Borderline Personality - Symptoms & Diagnostics
It is estimated that there are 18 million husbands, wives, boyfriends, girlfriends, parents, and children who are affected by Borderline Personality Disorder - even more if you consider traits. Few even know about their condition or seek treatment.
Symptoms of Borderline Personality Disorder
Trying to determine if someone in your life may suffer from Borderline Personality Disorder? This eight minute video is a good starting point (1).
You will soon find out, however, that this is a complex question. There are no simple behavioral checklists; no definitive tests. Identifying Borderline Personality Disorder requires having a working knowledge of the disorder and some insight into the past life of the person in question.
Borderline Personality Disorder is a disorder of the emotions. Imagine a person who is extremely sensitive to rejection (fearful of even perceived or anticipated rejection) and has a limited ability to modulate their emotional impulses (love, fear, anger, grief, etc.). To protect themselves from their own feelings, they are prone to adopt a multitude of dysfunctional rationalizations and cover-ups.
For example, a person suffering from BPD may so fear rejection in a new relationship that they recreate themselves in the image of a person they believe would be lovable. When the negative emotions for making such a sacrifice surface - and not having the ability to modulate them, they lash out at the target of their affections for "making them do it" - rather than face their own feelings of inadequacy / fear of rejection, ultimately damaging the relationship they so fear losing, and reinforcing their feelings of inadequacy / fear of rejection.
What is going on in a Borderline Personality Disorder sufferer's mind and how they are acting can be two entirely different things.
To the sufferer, BPD is about deep feelings, feelings often too difficult to express, feelings that are something along the lines of this (2):
- If others really get to know me, they will find me rejectable and will not be able to love me; and they will leave me;
- I need to have complete control of my feelings otherwise things go completely wrong;
- I have to adapt my needs to other people's wishes, otherwise they will leave me or attack me;
- I am an evil person and I need to be punished for it;
- Other people are evil and abuse you;
- If someone fails to keep a promise, that person can no longer be trusted;
- If I trust someone, I run a great risk of getting hurt or disappointed;
- If you comply with someone's request, you run the risk of losing yourself;
- If you refuse someone's request, you run the risk of losing that person;
- I will always be alone;
- I can't manage by myself, I need someone I can fall back on;
- There is no one who really cares about me, who will be available to help me, and whom I can fall back on;
- I don't really know what I want;
- I will never get what I want;
- I'm powerless and vulnerable and I can't protect myself;.
- I have no control of myself;
- I can't discipline myself;
- My feelings and opinions are unfounded;
- Other people are not willing or helpful.
To the family members, BPD behavior is often very frustrating and can feel unfair and punitive - something like this (3):
- You have been viewed as overly good and then overly bad;
- You have been the focus of unprovoked anger or hurtful actions, alternating with periods when the family member acts perfectly normal and very loving;
- Things that you have said or done have been twisted and used against you;
- You are accused of things you never did or said?
- You often find yourself defending and justifying your intentions;
- You find yourself concealing what you think or feel because you are not heard;
- You feel manipulated, controlled, and sometimes lied to.
As such, the most obvious "symptom" of Borderline Personality Disorder is a lifelong pattern of instability in interpersonal relationships, self-image and emotions.
Why is Borderline Personality Disorder Difficult to Diagnose
Borderline Personality Disorder is a relatively recent addition to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization International Statistical Classification of Diseases and Related Health Problems (ICD). Accordingly, the majority of practicing mental health professionals graduating prior to 2000 have not been trained on the diagnosis and the treatment of this complex disorder as part of their professional curriculum.
Additionally, the clinical definition of Borderline Personality Disorder is very broad. In the DSM-IV it is defined in terms of nine criteria of which 5 or more are indicative of the disorder. This translates to 256 clusters of criteria, or constellations as they are known, any one of which is diagnostic for BPD. Within these constellations, there are high functioning borderlines that operate well in society and whose disorder is not very obvious to new acquaintances or the casual observer. Also within these constellations are the low functioning borderlines who are more apparent as they can't hold jobs, or they self-harm (cutting). Suicidal attempts/ideation and anorexia/bulimia are some of the most serious aspects of this disorder - yet, many with the disorder do not exhibit either.
