Ask a Clinician: Borderline Personality Disorder 101 with Dr. Caroline Fenkel

Borderline personality disorder is a personality disorder that can impact the way you think, feel, and behave. In this article, Charlie Health interviewed our Chief Clinical Officer and Co-Founder, Dr. Caroline Fenkel, about this disorder, reviewed its signs and symptoms, and discussed treatment options. 

What is a personality disorder?

A personality disorder is a kind of disorder that describes ways of thinking, behaving, and relating to other people that fall outside of what’s considered the social norm.

What is borderline personality disorder (BPD)?

Borderline personality disorder is a specific type of personality disorder.  

People diagnosed with BPD often experience greater levels of childhood adversity, or difficulties, as compared to their peers. In early and later adulthood, these individuals tend to struggle with impulsivity and experience turbulence and instability in their relationships, emotions, and sense of self.  

Indeed, experiences of identity, relationship, and emotion are often entwined more intensely for people diagnosed with BPD than for others. For example, a difficulty in a relationship that most people would think is minor may create deep emotional turbulence for someone with BPD. Emotional dysregulation, mood swings, and feelings of emptiness are frequent.  

What are common behaviors, thoughts, signs, and symptoms of BPD?

People diagnosed with BPD often grapple with a tendency to either hold themselves in very high or very low regard. They may also do this with other people or specific situations, and these valuations may shift rapidly.  

Additionally, fear of abandonment and the misperception of abandonment is also often experienced by people diagnosed with BPD, and this is generally accompanied by frantic efforts to avoid it.  

Next, people with BPD often struggle with very intense feelings. These feelings can be accompanied by urges to act in self-destructive ways. Reckless driving, excessive spending, and other acts emerge at the interface of less-developed impulse control and intense emotion.  

Finally, in the grip of powerful feelings of emptiness, rejection, and worthlessness, feelings of suicidality or wanting to die are also frequently seen in people diagnosed with BPD. These feelings are often suffered chronically, meaning some people who are diagnosed with BPD feel suicidal every day. Suicide attempts are also much more common in people diagnosed with BPD. NSSI, or non-suicidal self-injury done without the intent to die, is also a behavior frequently seen in people diagnosed with BPD.

How is BPD diagnosed?

A licensed mental health provider diagnoses BPD. BPD is usually not diagnosed until adulthood. This is because adolescence is frequently marked by periods of intensity in emotional and relational experience, and identity is often in flux.  

Can children and adolescents be diagnosed with BPD, or only adults?

According to the DSM-IV, if an individual presents with relevant symptoms that have persisted consistently for a period of more than a year, BPD can be diagnosed, even in someone younger than 18.  Finally, there is a recent movement by some mental health professionals to diagnose BPD earlier than 18 in circumstances where withholding diagnosis may decrease the likelihood of access to appropriate care.  

Are there other mental health disorders associated with BPD?

BPD is a DSM-5 diagnosis. It is a mental health disorder and a type of personality disorder. People with BPD are also frequently diagnosed with disorders of mood, anxiety, stress, and trauma. Eating disorders and substance use disorders are also frequently co-occurring with diagnoses of BPD.  

How does BPD impact an individual’s ability to form friendships or romantic relationships?

People diagnosed with BPD tend to form intense connections quickly, but these connections can be short-lived or marked by instability.

Why is this the case? Research shows that people diagnosed with BPD often have a more challenging time than others understanding the thoughts and feelings of others.

At the same time, other research shows areas where people with borderline personality disorder experience enhanced empathy. Extra empathy in some areas and reduced empathy in others, coupled with difficulties in social information processing, often create complicated, tender, and excruciating relationship dynamics.

Additionally, fears of abandonment and sensitivity to perceived slights provoke intensely painful emotional experiences that are difficult to contain. A tendency to idolize or resent individuals at different times means that a friend or partner once seen as all good can suddenly be seen as all bad.

Deep hurt and intense anger or sadness coupled with difficulty containing impulsive reactions to perceived slights can fuel actions that cause pain to all parties.  As a result, friendships and romantic relationships often experience instability and chaos.

Is BPD more common in certain ages, gender identities, or races?

Survey research finds that approximately 1.6% of the population suffers from BPD, and there is no evidence that it impacts cisgender men more than cisgender women.

Women are diagnosed with BPD at a rate that’s three times higher than men.  This is thought to be because men who suffer from symptoms consistent with the BPD diagnosis are often diagnosed instead with depression or PTSD instead of BPD.

Little is known about the distribution of BPD diagnoses across racial and ethnic identifications. Some research suggests that people of Latino/a/x descent are more likely to be diagnosed with BPD than people of non-Latino/a/x descent.

Research on gender-diverse individuals and BPD is in its infancy, but some research suggests gender-diverse people are at least as likely or more likely to suffer from BPD than cisgender people. At the same time, researchers make clear that having a gender minority identity is not a symptom or sign of “an unstable sense of self,” a common symptom of borderline personality disorder. More research is needed to understand the prevalence of BPD among gender minorities.  

What is dialectical behavior therapy (DBT) and does it help with BPD?

Dialectical behavioral therapy is a type of cognitive behavioral therapy that was initially designed specifically to help people diagnosed with borderline personality disorder.  

