The Challenge of Borderline Personality Disorder in a Relationship

Teresa Burgado was in love again. Her relationship with Eduardo started on the A train. Every morning, she got on at the stop before his in Upper Manhattan. They both had jobs in Brooklyn, she as a crisis counselor for children, he loading trucks in a warehouse. They began to trade glances. He struck up a conversation. An immigrant from the Dominican Republic, he spoke only Spanish. She didn't know the language, but they managed to exchange numbers.

"Our conversations at first were just, 'Hi. How are you? Good? Goodbye, mañana,'" Teresa remembers.

The subway rides, and eventually halting conversations on the phone and over dinner at his favorite Dominican restaurants, quickly became Teresa's anchor in a life of turmoil. She had three children with two different men, both abusive. Her efforts to leave them were complicated by her profound fear of abandonment, which sent her into bouts of cutting, weeks without eating, and suicide attempts. She'd been in and out of homeless shelters and inpatient psychiatric care, but eventually, she rallied. Bright and eager to find a meaningful profession, she enrolled in college to study psychology and biology. She happily reunited with her mother, who hadn't been in her life since she was 4. Just as Teresa was about to graduate, she and her mother were in a car accident. Her mother died in her arms.

Still grieving, she immersed herself in Eduardo's world, making his interests her own. It's what she always did when she fell for someone. As a teen, she'd followed her first boyfriend from Florida to New York City. Her second loved baseball, so she became an instant expert in stats and players.

This time, she taught herself Spanish. She regularly picked up a Spanish-language newspaper, watched telenovelas with Eduardo's sister, and spent Sunday afternoons with his extended family. "My entire being was dependent on the person I was with," she says. "I would learn his preferences, so he would never have a reason to leave me."

Even after she quit her job to help her son manage his diabetes, she continued to join Eduardo on the train to Brooklyn, greeting him in the morning with muffins and hot chocolate. He knew she was no longer working, but he was grateful she was so devoted to him. Then she'd turn around and go home, the round trip consuming an hour and a half every day.

They planned to spend their first Christmas together. A few days before the holiday, she dropped him off at work. Then he disappeared.

Being ghosted is gut-wrenching for anyone. But for Teresa, the emotional blow was nearly fatal. After spending Christmas crying on the couch, she injected herself with 60 units of her son's insulin, a dose lethal for most. "I wanted to die and be with my mom," she says. Coming to, hours later, she was shaky, shocked to be alive—and very, very hungry.

When Eduardo showed up at her door after 10 days away, they had a difficult reckoning. He confessed he had a wife and child in the Dominican Republic and had gone to visit them. She told him that she had tried to kill herself. The stakes in their new relationship were suddenly very high. He wasn't sure whether he wanted to stay with her. "If she wanted to kill herself, maybe she would want to kill me, too," he says.

He already knew that Teresa had had a hard past. Now she confessed something else: She had borderline personality disorder. She googled Spanish-language videos explaining what people with BPD go through: intense, difficult-to-control feelings of anger, insecurity, and self-hatred; frantic efforts to avoid abandonment; self-harming behavior such as cutting; extreme mood swings; feelings of emptiness; and bouts of paranoia. Her overdose, Eduardo learned, was also a feature of the disorder. Many people with BPD make recurrent suicide attempts, and up to 10 percent end their own lives.

Eduardo recognized the symptoms. "Oh, my God," he said. "This is so you."

When people with BPD love, they love hard, idealizing partners and friends and forming obsessive relationships. When loved ones disappoint, BPD sufferers go to the opposite extreme, their terror of abandonment driving them to anxiety, rage, or paranoia. The drama of love on the borderline has long been fodder for the media and entertainment industry, from Glenn Close's murderous jilted lover in Fatal Attraction to the musical comedy series Crazy Ex-Girlfriend, which takes a dark turn when its obsessed heroine tries to kill herself. When pop star Ariana Grande and comedian Pete Davidson, who has been open about his BPD diagnosis, got engaged after only a month of dating, social media critics cried foul, underscoring a widespread belief that people with BPD should not be in relationships.

