An interview with Alexander L. Chapman, coauthor of The Borderline Personality Disorder Survival Guide
New Harbinger Publications: What is borderline personality disorder?
Alexander L. Chapman: Borderline personality disorder (BPD) is a disorder of instability in a variety of areas of life: relationships, emotions, behaviors, thoughts, and identity. People with BPD often feel like their relationships are a roller coaster ride, with many ups and downs. Their emotions tend to be intense and change very rapidly, and they often have great difficulty managing their emotions. As a result, they sometimes resort to self-harm, suicide attempts, drug use, or impulsive behaviours (over-spending, driving recklessly, binge eating) in order to manage and cope with their overwhelming emotions. People with BPD often suffer from an unstable sense of identity and chronic emptiness. In addition, some people with BPD dissociate (“check out” and become less aware of themselves and their surroundings) or have difficulty trusting other people when they are especially stressed out. Some researchers think that the main problem that drives all of the other symptoms of BPD is the combination of strong, overwhelming emotions with difficulty regulating or managing these emotions (“emotion dysregulation”).
NHP: What causes BPD?
ALC: Although we have not yet isolated exactly what causes BPD, we do know that BPD seems to result from a combination of biology and the environment. Biological factors that contribute to BPD include a tendency toward having intense, long-lasting, and easily triggered emotional responses. It does not take much for a person with BPD to feel emotional distress (a slight look of annoyance on a friend’s face might be enough). Some researchers have suggested that people with BPD are simply born more emotional than are people without BPD. Another biological factors is a hyperactive stress-response system. There is some evidence that people with BPD might be more likely to have increases in stress hormones and activity in emotional areas of the brain when they are upset. There is also some evidence that BPD might be heritable, suggesting that genes play a role as well. We do not yet know, however, what types of genes are involved in BPD.
The environment also plays a role in BPD. For instance, invalidating environments seem to play an important role. An invalidating environment is one that punishes, ignores, or dismisses the child when he or she is emotional. As a result, people with BPD often become afraid of their emotions, are unable to trust their emotions, or feel like they are very different from those around them. Dr. Marsha Linehan has proposed that BPD results from a combination of an invalidating environment and a tendency toward being strongly emotional. Other research suggests that, for some people, childhood trauma (physical, sexual, emotional abuse) might play a role in BPD. It is important to remember, however, that BPD is not caused by “bad parents”, and a good number of people with BPD have never been abused. Finally, many of the behaviours that make up the symptoms of BPD (impulsive, self-damaging behaviors, drug use, self-harm, suicide attempts) actually work to help the individual manage emotions. As a result, these behaviors are incredibly hard to quit.
NHP: Is it difficult to diagnose?
ALC: BPD can sometimes be difficult to diagnose, especially because some of the symptoms of BPD look a lot like some of the symptoms of other psychiatric disorders. For instance, the intense mood swings of BPD can look a bit like bipolar disorder, making it difficult for the diagnostician to determine whether the individual has BPD or some kind of rapid cycling bipolar disorder. Often, people with BPD have experienced traumatic life events, so it can sometimes be difficult to determine whether the individual has BPD or post-traumatic stress disorder. The best way to diagnose BPD is to use a combination of well-established structured interviews, self-report questionnaires, interviews and discussions with the patient about her or his life, and possibly, interviews with family members or others in the person’s social network. BPD is supposed to be a chronic, long-standing disorder; thus, the diagnostician often looks for patterns of difficulties that have been present for a long time.
NHP: Is BPD ever diagnosed in children?
ALC: BPD is not officially diagnosable in children. As with all personality disorders, it is only appropriate to diagnose BPD once a person has reached adulthood. Some of the individual symptoms of BPD, such as emotional ups and downs, impulsive behaviors, and identity problems, are actually somewhat common among adolescents. Therefore, most researchers believe that you should wait until adulthood to diagnose BPD, in order to make sure that these problems are long-lasting and more than simply “typical adolescence.” Now, on the one hand, we agree that it would be a mistake to diagnose someone with BPD when their difficulties may simply resolve over time. It’s not helpful to receive a diagnosis that isn’t accurate. On the other hand, because BPD is such a painful disorder, the best thing to do is to catch it early so that people can get the help they need as soon as possible. And, research has found that some people with BPD struggled with some of these symptoms for many years before they were diagnosed – even in childhood. Therefore, we believe that it is important not to ignore or dismiss possible BPD symptoms simply because the person is not an adult, as some of these symptoms (e.g., interpersonal problems, self-harm or suicidal behaviors, and emotional difficulties) may be the early signs of BPD. Basically, the best approach is to balance taking distressing symptoms seriously while not assuming that they are a guarantee that the person is going to develop BPD.
