make you dinner), and start by criticizing it.
      • Your loved one tells you something, and they want validation of their feelings, but you start by giving them advice or criticizing them.
  • Are there problems or stresses? It is in this zone that you can talk to them and try to problem-solve -- at least more easily than in other zones.

Is Your Loved One Emotionally Upset? (aka "Yellow Zone")

Life is stressful, and sensitive people can become easily triggered into a "yellow zone." During these times, they may be upset, and need emotional support -- they need "support not solutions" (aka "connection before direction").

Do's

  • Do start with "support not solutions" (aka "connection before direction".
  • Support
    • Support is about giving empathy, validation and acceptance, as opposed to starting with "solutions", which is giving advice.
      • Empathy is one of the most powerful ways to support an individual who is emotionally sensitive.
      • Your loved one: "I can't believe my friend was so mean to me today."
      • You: "I'm so sorry to hear that!" "I'm here for you... Do you want to tell me more? Or we can do something together to get your mind off it."
        • 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.
      • Don't start with advice, i.e. "Have you tried doing __?"
  • Is your loved one upset with you?
    • This might be hard, but try your best to see their perspective.
    • Example
      • You are busy with your work, and your loved one is upset that can't spend time with them.
      • Your loved one: "You just don't care!"
      • You: "I'm so sorry. You want to spend time with me, and it feels like I don't care because I'm busy with work right now..."
      • Don't get upset or critical when they are upset -- you may be absolutely correct in saying certain things, but if you do say something, better to say those things when your loved one is calmer in the "green zone".

Don'ts

  • Don't give advice unless your loved one is calm and ready for it. Or until your loved one is asking for it. All of us need to be accepted and validated. 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?”

Is Your Loved One OverWhelmed, in Fight/Flight/Freeze (aka "Red Zone")?

When people are emotionally overwhelmed, they are not able to access their logical brain, perhaps not even their emotional brain. They may be in a primitive "reptilian" brain.

Do's

  • Do give them time and space, so that their brain can calm back down into an emotional zone ("yellow zone.")
  • Do provide a calm, soothing environment, and do reduce any sensory overload, e.g. reduce sound if its too loud; dim the lights if its too bright.
  • Do talk in a calm, reassuring voice.
  • Do give eye contact which is gentle and calm, and try your best to not look aggressive or upset.
  • Do focus on doing whatever you need to do to help the person calm down.

Dont's

  • Don't talk too much when people are overwhelmed -- their brains can't process too much.
  • Don't give consequences when your loved one is overwhelmed, as they may feel threatened by it.
  • Are you upset with your loved one's behaviours?
    • Don't focus on punishment or consequences when your loved one is overwhelmed. Threatening punishment or consequences will lead them to feel threatened, which can worsen the situation. Focus on getting everyone calmed down, and logical consequences can be discussed when everyone is calm.
  • Don't be a therapist. Remembering that you are not the 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.
  • 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.

    Supporting a Loved One Who Self-injures

    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's:

    • 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 them about other family/friends, professionals (e.g. therapists) or a crisis line.
    • If your loved one has self-injured and needs require 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'ts

    • 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 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.

    Treatment

    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: 

    • Mindfulness; 
    • 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. 

     

    3. Medications

     

    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. 

    Dialectical Behaviour Therapy (DBT) Skills

    Mindfulness

     

    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 with difficult 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

    one:

    • 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. 

    Distress tolerance 

     

    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. "It's 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: 

    1. 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). 
    2. 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. 

    Positive coping 

     

    Individuals can learn many different ways to handle challenges and problems more positively. 

     

    Problem-Solving 

    • 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? 

    Grounding exercises

    • Connecting to the present moment.
    • For example:
      • “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. 

    Relaxation exercises

    • 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. 

    For More Information 

    About this Document 

    Written by Dr. 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. 

    License

    Under a Creative Commons License. You are free to share, copy and distribute this work 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/ 

    Disclaimer

    Information in this fact sheet may or may not apply to your child. 

     

    Date Posted: Jul 7, 2013
    Date of Last Revision: Nov 28, 2021