The Essential Family Guide to Borderline Personality Disorder

by Randi Kreger

  People with BPD feel the same emotions that we all do. The difference is the intensity of their emotions. On a scale of 1 (extreme negative feelings) to 10 (extreme positive feelings), the scale runs from an impossible 0 to 11.

  Shame, a hallmark of BPD, is an inner sense of being completely diminished or insufficient as a person. A shame-based person feels fundamentally inadequate, defective, and unworthy—not for anything they do, but just for existing.

  Impaired Behavior

  The DSM traits having to do with actions are impulsivity in areas that are potentially self-damaging; recurrent suicidal or self-harming behavior; and difficulty controlling anger.

  Add to this putting others in no-win situations, criticism, blame, creating chaos, and all the other behaviors that make you feel as though you’re walking on eggshells, and you have the king of BPD traits: DSM-IV-TR number 2, “A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.”

  Other BPD Traits

  Some other BPD traits are as follows:

  Not Telling the Truth

  While no one has done formal research on people with BPD and lying, anecdotally, family members say it is a major concern—especially for parents. One non-BP blogger found that 20 percent of the searches on the site for family members had to do with lying.

  People with BPD may tell lies consciously (as we all do, sometimes), unconsciously, or somewhere in between. Some statements start out as deliberate lies; over time, they’re recollected as the truth. Some statements may not be lies as much as they are blowing the truth out of proportion. They seem to happen more when the BP is under stress. Lying might serve to

  • deflect shame when something might make them look bad, thereby increasing their shame. Angelyn Miller says, “People who feel unworthy believe they have to say all the right things, true or untrue, so they can appear better or different than they really are. People with high self-esteem don’t feel like they have to create a cover. If they make a mistake, their own sense of worthiness allows them to admit it because they know everyone makes mistakes.”7

  • quell the fear that if non-BPs knew the truth, they would reject the BP.

  • create drama and gain attention.

  • mask real feelings and put up an impressive facade.

  • help make sense of why things happen to them in their mixed-up reality.

  A husband says:

  After denying it for months, she finally admitted she had gotten us seriously in debt. When I asked her follow-up questions, I was met with more lies. Once she realized I had the actual bills, they turned into partial lies. Then she told me she promised to never lie again. When she did lie again, I totally lost my trust in her.

  Need for Control

  People with BPD try to seize control of situations and other people to make their own chaotic world more predictable and manageable. Things that threaten the BP’s sense of control—as irrational as that sense of control may be—will be met with resistance. If you refuse to go along with your family member’s wishes, she may accuse you of wresting control from her. And she believes it. This dynamic ensues quite frequently when non-BPs try to set limits or to respond to provocation, even in a healthy way.

  Non-BPs everywhere experience these controlling tactics as manipulation. Dictionaries define manipulation as the intent to influence others by indirect, insidious, or devious means. The key word here is intent, which implies that the “manipulator” has thought through what he wants ahead of time and devised a clever scheme to get it.

  But BPs don’t think that far ahead. They’re much too impulsive to plan—they need what they need right now. They are not in stealth mode, either: they come right out and try their best to get what they need, while a true manipulator would work behind the scenes.

  Some BPs, after the immediate crisis is over, don’t realize the effects of their behavior on others. In a long “why-I-broke-up-with-you” letter to her BP ex-girlfriend, Terry, Chris writes:

  You think you have the right to be hostile to other people and treat them badly. But if they respond in anything but a kind manner, become upset or get angry back, you see it as further proof that you shouldn’t have been nice to them in the first place. You did this repeatedly to me—suddenly snapping at me for unclear or unjustified reasons, and then completely refusing to take any responsibility when I became upset.8

  Others look back and are ashamed of their actions. Their emotions are too overpowering, though, because the next time a similar situation comes up, they feel compelled to act that way again. That furthers a cycle of self-loathing.

  Types of BPs: Lower-Functioning Conventional,

  Higher-Functioning Invisible, and Combination

  BPs come in two overlapping categories, and which type you’re dealing with determines which struggles you will likely face. To be flip about it, individuals in the first category seek therapy and individuals in the second category provoke others to seek therapy. (See the chart on page 40.)

  Lower-Functioning Conventional BPs

  These are the classic borderline patients who result in the statistics you read about in chapter 1. Here are some characteristics of lower-functioning conventional BPs:

  1. They cope with pain mostly through self-destructive behaviors such as self-injury and suicidality. The term for this is acting in.

  2. They acknowledge they have problems and seek help from the mental health system, often desperately. Some are hospitalized for their own safety.

  3. They have a difficult time with daily functioning and may even be on government disability. This is called low functioning.

  4. If they have overlapping, or co-occurring, disorders, such as an eating disorder or substance abuse, the disorder is severe enough to require professional treatment.

  5. Family members’ greatest challenges include finding appropriate treatment, handling crises (especially suicide attempts), feelings of guilt, and the financial burden of treatment. Parents fear their child won’t be able to live independently.

  Because lower-functioning conventional BPs seek mental health services, unlike the higher-functioning invisible BPs we’ll talk about next, they are subjects of research studies about BPD, including those about treatment.

