Criterion, aetiology, relations to other conditions, connections to trauma and neurology.

Borderline Personality Disorder (BPD), Also known as Emotional Unstable Personality Disorder (EUPD) is a personality disorder that affects identity, impulse control, relational issues and emotional understanding.

In the general population, there is a diagnosis rate of 1.6-2.7%. (Lenzenweger, Lane, Loranger, & Kessler 2007; Tomoko, Trull, Wood, & Sher, 2014) It is commonly co-morbid with trauma & attachment disorders and is linked to trauma. Physical, emotional and sexual abuse have all been linked to the development of BPD.

It’s a highly controversial and stigmatized disorder causing productive and empathetic treatment to be very difficult to find. The stigma is horrible and comes from a misinformed placed, often making borderline people feel like that they are wrong, abusive or broken for having the disorder. It can also lead to therapists believing they are too difficult to treat or that no people with BPD want to get better. The converse of this is believing it’s not really a complex disorder but a failing of will of the person doing the harm.

The controversiality, however, is not completely unfounded, there are valid discussions to be had. Part of it is just about how we name the disorder and the best way to frame and understand what’s currently called BPD. The other controversiality is it’s relation to trauma and trauma disorders. Especially C-PTSD and developmental trauma, many believe it ought to be framed as traumatic stress responses and/or attachment-based issues. Not to dating the validity of the struggle it’self but in the framing and understanding how the disorder forms.

There are many ways that we can work to heal if we have BPD, understanding the disorder is key to start. For those out there who don’t understand or are misinformed learning more can not only just educate on mental health but foster a better understanding of treatment. 

Common Terms

• Anger out: Outward displays of emotions that are noticed by others. Often feels like anger at external factors but can be misplaced aggression or combinations of anger at others (sometimes justified) and at the self.
• Anger in: These emotions often go unnoticed as it is displayed covertly and quietly. Commonly felt as self-hatred and blame not always matching reality. Self-harm is associated with this.
• Attachment:  The process of forming attachment is our ability to connect and bond with others. It builds a solid foundation, gives a home to come back to, the ability to self-regulate and to communicate with others. Love, safety, resilience and identity all start with attachment.
• Complex trauma: Complex trauma refers to trauma of varying types that last over long periods. Ex: Child Abuse, exposure to a war environment, domestic violence or prostitution.
• Developmental trauma: Trauma that occurs during infancy, childhood and into adolescence. The neurological effects can be read here.
• Dissociation: Dissociation is a psychological experience in which people feel disconnected from their sensory experience, sense of self, or personal history. It is usually experienced as a feeling of intense alienation or unreality, in which the person suddenly loses their sense of where they are, who they are, of what they are doing.
• Favourite Person (FP): This term is used colloquially by those with BPD to refer to a person that the attachment issues common with BPD tend to show up. The person can become linked deeply to a sense of identity or emotional regulation. It is not a clinical term and is misused often. It can end up being used flippantly as “super best friend” when it diffuses into general usage. It is also over-romanticized within the community instead of being used to refer to problematic relational issues.
• Florid Borderline Episode: A visible and extreme episode of symptoms usually triggered by core fears like abandonment. Extreme emotions that are acted out in often harmful ways in an attempt to satiate fears and dysregulation. Behaviours might be used include picking fights, self-harm, eating disorder behaviours, destruction of property etc. Accompanied by perception and consciousness disturbances.
• Hyper valuation & devaluation: This pair of terms refers to the pattern were the self or others are considered to be amazing and completely central to self-concept and then feeling like the self or others are deeply flawed and shameful.
• Relational Rupture/Repair: The process of having difficulty, fight or stressor in a relationship and being able to then repair the relationship and continue forward without extreme lasting wedges in the relationship.
• Splitting: This term is used by clinicians but more so within the community. It refers to when in relationships when a hyper valuation turns into severe devaluation. It can cause relational rupture and even turn into aggressive reactions.