NHP: What are the treatment options for those with BPD? What is the most successful of these?
ALC: The good news is that BPD is actually very treatable. One treatment option that has been found to be particularly helpful is psychological treatment. Psychological treatments basically involve helping people make important changes in their lives, in terms of their emotions, thinking, and behaviors. The psychological treatment with the best scientific evidence thus far is Dialectical Behavior Therapy (DBT), developed by Dr. Marsha Linehan at the University of Washington. In DBT, the patient normally attends weekly individual therapy sessions and weekly group therapy sessions, and the therapist is available to be contacted in-between sessions if the patient needs help or is in a crisis. DBT is aimed at helping people reduce serious, self-damaging behaviors (self-harm, suicide attempts), learn useful life skills for managing emotions and relationships, and get motivated to move forward in life directions that are important to them. Recently, a small number of studies has shown that other psychological treatments have had promising effects for BPD, including Mentalization Based Treatment (developed by Drs. Peter Fonagy and Anthony Bateman), Schema-Focused Therapy (developed by Dr. Jeffrey Young), and Transference-Focused Psychotherapy (developed by Dr. Otto Kernberg).
Another treatment option is medication. The important thing to remember here is that there is no “anti-BPD” medication. Some medications seem to help with some of the symptoms of BPD, and interestingly, many different types of medications (antipsychotic medications, antidepressant medications, mood stabilizing medications) seem to have very similar effects. The medications with the best evidence and the fewest troubling side effects are a specific type of antidepressant – selective serotonin reuptake inhibitors (SSRIs, such as Prozac). Most experts agree that medication treatment alone is not advisable for BPD. So far, psychological treatments have the best evidence for their efficacy, and if a person is on medication, it is generally recommended that she or he also be in a psychological treatment.
NHP: Can you discuss the tendency of those with BPD towards self-harming or suicidal behavior?
ALC: Self-harming and suicidal behavior are very common among persons with BPD. One of the reasons for this is that they actually make up one of the nine symptoms of BPD. Approximately 75 percent of people with BPD have attempted suicide at least once really?, and eight to ten percent of people with BPD die by suicide. People with BPD also have high rates of self-harm (without intent to die), with some studies suggesting that up to 80% of people with BPD harm themselves. People with BPD struggle intensely with their emotions and often do not know how to reduce overwhelming emotional distress. As a result, when asked, the most common reason people with BPD give for attempting suicide or self-harming is that they were trying to escape their emotions and get some relief from their pain. Therefore, it is critical that treatment for BPD helps patients learn how to effectively manage their emotions.
NHP: In The Borderline Personality Disorder Survival Guide you mention several myths associated with BPD. What are a few of the biggest myths about those with BPD?
ALC: Two of the biggest myths have to do with whether BPD is something that people can recover from. One of these myths is that BPD is incurable. In fact, until several years ago, people thought that once you had BPD, you were stuck with it for life. However, we now know that this is not true, and that BPD actually has a very good prognosis. In fact, recent research suggests that people are more likely to recover from BPD than from bipolar disorder. The second myth related to this idea that BPD is incurable is the idea that BPD is untreatable, and that treatments don’t work for people with this disorder. Just like with the other myth, this is definitely not true. In fact, we now know that people with BPD can make incredible progress in short periods of time when treated with therapies developed specifically for BPD.
