First things first: please do not diagnose yourself or a loved one with this information. Only a licensed mental health or medical provider can give you a diagnosis – and even then, it’s not an exact science.
What is Borderline Personality Disorder?
Borderline Personality Disorder (BPD) is a mental health diagnosis given to people who meet five or more of the following nine criteria:
1) Engaging in ineffective behavior to avoid abandonment.
2) Difficulty maintaining healthy relationships.
3) Difficulty creating a consistent sense of self.
4) Impulsive behavior that could potentially cause harm
5) Frequently thinking about, talking about, or engaging in self-harm or suicidal behaviors.
6) Intense and frequently shifting moods.
7) Intense feelings of emptiness (often called “the Void”).
8) Episodes of intense anger that is inappropriate for the situation.
9) Occasional, stress-related psychosis.
For the purposes of this post, I’m going to talk in general terms about these symptoms. In the future I will talk about each symptom in-depth in its own article. But before we go any further, it might be helpful to learn a little bit more about what a diagnosis is, and what it means. You can find that information here.
Now that we’ve established a basic understanding of what a BPD diagnosis means, let’s take another look at the symptoms of BPD.
We can sum all the symptoms up as a lack of effective emotion regulation skills. All the symptoms are either the direct result of a lack of these skills, or an indirect result of ineffective actions made as an attempt to regulate emotions.
What is emotion regulation?
Think back to the last time you were very angry or sad. How did it feel in your body? Was your heart racing? Were your muscles tense? Did you get sweaty? Was your mouth dry? Was your face hot?
What about what happened in your mind? Did your thoughts go on a loop – replaying themselves over and over? Did you start to spiral – thinking of how things could get worse? Did your brain reach for all the other times things like this have happened? Did your mind use words like “always” and “never” and “can’t handle this” and other extreme phrases?
What did you do to make yourself feel better? Did you talk it out? Wait for it to pass? Exercise? Choose to think differently? All of those are emotion regulation skills.
Emotion regulation is the term we use to describe the way people change their feelings on purpose. We learn emotion regulation skills from our families, our friends, our teachers, self-help books, sports coaches, and a ton of other sources. But we usually learn the most from our families when we are little kids.
There are a million different ways someone can regulate their emotions. Sometimes people yell, sometimes they take a deep breath. Sometimes they force themselves to look on the bright side, or try to find a solution to their problem. Some people go for a run, dance it out, call a friend, sing, draw, or take a nap.
We call emotion regulation either “effective” or “ineffective” based on the consequences of the action. The consequences are dependent on the individual context of the action. No skill is good or bad by itself – it depends on how we use it.
So if I’m tired and I put on my pajamas and go lie down in bed, that might be “effective” because I’m getting rest. But what if I’m in the middle of a very important meeting? Or maybe it’s nighttime but I am lying down in my front yard. Then the same skill of taking a nap would suddenly become “ineffective.”
BPD and ineffective emotion regulation
When we study people who have BPD (this is a generalization! No two people are alike) we find that they do not know effective ways to regulate their emotions.
This is caused by a variety of factors:
1) studies show that people with BPD have hyper-reactive amygdala and other structural changes. This means that the parts of the brain that perceive danger over-react to stimuli that other people wouldn't find dangerous. When the amygdala over-reacts, it sends a message to other parts of the brain to ramp up the emotional response. There is also evidence that traits like impulse control are genetically inherited, and that people with BPD are often born with less ability to regulate their impulses.
2) as a child, they were a little more sensitive than average, possibly due to a genetic reason. When you ask someone with BPD to estimate how intense their emotion feels, they usually rate every emotion as between an 7-10 on a scale of 1-10, even in situations where a non-BPD person might only rate the emotion as a 2 or a 3, and
3) their caregivers were not able to regulate for them when they were young. Most babies learn emotion regulation by copying what their parents do. But if their parents aren’t able to soothe them, the baby has nothing to copy. An environment where caregivers cannot help a child learn to regulate their emotions is called an invalidating environment.
Notice that I am not saying why the caregivers were unable to do this. It could be because they don’t have the skills themselves – not because they are intentionally withholding.
We also know from studying people with BPD that childhood trauma is a common factor. Almost everyone with BPD has a history of Big T or little t trauma (more on that later). We know that trauma changes the way people process the events around them and makes them feel more threatened.
