Diagnosis of borderline personality disorder. Highly sensitive persons.

Borderline Personality Disorder usually conjures up images of a raging woman or explosive man whose attacks cause great suffering for their spouse, boy/girlfriend, and/or children.  Their   hyper-emotionality is almost guaranteed to bring about marriage problems  and a need for intensive counseling help

While this image does fit for some people who suffer with this disorder, many individuals with a bpd diagnosis in fact are highly sensitive persons who experience more intense fear and depression than they do anger. Raging may NOT be the central feature of this disorder.

The video in this link  explains the fear and depression that a young man suffering with a bpd diagnosis experiecd.  Alas, help came too late for this likable young man who last year took his life.  Thank you so much to his friend who forwarded the video link to me in a Comment in response to one of my earlier posts on bpd.  The nine-minute video is well worth watching to the end.

My professional colleague H.O. suffers wtith a borderline personality disorder.  H.O.  therefore has  both a professional and personal understanding of bpd diagnosis.  She has written to me recently about bpd diagnosis. I am pleased that H.O.  has given me permission to share her clarifying perspective with my readers, especially since my clinical specialty has been how to fix a marriage more than personality disorders

This article is the third in the series I have been publishing of H.O.'s insights.  The first explained the term borderline personality sufferer and the second addressed the stigma attached to the term bpd from its association with terms like drama queen for women and abusive for men. 


Dear Dr. Heitler:

The question of the diagnostic label for people with what we usually call bpd is very complex.  For a long time there have been controversies about dropping the term “borderline” as misleading and stigmatizing. 

Concerns have been raised also about putting BPD in the PD  (Personality Disorders) cluster.  There seems to be significant biological overlap between BPD and bipolar disorder for example, which the psychiatry establishment considers to be biological as opposed to “bad”.  And many of the most negative features that people often associate with bpd may actually stem from malignant narcissism (impulses to hurt people combined with hearing only one's own desires).

When I diagnose a client with the term Borderline Personality Disorder I base it on two aspects of DSM 5 diagnosis 

a) the general criteria for all of the Personality Disorders, that is, impairment and its continuity in time/across situations an 

b) the specific criteria for BPD 

What are the specific DSM 5 criteria for borderline personality disorder?

-Significant impairments in personality functioning

-Impairments in interpersonal functioning

-Pathological “personality” traits i.e. affective negativity and which consists of: lability of affect, anxiousness, separation anxiety, depressivity.



Stigmatizing and Blame

The term pathological personality traits is especially unfortunate.  This term conveys stigmatizing and blame.   Now not only is the client unhappy but it is his or her fault too.  That's a term that would benefit from deletion.

The DSM also unfortunately fails to clarify that affective negativity (lots of hurt, angry, depression and other negative feelings) is a function of vulnerability.  Because people with bpd have high emotional sensitivity combined with low resilience (ability to bounce back from negative feelings), negative emotions tend to take up more of their time, energies and relationships.  

What is a more helpful perspective for understanding ptsd?

Negative feelings are triggered more frequently for people with bpd at least in part because their amygdala, which controls emotional reactions, is set too sensitiviely.  That is, their amygdala reads "Danger!" where others would see none.  And their amygdala launches intense fight or flight reactions where others would calmly deal with the situation.  

This mood hyper-reactivity/hyper-intensity may stem from ptsd from traumatic childhood experiences including childhood emotional and/or physical abuse, often by a borderline parent. These hyper-intense emotional arousal reations are quite similar to the PTSD (post-traumatic stress reactions) of military personnel who have experienced extremely emotionally painful negative events in war situations.

Emotional hyper-reactivity and hyper-intensity is really the core issues here.  All the remaining items are consequences.

From this perspective, I feel the focus in our articles for psychologytoday.com on emotional hyperreactivity/hyperintensity, which also has been the focus of bpd expert Marsha Linehan's more recent work, has been correct.   

