By Dr. Jocelyn Markowicz, PhD, Psychologist

Attachment Hope for Couples: How to Improve Your Security Odds

You walk into the room and lock eyes with the most gorgeous human being you have ever seen. This individual locks eyes with you as well. You begin talking and realize that the chemistry between you is intense. You plan a date. You have several great dates. You fall in love and begin to talk about spending the rest of your lives together. You have the wedding. You go on the honeymoon. You begin to live your day-to-day lives together. (Perhaps not quite in that order.) But then, as you settle into shared lives, you notice that something is changing. The arguments are more frequent. The emotions are not all positive. Why does your partner leave when there is conflict? Why does your partner walk away when you need soothing? Why are they sometimes exhaustingly clingy and other times too independent? John Bowlby and Mary Ainsworth offered an answer rooted in attachment styles to these questions. Several researchers after them offered solutions. I’d like to share them with you. 

The Evolution of a Relationship

It is important to acknowledge that it takes time for interpersonal patterns to emerge within a romantic relationship. A perception bias occurs when you first fall in love that naturally heightens your connection to your partner’s strengths and limits your awareness of their weaknesses. Thus, it is in day-to-day living that you develop more accurate perceptions of patterns that are problematic. 

Why You Relate the Way You Do

In the 1960s, John Bowlby asserted that we learn positive and negative ways of relating based on our parent-child experiences. Our ways of relating are designed to strengthen our bond with our attachment figures (parents/caregivers) growing up. They help us survive. An attachment behavioral system gradually emerges wherein we attempt to regulate our emotions and behaviors toward an attachment figure. To do this, Bowlby (1980) asserted that the attachment system essentially asks the following fundamental question: Is the attachment figure nearby, accessible, and attentive? According to Bowlby (1980), an individual who has experienced a secure attachment is likely to view attachment figures as available, responsive, and helpful. An insecurely attached individual would view attachment figures as inaccessible, untrustworthy, and unreliable.

Different Attachment Styles

Ainsworth expanded on Bowlby’s attachment behavioral system and introduced specific attachment styles that explain our attachment behaviors. She outlined three specific attachment styles: (1) secure attachment and two insecure attachment styles: (1) anxious-resistant, and (2) avoidant (Ainsworth, 1979). In adult romantic relationships, the insecurely attached adult who is anxious-resistant would be dependent on their partner and yet reject their soothing attempts. The insecurely attached adult who is avoidant would not seek emotional or physical comfort from their partner when experiencing emotional distress. 

Bowlby and Ainsworth helped us to understand that our way of relating to others is guided by our early attachment experiences, but do we indeed exhibit the same attachment behaviors in our adult romantic relationships?

Further Research into Attachment Styles 

Hazen and Shaver (1987) evaluated Bowlby’s theoretical premise that early attachment behaviors extend to adulthood and are relatively stable. They conducted research and found that adults also reported the three attachment categories that Ainsworth determined (secure, anxious-resistant, and avoidant). Their research identified that romantic relationships are attachment bonds and share similar attachment behaviors that characterize parent-child interactions. In essence, Bowlby and Ainsworth were right to suggest that we can look at our adult relationships and evaluate our partner’s attachment behaviors based on their childhood attachment experiences. 

Are People Stuck Forever in Patterns from Childhood? 

What happens if you partner with someone with an insecure attachment style? Can their attachment style become secure? 

Researchers had the same questions about whether or not early attachment behaviors could be changed in adulthood. Findings across several studies did indicate that while early attachment style is relatively stable (Kim, Baek, & Park, 2021), attachment behaviors can change (Tmej, AMA et al., 2020; Sims, 2000; Rimane, Steil, Renneberg, & Rosner’s, 2020; Overall, Simpson, & Struthers, 2013; Gazder & Stranton, 2010; Park, Johnson, MacDonald, & Impett, 2019). Therein lies the hope for the couple. So, back to the question, what happens if you partner with an insecurely attached individual? How can you increase your secure attachment odds in your relationship?

Distress in romantic relationships is the leading cause for adults to seek psychological services (Bradbury, 1998). There are specific interventions that increase attachment security or reduce the negative impact of insecure attachment behaviors in romantic relationships. The following interventions are supported by empirical examination.

Transference-Focused Therapy

Transference-focused therapy (TFT) is a therapeutic intervention that aims to reduce impulsivity, stabilize mood, and improve interpersonal and occupational functioning. The intervention is specifically designed for individuals who struggle with borderline personality disorder. Trauma can impact the internalized representations of personality. It is not uncommon for individuals to develop maladaptive personality traits in response to trauma. Trauma impacts attachment bonds. TFT is a great choice for an individual partner in a couple dyad who may also struggle with borderline personality. A recent study found that individuals who participated in TFT moved towards securely attached with some preoccupied behaviors away from insecurely attached with preoccupied behaviors (Tmej, AMA et al., 2020)

Emotionally Focused Therapy

Emotionally focused therapy (EFT) for couples focuses on reshaping distressed couples’ structured, repetitive interactions and the emotional responses that evoke partners and foster the development of a secure emotional bond (Jonson, 1996; Jonson, 1999). The EFT model assumes that the negative emotions and interactional cycles typical of distressed couples represent a struggle for secure attachment (Bowlby, 1969). Sims (2000) randomized 26 couples in which at least one partner had been rated as insecurely attached to EFT or a waitlist control group. Couples in the EFT treatment condition increased their attachment security (and decreased attachment-related avoidance) more than the control couples. 

Trauma-Focused Cognitive Processing Therapy

Trauma-focused cognitive processing therapy (CPT) focuses on changing the dysfunctional beliefs associated with trauma. Trauma during our early attachment years impacts our attachment functioning, thereby shaping how we related to others in romantic relationships. CPT offers hope for couples in that an insecurely attached partner, who has been the victim of trauma, can participate in this mode of treatment to improve functioning. In Rimane, Steil, Renneberg, and Rosner’s (2020) study, individuals who participated in CPT experienced reduced avoidance attachment (insecure) behaviors when assessed post-treatment.

Dyadic Regulation Processes

Dyadic regulation processing occurs in couples therapy and is designed to improve attachment-relevant dyadic interactions between them. Applying the Dyadic Regulation Processing Model, researchers evaluated how partners can buffer the impact of their partner’s anxious resistant or avoidant behaviors due to their insecure attachments. Overall, Simpson and Struthers (2013) videotaped romantic couples discussing relationship problems identified by one partner who wanted changes in the other partner. Results indicated that insecurely attached partners whose partners displayed more softening exhibited less anger and withdrawal, and their discussions were more successful. These partners buffered their insecurely attached partner’s responses by learning to be sensitive to their autonomy needs, validating their viewpoint, and acknowledging their constructive efforts and good qualities.

Partner Relationship Mindfulness

General mindfulness is defined as the awareness of what is happening in the moment. In their study, Gazder and Stranton (2010) defined relationship mindfulness (RM) as open or receptive attention to and awareness of what is taking place internally and externally in a current relationship. They found that an individual’s own daily relationship mindfulness did not buffer the effects of their own insecure attachment on same-day relationship behaviors, but their partner’s daily relationship mindfulness did. In essence, you can buffer the impact of your partner’s insecure attachment behaviors by increasing your own relationship mindfulness. Therapy is a great place to learn how to practice relationship mindfulness techniques.

