For BPD Awareness Month

May is Borderline Personality Disorder Awareness Month. I will try to post about this disorder and treatment during this month to increase awareness of this very treatable and very painful disorder.

What makes BPD so fascinating to me is that it is a disorder described as and about relationships with others. This is very different from say a mood disorder. Someone with bipolar disorder, for example, may have close friendships and romantic relationships that are healthy, and if this person has proper medication and treatment, s/he may have episodes of depression and mania that will of course have an effect on their relationships, but the disorder is a mood disorder and people experience changes in moods as severe, but they are not necessarily connected with being “set off” by relationships, personal and business. When treated, people with bipolar disorder experience stability in a way that others do; however, people suffering from BPD who are in treatment or using their treatment well, are very aware of their “triggers”, which are other people, and their own thoughts and emotions. Imagine having a disorder that involves having to be very aware of your emotions, their intensity, your emotional reactions to other people on a constant basis.

So people suffering from BPD may be prescribed all sorts of medications, which may help with anxiety and mood swings, but so far there is no single medication that can alter your way of processing emotional reactions that occur on a moment to moment basis. THis is why the disorder is described in the DSM in terms of relationships and reactions. The description of BPD in the earlier DSM IV is very different from the DSM 5, but both are relevant to explaining the experience of BPD. In DSM IV, there is a description connected to relationship and a list of criteria:

“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 Criterion 5.
-a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
-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 Criterion 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

When you see that list, it is hard to see how people used to confuse Bipolar Disorder with BPD, as there are not many similarities, other than descriptions of mood instability and impulsivity. Many people with Bipolar symptoms do not have “anger” issues at all.

The new DSM 5 describes the disorder of BPD in a different way, dividing the symptoms between “self” and “interpersonal”, which is interesting, as people with BPD describe their suffering in terms of reactions in their relationships as well as difficulties with being OK in their own skin and difficulties having a concept of their own identity that is not defined in terms of another person. In her book, “The Buddha and the Borderline,” Kiera Van Gelder describes well how she went into different personalities based on the person she was in a relationship with, changing her way of dressing, her interests, her tastes and likes and dislikes to match whoever she was in a romantic relationship with, so her sense of self was constantly in flux…

I will end with the DSM 5 description and a few comments on it:

“Self (impairment in at least 1):
Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience. To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).
Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively. To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).”

So concept of self is divided into ideas around identity and then having some kind of direction in your life that is not defined by others or simply taken on when with others, ie. studying writing because your best friend is a writer, and then when your friend ends the friendship, delving into archeology because your new boyfriend/girlfriend is studying archeology. It’s as though we all have a compass we follow in our lives to figure out where we are going or trying to go, but people with BPD find someone’s compass and follow it while being with that person, then if that relationship ends, they have no compass until they find someone else they feel close to. So, it seems to me, that it is hard to separate the self from the interpersonal with this disorder as they are so connected due to the extreme lack of self identity…

Here are the Interpersonal descriptions from DSM 5:
“Interpersonal (impairment in at least 1):
Empathy*: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on others. To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Intimacy*: Depth and duration of positive connections with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior. To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).”

The issues I have with these descriptions of interpersonal issues is that it is very tricky to describe. Many sufferers of BPD feel too much empathy with others and may be hard wired in a bad way to sense energy from others in a minute level. It’s like being a “Highly Sensitive Person” but to an extreme that causes suffering and ruins relationships. On the other hand, it is true that people with BPD have difficulty when in highly disregulated intense emotional states with having any concept of their effects on other people or even the concept of checking in with others to find out what the other’s experience of their behavior is.

There is a desire and capacity for closeness, actually often to an extreme, however it seems like what may be impaired is that the person with BPD experiences closeness as vascillating from extremes of intense merging and intimacy and intense feelings of separateness that someone with BPD experiences not as separateness but as utter extreme abandonment. You may think you had a normal phone conversation with this person, but have no idea that because you rushed off, that person is obsessing all day long about it, feeling totally abandoned like a child left in a supermarket. S/he will believe until you reassure him/her that you are dumping them and never want to see you again. While experiencing such painful searing emotions, the person cycles through extremes of anger and rage at yout for not paying enough attention to them and possibly has several extreme stories about what you did that would make no sense to you but are very real for them.

Thus, it is clear that BPD is a hellish disorder and we need to have more compassion for what people with BPD go through daily.

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