Diagnostic Criteria:

DSM V:

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) or the following:

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
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 behaviour covered in Criterion 5)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
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)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper,
constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

(American Psychiatric Association, 2013.)

Note: Personality disorders are not generally diagnosed until 18. The behavioural pattern becomes apparent in adolescence but is not diagnosed as they can indicate many things and are generally seen to solidify into a more clinical pattern in early adulthood. 

DSM Classifications:

BPD is a cluster B personality disorder in the DSM V.

Personality Disorders are defined by the DSM V as: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. (American Psychiatric Association, 2013.)

There are 10 specific types of personality disorders, which DSM-5 breaks into three clusters. Cluster A is defined as odd or eccentric behavior that affects 5.7 percent of adults. Cluster C personality disorders consist of fearful and anxious behaviors, affecting 6 percent of adults.

Cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behaviors. They include antisocial personality disorder, borderline personality disorder, narcissistic personality disorder, and histrionic personality disorder.

ICD 11:

In the ICD they have reclassified personality disorders into two separate sections. A personality disorder is diagnosed as Mild Moderate or severe. Then given a sub category in the Prominent personality traits or patterns section.

Personality Disorder Criterion:

Personality disorder is characterized by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more). The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated) and is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles). The patterns of behaviour characterizing the disturbance are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict. The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

You would then have a severity level, then the borderline sub descriptor:

Borderline :

The Borderline pattern descriptor may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by many of the following: Frantic efforts to avoid real or imagined abandonment; A pattern of unstable and intense interpersonal relationships; Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self; A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours; Recurrent episodes of self-harm; Emotional instability due to marked reactivity of mood; Chronic feelings of emptiness; Inappropriate intense anger or difficulty controlling anger; Transient dissociative symptoms or psychotic-like features in situations of high affective arousal.

Subtypes:

There is no consensus on how we can use subtypes to analyse or educate others. But a lot of work has been done to give more understanding of the way symptom clusters present across patients. Not including the dissociative modifier from the DSM.
There are three main frameworks: Traditional & quite, Millon’s types & cluster analysis.

Traditional & Quiet:

This is the most basic and well-known breakdown.

Quiet borderline is conceived as people with BPD who turn into themselves and tend to experience their extreme emotions in a way others can’t see. So instead of anger coming out in fights or screaming they turn the anger in and might manifest as self-harm, eating disorder. Splitting on others might happen and end up with cutting them off or passive aggression never sharing these emotions. .

This framework is a good first step because it shows how that BPD is not the same in everyone. I think it does form a black and white manifestation as always inwards covert actions and always outward. This is not true many people do both, many have a direction they lean to but a complete dived is simplistic. It also can make it seem like quite is better because they “only hurt themselves”. Instead of realising both of these broad presentations could result in the person with BPD hurting themselves and passive aggression can be toxic as well.

Theodore Millon’s 4 types:

1. Discouraged Borderline/Quiet:
   • Compensates for fear of loss by being “clingy”
   • Co-dependency common in relationships
   • Crave the approval of others
   • Does not show typical attention-seeking behaviours
   • High rates of depression
   • High rates of self-harm
   • High rates of suicidal ideation
   • Inward anger is much more common
   • Somber affect
   • Splitting very common
   • Tend to feel the need to follow others
   • Will show outward anger after long periods complete internalization 
2. Petulant Type:
   • Alternate between high levels of internalization ( shame & self-blame) with externalization (blaming others)
   • Anger is felt and expressed as resentment and bitterness
   • Crave connection with others but have walls up against it
   • External locus of control
   • Fear that others will disappoint and let them down.
   • Feel that others will not be there for them
   • Frequent episodic outward expressions of anger
   • High rates of irritability
   • Hopelessness about prospects
   • Impatient with self and others
   • Oppositional to others
   • Pessimistic outlooks on life
   • Tend to be passive-aggressive with others
   • Unpredictable reactions
3. Impulsive type:
   • Addiction often used to self regulate
   • Commonly use sex as a coping skill
   • Episodes of high energy
   • Experience chronic and painful boredom
   • Expresses strong emotions through thrill-seeking
   • Fears that others will let them down
   • Lack Co-dependency on others
   • Lacks the ability to self regulate and co-regulate
   • Misdiagnosed as Historionic often
   • Need constant stimulation
   • Seeks the attention of others
   • Struggle to get past superficiality of self and others
   • Tend to be very charismatic and friendly with people
   • Tend to seek out conflict with others
   • Tries to control their life through their outward manifestations
   • Use lots of masks around others & identity can feel empty
4. Self Destructive Type:
   • Cycles between being overly submissive and combative
   • Difficulty with decision making
   • Struggles with commitment in relationships
   • Impulsivity
   • High rates of self-injury
   • Feels completely isolated
   • Tends to exhibit reckless behaviours that verge on suicidality and might endanger others (driving recklessly)
   • High rates of alcohol and drug addiction
   • Self-sabotage in all areas of self
   • Have underdeveloped self-concept
   • Lacks emotional and somatic awareness
   • Attaches their identities to others perceptions of them