Close friendships, romance, and family bonds are often what people on the borderline crave the most, and they often move in whirlwind style to win over others. But sustaining intimacy is a colossal challenge, as the disorder embodies a most poignant paradox: Sufferers yearn for closeness, but their overriding insecurity tends to drive away those most dear. Despite the self-defeating actions they typically deploy, it is not impossible for them to get beyond the histrionics to maintain closeness—and the very stability of a partner often proves curative.

Hungers Most Human

"To be in a borderline state means never feeling sated," observes psychotherapist and sociologist Ross Ellenhorn. "You pursue feeling full in your relationships. Yet they don't fill you."

The volatility—and vulnerability—of life on the borderline, however, reflects near-universal human hungers. "We are all amazing and ugly creatures," says Ellenhorn. "We're all difficult. On the list of things that make us difficult: We all sometimes shut down our willingness to understand others. We all want to be fed sometimes. We're all wired to react strongly when the prospect of rejection looms." The fear of abandonment shadows even our most secure relationships. When a friend seems to be avoiding us or a co-worker becomes critical, we may grapple with paranoia about whether we're being cast aside. The dissolution of a serious relationship typically brings on a cascade of trying emotions and a diminished sense of self; it can cause us to act out in ways we normally wouldn't.

Although the dramatic volatility of borderline personality disorder has given it a bad rap as a condition that's impossible to treat and an ongoing torment to friends, family, partners, and even therapists, Ellenhorn contends that we will best understand the disorder—and ourselves—when we reckon with the ways it's reflected in the experiences we all share. "I've had plenty of everyday interactions that feel like jarring, daily assaults on who I am. We can call it a borderline state, but it's also called working in an office!" he says. "In this way, I'm very similar to people with BPD. My capacity to bounce back is what makes me different."

In short, the darkest, most difficult parts of our lives look a lot like the diagnostic criteria for BPD. "We all enter borderline states," Ellenhorn says. "Borderline reflects an attachment injury. We all have attachment injuries. That's why I have very mixed feelings about the diagnostic label. On the one hand, it's applied to people whose struggles are not completely separate from basic human experiences. On the other hand, when these states become traits, they cause profound distress. Feeling this way is a living hell."

Frank Yeomans, a New York City psychiatrist, describes those with BPD as "failed romantics." They seek an ideal of perfect love and pursue it zealously. But as soon as the people they're besotted with are a few minutes late, or can't text during a busy work day, BPD sufferers go into a tailspin. They'll rage, slice lines up their legs with a razor, stop eating, or simply flee, deeming their partner the enemy, even when the relationship has real potential. "They're feeling angry, but they see the other as the angry, rejecting one," he says.

This black-and-white thinking is known as "splitting." A friend or lover is either "just perfect or all hell breaks loose," he says. "The borderline mind has not yet been able to integrate positive loving feelings with negative ones, such as frustration and anger. Since every relationship includes a whole range of emotions, you've got to deal with all of it to have the relationship work out."

When Maddi Mathon, a 22-year-old student in Toronto with BPD, first joined Tinder, every time she had a new date she became ebullient, envisioning a future of marriage and children. When things inevitably didn't go as well as she'd fantasized, she'd have a "giant letdown" and spend weeks obsessing over what happened. "Even though we'd spent only two hours together, and he was barely an acquaintance, it felt as though a lot was at stake. I felt abandoned," she says.

Then one of her dates turned into a relationship. Her boyfriend was warmly supportive. Six months in, her job became acutely stressful. Her boss reprimanded her for mistakes she felt weren't her fault. One day she came home so distraught that she called her boyfriend and told him she wanted to die; she pleaded with him to come over. He couldn't leave his house right away and asked her to come to him. "He was doing his best, but after that I didn't trust him and put my defenses up," she says. "That's how my BPD has always presented. Something goes wrong and I jump ship. The guy goes from being an awesome person to a terrible person." She left him soon after.

Rejection sensitivity is a key feature of borderline personality disorder, observes Eric Fertuck, a psychology professor at the City College of New York. At times, borderline sufferers cope by being wary of forging any kind of emotional bond with anyone. Other times, they overtrust. "They are scared, so they may throw caution to the wind about entering a relationship. Then they can feel betrayed when a partner lets them down," he says. "Or they may feel trapped in a relationship because they'll feel worse off alone. They may feel compelled to deny flaws and inadequacies in their partner just to know that someone is in their life."

