BORDERLINE

PERSONALITY
DISORDER
Everything You Didn’t Know You
Needed to Know
You Need to Know Because You or
Someone You Know Might Live with BPD
■ Prevalence of lifetime BPD is roughly 6% (Grant et al., 2008).
■ On any night of any week, about 4-6 of any randomly chosen 100
people in this bar will meet at least 5 of 9 criteria for BPD at some
point in their lives.
■ Adult population of NYC = approximately 6,765,428.
– Presently approx. 405,926 adults who have lived, are living, or
will live with BPD in NYC.
– Total population of New Orleans (+) about 10,000.

Data via US Census (2017 ACS 5-Year Surv

Border-what?
■ Borderline personality disorder (BPD) = a psychiatric diagnosis
like a retro genre movie with an intense cult following. You’ve either
never heard of it . . . Or, you know exactly what it is.
– Not one of the more well-known diagnoses (e.g., attention-
deficit/hyperactivity disorder; obsessive-compulsive disorder;
major depressive disorder).
– Name originates from early (i.e., 1938) theoretical conjecture.
■ Namely, what we call “BPD” happens when a person’s psychology
occupies a space, or border, between psychosis and neurosis.
– Okay, wait: depression = ”I feel depressed;” OCD = I “obsess
about, compulsively do things, or both;” BPD = “I . . . border
things?”
In Their Own Words . . .
■ ”You know you’re borderline when you fluctuate between fearing
abandonment and encouraging it.”
■ “I despise my own hypersensitiveness, which requires so much reassurance.
It is certainly abnormal to crave so much to be loved and understood.”
■ “I don’t know what it’s like to not have deep emotions, even when I feel
nothing, I feel it completely.”
■ “One second I’m perfectly fine, and the next it’s like a volcano erupts inside
me, leaving me miserable.”
■ “I’m trying my hardest not to act how I feel.”
■ “It’s hard to be accused of manipulation when really it’s a scream for
love.”
■ ”My skin is so thin that the innocent words of others burn holes right
through me.”

Quotes retrieved from https://www.healthyplace.com/insight/quotes/borderline-personality-

Figure 1. Words associated with BPD. 2015. By NAMI, Westside Los Angeles,
2015. Retrieved from https://namila.org/borderline-personality-disorder/
Cutting to the Chase: What is
BPD?
■ Personality disorder = enduring, maladaptive patterns of thinking, behaving, and
experiencing oneself and others.
– Happens across contexts (e.g., friends, family members, romantic partners).
■ Everyone might have troubles from time to time, with certain people, or in different settings
(e.g., a particular job).
– Not consistent with cultural norms.
■ 10 specific personality disorders listed in DSM-5:
– Paranoid, schizoid, schizotypal (associated with schizophrenia spectrum-like thinking and
behavior)
– Antisocial, borderline, histrionic, narcissistic (associated with dramatic, unpredictable, or
emotionally volatile thinking and behavior)
– Avoidant, dependent, obsessive-compulsive (associated with anxious, fearful, or overly-
controlled thinking and behavior)
5 of 9: Meeting DSM-5 Criteria
for BPD
■ DSM-5 is our handbook for applying diagnoses to people who seek treatment for mental
health-related difficulties.
– Intense fears of abandonment, with frantic efforts to avoid it (e.g., frantic texting).
– Impulsive actions and choices (e.g., risky sex; shoplifting; spending sprees).
– Frequents suicidal thoughts, or attempts; hurting self to relieve anxiety/tension (e.g.,
cutting).
– Feeling detached from reality or oneself, becoming very paranoid, or both, when very
stressed out.
– Rocky relationships, with shifting extremes of feelings (e.g., from to love to hate).
– Frequent angry outbursts (e.g., throwing things, raging at people).
– Identity problems (e.g., “I feel like I have no idea who I really am, or what I really want”).
– Chronic feelings of emptiness.
– Highly emotionally reactive, with intense mood changes lasting from a few hours to a
few days.
256 Symptom Combinations
Meet Criteria (!)
■ Not uncommon to hear, “Oh, I/my friend have/has many of the
symptoms, but never [X], so I guess BPD doesn’t fit.”
– NOT SO!
■ Criticism of the diagnosis: so heterogenous (i.e., people can have
very different experiences within the same diagnosis).
■ BPD “stereotype” = suicidal/self-harming, chaotic relationships,
emotional rollercoaster.
– Can have none of these experiences and still meet 6 of the 9
criteria!
Watch Out for Misdiagnoses

■ It is exceedingly common for people with BPD to receive misdiagnoses.

