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This feature is a new one that I have added to my “model” of BPD. I added it because I was attending the International Society for the Study of Personality Disorders (ISSPD) and listened to Dr. John Gunderson present a detailed model of his experience with BPD. The purpose of the presentation was to present a “real world” clinical model of BPD from the viewpoint of someone with many years of experience treating the disorder. One of the features that Dr. Gunderson provided was this “preoccupation with attachments.”
I believe this feature is born of an unstable sense of self. A person with BPD has difficulty “locating herself in the world.” While two of the other “core” features of BPD are “systems related” (meaning, those features are based on subsystems of the mind – the emotional regulation system, the impulsivity control system), shame and the preoccupation with interpersonal relationships are based more on a person with BPD’s view of herself. While it might seem that interpersonal relationships are outside of self, a more complex picture arises as we look more deeply into the mental configuration of BPD.
A recent study showed that the number one trigger of systems dysregulation (like wildly swinging emotions and impulsive behavior) is interpersonal distress. This interpersonal distress is more important as a trigger of dysregulated behavior than sweeping/major life changes – in fact major life changes, such as changing jobs, getting married, having a child – were ranked last of nine factors that trigger BPD distress. The interpersonal, moment-to-moment perception of the state of an important relationship is the most important trigger. That can be bad news for someone in a close relationship with someone with BPD. The person with BPD will be continuously scanning the interpersonal landscape for threats. Since shame is involved, people with BPD are likely to use others to regulate their internal systems and their self-view. In other words, a person with BPD uses others as a mirror to view their self.
Why is this so? I believe that a person with BPD’s lack of internal regulation causes her to internalize other people and use others to self-regulate. When someone has an inability to locate herself in the world, which very possibly arises from the emotional instability as a child, she seeks to have others locate her for her. She needs others to verify and validate that she’s “ok”. Unfortunately, because few of us are taught the language of emotional regulation, a person with BPD will likely learn that the interpersonal landscape is not safe; it is full of threats to their very self. It’s not an easy situation in which to live. If a person requires external validation and regulation, there develops a sense of a lack of control. Others are unpredictable, don’t understand how it feels and can damage the very core of her being.
People with BPD have described this internal feeling of emptiness and lack of internal controls as feeling “dead inside,” which is in itself, tragic. Extending this feeling to others through this preoccupation with close interpersonal relationships leaves a person with BPD with the feeling that others contribute to this unpleasant internal feeling. In other words, “it’s your fault that I feel this way.”
Many Non-BPD’s ask me why their loved ones with BPD don’t seem to trust them. To me, this aspect of BPD is a significant factor, along with other biological factors.
All of that being said, let’s suffice it to say that interpersonal relationships play a huge role in BPD. Social connections and attachments, including parent/child attachments, are the focus point of a person with BPD’s sense of well being. When these trigger dysregulation and/or ineffective modes of thinking and behavior, a person with BPD is lost in the world, floating free in a threatening sea of feelings, thoughts and behaviors.
One must understand that in order for the interpersonal tools to work properly, they need to be understood and applied in a step-wise fashion. I have often said to my list members that “you can’t boil the ocean” which means that you can’t jump to the end before you walk the path. You can’t do everything all at once. Instead, you have to take one small step at a time in a longer journey. The goal of all of my tools, attitudes, skills and approaches is (in my mind) a compassionate, trusting, respectful and two-way relationship in which both parties feel known, heard, understood and worthy. Achieving that goal is hitting a grand slam so to speak. Yet, I feel that a person must be given the fundamentals and practice those fundamentals before you can hit one out of the park. Emotions which are the first layer to unravel peel back from the onion that is BPD. Understanding emotions in oneself and others is vital to having a two-way relationship with someone with BPD.
When I saw this article come through the Google news alerts I thought: “Oh no, an article that’s going to say ‘she did it for attention’ because she has BPD and they are attention-seeking.” I was mightily surprised when I read the article and realized that here’s someone that actually knows what she’s talking about.
Why would Bethany Storro douse herself in acid? Experts try to explain
When news broke Thursday that a Vancouver woman admitted dousing herself with powerful acid, causing severe facial burns, one question reverberated:
Why would anyone do such a thing?
