Categories
mental health Psychology

Understanding Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a complex diagnosis. It can be confusing to understand, I think because its traits can be observed at one time or another within the general population. The diagnosis is controversial because some people hold the belief that the feelings and behaviours associated with it are a reasonable, human reaction to difficult life experiences. Indeed emotional experiences like loneliness, fear of abandonment, excessive self-criticism and pessimism about the future have the potential to affect us all – especially so during difficult life events, such as romantic break-ups, bereavement or job loss.

Having said that, the mental health conditions known as personality disorders are some of the most stigmatised. BPD is a serious and debilitating condition that, unfortunately, still receives a lot of negative attention based on misinformation and inaccuracies. It is important to remember that for a diagnostic decision to be reached the criteria must be persistent (occurring within a substantial time frame), pervasive (spanning several life areas) and problematic (severe enough to cause significant difficulties). Some people find that getting the diagnosis helps them to name and understand their experiences and get access to treatment and support they otherwise might not. Recovery is possible, especially with the right treatment. These problems need not persist for a whole lifetime.

This is my summary of the Stronger Minds Podcast episode Understanding Borderline Personality Disorder. The host is Kimberley Wilson, a Chartered Psychologist and author of the book How to Build a Healthy Brain. In the episode she addresses misrepresentations of BPD through an expert appraisal, challenging the rhetoric that sufferers of the condition are deliberately manipulative or attention-seeking. This includes an excellent explanation of black-and-white thinking, also known as “splitting” – an often misunderstood term, even by professionals. Before you read on, it is worth noting that the diagnostic criteria discussed in the episode is from the DSM-5 – a diagnostic tool that is highly contested (which Wilson does touch upon). The ICD-11, which will eventually replace the ICD-10 (the diagnostic manual used by clinicians in the UK currently, in which Emotionally Unstable Personality Disorder [borderline type] is one of the categories) will instead classify personality disorders along three levels of severity (mild, moderate and severe), with the option of specifying one or more prominent traits. Whether this will have much impact on destigmatising the label is yet to be seen – but the more stigma is reduced, the sooner people will learn about personality disorders and seek treatment.

With these technicalities about diagnosis now out of the way (no wonder it is confusing!), all that remains to be said is how valuable this episode is. It is the clearest, most comprehensive explanation of BPD/EUPD I’ve heard from a professional. Every point made is succinct, substantiated and well-illustrated, so I would encourage you to listen to it in its entirety.

In the meantime, here is my summary (all content is Wilson’s own).

BPD/EUPD: what is it?

BPD is a diagnostic label given to a group of overlapping symptoms that relate to a person’s ability to form relationships, manage emotions and behave in predictable or socially acceptable ways.

The name refers to living at the “borderline” between neurosis and psychosis. Some prefer to use the term Emotionally Unstable Personality Disorder (EUPD), as it is currently known in the UK.

A BPD diagnosis can feel fixed or condemning due to the name alone. The diagnosing professional must be very careful to explain the condition so the person does not leave the assessment room thinking there is something wrong with them, or that their personality is broken.

BPD diagnosis is more prevalent in women. Why?

In the general population the gender split seems to be about equal. But epidemiological studies from the early 2000s suggested that 75% of people diagnosed with BPD are women.

There may be a bias in diagnosis. Since society largely expects men to be more impulsive and engage in more risk-taking behaviours, these traits are seen in the context of “normal” behaviour – leading to under-diagnosis of BPD in men, or anti-social personality disorder diagnoses.

There is an element of sampling bias too because women are more likely than men to contact a doctor or therapist for help.

It could be something to do with the invalidating environment, specifically the greater tendency of girls to internalise their distress, combined with the social expectation for women to be compliant.

People with this diagnosis are disproportionately ending up in prisons.

It is rare for someone to fit neatly into the diagnostic criteria for one disorder.

People with a BPD diagnosis also present with mood disorders 80-96% of the time. In addition:

  • 88% present with anxiety disorders.
  • 64% present with substance use disorders.
  • 53% also have eating disorders.
  • ADHD is present in one third of people.
  • 1 in 10 people have co-occurring somatoform disorders (emotional distress manifesting as physical illness).
Diagnostic criteria

The criteria describe problems with one’s own sense of identity combined with problems relating with others. We would expect these two things to be connected. After all, it would be incredibly difficult to interact with others in a consistent way without a clear sense of who you are, or your own value. Let’s go into this in more detail.

Part One: Identity

Unstable self-image/identify issues: excessive self-criticism; chronic feelings of emptiness; and dissociative states during distress, experienced as a “checking out” psychologically and considered to be a protective mechanism of the mind (often in response to trauma).