The Types framework is much better than the basic quiet vs typical as it addresses more symptom clusters and their interplay. Millon designed his types with the idea people will likely fit two. The ability to present how florid episodes will have different presentations, and how attachment struggles aren’t felt the same for everyone.

This model is best for people trying to understand themselves. It can be helpful to see the symptoms laid out in a manner other than as criterion and more understandable language. Using these types can offer some ability to see where your primary issue is. These categories are better at breaking down common stereotypes then the other popular ideas.

The biggest drawback of The Four Types is that it doesn’t include dissociative symptoms, psychotic symptoms and consciousness alterations in general. Another consideration is that these don’t relate to specific data or offer causal links to specific symptoms. Though it can be used with education and communication.

Cluster Analysis

Cluster analysis has three types:

1. Core BPD: 
   • Crave intimacy and simultaneous fear it
   • Experiences of strong emotions
   • Generally explained as the typical presentation of BPD.
   • High anxiety
   • Lack of affect regulation
   • Manipulative in fear of abandonment
   • Self-concept disruption
   • This population had lower incidents of childhood trauma
   • Under assertive with episodes of intrusive behaviour
2. Extravert/ Externeralzing:
   • Doesn’t seek out close relationships
   • Externalizes problems on to others
   • High avoidance
   • Highly critical of events, self and others
   • Narcissistic, antisocial and/or histrionic tendencies
   • Show avoidant attachment behaviours
   • Shows a need for control over self and others
   • This population is predominantly male and shows higher rates of childhood trauma to core BPD
3. Schizotypal/Paranoid:
   • Emotionally withdrawn
   • Fears and craves intimacy
   • Feels disconnected from others
   • High dissociative tendencies
   • Includes psychotic symptoms
   • Lack of a sense of reality
   • Low self-confidence and esteem 
   • Overly accommodating to others
   • Self isolates
   • Shows schizotypal and paranoid traits
   • Trust issues

This version has show promise in research studies and has population and causation linkage in the analysis. It is also grounded in historical forms of analysis of personality and mental illness classifications. Though these classifications have complex histories and can carry a stigma.  

I Belive this version is difficult for the population of patients to understand or for clinicians to communicate with patients. It is also very divisive and has very little understandings of symptom overlap. Having patterns of isolation, loss of reality, trust issues or high dissociation can also be seen in people who do want intimacy and lack affect regulation. Psychosis symptoms also can be experienced with other symptoms that are not in this category, you can both of narcissistic tendencies and psychosis for example.

These categories also have some condemning language in them can feed stigma as well. I think this model is useful but should not be considered the be all end all without more research and should be “translated” for better patient understanding as well.

BPD Comorbidities & Diagnostic Confusion:

BPD patients have high rates of comorbidities and tends to be confused with other disorders.