Friday, a leading researcher in the field of self-harm discounted theories that Bethany Storro, 28, was crying for attention, trying to manipulate others or attempting suicide.
“The biggest reason people do this,” said Kim L. Gratz, “is because it makes them feel better in the moment … It can really distract people from all the emotional pain that they’re feeling.”
Gratz, director of personality disorders research at University of Mississippi, is co-author of books on self-harm and borderline personality disorder. Before she was contacted by The Oregonian, Gratz hadn’t heard about Storro, 28, who told police an assailant threw acid in her face near Vancouver’sEsther Short Park on Aug. 30. Storro described the attack in detail, sending police searching for an African American woman in her 20s or 30s. A couple days later, before a crowd of reporters at Legacy Emanuel’s Oregon Burn Center, Storro said, “I have no enemies … I don’t get it.”
No one is sure how many people mutilate themselves each year; those who do typically hide it.
The U.S. Centers for Disease Control and Prevention put the number of emergency room visits for self-inflicted injury at 594,000 in 2006, the most recent data available. But the vast majority of people who intentionally hurt themselves don’t seek treatment, Gratz said, either because they don’t need medical attention or because they’ve become good at treating themselves.
“Our best estimate in adult populations,” she said, “is probably 4 percent … with much higher rates among adolescents and young adults.” Large-scale studies of college students around the world put rates of self-harm at 17 percent to 40 percent, she said. Incidence among females and males appears comparable.
The most common form of self-harm, or self-mutilation, as it’s also called, is by cutting; those who engage in the behavior frequently slice their arms, then wear long sleeves to hide the injuries.
Dr. Thomas Dodson said such patients describe a state in which they don’t feel any emotions. “They cut on themselves,” he said, “because they can’t tolerate a state of not feeling anything. It becomes habitual and relieves tension that they have.”
Dodson, a Southwest Portland psychiatrist, chairs the public information and education committee for the Oregon Psychiatric Association.
Beyond cutting, the list of self-harm behaviors is as long as it is gruesome, from burning to sticking the skin with needles, punching one’s self to banging the head or another body part repeatedly against hard surfaces. Use of acid, apparently, is rare.
The most typical diagnosis among self-harmers is borderline personality disorder, Gratz said. But the behavior also is associated with eating disorders, substance-use disorders, depression and anxiety.
If Storro has a diagnosed illness, it has not been publicly disclosed.
Self-harm is not a suicide try. Yet those who mutilate themselves are fragile, Gratz said, and are at higher risk of suicide than the general population.
Gratz has no idea what might have triggered Storro to hurt herself, but life transitions, always increase stress, she said. Storro recently divorced and moved from Idaho to Vancouver to live with her parents. She had just started a new job at Safeway.
The best treatment for self-harm, Gratz said, was developed by University of Washington’s Marsha M. Linehan, a psychology professor. Called dialectical behavior therapy, it involves a year of intensive psychotherapy, plus weekly group sessions in which patients learn to regulate emotions, tolerate distress, be more mindful of and negotiate relationships better. DBT, for short, includes telephone coaching, so therapists can help patients whenever a problem arises, and a consultation team offering peer support for the therapists themselves.
The method is the treatment of choice for borderline personality disorder.
At Portland Dialectical Behavior Therapy Program on Southwest Macadam Avenue, Tracy Jendritza, a psychologist on staff, estimated that half the clinic’s patients have engaged in self harm.
“People get so dysregulated emotionally that there’s something about self harm that actually calms people down,” Jendritza said. “Initially they feel better but in the long term it makes things worse.”
Self harm, Gratz said, frequently goes hand in hand with shame and feeling alone. She figures that Storro has landed in that deep well.
“My guess is that she’s experiencing incredible shame” since police learned the truth about the attack. “It’s so public … I’m sure she’s in a much more intense state of distress” than she was before applying the acid that burned the skin off her beautiful face.