Partner with Someone with a Secure Attachment Style

As outlined, various treatment interventions can move an individual and couple towards more secure attachment relating. At this point, you may be thinking that hope is only achieved within a therapeutic setting. I have good news for you. If you are a securely attached individual, you play an important role in your relationship with an insecurely attached partner. Experiencing secure behaviors within romantic relationships can reduce representations of insecure attachment style (Park, Johnson, MacDonald, & Impett, 2019). How romantic! Your secure attachment behaviors can provide a secure base for your insecurely attached partner to grow. In the context of your relationship, you and your partner will experience many life events together. In their most recent study, Fraley, Gillath, and Deboek (2020) found that life events could change attachment style presentations in adulthood, with some changes yielding an enduring pattern.  

What Lies within Our Power?

We cannot go back to our childhood and choose caregivers that would prevent us from developing an insecure attachment style. We, therefore, cannot prevent the impact of any dysfunctional early childhood attachment experiences on who we are, interpersonally, as adults. However, there is hope. We can increase our secure attachment odds by choosing partners who are securely attached. We can participate in couples therapy interventions. We can also offer a secure attachment base for our insecurely attached partner. Attachment styles do not equate to fixed potential in your relationship – there is always room for growth. 

If you’re ready to explore how therapy can help you and your relationship, click through to find a couples therapist near you.

References

Ainsworth, M. D. S. (1979). Attachment as related to mother-infant interaction. In Advances in the study of behavior (Vol. 9, pp. 1-51). Academic Press.

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.

Bowlby, J. (1980). Loss: Sadness & depression. Attachment and Loss (vol. 3); (International psycho-analytical library no.109). London: Hogarth Press.

Bradbury, T. N. (1998). The developmental course of marital dysfunction. New York: Cambridge University Press.

Gazder, T. & Stanton, S. C.E (2020). Partners’ Relationship Mindfulness Promotes Better Daily Relationship Behaviors for Insecurely Attached Individuals. Int J Environ Res Public Health. 5;17(19):7267.

Hazen, C., & Shaver, P.R. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511-524.

Johnson, S. (1996). The practice of emotionally focused marital therapy: Creating connection. New York. Brunner/Mazel.

Johnson, S. (1999). Emotionally focused couples therapy: Straight to the heart. 

In J. Donovan (Ed.), Short term couple therapy (pp. 14-42). New York Guilford Press.

Fraley, R.C., Gillath, O. & Deboeck,P.R.(2020, August13).Do Life Events Lead to Changes in Adult Attachment Styles? A Naturalistic Longitudinal Investigation. Journal of Personality and Social Psychology. 

Kim, S.‐H., Baek, M., & Park, S. (2021). Association of parent–child experiences with insecure attachment in adulthood: A systematic review and meta‐analysis. Journal of Family Theory & Review.

Overall, N.C., & Simpson J. A.( 2013) Regulation processes in close relationships. In: Simpson JA, Campbell L, editors. The Oxford handbook of close relationships. New York: Oxford University Press; 2013. pp. 427–451.

Park, Y., Johnson, M. D., MacDonald, G., & Impett, E. A. (2019). Perceiving gratitude from a romantic partner predicts decreases in attachment anxiety. Developmental Psychology, 55(12), 2692–2700.

Rimane, E., Steil, R., Renneberg, B. & Rosner, R. (2020). Get secure soon: attachment in abused adolescents and young adults before and after trauma-focused cognitive processing therapy. European Child and Adolescent Psychiatry.

Sims A. Unpublished doctoral dissertation. University of Ottawa; Canada: 2000. Working models of attachment: The impact of emotionally focused marital therapy.

Tmej, A., Fischer-Kern, M., Doering, S., Hörz-Sagstetter, S., Rentrop, M., & Buchheim, A. (2021). Borderline patients before and after one year of transference-focused psychotherapy (TFP): A detailed analysis of change of attachment representations. Psychoanalytic Psychology, 38(1), 12–21.

Posttraumatic stress (PTSD) and complex posttraumatic stress (C-PTSD) are related but distinct from each other. C-PTSD is thought to be an enhanced version of PTSD. C-PTSD is, in turn, related to borderline personality (BPD).

Ongoing Interpersonal Trauma and C-PTSD

PTSD is usually caused by a single traumatic event (or a series of traumatic events) that result in a real or imagined threat to one’s life or bodily integrity. Events that could cause PTSD include exposure to war, a terrorist attack, physical or sexual assault, or even the threat of such attacks. C-PTSD is different in that it’s typically caused by ongoing trauma which is often interpersonal in nature. C-PTSD tends to be associated with continued trauma that occurs at a young age. Children who grow up in neglectful or abusive environments may go on to develop C-PTSD (Giourou et al., 2018).

Borderline Personality and Ongoing Interpersonal Trauma

Borderline personality is also connected to ongoing interpersonal trauma during childhood. Researchers have linked exposure to chronic fear and stress as a child, as well as suffering from physical, sexual, and/or emotional abuse as a child, to the development of BPD. Growing up with a parent who had a serious mental health issue is also a risk factor for the development of BPD.

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood.

BPD is a serious issue characterized by a constellation of emotional, social, cognitive, and behavioral dysregulation. The most notable features of BPD are difficulty managing emotions, impulsivity, identity problems, and dysfunctional interpersonal relationships (Hecht, Cicchetti, Rogosch, & Crick, 2014).

Common Characteristics of C-PTSD and BPD

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood. BPD and C-PTSD also share symptoms. Overlapping symptoms relate to the areas of emotion processing and regulation, security in relationships, and self-concept (Ford & Courtois, 2014).

Some common symptoms of BPD and C-PTSD include:

Emotion processing and regulation difficulties

People with BPD and C-PTSD are known to have difficulties managing and regulating emotions. When experiencing uncomfortable emotions such as anger, fear, or sadness, the person may have difficulty controlling the intensity and duration of the emotion. It can be very hard to “let things go” and return to a neutral or uplifted mood once they’ve been thrown off balance.

Relationship issues

Those with BPD and C-PTSD often have relationship issues. Relationships may be unstable, insecure, and can often be traumatic or stressful for one or both partners. We start learning how relationships work in childhood. If our caregivers in childhood were neglectful or abusive, we tend to carry these learned perceptions of ourselves, such as “I’m bad, worthless, or not worthy of support,” into our adult relationships, as well as lessons about relationships, such as “They are unpredictable, unreliable, and sometimes dangerous.”

Individuals with BPD may have an especially difficult time trusting and relating to others. It is thought that because they may not have experienced empathy from their primary caregivers during childhood, they have developed limited abilities to see past their own emotional responses and understand how others may be feeling.

Adults with C-PTSD may also have difficulty with empathy and relationships, although it depends on the nature of the trauma and whether they had access to at least one caring adult during their childhood. We are all unique, and how we develop and respond to early trauma is variable and can depend on many different factors within the environment and the individual.

Self-concept

BPD and C-PTSD are both associated with impulsive behaviors and dissociation. People may behave in ways that are self-destructive and reckless. Unsafe sex, abuse of drugs and alcohol, and disregard for one’s own safety can occur.

