Since 1938, when many of the recognizable features of modern BPD were first described, the criteria for defining BPD have changed. The diagnostic criteria for BPD are outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (2000), also known as the DSM. For a person to be diagnosed with BPD, the DSM requires that at least five of nine symptoms be present, but there are 256 different possible symptoms that someone with BPD may experience. There are very few, if any, other conditions in medicine where there is so much potential variation. To make matters more complicated, within these 256 possible types, how these people function in life can be very different, so there might be some people with BPD who, despite their difficulties, have stable relationships, and are employed or completing their education. Conversely, others with BPD have a very difficult time holding onto a job, make repeated suicide attempts, or struggle with impulsivity and have chaotic relationships.
As you can see, there can be tremendous variability in the symptoms that someone with BPD has to deal with. The DSM will continue to refine the definition of BPD in updated editions, but regardless, the DSM reflects the current professional consensus regarding the definition of BPD. Almost all the professionals making the diagnosis and involved in treatment will use the DSM as a reference in their professional training. The following are the nine DSM (2000) criteria for BPD, and how they might apply to those suffering from BPD:
1. Efforts to avoid abandonment
A person with BPD might have a strong fear that the people closest to her will abandon her. Her fear of abandonment might be triggered by what seems like a minor rejection, like a friend cancelling a plan to go to a movie together or a therapist running two minutes late for an appointment. This fear might lead her to become enraged, because she feels uncared for or unimportant. To others, this rage seems disproportional to the situation at hand, but for her, the suffering and fear are nearly intolerable. When she feels abandoned, she might resort to reassurance-seeking behaviors, which are ways of acting that provide reassurance that one will not be left, like calling a friend or therapist so many times that the person feels annoyed. Such behaviors can lead to the destruction or relationships and to the very abandonment that she fears.
2. Unstable and Intense Interpersonal Relationships
As with the fear of abandonment, the BPD sufferer might also recognize the fear of being alone. Often, out of the fear of being alone, some people with BPD tend to attach rapidly and intensely to others in relationships. She might notice the feeling that she has to know whether the other person feels as deeply as she does: that when she loves others, they love her as much and that when she suffers, they suffer as much. Because people with BPD don’t tend to have as intense emotions as she does, they will most likely not respond as deeply as she does, which can feel hurtful. When the hurt is intolerable, she might resort to saying some pretty mean things, simply to get back at the other person. Saying such things can leave her feeling ashamed and regretful about what she said, which may prompt her to swing from delivering demeaning comments to assuring the other person that they are the most wonderful being on earth. For the person she loves who is on the receiving end of these extremes of attacks and praise, life gets pretty unpredictable, and often, the person feels that it’s too much to handle. These kinds of relationships are stormy and unstable.
3. Identity Disturbance
For the BPD sufferer, deciding who she is and what her values are can be difficult. She might notice that frequently she has relatively sudden and unexpected changes in her life goals, interests, romantic preferences, and values. These sudden changes can lead to an erratic employment history, wreak havoc in relationships, and make her unpredictable to others in her life.
When we talk to people who are seeking treatment for BPD, the symptom they say gets them into trouble the most is impulsivity, or behaving quickly without evaluating consequences of the behavior; in fact, sometimes it involves even disregarding potential consequences. Impulsivity usually occurs when the BPD sufferer has strong emotions or when she is struggling in a relationship. There are many examples of impulsive behavior in BPD, but typically the most dangerous ones are self-injury, drug-use, unprotected sex with unknown or casually known partners, and reckless driving. Although these are not necessarily suicidal behaviors, they are dangerous and can seriously affect long-term health.
5. Recurrent Suicidal Behavior and Self-Injury
Although suicide is not the same as self-injury, throughout their book Mindfulness for Borderline Personality Disorder, Drs. Blaise Aguirre and Gillian Galen mention these two behaviors together because research (Cooper et al. 2005) shows that people who self-injure have an approximately thirty-fold increase in the risk of suicide, compared with the general population. The risk is substantially higher for women who self-injure. Suicide rates were highest within the first six months after the first self-harm episode. So even though suicide and self-injury serve different functions, and it is important to recognize that they are usually behaviors with different goals, they are closely linked. Like impulsivity, self-injurious behavior is a common reason why people with BPD seek therapy. BPD sufferers use self-injury to help regulate emotions, calm down, as well as to stop feeling numb, and to use physical pain as a way to distract from emotional pain. With emotions going up and down, once can feel as if she were being whipped about in the wind, which can make life pretty miserable. In people with BPD who have been hospitalized, 90 percent will have made at least one suicide attempt and 10 percent will complete suicide (Black et al. 2004). This also means that most suicide attempts are unsuccessful in BPD, and many of these people feel cheated by or ashamed of their failures and attempts.
6. Emotional Instability
Unstable mood, along with difficulty controlling emotional extremes, is a defining problem for people with BPD, whose mood can shift in a matter of hours. This can also be true of people without BPD, but for those with the disorder, the emotional ups and downs are often powerfully triggered by frustration and interpersonal conflict. It is the intensity of the emotions and how uncontrollable they are that makes them different. It is generally believed that people with BPD feel emotions more deeply and for a longer period of time, and take longer to return to their emotional baseline than do people who don’t have BPD (Linehan 1993). Another aspect is that when a person with BPD feels a powerful emotion, it can feel as if they have always felt that way. When she is miserable, for example, she may be unable to remember a time when she felt differently, even if just yesterday she was feeling pretty good.