Problems with self-direction: instability in goals, aspirations, values or career plans.

Part Two: Relationships

Difficulties in empathy, interpersonal hypersensitivity and perceptions of others selectively biased towards negative attributes or vulnerabilities.

Intimacy issues: intense, unstable and conflicted close relationships marked by mistrust, neediness and anxious preoccupation with real or imagined abandonment, often viewed in extremes of idealisation and devaluation and alternating between over-involvement and withdrawal.

This is experienced as not knowing what distance is safe or healthy. Sometimes close feels too close and sometimes separate seems isolating, to the point of feeling left and abandoned.

There may also be fears of rejection by and/or separation from significant others associated with fears of excessive dependency or complete loss of autonomy. This is sometimes described or experienced as a “push/pull” dynamic in relationships.

These difficulties can express themselves in the following ways:
  • Negative affectivity characterised by unstable emotions and frequent mood changes.
  • Emotions that are easily aroused, intense and/or disproportionate to circumstances.
  • Anxiousness: nervousness; tenseness; or panic – often in reaction to things that come up in relationships.
  • Worrying that the bad things that have happened to you in the past have tainted or corrupted your opportunities in the future.
  • Feeling fearful and apprehensive about, or threatened by, uncertainty.
  • Pessimism about the future.
  • Fears of falling apart or losing control.
  • Frequent feelings of being down, miserable and/or hopelessness and difficulty recovering from such moods.
  • Feelings of inferior self-worth and pervasive shame.
  • Thoughts of suicide and suicidal behaviour.
  • Impulsivity in response to immediate stimuli.
  • Difficulty establishing or following plans.
  • Self-harming behaviour and/or sense of urgency under emotional distress.
  • Risk-taking engagement in dangerous and potentially self-damaging activities
  • Hostility: persistent or frequent angry feelings; or anger/irritability in response to minor slights.
BPD and brain development

Brain imaging studies indicate that people with BPD have different patterns of activation in the amgydala – the threat recognition area of the brain – that could contribute to symptoms.

Trials have shown that people with BPD are more likely to see hostile emotions (anger/disgust/condemnation) in neutral faces, suggesting that they both anticipate and see more hostility in the world around them (known as hyper-vigilance). Wilson goes on to explain it like this: “the more you look for something the more likely you are to find it.”

There can be a history of extreme or prolonged emotional distress in childhood. This includes serious parental psychopathology, including extreme emotional abuse. Such interpersonal abuse and terror is not uncommon for people with BPD.

These environments are described as “emotionally invalidating”. In other words, children who grow up in such environments are made to question the reality or the validity of their emotions. For example, they may have been consistently told that they deserved the abuse or neglect they were receiving, or that their emotional reactions were silly or stupid (known as emotional dismissal).

Black-and-white thinking or “splitting”

Abuse coming from someone who is supposed to play a caring or protective role for a child is particularly harmful. This is because it forces the child to question or actively distort their reality in order to help them survive and create some semblance of a sense of safety.

When faced with the dilemma of parental abuse the child (whose psychological apparatus is not yet developed fully enough to comprehend that the problem lies in the adult and not the child) has to come up with some other solution for why this is happening to them.

That solution is often a process called “splitting” or black-and-white thinking. The child is forced to separate the good from the bad, for example: “my parent is good and I am the cause of all the problems”.

This black-and-white thinking, arising out of this conflict between dependence and fear, has potential knock-on effects for self-identity that continue to cause problems for the individual later in life. People with this diagnosis can behave as if their internal thoughts and beliefs are external objective truths, due to the inflexible nature of their thinking.

This all-or-nothing approach to the self and to the world becomes a template for all significant relationships and social interactions.  

For example, someone with BPD may be constantly worried that any negative thing they do will cause the other person to leave them – an experience known as fear of abandonment. They may engage in a pattern of idealisation/devaluation in close relationships.

Normalising “splitting”

It can be very hard for someone on the outside to see how a small disagreement about something tiny or seemingly meaningless can lead to self-harm or suicidal ideation.

But the symptoms of BPD become much more understandable when you get to know the psychological habits and environmental conditions in which they developed. And once you understand something you are in a much stronger position to intervene.

“Splitting” isn’t only seen in people with psychiatric diagnoses. We can all fall into the trap of black-and-white thinking. We even see this every day in two-party politics. Whenever you hear someone say “all of (group of people) are bad/evil”, this is an example of “splitting” by all-or-nothing thinking. We can think about splitting as positions you move in and out of rather than consistent states, which often happens when we are in unfamiliar or threatening situations. But rather than being an occasional trap to fall into, in BPD black-and-white thinking becomes one of the dominant ways of understanding the world and others.

