BPD Criteria

The source of this document is a DBT graduate, not a professional.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) identifies those with BPD as having:

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:

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. This is called "splitting."
3.Identity disturbance: markedly and persistently unstable self-image or sense of self.
4.Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5.Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6.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).
7.Chronic feelings of emptiness.
8.Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9.Transient, stress-related paranoid ideation or severe dissociative symptoms.

It is called "Borderline" because at the time of conceptualization of BPD the symptoms patients exhibited were in between the borders of neurosis (mild mental illness) and psychosis (severe mental disorder where contact is lost with reality).

Often BPD doesn't stand alone. Suffers of BPD may suffer from elements of other personality disorders. This is due mainly to the fact that it is not possible to define an exact set of criteria for each personality disorder which will apply to all cases. Personality disorders are a relatively new field of research and it is likely the criteria used to define specific disorders will change over time.

Most sufferers diagnosed with BPD are women.

Each of us is born with a temperament which in part determines how we react to life. Parents of multiple children can see differences between their offspring's character traits at an early age. There has been an increase into scientific research which shows that biological factors play a larger part in the development of personality than was once thought. Bockian states that "It is extremely unlikely that someone with a placid, passive, unengaged, aloof temperament would ever develop borderline personality disorder. To become labile and erratic demands that one have proclivities in that direction." (pg. 30)

He references a number of studies that show patients diagnosed with BPD had brains that tended to function differently to non-disordered subjects (pg. 32-33). The findings include reduced activity in the frontal lobes which relate to aggression and reduced or dormant activity in the prefrontal cortex on the right side (and several areas of the left side) of the brain relating to the regulation of impulsive behaviour. In addition one experiment found that the part of the brain that is critical for memory was "nearly 16% smaller in the borderline group".

The argument of nature versus nurture continues to be researched and at the moment the influence of environment and genetics appears to be at a 50/50 standpoint. Increasingly Psychologist aim to show that "negative" characteristics that appear from birth which are left unchecked or dealt with un-empathically can lead to problems later in life.

Parenting/Development Environment
Borderlines usually come from traumatic backgrounds. It is not uncommon for them to have parents/family members who are alcoholics or abusers. Sometimes the abuser is not a parent but a close family member, friend or someone the child knows. The abuse may not even be directed at the child, they may witness abuse towards others within the home.
Whilst there are instances where Borderlines have been raised by loving parents Bockian states that "adults who have borderline personality disorder usually experienced some form of significant abuse, such as sexual or physical abuse, as a child. Incest and other forms of sexual abuse are particularly implicated." (pg.37).

The environment they grow up in is usually "invalidating" which means that the child is taught to believe that their feelings, thoughts and perceptions are not real or do not matter. The child learns to deny/cut off their real feelings leading to dissociation, splitting, low self-esteem, dependency and fear of abandonment, suicidal feelings and depression.
In these environments the boundaries are unclear. Physically their body may be abused, mentally their emotions may be tortured or ignored, materialistically they may not be provided for or stolen from e.g. a grandparent gives the child money for a birthday present and the parent uses it to buy drugs. Their privacy may be evaded; parents reading their diaries, listening in on telephone calls, watching them undress or bathe etc. As a result Borderlines usually have poor boundaries which can spill over to new relationships and jobs i.e. taking others boundaries for granted and allowing their own to be violated.

Generally the environment in which they are raised is un-empathic and the child's real needs are not met.

Social Conditioning
Society is becoming more and more narcissistic. People drive themselves to ensure their own needs are met and that they achieve a particular success or status in life.

Parents spend less time at home preferring/having to work long hours and when they come home they may be too tired to invest themselves in their children. They change their jobs more frequently perhaps even moving geographical location uprooting their children from their homes. The value of extended family has been eroded in order to make way for the change friendly nuclear family; while they are at work their children may no longer be cared for by family members who are emotionally connected. Marriage rates are declining and divorce rates are increasing, more children are growing up shuttling between their mum's house and their dad's house. Parents may opt to drink more, do drugs etc. to escape from the pressures of modern living. The decline in religion and changes in the law have made previously "prohibitive activities" more acceptable. All these changes are leading to an increase in unstable environments in which child development takes place.