Ok, after posting about book sales recently and stuff like that, now it’s time for a much more substantive post about BPD. Today, I plan to talk about self-regulation and a new study that points out an intriguing aspect of BPD. There has been much talk in the BPD research and clinical community about the “core” of BPD. Once it was thought to be a personality disorder or even an extreme form of PTSD. Dr. Marsha Linehan (the inventor of DBT) talks about dysregulation in a number of systems, the most important of which (in my interpretation) is the emotional regulation system. People with BPD are extremely emotionally sensitive and subject to emotional “cues” or triggers. They seem to have a less tolerant (in the “controls” sense of the word, meaning more highly sensitive) emotional system. They are triggered more easily and the reactions seem to be more intense and longer-lasting. In “When Hope is Not Enough” I compare this feature to a heat-sensing device and say:
The core problem with BPD is poor emotional regulation. That particular problem can cause other symptoms to arise as the person with BPD becomes emotionally dysregulated. This term emotionally dysregulated (or just dysregulated) is used to denote the state in which a person with BPD is overcome with powerful and, at many times, misaligned emotional reactions. Remember that emotions don’t arise on their own; they are based on cues or triggers from the environment and compared by our “emotional immune system” to the meaning of the cue. For a person with BPD, the meaning can be misjudged or, as is more often the case, the sensitivity to emotional cues is greatly heightened.
An example is a heat-sensing system that helps to detect and suppress fires. Sometimes companies will install heat-sensing equipment in addition to smoke detectors so that they can protect assets that need a certain temperature to operate (e.g. computer equipment which might cease working at a high temperature). The setting at which an alarm goes off might be 80 degrees Fahrenheit. In the case of someone with BPD, the setting (or “tolerance” as it is called in the control community) is naturally set much lower, at say, 50 degrees Fahrenheit. That means that the alarm will be raised much more often and lead to a reaction to the alarm. In other words, people with BPD will experience many, many (what you would consider) false alarms. However, these false alarms seem completely real to them, because their tolerance for emotional triggers is set very low. They are constantly running a fire drill. Unfortunately for you, the BP may drag you along unwillingly and unwittingly for the drill. (Pages 32-33 of WHINE)
As you can see, the position I take in WHINE is that emotional regulation is the “core issue” of BPD. This position is in line with the DBT way of thinking, which is why one of the “modules” of DBT is emotional regulation skills.
The question is today: is emotional regulation at the “core” of BPD? Or does it go deeper than that? Is there a “cause” for emotional regulation? What are the triggers and how does a person with BPD’s internal feelings affect this “systems dysregulation”?
In the American Journal of Psychiatry, Drs. Stanley and Siever recently (January 2010) publish an article entitled “The Interpersonal Dimension of Borderline Personality Disorder: Toward a Neuropeptide Model “ in which they seem to posit (in my interpretation again, since I am a lay person and not a doctor) that this systems dysregulation actually has another cause instead of being a “core cause’ of the disorder. They begin the article like this:
Borderline personality disorder is a complex disorder associated with substantial morbidity, mortality, and public health costs. Prominent symptoms include suicidal behavior, nonsuicidal self-injury, aggressive outbursts, and emotional reactivity, all of which typically manifest in an interpersonal context. For several years, there has been an ongoing discussion about whether impulsive aggression or affective dysregulation is at the core of the disorder. While these factors are important in borderline personality disorder, it is the exquisite interpersonal sensitivity that frequently triggers both dysregulated affect and impulsive behaviors, which suggests that this sensitivity perhaps rests at the core of the disorder and may in turn drive impulsivity and dysregulated affect.
In researching the implications of shame in BPD, I found this research study:
Shame and Implicit Self-Concept in Women With Borderline Personality Disorder
* Nicolas Rüsch, M.D., Klaus Lieb, M.D., Ines Göttler, M.D.,
Christiane Hermann, Ph.D., Elisabeth Schramm, Ph.D., Harald Richter, Ph.D.,
Gitta A. Jacob, Ph.D., Patrick W. Corrigan, Psy.D., and Martin Bohus, M.D. *
*OBJECTIVE: *Shame is considered to be a central emotion in borderline personality disorder and to be related to self-injurious behavior, chronic suicidality, and anger-hostility. However, its level and impact on people with borderline personality disorder are largely unknown. The authors examined levels of self-reported shame, guilt, anxiety, and implicit shame-related self-concept in women with borderline personality disorder and assessed the association of shame with self-esteem, quality of life, and anger-hostility.