Dissociation is highly prevalent in BPD, and it’s known to occur in PTSD as well (Krause-Utz & Elzinga, 2018). Dissociation can result in a feeling of being disconnected from oneself and the world. Especially during times where stress levels are high, dissociation can act as a defense mechanism where the sufferer feels detached from themselves and what’s happening around them. In certain cases, amnesia may result, as well as a feeling of “lost time.” Identity confusion can also occur, and the person may feel as though they don’t have a strong sense of self or that their identity seems to shift depending on the circumstances and the environment they find themselves in.

High levels of worry, sadness, and shame

Borderline personality and C-PTSD are associated with high levels of general distress. Many feel isolated and empty, as a significant portion of their symptoms can affect their relationships and connection with others. They may have high levels of shame and sometimes experience a feeling that they have been permanently damaged. This can lead to the desire to withdraw from others, as relationships are often a source of stress, insecurity, and/or conflict.

What If You Have Symptoms of Both C-PTSD and BPD?

Complex posttraumatic stress and BPD require treatment and support. If you are experiencing symptoms of C-PTSD and BPD, it can help to first receive an accurate assessment and diagnosis. It is important to understand that nobody is permanently damaged, and there are treatment approaches that have demonstrated effectiveness for both C-PTSD and BPD.

Therapy can help you develop strategies and techniques that allow you to better cope with stress and manage difficult emotions. Ongoing support from a therapist who understands what you are experiencing and where your feelings and symptoms are coming from can be enormously helpful for your healing journey. Find a therapist near me.

If you are struggling, it is important to reach out and take advantage of the support and options available. With treatment, you can not only feel better, but also avoid the negative consequences of behavioral and emotional symptoms. Feeling better and coping with stress can improve other areas of your life as well, such as how you function in professional and personal relationships.

References:

1. Ford, J. D., & Courtois, C. A. (2014, July 9). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. doi: 10.1186/2051-6673-1-9
2. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018, March 22). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12-19. doi: 10.5498/wjp.v8.i1.12
3. Hecht, K. F., Cicchetti, D., Rogosch, F. A., & Crick, N. R. (2014). Borderline personality features in childhood: The role of subtype, developmental timing, and chronicity of child maltreatment. Development and Psychopathology, 26(3), 805-815. doi: 10.1017/S0954579414000406
4. Krause-Utz, A., & Elzinga, B. (2018). Current understanding of the neural mechanisms of dissociation in borderline personality disorder. Current Behavioral Neuroscience Reports, 5(1), 113-123. doi: 10.1007/s40473-018-0146-9
5. Luyten, P., Campbell, C., & Fonagy, P. (2019, May 7). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of Personality. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jopy.12483

Impulsivity, mood swings, irritability, high and low periods, patterns of troubled relationships—these symptoms often indicate bipolar, but they can just as easily appear in people who have borderline personality (BPD).

Neither condition is uncommon. Approximately 2.6% of adults in the United States live with bipolar. Estimates for BPD vary, but it’s believed somewhere between 1.6% and 5.9% of adults in the U.S. live with this condition. Many people have a dual diagnosis, or both conditions.

The resemblance between the traits characterizing each issue and the possibility of co-occurrence has led some professionals to question whether BPD is a subtype or variation of bipolar. The general consensus among mental health experts, however, is that while these conditions often present with similar features, they are two separate mental health issues that can usually be distinguished in a few key ways.

It’s during periods of mania that bipolar may be most suggestive of BPD, as manic episodes often involve thrill-seeking, impulsive, or aggressive behavior.

Bipolar vs. Borderline Personality

A mood disorder, bipolar is primarily characterized by shifts between high-energy (manic) states and low-energy (depressive) states. Bipolar-related mood changes can range from mild to extreme, and they’re typically accompanied by changes in a person’s energy and activity.

Not every person who has bipolar will experience a classic manic episode. These episodes generally last several days and frequently involve increased activity and productivity in schoolwork, work-related tasks, or creative pursuits. Feeling very energized or charged, with little or no need to sleep, is common.

People living with bipolar II experience milder manic periods known as hypomania. Cyclothymia, a subtype of bipolar, involves hypomanic and depressive periods that don’t meet typical bipolar criteria. But mania is a symptom specifically linked to bipolar, so having even one manic episode indicates bipolar in most cases.

It’s during periods of mania that bipolar may be most suggestive of BPD, as manic episodes often involve thrill-seeking, impulsive, or aggressive behavior. Impulsive actions might include risky sex, excessive spending, or substance abuse, along with other behavior that isn’t typical. Rapid cycling bipolar may particularly resemble BPD, as mood fluctuations happen more frequently than with typical bipolar.

Frequent manic episodes could also contribute to relationship difficulties, since the way a person behaves during a manic episode could have a negative impact on the people close to them. For example, during a manic episode, a person in a monogamous relationship may cheat on their partner or decide to redo all of their home furnishings and max out multiple credit cards in order to purchase new interior decorations. A person who uses drugs during a manic episode could face legal consequences, especially if their actions while under the influence of drugs cause harm to others.

But with BPD, particularly untreated BPD, emotional shifts tend to be sudden and happen frequently. BPD is a personality disorder, so the associated traits don’t simply relate to mood changes, they’re persistent behavior patterns. Extreme, all-or-nothing thinking patterns also help characterize this condition. For example, a person with BPD who experiences mild criticism at work may become very upset and distressed. They may feel they’ve failed and fear they’ll lose their job.

Another characteristic of BPD is difficulty interpreting emotions. People often view neutral or other expressions as negative, and this misinterpretation could lead to conflict or strained personal relationships.

Similarly, a minor disagreement with a partner could lead someone to believe they’re unlovable and the relationship is over. They might end the relationship first, fearing rejection. Relationship conflict can also trigger devaluation of a partner who was previously idealized, depending on the circumstances. With devaluation, feelings of anger, disdain, and contempt may abruptly replace feelings of love and happiness in the relationship.

Lifetime suicide risk is high with either bipolar or BPD, while recurring non-suicidal self-harming behaviors as well as multiple suicide attempts are common with BPD. Cutting and other self-harm doesn’t necessarily indicate suicidal intent. Research indicates many people with BPD self-harm as a way of coping or as a way of feeling something during a period of dissociation.

How Do Treatment Approaches Differ?

These two conditions have separate underlying causes, though people with a family history of either bipolar or BPD have a higher risk for that condition.

The causes of BPD aren’t fully known, but it’s believed to develop from a combination of factors. A tendency to experience extreme emotionality, which can also run in families, is believed to contribute, especially in people who’ve experienced abuse, trauma, and neglect. Brain chemistry is a significant contributing factor to bipolar, though environmental factors can also increase risk.

Correct diagnosis is important, because treatment approaches vary depending on the condition. It’s important to understand that therapy alone typically can’t treat mania in people living with bipolar. It may also not be enough to treat severe depression in some people.

Therapy can help address some symptoms and challenges of living with bipolar, but in most cases people with typical bipolar will need medication to help stabilize mood shifts. Untreated mania and depression can have serious emotional and even physical health consequences, so it’s important to seek, and continue with, treatment.

