A New Way To Understand Borderline Personality Disorder

Nicole Cardona discusses research that sheds new light on Borderline Personality Disorder, or BPD.

By Mark Travers, Ph.D. | October 18, 2021

A new research article published in the academic journal Personality Disorders attempts to catalog the nuanced emotional experiences associated with borderline personality disorder and offers new insight on how to effectively treat one of the more "treatment-resistant" personality disorders.

I recently spoke with Nicole Cardona, a graduate student at Boston University's Center for Anxiety and Related Disorders and the lead author of the research, to discuss these findings in more detail. Here is a summary of our conversation.

What inspired you to investigate the topic of Borderline Personality Disorder and what did you find?

The main thing that has drawn me to studying and treating BPD is how stigmatized a mental health condition it is. Many people, including professionals in healthcare and psychology, still hold misconceptions and negative judgments about BPD, but BPD symptoms actually make a lot of sense when you think of them as behaviors designed to help that person feel more "in control" of their out-of-control emotions. For that reason, understanding the context of emotional experiences in BPD — for example, which specific emotion the person is feeling, how intense the emotion is, what was happening for the person before they felt the emotion — is important for helping that person with BPD understand the best way to manage their emotional experience. So, this study was an attempt at understanding the context of emotional experiences in people with BPD.

Study participants were prompted on their cell phones, once per day for up to 12 weeks, to report on at least one of their emotional experiences from that day. They also participated in treatment for 4 out of those 12 weeks as part of the study. In general, 1) they reported anxiety more often (43.6% of the time) than sadness, anger, or guilt/shame; 2) their emotion was preceded by some sort of interpersonal or social trigger more than 50% of the time; 3) they most often tried to manage the emotion by problem-solving (28.7% of the time) or pushing the emotion away (27.5% of the time), and 4) they used adaptive strategies (problem-solving and mindful acceptance) at higher rates after they received the brief treatment.

There were some interesting findings regarding factors that predicted participants' use of specific emotion regulation strategies. For example, when participants reported the specific emotion of anxiety, they were more likely to try to problem-solve, but when they reported sadness, they were less likely to problem-solve and more likely to push it away. Participants with more severe BPD symptoms tended to "amplify" their emotions (e.g., try to make them bigger). And, again, going back to situational context: impulsive regulation strategies were more likely when the emotion was precipitated by some kind of physical vulnerability, like feeling sick or tired. When the precipitant was having interpersonal conflict, participants tended to amplify their emotion, and when it was precipitated by interpersonal disconnection, they were less likely to manage it with mindful acceptance.

Each pattern we found across this group of participants with BPD makes sense on some level — e.g., it makes sense to problem-solve when you're anxious about something that's in your control and it often feels empowering or validating to "dig in" to your side of an argument. Some of these patterns also open the door to asking more questions that may potentially have implications for BPD treatment. For example, is the greater likelihood of impulsiveness when a person has high physical vulnerabilities due to a depletion of that person's usual coping resources? Is interpersonal disconnection or loneliness a situation that is particularly difficult for people with BPD to tolerate mindfully? Adding to these questions is our finding that individual participants showed their own unique patterns of emotional experiencing that weren't captured in the group-level patterns (e.g., the patterns you see when you look at all the participants' data together).

You mention that BPD is characterized by three things: emotion dysregulation, behavioral difficulties, and interpersonal hypersensitivity. Can you expand on that?

Emotion dysregulation refers to strong, unwanted emotions that come on quickly and shift rapidly as well as maladaptive attempts to manage or control them. Interpersonal hypersensitivity refers to a proneness toward feeling rejected or dismissed, with a resultant difficulty maintaining important relationships. Finally, "behavioral difficulties" refers to impulsivity and self-damaging behavior, which can include substance use, reckless driving, aggression, and self-harm.

