Understanding borderline personality disorder

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What is borderline personality disorder?
How would a clinician make this diagnosis?
What if they've made a mistake in my diagnosis?
Will I get better?
What causes borderline personality disorder?
What sort of treatment can I get?
What about medication?
What happens if I can't cope?
What should family and friends do?
References
Useful organisations
Useful websites
Further reading

'I wish I had never been diagnosed with BPD. With another diagnosis yet similar behaviour I was treated so differently. Possibly the most painful part of this illness (I will call it that) is the discrimination. And the only reason for this is the diagnosis, not the way I feel, behave or speak, because that was the same before.'

Borderline personality disorder (BPD) is a controversial diagnosis. This booklet aims to help people to understand when the diagnosis might be given and its consequences. It suggests sources of help for those diagnosed with this problem, their friends and relatives.

What is borderline personality disorder?

BPD is one of many personality disorders listed in the manuals used by clinicians when they are giving someone a psychiatric diagnosis. The word 'personality' refers to the ongoing pattern of thoughts, feelings and behaviour that makes us who we are.

A personality disorder may be diagnosed when it's felt that several areas of someone's personality are causing them or others problems in everyday life. This diagnosis is very controversial, because it implies that someone's whole personality is flawed - rather than just one aspect of them. Some psychiatrists argue that it's impossible to treat someone's personality and that it's wrong to apply medical terms and treatments to a personality. This means it's usually the symptoms of BPD that are treated, rather than the disorder as a whole. (See Understanding personality disorders for more information about this particular group of diagnoses.)

BPD is sometimes referred to as Emotionally Unstable Personality Disorder. Some argue that the term 'borderline' is misleading. Originally, the term was applied to people who seemed to be on the border of being given a diagnosis of schizophrenia. However, now BPD is seen as distinct from schizophrenia diagnoses, the 'borderline' aspect is seen to express being on the border of psychosis. If someone has a psychosis, it means they have beliefs or experiences not shared by others. Those diagnosed with BPD may have these at times of stress.

BPD is thought to affect about two per cent of the general population. It’s been estimated that three-quarters of those given this diagnosis are women. It's a condition that isn't usually diagnosed until adulthood, because the personality is seen as still developing until then.

Because of the controversy surrounding this diagnosis, services are often not readily available. However, there are routes you may be able to take, which are listed later in this booklet.

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How would a clinician make this diagnosis?

There are no biochemical or physical tests to tell whether someone does or doesn't have BPD. The UK and Europe use slightly different criteria and ‘number of symptoms present’ to diagnose BPD, compared to the USA. But on the whole, if five or six of the symptoms below are present for a year or more, the diagnosis of BPD is given. Note: anyone can experience any of these symptoms occasionally, but with BPD the experience is much more intense and prolonged.

• Self-harm (for example, cutting yourself) or repeated attempts or expressions of the desire to commit suicide. This behaviour can only be counted as one of the criteria for diagnosis; it can't be counted again as demonstrating any of the other symptoms. (See Mind's booklet Understanding self-harm)
• Frantic efforts to avoid being alone, due to an intense fear of being abandoned. Others may not see this fear as justified, but you may go to great lengths to avoid being alone. For example, you may say that you will harm someone if they leave.
• A pattern of unstable and intense relationships. Feelings often alternating between idolising the other person and then thinking they are really awful.
• A very uncertain, shaky self-image or sense of self. You may feel good whilst you feel loved by someone you think is wonderful. If you later see them as bad, your own sense of self could be affected. You may also have doubts about your sexual identity.
• Two or more areas of your life where your behaviour could cause you harm and be seen as impulsive. Examples would be: spending money extravagantly and having huge debts, having unprotected sex, abusing drugs or alcohol, driving without due care, or binge-eating. (See Mind's booklet Understanding eating distress.) You may do these things because you're trying to deal with awful feelings of pain or emptiness.
• You may have moods that are very difficult to come out of. For example, you may go through long periods (usually lasting a few hours) of extreme irritability, restlessness, unhappiness or anxiety.
• Terrible feelings of emptiness.
• Anger that's inappropriate, intense or difficult to control. You may lose your temper a great deal, experience constant anger or be involved in physical fights. You may feel particularly angry when you think you're being criticised. Anger is often a very difficult feeling for people to acknowledge and deal with, but may cause particular problems in the life of someone diagnosed with BPD. (See How to deal with anger.)

• Periods of paranoia or feeling unreal when under stress. This might be accompanied by an almost complete lack of physical sensation. At difficult times, you may experience yourself as having more than one personality or feel you are in a trance-like state.

As a result of confusion about your personal identity and a terror of being left alone, you may find yourself clinging to very damaging relationships. Many people who meet the criteria for BPD also meet the criteria for histrionic, narcissistic or antisocial personality disorder. (See Mind's booklet Understanding personality disorders.)