*METHOD: *Sixty women with borderline personality disorder completed self-report measures of
shame- and guilt-proneness, state shame, anxiety, depression, self-esteem, quality of life, and clinical symptoms. Comparison groups consisted of 30 women with social phobia and 60 healthy women. Implicit shame-related self-concept (relative to anxiety) was assessed by the Implicit Association Test.
*RESULTS: *Women with borderline personality disorder reported higher levels of shame- and guilt-proneness, state shame, and anxiety than women with social phobia and healthy comparison subjects. The implicit self-concept in women with borderline personality disorder was more shame-prone (relative to anxiety-prone) than in women in the comparison groups. After depression was controlled for, shame-proneness was negatively correlated with self-esteem and quality of life and positively correlated with anger-hostility.
*CONCLUSIONS: *Shame, an emotion that is prominent in women with borderline personality disorder, is associated with the implicit self-concept as well as with poorer quality of life and self-esteem and greater anger-hostility. Psychotherapeutic approaches to borderline personality disorder need to address explicit and implicit aspects of shame.
http://ajp.psychiatryonline.org/cgi/content/abstract/164/3/500
This message was posted by me on the “Anything to Stop the Pain” email list way back in September 2006. The message is in response to a member’s message about another member’s husband (who has BPD). The messages in brackets [ ] are the messages of the male member speaking with the female member about her approaching her BPD husband about money. Remember, the husband has BPD and doesn’t work. When the female member approached her husband with questions about money, he blew up and told her that she was criticizing him and calling him a “lazy good-for-nothing.” The male member replied with some suggested reasons why he might rage. I replied to his “analysis” because I disagreed with his assessment.
I post this message here because I am doing a review of my postings and discovering content that can be helpful or relevant to the non-BPD people out there. This particular one concerns the shame, self-image and pain of someone with BPD.
[Male member of list to female member: You asked him to "modify" his behavior. That literally means he needs to change. And, as you wrote to me, if people feel they're right -- they'll feel they don't need to change. In other words, he's good.]
My reply: I will respectfully and forcefully disagree. No, he is NOT fine and that is his very issue. He KNOWS he is flawed, he KNOWS he “needs” to change. He is shameful about himself. He uses tools to make himself feel better – to escape his suffering. Those tools are: alcohol and drugs, cutting, suicide attempts and raging. He does this not because he is being criticized, he does this because he believes deep down he DESERVES to be criticized. What works better is to give him new tools – but doing that non-judgmentally is the key.
Jealousy has the same root as the suffering. Of course he thinks he “should be appreciated” but it ain’t because he is not appreciated, it is his deep sense of shame that he doesn’t DESERVE to be appreciated that scares the shit out of him and makes him rage. He thinks “you’re not appreciating me”, then “you think I’m a loser” and then “I am a loser”. But when you are being threatened, you fight back. He feels threatened because he is being “found out”.
[Male member to me regarding female member’s husband’s words: What about the underlying positive stuff... the "I'm hot, I'm brilliant, I'm special, I'm sexy, I'm fascinating, I'm irresistible, everybody loves me, I'm meant to be famous, etc.” What filter is that?]
My reply: That’s the “I don’t really believe this, but I’m going to say it so you will confirm/validate it so I might start to believe it”. It is the needy, sad, shameful self, desperately seeking approval. The filter ain’t what he says, it’s what he HEARS.
BPD is an emotional disease. It is a disability. I’m not trying to let anyone off the hook here, but I think that you have assumed that everyone is slightly neurotic, but basically mentally healthy and extended that to this husband with BPD. I disagree because he has a mental illness (an emotional illness actually) and he thinks in a different fashion than you do. Inside he is profoundly shameful and dreads judgment. If anyone even HINTS at that, he blows up – either in a rage or with self-injury or with drugs or whatever. He is using those things to escape his suffering and to hide his shame from even himself. Those tools work: cutting makes the pain go away – but they are not “healthy” tools. He desperately protects that shame and when she says: “We have to discuss money” he hears: “You are a no good son-of-bitch who is crazy and lazy”. Why? Because he is disordered and has disordered thoughts. He is afraid that she can see right through him and see the shameful broken person inside.