An Unquiet Amygdala

The extreme way people with BPD experience the world reflects a glitch in brain dynamics. Typically, the prefrontal cortex, the part of the forebrain responsible for self-control and decision-making, governs the limbic system, an evolutionarily ancient set of brain regions that generate primal emotions such as fear, centered in the amygdala. "People with BPD seem to have less input from the prefrontal cortex to the amygdala," explains Sarah Fineberg, a clinical neuroscientist at the Yale School of Medicine. Brain scans of those with BPD show that the amygdala is overactive. "Without the quieting influence of the prefrontal cortex," says Fineberg, "amygdala activity is increased all the time and reacts more strongly to experiences."

The high levels of amygdala activity, researchers believe, also encourage those with BPD to misinterpret certain social cues. They are more likely to interpret neutral facial expressions as angry and to feel excluded.

One way of gaining insight into the subjective experience of closeness in relationships is to look at preferences about personal space—how people react to physical proximity to others. Researchers have found that the amygdala is an important regulator of interpersonal distance, with activity increasing when someone gets too close. Fineberg suspected that amygdala activity might be a factor in the difficulty those with BPD have in regulating personal closeness.

She and her team tested interpersonal distance in 30 women with BPD and 23 healthy controls by walking slowly toward them. Subjects were asked to indicate when they began to feel uncomfortable. Those with BPD halted her at a significantly greater distance than did healthy controls. "People with BPD are going around in the world with brain signals constantly telling them that people are threatening," Fineberg says. "They need more space around them to feel safe."

In a recent study conducted with Yale neuroscientist Philip Corlett, Fineberg found that people with BPD are highly attentive to social cues but adapt more slowly than healthy controls when circumstances shift. Noticing and reacting to a social cue—feeling afraid and bristling at the slightest sour expression, for example—is not the same as adjusting behavior to it. "People with BPD have learned that trying to change your mind when things get unpredictable is ineffective," she says. "They keep using old paradigms even when they don't work well."

Early life abuse and neglect are among the most significant risk factors for BPD, Fineberg explains. Children scramble to cope with the unpredictability of parents or other primary caregivers: "Sometimes the caregivers show up, but the child doesn't know when or what kind of state they'll be in. We hypothesize that children in this situation try to understand the caregiver, and work hard to adapt to changing circumstances. Some amount of this experience likely contributes to emotional intelligence. However, if children try to adapt over and over and are unsuccessful, they may ultimately learn that adapting doesn't work. BPD sufferers may find that changing strategies all the time to secure a caretaker's attention is energetically too expensive."

Emotional Intelligence Overruled

City College's Fertuck finds that those with BPD do better than healthy controls at interpreting the emotions in people's eyes, whether it's flirtatiousness or discontent. Such ability, however, is motivated by "this intense worry that they will be hurt," Fertuck says. "They can't trust the past. They have to keep checking in on what their partners are feeling."

The combination of exquisite sensitivity to the feelings of others and the tendency to have outsized reactions to the slightest hint of anything negative constitutes what researchers call "the empathy paradox" of BPD. Pervasive rejection sensitivity drives people with BPD to accurately read others' emotions in the moment but, unable to accurately infer others' character and trustworthiness, they cannot make predictions about how people will behave over time. "Someone with BPD might read anger accurately in a person's face, and quickly assume this means they are a threatening person," Fertuck says. "People without BPD would not necessarily assume someone's momentary angry expression means that that person will be untrustworthy or threatening over time."

For Emily Cutler, a 23-year-old graduate student in Tampa with BPD, that exquisite sensitivity to others, even when it feels painful and ignites fears of abandonment, is a source of pride. "I get very attached to close friends as well as significant others," she says. "I rely on others for having my emotional needs met. It creates an opportunity for really deep personal relationships, but also intense suffering."

Yet for others, the sensitivity of BPD becomes too exhausting to include intimacy. For much of his life, Ross Trowbridge, a 39-year-old vocational rehabilitation assistant in Waterloo, Iowa, inhabited a "living hell." He had a pattern of quickly jumping into relationships, only to find himself feeling terrified. He would suddenly disappear, spending days in bed, crippled by thoughts of killing himself, unable to hold down a job. He tried to hang himself with his belt and was hospitalized several times.