In addition Bockian explains that "Television and other video media also have a profound impact on personality development. Role models and heroes have become increasingly violent, unstable and outwardly sexual. People who see more violence behave more violently. emotional shallowness and instability often dominate TV programs. Problems develop and are resolved in 30 to 60 minutes. The sincere expression of feelings and negotiations that compromise real conflict resolution doesn't happen on TV. as our children watch television they are learning how to be impulsive, cynical, sexually unrestrained, explosively angry and melodramatic - that is more borderline." (p.g. 41)

What is life like for a Borderline?
The best way to describe it is as an "emotional roller coaster" ride. Borderlines have much insecurity. They experience a variety of rapidly changing feelings. Bockian states that "it is not uncommon for feelings to swing from thrilled, excited, and on top of the world to suicidally depressed in the space of a few hours." (pg. 20). Some emotions seem to be constant in their repertoire.

Their feelings of emptiness stem from the fact that they have a poor sense of "Self" (see "When Does Narcissism Develop?" for further information on development of the Self). Borderlines do not know who they are and can spend a life time trying to find out. This may be evidenced through numerous career changes, frequent moves to different geographical locations and attempts to fit in with others.

Borderlines lack trust in others and do not value themselves highly, as a result they tend to feel they are unworthy of love and that they will be let down by those close to them. This is understandable when interactions with parents and family members were abusive, they have been taught not to trust. They expect to be let down even abused.

As a result of their lack of self-esteem they tend to choose dominant partners who are able to give their life purpose and meaning through association. They fear abandonment which is either real (such as the impending break up of a relationship) or imaginary e.g. distrust of a partners fidelity. They also undertake in behaviour that perpetuates their own abandonment.
Borderlines tend to have strong feelings of guilt seeing themselves as "bad", "not good enough" or when sexual abuse has occurred"dirty". They may even feel they deserve the punishment they get when their adult relationships become abusive - it's comfortable to them because they may be used to it.

Sex is usually an ordeal for Borderlines if sexual abuse occurred in their childhood as they associate the act with their abuse.

Borderlines are angry people reacting inappropriately to trivial situations. They can rage when their needs are not met (having a sense of entitlement despite their apparent lack of self-worth) or when they fail to be good enough and can remain angry for a long time after the event.

When relationships end normal people grieve then accept that it is in effect over and move on with their lives. Borderlines will often "to and fro" impulsively ending a relationship then go on to regret their decision. They feel overpowered by emptiness and not knowing who they are and become desperate to go back to their ex who largely defines their existence. This can happen several times before the relationship finally ends.

Being the partner of a Borderline can be a harrowing experience and inevitably partners have thoughts of leaving. If a Borderline has been dumped (or suspect they will be) they will say and do anything to win back their ex. This may include attempting to or make threats to commit suicide in order to show their commitment to "die for love", gauge the depth of her ex's feelings or even to make them feel sorry for what they did to hurt them. Of course suicide is also a way out of the despair they feel. These attempts to avoid abandonment may work in the short term but they do nothing to keep a partner long term. They do not reinforce feelings of love, more often that not it just evokes guilt and pity.
Bockian (pg. 18) quotes Marsha Lineham's assertion that "The desire to be dead among borderline individuals is often reasonable, in that it is based on lives that are currently unbearable. the problem is usually that the patient simply has too many life crises," which are either no fault of their own or brought about by their dysfunctional behaviour. For some their lives have been tortuous (having possibly suffered sexual, physical and emotional child abuse) and as such it is not surprising that they are unable to find happiness and meaning in life.

Not all Borderlines try to commit suicide, some may opt for self-injury to feel better by numbing one kind of pain (emotional) with another (physical). Self-injury may come in the form of cutting their arms with razor blades, burning their skin with a flame etc. They are also impulsive and prone to partake in hazardous activities in order to escape negative feelings e.g. taking drugs, drinking heavily, having random unprotected sex, spending large sums of money they don't have. They may even binge eat or suffer from bulimia or anorexia. These behaviours may reduce negative feelings in the short term but in the long term they inflict more damage which the Borderline is not emotionally able to cope with. They look to others to take responsibility/care of them. In fact they expect to be taken care of.