These three components of BPD, which are thought to be core to the disorder (particularly the emotional and interpersonal components) all fit together. Interpersonal events are a very common trigger for emotion dysregulation, which people with BPD tend to try to manage through self-damaging and often-impulsive behaviors. And these components feed back into one another in a sort of loop — acting without thinking can further damage important relationships, which can increase emotional distress and make it more likely that the person with BPD continues engaging in maladaptive coping behavior.

Why does BPD have the reputation of being difficult to treat? Are advancements in BPD research changing this?

Healthcare providers are vulnerable to the same biases as everybody else, and unfortunately, BPD stigma is often taught or reinforced in our training programs. Some of BPD's reputation of being "difficult to treat" comes from the antiquated idea that BPD is intractable and that people with BPD have a characterological problem that makes them "attention-seeking" and "help-rejecting." In addition to this stigma, therapists can become "burned out" by the interpersonal symptoms of BPD, especially if they view these symptoms as a barrier to treatment rather than an important target of the treatment. Therapists may especially struggle with this if they don't have access to consultation and support. Furthermore, because BPD is associated with a high risk for suicide, some providers and systems consider BPD a high-liability illness and are anxious about holding responsibility related to that risk.

All that said, advancements in BPD research over the last 30 years have absolutely begun changing this reputation. There are currently several evidence-based treatments for BPD that have been shown to reduce symptoms and greatly improve quality of life. Dialectical behavior therapy (DBT) is one specialized BPD treatment with a lot of empirical support, and it's continuing to grow in popularity. However, specialized treatments can be challenging for providers to access and learn, so more generalized approaches (e.g., general psychiatric management [GPM]) have been developed, as well as shorter treatments for people with less severe BPD.

After conducting your research, are you more likely to view BPD as a coherent diagnosis? Or does its presentation vary widely from person to person?

To meet criteria for BPD, you need to have 5 symptoms out of the possible 9 criteria. This means that there are 256 possible combinations of symptoms that can get a person the BPD diagnosis — this fact alone makes it a bit difficult to view the diagnosis as uniform and cohesive. You will also find psychologists who make the argument that if any major component is missing — e.g., if the person meets 5 of the criteria but the interpersonal symptoms aren't included in that 5 — then that person does not truly have BPD. Our field is always evolving in its understanding of mental health, and the field may end up deciding that there's a better model of BPD than our current, "5 of 9" disorder category. Either way, when I think of people who may fit this diagnostic category, I still tend to come back to these three core components:

1. Does this person struggle with intense emotions that change quickly?
2. Does this tendency tend to either cause or result from problems in their relationships, especially insecurity in those relationships?
3. Do they try to regulate themselves with behaviors that are self-destructive or maladaptive in the long term?

What are the practical takeaways from your research for someone with a BPD diagnosis or someone who has a friend or family member with BPD?

The practical takeaway is this: emotions are signals, and specific signals can lead to specific courses of action. Especially if you struggle with BPD, understanding your own patterns of emotions and responses is the first step toward learning how to use strategies that are more adaptive in the long term.

Do you have any plans for follow-up research? Where would you like to see research on BPD go in the future?

Yes! Going forward, I'm hoping to study "primary" and "secondary" emotions — in people with BPD, in people with marginalized social identities, and with the general population. Basically, there are theories that say we sometimes experience an emotion that is "secondary" to some other emotion because that other emotion is more painful. For example, sometimes it's easier to be angry than it is to feel sad; if a person is faced with a loss and their response is to become angry, the hypothesis is that the anger may be masking the primary sadness. I would love to see research on this phenomenon in BPD, as I wonder whether part of the difficulty in regulating emotions for people with BPD has to do with people choosing strategies that fail to address the primary emotion.

Do you have any words of wisdom for people struggling with BPD or other related/Cluster B traits?

The first thing that comes to mind is, "You're not crazy, you're not damaged, and your experiences make sense." Make peace with your emotions — you need them! There are good treatments for BPD, and you absolutely can live a life with joy, love, and meaning.