The role of invalidating environments

Invalidating environments can be much more subtle than emotional abuse. The emotional dismissal may take the form of facial expressions, looks or behaviours that are designed to minimise the child’s emotional expression. Essentially the child gets the idea that their emotions are unwelcome or unbearable for the parent/teacher/friend – and that they have to deal with their emotional distress by themselves.

The cruel injustice of this situation is that we learn to manage our own emotions by initially having someone else help us to do it. It is the process of internalising repeated kindness and understanding that helps us to learn how to soothe ourselves later in life.

So there is this double whammy of not having your emotional needs attended to in the first place and therefore not learning how to take care of your emotions yourself later in life.

This is why we see a lot of the externalising behaviours in BPD, such as self-harm. With this developmental understanding, the risk-taking behaviours associated with BPD suggest someone who doesn’t know how (and perhaps never learnt) how to look after or protect themselves.

Understanding self-harm

The function of self-harm is dependent on the individual person and their particular developmental history, but here are four common examples:

  1. Emotional pain may feel much harder to address than physical pain. Self-harm is a more manageable alternative that may even symbolise emotional pain and self-care.
  2. People who grew up in environments that were actively hostile to emotions come to (unconsciously) link deserving care only with having a physical illness or injury. Often the only “real” or acceptable pain or injury is a physical one. Self-harm may be an unconscious adaptation that emerges as a means of getting some care from an invalidating environment.
  3. Occasionally self-harm is a pathological form of control in the face of suffering. This includes abuse that is so inescapable it leads to a decision that sounds like: “if I’m going to suffer, then I might as well be in charge of what that suffering looks like.”
  4. Sometimes self-harm is a manifestation of self-hatred and this occurs when someone has taken in the idea that they are unwelcome, unwanted, a burden or a problem. People may be driven to punish themselves for not being a “better person”.

In all of these examples we’re talking about self-harm as a remedy for, an escape from, or as a management of emotional suffering.

This is why many patient groups and advocates campaign against the diagnosis of BPD as a disorder in itself, but rather an adaptive response to complex trauma.

Advocacy

Some anti-stigma campaigners say that what is being called an illness or disorder is really an understandable response to trauma experiences.

They argue that someone who has already been harmed in this way should not be further harmed by what can be a very stigmatising diagnostic label.

But – diagnosis is often the key to opening the door to treatment. In the UK this is Mentalisation-Based Therapy (MBT) and Dialectical Behaviour Therapy (DBT), which are group therapies developed specifically for people with BPD based on CBT and psychotherapy.

Self-help resources

Coping with BPD: DBT and CBT skills to sooth the symptoms of Borderline Personality Disorder, by Blaise Aguirre and Gillian Galen. There are a few good self-help books out there, including DBT skills workbooks. This one is a practical, straightforward guide offering evidence-based solutions for adressing over 50 common problems experienced by people with BPD.

Borderliner Notes is a Youtube channel featuring short videos about BPD. Interviewees are people with lived experience of BPD and their families, as well as some clinicians – including psychologists Marsha Linehan (who developed DBT) and Peter Fonagy (co-founder of MBT).

Mind has some self-care ideas for Borderline Personality Disorder.

UK-based author Shehrina Rooney talks about living with BPD on her Youtube channel Recovery Mum. She was diagnosed at age 21.

Finally, there are two follow up episodes on Stronger Minds featuring talks with bloggers Rosie and Bryan about living with their BPD diagnosis.

Connecting with others who have similar experiences (such as through peer support) can be really helpful for people with BPD, especially for overcoming feelings of isolation and maintaining hope. If you cannot access peer support groups right now then hearing other people’s stories on podcasts or Youtube channels could be a helpful alternative.

Image: The Brooch / Eva Mudocci by Edvard Munch.

Categories
Creativity Psychology Writing

In praise of… Bullet Journaling

Despite the challenges of life in lockdown, this “new normal” has presented some unexpected opportunities. Previously, I’d been an intermittent diarist. Each January I would resolve to record daily my every negative thought and feeling, resulting in very little progress. As meditators and neuroscientists alike will tell you, “where attention goes, energy flows.” Attention has the potential to change the structure of the brain (ever considered the less catchy ‘where attention goes, neural firing flows and neural connection grows’?). I didn’t look forward to diary-writing and after a few half-hearted entries I would soon get fed up and leave the remaining pages untouched. One issue was uncertainty about my diary’s purpose. Should I be writing down the content of my dreams, or focussing on my waking life? Do I want to record my day, or forget it ever happened? How do I make my goals SMART – and do I even want to?