When working with a BP, you have to think about what they’re REALLY saying and you have to think about what they’re REALLY hearing as well.
 Non-BPDs and self-image I have starting thinking about the concept of “trade” words. What that means is that we nons “trade” certain words for other words. The purpose behind this is to re-make our ways of thinking – it helps to combat black-and-white thinking, shame and fear in ourselves. One of the concepts that I expound on in “When Hope is Not Enough” is the idea that one’s own language shapes one’s thoughts. While in that section of the book, I focus on the non-bp’s thoughts and words in relation to the person with BPD, here I am interested in how a non-BP thinks about his/herself.
Here are some examples of “trade” words and phrase that I have either discovered or developed:
Old Word: Must
Trade Word: Prefer, would like to
Old Word: Should
Trade Word: Choose to
(from now on the old word/phrase will appear first, the trade word next – just so I don’t have to type “Old Word:” “Trade Word:” over and over again…)
Can’t
Choose not to
Have to
Want to
Ought
Had better
All
Many or most
Always
Often or typically
Can’t stand
Don’t like
Awful
Undesirable
Bad Person
Bad Behavior
I am a failure
I failed at
Anxious
Concerned
Depressed
Sad
Angry
Annoyed or frustrated
Hurt
Disappointed
Guilt
Remorse about
Jealous
Concerned about the relationship
Never
Not often
is
seems like
is
feels like
I am certainly open to more suggestions. Here are some examples when thinking about yourself:
“I must do well” = “I want (or wish) to do well”
“I shouldn’t do that” = “I prefer not to do that”
“I am a bad person” = “I did a negative thing”
“I need love” = “I want love, but not need it to live”
“I can’t stand this” = “I don’t like this”
“I am a loser” = “I lost (or failed) at a task”
 Are you and your BP on the same team? I often hear people with BPD/ERD say that they feel that their loved ones are “not on my side” or that the loved ones are “supposed to be on my side.” This phrase stuck out at me when I read the story about the suicide of Megan Meier (the “MySpace suicide” case), because, although I have no insight into Megan’s mental health, clearly when she was insulted and rejected on MySpace, and she was emotionally dysregulated. She came to her mother, and after her mother admonished her for the use of foul language on MySpace, Megan cried and said, “You’re my mom. You’re supposed to be on my side!” ( This according to her mother’s reports).
When someone is highly emotional, they need to know that they have an advocate and that someone is on “their side.” I often ask my consulting clients (especially partners of people with emotional regulation issues) if they feel that their partner and they are “on the same team.” Many times the answer is no. Why does someone have a desire to have someone on their side, even when the “sides” are not desired, intended or even clearly delineated? The answer in my mind comes down to shame and rejection sensitivity.
If a person has shame (or even low self-worth, which is similar), then the person is likely to have a high level of rejection sensitivity. Being rejected by others is painful, especially for emotional people. Having an advocate of their “side” of the issue, which is essentially answering, “I am on your side no matter what the situation,” is tantamount in these highly emotional, social interactions that involve rejection. One can be “on their side” emotionally without condoning whatever behavior that one doesn’t agree with.
There are teaching moments and there are times that one doesn’t teach. If you try and teach, punish or impart values during a period of emotional dysregulation, the relationship will be damaged and nothing effective will be accomplished. Instead, emotional validation and support can be used to cool the bonfire. Once it is cool, then a teaching moment can present itself.
This is my response to someone who asked why shame is corrosive in a BP/Non-BP relationship…
Shame is corrosive to a relationship because it keeps the BP or NP in “pretend mode” where they are behaving “as if” they are engaged in the relationship, but in reality their only real goal is to protect themselves from discovery. The closer you get to it, the more panicked they become. Often the shame is never revealed to others and covered up with bullshit (in the art term, not the common term). If a person is bullshitting their way through something (and sometimes they bullshit themselves too) then they are not genuinely engaged in the relationship. THAT is corrosive, especially when it is discovered and you think “was this EVER real?” That’s what leads people to think BPs can’t really love. But the bullshit is a defense mechanism to protect against mind numbing shame. In fact it could be argued that all defenses are at some level bullshit (or pretending things are ok). Still, we need them on some level to protect us from the brutal truth at times. Acceptance is not bullshit, it is taking things how they really are. If a BP can’t accept themselves as they are (and want to change) then you’re in for a steaming pile of bullshit in the form of protecting their shame – and that is no way to have a genuine relationship. Still, if they had no defenses against experiencing shame, they would all commit suicide.