Proper diagnosis and treatment of Borderline Personality Disorder is spotty at best with community healthcare providers, marriage counselors, and family therapists who are often hesitant to diagnose or treat the disorder. As a result, most borderlines are undiagnosed or in treatment for other maladies such as depression or PTSD. If you suspect Borderline Personality Disorder, it is best to use a specialist, preferably one associated with a University.
Below we have listed available testing resources for BPD as well as several characterizations of this disorder by professional organizations.
Below are several diagnostic testing methods.
Diagnostic Interview for Borderline Patients (DIB-R)
The Diagnostic Interview for Borderline Patients (DIB-R) is the best-known "test" for diagnosing BPD. The DIB is a semi structured clinical interview that takes about 50-90 minutes to administer. The test, developed to be administered by skilled clinicians, consist of 132 questions and observation using 329 summary statements. The test looks at areas of functioning associated with borderline personality disorder. The four areas of functioning include Affect (chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, emptiness), Cognition (odd thinking, unusual perceptions, nondelusional paranoia, quasipsychosis), Impulse action patterns (substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors), and Interpersonal relationships (intolerance of aloneness, abandonment, engulfment, annihilation fears, counterdependency, stormy relationships, manipulativeness, dependency, devaluation, masochism/sadism, demandingness, entitlement). The test is available at no charge by contacting John Gunderson M.D. McLean Hospital in Belmont Massachusetts (617-855-2293).
Structured Clinical Interview (SCID-II)
The Structured Clinical Interview (now SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It closely follows the language of the DSM-IV Axis II Personality Disorders criteria. There are 12 groups of questions corresponding to the 12 personality disorders. The scoring is either the trait is absent, subthreshold, true, or there is "inadequate information to code". SCID-II can be self administered or administered by third parties (a spouse, an informant, a colleague) and yield decent indications of the disorder. The questionnaire is available from the American Psychiatric Publishing ($60.00).
Personality Disorder Beliefs Questionnaire (PDBQ).
The Personality Disorder Beliefs Questionnaire (PDBQ) is a brief self administered test for Personality Disorder tendencies. We have included a list of questions most often answered as "yes" by people with Borderline Personality Disorder .
Other commonly used assessment tests are rating tests such as the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). In addition there are some free, informal tests available - some BPDFamily.com members have found that these tests are helpful.
Below are characterizations of the disorder by the National Institute of Health, The Mayo Clinic, and the American Psychiatric Association.
Symptoms of Borderline Personality Disorder - National Institute of Health
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.
Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Symptoms of Borderline Personality Disorder - The Mayo Clinic
People with BPD often have an unstable sense of who they are. That is, their self-image or sense of self often rapidly changes. They typically view themselves as evil or bad, and sometimes they may feel as if they don't exist at all. This unstable self-image can lead to frequent changes in jobs, friendships, goals, values and gender identity.
Relationships are usually in turmoil. People with BPD often experience a love-hate relationship with others. They may idealize someone one moment and then abruptly and dramatically shift to fury and hate over perceived slights or even misunderstandings. This is because people with the disorder have difficulty accepting gray areas — things are either black or white. For instance, in the eyes of a person with BPD, someone is either good or evil. And that same person may be good one day and evil the next.
In addition, people with BPD often engage in impulsive and risky behavior. This behavior often winds up hurting them, whether emotionally, financially or physically. For instance, they may drive recklessly, engage in unsafe sex, take illicit drugs or go on spending or gambling sprees. People with BPD also often engage in suicidal behavior or deliberately injure themselves for emotional relief.
Other signs and symptoms of borderline personality disorder may include:
* Strong emotions that wax and wane frequently
* Intense but short episodes of anxiety or depression
* Inappropriate anger, sometimes escalating into physical confrontations
* Difficulty controlling emotions or impulses
* Fear of being alone
Symptoms of Borderline Personality Disorder - American Psychiatric Association DSM-5
The DSM-5 work group is recommending that this disorder be reformulated in the DSM-5 as the Borderline Type.
Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness. As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. Self-appraisal is often associated with self-loathing, rage, and despondency. Individuals with this disorder experience rapidly changing, intense, unpredictable, and reactive emotions and can become extremely anxious or depressed. They may also become angry or hostile, and feel misunderstood, mistreated, or victimized. They may engage in verbal or physical acts of aggression when angry. Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment.