When this pandemic was in its early stages I found myself aimlessly browsing my local library’s creative writing section. I came across a book entitled How to Bullet Plan: Everything You Need to Know About Journaling with Bullet Points by Rachel Wilkerson Miller. I had heard of bullet journaling – a creative colleague I had worked with uses it (she loves Ali and Finn’s Positive Bullet Diary*) – but I still didn’t really know what it was. Is it a planner? A to-do list? A diary? It turns out it’s all of those things.

Bullet journaling, so-called because it uses bullet points as its core structure and utilises dot grid paper, was devised by Brooklyn-based digital product designer Ryder Carroll as a personal method of organisation to manage his ADHD. Encouraged by a friend, in 2013 he began sharing his method online. By the end of 2018 it had been the subject of 3 million Instagram posts. As Carroll explains in his book The Bullet Journal Method, it is an individually-customisable system: a way of tracking your past; ordering your present; and planning your future. And, as I’ve recently discovered, it is excellent for promoting and maintaining wellbeing.

During the past three months I have dedicated more energy to running, recording my distances and times in my bullet journal – leading me to run a half marathon. My mood has improved massively, which I attribute to this newfound love of goal setting (meditation, healthy eating and early nights have helped too). Imagining how I’ll feel looking back over this diligently-kept document of my past accomplishments, or dreaming up topics to devote future journal entries to, brings me joy. I actually look forward to opening my beautiful, brightly coloured journal every day and leafing through its thread-bound pages. Selecting the perfect pen and colouring in each square has become a daily ritual I relish. I am a true bullet journaling convert.

If you think this sounds overzealous or fanatical, there’s a reason: bullet journaling works. Here’s why. It’s a quick, simple form of regular note-taking (Carroll calls this “rapid logging”) that you’re more likely to stick to, because it’s flexible and uncomplicated. You make space to record all your appointments and important tasks in such a way that you can’t miss them, meaning you actually stay on top of things (imagine that!). Consider the principle that nothing need be lost if it is written down. You create one single place to list all those films and TV shows you’ve been hearing about, or those books you’ve been meaning to read. All too often my smart phone gets in the way of good sleep, so I prefer putting pen to paper before bedtime. It’s also very beneficial to get creative. And some have suggested that writing, as opposed to typing on a laptop, allows you to better organise your thoughts and can even boost memory.

Getting Started

The first step is to arrange your calendars, known in the bullet journaling world as ‘spreads.’ These are commonly broken down into annual, weekly and monthly. You can include daily spreads too, if you decide to use your bullet journal more like a diary (I’ve chosen to keep a separate reflective journal for this kind of thing). Then you start adding in your other sections. A key one for me has been my mood tracker (which I prefer to call ‘mind and body’). I also record my workouts, circling the dates on a one-page annual calendar spread using different colours to denote each different type of exercise (fancy). I log the good habits I want to stick to and the goals I’d like to achieve. I set a main focus every week and then review it at the weekend. You can even log when you do your chores, last visit the dentist, or take your car for its MOT – called a ‘when did I last…?’ log. At times when life is particularly hard this becomes an invaluable resource. It’s an approach that focuses on achievements and prioritising your values, rather than denying yourself or giving things up. By focussing your attention you create the right intention.

If this all sounds a bit too much to contend with, I can assure you it isn’t. I use about half an hour every Sunday to review my week and set up next week’s pages. It then takes five to ten minutes at the beginning and end of each day to fill in. The secret is keeping it simple; only keep the sections that work for you. Finding that you’re not filling in your daily diary? Write a weekly summary instead. Not sticking to the habits you’re tracking? Throw them out and set new ones. Mine went through three or four different setups before I settled on its current layout. And when things are more normal and I can hopefully return to work, I expect my system to change again. Unlike a traditional diary (which I found to be too rigid), you can purchase a blank grid page notebook that includes an index and page numbers, making your journal simple to navigate. The beauty of the bullet journal method is that you can change your system to suit you as you go along.

The Science-y Bit

Increased self-awareness can bring about change. This is a central tenet of Dialectical Behaviour Therapy (DBT), a type of talking therapy developed by psychology researcher Marsha M. Linehan for people who experience strong emotions. By tracking your mood, sleep, exercise, energy levels and physical health status you can increase your awareness of thoughts and feelings in relation to your activities – and hopefully begin to see patterns. Goal attainment can increase positive emotions – and we will reach our goals sooner and more easily if our emotions are positive. Positive psychology pioneer C. R. Snyder first began theorising about this in the 1980s, going on to write six books on hope and its relatedness to optimism. He demonstrated that clearly conceptualised goals provide direction and an endpoint for hopeful thinking. His “hope theory” comprises three components: having focused thoughts; developing strategies to achieve goals; and being motivated to make the effort required. We can apply this theory to our own bullet journal method. Its four subcategories are goals, pathway thoughts (the routes we take to achieve our desired goals), agency thoughts (our motivation) and barriers (which make it difficult for us to attain our goals). Goals that are valuable but uncertain are described as the “anchors” of hope theory. This is because we need to reevaluate our strategies along the way. Barriers offer an opportunity to strengthen new pathways; when faced with barriers we can either give up, or use our pathway thoughts to create new routes.