7. Chronic Feelings of Emptiness
Many people with BPD experience unrelenting feelings of emptiness. Emptiness is often the feeling of aloneness, and can lead to difficulties in setting goals and expressing aspirations, which in turn can lead to judgment from others that the person with BPD is uncaring or unmotivated. She might find that being close to others alleviates this sense of emptiness, but this can lead to others finding her need for closeness to be more than they can provide.
8. Expressions of Intense, Uncontrollable Anger
To others, a person with BPD may exhibit anger that may seem excessive, as if they were making a big deal of small things. To a person with BPD, anger can be something that drives others away. Her anger is difficult for others to tolerate, which causes them to avoid interaction, and in turn often triggers abandonment fears.
9. Paranoid and Dissociative Symptoms
Typically a person with BPD would experience paranoid and dissociative symptoms during times of high stress. She might imagine that other people are intentionally trying to hurt her or make her life miserable. She might experience the feeling that she is not real, or that the rest of the world is not real. She might feel disconnected from herself. These symptoms appear particularly when there has been a history of abuse or trauma.
Although the DSM defines the symptoms of BPD, many specific experiences that are typical of living with the disorder are not featured in the DSM. Some such symptoms include:
1. Feeling Misunderstood
A person with BPD might feel that people don’t understand them or why they do the things they do. Because of the extreme nature of her experiences and emotions, it’s true that people often do not understand. Not feeling understood often goes together with feeling lonely or alone in the world, which can be alleviated with group therapy, where one can engage with a community of people who share similar experiences.
Self-hatred can be another particularly troubling symptom that is not included in the DSM. A person with BPD might hate how she looks, or feel insignificant, as if she always screws things up or is a terrible person.She may blame herself for everything bad that happens in life, and may quickly dismiss any positive outcomes in life, or conclude that she is toxic or evil.
3. Extreme Sensitivity to Others’ Emotions
A person with BPD might notice that she is extremely sensitive to others’ emotions, that when they are anxious, she gets jittery; when they are sad, she is sad; and so on. It might also bother her or seem confusing that others apparently don’t pick up on her emotions. And other people may find it unsettling that she can detect what they are feeling even before they do. This can be unsettling to other people in your life who might not be fully aware of their own experiences. In fact research shows that people with BPD consistently identify others’ emotions sooner than do people without BPD (Fertuck et al. 2009). This capacity can lead to trouble when the brief hint of annoyance in the face of a friend triggers an intense fear of abandonment. She may also pick up on happiness in another person and interpret it as intense love rather than joy, which can cause complications in relationships.
4. Being “Right” over Being Effective
Almost all of us pride ourselves in the ability to discern right from wrong, and we try to do the “right” thing in any given situation. The idea of what is right can be derived from our faith, our morals, and our values. The person with BPD might feel that life has not been fair to her and that she must hold on to some position because she is right. This can be problematic, especially when being “right” causes damage to important relationships.
5. Lack of a Sense of Continuity of Time
Many parents, partners, and clinicians note that people with BPD have difficulty establishing a continuous and coherent sense of time and sense of self. She might feel that she is living a life of endless repetition, in and out of the same mood states, where she is unable to distinguish one situation from another. This creates the illusion of living a life without time, which can feel intolerable as she imagines that she will never escape. Or, she might rapidly get over a long-term relationship as if it had never even happened. This can help her deal with the pain of difficult relationships and emotions. When there has been a history of trauma, integrating past events into the present can lead to a fragmented sense of who she is, and a feeling that there is nothing of substance there. To a person with BPD, it can feel as if the pieces and moments of her life don’t flow in a straight line, and memories from the past can jump out into the present and feel as if the past events are actually occurring in the present.
For the person with BPD, perfectionism can show up as extreme obsession about details in life and work to the point of rigid inflexibility. In the quest for a perfect outcome, she might do and redo a project, and at times never actually get it done. Then she feels overwhelmed by the amount of work that’s left to do.
7. Being Considered Manipulative by Others
Drs. Blaise Aguirre and Gillian Galen, authors of Mindfulness for Borderline Personality Disorder, say that sometimes when they ask people with BPD why they have come into treatment, they say “To stop being manipulative.” When asked how they know they are manipulative, they cite feedback from others. Often people with BPD are described as manipulative by clinicians and family members. People in their lives might feel manipulated or lied to even if it was never their intention to deceive or trick. In most situations, the person with BPD might just be doing whatever she can, such as engaging in self-injury to reduce painful emotions. This behavior, however, can feel to others as if it were being done in order to manipulate them.It is important to note that just because others say the BPD sufferer is being manipulative does not mean that they actually are.
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV- TR. 4th ed. Text rev. Arlington, VA: American Psychiatric Publishing.
Black, D. W., N. Blum, B. Pfohl, and N. Hale. 2004. “Suicidal Behavior in Borderline Personality Disorder: Prevalence, Risk Factors, Prediction, and Prevention.” Journal of Personality Disorders 18:226–39.
Cooper, J., N. Kapur, R. Webb, M. Lawlor, E. Guthrie, K. Mackway-Jones, and L. Appleby. 2005. “Suicide after Deliberate Self-Harm: A 4-Year Cohort Study.” American Journal of Psychiatry 162 (2):297–303.
Fertuck, E. A., A. Jekal, I. Song, B. Wyman, M. C. Morris, S. T. Wilson, B. S Brodsky, and B. Stanley. 2009. “Enhanced ‘Reading the Mind in the Eyes’ in Borderline Personality Disorder Compared to Healthy Controls.” Psychological Medicine 39 (12):1979–88.
Linehan, M. M. 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press.