Relationships are based on the fantasy of the need for others for survival, excessive dependency, and a fear of rejection and/or abandonment. Dependency involves both insecure attachment, expressed as difficulty tolerating aloneness; intense fear of loss, abandonment, or rejection by significant others; and urgent need for contact with significant others when stressed or distressed, accompanied sometimes by highly submissive, subservient behavior. At the same time, intense, intimate involvement with another person often leads to a fear of loss of an identity as an individual. Thus, interpersonal relationships are highly unstable and alternate between excessive dependency and flight from involvement. Empathy for others is severely impaired.
Core emotional traits and interpersonal behaviors may be associated with cognitive dysregulation, i.e., cognitive functions may become impaired at times of interpersonal stress leading to information processing in a concrete, black-and white, all-or-nothing manner. Quasi-psychotic reactions, including paranoia and dissociation, may progress to transient psychosis. Individuals with this type are characteristically impulsive, acting on the spur of the moment, and frequently engage in activities with potentially negative consequences. Deliberate acts of self-harm (e.g., cutting, burning), suicidal ideation, and suicide attempts typically occur in the context of intense distress and dysphoria, particularly in the context of feelings of abandonment when an important relationship is disrupted. Intense distress may also lead to other risky behaviors, including substance misuse, reckless driving, binge eating, or promiscuous sex.
- Negative Emotionality: Emotional Lability Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances
- Negative Emotionality: Self-harm Engaging in thoughts and behaviors related to self-harm (e.g., intentional cutting or burning) and suicide, including suicidal ideation, threats, gestures, and attempts
- Negative Emotionality: Separation insecurity Fears of rejection by, and/or separation from, significant others; distress when significant others are not present or readily available
- Negative Emotionality: Anxiousness Feelings of nervousness, tenseness, and/or being on edge; worry about past unpleasant experiences and future negative possibilities; feeling fearful and threatened by uncertainty
- Negative Emotionality: Low self-esteem Having a poor opinion of one’s self and abilities; believing that one is worthless or useless; disliking or being dissatisfied with one’s self; believing that one cannot do things or do them well
- Negative Emotionality: Depressivity Having frequent feelings of being down/ miserable/ depressed/ hopeless; difficulty “bounding back” from such moods; belief that one is simply a sad/ depressed person
- Antagonism: Hostility Irritability, hot temperedness; being unfriendly, rude, surly, or nasty; responding angrily to minor slights and insults
- Antagonism: Aggression Being mean, cruel, or cold-hearted; verbally, relationally, or physically abusive; humiliating and demeaning of others; willingly and willfully engaging in acts of violence against persons and objects; active and open belligerence or vengefulness; using dominance and intimidation to control others
- Disinhibition: Impulsivity Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans; failure to learn from experience
- Schizotypy: Dissociation Proneness Tendency to experience disruptions in the flow of conscious experience; “losing time,” (e.g., being unaware of how one got to one’s location); experiencing one’s surroundings as strange or unreal
Symptoms of Borderline Personality Disorder - American Psychiatric Association DSM-IV
Personality disorders are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with borderline personality disorder, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria note that people with BPD have a pattern of unstable relationships, self-image and mood, as well as impulsive behavior. These typically begin in early adulthood. This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.
Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
- a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- identity disturbance: markedly and persistently unstable self-image or sense of self.
- impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
- recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- chronic feelings of emptiness
- inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- transient, stress-related paranoid ideation or severe dissociative symptoms
Written by R. Skip Johnson. Excerpts from National Institute of Mental Health, Mayo Clinic, American Psychiatric Association, and information on the Diagnostic Interview for Borderline Patients (John Gunderson, MD), Structured Clinical Interview - SCID-II (Michael B First, MD), Personality Disorder Beliefs Questionnaire - PDBQ (Arnoud Arntz, Roos Dietzel and Laura Dreessen)
(1)BPDFamily Staff Production.
(2) Assumptions in borderline personality disorder: specificity, stability
and relationship with etiological factors. Arntz, A., Dietzel, R., & Dreessen, L. (1999). Behaviour Research and Therapy, 37, 545–557
(3) Stop Walking on Eggshells, Paul Mason,MS and Randi Kreger, New Harbinger Publications; 1st edition (July 1998), ISBN-10: 157224108X