Borderlines tend to fall in love quickly, their relationships develop fast and may burn out just as fast. They do not take the time to get to know the person they are attaching themselves to, their values or their character. They open themselves up to the other person quickly possibly having sex on their first date, moving in with their new partner within a few weeks and getting married within a few months. They will have an inflated view of their partner - that their new love interest is the best thing that has ever happened to them, good and true.

Not long after the relationship starts reality starts to creep its way in. A Borderlines partner may do something that shows they are not perfect and the situation does a complete 180 degree turn. The Borderline sees their partner as distasteful and unworthy, this is deflation.
The Borderline can only see in black and white, someone is either "all good" or "all bad" at one time. This is known as "splitting". For example, imagine that a woman spends all day in the kitchen preparing a surprise meal for her partner. She cooks all his favourite dishes, dims down the lights and sets the table just so. She has thoughts about how great her partner is, how much they love them and how well the evening is going to go. The partner comes home an hour late, possibly because work was busy and there was heavy traffic etc. With a Borderline there is no "he's late, I wonder why? I'm upset because my effort has been spoiled but then again I didn't warn him. well he looks upset he's late let's enjoy what we can." there is only "he doesn't appreciate what I do for him, he doesn't love me, he's useless". So they rage, say hurtful things and lash out. Later on when they calm down they reflect on what they have done and become afraid of abandonment they will try to make amends. Their relationships can be extremely passionate where good "make up sex" seems to support the idea that the relationship is meant to be but ultimately the relationship starts to suffer and often ends as quickly as it started.

This black and white view of others is also mirrored in their view of themselves. Moskovitz explains that as a Borderline "When you are good, you may feel entitled to special treatment and live outside the rules made for others. You may feel entitled to take whatever you wish and to have everything good all to yourself. When you are bad, you may feel entitled to nothing. You may feel responsible for all that is evil and expect punishment. If punishment does not come, you may invite it from others or inflict it on yourself" (pg. 15). He goes on to explain that a Borderline has the ability to affect other people's feelings and behaviours on the basis of the intensity and changeability of their feelings (projection/transference).

Borderlines experience paranoia and dissociation when they are under stress. They fear people are conspiring to harm them and experience a "loss of awareness, time, location or their identity" (Bockian pg. 25). Most people experience dissociation to some degree in their lives e.g. daydreaming in lectures or whilst driving a car. People with BPD may experience more regular and lengthier episodes to the point where they have lost days and can't remember where they have been or what they have done - it feels as if they are losing their mind or having a nervous breakdown. It is not uncommon for normal people to experience such dissociation during periods of stress.

BPD can lie dormant for years where Borderlines can get along without major acting out. BPD's are often workaholics and can be successful in their careers, particularly in environments that follow rigid rules (it fits in with their black and white method of thinking). A demanding workload aids to distract from negative emotions. However, when stress is applied, when things start to go wrong or their routine changes the Borderline symptoms appear as the emotions become too much for the Borderline to cope with. Even anniversaries of traumatic events can lead to self-destructive behaviour. Moskovitz uses the example of a mother who "attempted suicide for the first time at age thirty-three, shortly after her oldest daughter's eight birthday. She had had her first incestuous encounter with her father at age eight." (p.g. 51)

Can Borderlines love other people?
Borderlines love love - they are obsessed by it and will do anything to ensure they get it. To them it is a means of filling up their loneliness and lack of Self through another person rather than an expression of regard or caring for someone as an equal partner.

While their need for love is apparent they don't know how to return love. In reality they are afraid of intimacy and do not have the emotional strength to fight their fears of inadequacy or abandonment in a manner that makes it possible for them to return love. After the passion of new love subsides they become bored, often moving on to a new partner. If they continue in the relationship "instead of deepening concern and communication, there ensues a struggle for control. The arena of this often violent struggle may include time, money, sex, fidelity, spiritual beliefs, children, or physical and emotional distance. The centerpiece of the struggle is the threat of abandonment." Moskovitz (pg. 144).

Borderlines do not trust others and as such their relationships are fraught with battles. They are manipulative and will hurt others when their needs are not being met by raging or sometimes by physically hurting themselves or less likely their partners. Because partners get frustrated and try to regain their own power they may "strike back or flee." Moskovitz (pg. 144)
Borderlines do not love themselves, in fact they practice self-hatred. Psychologists often comment that anyone who doesn't love themselves can't truly love others.