So we have people who are genetically predisposed to be more sensitive, combined with an environment that doesn’t teach them how to manage their emotions, and then we (usually) add in some trauma, which makes emotions even more intense.
So what do people with BPD do to manage their emotions?
They do whatever they have access to. Whatever works in the short term.
Let’s go back to the nap example. Imagine I’m tired and I want to take a nap. Except when I feel tired, I don’t feel a little bit tired. I feel completely and totally exhausted. I could fall asleep just sitting up – so maybe I put my head down on my desk in the middle of an important meeting.
That’s very effective in the short term – after all, it’s going to cure my exhaustion. But it has some pretty nasty consequences in the long term – I might lose my job, I might upset the people around me, I might get a reputation as lazy.
But if I don’t have any other more effective ways to manage feeling tired, then I just have to take that nap and deal with the consequences later.
That’s how people with BPD feel, every single time they feel an unpleasant emotion.
When we review the nine symptoms of BPD and look at them through an emotion regulation lens, we see how they are all related.
Of course, every person will have a different combination and severity of the symptoms, so this is just a general overview:
1) Engaging in ineffective behavior to avoid abandonment – someone who has trouble regulating their own emotions would naturally be very afraid if a loved one was leaving them. It would mean they are left alone to manage their own emotions – something they have great difficulty with. So they will try to stop the abandonment from happening, but since they don’t have effective ways to label their emotions and interact with others, they may actually push them further away.
2) Difficulty maintaining healthy relationships – every interpersonal relationship has challenges, brings up anxiety, and makes us feel insecure sometimes. People with BPD have to navigate all the same challenges that come with a relationship – but they have to do it with very few effective skills to help themselves feel better or solve problems. They may feel intense affection for another person, and then the next day they may feel hurt and decide that the safest course is not to love that person anymore at all.
3) Difficulty creating a consistent sense of self – people with BPD tend to define themselves from the outside-in. They use feedback from the people around them to determine what they like or don’t like about themselves. When things are going well, they feel good about themselves. When things are going poorly, they feel badly about themselves – and can’t stop that shame or self-loathing from spiraling out of control.
4) Impulsive behavior that could potentially cause harm – this is a way that people with BPD regulate their emotions from the outside-in. Shopping, reckless driving, unsafe sex, and substance use are all ways that people try to change the way they feel.
5) Self-harm or suicidal thoughts / actions – the ultimate recourse for someone who cannot regulate their own emotions. When someone consistently feels overwhelmed with pain, and doesn’t know how to make themselves feel better, they may wish for an escape. Please note that two things can be true at the same time: I can say that suicidal thoughts make sense, but I am not endorsing suicide as a way to end suffering. Please call your local emergency services or a crisis hotline if you are having thoughts of suicide.
6) Intense and frequently shifting moods – this one feels self-explanatory at this point.
7) Intense feelings of emptiness (often called “the Void”) – because people with BPD cannot regulate their emotions, and have a hard time maintaining a consistent sense of self, plus the fact that most people with BPD have experienced a history of trauma, makes just existing extremely painful. Feelings that other people might call “boredom” are actually moments when a person with BPD has no external feedback about how they’re doing. People with BPD describe this as having a gaping hole inside their chest that they might fall into at any moment. They act in impulsive ways (#4) to make this feeling go away.
8) Episodes of intense anger that is inappropriate for the situation – a lack of effective emotion regulation skills means that the person with BPD cannot control their anger once it reaches a certain point – so they let it show in ways that are not appropriate for the situation, and usually backfire in the long term.
9) Occasional, stress-related psychosis – in extreme situations, when the person with BPD is completely overwhelmed and cannot regulate their own emotions, their brain may use psychosis as an “escape hatch.” Basically, the brain stops trying to figure out what’s real and what isn’t real. This may mean the person sees or hears things that aren’t there. It could also mean that the person dissociates – their brain no longer feels connected to their body, they feel like they aren’t fully present in the moment, or like they aren’t fully human.
When we look at BPD through an emotion regulation lens, there is a lot of hope: every single symptom can be addressed, simply by learning emotion regulation skills!
It is hard work to re-wire your brain and learn brand new ways of coping with emotions and interacting with the world. But it is absolutely possible.
All therapies for BPD work by teaching people to accept their current emotions, and act effectively to change them in the future.