Mood stabilizers such as lithium won’t help BPD symptoms. In some cases, bipolar treatment might even make certain symptoms worse. There’s no medication that specifically treats BPD. The typical treatment is dialectical behavior therapy, though other therapy approaches such as schema therapy can also have significant benefit.

Can Bipolar and Borderline Personality Co-occur?

A person experiencing symptoms of both bipolar and borderline personality may have both conditions.

A person experiencing symptoms of both bipolar and borderline personality may have both conditions. This isn’t uncommon, in fact. A 2013 review of multiple studies on the two conditions found that around 10% of people diagnosed with borderline personality also had bipolar I, while about 10% had bipolar II as well as BPD.

Living with untreated borderline personality and bipolar can cause significant distress, in part because the two conditions may play off each other.

• Feelings of emptiness or failure may be even worse during a bipolar depressive period, causing emotional turmoil or disconnect, both of which may increase risk for self-harming behavior or suicide.
• A person struggling with trust or abandonment issues in their relationship could have an even harder time maintaining a healthy relationship during a low mood state.
• A period of mania may be more likely to trigger risky or impulsive behavior in a person who feels distressed or disconnected from their sense of self and wants to feel something.
• Substance abuse isn’t uncommon with BPD or bipolar, and alcohol and drugs can often trigger mania.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recommends mental health professionals avoid diagnosing personality disorders during untreated mood episodes. Taking a detailed mental health history that looks back at patterns and symptoms over a longer period of time can help differentiate the two conditions.

Between manic and depressive episodes, people with bipolar generally experience fairly normal moods. Months or even years could pass between high and low periods, especially when treatment is effective at managing symptoms. So once a mood episode has stabilized, diagnosis may be somewhat clearer. When a manic or depressive mood seems to respond to treatment but symptoms of emotional dysregulation persist, a dual diagnosis is likely.

Treatment for Co-occurring Bipolar and Borderline Personality

Living with co-occurring BPD and bipolar may be more challenging than having either condition alone, especially if it takes time to get an accurate diagnosis. Bipolar-related mood swings, when combined with more frequent and rapid changes in emotional state, can make daily life difficult and negatively affect work, school, and personal life. People living with bipolar and BPD may feel even more unstable or unable to control what’s happening around them than those living with only one of these conditions.

While treatment such as therapy can be very helpful for reducing symptoms and improving quality of life, the recommended treatments for each condition differ. This makes an accurate diagnosis essential for successful treatment.

For bipolar, therapy may involve learning to recognize mood triggers, developing ways to cope with bipolar symptoms, and working to reduce the effects symptoms have on daily life. The combination of mood stabilizing medication and dialectical behavior therapy may be recommended for people with both bipolar and BPD, since DBT is generally the ideal approach to therapy for BPD. This therapy involves developing the skills to manage and cope with difficult emotions and practicing positive ways of relating to others.

For people experiencing BPD-related distress during a manic or depressive episode, mood stabilization is an important first step. Research suggests BPD symptoms may improve slightly once mood has stabilized, which can increase the chance of successful treatment. It’s also essential to talk about suicidal thoughts or self-harm, since these may be more likely in people with both conditions than people who only have bipolar.

Psychotic symptoms such as hallucinations can also occur during a manic episode, and these can be dangerous. They’re not as common with BPD, but they do occur, so it’s important to discuss any hallucinations, delusions, or magical thinking when a person presents with symptoms of both conditions.

Finding a Therapist for Bipolar or Borderline Personality

For some mental health concerns, diagnosis may not significantly impact treatment since symptoms can still be addressed in therapy. But when bipolar and BPD, which sometimes present similarly, are misdiagnosed for each other, treatment may be less effective. Symptoms of both conditions can further complicate diagnosis. Some mental health professionals may fail to recognize the presence of both issues, particularly if they’re less experienced with the differences between the two or unaware bipolar and BPD often occur together.

When seeking a diagnosis or working to address symptoms of both bipolar and BPD, it’s recommended to seek support from a therapist who has experiencing helping people with both conditions. While other trained, empathic therapists can certainly provide compassionate care, a therapist who specializes in working with people living with these conditions may offer support that’s designed to address specific symptoms of these conditions. This may be especially important when beginning therapy for the first time.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
2. Bipolar disorder. (2017). National Alliance on Mental Illness. Retrieved from https://www.nami.org/learn-more/mental-health-conditions/bipolar-disorder
3. Bipolar disorder. (2018). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml
4. Borderline personality disorder. (2017). National Alliance on Mental Illness. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
5. Borderline personality disorder. (2017). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
6. Fenske, S., Lis, S., Liebke, L., Niedtfeld, I., Kirsch, P., & Mier, D. (2015, June 26). Emotion recognition in borderline personality disorder: Effects of emotional information on negative bias. Borderline Personality Disorder and Emotion Dysregulation, 2, 10. doi: 10.1186/s40479-015-0031-z
7. Ghaemi, S. N., Dalley, S., Catania, C., & Barroilhet, S. (2014). Bipolar or borderline: A clinical overview. Acta Psychiatrica Scandinavica, 130(2), 99-108. doi: 10.1111/acps.12257
8. Kvarnstrom, E. (2017, October 5). Borderline personality disorder misdiagnosed as bipolar disorder: Differences and treatment. Retrieved from https://www.bridgestorecovery.com/blog/borderline-personality-disorder-misdiagnosed-as-bipolar-disorder-differences-and-treatment
9. Linehan, M. M., Korslund, K. E., & Harned, M. S. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475-482. doi:10.1001/jamapsychiatry.2014.3039
10. Paris, J. (2004). Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harvard Review of Psychiatry, 12(3), 140-145. doi: 10.1080/10673220490472373
11. Zimmerman, M., & Morgan, T. A. (2013). The relationship between borderline personality disorder and bipolar disorder. Dialogues in Clinical Neuroscience, 15(2), 155-169. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811087

Consider a person in therapy whose most evident trait is their inconsistency. From session to session, they vacillate between excitement and anxiety. One week they feel fully confident, the next, totally overwhelmed. They demonstrate or recount instances of emotional instability and mood swings, alienation and avoidance, impulsiveness and overreaction, and past trauma and continuing flashbacks.

A combination of the above symptoms could lead you to two very different diagnoses: borderline personality or complex posttraumatic stress (C-PTSD). At first glance, they share a remarkably similar list of symptoms and triggers. Their potential comorbidity (the presence of both concerns) only adds to the confusion.

However, the distinction between these two conditions is real—and often critical. Research has backed up the need to categorize them separately in the Diagnostic and Statistical Manual. The best treatment practices for addressing one condition could potentially exacerbate the other condition, should a person seeking help be misdiagnosed. It is therefore vital that practitioners are aware of the differences between BPD and C-PTSD. Therapists must also be open to revisiting their initial conclusions as therapy sessions progress.

BPD vs. C-PTSD: Understanding the Differences

The key difference between BPD and C-PTSD is that symptoms of BPD stem from an inconsistent self-concept and C-PTSD symptoms are provoked by external triggers.