One of my commenters pointed out that the DSM-IV allows (because of the 5 of 9) for 256 different configurations of BPD. I can’t help but feel that perhaps if there are 256 configurations of a disorder, we are talking about a very non-specific diagnosis here. Perhaps we’re talking about several different diagnoses. I don’t really know. I try and address the idea of ERD (although I call it BPD throughout my book because that is the diagnosis that is recognized) in my book, with the core features being emotional dysregulation, impulsiveness and shame. I don’t think all 256 configurations would include all of those – but IMO (and I am NOT a doctor – that’s important to remember – and my book is almost entirely my opinion – with some research of course) a person doesn’t have BPD/ERD without these features. Of course, the medical community might disagree on this.
If we look at the diagnostic criteria of BPD, I’d say some of those features are REQUIRED to have the disorder (again this is my opinion). From the DSM IV:
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 – and the diagnosis only applies to 5 or more of ANY of these traits….
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
OK, almost EVERY borderline I have come into contact with or have learned about has this feature including my wife. I didn’t think this was a big deal in my wife until she went into a crisis with one of her close friends and she told me (about the friend) “Don’t touch abandonment! That’s my ISSUE!” Abandonment by her father has had DEEP wounds for her. However, while it is very common, I don’t think it is required.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
I think this is a requirement, but not a “distinguishing characteristic” of BPD. Nons would not have a problem if this wasn’t an issue. It’s about splitting – however, splitting is not a feature that is exclusive to BPD. You see it in other disorders (although it might not be a diagnostic feature of others). You see it in PTSD, you see it in emotional immaturity… it is a very common cognitive distortion.
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
I don’t know if this is required. I think this could be replaced with pervasive SHAME (which IS required IMO). The sense of self is more than “unstable” – it seems a bit self-judgmental… the invalidating of one’s emotions leads to shame, because it is wrong to feel like one feels. I think that causes an “unstable sense of self” because people have (or you yourself have) invalidated your very essence. It is not OK to be the way you are, so you have to search for a different way to be – in vain. That’s where acceptance can help.
4. 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.
Personally, I think the impulsiveness is a requirement too. Maybe not the behaviors mentioned here… but BPs are in my experience incredibly impulsive. If you look at this from wikipedia you will see how other countries view BPD:
Comparable diagnoses
The World Health Organization’s ICD-10 has a comparable diagnosis called *Emotionally unstable* personality disorder – Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.
The Chinese Society of Psychiatry’s CCMD has a comparable diagnosis of *Impulsive Personality Disorder (IPD)*. A patient diagnosed as having IPD must display “affective outbursts” and “marked impulsive behavior”, plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10′s Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.
5. recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior
Self-mutilating… probably not. Although I have known of many, many BPs that do cut, burn or pull at their hair. Or starve themselves. I think suicidal ideation is a given. According to some sources 75% of BPs attempt suicide at sometime in their lives.
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).
THIS is IMO the CORE feature of ERD (and possibly BPD if it is the same diagnosis – see WHO above). This – in combination with impulsiveness – seems to the the very foundation for BPD/ERD. I don’t think someone can have the disorder that I describe in my book (which I call BPD – or at least my experience with it) without this. This is the main thing the skills in my book try and address, because IMO this is the engine of all other feelings and behaviors. If this can be healed/managed most other things will fall away. Again I am NOT a doctor.
7. chronic feelings of emptiness
Probably important, but not required. I think many BPs DO feel this. It is difficult for me to see this from the outside (or for any non, unless the BP reveals it).
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
Again, this is probably required and is what gets most nons to seek help. I think this is an out-growth of emotional dysregulation and shame. They FEEL angry, because angry is a powerful emotion and a natural reaction to threat – even if the threat is “imagined” (although felt).