In the four years since he was diagnosed with BPD, he's largely avoided romantic relationships. He prioritizes sleep, healthy food, therapy, and meditation. He recently felt strong enough to return to work, and he's also thrown himself into mental health advocacy as the founder of #Project I Am Not Ashamed, a campaign to end the stigma of BPD and other mental health disorders.

Trowbridge says he's simply not ready to add a relationship to the complicated and time-consuming work of keeping himself stable. "I need to be cautious about getting too high or too low. While others can ride the waves of joy and happiness, I cannot. It can be dangerous for me. I could be fine today and have a belt around my neck by the weekend."

Nevertheless, over the past year, he's become close with Judd, a 64-year-old man with BPD he met in a psychiatric ward. With Judd, Ross says, he can be completely honest about his disorder, without fear of being judged. They've even been able to push through the ups and downs typical of any friendship. "I'm learning a lot," Trowbridge says. "My friendship is teaching me how to have a relationship."

Work Before Love

Yale's Sarah Fineberg contends that, with the right help, BPD sufferers can build the emotional muscle for better relationships through small, repeated encounters at work, in their community, and with friends. "Work before love is the first thing most therapists recommend," she says. "Have relationships at arms' length that are steady and successful before taking on intimate relationships. Don't make love the foundation of your stable base."

Talk therapy, experts say, is fundamental to treating BPD. Medication may help quell symptoms, such as anxiety, but the go-to treatment for BPD has long been dialectical behavior therapy (DBT), an intensive program of group skills training on mindfulness, distress tolerance, conflict management, and emotion regulation, supplemented by psychotherapy and phone coaching. Developed by University of Washington psychologist Marsha Linehan—herself a BPD sufferer—DBT focuses on controlling the behaviors that characterize the disorder. Clients use techniques of mindfulness and distress tolerance to endure painful emotions instead of acting out through cutting, suicide attempts, unsafe sex, substance abuse, or disordered eating.

Powerful as DBT can be in helping people stop binge eating or flying into a tirade at the slightest disappointment, it doesn't necessarily affect the underlying disorder—a fragile, fragmented sense of identity. "My patients come to me and say, 'I don't cut myself anymore, but I can't get close to anybody. Can you help me get close to somebody?'" Frank Yeomans reports.

He finds that transference-focused psychotherapy (TFP), a psychodynamic approach, helps patients work through the emotional factors that trigger borderline behavior. Transference is a universal human tendency to relate to people reminiscent of important others in our past—a parent, a lover—as if they were that important figure. TFP utilizes the transference that occurs between patient and therapist to redress relationships with others. "Change in therapy happens when thinking and reflection take place as the related emotion is being experienced in the therapy session in real time," Yeomans explains.

In one instance, he recalls, a patient asked if she could borrow one of his books. When he refused, she raged at him and threatened to throw a can of soda at the wall. After calming her down, he helped her recognize that underlying the anger was a feeling of rejection. Once aware of what she was really feeling, she could control it and how she expressed it. "Through their intense reaction to me, they can look at their inner experience and feelings and evaluate how they're reacting to the world," he says.

When BPD sufferers go to extremes—begging partners for attention, attacking them as hostile enemies, or reacting to a real or perceived slight by engaging in self-harm—the emotional upheaval shuts down their own ability to read how their partners are feeling. Ross Ellenhorn deploys mentalization-based treatment, which helps patients regain curiosity about what's going on inside the mind of someone else so they can see themselves from the outsider's perspective. In situations of conflict, he urges them to step back and become an emotional detective, carefully figuring out what the other person is feeling.

The process is useful to anyone navigating an intense conflict, he finds. "If you don't understand the psychological state of another person, it's very hard to be in a relationship," he says. "Mentalizing teaches you that instead of feeling angry and thinking the other is a horrible person, you feel the anger and recognize that is what is happening to you. Then you step back and try to understand what's happening to the other person."

Such therapeutic efforts make recovery from BPD possible. In a 10-year study of 290 people who had been hospitalized with BPD, more than 90 percent had passed a two-year milestone without symptoms, and 86 percent were symptom-free for at least four years. Half achieved what the study defined as full recovery—they not only had no symptoms, they had at least one close relationship and were working or going to school full-time. Sixteen years after being hospitalized for BPD, 79 percent of recovered subjects had gotten married or lived with a partner for more than five years.