It all sounds very bleak. However, with effective treatment Borderlines can learn to understand their feelings, control their impulsive behaviour and strengthen their sense of Self enabling them to improve the quality of their relationships.

How is BPD different or the same as NPD?
"We have known for a long time that feelings of superiority and inferiority exist together. If one is on top, the other is underneath." Lowen (pg. 20)

The origins of NPD are believed to develop from abuse/lack of empathic parental care in the earliest years of life. BPD may also have it's origins at this early stage but the traumatic abuse (physical, sexual etc.) that is usually experienced by Borderlines can also be the cause of their personality disturbance at a much later age.

People with BPD are Narcissist's because they focus solely on getting their own needs and wants fulfilled. They are placed in the middle of Lowen's "spectrum of narcissistic disorders" (pg. 14). The symptoms of NPD and BPD overlap and as such making a clear cut diagnosis is not always easy for a Therapist. However, it is accepted that Borderlines are more disturbed as they are more likely to suffer from splitting and disassociation. Borderlines can experience hallucinations, delusions and thought disorders. Those with NPD tend not to exhibit these afflictions. As a result a Borderlines grasp of reality is much less secure than that of a person with NPD hence the placement of the condition at the middle of Lowen's spectrum. Some would argue that there is the need for another scale within the scope of BPD to differentiate between those with milder Borderline tendencies and those who verge on the psychotic.
Narcissist's may also suffer from splitting and both the Narcissist and the Borderline have a tendency towards inflation and devaluation of others, transferring their secret feelings/views of themselves on to those they interact with. They tend not to be able to see another persons good and bad traits at the same time.
Both suffer from depression and cover up their insecurities via a false Self which helps them to project a grandiose image. They deny their feelings and manipulate others but the Borderlines false Self "readily crumbles under emotional stress, and the person reveals the helpless and frightened child within." thus indicating that those with NPD have a stronger sense of Self (Lowen, pg. 18).

While Borderlines tend to have grandiose perceptions of themselves e.g. being superior to others or being irresistible to the opposite sex they are afraid to follow through with their convictions. Lowen (pg. 19) states that "narcissistic characters do not hold back. They have the necessary aggression to achieve some degree of success, suggesting an ego strength that the borderline personality lacks." This doesn't sound as good for the Narcissist as is implied because their grandiosity is still often contradictory to reality.

Narcissist's may have a stronger sense of Self but this is a result of consistently being pumped up by others. Their ego "has never truly been smashed down" by their parents (Lowen, pg. 20). As a result of their stronger ego they are less likely to self-harm, less likely to commit suicide (because they see it as a sign of weakness) and they are less impulsive. That is not to say that traumatic life events in their future e.g. ill health, divorce, death of a significant NSS, financial loss etc. will not result in breaking their inflated ego as they fail to live up to their grandiose fantasies. If this happens and NS is not in abundant supply Narcissist's can also respond with despair and may even seek to end their own lives.

The acquisition of NS is of vital importance to both personality structures. A Narcissist will derive their NS from extracting admiration and acknowledgement from others but unlike a Borderline they are not reliant on the presence of another person in order for them to feel "whole".

Borderlines experience guilt for not being good enough, for being victims of abuse they feel they deserve. Narcissist's on the other hand do not experience guilt. They only experience shame and fear of humiliation if their false image is called in to question.

Unlike those who suffer from NPD, Boderline's are capable of great empathy. In the case of Borderlines who have experienced abuse they are able to recognise or associate the painful feelings that are/may be experienced by others.

Both the Borderline and the Narcissist rarely admit they have a psychological problem. Borderlines are more likely to come to the attention of the mental health profession at a younger age, their capacity to experience guilt makes it more likely they will go in to therapy in search of help and the existence of a medical cause for BPD makes it treatable in part through medicine. These factors mean that the treatment of BPD is more likely to be a success than the treatment for NPD. However, any treatment requires commitment from the patient for it's continued success.

