Supporting Someone With Borderline Personality Disorder
Of the different diagnoses that exist in mental health, Borderline Personality Disorder, often simply called ‘BPD’ is one of the most heavily stigmatised of all. As a clinical psychologist, I have heard numerous times about the unexpected significant challenges individuals and their family members have encountered when attempting to access professional treatment and support due to frequent experiences of discrimination and stigma. These reports are often mirrored in the academic literature (Klein et al., 2022; Stiles et al., 2023), along with suggestions that this may originate from fear of mistreatment claims, unhelpful beliefs that the disorder is untreatable, and damaging reputations for intimidating or hostile interactions, commonly leading clinicians to prefer avoiding people with the diagnosis (Black et al., 2011; Gunderson et al., 2018). As a consequence, parents, family members, and friends often play a key role in providing emotional and practical support. The following article is aimed towards these people who are possibly hearing about Borderline Personality Disorder for the first time so that they can to increase their knowledge and feel better equipped to fulfil this role. This article will review some background information about Borderline Personality Disorder and personality disorders, discuss symptoms and diagnosis, how this can affect provision of support, and tips on ways of supporting a loved one (and yourself) through the treatment process.
Before we jump in, I encourage the reader to ensure that they have sufficient internal resources to engage with this content before beginning, as parts of it may feel distressing or confronting depending on where you’re at. Many family members only first hear about Borderline Personality Disorder after a loved one has recently received a diagnosis following a crisis event. So if you’re low on energy or feeling vulnerable, I encourage you to take the time to maintain your own well-being.
Understanding Borderline Personality Disorder
Borderline Personality Disorder also known as ‘Emotionally Unstable Personality Disorder’ in some diagnostic frameworks (WHO, 1992; NCCMH, 2009), is a mental health condition characterised by long-term patterns of strong or unpredictable emotional reactions, marked impulsivity, unstable or intense interpersonal relationships, a distorted sense of self, and fear of real or perceived abandonment or rejection from others (Chapman, 2019; APA, 2013; NIMH, 2022). People diagnosed with Borderline Personality Disorder often display frequent mood swings, difficulties being alone, abrupt emotional outbursts, and repeated crises including urges, acts, or threats of self-injury or suicide. A tendency to experience hypersensitivity to perceived criticism, including from misinterpreting nonverbal expressions or tone, and rapidly alternating shifts in extreme thinking, where something or someone is judged as either ‘all good’ or ‘all bad’, are also common (Matusiewicz et al., 2010; Niedtfeld, 2017; NIMH, 2022). Additional symptoms of transient paranoid ideation or dissociative symptoms can also be linked to periods of high stress (Leichsenring et al., 2024), however, people with the diagnosis may not struggle with all of these possible features as each person’s experience of the disorder is unique. This generates a diverse range of clinical presentations with symptoms that can overlap with many other mental health conditions (Luyten et al., 2020; Cavelti et al., 2021).
When two or more distinct conditions occur simultaneously these are referred to as comorbidities, and can mask, obscure, and complicate diagnosis and treatment (APA, 2013). For example, although Borderline Personality Disorder is commonly confused with the more popularly known Bipolar Disorder, due to shared traits such as mood instability, the two are distinct (Black et al., 2011). In Borderline Personality Disorder, emotional changes tend to occur more rapidly, within minutes to hours, and are often brought on by relationship conflicts and stress. In Bipolar Disorder, mood episodes are typically longer-lasting, occurring over days to weeks, with periods of depression, hypomania, or mania and are not as strongly influenced by immediate external triggers (APA, 2013; Gunderson et al., 2018). That being said, it is possible for an individual to receive a diagnosis for both.
Due to shared risk factors, such as neurobiological vulnerabilities or adverse childhood experiences including trauma, abuse, or neglect (Weiner et al., 2019; Porter et al., 2020), Borderline Personality Disorder has high comorbidity rates with a range of other conditions. Comorbidities are widely ranging and may commonly include Major Depressive Disorder, anxiety disorders, Attention-Deficit/Hypertension Disorder (ADHD), Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Substance Use Disorder, eating disorders, Body Dysmorphic Disorder, somatoform disorders, dissociative disorders, and other personality disorders (Zanarini et al., 1998; Grant et al., 2008; Semiz et al., 2008; Fornaro et al., 2016; Schmaling & Fales, 2018; Weiner et al., 2019; Leichsenring et al., 2024). These comorbidities may also require their own targeted treatment interventions, though sometimes the treatment of Borderline Personality Disorder should remain the priority focus (Gunderson & Links, 2014; Gunderson et al., 2018; Choi-Kain & Sharp, 2021).