So, when we use our journal to review our goals each week, we are looking for new ways (via pathway thoughts) to reach them. Snyder says it helps if you ask yourself things such as “what is going on?”, “where do I want to go?” and “what is stopping me?” These are typical pathway thinking questions. Research on brain plasticity has shown that we can increase our neural growth through our actions, such as asking questions and deploying good strategies. This is what is also known as the “growth mindset”, a term coined by psychologist Carol Dweck to describe a type of positive attitude that, crucially, can be learnt and practiced to increase motivation and achievement. By recording and reflecting on our progress we activate agency thoughts, thereby increasing positive motivation. According to Snyder, if we view barriers to growth as challenges to overcome, using these pathway thoughts to plan alternative routes to our goals, we are said to have “high hope”.  High hope has been associated with many benefits, including increased wellbeing and academic achievement. Reflection is the foundational principle of bullet journaling as a practice. It declutters the mind, cultivates curiosity and helps us to remain focussed over time (for more on this see Carroll’s Tedx talk).

The “father of positive psychology” Martin Seligman has spent his life’s work researching wellbeing and happiness. His Three Good Things exercise, explained in his most recent book Flourish, invites you to write down three good things that happen each day. Next to each positive event, you answer one of the following questions: “why did this good thing happen?”, “what does this mean to you?” or “how can you have more of this good thing in the future?” These questions encourage us to really reflect on and immerse ourselves in the good event, which increases our degree of positive emotion. It’s possible to incorporate this exercise into your bullet journal – and you should, because once you start you’ll want to keep going. Alternatively you could keep a daily gratitude list or note down one achievement each day. These exercises may even support healthier thinking patterns, the same way Cognitive Behavioural Therapy (CBT) seeks to do. For example, by keeping a record of your achievements you are building evidence to challenge negative thinking biases. Another CBT intervention that is very effective is Behavioural Activation, which focuses on behaviour and environment, rather than thoughts. By tracking good habits and logging your daily activities – known as Activity Scheduling – you increase the amount of positive reinforcement you experience. This helps to reduce the negative behaviours that may provide temporary relief, but ultimately maintain your anxiety or low mood. Become your own therapist!

Why else do I like bullet journaling? Because it is associated with positive emotions, not negative symptoms. Our brains have a natural tendency to focus on what goes wrong in our daily lives, as my previous diary attempts had illustrated. Using a bullet journal for wellbeing encourages us to dwell on the good things instead. It’s not a CBT worksheet with a mysterious acronym. Or a mnemonic that’s actually not so easy to remember. Or a digital calendar on an app. It is a holistic tool: something you can choose to build and create according to your own unique agenda. And that’s very empowering.

Books

The Bullet Journal Method: Track Your Past, Order Your Present, Plan Your Future by Ryder Carroll (2018)

Flourish: a New Understanding of Happiness and Well-being – and How to Achieve Them by Martin Seligman (2011)

Positive Psychology for Overcoming Depression: Self-help Strategies to Build Strength, Resilience and Happiness by Miriam Akhtar (2018)

The Right to Write: an Invitation and Initiation into the Writing Life by Julia Cameron (2017)

Online

Action for Happiness: Find Three Good Things Each Day

Bullet Journal: the Analogue Method for the Digital Age.

Mental Health Bullet Journal by Rachel W Miller for BuzzFeed.

The Positive Bullet Journal by *Positive Planner (AKA Ali and Finn) can be purchased here (you’ll be supporting the amazing arts charity Arts at the Old Fire Station too!).

Getting Started

How to Bullet Journal, by Ryder Carroll. Start here.

Journaling vs Bullet journaling. How to add long-form journaling into your Bullet Journal practice and why it can help.

How to Declutter Your Mind – Keep a Journal by Ryder Carroll, TEDxYale (2017).

Acknowledgements

Many thanks to the wonderful people at Restore and Oxfordshire Recovery College for their encouragement.

A big thank you to Ruth for reading earlier versions of this essay.

Photograph: Leuchtturm 1917.