A person with C-PTSD may react to or avoid potential triggers with behaviors similar to those that are symptomatic of BPD. But even if their self-representation is extremely negative, it will be consistent. This differs from the inconsistent self-representation that characterizes BPD.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

As such, treatment for BPD should focus on creating a more stable, internalized sense of self. Developing a more stable sense of self can help reduce the tendency toward self-injury and dependency upon other people.

DSM guidelines also propose a longer treatment course for BPD (at least a year), as ending therapy too soon can increase the risk of relapse due to a sense of instability or abandonment. In contrast, C-PTSD treatment aims to engage traumatic memories, foster development of a positive sense of self, reduce interpersonal avoidance, and teach resetting techniques to apply when triggers are encountered.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

Even so, most diagnoses that include BPD tend to stem from complex childhood trauma of some kind. Therapists can best support the people they are working with by determining the frequency and extent of symptoms, any potential stimuli for these symptoms, and whether symptoms can be easily regulated after being triggered.

People who are experiencing C-PTSD rather than BPD typically find it easier to overcome their emotions. If past traumas are addressed and healed, the emotional reactions that result when these memories are triggered can be lessened or subdued. People with BPD, on the other hand, often find it more difficult to calm down following intrusive memories and flashbacks. The intense emotions triggered may persist, regardless of how well the memories behind them have been engaged in therapy.

Another identifier involves looking at what is missing. Consider a person who has experienced abuse. Instability, mood changes, or re-experiences may occur in discrete instances, but if a person has no history of self-harm or fear of abandonment, a diagnosis of C-PTSD is more likely. Alternatively, when these behaviors are not always accompanied by an external trigger, or occur even when expected triggers are not present, their reactions may have been caused by internal feeling stemming from BPD.

When a person begins to notice and fear their own instability, they frequently begin to exhibit other behaviors. These might include social avoidance, alienation, hypervigilance, mood changes, and increased propensity to anger. They may describe their symptoms in terminology associated with one diagnosis or the other—for example, experiencing panic attacks (BPD) as opposed to outbursts of posttraumatic stress (C-PTSD). But clinicians need to analyze the factors above in order to accurately label and consequently treat the issues underlying the shared symptoms.

Misdiagnosis Can Affect Treatment

Focusing upon the differences between BPD, C-PTSD, and comorbid BPD and PTSD allows for distinct symptom profiles to emerge, in spite of the common symptoms that may initially be more readily apparent. These separate profiles are clinically significant, since person-centered care requires accurate identification of any and all issues experienced. This ensures that treatment methods and duration can be adapted to the specific needs of each person in therapy.

It’s important for therapists to remember that the techniques that can help people with C-PTSD reset their moods may aggravate BPD symptoms. These techniques may include reminding themselves they are safe, focusing on their present surroundings, visualizing a safe location, or moving outdoors, among others. People with BPD, who often experience apparent “overreactions” or mood swings, require acknowledgment and validation of the emotions experienced, rather than a reminder that their behavior is unnecessary or irrational.

There are effective treatments for both C-PTSD and BPD. But the best approaches for each issue differ in significant ways. Consequently, misdiagnosis can be extremely detrimental. Clinicians must therefore be prepared to weigh the differences and indicators separating the two diagnoses. It’s also important to keep in mind that it may take longer than usual to confirm or revise their initial deductions.

References:

1. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 10.3402/ejpt.v5.25097. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165723
2. Ehrenthal, J. C., Levy, K. N., Scott, L. N., & Granger, D. A. (2018). Attachment-related regulatory processes moderate the impact of adverse childhood experiences on stress reaction in borderline personality disorder. Journal of Personality Disorders, 32 (Supplement), pp. 93-114. Retrieved from https://doi.org/10.1521/pedi.2018.32.supp.93
3. Hyland, P., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … Vallières, F. (2018, April 16). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health, 5, e14. Retrieved from http://doi.org/10.1017/gmh.2018.2
4. Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013, May 15). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1).  http://doi.org/10.3402/ejpt.v4i0.20706

Borderline personality (BP) is estimated to affect between 1.5% and 6% of people in the United States. Core features of BP include black-and-white, all-or-nothing thinking, intense, rapidly shifting emotions and difficulties with emotion regulation, challenges in relationships and with self-image, and a tendency toward impulsivity. All of these can exacerbate distress, decrease coping, and make it harder to function socially, at work, and in general. Furthermore, the prevalence of BP in people with chronic pain is significantly greater than in the general population (30%) and is linked to increased pain severity and poorer coping with pain.

Non-suicidal self-injury is a tool frequently used by those with borderline personality in an effort to decrease emotional pain and induce calm. Those who have BP often report both the absence of pain and an increase in well-being or feelings of euphoria when engaging in self-harm, both of which may reinforce the tendency to continue self-harming as a way of coping.

The Pain Paradox

The relationship between pain, self-injury, and BP is complex. Between 70% and 80% of those diagnosed with BP engage in self-injury to distance themselves from painful emotions and distressing thoughts. On the surface, it is perplexing that BP predisposes individuals to not only higher pain tolerance in the face of acute (short-duration) and self-inflicted pain, but lower pain tolerance, as well as greater pain severity and poorer coping, in response to chronic (ongoing) pain.

[fat_widget_right]

The Overlap of Emotional and Physical Pain

Contrary to popular belief, there is no one “pain center” in the brain; multiple brain structures are responsible for the experience of pain. A complex and multifaceted experience, “pain” refers to sensing the location of discomfort, assessing pain severity, registering the quality of pain (e.g., piercing, hot, throbbing, intermittent, etc.), linking to memories related to pain, the emotional response to pain, beliefs one has about the potential for coping with pain, and the ability to devise and follow through with a plan for pain management, among others.

The current and rapidly growing body of research on pain has found that distressing cognitive responses, such as catastrophizing (“I can’t handle this pain; I’m never going to get better!”) and emotional responses, such as depression and anxiety, can worsen both pain severity and coping, as well as challenge one’s ability to stick with a pain management plan that may require patience, persistence, and possibly a temporary increase in pain severity (such as with physical therapy).

This relationship among thoughts, feelings, and physical sensations and their related brain structures is not one-directional: physical pain tends to increase distressing thoughts and emotions and impair coping; distressing thoughts and feelings and poor coping strategies are linked to worsening physical pain. Relatedly, employing adaptive coping, such as taking good care of one’s body via a healthy diet, exercise, and stress management program, and treating any issues related to anxiety or depression, can improve pain and general well-being.

The Brain and Self-Harm as Self-Medication

Borderline personality is associated with increased rejection sensitivity and a tendency to personalize others’ intentions and emotional states. This is thought to occur in part due to over-activation of the amygdala, a small, almond-shaped structure deep in the brain, and under-activation of the anterior cingulate cortex, or ACC.

The amygdala is involved in the experience of intense, often unpleasant emotions, such as anger and fear, as well as emotional memories. The ACC is involved in, among other things, decision making and regulating emotions. Recent research has found that BP is linked to having less gray matter density in the ACC and more in the amygdala, as well as decreased activity in the ACC and increased activity in the amygdala in response to viewing fearful or angry faces.

Theoretically, in response to perceived social rejection, the ACC should help assess the situation, turn down the volume on intense, negative emotions (calm down the amygdala), and help make a “rational” decision about how to handle the situation. This process is compromised in people with borderline personality. Emotional distress due to social pain is a frequent trigger of self-harm in those with BP.