Still, even those who recover from BPD are unlikely to ever be low-maintenance partners and friends (who among us truly is?). Loved ones need to develop such skills as stress management, self-care, and maintaining good boundaries so they can look out for themselves while helping their partner, says New York psychiatrist Grant Brenner, a co-author of Relationship Sanity: Creating and Maintaining Healthy Relationships. "With mental illnesses that affect the way people behave toward one another, especially if they can be attacking and hurtful, more is demanded from the partner," he says.

But life on the borderline also provides an opportunity for growth of what he calls the "us-ness" of a relationship. In any relationship, he explains, each partner has individual needs, but for the relationship to thrive, partners need to consider it a shared entity and nurture it. "Dealing with BPD requires a concerted effort to use overcoming difficulty together to deepen the bond and build a track record of getting through things jointly, which often strengthens the relationship over time," he says. "Two people oriented toward learning and looking for growth can use the challenges of BPD to cement the relationship rather than drive it away."

Five years after Teresa played the BPD videos for Eduardo, they're still together. Perched across from Teresa at a neighborhood pub, Eduardo tears up as he remembers their first crisis. "When she explained the problem, I decided to care more for her," he says. "I wanted to be there for her, and I wanted to help. A lot of people would run away, but for me it had the opposite effect."

Staying together took work. She went back into therapy; Eduardo participated in some of her telephone sessions, with Teresa translating for him. Her therapist noted that even though he was married, he was a good partner to Teresa. The therapist also helped them set some clear terms. If he had to leave to see his wife, he had to tell Teresa in advance so she could arrange to have a friend stay and help her through her terror of abandonment. Teresa attended daily DBT sessions. One of her treatment goals was to stop the obsessive and time-consuming commutes with Eduardo.

After the rocky first months, Teresa rallied once again. She finished her degree and now works as a case manager for people with mental health and addiction issues. She and Eduardo are devoted to each other, so enmeshed in each other's lives that he sometimes calls her his wife—despite his marriage. "I had to accept that if we were going to stay together, this other woman was going to be there," she says. "Right now, it's okay. I don't know if he's the be-all and end-all guy, but for the first time with someone, I'm in the gray area instead of thinking it's all or nothing."

To Love Someone With Borderline Personality Disorder

A friendship or romantic relationship with someone who has BPD can be challenging. Learning ways to cope, however, can not only strengthen the bond but also help a loved one recover.

Strike while the iron is cold. People with BPD have trouble thinking clearly when their emotions are running high. Avoid discussions about conflicts in your relationship until your partner feels calm and safe. "Try not to take comments about you too personally when she's distressed," says New York City psychologist Eric Fertuck. "She will feel different about you when she's less upset."

Emphasize that it's okay not to be perfect. Any relationship brings lots of hopes and dreams about what the other person will be like. It can be easy to see the person in extremes—the Ideal Mate or the Huge Disappointment. "Look out for ways you and your partner are imperfect and acknowledge that this is normal," says Yale neuroscientist Sarah Fineberg. "Acknowledge your mistakes and challenges and how you might benefit from support to change. Acknowledge that relationships include a range of emotions, and sometimes you'll feel upset with each other."

Beware of feeling trapped. People with BPD may threaten suicide or self-harm to keep you close. If you're staying with a partner or a friend only because you're worried he can't survive without you, it's time to seek help. Couples therapy can be a safe environment to express the impact of the person's behavior on your life. "When you shift the attention to yourself, you're sending the message: I respect you, I value you, and I'm going to tell you the effect of your behavior instead of sparing you all the time," says New York psychotherapist Esther Perel, author of The State of Affairs and Mating in Captivity. "The more you spare the person your feelings, the more you devalue him and the more you're afraid of him."

Stay curious. Coping with someone who is in a state of fury and helplessness can put you in your own emotional turmoil. Try to set that aside and ask your loved one about what's going on inside. "Your curiosity is the medicine your partner needs," says psychotherapist and sociologist Ross Ellenhorn.

Facebook Image: AT Production/Shutterstock