Rates of comorbidity of disorders with BPD:

• Complex Post Traumatic Stress Disorder: 55-59% (Brand & Lanius 2014, Sack, M., Sachsse, U., Overcamp, B., & Dulz, B. 2013)
• Dissociative Disorders [DID & OSDD]: 41-72% (Brand & Lanius 2014)
• General Lifetime Anxiety Disorder: 84.8-88% (Tomoko Et Al 2014; Zanarini, Frankenburg,Dubo, Sickel, Trikha Levin & Reynolds 1998)
  • Panic Disorder: 34%-48% (Tomoko Et Al. 2014; Zanarini Et Al. 1998)
• General Lifetime Mood Disorders: 82.7-96% (Tomoko Et Al 2014; Zanarini Et Al. 1998)
  • More common in females
  • Depression: 71%-83% (Tomoko Et Al 2014; Zanarini Et Al. 1998)
  • Bipolar Disorder 20% (Scott 2017)
• Lifetime rates of general Eating Disorders: 7%-26% (Tomoko Et Al 2014; Zanarini Et Al. 1998)
  • Significantly higher rate in females
  • Anorexia, Other Specified Feeding or Eating Disorder [OSFED] & Bulimia: 90% (Zanarini, Reichman, Frankenburg, Reich, & Fitzmaurice 2009). {Study done in an inpatient clinical population}
• Lifetime Substance Abuse Disorder: 50-78.2% (Tomoko Et Al 2014) (Tomoko Et Al 2014; Zanarini Et Al. 1998)
  • Significantly higher rate in males
• Post Traumatic Stress Disorder 53-79% (Tomoko Et Al 2014; Zanarini Et Al. 1998; Scheiderer, Wood, & Trull, 2015; Brand & Lanuis 2014, Sack et al 2013)

Bipolar Disorder Vs. Borderline Personality Disorder:

What is Bipolar Disorder?

Bipolar Disorder is a disorder from the class of Bipolar and Related Disorders. There are two types of Bipolar I and Bipolar II. It’s characterized by episodes of extreme emotional states. These two polls are Mania/Hypomania & Depression. Those with Bipolar II disorder only experience hypomania. Mixed episodes can also exist where symptoms of both are experienced at the same time.

Bipolar Mania is described as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). Along with with the heightened energy & mood disruption for 3 weeks (4 if only irritable mood is experienced) of the following symptoms most present:

• Inflated self-esteem or grandiosity
• Decreased need for sleep or insomnia
• More talkative than usual or pressure to keep talking
• Flight of ideas or racing thoughts
• Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
• Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless, non-goal-directed activity)
• Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Hypomania is characterized by the same symptoms of mania but causes no severe impairment to function, only has to last for four days and can not include psychotic features.

How are Bipolar & BPD similar?

BPD and Bipolar disorder are both characterized by unstable mood states, intense emotions, extreme presentations of emotions, self-injury and impulsive behaviour and a tendency for recklessness.

The unstable moods and intense emotions tend to be where the difficulty in diagnosis and confusion tends to occur. The common confusion is worsened by lack of proper diagnosis of both groups 69% of bipolar patients were misdiagnosed at the start of their treatment which indicates how professionals and patients alike experience confusion over the disorder (Fox. 2018). Underdiagnosis caused a recent overdiagnosis in medical situations. Comorbidity is also seen in 10.7% of those with borderline personality disorder. (Fox, 2018)

Florid episodes in those with BPD is similar to hypomania in behaviour disturbances and the possibility for an increase in issues connecting with reality (psychosis or dissociative symptoms. 

How do they differ?

Bipolar disorder is episodic in nature and the episodes of both mania and depression have to last for days at the least and weeks at most. These episodes don’t happen in reaction to life experiences or interpersonal relationships. It’s a cyclical process even if the episodes shift in duration and severity. [life conditions affect bipolar but it’s not directly reactive, outside of medical or drug use]

BPD’s emotions are not cyclical they are reactive and continuously dysregulated. Florid episodes are usually triggered by experiences of relational rupture or things that trigger emotions connected to core experiences of shame, isolation, abandonment or guilt. Extreme moods and emotions often last for much shorter periods. The dysregulation experienced by BPD is based on an inability of emotions to be in proportion to experiences and the behaviours are generally out of the need to regulate the emotions. Self-destructive behaviours tend to be more of a real punishment or maladaptation instead of the general thought confusion and loss of impulse by manic experiences.