Repeatedly self-harming is thought to stimulate the release of the body’s opioid and cannabinoid receptors, leading to feelings of increased well-being, relaxation, and euphoria. You may be familiar with the effects of exogenous cannabinoids and opioids (those from a source outside of the body). Opioid pain medications are exogenous opioids, and marijuana contains exogenous cannabinoids (the most well known of which is THC). Both substances can prompt feelings of pleasant detachment, pain relief, and euphoria, among other effects.

Self-harm has also been found to increase the predominance of theta brainwaves, which are associated with light sleep, deep meditation, and dissociation, or feeling disconnected from one’s thoughts and feelings. Other studies have found that those with a history of repetitive self-injury had lower cerebrospinal fluid levels of two neuropeptides (proteins) that are associated with analgesia (pain reduction): beta-endorphin and met-enkephalin. It is unclear if low levels of these neuropeptides result from severe childhood trauma, a biological predisposition, or some combination of these. Thus, self-injury appears to prompt the body to release pain-relieving chemicals and induce a trance-like state that blunts physical and emotional pain.

Challenges in Treating Pain

It remains an unfortunate truth that most medical and mental health professionals generally receive minimal or no education about diagnosing and treating chronic pain unless they pursue specialized postgraduate treatment in this area. Imaging, blood tests, and physical exams frequently fail to isolate a cause for many pain syndromes, which can leave both patients and providers feeling frustrated or on the defensive. In the absence of physical evidence for pain, providers may conclude that a person is reporting pain in an effort to gain attention or assistance from others, referred to as “secondary gain.” Providers may also conclude that overwhelming emotions are the sole cause of physical pain.

There is no definitive answer for why borderline personality would be so much more prevalent in people with chronic pain than in the general population.

Although some people do manufacture or exaggerate reports of pain, and emotional distress can be experienced via physical symptoms, the picture is typically more complex for most of those in pain. Furthermore, advances in genetics, immunology, endocrinology, and brain imaging are revealing biological correlates of many pain syndromes once thought to be purely psychogenic (caused by the mind), such as phantom limb pain, irritable bowel syndrome, chronic fatigue/myalgic encephalomyelitis, and fibromyalgia.

Providers who are not well informed about pain can leave pain sufferers both without a plan for pain management and vulnerable to feeling unheard and invalidated. In addition, those who react dismissively to reports of pain and distress are likely to trigger feelings of rejection and abandonment, particularly in those with borderline personality, who are already more vulnerable to these feelings. Overwhelming painful emotions may worsen pain and decrease the ability to manage it.

Why Is Borderline Personality Common in People with Chronic Pain?

There is no definitive answer for why borderline personality would be so much more prevalent in people with chronic pain than in the general population. Because pain is a complex, mind-brain-body phenomenon, one hypothesis is that pain that feels random or beyond one’s control may induce feelings of depression, hopelessness, helplessness, anger, and anxiety—all of which amp up pain. Invalidation by ill-informed providers is more likely to elicit poor coping, particularly in those who may struggle with coping already.

Reports of increased severity of pain and other bodily symptoms in those with BP are correlated with greater levels of anxiety and depression. When researchers have statistically controlled for anxiety and depression in those who have both BP and pain, symptom severity has been similar to that of those without BP.

Another possible explanation for the greater prevalence of BP in chronic pain is that when under significant and prolonged stress, everyone is vulnerable to psychological regression, or using earlier ways of coping that are not adaptive in adulthood. Factors associated with BP, such splitting or black-and-white thinking, emotional instability, impulsivity, and greater emotional intensity, may become more prominent when dealing with the ongoing stressor of chronic pain. Furthermore, because many who have borderline personality experienced trauma or neglect at a developmental stage prior to being able to express feelings verbally, regulate their emotions, or negotiate relationships skillfully, the regression prompted by pain may be both retraumatizing and leave those with BP or BP traits feeling unable to process overwhelming emotions directly. This distress may be acted out in interpersonal relationships with providers and others. In addition, unexpressed distress may be somatized, or experienced as bodily pain. This does not mean that a person cannot have an actual chronic pain condition and also somatize; the relationship between the two is often difficult to tease apart.

Finally, as stated above, clinicians unfamiliar with chronic pain may respond in a way that reactivates the experience of invalidation that is thought to be an important factor in developing BP.

Although there is no definitive conclusion as of yet about the reasons for the pain paradox in borderline personality, it appears to be the result of a complex relationship among the following: a biological predisposition to greater emotional pain, and a higher pain threshold for acute pain but a lower tolerance for chronic pain; the analgesic effects of self-harming; and the feelings of helplessness and rejection often inherent in the processes of seeking treatment for chronic pain. For those with BP, self-harming may serve what feels like an essential function in relieving emotional pain; yet, the ongoing and intense stress of chronic pain can overwhelm coping resources and diminish the ability to cope with either pain or the social, medical, and interpersonal challenges that accompany it.

References:

1. Ducasse, D., Courtet, P., & Olie, E. (2014). Physical and social pains in borderline disorder and neuroanatomical correlates: A systematic review. Current Psychiatry Reports, 16, 443.
2. Magerl, W., Burkart, D., Fernandez, A. Schmidt, L. G., & Treede, R. (2012). Persistent antinociception through repeated self-injury in patients with borderline personality disorder. Pain, 153, 575-584.
3. Mayo Clinic News Network: Irritable Bowel Syndrome. Retrieved from http://newsnetwork.mayoclinic.org/discussion/mayo-clinic-researchers-find-genetic-clue-to-irritable-bowel-syndrome/
4. Minzenberg, M. J., Fan, J., New, A. S., Tang, C. Y., & Siever, L. J. (2008). Frontolimbic structural changes in borderline personality disorder. Journal of Psychiatric Research, 42(9), 727-33.
5. National Alliance on Mental Illness (NAMI) – Borderline Personality Disorder. Retrieved from http://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
6. Niedtfeld, I., Schulze, L., Kirsch, P., Herpertz, S. C., Bohus, M., & Schmahl, C. (2010). Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury. Biological Psychiatry, 68, 383-391.
7. University of Maryland: Chronic Fatigue Syndrome. Retrieved from http://umm.edu/health/medical/reports/articles/chronic-fatigue-syndrome
8. Light, K. C., White, A. T., Tadler, S., Iacob, E., & Light, A. R. (2012). Genetics and gene expression involving stress and distress pathways in fibromyalgia with and without comorbid chronic fatigue syndrome. Pain Research and Treatment. Retrieved from http://www.hindawi.com/journals/prt/2012/427869/

The diagnosis of “borderline personality disorder” carries profound stigma for many people. Even some mental health professionals use the term pejoratively, which is not difficult considering that the diagnosis itself implies that someone’s personality is flawed. In reality, the flaw lies within the diagnosis—not to mention all the painful and agitating symptoms that come with it.

I will go into more depth about these challenges, but first a definition is in order.

What Is ‘Borderline Personality Disorder’?

People who are diagnosed with borderline personality tend to have problems with unstable self-image, moods, and relationships. They may experience suicidal thoughts, self-harming behaviors, displays of anger or irritability, and periods of intense sadness or despair called “dysphoria” (the opposite of euphoria).