Unfortunately, those diagnosed with BPD have a greater risk of committing suicide than the general population. Most studies suggest between eight and ten per cent of those diagnosed with BPD commit suicide. If you are diagnosed with BPD, it's important to know where to turn to if you are feeling suicidal.
(See Useful organisations, below)

Whilst some people may see themselves in the symptoms of BPD and feel relieved to have a label to apply to the problems they experience, others may be devastated at the idea that their personality is disordered. It's worth remembering that aspects of almost any type of personality can be found within the pages of the diagnostic manuals. What matters is that you get the help you feel you need. If after reading this booklet you feel you may have BPD, talk to someone who is medically qualified - be very wary of making a self-diagnosis.

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What if they've made a mistake in my diagnosis?

Strictly speaking, a medical diagnosis can only be given by somebody who has been medically trained - usually a GP or psychiatrist. However, because the term 'borderline' comes from psychoanalytic thinking, you may have this term applied to you by someone who has not been medically trained. There is a recognised and very worrying danger of mistaken diagnosis. Mental health professionals sometimes fall into the trap of applying it to people they have difficulties dealing with, perhaps because of a conflict of personalities. Within the NHS, you are entitled to ask for a second opinion, although this doesn't necessarily mean that your request will be granted.

If you feel your GP or psychiatrist has misunderstood you, and you are having problems getting the help you need, you may find an advocate useful. (For more information about advocates, contact the MindinfoLine or see The Mind guide to advocacy.)

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Will I get better?

It's often thought that personality problems are too deep-seated to be treatable. But this is contradicted by evidence that symptoms may get better as people get older. Some research suggests that after 10 to 15 years, or so, between 50 to 75 per cent of those diagnosed with BPD no longer display enough of the symptoms to meet the criteria for the diagnosis.

Recent research suggests that talking treatments and medication can reduce the behaviour problems associated with the problem. Day-care programmes may also be useful. (See below for more information.)

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What causes borderline personality disorder?

The causes of BPD are still not clear and research is still continuing.

Often, those diagnosed with BPD turn out to have had very traumatic experiences in childhood. You may have experienced the early loss of a parent, or be a survivor of childhood sexual or physical abuse (see Mind's web-based factsheet Sexual abuse). You may have been neglected as a child. Such difficult life events are very common in those diagnosed with BPD. The problems associated with BPD may become much worse following a stressful experience, for example, the loss of a loved one or an established routine, such as a job.

An American psychiatrist, Dr Leland Heller, believes that BPD is a 'neurological illness', probably a form of epilepsy, and that it can be managed with  appropriate medication and talking treatments. (For more information about his theories, see Useful websites.)

There is a school of thought that suggests that some people may be genetically predisposed towards BPD, and that if those people are exposed to negative nurturing in childhood, they are more likely to develop symptoms.

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What sort of treatment can I get?

Talking treatments
Psychotherapy is a relatively long-term talking treatment that aims to find the roots of present feelings and behaviour in your childhood. The relationship you have with the therapist is seen as an important reflection of your past and present relationships. Exploring this relationship can help to break unhelpful patterns of behaviour. The in-depth nature of psychotherapy can make it particularly appropriate for those diagnosed with BPD.

Some forms of counselling are quite similar to psychotherapy. Psychodynamic counselling, for example, places great emphasis on childhood experience. (See Further reading and Useful organisations for sources of more information.)

Cognitive behaviour therapy is a more short-term treatment that aims to tackle practical, everyday difficulties with problem-solving techniques. It works towards identifying negative thinking patterns and replacing them with more positive ones. (See Mind's booklet .Making sense of cognitive behaviour therapy)

New therapies have been developed which combine elements of cognitive therapy and psychotherapy. Dialectical behaviour therapy (DBT) and cognitive analytical therapy (CAT), have been found to be particularly useful for people diagnosed with BPD.

People often have high expectations when they enter a talking treatment. It's worth bearing in mind that therapists aren't miracle-workers and that change can take time. If you find it painful to be separated from others, you might want to think about how you will manage breaks in the therapy early on. You could ask when the breaks will occur so that you can look at how you will cope beforehand. There may be times when you think your therapist is wonderful and times when you may hate him or her. It may help you to express these feelings, so that you can look at them together. If you are interested in pursuing a talking treatment, you could talk to your GP about seeing someone through the NHS, or getting treatment subsidised. (Also see organisations that provide lists of registered practitioners, below.)