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Well, this is a hard one. I have seen this in my wife a couple of times. She walked around talking to pillows as if they were people at one point. It’s tough to say if this is “required.”
So, I have a certain view of the disorder that I think works in most cases (but possibly not all). I would encourage you guys to read the book and try it out. It takes some time to figure out what I’m saying though… because of the above view of BPs/nons is slightly “unstandard”. Again I’m not a doctor.
UPDATE: see this link.
Today’s subject is the Myth of the High-Functioning Borderline. I have been scouring the research on BPD to find out if anyone in the research or therapeutic community uses this term or concept high-functioning versus low-functioning Borderline. I have yet to find any author in either the research community or therapeutic community reference this concept. It crops up in the support community (in “Stop Walking on Eggshells” and on both bpd411.org and bpdcentral.com). It also crops up in the “cross-over” community (see more later) but only in a sarcastic way. The idea of high vs. low-functioning BPD doesn’t seem to hold much weight in any other community than the support community.
What do I mean by referencing these “communities”? I think that there are basically three BPD/Non-BP “communities” out there: the research community, the support community and the therapeutic community.
The research community is comprised those scientists doing medical research (and psychological research) on BPD. They publish scholarly articles and research in medical and psychological journals. Some “supposed” psychological researchers publish in the less-well-known and scientifically suspect journals (see my article about “Demonic Possession and BPD” for an example of this type of researcher). For the most part, these researchers don’t try and “cure” BPD, they merely provide data to other professionals about the configuration of BPD, the biology of BPD and the “common” features of BPD. This group of people does not differentiate between high-functioning and low-functioning BPs. In fact I have found no reference to high- or low-functioning BPD at all in any of these research papers or reports.
 When Hope is Not EnoughGet the Non-BPD book that is designed for staying and working on the relationship The therapeutic community is those practitioners (mainly psychologists, psychiatrists, social workers, other “therapists” and consultants) that try and “cure” or remediate BPD in patients. Some (very few) also serve the families, friends, spouses, children, etc. (the Non-BPs). Their purpose in life is to help the BP overcome or to effectively manage their disorder. In this group of people, I have found no mention of high- or low-functioning BPs. The only “partial” mention is that of Dr. Paul Mason, who co-wrote “Stop Walking on Eggshells” with Randy Kreger. Several of these people within the therapeutic community have written popular books about BPD, including “Sometimes I Act Crazy,” “Lost in the Mirror,” “The Angry Heart,” and “I Hate You, Don’t Leave Me.” None of these books, as far as I can tell, refer to the idea of high-functioning vs. low-functioning BPD. Of course, Dr. Marsha Linehan and Dr. John Gunderson are prominent individuals within the therapeutic community. Their theories about BPD have a distinct influence on how therapy is conducted with people with BPD.
The final community is the support community. This community is comprised of ex-BPs, Non-BPs and others who provide advice about how to “deal with” BPD or with someone with BPD. This community includes myself, the authors of “Stop Walking on Eggshells,” the author of “Tears and Healing,” A. J. Mahari, the proprietors of bpd411.org and others. Only in this community have I seen any mention of high- vs. low-functioning BPD.
Some individual and organizations actually straddle the support/therapeutic (or even the research/therapeutic) community split. These include: myself (at least I hope so), TARA, A. J. Mahari and others. Some of these are more therapeutic (or at least psycho-educational) like TARA. I try and be both psycho-educational and to offer support resources to Non-BPs; yet, in doing so, also try and dispel the many, many myths about BPD (where possible).
The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state. If a BP is emotionally dysregulated they will adapt to that (usually) painful state in whatever way that they have learned will assuage the pain. Some people with BPD will cut themselves, take drugs, avoid situations or behave in other ways that might be considered harmful to themselves or those around them. If a BP is not dysregulated, he/she has no need to behave in these ways. The core point is that BPD is about emotional instability and no person with BPD will be always high- or low-functioning. A person with BPD will swing – sometimes wildly – between several polar ways of feeling and behaving.