To receive a diagnosis of borderline personality, a person must meet at least five of the nine characteristics below. Keep in mind while reading the list that, in order to qualify for the diagnosis, the person’s symptoms must be longstanding and inflexible, not just occasional ways of relating to life:

1. “Frantic” attempts to avoid abandonment
2. Intense and turbulent relationships, with a tendency to alternate between seeing the other person as all good or all bad
3. Unstable sense of self, which could lead to radical changes in major aspects of identity such as career, religion, or sexual orientation
4. Frequent suicidal thoughts or self-harming behaviors, such as cutting
5. Impulsive behaviors in at least two other areas, such as substance abuse or binge eating
6. Wild mood swings with extremes of anxiety, irritability, or dysphoria
7. Persistent feelings of emptiness
8. Intense anger or rage that is often close to the surface
9. Brief periods of paranoia or dissociation when under stress

I have seen more than one writer refer to borderline personality as the equivalent of emotional hemophilia: when a person with borderline personality experiences a hurt, even a small one, the emotional bleeding is profuse. The suicide rate for people with borderline personality is about 10%. Most people—up to 90%, by some estimates—with borderline experienced neglect or abuse, particularly sexual abuse, during childhood. Individuals with borderline personality commonly view themselves as inherently defective, bad, or broken.

For many years, borderline personality disorder was considered untreatable. Now, decades of research and treatments have illuminated the errors in such thinking. For one thing, we know that many people “grow out” of the disorder as they age. For another, a great many people with the diagnosis respond positively to treatments such as dialectical behavior therapy.

Stigma and Borderline Personality

All personality disorder diagnoses are controversial. The mere phrase “personality disorder” situates the problem in the person’s personality, rather than neurology or life stressors (including trauma). GoodTherapy.org’s founder, Noah Rubinstein, LMFT, has even explained why he views personality disorder diagnoses to be flawed:

“I believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their person-hood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very, if not absolutely, likely to produce more shame, worthlessness, and rejection in a person who probably has enough of it already.”

I agree with his analysis. In some ways, the situation is even worse for people diagnosed with borderline personality. Any mental health diagnosis can engender feelings of shame, or of being “fundamentally flawed.” On top of that, feelings of shame and badness are both symptoms and consequences of borderline personality. This can create a vicious cycle, as if the diagnostic label alone confirms the feelings of defectiveness that came well before the diagnosis.

Too often, some mental health professionals add to the stigma. It is well known that some clinicians have applied the label “borderline” merely because they do not see an individual improving, or the individual poses challenges such as expressing overt anger toward the therapist. For some therapists, it is easier to blame the client for treatment’s lack of success than it is to look at the clinician’s own inability to help.

Another source of stigma concerns others’ tendencies to judge the person, rather than the person’s behaviors. Some, though certainly not all, people with borderline personality may cope or express their pain in ways that hurt those around them. They may yell or even be physically violent, make unrealistic demands, display intense sadness or anger at what seems a disproportionately small provocation, or even attempt suicide or hurt themselves in ways that make another person feel manipulated.

It helps to keep in mind the fundamental, excruciating pain that often underlies borderline personality disorder. Marsha Linehan, the psychologist who created dialectical behavior therapy, compares the behaviors of people with borderline personality disorder to those of people with painful cancer who will do anything to reduce their pain. The cancer patients may cry, scream, or attempt to “manipulate” others in order to get their pain medication. But we seldom view their efforts negatively, because we understand their abject suffering. Their behaviors make sense.

So, Should the Diagnosis Be Abolished?

I agree with other critics that the label “borderline personality disorder” can compound an already painful situation for people, especially the newly diagnosed. But I also find value in the diagnosis—not the name, but the concept.

Before diagnosis, people with borderline personality often feel bewildered. They may deeply experience their internal chaos yet find that few people understand. I have worked clinically with many people who felt soothed when they learned their problems fell into a distinct category that millions of other people shared. These people felt they were no longer alone.

Once people have a name for a condition, they can more easily find information about challenges and ways to heal. They can find other likeminded people in online support groups. Also, diagnoses enable clinicians to better treat people. Clinicians can draw from a large body of research on borderline personality to identify the best treatment options for individual clients.

The diagnostic label deserves to be changed, but the construct itself should remain, as long as it is supported by continued research. Some researchers, like the psychologist Judith Herman, think that borderline personality actually is a type of posttraumatic stress, and should be reclassified as such. But the idea has not gained much momentum in the field of psychiatric diagnosis.

Changing the name, too, is a pipe dream for now. The American Psychiatric Association only months ago released its first overhaul in almost 20 years of the Diagnostic and Statistical Manual of Mental Disorders, and the group never seriously considered altering the name. That is a shame. The name of a diagnosis should describe the problem—in this case, problems regulating emotions—not the personality. Others have proposed alternate names. My preferred label is one proposed by Dr. Linehan, “Emotion Dysregulation Disorder.”

What Can We Do to Diminish the Stigma?

Use the word “borderline” appropriately. Do not use the word “borderline” as an insult. This especially applies to mental health professionals. I have worked in the mental health field for almost 20 years, and it is disheartening how many times I have heard a professional say “She is so borderline,” or “What a borderline.” Borderline is an adjective to describe a series of symptoms, not a person. And it certainly is not a noun.

Be clear that stigma is undeserved. When we discuss how stigmatizing the diagnosis of borderline personality can be, it is necessary to make clear that the stigma is unfounded. Despite appearances or assumptions, the label does not truly mean that somebody’s personality is flawed. We need not buy into the pejorative meaning.

Exercise compassion. Whether you know somebody with borderline personality or have the symptoms yourself, always keep in mind the underlying pain and anger that can drive behaviors. This is not to say that people with borderline personality are not responsible for their behaviors and cannot make changes. Rather, a compassionate stance helps diminish shame. It also emphasizes the possibility that people can learn more constructive ways to manage their emotions.

Avoid stereotypes. The diagnosis of borderline personality captures a very heterogeneous group. Only five of the nine diagnostic criteria are required for a diagnosis. Two people with the diagnosis could have only one symptom in common. In fact, there are 256 different possible symptom combinations for borderline issues, and every person who has been diagnosed with borderline personality has his or her own unique stories.

Maintain hope. As I noted above, borderline personality need not be a lifelong struggle. The symptoms of borderline personality often mellow with age. Borderline personality disorder, as a diagnosis, also has the advantage of garnering significant attention among researchers, clinicians, and grant funders. New discoveries continue to be made.

More and more, we learn about effective ways to treat people who are diagnosed with borderline personality. These gains in knowledge lead to more hope: hope for people to heal, and hope for the condition, by whatever name, to elicit less stigma and more understanding.

References:

1. American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders – 5. Washington, DC: Author.
2. Gunderson, J. G., Stout, R. L., McGlasham, T. H., Shea, T., Morey, L., Grilo, C. M., Zanarini, M. C. et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry, 68, 827 – 837.
3. Leichsenring, F., Leibling, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 9759, 1 – 7.
4. Lilienfeld, S. O., & Arkowitz, H. (2012). Diagnosis of borderline personality disorder is often flawed. Scientific American. http://www.scientificamerican.com/article.cfm?id=the-truth-about-borderline
5. Linehan, M. M. (1993). Cognitive behavioral treatment for borderline personality disorder. New York: Guilford.