The word “dialectic” comes from the Greek word dialecktos, which means to converse. The creator of dialectical behavior therapy, Marsha Linehan, uses the word to describe how therapy works to balance acceptance and validation techniques with change techniques. DBT teaches skills in four main areas:

• Mindfulness
• Distress tolerance
• Emotional regulation
• Interpersonal effectiveness

DBT involves individual therapy and group therapy. Individual therapy has three discrete phases.  

1. First, you work with your therapist on stabilizing, creating safety, and achieving behavioral control.  
2. Second, your therapist will assist you with trauma resolution and making sense of your past.  
3. In the third and final phase, you work with your therapist to build the life you want to lead, working towards increasing happiness, enhancing your sense of freedom and peace, and creating a positive future.

In supported groups, you work intensively and specifically on skills building. Groups alternate mindfulness training work with skills building in the other three modules. In distress tolerance skills training, you learn skills to help you with crises and extreme emotional experiences. In emotion regulation training, you learn skills to help you decrease vulnerability to extreme emotions. In interpersonal effectiveness skills training, you learn skills in negotiating to get your needs met in ways that protect your relationships and keep them healthy.

A full course of DBT usually takes 6-12 months to complete. Anyone who struggles with suicidal ideation or intense emotional experiences can benefit from DBT. Research has shown DBT is an effective treatment for BPD, depression, anxiety, eating disorders, substance use disorders, and PTSD.

How should families best interact with a loved one with BPD?

You can help a loved one with BPD by validating their experiences and being mindful not to allow stigmas associated with the diagnosis to cloud your ability to see and respond to them as whole people deserving of your love and care.

Read and learn all that you can about the diagnosis. At the same time, remember that your loved one is not their diagnosis.  

Supporting someone with BPD often means learning to be tender with regard to understanding their struggles with feeling safe in relationships and creating healthy attachments while being mindful to simultaneously set healthy boundaries that protect you and your loved one.

If possible, try to learn about your loved one’s triggers, pain points, and areas of special sensitivity. This will help you to support them when attachment insecurities arise.

Take your loved one with BPD seriously. Don’t discount their emotions as “just a part of their disorder.” This will intensify their sense of invalidation. Instead, work to validate both of your emotional experiences. Look for the “grain of truth” in a strong emotional reaction and try to practice teflon mind–be like a nonstick pan, and try not to personalize difficult interactions.

Take your loved one’s communications of wanting to die, if they voice these, seriously, too. Remember that up to 10% of people diagnosed with BPD die by suicide. Encourage your loved one to seek treatment, stay in treatment, and seek emergency crisis support or services if they express difficulty or uncertainty in their ability to keep themselves safe.

Try to practice compassion, consistency, and non-judgment. Work to show appreciation and love where these feelings emerge genuinely for you. Be sure to cultivate self-love and self-compassion, too. Learn to feel your own boundaries and be as gentle and as respectful of your needs as you are of the needs of your loved one. This will help you, will help your loved one, and will help your relationship with them to stay healthy over the long term.  

Can medication help borderline personality disorder?  

There is no FDA-approved medication for BPD.  The main treatment indicated for BPD is psychotherapy. A doctor may prescribe medication to treat a co-occurring disorder or may prescribe medication to help with a specific symptom of BPD. Some medications prescribed to people with BPD include antidepressant medications, atypical antipsychotic medications, and mood-stabilizing medications. A prescribing clinician should review the benefits and risks of the medication prior to its initiation.

Are there any known risk factors for developing BPD? Can a parent “prevent” their child from developing BPD?

The commonly accepted cause of BPD is biopsychosocial in nature. This means that it is caused by both genetic factors and environmental factors like the relationships, social environment, and developing psychology of an individual.

Genetic and biological factors in BPD relate to factors of inborn temperament. There’s no “gene” for BPD, but traits related to high activity levels, high emotions, and high shyness coupled together put one at a greater risk for later developing BPD.

Social and environmental factors play a significant role, too. Neglect, abuse, and experiences of inconsistent validation are all thought to contribute to the development of most personality disorders, especially BPD.

Protecting your child from trauma and conditions of extreme stress, creating a predictable, validating environment at home, and promoting the development of positive, healthy attachments are all thought to decrease the likelihood of a child later developing BPD.

Can BPD be “cured?”

BPD symptoms often decrease over time. BPD can go into remission. Intense mood dysregulation, impulsivity, and suicidality experienced in early adulthood often wane. The predominant symptoms in middle adulthood often relate primarily to difficulties in function, both in interpersonal relationships and in work and civic life.  

More than half of all people diagnosed with BPD do recover interpersonally and with regard to their careers. Impulsivity and suicidality often decrease with age.  60% of people who met the criteria for BPD in early life will no longer meet the criteria in late life.  

Quality treatment can increase the chances of the full resolution of symptoms.

Support for borderline personality disorder at Charlie Health

If you or a loved one is struggling with some of the symptoms described above, Charlie Health is here to help. Our specialized clinicians can help with therapy specifically designed for individuals with BPD or any other mental health disorder.

‍We’re available 24/7 to get you started on your healing journey.