Those with BPD lack a self-image, fear abandonment, and experience extreme issues with relationships that those with bipolar don’t experience as a core of the disorder. it can feel like you have lost yourself, but that differs from the lack of personality and self those with BPD experience.

Relationships can suffer as a result of the symptoms, lack of coping skills and after-effects of things like suicide or dangerous activity for those with bipolar disorder but it’s not tied to the same disorganized ability to relate to others. Attachment issues and trauma are understood to be the baseline of BPD while bipolar is still understood as biosocial but it hasn’t shown a direct link to interpersonal childhood trauma. 

Dissociative Identity Disorder (DID) Vs. Borderline Personality Disorder

What Is Dissociative Identity Disorder?

DID is a dissociative class disorder caused by severe, complex and chronic childhood trauma that occurs before the age of 9. The identity of those with DID never fully solidified into one cohesive identity and instead stays into multiple full identities. The brain itself along with the nervous system becomes altered by childhood trauma. The collection of these identity states, often called alters or parts, are called a system, so a person with DID can refer to themself as a system or member of system. These alters often have a different memory of events sometimes complete amnesia between them. Perception and sensory integration differ between them causing even shared memories to be felt differntly. Vision changes, experiences of pain and experiences of mental health also differ between alters. 

The alters are seperated and can have a solidifed sense of self within the dissoctaive barries. These parts themselves can have their gender, sexuality, spiritual beliefs, political beliefs, taste in music or art. Everything we see as identity and personality can vary between them. 

We have an article Diagnosis Primer: Dissociative Disorders if you would like to learn more.

How are DID & BPD similar?

Both of these disorders stem from similar situations in failed attachments and both are heavily linked to child abuse. Structural dissociation is considered to be a basis in the development of both disorders. Those with DID and BPD will both likely struggle with having a lack of core self, feelings of confusion, emotional control issues and difficulty connecting with themselves. Feelings of isolation, loneliness and chronic anxiety are common with them both. 

These disorders are often confused as BPD is much more likely to be diagnosed as DID has a history of even stronger stigma and disbelief then BPD. Clinicians and those with these disorders are woefully undereducated to understand and treat them. 

 In populations studied with DID, they showed a rate of up to 70% comorbidity of BPD. (Brand & Lanius, 2014). 

How do they differ?

On the most basic level, BPD creates an unstable and disjointed sense of identity but has one continuousness consciousness while DID has differentiated parts that have amnesia and can experince the same identity confusion of BPD differently between them. 

The facets of a person with BPD can feel as if they are a fragmented person but they are versions of the same self, different versions of the self masking to fit in or based of different states of arousal. This sense of fragmentation with BPD is connected to situations generally interpersonal while the switches in DID can be based on many triggers as basic as needing to ADLs. 

Extremely severe periods of amnesia and essentially constant dissociation is diagnostic of DID whereas BPD dissociation is chronic it’s not as severe and amnesia is less common more towards depersonalization. 

BPD also does not cause the same complex internal voices (Not intrusive thoughts) that those with DID generally have. Inner worlds are common in DID where the different selves have an internal representation of self that differs from the body. 

Narcissistic Personality Disorder (NPD) Vs. BPD

Note: NPD is not synonymous with the colloquial usage of the term narcissistic. 

How are they similar?

They are the same class of disorder in our current understanding of diagnosis, specifically, Cluster B personality disorders.

The key overlaps are

1. Compromised identity formation and attachment
2. Difficulty with interpersonal relationships
3. Feelings of control and how to have it.  
4. Unstable self-perception highly influenced by situations

Attachment and the ability to understand the self and others this brings is something seen in both of them. Perception of the self and how they view themselves for both groups are unstable and can cause feelings of confusion The overvaluation of self in NPD is thought to be consistent but is generally unstable and levels of self-esteem are influenced by others. Self-evaluation with those with BPD is also unstable and influenced by relationships with others. 