– Bipolar disorder I or II
– “Anxiety/depression”
■ Why? Providers often hear some variation(s) of the following statements:
– ”I feel like my mood changes all of the time throughout a single day, one minute I’m
happy, the next I want to die.”
– “So much of the time, I feel on edge, just miserable.”
■ So how is BPD different?
– Bipolar disorder(s): mood fluctuations happen independently from what’s going on in
your life (e.g., you wake up, *boom* you’re depressed; 2 weeks later, you wake up,
*boom* you’re ready to take on the world).
– Anxiety and depression stem from living with BPD.
What Do You Mean about
“Identity Problems?”
■ Simply put, people with BPD have a difficult time knowing themselves.
– They might find easy to identify with the interests, preferences, and
values of their friends and partners so much that they feel as if they
“lose themselves” in other people.
– They might change majors, jobs, careers, or move frequently from city
to city, because they rarely feel that a particular field, occupation, or
place “fits” them.
– When asked to describe themselves, they might have difficulty
choosing more than a few adjectives.
■ They might profess an inability to remember swaths of time from their
lives.
– They might have a sense of their personalities, interests, and so on, as
unpredictable or evanescent.
Here, but Not Here
■ Upsetting or disruptive dissociative experiences happen frequently for many people
with BPD, especially in response to intense emotional or relational experiences.
– “. . . wide array of experiences from mild detachment from immediate surroundings
to more severe detachment from physical and emotional experiences” (Wikipedia).
■ Most of us have mild experiences. We “zone out” for a few moments, feel “as if our
minds are somewhere else” for a few hours, ”space out” in the middle of a
conversation, and so on. We shake them off and continue our days.
■ For many people with BPD, experiences are more chronic, disruptive, and unpleasant.
– Feelings of disconnect in session w/ therapist(s), almost catatonic.
– Some people w/ BPD might self-harm to disrupt dissociative experience.
The Linchpin
■ You might’ve noticed, many, if not most, BPD experiences have to do with relationships:
– Angry outbursts.
– Fears of abandonment.
■ Might feel that being alone is painful, intolerable; dread of rejection; dread of being ultimately
unlovable.
– Chronic turbulence and inconsistencies in relationships with friends, family, and/or partners.
■ Serial, brief romantic partners, or longer-term relationships with many break-ups/make-ups.
– Feelings for partners might move from intense desire to boredom/dislike, and back again.
■ Poor choice(s) in partners (e.g., poor compatibility; ignoring for missing “red flags”).
– Relationships might move too quickly.
■ ”Burned bridges,” estrangement from family members; few long-lasting friendships; sensitivity to
real and imaginary slights. Social media can be hellish for people with BPD.
■ Feeling never understood, feeling chronically unloved or unable to feel “secure.”
– Impulsivity.
– Suicidality.
How Do We Help People with
BPD?
■ Dialectical Behavior Therapy (DBT)
– DBT is a structured, manualized psychotherapy built for people with
BPD.
■ Weekly DBT skills group: Led by one or more group therapist(s); group of
participants with BPD, learning and practicing skills shown to help people
with BPD cope with their symptoms.
– Mindfulness, distress tolerance, interpersonal effectiveness, and
emotion regulation.
■ Transference-focused Psychotherapy (TFP)
– TFP is an intensive, twice-weekly therapy also built for people with BPD,
as well as people with other personality disorders.
■ Experiences in early relationships form a person’s sense of self and other.
■ Person rigidly, albeit unconsciously, enacts that sense of self and other
across relationships, leading to recurring problems across settings.
■ Therapy helps person notice, understand, and work through (reconfigure)
sense of self and other.
How Do We Know These
Therapies Help?
■ To better understand if and how therapists and therapies help people, we
conduct case studies and clinical trials.
– Case study = follow a single individual from pre- to post-treatment,
vigorously and meticulously documenting both your therapeutic efforts
and your patient’s responses to them over the entire length of treatment.
If a patient seems to have improved by the end of treatment, follow up
with them post-treatment to see if gains have continued.
– Clinical trial = select a sample of patients with similar characteristics;
select a group of therapists with matched skills and techniques.
■ Therapists follow a strict procedure for treating patients (keep the therapy as
equal as possible across patients).
■ Measure patients’ progress over time.
■ (Ideally) compare progress to that of similar patients treated with another
therapy for same length of time.
How Do We Measure Experience?
■ Broadly speaking, people with a given psychiatric diagnosis tend to have
common experiences, no matter their background, gender, or current life
situations.
■ Basis for how we make diagnoses. Also basis for how we can measure change.
– Interviews, self-report measures (e.g., pencil-and-paper), neuropsychological
tasks (e.g., control of attention), physiological readings (e.g., brain
functioning), and so on. All can provide useful data about a single
mental health problem.
– The more sources of data, (usually) the better. If a person or group of people
show(s) improvements on multiple measures of a mental health problem, then
we are more certain of a therapy’s usefulness for that problem.
– For quantitative data (i.e., range of severity or experience represented
numerically), we use statistical analyses to better understand if changes in
their values over the course of therapy are likely or not likely due to chance.

■ Research shows that both TFP and DBT help people

with BPD!
The Takeaway
■ BPD is an under-recognized mental health difficulty, affecting many
people, as well as their friends and family members.
– Because BPD has to do with relationships, both people with BPD
and those around them might feel frustrated, helpless, and
confused.
– Awareness is vital.
■ BPD can, and often does, look different from person to person.
– Avoid stereotyping: Not all people with BPD experience the same
things.
– Be wary of misdiagnoses.
■ BPD is TREATABLE!
Resources!
■ I am research coordinator for a clinical trial of TFP for BPD at Weill
Cornell Medicine! And yes, we are recruiting participants for our study!
– Must be a woman between the ages of 18 and 35.
■ See me for a list of resources in the area if you, or someone you know,
might be interested in seeking psychological assessment or treatment
for BPD.
■ See me also for a list of resources for friends, partners, and family
members of people with BPD.
– Because BPD has to do with relationships, BPD affects *everyone*.
■ Alternatively, if you have questions about anything I’ve discussed, email
me at rim2016@med.cornell.edu
Before You Deep-Dive Down
those Online Rabbit Holes . . .
■ CAUTION: Beware of the “I-survived-a-partner-with-BPD” personal narrative!
– Written or spoken by people who are hurting.
– Often villainize people with BPD or else reduce them to two-dimensional
cartoons (e.g., the “psycho ex,” always crazy, always out of control).
– Perpetuate stigma and myths about BPD.

■ People living with BPD are people, and diagnoses describe only parts of a person.
– “NYC has more Thai restaurants than Omaha” is true, but hardly describes NYC.
– Just like everyone else, some people with BPD can be jerks, some can be the
sweetest you’ll ever meet.
– “Asshole” is a transdiagnostic phenomenon.
 N K Y O U !
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