Is BPD real or is it a matter of being too sensitive and living through a lot of stuff?
What is BPD?
Borderline Personality Disorder is a chronic mental health condition that most noticeably disrupts emotion regulation in the people who have it. The DSM-5 (the most current edition) defines it as: “Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.”
A big part of BPD is a fear of abandonment. It might be real or might be perceived. People who have BPD suffer from chronic feelings of emptiness, markedly impoverished self-esteem, unstable relationships (love/hate), suicidal ideations, and usually some type of self harm or substance use. Suicide attempts are incredibly common, though aren’t present in every person who has BPD.
Developing BPD is mostly the result of some sort of childhood trauma like sexual assault or child abuse or neglect, or something as seemingly small as being bullied, or growing up with an inconsistent parent, addicted parent, or mentally ill parent (note: the mental illness part isn’t always a given; it depends on how the parent copes with it.)
Biology does play a role here. A lot of people believe it’s nature vs nurture but I assure you, it’s always some combination of both. Our brains are originally wired a certain way, based on our genes and what we’re predisposed to (same can be said for something like stroke or heart disease; being predisposed to it does not mean a person will develop it because biology is pretty cool like that.)
The National Institute of Health has done studies on the biological factors for BPD. To quote this http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1863557/?report=classic article, “The heritability of BPD has been suggested to be moderate to high, based on findings of concordance between monozygotic twins in the area of 35% (examining 92 twin pairs) and dizygotic twins in the area of 7% (examining 129 twin pairs). …. Current research has suggested several promising directions for investigating genetic causes of BPD, although presently no specific genes have been clearly suspected as being causative.” The article goes on to say that because BPD often co-exists alongside other mental health issues and is mostly brought about by environmental factors, doctors usually trace the biologic roots for each patient specifically, rather than the disease as a whole. So far, they know it’s serotonin and dopamine-related, but not much else, as science has just recently even started looking for a biological cause.
Trauma and Environmental Factors
Trauma can come in many forms. There are what they call Big T and Little T categories http://fountainhillcenter.org/articles/big-t-vs-little-t-trauma-second-article-series-trauma-today/ . Something with a small t would be starting back at school, arguments with your loved ones and/or children, or something like a getting a speeding ticket. These little t’s can build and build and build up until you have a mountain of little t’s that weighs as much as one big t. Big T trauma is something along the lines of surviving a natural disaster, surviving an abusive relationship, surviving sexual assault, or the deaths of friends and loved ones.
Trauma in childhood is a lot more complex than most people think. Our usual view is that kids are so young they won’t remember it. It’s actually the opposite. Childhood trauma can shape the way your brain grows and develops, or how it doesn’t. http://www.aaets.org/article196.htm Our brains develop throughout our entire lives, but most of it happens during childhood. By age 3, our brains are about 90% adult size while our bodies are roughly only 18% and in turn, that shows just how much development happens during early childhood. When we experience something traumatic at such a young age, the event(s) shape the developing brain.
Because of the way the brain grows, our brains develop the skills necessary to survive in whatever environment we’re in. It could be post-war ravaged countries or having a parent that drinks a lot and gets angry. In cases of BPD it’s usually a big T that really sets things in motion, and small T’s pile on top of it over time, reinforcing the damage the big T did.
Anthony C. Ruocco http://media.utoronto.ca/media-releases/new-insights-into-the-borderline-personality-brain discovered that the area of the brain called the insula (which helps us regulate and process negative emotions) fires a lot more neurons than in people who don’t have BPD. At the same time, the frontal cortex (helps control emotional reactions) is markedly less active than people who don’t have BPD. So while people with BPD may seem overly emotive, part of it is due to our brains not really being able to stop and regulate those negative emotions. That part of our brains just isn’t doing what it used to.
Everything we do impacts our brain development, but not all events and acts impact our brains the same way. During childhood our brains are working so fast to process everything, so what we’re exposed to has more of an impact on us than a full-grown adult.
Family of origin and schemas
The environment we grow up in shapes our lives, we all know that. Well, there are classifications called Early Maladaptive Schemas that correspond with the households we grew up in and our behaviors and thought processes. They’re multidimensional and are broad and deep and long-lasting and deeply rooted. They set the tone for our entire mind in most cases. They can differ on levels of severity and the way the schema is presented. They go beyond our core to something much deeper.