A struggle with having an internal locus of control is also similar to both groups. What this means is that they feel as if they are out of control. It can present as either blaming others for their problems and exerting control on them or just feeling as if they have little choice. 

Relationships are compromised in both, an example being the concepts of supplies and favourite people and forms of compromised empathy and relations. A need for others to have focous on them is common, though with NPD it is more connected to needing to feel like others look up to them while with BPD it’s about wanting attachment and needing connection.

There are also high rates of commodity, however, these rates have been questioned when looking at cognition and empathy as aspects of these disorders. The new models of NPD show a wider chasm due to internal perception and looking at BPD as a structural disorder. 

They also relate in have horrible reputations with therapists and being seen as inherently abusive by others.

How do they differ?

Here are the base definitions as given by the DSM V:

• Borderline Personality Disorder: is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
• Narcissistic Personality Disorder: is a pattern of grandiosity, need for admiration, and lack of empathy.

Empathy is key here. People with Borderline Personality Disorder do have Affective Empathy and can exercise cognitive empathy. People with BPD tend to have overactive affective empathy facilitating enmeshment and also a strength. Those with NPD do not have affective empathy they can have cognitive empathy, the ability to understand the cause of effect of others situations but not feel others

Instability overall is characteristic BPD from actions, emotions, affective, relationships, impulse issues and identity separates the two as well. What they are looking for in others is also different, any connection can be searched for to feel chronic emptiness and combat depression and dissociation. Emotional control, affect issues and dissociation are characteristic of BPD but not NPD. Dissociation, self-harm and suicidality are characteristic of BPD but don’t have the same rates of NPD.

Feeling constant envy or being envied, believe they deserve influence on others, dislike of others who can’t fulfil this goal, having a higher estimation of self (exceeds that swings of BPD), preoccupations with visions of success and feeling as if they are singularly unique are characteristic of BPD. Thought distortions of worth and feeling alienated do appear but the alienation is negative and the distortions of worth aren’t as tied to achievement and the highs aren’t as strong in BPD.

Childhood Trauma & BPD

Trauma, especially developmental chronic trauma, is highly associated with BPD. It’s been shown to not only be common in those with PTSD/C-PTSD but as a causal factor in BPD.

Statistics on Trauma and BPD:

1. 80-86% of BPD patients experienced Child Abuse (Brand & Lanius, 2014)
   1. 67% Child Sexual Abuse
   2. 62% Domestic Violence exposure
   3. 71% Physical Abuse
2. 84% have experienced child abuse (Battle, et al2004)
   1. 49% Child Sexual abuse
3. 96% rates of significant lifetime trauma (Sack, et al2013)
   1. 48% of all women and 28% of all men CSA
   2. 65% experience different forms of physical violence

Attachment & BPD:

• 81-97% of patients with BPD have an insecure attachment. (Fonagy, et al., 1996)
  • Insecure organized types:Dismissing 51% & Enmeshed 35% {Preoccupied}
• Disorganized/Unresolved attachment: 40%
  • (Barone, Fossati, & Guiducci, 2011)

Studies show an inverse relationship between secure attachment and the presentation of borderline symptoms. Markers in self-assessments of insecure attachment were shown to be raised in Borderline Patients these including preoccupation, discomfort with closeness, need for approval, and relationships as secondary. Fearfulness during the relationship was also seen in many borderline patients. (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004)

The attachment patterns overlap with the facets of BPD showing how it is part of the causal factors of BPD. We can see this as BPD and attachment both have connections between emotional regulation, ability to form stable relationships, core beliefs of self, emotional object permanence and forming trust.