Hyperreactivity refers to seeing threat when there is none.  Hyperintensity refers to reacting to actual threats with excessively high levels of emotional arousal, which may take the form of anger or alternatively can be of depression or anxiety.

So for instance, someone with bpd might hear a comment made by a friend as critical when it was intended to be neutral or positive. "Your hair looks lovely" might be interpreted as "Usually your hair does not look lovely." That's hyperreactivity. And if the reaction is of strong hurt and anger rather than mild concern, that's hyperintensity

Hyper-reactivity/hyper-intensity in experiencing the “abuses of daily life” results in “abnormal” behaviours, attitudes and impairment. Here's another example.  An ambiguous facial expression on a loved one’s face might be read by a bpd individual as sarcasm, in turn evoking either anger and a hostile outburst or intense self-oathing and dispair, which in turn impairs the continuity of relationships.  That’s the chaos-making of bpd in action.

Hyper-reactivity/hyper-intensity also causes ithe frequent diagnostic confusion about whether a patient is bipolar vs. BPD. The therapeutic effectiveness of mood-stabilizing drugs (topiramate, lamotrigine) in both bipolar and BPD also support biological overlap/common.  In both disorders, the underlying mechanism is something biological that causes mood hyper-reactivity/intensity/lability.

What causes this kind of highly sensitive emotional reactivity?

Some people with bpd, men and women alike, have been emotionally reactive and hypersensitive from early on in their childhood.  This hypersensitivity can be challenging for parents to deal with. A combination of kindly and firm parenting can make a significant difference for such children.

Alas, all too often the parents of highly sensitive children often have emotionally hyper-reactive bpd and/or narcissistic parents.

Unfortunately the spirit of biologically sensitive individuals can be broken early, and all the more so if their parent, perhaps suffering from bpd and narcissism as well, contributed abusive parenting  Such individuals then spend most of their lives just trying to survive, feeling constantly torpedoed by “abuses of daily life.”

Normal people are able to shake off or deal with mild conflicts or differences or misunderstandings via cooperative talking.  Such events however  trigger disproportionate, overwhelming and excessively long-lasting emotional responses in BPD individuals.

Diagnosis of borderline personality disorder. Highly sensitive persons
Borderline features begin in childhood.

In sum, all you need to “achieve” the full-blown BPD phenotype as described by DSM 5 is to  start with a  sensitive  and vulnerable biologically hyperreactive/hyperintense/labile child and then expose him or her to an emotionally painful enough experience that the child, being vulnerable, can’t handle or get over  Add in parents who tend toward punishment more than understanding and/or who are excessively permissive instead of helpful in teaching the child to manage his or her emotional storms more effectively, and voila, bpd. 

A highly sensitive child is likely to exhibit emotional hyperreactivity/hyperintensity, putting him or her at risk for BPD in adulthood, espeically  in the absence of a strongly supportive/nourishing environment, even if this environment includes little adversity or trauma. Such extra-supportive environment is unfortunately uncommon, while the vulnerability is quite common.  The result is the high incidence of BPD. 

Of course, Dr. Heitler, I have no objections and give my permission to you to publish anything I write to you about borderline personality disorder and bpd diagnosis, causes and treatment. 

Warm regards,



For links to other articles on borderline personality disorders by Dr. Heitler and H.O., as well as a listing by topic of Dr. Heitler's PT blogposts, please see this index

In addition, my relevant earlier posts on the issue of prevention of raging include:

Anger is a Stop Sign

A Plan for Zero Arguments

What can you do about parental verbal abuse of children?


Understanding highly sensitive persons and bpd.

Susan Heitler, Ph.D., a private practice clinical  psychologist in Denver, has written From Conflict to Resolution on therapy, and The Power of Two and The Power of Two Workbook on the skills for marriage success.  Her website PowerOfTwoMarriage.com offers an interactive online option for learning how to communicate collaboratively in relationships.  




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