There are a few different categories of schemas which you can find by clicking the above link. One of the biggest and most important domains (groups) is called Disconnection and Rejection. The typical family-of-origin for the DR group is: “detached, cold, rejecting, withholding, lonely, explosive, unpredictable, or abusive.” One of the schemas that fall under the DR umbrella is called Abandonment/Instability. Fears of abandonment are a really big deal for people with BPD. The AB definition is: “The perceived instability or unreliability of those available for support and connection.” (For full definitions for all schemas, visit www.schematherapy.com Because we’re all different biologically, and because not everyone with this schema will experience all of the same family-of-origin issues, the schemas can show and come out of a person in different ways.
There are three coping styles with schemas. The first is surrender, which is not fighting the schema at all. The second is avoidance, where the person avoids any emotional stimuli that could potentially set the schema off. The third is overcompensation, which is exactly what it sounds like. AB examples would be: surrender- someone who dates a person that can’t commit yet stays in the relationship; avoidance- totally avoiding relationships altogether and possibly drinking or doing downers when alone; overcompensation- the person clings to or smothers their partner, then may verbally attack the partner at the sign of the smallest separation. All schemas are incredibly complex, incredibly deep-rooted.
There’s a finding called Attachment Theory states that our relationships with our parents or guardians or caregivers growing up set the tone for the rest of our relationships throughout our lives. This plays a very big role in the development of all PD’s and even in cases of addiction. Say you have a parent that only comes around sometimes and a lot of the time you just kind of wonder what happened to your other parent. Or maybe they go up and down mood-wise, going from being fun loving and free to being angry and possibly harshly punitive. This is what’s called an inconsistent attachment figure. When an inconsistent attachment figure is present, the child will become clingy and desperate and anxious while this figure is around (and consequently, whenever they’re around someone they love.) On the other hand, if said attachment figure just stays gone, the child becomes indifferent and apathetic to the figure’s presence (and consequently this can manifest in a back-and-forth cycle in the person’s relationships with others.) Attachment figures play huge roles in everyone’s lives, but having an inconsistent attachment figure or a completely absent one can set a lot of BPD traits and schemas in motion (love/hate, chronic feelings of emptiness, low self-esteem.)
Differences between DSM-IV-TR and DSM-5
A lot of people see the new edition of the DSM as too much of a change and feel like certain disorders have totally changed. But I can assure you, BPD hasn’t changed- it has evolved.
The DSM-IV-TR criteria are from the year 2000. The DSM-5 came out in 2013. That’s a 13 year gap between updates. Things are bound to look different after that long. What with time passing and scientific advancements, it makes sense that we’d come leaps and bounds from where we were in the year 2000.
The DSM-IV-TR also likes to use worst-case-scenario, very limited criteria. The IV-TR language itself is pretty shaming, so it often reads back as cold or harsh, making it a little difficult to really get on board with. Couple that with stigma (BPD faces more than most disorders) and you’ve got a heaping pile of, “What do we do with this now?” There are too many unanswered questions. For example, criterion 2 says, “A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.” That doesn’t really cover a whole lot about the nature of BPD relationships. But if you look at the DSM-5, in criterion A, the Empathy and Intimacy categories elaborate on the old criterion 2.
“Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e. prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between overinvolvement and withdrawal.”
Those are just two examples as other criteria (Emotional liability and Separation insecurity) go on to elaborate on that one single criterion 2. The DSM-5 specs are just better-developed versions of the IV-TR criteria. The 5 delves deeper than the IV-TR which makes sense because it’s been so long between updates.
Why are there a set number of symptoms?
This is because in the DSM-IV-TR those 9 areas were the most apparent that were so totally different from a person who has BPD and a person who doesn’t. There are no real set numbers exactly in the 5 because it’s more of a comprehensive approach. The reason it looks like something is missing in the IV-TR is because it was, and they fixed it in the 5.
What makes these traits specifically BPD and what gages the intensity and severity are the levels of suffering on behalf of the person with BPD and those close to them. Someone who occasionally has flares of emotion and gets into an argument with a loved one will generally calm down a bit and will realize it’s not the person that’s the problem, it’s the subject of the argument, and then they go on with their lives. Because of the horrible things in a person with BPD’s past, something small can set them off and all of the sudden they hate this person, kick them out of their lives, then regret it and hate themselves on top of it.
BPD is very hard to understand, and I definitely understand why people are skeptical of its accuracy. But I can assure you that it’s very real, and that the clinicians in power right now are working fastidiously to be able to tell us more and help people who have the disorder.