What Makes Borderline Personality Disorder So Difficult?

By Daniel J. Fox, PhD, author of Complex Borderline Personality Disorder

Borderline personality disorder (BPD) is one of the most challenging and confusing disorders within the realm of mental health. It’s been around since the 1930s. It was originally called “borderline” because it identified individuals who appeared to be experiencing a mild form of schizophrenia, and appeared to be on the borderline between neurosis and psychosis. So here we are, ninety-two years later, and what do we know, have things changed for practitioners and patients? I’d say a resounding YES! I’m going to identify three areas that show we’ve moved forward in our understanding, while also discussing points of confusion.

BPD Is Not a Pure Diagnosis but a Complex One

Many individuals still view BPD as the central cause of all the maladaptive beliefs, behaviors, and patterns seen in those with this full disorder or traits. The reality is that most individuals with BPD have comorbid conditions, and this combination creates a complex form of BPD that I call Complex BPD (CBPD). CBPD is estimated to account for 85 to 97 percent of all BPD cases. Knowing that such a high percentage of co-occurring issues exist will increase the awareness that cause and treatment needs to be taken into account when examining one’s life, behavior, perceptions, and consequences.

For example, major depressive disorder (MDD) has been found to occur in 83 percent of individual with BPD. Those individuals with CBPD that is made up of MDD and BPD need to be seen and treated in a very different way, as opposed to when these disorders occur alone. In the CBPD case, the MDD symptoms are likely driven by BPD content. This means that medication and cognitive-behavioral techniques that are directly targeted to depressive symptoms are going to have a diminished impact. However, interventions that focus on the underlying component, BPD, which drives the depressive symptoms, is likely to remit both BPD and MDD symptomatology. You have to know what you’re dealing with to deal with it effectively.

BPD and Other Personality Disorders Need to Be Understood Differently

Personality disorders are not made up of a single construct, but a dual construct. This means that there are two levels to consider when a personality disorder is present: core and surface content. Core content is made up of the internal parts of yourself that represent how you feel and think about yourself, others, and your world. Commonly identified core content in individuals with BPD includes abandonment and emptiness. Surface content often seen in those with BPD includes impulse control and substance abuse. These two constructs need to be explored and identified to achieve long-term change in individuals with BPD or others personality disorders.

For example, Betty has been diagnosed with BPD. She has a history of substance abuse and anger issues (surface content). In session, when Betty is asked about what drove her to use drugs and what activates her anger, she’ll tell you it’s because her partner did not respond to her texts, he is cheating on her (she has no evidence but she feels it so intensely), and it’s just a matter of time until he leaves her and she’s alone forever—leaving her as a “true spinster”. You’ll notice that the underlying issues are fear of abandonment and emptiness (core content). Betty engages in her surface content (drugs and anger) to manage her core content. When her core content is explored, she builds insight into it, and she is receptive and willing to learn and utilize more adaptive strategies such as mindfulness or freeze-consider-reengage, which gives her a greater sense of control. By only addressing her surface content, as many mental providers tend to do, she doesn’t develop the same level of insight and has greater difficulty managing her anger and drug use. The dual construct approach is critical, and knowing your core and surface content is a huge step in the direction of mastering self-control.

Not Knowing That BPD Is a Good Prognosis Diagnosis

BPD can be successfully treated and has a good prognosis. To attain therapeutic success, the mental health provider you’re working with needs to know this, but should also have experience in treating those with BPD, understanding the complexity of the diagnosis, and maintaining an open-minded perspective of the treatment course. Experience is a central component to achieve your therapeutic goals. Therapy is unlikely to be a linear process, such as only successes and no regressions. There will be periods of symptom remissions; times when symptoms lessen and the individual functions well. The antithesis is also likely to occur—resurgence of symptoms—and this is where the impact of experience is most powerful. The experienced clinician knows that these ebbs and flows occur and helps you manage them effectively, as opposed to feeling disheartened. The experienced clinician understands that the road is long and can be quite challenging, but the prognosis is a good one, and you need encouragement to hold on to hope for your success because it can be achieved.

Deepening your level of understanding and feeling empowered to confront your challenges along the way are invaluable resources you will need to keep going as you progress through treatment. You and your therapist need to know to look for themes and core content activations to build insight into your beliefs, behaviors, and patterns. You and your therapist need to align to peel back the armor of pathology and maladaptive surface content to block it and change it. This approach provides you and your therapist with the flexibility to change course when necessary; explore treatment goals that need to be fluid and not dogmatic; and to hold a steadfast, encouraging approach. Dealing with BPD has often left you feeling derided, rejected, and overwhelmed by a whole host of emotions and life experiences that have strengthened your pathology. Some of these may have been from past mental health providers. But the provider who knows the prognosis and embraces it, can help you rise to the challenge and empower you to learn and grow beyond your BPD.

What do you think makes BPD difficult to understand? What challenges and successes have you had that encouraged your growth, whether you’re a provider or patient. Remember, knowledge is power, and power is control, and control leads to choice—of not only where you go in life, but how you get there.

Daniel J. Fox, PhD, is a licensed psychologist in Texas, international speaker, and award-winning author. He has been specializing in the treatment and assessment of individuals with personality disorders for more than twenty years, and is author of several books, including The Borderline Personality Disorder Workbook.