Emotional regulation is pretty easy to understand, extreme emotions are one of the easiest to grasp of BPD and has been linked to the insecure especially disorganized attachment. It’s also easy to grasp that attachment, the formation of first relationships, would influence BPD. Unstable relational patterns are on visible and most remarked upon BPD traits. Lacking proper abilities to connected with others creates people who lack repair skills and have short and volatile relationships. 

Trust is connected to unstable relational patterns and with BPD. Insecure attachment taught children that they can not trust the people who ought to love them the most and this will carry into later familial and romantic relationships.

A more difficult to grasp but something deeply important to internal feelings of BPD is the impaired formation of core beliefs of self. This is something outsiders can’t see but those of us with BPD suffer greatly. Lacking healthy attachment can cause us to not understand who we are and to view our self in a negative light. This is because brain development, as well as the messages from caregivers, gives the idea we should not exist, are not worthwhile or are less than others. 

The most complex and often overlooked aspect of both attachment and BPD is a lack of emotional permanence can form. This concept can be explained as:

“The emotion I feel now is all I’ve ever felt, and after it passed I can’t remember how it felt”

This is deeply important because it can help people grasp how it feels to experience BPD. When our emotions are both extreme and feel as if we can not feel anything else. It can also lead to the “needy” behaviour and need for constant reassurance.

Work on this has also shown connections between the specific factors in insecure attachment someone deals with and presentation of BPD. This adds strength to the theory of attachment as causal in borderline symptoms.

Preoccupied/Ambivalent attachment: This is considered the prototypical style relating to BPD. It presents as BPD where people seek out relationships but then being in a place where they deeply need connection but will push others away. This is connected with the “splitting” term in the community. and is highly cyclical. Preoccupied attachment is also related to people forming masks and personas that change to be what others want them to be. Fearful aspects are generally present causing severe anxiety

Nervous system dysregulation for these tends to result in extreme outward actions. This is also related to confusion between having an internal and external locus of control.

Dismissing/Avoidant attachment: This presents as a persistent disengagement from any emotions. Identity can stand as a rigid and constructed formation. Emotional dysregulation in these cases presents as emotions being split off and then unable to be processed. When strong emotions can’t be split off, obsessive tendencies to attempt to control emotions and self. Compulsive behaviours can present and self-harming behaviours tend to be when clinical intervention can happen.

Relationships tend to be dogged by pushing others away and using walls as a protective measure.

Disorganized attachment: This attachment style is linked to many severe identity issues and structural dissociative patterns which leads to a lack of core self. Lack of stable self is characteristic of BPD but will be the most pronounced in those who experience the splitting of ANPS. Negative self-perception and guilt are also connected with disorganized attachment. 

Disorganized attachment fosters extreme nervous system dysregulation which connects with extreme emotions, erratic behaviour anger and depression. 

Disorganized attachment ingrains a fear of being hurt emotionally abused, abandon and even hurt physically or sexually which can feed the splitting aspects. However, it is also linked to “freeze” and “fawn” responses meaning that like preoccupied attachment they can link identity to those they want to be connected with. Disorganized attachment is linked to a complete external locus of control.

Chronic Developmental Trauma as a Basis of BPD

BPD is starting to be viewed as a traumatic disorder over any other class of disorder. Genetics and other environmental factors influence all mental health. Attachment is the most accepted form of trauma-related causal ideas but we are starting to see that developmental trauma, in general, has the highest explanatory power for BPD.

We can see this in the overlap of BPD symptoms with other trauma-based mental health struggles.

Comparing C-PTSD & BPD

This comparison shows that the two disorders even with the common understanding are experienced in a majority of the experiences between people with these conditions. This combined with the research showing histories of attachment issues and abuse is clear signs of BPD being trauma linked disorders.

Neurobiology of BPD

Heightened limbic reactivity as part of primary dissociative episodes (a hyperarousal state) affecting the amygdala and insula as a response to the exposure of negative emotional stimuli has been shown in BPD patients. Hyporeactivity of frontal regions has frequently been observed in response to emotionally arousing stimuli in BPD, (including emotional faces and pictures, trauma-related stimuli). Altered brain activation in the orbitofrontal cortex has also been suggested to be associated with impulsivity in BPD. These neurological changes are similar to those with trauma and it’s a related disorder of PTSD, C-PTSD DD and DID.