Research on borderline personality (BPD) has explored various avenues in search of risk factors. But according to a recent study, some of the biggest risk factors for BPD may develop in the womb. Cornelia E. Schwarze of the Department of Psychiatry and Psychotherapy at the University Medical Center Mainz in Germany led the study that looked at the prenatal conditions of 100 individuals with BPD and compared them to 100 participants with no history of BPD.

Schwarze interviewed the mothers of the participants and reviewed prenatal and medical records. She looked at factors such as prenatal smoking, stress, family conflict, and medical problems. Schwarze also assessed environmental risk factors for the participants by evaluating levels of childhood adversity including maltreatment, neglect, physical and sexual abuse, emotional abuse, or other traumatic events.

The results revealed that the mothers of the BPD participants were more likely to have smoked during pregnancy when compared to the mothers of the 100 non-BPD control subjects. Additionally, the mothers of the participants with BPD also had higher rates of prenatal medical problems, stress, and conflict. Other risk factors that increased the likelihood of BPD were childhood sexual abuse and other childhood trauma. However, prenatal smoking and prenatal medical problems and stress had the strongest associations with BPD.

Exposure to prenatal smoke has been linked to impulsivity, identity issues, affective problems, and some borderline personality symptoms. The results of this study support existing research in this area. Schwarze also noted that medical problems that occur during pregnancy can have a significant impact on neurological development and specifically, on regions of the brain that affect emotional regulation. Although this should be explored further in future research, the strong link between prenatal medical problems and later BPD in children supports this as well.

Finally, prenatal stress, resulting from maternal stress during pregnancy, can be caused by a number of factors, including relationship problems, psychological issues, occupational conditions, or socioeconomic conditions, just to name a few. Each of these may also have a unique impact on the development of BPD or increased risk for BPD in unborn children. Schwarze added, “Future prospective longitudinal studies are essential to verify the impact of the observed potential prenatal risk factors.”

Reference:
Schwarze, C. E., et al. (2013). Prenatal adversity: a risk factor in borderline personality disorder? Psychological Medicine 43.6 (2013): 1279-91. ProQuest. Web.

Borderline personality (BPD) is characterized by hostile behavior, negative affect, hypersensitivity to others, anger, worry, and fear of rejection or abandonment. These traits can make life difficult for people with BPD, causing them to react in ways that may be considered socially unacceptable. Additionally, the hypersensitivity that BPD causes can result in outbursts to perceived insults and can damage personal relationships and lead to rejection and isolation. This can then set the stage for further sadness, anger, and fears of abandonment, which perpetuate the cycle of rejection and hostility. Therefore, it is imperative to get a better understanding of what mechanisms lead to this pattern of behavior in people with BPD.

To do this, Gentiana Sadikaj of the Department of Psychology at McGill University in Quebec recently conducted an experiment involving 38 people with BPD and 31 non-BPD control individuals. All of the participants reported their levels of quarrelsome and hostile behavior, perceptions of their partner’s behavior, and their own affect over a three-week period. Specifically, Sadikaj wanted to evaluate the participants’ own behavior in response to their negative affect, their behavior resulting from their perceptions of others, and their attitude resulting from those perceptions.

Sadikaj found that the BPD participants did indeed have more intense reactions than the non-BPD participants. With respect to behavior response to their own affect, all the participants responded similarly. But the BPD participants perceived others as being cold and rejecting, thus causing them to react with increased hostility and anger. This increased their level of quarrelsome behavior and prompted those they interacted with to also become more difficult. The BPD participants also reported feeling more worried, isolated, and sad than the non-BPD participants as a result of these perceptions and resulting quarrels. Sadikaj said, “Such reactions from others may, in turn, reinforce fears of rejection and disconnection, and sensitivity to others’ behavior among individuals with BPD, thus maintaining the painful cycles of disturbed interpersonal relationships.” Sadikaj hopes these results guide interventions for people with BPD toward focusing on their perceptions of others’ and their behavior in response to those perceptions.

Reference:

1. Sadikaj, G., Moskowitz, D. S., Russell, J. J., Zuroff, D. C., and Paris, J. (2012). Quarrelsome behavior in borderline personality disorder: Influence of behavioral and affective reactivity to perceptions of others. Journal of Abnormal Psychology. Advance online publication. doi: 10.1037/a0030871

A study sponsored by the University of Chicago will test the effectiveness of Lexapro (escitalopram), a selective serotonin reuptake inhibitor (SSRI), in the treatment of borderline personality (BPD). As an SSRI, Lexapro belongs to the most commonly prescribed class of antidepressant medications. In recent years, the use of antidepressants has expanded to include chronic pain conditions, irritable bowel syndrome, and other mental health issues distinct from depression. In the current study, researchers intend to show that antidepressants can reduce thoughts of self-harm in individuals with BPD. The study is currently recruiting male and female subjects aged 18 to 40 years who have not taken an SSRI in the last two months.

As a mental health condition, BPD has not always been taken seriously. Many therapists simply viewed people with borderline personality issues as difficult cases, rather than examples of a specific but little-understood condition. People with borderline often respond poorly to traditional therapies, perhaps leading to the damaging stigmatization of BPD (Kernberg and Michels, 2009). Recently, however, BPD is among the most intensely studied personality issues.

While there are still more unknowns than knowns, the recognition of BPD as a legitimate condition with both a biological and psychiatric basis is firmly established. Approved treatments include customized cognitive behavioral therapy, anti-anxiety medications, and in some instances, low doses of antipsychotic medications. An ideal, one-size-fits-all approach has yet to be discovered. Because of the variable manifestations of the condition, such an approach may not even exist.

Self-loathing, self-harm, and thoughts of suicide are unfortunately quite common in people diagnosed with BPD. The University of Chicago study will include a placebo control group and an experimental group. Both groups will undergo eight weeks of treatment, with the experimental group receiving 10 to 20 milligrams of Lexapro.

The primary outcome measure for the study will be self-harm ideation; researchers expect the experimental group to report far fewer thoughts of self-harm. A second outcome measure will be symptoms of depression. The study’s recording methods will consist of electronic diaries for each participant and weekly therapeutic interviews.

Despite mountains of research and clinical investigations, there is still a long way to go in the treatment of BPD. Therapists are in search of methods that ensure long-term improvement in patients’ symptoms. Even today’s best interventions often only deliver short-term success. Because the risk of self-harm and suicide is so very real in this population, the University of Chicago Study will hopefully offer insight into reducing these outcomes.

References:

1. Kernberg, O., & Michels, R. (2009). Borderline personality disorder. The American Journal of Psychiatry, 166(5), 505-508. Retrieved May 25, 2012, from the ProQuest database.
2. Selective Serotonin Reuptake Inhibitors (SSRIs) in Borderline Personality Disorder – Full Text View – ClinicalTrials.gov. (n.d.). Home – ClinicalTrials.gov. Retrieved May 25, 2012, from http://clinicaltrials.gov/ct2/show/NCT01103180?cond=%22Personality+Disorders%22&rank=11