What is Quiet Borderline Personality Disorder?

Borderline personality disorder (BPD) is a personality disorder characterized by difficulty managing emotions, sensitivity to perceived insults, and outward bursts of emotion.  Outbreaks may include crying or screaming, fighting with family, or breaking up with a romantic partner repetitively.  

But what if these outbursts were kept inside? A subtype of BPD described by some psychologists as quiet borderline personality disorder does just this. In quiet BPD, the outward emotional displays typically seen in BPD are kept inside and internalized. In this article, we hope to introduce quiet BPD so that individuals can more easily spot it and seek help when needed.  

What is quiet BPD?   

As discussed, people with BPD have difficulty with self-esteem, relationships, and management of emotions. People with quiet BPD have these same difficulties, but instead of outward displays of emotion, they keep these feelings bottled up. For example, instead of expressing anger or sadness explosively, individuals with quiet BPD may “implode” and hold feelings inside. Quiet BPD, though, is not an official clinical diagnosis. Instead, it is a subtype of BPD described by some mental health clinicians based on specific symptoms. 

In addition to the symptoms mentioned above, people with quiet BPD often display the following symptoms: 

• Anxious or avoidant attachment tendencies. 
• Submissive behaviors 
• Feelings of vulnerability and powerlessness 
• Feeling that you are defective or wrong 
• Extreme mood swings 
• Hiding feelings of anger or sadness very well to the point where no one knows anything is wrong 
• Dissociating when becoming stressed 
• Feelings of resentment
• Clinginess with a few individuals 
• Depression, feeling empty or numb 
• Self-blame, even for things that are not the individual’s fault 
• Loss of trust in individuals 
• Feeling unsafe in the world 
• Withdrawing after feeling hurt instead of confronting or speaking with the individual

How is quiet BPD diagnosed? 

BPD is diagnosed by a trained mental health clinician. Usually, a mental health clinician will get to know an individual before determining if they meet the criteria for BPD. Because quiet BPD is not a formal diagnosis, it may be more difficult to diagnose, especially in teenagers or young adults. Finding a clinician specializing in personality disorders and working with young people may be helpful in these specific cases. 

What is a personality disorder? 

Personality disorders are disorders in which a person’s personality – the way they understand, relate, and act in the world – has deficiencies that prevent them from being flexible in difficult situations, getting along with others, or completing daily acts of living like going to work or school. 

A person with a personality disorder who is always angry, for example, may have difficulty connecting with or trusting others. An individual with a personality disorder who is deeply insecure may fear abandonment and need constant reassurance in romantic relationships. Individuals with personality disorders often have lifelong problems that begin in childhood or early adolescence. 

There are 10 personality disorders listed in the Diagnostics and Statistical Manual of Mental Disorders (DSM-5), a diagnostic manual used by psychiatrists to define and diagnose mental health conditions. These 10 personality disorders are: 

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder
• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder
• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder 

Often, BPD is grouped with antisocial personality disorder, histrionic personality disorder, and narcissistic personality. This group, sometimes called Cluster B personality disorders, have overlapping features. People with Cluster B personality disorders are often dramatic, impulsive, self-destructive, emotionally unstable, and have difficulty interacting with others. 

Because quiet BPD is considered  a subtype of borderline personality disorder by some mental health clinicians, it is not a defined personality disorder in the DSM-5.

While the DSM-5 is used for diagnosing mental health conditions, including personality disorders, some psychologists feel that the field of mental health should be moving to a dimensional diagnosis model—an approach where clinicians classify mental health conditions based on various dimensions rather than categorical criteria. 

In the case of personality disorders, for example, clinicians would look for areas of improvement in a client’s personality, without worrying about a specific diagnosis, instead of categorizing and placing an individual into one of the DSM-5’s constructed personality disorders. Asking your clinician’s thoughts on the dimensional diagnosis model may be useful if you feel this diagnosis style fits better for you or your loved one. 

What is borderline personality disorder? 

An estimated 1.6% of the U.S. population has been diagnosed with BPD, and it is often recognized and diagnosed more frequently in women as compared to men. As mentioned above, individuals who have borderline personality disorder have difficulties with relationships, self-image, and impulsivity. This type of behavior can begin at an early age, although it is sometimes difficult to diagnose. In addition to these difficulties, an individual with borderline personality disorder may meet several of the following criteria listed in the DSM-5.  

• Imagining abandonment: Individuals with BPD go to great lengths to avoid real or imagined abandonment. 
• Unstable personal relationships: Relationships that go through extreme highs and lows are often seen in individuals with BPD. 
• Self-image issues: People with BPD have a persistently low or unstable sense of self. 
• Impulsive behavior: Impulsivity can come in many forms. This could include substance abuse, binge eating, reckless driving, excessive spending, and more. 
• Mood instability: Feeling high highs and low lows as well as depression, anxiety, and irritability are common features of BPD. 
• Emptiness: Many individuals with BPD express longstanding feelings of emptiness. 
• Anger: Inappropriate, intense anger and displays of temper are common. When this feature is seen in men, it is sometimes brushed off as “normal.” This may be a reason why BPD is underdiagnosed in men. 
• Paranoia: Paranoia can come and go quickly for people with BPD. People with BPD may also have dissociative symptoms and feel disconnected from their body, mind, and the world around them. 

What causes BPD?

There are likely multiple causes of borderline personality disorder. 

• Genetics: Genetics are thought to play a major role in BPD. Studies performed in twins demonstrate that BPD is at least 50% heritable. This means that at least half of the reason an individual gets BPD could be related to a family member with BPD. 
• Brain structure and chemistry: Studies imaging the brain (for example, the amygdala, hippocampus, and medial temporal lobes) have identified differences in parts of the brain between individuals with and without BPD.  
• Parental influence: Parents who are more nurturing and patient with sensitive children may help their children age out of or grow out of borderline personality traits. This is the opposite of an environment that is chronically invalidating or negative. 
• Innate personality: Individuals with BPD often show signs of the personality disorder in childhood or early adolescence. These individuals show a lack of resiliency, meaning they can not fight back against negative events or stressors to the same capacity as others. 

How is quiet BPD treated?

When someone is diagnosed with BPD, dialectical behavior therapy (DBT) is traditionally used to help them raise self-awareness of their personality deficits, lower stress levels, and increase tolerance for stressful situations. 

However, people with quiet DBT have different treatment goals. For example, those with quiet DBT are overly tolerant of stressful situations meaning they tolerate stressful environments by keeping quiet instead of acting out. They are also overly self-aware and insecure. And they are very good at quietly hiding how they manage stress. This style of behavior is called “overcontrol.” Other conditions in which a person may have overcontrol is anorexia nervosa, OCD related to perfectionism, autism, and more. 

Because of how its symptoms present, people with quiet BPD may benefit from radically open dialectical behavior therapy (RO-DBT). This therapy helps people address rigid thinking patterns and develop more flexibility. RO-DBT encourages people to question their beliefs and behaviors, accept feedback, learn social connectedness skills, adapt to stressors, and more. 

How Charlie Health can help with quiet BPD

If you’re struggling with BPD or quiet BPD, Charlie Health can help. Charlie Health’s compassionate mental health professionals are here to listen to your story, understand your needs, and match you with an appropriate treatment plan. Our personalized virtual Intensive Outpatient Program (IOP) offers mental health treatment for teens, young adults, and families who are dealing with a variety of mental health struggles, including BPD and quiet BPD. Fill out this form to get started today.