  Higher-Functioning Invisible BPs

  Unlike lower-functioning conventional BPs, higher-functioning invisible BPs have the following characteristics:

  1. They strongly disavow having any problems, even tiny ones. Relationship difficulties, they say, are everyone else’s fault. If family members suggest they may have BPD, they almost always accuse the other person of having it instead.

  2. They refuse to seek help unless someone threatens to end the relationship. If they do go to counseling, they usually don’t intend to work on their own issues. In couples therapy, their goal is often to convince the therapist that they are being victimized.

  3. They cope with their pain by raging outward, blaming and accusing family members for real or imagined problems.

  4. They hide their low self-esteem behind a brash, confident pose that masks their inner turmoil. They usually function quite well at work and only display aggressive behavior toward those close to them. Family members say these people bring to mind Dr. Jekyll and Mr. Hyde.

  5. If they also have other mental disorders, they’re ones that also allow for high functioning, such as narcissistic personality disorder (NPD).

  6. Family members’ greatest challenges include coping with verbal, emotional, and sometimes physical abuse; trying to convince the BP to get treatment; worrying about the effects of BPD behaviors on their other children; quietly losing their confidence and self-esteem; and trying—and failing—to set limits. By far, the majority of Welcome to Oz (WTO) members have a borderline partner.

  Recovered BP A. J. Mahari explains how higher-functioning invisible BPs live in denial:

  A borderline’s frantic search for a way to meet their need
s and avoid pain creates layers and layers of defense mechanisms—[which leads to] an unstable identity. That’s why borderlines are not aware they need help. To them, life is just as it has always been. The hurts, the problems, the torments are everyone else’s fault and/or responsibility. Many borderlines do not have any understanding or self-awareness from which to “know” that they do indeed need help.9

  Recovering BP Alice says:

  BPs can perform flawlessly, as if on stage, because they put themselves in different roles for different situations. In public, [a higher-functioning invisible BP] becomes a different person; a person who is in control and would never let borderline behaviors show because at that time, that other part of her personality doesn’t exist. The BP really believes she’s in control, so she acts in accordance with that personality.

  The performance, however, doesn’t always fool everyone forever. Something triggers the other personality, and if that trigger is strong enough, it will take precedence and the BP’s sense of control will be lost.

  BPs with Overlapping Characteristics

  Many BPs possess characteristics of both lower-functioning conventional BPs and higher-functioning invisible BPs. Author Rachel Reiland is typical of a BP with overlapping characteristics. When she insinuated she was going to shoot herself, her psychiatrist admitted her to a psychiatric hospital. Yet she held a job as a full-time mother and was active in church. Although she acted out toward her husband and psychiatrist, she was able to appear nondisordered toward most people outside her family.

  BPD in Children and Adolescents

  Dr. Blaise Aguirre, medical director of the Adolescent Dialectical Behavioral Therapy Center at McLean Hospital, Belmont, Massachusetts, says that the DSM allows for a BPD diagnosis in childhood if the patient has had the symptoms for more than a year. He has seen children as young as thirteen meet criteria for the diagnosis. Parents often identify BPD traits beginning at puberty.

  BPD symptoms in adolescents aren’t that different from those of adults with the disorder: self-injury (including piercing), drug abuse, promiscuity, rages (especially when the child doesn’t get his way), extreme overidealization and devaluation of friends and family, and ongoing thoughts of suicide or suicide attempts.

  Today, leading clinicians say that the best early intervention is predictable and consistent caregiving. Caregivers need to be aware of how the environment may be invalidating. For example, there might be a mismatch between how the caregiver sees the world and how the child sees the world. The most important thing is to close this gap—not by blaming the parents or the child, but by recognizing the problem and working with a family therapist who is familiar with BPD dynamics. This message desperately needs to get out to the rank-and-file therapists who are out of date with current research.

  BPD Diagnosis in Men

  The DSM says that the percentage of men with BPD is 25 percent, or one out of every four people with BPD. The percentage may be higher—half of the non-BPs on the WTO groups for partners are women. (Frequently, their male partner has BPD with co-occurring narcissistic personality disorder.) Yet we know very little about how BPD expresses itself in men or if treatment programs designed for women are as effective for men. Why do we know so little about borderline men? Several reasons:

  Men Seek Professional Help Less Often

  Research has shown again and again that men won’t even seek treatment for less complex but equally serious mental health problems such as depression, let alone a stigmatized disorder like BPD. Many men see it as “unmanly” to acknowledge feelings, especially the vulnerability and abandonment fears associated with BPD.

  Clinician Bias

  One study found that when fifty-two professionals from a mental health agency in California assessed patient vignettes, they were unable to accurately diagnose the presence of BPD in males—even though the symptoms were identical to those in vignettes of females.10

  These results help explain the way anger is interpreted differently depending upon whether it comes from a man or a woman. “For the most part, when women are angry they are classified as irrational, frenzied, or too emotional,” says therapist Andrea Brandt. “On the other hand, men’s anger is sometimes recognized as strength and aggressiveness.”11

  Cultural Influences

  Men are socialized not to expose their fear of abandonment or other emotional vulnerabilities, which are hallmarks of BPD. They are supposed to be macho and fearless, sexual studs seeking the maximum number of sexual conquests with a minimum of commitment. And if he does get “roped” into marriage, he’s the one who’s supposed to be on top, for fear of being called “whipped.”