The third myth that is quite common – and also completely untrue – is that people with BPD are manipulative and attention-seeking. As we discuss in our book, this myth probably came about as a misguided attempt to explain some of the problems that people with BPD tend to struggle with (especially suicidal and self-harm behaviours), as well as others’ reactions to these behaviors. Basically, because these behaviours are so serious and life-threatening, many people find that they want to intervene quickly to help the person engaging in these behaviours. However, when they see themselves acting this quickly to provide support and reassurance to people with BPD, they conclude that people with BPD use these behaviours to “manipulate” others into paying attention to them or helping them. The problem with this way of thinking is that you can’t infer what someone’s intentions were based on the effects of her or his behavior. That is, knowing that self-harm and suicide attempts may lead others to provide attention or help does not actually tell us why someone engages in those behaviors. What’s more, even if people have learned that the only way to get any kind of attention from someone else is to engage in a behavior as extreme as self-harm, the fact that they resort to this behavior does not mean that they are manipulative. It may simply mean that they are desperately in need of some kind of attention from another human being, and have not yet learned any other way of getting that need met.
NHP: For friends and, especially, family members BPD must be difficult to understand and deal with. Do you have any suggestions for those who have loved ones with BPD?
ALC: One thing that is very important to keep in mind is that people with BPD are often in intense emotional pain. They often feel overwhelmed by the intensity of their emotions and don’t always know what to do to manage their emotions. Keeping in mind just how much people with BPD tend to struggle with their emotions, behaviours, and relationships may help those who care for them have more understanding of what they are going through.
Another thing that is important to keep in mind is that many people with BPD can do really well when they are not stressed out. They have many strengths and, when things in their lives are going smoothly and they are not distressed, they can manage to accomplish many things. However, when they are really stressed out or upset, they may not have access to some of these abilities and strengths. In other words, they may simply not be able to handle things as well or do some of the things they normally could easily do when they are not stressed out. This can be really confusing to their loved ones, who have seen them respond well to certain situations. And, it can sometimes seem like the person with BPD isn’t trying hard enough or is just “refusing” to respond effectively. Now, we definitely understand how it could seem this way, especially when someone looks so good some of the time. But, the thing to remember is that when they are really upset, many people with BPD really do not know how to access skills and abilities that are sometimes easy for them. They are not being stubborn or refusing to try -- it is simply the case that one symptom of BPD is having a hard time doing things when feeling upset or stressed out.
Of course, in addition to these things, it is important for anyone who cares about someone with BPD to take care of themselves as well. None of us can provide good support to someone else if we are not taking care of ourselves. So, if you love someone with BPD, make sure that you put aside time to take care of yourself and do things that can help you relax and feel better as well. And, keep in mind that even if you work to understand where your loved one is coming from and the reasons for her or his maladaptive behaviours, that does not mean that you cannot also set your own limits. You can validate someone’s emotional pain and provide support to that person while at the same time making it clear what is and is not okay with you and the behaviours that you will and will not tolerate. You can set limits without taking away your support and validation. The best approach is to balance acceptance of your loved one for who he or she is, and compassionate but firm help in making changes.
NHP: What is the best way to calm a loved one with BPD who is experiencing extreme anger or sadness?
ALC: Starting with validation is a really useful way to help someone regulate their emotions. When a person is really upset, it is best to begin by acknowledging why they are upset and the ways in which this understandable. In fact, studies have found that validation actually decreases a person’s emotional arousal, whereas invalidation increases arousal. So, we would suggest beginning with validation. We mention this because it is quite common for people who see someone else in distress to want to “fix” that distress and jump into problem-solving. And, although this can eventually be helpful, beginning with validation can pave the way for these other approaches.
Now, after you have validated the person’s pain and provided some support, you can gradually begin to help him or her identify solutions to problems or to feel better. With someone who is really angry, it is important for you to act calm and speak in a calm, neutral voice. The important thing here is that you don’t imply that he or she shouldn’t be upset or should feel better immediately. Instead, you can gently suggest some things that the person could do to soothe him or herself. For anger, soothing, calming activities, or relaxation skills (breathing slowly, muscle relaxation) can be very helpful. For example, you might also suggest a hot bath, a warm cup of cocoa, watching TV, or a variety of other strategies. For sadness, sometimes, it is useful to help the person soothe him or herself and/or get active and do something, such as go for a walk, exercise, or spend time with other people.