Why are women more likely to suffer from BPD than men?
The trauma sustained from sexual abuse is more likely to lead to a greater dissociation with reality as the child attempts to block out what has been done to them by someone they love and depend upon (if the abuser is a member of their family). As girls are more likely to be sexually abused than boys this may explain to some degree why women are more likely to suffer from BPD than men.

As discussed in "What kind of parenting leads to NPD?" children can have strong reactions to constant perceived criticism. Boys and girls usually have different ways of dealing with criticism. Girls tend to internalise the criticism they receive whereas boys tend to cast it out. This may be explained by the fact that the female brain functions in a different way to that of a male brain. It could also be due to the manner in which girls are primarily socialised as nurturers who shoulder the burden when things go wrong within the family. This role of the female nurturer is also encouraged through the mass media. This conditioning may lead to low-self esteem and feelings of guilt that are evidenced in patients with BPD. This guilt and low-self esteem is one of the reasons why women tend to seek help more often than men in order to allow a diagnosis to be made.

Women are also conditioned to be subordinates to partners and are therefore "more prone to anxiety, depression, and feelings of helplessness than men. Similarly, submissiveness and fear of abandonment are more consistent with women's social role than men's" (Bockian pg. 46)

In addition to their tendency to cast out criticism boys are encouraged (more so than girls) to act out any aggression they feel towards others through viable channels e.g. contact sports and competition in business. As a result they are less likely to suffer from guilt and low self-esteem.

Some Psychologist's believe the reason there are more women diagnosed with BPD than men is because the Psychologist making the diagnosis has their own bias and stereotypes of relating to the sexes eg. a man who acts out in anger and takes part in self-damaging behaviour such as alcohol abuse is seen as antisocial rather than emotionally disturbed.
Can BPD be cured?

Despite suffering from a greater narcissistic disturbance the prognosis for successful treatment of a Borderline patient is a little better than that of a patient with NPD. A Borderline is more likely to be referred for help based on their self-harming behaviour and thanks to their guilty feelings in periods of regret they are more inclined to look for a recovery than those with NPD. In addition BPD is in part attributed to chemical imbalances in the brain which can be treated medically.

However, like other Narcissist's those suffering from BPD can be the barrier to their own recovery. Not all will admit they have a problem - they may even claim that people they interact with are in need of help not them. Borderlines have a tendency to go in and out of therapy rather than working through the treatment long term and often expect special treatment from their Therapist wanting attention at a moments notice regardless of if it is convenient e.g. the Therapist is with another patient or on holiday. Some will verbally abuse their Therapist and may use emotional blackmail to get the attention they crave e.g. threatening to commit suicide - even making an attempt where the Therapist has not met their needs.

Whilst Borderlines can be intelligent and accomplished members of the community it is the degree of disturbance that determines the effectiveness of treatment and the Borderlines ability to stick with it.

The two most successful treatments used to help treat people with BPD are Dialectical Behaviour Therapy (DBT) and medication.

Dr Marsha Lineham has pioneered the DBT treatment for BPD. Indications show that it is successful in helping those with BPD to change their behaviour with many going through treatment not exhibiting any symptoms of BPD afterwards.

The treatment uses four techniques; individual therapy, group skills training, telephone contact and Therapist consultation. The process is not quick, it often takes years to benefit from treatment and it requires the Borderlines continued commitment to treatment.
Medication can be used to help stabalise the chemical imbalances in the brain. Prescriptions are usually for antidepressants like Prozac which helps to regulate serotonin levels thus improving the Borderlines mood and alleviating some of the symptoms of BPD. There are, however, a wide variety of pills that can be used to treat the condition and can include Antipsychotic Medications (for treatment of hallucinations and delusions), Atypical Antipsychotic Medications (to reduce psychosis and improve overall functioning), Mood Stablilsers and Antianxiety Medications (Bockian, pg. 121). These pills do of course have side effects which need to be considered before treatment begins.

Most likely a combination of therapy and medication is used to treat BPD.

While reportedly less effective, other therapies can also be used in treating BPD:

Psychodynamic Psychotherapy - a talking therapy where the Therapist attempts to get the patient to recognise parallels between the patients current issues/behaviours and their past experiences.
Cognitive Behaviour Therapy - used to change the way the patient processes their thoughts and behaviours in reaction to external and internal stimuli.

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