Therapeutic communities
The NHS runs some inpatient therapeutic communities that specialise in treating clients with personality disorders. (See Useful organisations, further down) In a therapeutic community, staff and residents share responsibility for tasks and decisions. If you decide to go to into a therapeutic community, you will need to be prepared to talk about your life with others before the group decides whether to give you a place. This can be hard, especially if it's the first time you have talked in front of a group in this way.

Once part of the community, you would be encouraged to talk about your feelings about others' behaviour in group discussions. This may seem difficult at first but it can be very beneficial. It may give you the opportunity to see how others react to you and what you say. You can then think about what you like and what you want to change about yourself. Some, but not all communities may offer you individual therapy and, possibly, medication.

Alternative therapies
There are a whole range of alternative therapies, which some people find useful, from acupuncture to yoga. (See Further reading.)

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What about medication?

Antidepressants
Research has found low levels of the chemical serotonin in people diagnosed with BPD who have committed impulsive acts of violence. Some of the antidepressants work to increase levels of serotonin. (For more information about antidepressants and their side effects, see Mind's booklet Making sense of antidepressants.)

Antipsychotics
Antipsychotics (also referred to as major tranquillisers) may be prescribed to help with feelings of unreality or paranoia. They should be prescribed with caution, as they can have distressing side effects, especially in long-term use. (For more information, see Mind's booklet Making sense of antipsychotics.)

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What happens if I can't cope?

In response to demand from mental health service users, crisis services have been developed in some areas. In these services, the emphasis is on talking treatments and informal support. A crisis service may be somewhere safe to stay, or an out-of-hours telephone helpline. (see Mind's web-based factsheet Crisis services for further details.)

Hospital
At times of great distress, you may feel you need to be somewhere safe. This could mean going into hospital. It can be upsetting to be around others who are in pain, however, and you may feel a lack of privacy and support. Service-user or patient groups based in the hospital can be useful and supportive.

Most admissions are voluntary. However, if you are regarded as a danger to yourself or to others, but you don't wish to go, you may be admitted compulsorily under the Mental Health Act 1983. Mind rights guides explain your rights with regards to mental health law.

Guidelines on treatment
The National Institute for Mental Health in England (NIMHE) and the Department of Health (DoH) have recently issued guidelines with the aim of enabling people with a personality disorder to get appropriate clinical care and management from specialist mental health services. The guidelines, titled Personality disorder: no longer a diagnosis of exclusion, can be found on the Internet (it is best to type the title into your search engine, as the document appears in several places). NICE (The National Institute for Health and Clinical Excellence) will also be publishing clinical guidance on the treatment of BPD - due to be published by the end of 2008. (See Useful websites.)

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What should family and friends do?

It's important not to see someone purely in terms of their diagnosis. People with BPD can have very low self-esteem, and it can help them enormously if you can emphasise the positive parts of their personality.

It can be extremely difficult caring for someone with BPD. They may try very hard to control you, because they feel so out of control of themselves. There may be periods when they refuse to talk to you or when they rage at you. This can be very painful and may make you feel powerless.

You may find that the person panics and perhaps reacts very angrily when you want to leave or to go somewhere. They may beg you to stay, or hurl words of abuse. It can help if you focus on how they are feeling, rather than trying to argue them out of their fears.

Looking after yourself
It's very important to look after yourself and to remember that you need time to yourself, if you are to care for others. If you are experiencing problems - for example, if the person calls you many times a day at work - it's vital to set down some boundaries. It might be important to decide how often you will be available. This can be hard to stick to, especially if you are being threatened, and you may need to enlist other people's help. Offer to help draw up a list of numbers the person could call when they feel afraid.

A person diagnosed with BPD may feel that they have no control over their feelings; they may blame you for everything. Make sure you have someone you can turn to, to help you look at what is happening and make sure you don't take the blame for absolutely everything. Nobody deserves to be abused. There are organisations that can help you talk about the situation and make decisions about what you're going to do. You may need support in the form of a self-help group or some kind of talking treatment. (See Useful organisations for more information.)

In an emergency
If you feel that the person you care for is a serious danger to themselves or others, you might need to think about the last resort of compulsory admission to hospital. The 'nearest relative' as defined under the Mental Health Act 1983 can request a Mental Health Assessment from a social worker specially trained in mental health law. The social worker would decide, with the help of medical advice, what the treatment options should be and whether the person needs to be detained. (See Mind rights guides.)

