The Perfect Storm in Borderline Personality Disorder
Three factors that collide in one of psychology's least understood disorders.
Posted Aug 19, 2014
If you’ve known anyone with borderline personality disorder (BPD), or if it’s a disorder with which you struggle, you’re aware of the emotional highs and lows that are part of its symptom picture. Indeed, researchers are interested in the concept of “emotional dysregulation” as a problem experienced by people with this disorder (Speranza, 2013). Ordinarily, we become better able to control our emotions as we leave behind the childish tantrums of infancy. People with BPD don’t seem to have figured out just how to keep their feelings, particularly their anger, within bounds.
Theories of BPD for many years have emphasized disturbances in caregiver (usually mother)-child relationships as lying at its core. People with BPD disorder have an unstable sense of self, tend to see others as either all good or all bad (“splitting”), are prone to dramatic episodes in which they threaten to commit suicide (but don’t, especially in “cutting”), and have difficulty negotiating the difference between “you” and “me.” According to classic views of BPD, these symptoms reflect abnormalities in the attachment bonds which, in normally developing people, allow the child gradually to achieve psychological separation from the caregiver. The child doesn’t become so separate as to disengage emotionally, but is separate enough to have a stable and secure sense of self.
Because the psychiatric manual, the DSM-5, places BPD in the set of “personality disorders,” its characteristic symptoms are viewed by mental health professionals as essentially unchangeable throughout life. Part of the fabric of your personality, you’ll never really get over the instability and relationship turmoil that BPD entails. However, a new view of BPD is placing increasing emphasis on the emotional, or mood, components of the disorder.
According to Boston University psychologists Shannon Sauer-Zavala and David Barlow (2014), BPD reflects an emotional disorder reflecting high levels of the personality trait neuroticism. The product of genes, general vulnerability, and specific early parenting experiences, BPD is at its heart much like an old-fashioned "neurosis."
Like people with other psychological disorders involving intense and frequent negative emotions, such as major depressive disorder, those who have BPD are often intensely unhappy and anxious. As a result, they are predisposed to overreact when something doesn’t go their way, like a powder ready to explode with the slightest provocation.
In reviewing the evidence, Sauer-Zavala and Barlow note people with BPD not only have strong negative emotions, but that they also have strong negative reactions to their negative emotions. Nobody really does want to experience negative emotions, but for people with BPD, the aversion is so strong that they develop coping strategies to avoid getting in touch with their feelings. Called “experiential avoidance,” this unwillingness or inability to feel strong emotions can create serious psychological difficulties in coping with stress.
As a result of the emotional distancing that people with BPD engage in, they lack “mindfulness,” or the ability to be aware of and accept what’s going on around you. The kind of disengagement that people with BPD show toward their internal emotional states could, according to Sauer-Zavala and Barlow, account for their tendency to engage in acts of bodily self-harm. As difficult as it may seem to understand, by cutting or otherwise harming themselves, people with BPD experience this physical pain as a relief from the pain of their intensely negative emotions.
Unfortunately, the reactions that people with BPD have toward their negative emotional states only intensifies those very same negative emotional states. The effort they make to not think or feel results, paradoxically, in creating more emotional turmoil and a host of problems in living. Experiential avoidance is an almost completely ineffective coping strategy.
In drilling down to the core of BPD, Sauer-Zavala and Barlow show how high levels of neuroticism can explain much of the misery suffered by people with this disorder. Studies of people with BPD consistently show that they score high on measures of neuroticism, and higher than people with other personality disorders. Genetics is partly to blame for these high neuroticism levels. Inheriting high neuroticism makes people with BPD more likely to suffer negative consequences if they have early life experiences that make it difficult for them to learn how to manage their emotions. Ordinarily, parents impart a sense of security and predictability about life to their children. When this doesn’t happen, the individual fears that life itself is uncontrollable.
Added to general vulnerability that people with BPD have due to high levels of neuroticism and an unpredictable environment is the “invalidation” that these individuals have in their relationships with their parents. Constantly being criticized, blamed, and punished for expressing their feelings, these children develop into adults who show the characteristic BPD symptoms of experiential avoidance, instability, and inability to regulate their own emotions.
As gloomy as the picture sounds for people with BPD, this recognition of emotional difficulties at its core could prove ultimately helpful in treatment. Sauer-Zavala and Barlow believe that “transdiagnostic” approaches could focus not only on specific symptoms but on the root cause of high neuroticism levels. Cognitive therapy, which targets faulty thinking as the cause of emotional problems, would be one component. In addition, people with BPD could benefit from looking squarely at their high levels of the neuroticism trait, identify how it’s creating difficulties in living, and then ultimately try to lower it. Helping individuals with BPD through mindfulness training would be another essential component to treatment.
There is still, then, a personality component to the personality disorder of BPD–namely, high levels of neuroticism. However, even though we think of neuroticism as an immutable trait, the negative emotional consequences it brings with it can be addressed and even changed.
Following from Sauer-Zavala and Barlow's model, If you or someone you’re close to has BPD, these are the practical steps you can take:
1. Recognize that people with BPD experience strong negative emotions. As challenging as it can be to live with someone who’s constantly overreacting, this isn’t a behavior that the individual can easily control. People with BPD aren’t faking it when they become enraged.
2. Ensure that the person with BPD is safe. The tendency toward self-harm can obviously lead to serious physical consequences. Although they may not mean to commit suicide, people with BPD may be engaging in gestures that put their lives at risk.
3. Give people with BPD the opportunity to examine their feelings. Because experiential avoidance is such a significant aspect of their lives, people with BPD are constantly trying to keep their negative feelings out of their awareness. Learning to read their own emotional state can be an important step to changing those negative emotions.
4. Help people with BPD become more accepting of their emotions. Part of the reason that people with BPD try to stay away from recognizing how they feel is that they fear what will happen if they do. They can benefit from learning that disastrous consequences don’t have to follow from recognizing that they’re unhappy or anxious.
5. Be patient. Changing longstanding personality and emotional patterns takes time, no matter how skilled the therapist or understanding the friend, lover, or family member.
The main point of the Sauer-Zavala and Barlow formulation is that we need a new framework to approach the understanding and treatment of BPD. The underlying theory and practice that they recommend is one that we can hope will become increasingly adopted by therapists. By looking at the root causes of these fascinating but challenging disorders, you can help yourself, or those you care about, live a more fulfilling and symptom-free life for many years to come.
Sauer‐Zavala, S., & Barlow, D. H. (2014). The case for borderline personality disorder as an emotional disorder: Implications for treatment. Clinical Psychology: Science And Practice, 21(2), 118-138. doi:10.1111/cpsp.12063
Speranza, M. M. (2013). Borderline personality disorders: The central role of emotional dysregulation. European Psychiatry, 28(8, Suppl), 61. doi:10.1016/j.eurpsy.2013.09.160