Source: Andrea Piacquido/Pixabay

Self-destruction, rage reactions, push–pull interactive style, "manipulative." Tends to be female.

That about sums up borderline personality disorder (BPD), right?

From a popular viewpoint, sure. In reality, however, jumping to BPD conclusions based on a couple of signs, especially if it's a "difficult woman," is premature. To be clear, BPD as a feminine diagnosis is a relic. The gender gap seems much less than once thought (e.g., Sansone & Sansone, 2011; Bayes & Parker, 2017).

First, as noted in "A Symptom Is Part of a Pattern," concluding any diagnosis based on one chief symptom is poor practice. Symptoms must be contextualized and observed within a pattern, and that pattern must be sustained. Second, although the traits/characteristics in the first sentence are perhaps the most dramatic and seem to clinch the diagnosis, those working with BPD know there's more to it, including the following:

1. Dissociation: Those with BPD usually have histories of significant trauma(s), so it should be no surprise that dissociation occurs. In fact, Krause-Utz et al. (2021) noted it is present in about 80 percent of cases to varying degrees. However, it's not just flashbacks like in posttraumatic stress disorder (PTSD). BPD dissociation is not unusually a way for the BPD sufferer to distance themselves from overwhelmingly strong emotions they regularly experience. Thus, it may be more of a derealization or depersonalization state. Korzekwa et al. (2009) reported that the latter was the most common BPD dissociation in their research.

It's been my experience that dissociation is a marked risk factor, as it can lead to self-injury in an effort to leave the dissociative state. More than one patient has said they cut or burned themselves "to feel something." Therefore, at the very least, clinicians ideally will regularly assess for dissociation to develop more constructive management.

2. Psychotic experiences: Despite the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) only mentioning "transient, stress-related paranoia," for psychotic symptoms, D'Agostino et al. (2019) noted that paranoia and hallucinations are "relatively common" in BPD. Further, Cavelti et al. (2019) tell us that auditory hallucinations of a critical type seem the most common such symptom. Further, they are correlated to poorer outcomes, especially suicidal activity. Cavelti also mentioned that hallucinations can be a regular occurrence that providers may feel are falsely reported. In my experience, given the "manipulative" lens through which BPD is viewed, providers are quick to dismiss such symptoms as part of attention-getting. As for paranoia, for my patients over the years, it always seemed correlated to an acute rejection fear. Consider the case of Alan (name disguised):

Alan attended his girlfriend's work party. She introduced him to a new male co-worker that she spent more time talking to than others. Being hypersensitive to any potential signs of abandonment, Alan became convinced she invited him to the party to introduce him to this colleague, whom she surely is involved with, to hurt him and push him away. Feeling he must catch her in the act, the next day, Alan surveilled her office parking lot, and saw his girlfriend exit the complex with the new colleague. Enraged, Alan confronted them, prompting security involvement, accruing a charge of disturbing the peace, and, ultimately, his referral for therapy.

Considering the research on the prevalence of legitimate psychotic symptoms in BPD, clinicians would be wise to take reports of hallucinations and apparent paranoia at face value and not assume it is part of "manipulation." This is not simply to manage liability. Rather, their hallucinatory activity is most likely driven by their own self-image. The paranoia is a classic example of projecting one's internal conflict, in this case how acceptable they are, outwardly as a defense. For more about projection, readers are invited to see Nancy McWilliam's Psychoanalytic Diagnosis (2013). Thus, clinicians gain insight into the internal landscape of the BPD individual from their psychotic experiences and what directions therapy must take.

 

Source: Lisa/Pexels

3. Unstable sense of identity: Of all the BPD symptoms people tend to notice, fragmented identity, despite its being a frequent feature (APA, 2022), seems to be the least recognized. Anyone working with BPD has met more than one patient who, upon entering into a new romantic relationship, chameleonizes to that individual. I've noticed over the years that this serves two purposes. First, it seems like built-in abandonment control. If the BPD individual "speaks the same language" as their new partner, how could they be denied? Second, it can hold the promise of a sense of identity other than "victim." It's an identity cycle that repeatedly occurs, like in the case of Brandi (name disguised):

Brandi had many shifts in her identities over the years in therapy. Earlier on, she dated a religious man, and immediately began attending church, wearing religious symbols, and volunteering to teach bible school. This, from a woman who, in her 30s, had only been to church for the occasional wedding. After a few months, she showed sexual advances, but was, not surprising given the beau's piousness, denied. Reeling with rejection, Brandi denounced religion as a scam and said, "He just wanted to recruit me."

In short order, Brandi met a folksy guitarist who wore hippie garb, dropped acid, and dreamt of a record deal. Sure enough, Brandi's hair was soon in braids, she wore bell-bottoms, and she said acid really generated thoughtful lyrics. They were writing music together, and he was teaching her guitar.

Eventualy, Brandi learned that it's more effective to bring her uniqeness to a relationship— her humor, creativity, and intellectual side, than simply sex and mirroring another. She so desperately wanted to identify with others, she assumed they operated similarly, and sacrificed her individuality in the name of abandonment insurance.

Finally, readers may find Kiera Van Gelder's autobiography, The Buddha and the Borderline (2010) an entertaining, though poignant, account of BPD from the inside-out, including this matter of identity conflicts.

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Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.