Overview of Diagnostic Criteria
All personality disorders have these criteria:
- An enduring pattern of inner experience and behavior that is significantly different compared to the culture of that person. This includes at least two areas, including cognition, emotional response, interpersonal functioning, and impulse control.
- This pattern shows up across many types of social and personal situations and does not change easily.
- This pattern leads to significant distress or functional impairment.
In addition, BPD has these criteria (at least 5 must apply):
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of intense and unstable relationships where the person rapidly changes between overwhelmingly positive response and overwhelmingly negative response to the other person.
- Significantly unstable self-image, including lack of sense of self.
- Harmful impulsivity in at least 2 areas (for example, reckless spending, driving, substance use, sexual activity).
- Chronic suicidal behavior, gestures, threats, or self-harm.
- High emotional responsivity and difficulty managing emotions.
- Chronic feelings of emptiness.
- Difficulty controlling anger, and/or intense and inappropriate anger.
- Short lived feelings of paranoia and/or dissociation due to stress.
Prevalence of BPD
It’s unclear exactly how many people have BPD. Typical estimates are about 1.6% of the population, but other studies have reported up to 5.9%. People receiving mental health care, especially inpatient care, are more likely to have BPD, while older adults are less likely to have BPD.
Treatment of BPD
Dialectical Behavioral Therapy was created to help manage chronic suicidality, and is now the gold standard treatment for BPD. People with BPD may also benefit from mindfulness-based therapies, Acceptance and Commitment Therapy, Cognitive Behavioral Therapy and evidence-based therapies for trauma. There is no gold standard medication for BPD, but some people benefit from anti-depressants and/or mood stabilizers.
Myths & Misunderstandings
1. People with BPD are “attention seeking,” “manipulative,” and “faking” their symptoms
First of all let me just say that I hate that term, “attention-seeking.” Everyone seeks attention constantly- we are social animals and it is beneficial to have interpersonal contact.
In any case, people with BPD are not more “attention seeking” than others- they just have difficulty “attention seeking” appropriately. They are also not manipulative, or lying about symptoms or their experience (at least, not as a group)- again, they just don’t have the same skills as most people do to communication effectively. So when they need to tell someone they are really upset, they tend to do it in ways that feel incongruent or inappropriate to others, but make complete sense to them.
2. BPD is defined by being “hot and cold” interpersonally
While having unstable relationships is a big part of BPD, it’s not the only piece. The key components of BPD are unstable relationships, unstable or nonexistent sense of self, and emotion dysregulation. I think the sense of self bit is often ignored. One of the reasons why people with BPD often have unstable relationships is because they are trying to identify a sense of self via connection to someone else, but that strategy is often ineffective.
3. Only women have BPD
About three times as many women versus men have BPD, but there are a lot of men with BPD, and symptoms are similar between men and women. This misconception is due to gender bias. Men and women who meet criteria for BPD and Cluster B disorders in general are perceived differently by clinicians and other people. Men are usually perceived as aggressive, dangerous, and lacking in empathy, and so are usually diagnosed with Antisocial Personality Disorder or Narcissistic Personality Disorder. Women are usually perceived as emotional, neurotic, and dramatic, and so are usually diagnosed with BPD or Histrionic Personality Disorder.
4. BPD is always caused by childhood sexual abuse
Many people with BPD experience CSA, but not all. BPD is theorized to be caused by chronic instability, fear, and isolation due to neglect, loss, chaos, and/or abuse during childhood and early adolescence.
5. People with BPD can’t be helped
DBT and other therapies are highly effective for BPD. People with BPD who receive good treatment do sometimes become “cured,” or stop meeting criteria for BPD. Although this doesn’t happen for everyone, people with BPD can make huge improvements that improve their quality of life whether or not they are “cured.”
6. People with BPD are terrible to work with clinically
People with BPD can be tough to work with- they are often high risk, for example –but perceptions that people with BPD are terrible to work with is usually due to stigma about BPD rather than based in any reality. Staff working in mental health treatment programs often confuse BPD with “hard to work with,” and so label anyone (especially women) they find tough or unpleasant to work with as BPD whether or not they actually have any BPD symptoms.