Secondary dissociative episodes (hypoarousal including derealization & depersonalization ) are shown in BPD. Excessive corticolimbic inhibition is the main neurological signs. This, when seen in co-morbidity with PTSD, shows increased pain tolerance. Decreased activity of the amygdala has been seen during dissociative experiences and it has signs of effecting memory and focus. (Brand & Lanius, 14)

This research shows on physiological level BPD is similar to dissociative and trauma class disorders. It also helps us understand much of the emotional reactivity and dissociative symptoms are connected to altered neurological activity patterns and central nervous system dysregulation showing something is happening that is not a fabrication of patients. The similarity to DID, DDs and PTSD patterns also supports tat on a physical level the brain is reacting as if traumatized.

Dissociation & BPD

Around 75% – 80% of people with BPD experience severe chronic stress-related dissociation. (Krause-Utz & Elzinga, 2018) 59% of the borderline patients met criteria for a dissociative disorder [of one kind or another] compared with 22% of the non-borderline patients (Ross, 2007, Salters-Pedneault, 2018)

Forms of dissociation seen in BPD

1. Derealization: The world around you feels unreal or that you are not a part of this world
2. Depersonalization: You and/or your body are not real. Highly linked to feeling of emptiness of self. 
3. Amnesia: Being unable to recall periods of time triggered by stressors or trauma. Least common in BPD. 

Why does this matter? Because dissociation is inherently linked to trauma. The most common forms in BPD patients who experience severe dissociation are physical abuse, sexual abuse, living in a domestic violence situation and severe neglect. (Brand et al, 2014 & Salters-Pedneault, 218 & Fox, 2018). This supports the theory of BPD as a developmental trauma disorder based on structural dissociation. 

Structural Dissociative Model & Theory of Structural Dissociation of the Personality (TSDP)

The general Structural Dissociative model is based on the idea that developmental trauma disrupts the development of identity and personality. If the identity before age 6-9 fails to properly integrate the ego states you can experience structural dissociation. Primary can occur later in life after trauma, but secondary and tertiary can not. Primary and Secondary have on ANP [a multifaceted full identity] and EPs [traumatic states, single facets], Teritrary has multiple full ANPs.

TSDP provides a conceptualization of post-traumatic clinical pictures. It has been shown that the dissociative splitting off parts of personality and consciousness is the basis of traumatic stress profiles. Post-traumatic clinical issues are a spectrum ranging from acute trauma and PTSD on one end [Primary] to DID [complex tertiary ] BPD presents in the middle of the spectrum [Secondary]. 

So those with BPD experience emotional parts these consciousness states are stuck in a traumatic state. These parts did not integrate into the main consciousness causing a person to have portions of their history sectioned off from them that carry extreme stress, the person can also slip into states of being in trauma via these EPs. Secondary dissociation is a spectrum in and of itself including C-PTSD & BPD at one end as then OSDD which is on the line between Secondary and tertiary having more fully formed EPs that are majorly differentiated from the ANP and can have amnesia. BPD & CPTSD have no identity separation but unstable personality and consciousness and perception separation. (Nijenhuis, Der Hart, & Steele, 2004 & Mosquera et al 2014)

This understanding as being based on structural dissociation and trauma is the best and most clear. While some studies have shown people with BPD do not all have extreme trauma that might cause PTSD or DID the almost ubiquitous attachment struggles show some extreme stressor was present during development. Overall BPD ought to be understood as a profile of traumatic stress and broken attachment. Creating a cluster of varying trauma reactions including; PTSD, C-PTSD, DTD, OSDD, DD, and DID. These then overlap with an anxiety disorder and mood disorders. 

All of these profiles do overlap and are comorbid. BPD is a presentation of traumatic stress and not an intransigent personality flaw.

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