Borderline Personality Disorder / Emotionally Unstable Personality Disorder

What is it?

A serious condition as defined by the DSM 5 in which one must meet one of the following 5 criteria out of 9, it must be persistent, pervasive and pathological in all areas of life. A full diagnosis can only happen by a trained clinician using a recognised tool such as the Structured Clinical Interview over the course of 6 – 8 hrs taking a full psychological, personal and family history. Unfortunately, in the NHS individuals are given a ‘working diagnosis’ when they first present usually after a 30 minute consultation which can be harmful.

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two potentially self-damaging areas i.e. spending, sex, substance misuse, recknless driving, binge eating, purging
5. Recurrent suicidal behaviour, gestures or threats or self-harm
6. Affective instability due to marked reactivity of mood (i.e. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

With that all being said if an individual grew up in an invalidating environment all of the above would be a naturally occurring as creative adaptation. If children grow up without an adult to teach them how to be in relationship, to regulate emotions, to navigate distress then the child wont learn this and will struggle with all of the above.

How is it caused?

I always describe to my clients that it is a result of 100% nature and nuture in the development of these difficulties. BPD is also a trauma response above anything else so if you are someone reading this who holds critical views because understand this as I hope this helps with compassion. Unfortunately social media and press don’t provide accurate information and often vilify those who struggle.  Over 80% of individuals who meet the criteria for BPD / EUPD experienced some form of childhood emotional neglect, physical abuse or sexual abuse.

What to do about it?

The best treatment is psychological therapy, now there are different opinions as to what ‘type’ of therapy is best suited and what I will say is that there are far more commonalities in all the types of therapies than there are differences so its not about do X therapy for X problem and Y therapy for Y problem.

The best predictor of therapeutic success is the relationship you develop with your therapist. What I would say though is that often within my NHS work clients have experienced rejection from other modalities of therapy because often the behaviours that individuals engage in which to self-soothe and cope such as self-harm and suicide attempts mean the individual therapist in private practice struggles to see them safely because they are not part of a wider team. Therefore, my first recommendation is stabilisation work such as DBT, it has a proven track record to help individuals even with the most severe forms of shame which leads to self-destructive behaviours. Once this happens moving more towards psychotherapy.

Medication can help but is limited in effect. There is no medication which is recommended for BPD but the impact of living with BPD can lead to depression or anxiety for which anti-depressants such as SSRI’s and SNRI’s can be really helpful.