The recommended first-line of treatment and management for Borderline Personality Disorder is psychotherapy or talk based therapies, with medication typically seen as a common accompanying treatment approach for severe symptoms, discrete comorbidities, or short-term management of crises (NIMH, 2022; Leichsenring et al., 2024). Dialectical Behaviour Therapy (DBT) is the psychotherapy treatment most regularly associated with interventions for Borderline Personality Disorder, however Mentalisation-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), and Schema Therapy (ST) are also empirically supported as effective (Leichsenring et al., 2024). Good Psychiatric Management (GPM) also has solid evidence for its effectiveness in treating Borderline Personality Disorder, including in adolescents displaying subthreshold symptoms where early intervention can be particularly beneficial (Gunderson & Links, 2014; Gunderson et al., 2018; Choi-Kain & Sharp, 2021). Group therapies, such as typically found in Dialectical Behaviour Therapy and Mentalisation-Based Therapy, can provide additional benefits via the social learning processes, though can be resisted at first for a variety of reasons such as general discomfort, anxiety, fear of judgement, or perception of insignificance (Jørgensen et al., 2013; Linehan et al., 2015; Gunderson et al., 2018; Yalom & Leszcz, 2020). Research suggests that with formal treatment many individuals improve, with approximations of 50-60% achieving symptom remission within 10 years (Zanarini et al., 2010a, 2010b). Maintaining physical health, reintegration into school, and stable engagement in structured vocational or extracurricular activities are also critical factors supporting treatment and recovery (Zanarini et al., 2010a; Keuroghlian et al., 2013; Hengartner et al., 2014; Gunderson & Links, 2014; Gunderson et al., 2018; Choi-Kain & Sharp, 2021), as is consistent access to social or family support, to help stabilise recovery.
The emotional sensitivity, intensity, and duration that people with BPD experience can be confusing for everyone and often leads to ‘traumatic invalidation’.
What Does A Personality Disorder Diagnosis Mean?
Our personalities incorporate the enduring behavioural and mental traits, including the thinking patterns and thoughts, actions, and emotions or inner experiences that we all embody, which collectively make each of us unique (Smith & Segal, 2021). Personality Disorders are a class of mental disorders which are characterised by maladaptive patterns observed in these traits. These maladaptive patterns are pervasive, long-standing, enduring, and observable across multiple different contexts. For a person diagnosed with a personality disorder, the deviation of these traits is significantly beyond that which is typically accepted by the individual’s culture and leads to significant distress or impairment. To be cautious and try to rule out other possible explanations, these maladaptive patterns also cannot be better explained by another mental disorder, substances, or medical condition (APA, 2013), which means receiving a diagnosis can take time or the diagnosis might change or evolve over time. This then more confidently identifies that patterns in how this person relates to other people, themselves, or the world more broadly is distinguished as significantly different from their cultural norm and it causes negative outcomes which are likely to decrease quality of life without treatment.
Essentially, a personality disorder diagnosis indicates that a person may not act in ways that would typically be expected by most other people and it causes trouble (Smith & Segal, 2021). As a consequence, this can result in a wide range of difficulties.
Socially, individuals might struggle to sustain stable relationships as a result of frequent misunderstandings or conflict due to suspicious, detached, eccentric, self-serving, unstable, dramatic, arrogant, fearful, clingy, rigid, or otherwise inappropriate social behaviours (APA, 2013). This can pose a significant barrier to integrating with society and increase feelings of loneliness, sadness, anxiety, frustration, shame, hopelessness, and helplessness.
Occupationally, there may be issues with lower educational attainment, inconsistent performance, frequent job changes, and difficulty working or collaborating with others. These workplace problems may develop from the social issues listed above or other problems arising in independent decision-making, emotional reactivity, or absenteeism which also gives rise to workplace conflicts, disputes, demotion, and dismissal (Skodol et al., 2005; Zanarini et al., 2010a; Hengartner et al., 2014).