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References

Amongst ourselves: a self-help guide to living with dissociativeidentity disorder T. Alderman, K. Marshall (New Harbinger 1998)
A possible new name for borderline personality disorderDr L. M. Heller
Advice for carers on BPD First Steps to Freedom
www.borderlineuk.co.uk Borderline UK (August 2007)
Diagnosis K. Darton (OpenMind 95, Jan/Feb 1999)
DSMIV-IV, diagnostic and statistical manual of mental disorders(American Psychiatric Association 2000)
ICD10 classification of mental and behavioural disorders(World Health Organisation 1992)
Making us crazy H. Kitchings, S. Kirk (Constable 1999)
Medical treatment of the borderline personality disorderDr L. M. Heller (1998)
Personality disorder: a way forward? H. Castillo, D. Tallis (MindAnnual Conference 2000)
Should psychiatrists treat personality disorders? P. Moran(Maudsley Discussion Paper No. 7)
The structure and development of borderline personality disorder:a proposed model A. Ryle (British Journal of Psychiatry 170, 1997)
The care programme approach and risk assessment of borderlinepersonality disorder P. Whewell, D. Bonanno (Psychiatric Bulletin24, 381-384, 2000)

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Useful organisations

Association of Therapeutic Communities
tel. 01242 620 077
web: www.therapeuticcommunities.org
Produces a directory of therapeutic communities

Borderline UK
email: info@borderlineuk.co.uk
web: www.borderlineuk.co.uk
User-led network of people with a BPD diagnosis in the UK

British Association for Behavioural and Cognitive
Psychotherapies (BABCP)
tel. 0161 797 4484
web: www.babcp.com
Full directory of psychotherapists available. Can be searched on their website by specialism ‘personality disorders’

NAPAC (National Association for People Abused in Childhood)
infoline: O800 085 3330
web: www.napac.org.uk
Support, advice and guidance for adult survivors of any form of childhood abuse – sexual, physical or emotional

TalktoFrank
tel. 0800 776 600
web: www.ndh.org.uk
Free 24-hour national drugs helpline

The Cassel
tel. 020 8483 2900
web: www.wlmht.nhs.uk
Inpatient therapeutic community (part of West London Mental Health NHS Trust). Click ‘services’ and then ‘C’ on the website

The Henderson Hospital
2 Homeland Drive, Sutton, Surrey SM2 5LT
tel. 020 8661 1611
web: www.swlstg-tr.nhs.uk/services/henderson_hospital.asp
Therapeutic communities for people with personality disorders

NHS Direct
tel. 0845 46 47
They can advise you on local services and courses of action

Samaritans
By post: Chris, PO Box 9090, Stirling, FK8 2SA
Helpline: 08457 90 90 90
Minicom: 08457 90 91 92
web: www.samaritans.org.uk 
email: jo@samaritans.org
A 24-hour emergency helpline

UK Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: www.psychotherapy.org.uk
Has a directory of accredited psychotherapists

Useful websites

www.behavioraltech.com
The Behavourial Technology Transfer Group. Contains a section on Dialectical Behaviour Therapy

www.biologicalunhappiness.com
About BPD as a neurological illness

www.nice.org.uk
For information on clinical guidance

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Further reading

How to assert yourself (Mind 2006)
How to cope as a carer (Mind 2006)
How to cope with doubts about your sexuality (Mind 2006)
How to cope with hospital admission (Mind 2004)
How to cope with suicidal feelings (Mind 2006)
How to deal with anger (Mind 2006)
How to help someone who is suicidal (Mind 2004)
How to restrain your violent impulses (Mind 2006)
Making sense of antidepressants (Mind 2006)
Making sense of antipsychotics (major tranquillisers) (Mind 2007)
Making sense of cognitive behaviour therapy (Mind 2007)
Managing intense emotions and overcoming self-destructivehabits: a self-help manual L. Bell (Brunner-Routledge 2003)
Mental Health Act 1983: an outline guide (Mind 2003)
The Mind guide to advocacy (Mind 2006)
The Mind guide to massage (Mind 2004)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind 2006)
The Mind guide to yoga (Mind 2004)
Mind rights guide 1: civil admission to hospital (Mind 2007)
Mind rights guide 2: mental health and the police (Mind 2006)
Mind rights guide 3: consent to medical treatment (Mind 2007)
Mind rights guide 4: discharge from hospital (Mind 2005)
Mind rights guide 5: mental health and the courts (Mind 2007)
Overcoming anger and irritability W. Davies (Robinson 2000)
Stepping off the map: a project about personality disorders (DVD) (South Somerset Mind 2006)
Understanding attention deficit hyperactive disorder (Mind 2005)
Understanding eating distress (Mind 2004)
Understanding personality disorders (Mind 2007)
Understanding self-harm (Mind 2005)
Understanding talking treatments (Mind 2005)
Voices beyond the border: living with borderline personalitydisorder L. Robinson and V. Cook (eds) (Chipmunka 2006)
Working with personality disorders S. Hannell, C. Kinsella (ROCC 2001)

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This booklet was written by Louise Flory. Revised by Mind
First published by Mind 2001. Revised edition © Mind 2007
ISBN 9781903567197
No reproduction without permission