  Most of all, if he’s not as confident as he “should” be, or if he’s feeling alone, depressed, or scared, by the Male Code he is not supposed to let these feelings show. He is, however, permitted anger. In some circumstances, beating someone up is even the righteous thing to do.

  Borderline Men and Domestic Violence

  Imagine you’re a man whose greatest fear in the world is being abandoned, second only to the terror of looking into the mirror and seeing an empty, worthless self looking back. Imagine how hard it would be to share these emotions with the people you fear will reject you, let alone to admit you need professional help.

  Those feelings have to go somewhere. Some men use the same outlets as borderline women do, such as making suicide threats. A great many of them (perhaps even more than women) anesthetize themselves with alcohol and drugs such as cocaine or methamphetamine. A subset, however, channel their feelings into their more socially acceptable cousins, rage and aggression.

  Both men and women can express their fear of abandonment as physically aggressive rage toward the “cause” of their distress. However, men’s level of violence is often more lethal. A perceived betrayal or a real or imagined act of abandonment may trigger acting-out activities such as kicking down a door, forcing sexual activity, blocking the partner’s escape, and threatening the partner with a weapon. Some are involved in controlling and stalking behaviors, such as tapping phones, installing secret cameras, and hiring private detectives.

  This aggression often results in a misdiagnosis of antisocial personality disorder (sociopath) or, in adolescents, a conduct disorder. As a result, these men don’t get the right treatment. What they do get is incarcerated. As a matter of fact, so many males with BPD have been incarcerated that a form of therapy for BPD, dialectical behavior therapy, has been adapted for male offenders in correctional settings.12

  Sexual Acting Out

  Mary Gay, a therapist who treats many men with BPD, finds that borderline men frequently engage in addictive, sexually compulsive behaviors, including regularly hiring prostitutes, having serial affairs, going to strip clubs, obsessively viewing pornography, engaging in voyeurism or exhibitionism, and compulsive masturbation.13

  One borderline man used high-risk sex as his form of self-harm. He says:

  The out-of-control sex was something I hated myself for, it was obsessive, it felt like an invisible hand grabbing me by the collar and dragging me off to do whatever. I needed to cause enough pain and degradation to myself. The incredible guilt of the risks I was exposing my partner to really destroyed something inside me. But when the inner loneliness was strongest, sex was the only thing that would quiet the fear.

  Older People with BPD

  Experts differ on whether people with BPD “grow out of BPD” when they get into their fifties and above. The popular thinking is that they do. But that is not the last word. Jim Breiling, PhD, from the National Institute of Mental Health, says that while some studies show that age has a mellowing effect, much more research needs to be done.14

  Co-occurring Disorders

  Most people with BPD have what is known as a co-occurring illness; that is, another brain disorder in addition to BPD. Each complicates the other.

  According to the National Alliance on Mental Illness, depression is the most common co-occurring disorder (up to 70 perce
nt; however, other sources believe it’s almost universal). Following are substance abuse (35 percent), eating disorders (25 percent), narcissistic personality disorder (25 percent), and bipolar disorder (formerly called manic-depression) (15 percent) and histrionic personality disorder (unknown).15

  Depression

  Depression, which is nearly universal in those with BPD, can make BPD more difficult to treat, especially if it is severe. Symptoms of depression include feelings of overwhelming sadness; fear of abandonment; loss of energy; and intense feelings of guilt, nervousness, helplessness, hopelessness, and worthlessness.

  Substance Abuse

  Nearly one-third of people categorized as having a substance use disorder (abuse of or dependence on alcohol or other drugs) also have BPD. Conversely, more than half of those with BPD also have a substance use disorder. Their drugs of choice can include everything from alcohol and prescription drugs to illegal drugs such as cocaine and crystal methamphetamine.

  Substance abuse and dependence are disorders unto themselves, but they are also part of the DSM-IV-TR definition of BPD (trait 4, impulsivity in at least two areas that are potentially self-damaging). BPs may use alcohol and other drugs to temporarily relieve emotional pain. Many clinicians who specialize in substance use disorders see the primary problem as the substance abuse or dependence and may not be aware that BPD is an underlying factor.

  BPs who abuse chemicals have a marked decrease in the effectiveness of both medications and psychotherapy and an increased risk of suicide attempts and other severe psychiatric problems.16 If borderline patients undergo treatment only for substance dependence and not the underlying BPD, they may be more prone to relapse or may put another unhealthy coping mechanism in its place. In a presentation to Congress, psychiatrist Robert Friedel said that patients should first get treatment for substance dependence before addressing BPD. Otherwise, there is little to no hope of gaining control over BPD.17

  Eating Disorders

  While substance abuse is significantly more common among borderline men than women with the disorder, eating disorders (particularly bulimia) are more prevalent among women.18