I suspect many “high-functioning” BPs do not have BPD at all. I have read many, many posts on Internet boards in which the “BP” in question clearly does not have the disorder. Many times, if you read carefully, you will find that these “high-functioning” BPs are diagnosed by their (usually) ex-wives, just because the “xBPh” (ex-husband with BPD) raged or was selfish during their relationship. BPD is more than raging – and as a Non just because you’re “walking on eggshells,” it doesn’t mean that your “BP” has the disorder at all. In fact, recently the list owner of WTO (the Welcome to Oz Internet list) asked the women Nons on the list if there husbands (or, more appropriately, ex-husbands) exhibited the symptoms of Narcissistic Personality Disorder (NPD). Every “Non-BP” that responded to that request confirmed that their “BP” met the criteria for NPD.
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NPD (which IMO is more likely a disorder that appears to be “high-functioning ‘BPD’”) and BPD are distinctly different disorders. There may be a slight bit of overlap – deep, deep down within the psyche of the individual (and that is shame, most likely), but the basic configuration of the disorders are quite different. People with BPD do not like themselves, for whatever reason. People with NPD adore themselves, for whatever reason. That alone separates the two disorders. While people with BPD may exhibit “deserving” behavior (that they deserve love, riches or whatever), people with NPD believe that being “special” is their birthright and want to be surrounded by important or exclusive groups of people. The thing to note with BPD is that the “deserving” behavior is counter-balanced with “undeserving” behavior – polar opposite feelings and behavior that is the hallmark of BPD. So, it seems unlikely to me that “high-functioning” (or low-functioning) BPs can actually exist.
Let’s briefly look at the DSM-IV diagnostic criteria for BPD and NPD , and we can illustrate the differences. First, BPD:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called “splitting.”
- 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 (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.
And now NPD:
- has a grandiose sense of self-importance
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- believes that he or she is “special” and unique
- requires excessive admiration
- has a sense of entitlement
- is interpersonally exploitative
- lacks empathy
- is often envious of others or believes others are envious of him or her
- shows arrogant, haughty behaviors or attitudes
Clearly, these two conditions are different. Some interpersonal aspects may seem similar (#8 in BPD and #6 and #7 in NPD); however, the emotional aspect of BPD (#6) is not present in NPD. There seems to me to be a split between self-hatred and the instability of self (in BPD), and self-importance and self-love (in NPD). I’m not sure this a gulf that can be bridged sensibly between the two disorders.
Why does it matter? Well, IMO it matters a lot, because the “prescription” that is effective for BPD is not the same prescription that works with NPD (or other variants on the Narcissistic spectrum). NPD is not a chiefly an emotional disorder, and emotional tools that are so effective with BPD will not be effective with someone with NPD. Now, you might say, “My ‘BP’ is diagnosed and he/she is always thinking about his/herself.” That may be true, yet, IMO, this type of “thinking” about oneself is really experiencing overwhelming negative emotions. It is difficult for anyone to think about anyone else when they are in deep emotional pain. As I have said in the past, I have coined (with the help of others) the term IAAHF (it’s all about his/her feelings) to help represent this state to Non-BPs.
Which brings me to my final point: self-diagnosis. It is dangerous to diagnose your loved one with BPD (or any other mental disorder). Only a trained and knowledgeable (and yes, I know, there are too few of these) professional can diagnose a person with any disorder. Assuming on your own that your loved one has BPD can be troubling for the relationship (at best) and damaging to their (and your) mental health (at worst). After reading a self-help book, such as “Stopping Walking on Eggshells” (SWOE), one has to be careful to diagnose someone else with the disorder. Even my book, “When Hope is Not Enough” (WHINE), can be used to “diagnose” your loved one with BPD, but I’d like to dissuade you from doing so. Instead, I would suggest you use the tools in my book (or, for that matter, SWOE) and see if they work. If my tools do not work, I suspect either you haven’t practiced enough (it takes time, believe me, it took me 2 years) or your loved one does not have an emotional disorder. I personally tried what I learned in SWOE for months before I realized that those “tools” were not effective in my life – which is why I bothered to write a book in the first place.
If you are tempted to introduce yourself to a support group with the statement, “I am married to a high-functioning BP…,” I’d suggest you take a step back and see if your loved one has the other signs of an emotional disorder (which BPD is and NPD is not).
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