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Understanding Borderline Personality Disorder
When we talk about mental health disorders, there’s usually a silent assumption that any two people who have a disorder feel similar symptoms. Depression is depression. Anxiety is anxiety. Borderline is borderline, right? Maybe not. In fact, Borderline PD is very diverse and has several different types.
As a result, it’s routinely a challenge for doctors to diagnose, so much so that many clinicians feel that we need to take a fresh look at how we think of personality disorders altogether.
The American Psychiatric Association recognizes these changes. The DSM-5 – the most recent catalog of mental disorders – actually offers an “alternative model” for personality disorders.
The alternative model
The problem with the current concept of these disorders is that people often have symptoms that fit with more than one disorder. This way of thinking tries to put people into distinct categories – they are ‘this’ and not ‘that’. The new model takes a more flexible approach.
This view holds that the symptoms of personality disorders result when people sit on the extreme ends of different traits that everyone goes through. Rather than saying someone has a given disorder, the idea is that people struggle with functioning in certain areas because of unhealthy character traits. Instead of categories, we see these traits as part of multiple ranges.
First, there are the basic aspects of personality: who you are (the sense of self) and how you interact with others (interpersonal skills). Problems in these areas are the core of personality disorders. After this, there are 5 traits that combine in different ways to create the various struggles that these people face. They are negative affect, detachment, antagonism, disinhibition, and psychoticism.
Sense of self and interpersonal skills
Self has two parts: identity and self-direction. Identity is your own individual sense of who you are. It consists of self-esteem and the ability to evaluate yourself and your feelings while managing a wide range of emotions. The area of self-direction includes setting, planning for, and achieving short- and long-term goals. It requires that people adapt to situations and learn from their experiences.
Empathy and intimacy make up the interpersonal side of things. Empathy describes a person’s ability to understand and accept others’ feeling states. This includes awareness of how one’s own actions affect other people. Intimacy covers how well someone is able to connect emotionally and form close, lasting bonds with others.
Traits of trouble
1. Negative affect vs. emotional stability.
People with negative affect go through repeated, severely negative emotions – think anger, fear, worry, and depression. As a result, they commit acts of self-harm and contemplate or attempt suicide.
2. Detachment vs. extraversion.
Detached people avoid social connections on multiple levels, including everything from casual acquaintances to serious, long-term relationships. They prefer to be alone, have trouble with making romantic connections, and are often suspicious of others.
3. Antagonism vs. agreeableness.
Antagonistic people have inflated feelings of self-importance and expect special treatment, attributes that lead them to frequently butt heads with others. They can be unaware or uncaring about others’ needs and often manipulate people to get what they want.
4. Disinhibition vs. conscientiousness.
Disinhibited people are impulsive and seek instant sources of pleasure with little attention paid to the results. They are irresponsible and fail to follow up on agreements. Risk taking, trouble focusing, and often have trouble accomplishing goals.
5. Psychoticism vs. lucidity.
People with psychotic symptoms have strange, unusual beliefs and behaviors. They have odd ways of speaking and often think they have special powers, such as communicating with the dead or reading others’ thoughts. They even have odd experiences, such as feeling disconnected from their bodies or their surroundings.
Problems in personality and combinations of these different traits lay the basis of this new conception of personality disorders. People with these disorders have impairments in at least 2 of the 4 personality dimensions and at least 1 of the 5 personality trait domains.
What this means for Borderline PD
This new concept opens the door for a much more nuanced concept of Borderline PD. In fact, one has already existed for decades. Dr. Theodore Millon, one of the leading modern personality researchers, proposed four types: discouraged, impulsive, petulant, and self-destructive. Dr. Millon was one of the early proponents of the more flexible theories behind personality disorders in general. He advocated for viewing personality disorders as mixtures of difficult personality traits rather than firm, distinct categories.
The four sub-types of Borderline Personality Disorder
1. Discouraged borderline
These people develop strong, submissive bonds to one or two other people. No matter the true health of that relationship, the individual is always afraid of it ending. They worry constantly about being abandoned and cling desperately to that connection. They can become extremely dependent, to the point where they cannot stand any separation. When they find themselves alone, they feel helpless and depressed. Even the simple tasks of daily life become very taxing. These people have strong depressive traits and are prone to acts of self-harm or suicide attempts.
2. Impulsive borderline
This borderline personality type is rash, unstable, and careless. They are desperate for attention and external approval. To achieve this, they construct wild, unpredictable personas. Their emotions are often positive, but inauthentic, bouncing from one type of excitement to the next. They feel most secure when this behavior draws notice from other people. Their identity is rooted in this attention, and when they don’t get it, they become depressed and withdrawn.
3. Petulant borderline
These people suffer from a wide range of negative emotions, rarely feeling content both alone and in relationships. They generally feel irritable, angry, and impatient. As often as the feel depressed, they also attack others. They lash out at those around them, constantly demanding, never satisfied, and always resentful of those helping them. After these outbursts, they often feel remorse. However, this remorse is often tainted with behaviors that continue to demand a lot of those around them.
4. Self destructive borderline
People with this type, like the other types, have trouble forming stable connections with other people. They will go overboard to impress and please others, but then they feel resentful as well. These people turn their frustrations inward, taking it our on themselves. They may have vague physical symptoms, and depression is common. When they feel underappreciated, they suspect that people close to them will abandon them. This is often when they self-injure or attempt suicide.xii
Guiding treatment for Borderline Personality Disorder
The vast differences in types of Borderline PD have made treating it difficult, but understanding the types can change that. Although these are not official categories, simply introducing this more flexible view is a step forward. It can give therapists new avenues to explore when a someone they are seeing doesn’t fit the traditional mold of Borderline.
People with this disorder are intriguing and compelling, but relationships with them can sometimes feel exhausting at times. (If you have Borderline PD, you may feel quite tired of it yourself at times.) As a result, forming lasting bonds between clients and therapists is really hard. People often impulsively quit therapy when it becomes challenging and fiercely resist any boundaries the therapist tries to set. Even worse, they impulsively quit therapy, only to return when they are in crisis.
Every step of living with Borderline PD is tough. For people with Borderline and their families, friends, and treatment providers, learning more about the subtleties of this personality disorder can make of those steps a bit easier.