Internally, a fragile self-esteem or immature sense of identity can readily produce chronic feelings of emptiness, dissatisfaction, and hypercritical interpretations which undermine or prevent establishing personal goals due to uncertainty, lack of motivation, mistrust, or fear. This often further contributes to emotional dysregulation and inappropriate or rigid reactions to stress due to instability and inconsistency, especially when this is critically appraised by others which can heighten awareness of dissimilarities and reinforce a negative self-concept.
These difficulties can significantly impact overall quality of life and increase vulnerability to other mental health problems, but there is good evidence for the ability to learn how to cope more effectively. Diagnosis with a specific personality disorder, such as Borderline Personality Disorder, then helps to define the types of challenges an individual tends to or could experience most often, so that evidence-based treatment options can be more easily identified, recommended, and accessed.
Diagnosis of a personality disorder is not a judgement.
Diagnosis of BPD
Borderline Personality Disorder is typically diagnosed during early adulthood by clinical psychologists or psychiatrists, though can be diagnosed in those under 18 years of age. This may be precipitated by adverse life experiences, such as relationship breakdown, job loss, or experiences of abuse or trauma (Gunderson et al., 2018).
People with Borderline Personality Disorder are approximately 14x more likely to report childhood adversity than non-clinical controls, which is approximately 3x more likely than other psychiatric groups (Porter et al., 2020). In some people, repeated stressors in late adolescence that might not impact others or even be considered as ‘normal’ are also identified as contributing factors for developing Borderline Personality Disorder (APA, 2013; NIMH, 2022). This potentially highlights the importance of understanding the underlying influence of inherited temperamental factors and socioemotional hypersensitivity (Gunderson et al., 2018).
In clinical settings Borderline Personality Disorder is more frequently diagnosed in women than men, at around a 3:1 ratio, despite suggestions of similar prevalence rates across genders in the community (Grant et al., 2008; Bayes & Parker, 2017; Gunderson et al., 2018). This imbalance has been attributed to differences in symptom internalisation versus externalisation, social stigma increasing help-seeking reluctance, and biases in clinician interpretation of symptoms (Skodol & Bender, 2003; Bayes & Parker, 2017; Cavelti et al., 2021; Qian et al., 2022).
The impacts and impairments from the disorder, including risk of self-injury and suicide, tend to be greatest during the younger adult years. Though these risks typically gradually decrease with age, tendencies for affective dysregulation, behavioural dyscontrol, and disturbed interpersonal relatedness are often lifelong (Skodol et al., 2002; Zanarini et al., 2010b; APA, 2013; Hawkins et al., 2014).
Individual presentations vary considerably, but the key symptoms of BPD are:
Frantic efforts to avoid real or imagined abandonment (Not including Criterion 5).
A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation, also known as 'splitting'.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., over-spending, unsafe or risky sex, substance abuse, reckless driving, binge eating; Not including Criterion 5).
Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms (e.g., feeling cut off from oneself, observing oneself from outside one’s body, or feelings of unreality; APA, 2013).
Five Areas of Dysregulation
One approach to understanding the complex symptoms of Borderline Personality Disorder is through the framework of Marsha Linehan (2018), a key researcher and clinician, who identifies Five Areas of Dysregulation that characterise the challenges Borderline Personality Disorder can present.
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Where the range of emotions experienced are often highly reactive and rapidly presenting, with alternating brief mood episodes that can occur within minutes or hours of each other. These can be difficult to manage or regulate and are often experienced as overwhelming (e.g., “I’m losing my mind”, “I’m out of control”, “there’s something wrong with me, I’m broken”). While these situations can extend to all emotions, certain emotions tend to be more frequent and persistent, such as irritability, anger, loneliness, fear, sadness, despair, and uncertainty.
An example of this might be feeling an overwhelming flood of anger when a friend cancels plans which rapidly shifts into feeling distraught within minutes due to a deep sense of abandonment which is attributed to being defective, before progressing into uncontrollable crying for the rest of the day.
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The ability to think clearly and the quality of thoughts can be significantly impacted when under stress or while experiencing heightened emotions, even without the presence of evidence to support these thoughts. This can extend into significant cognitive distortions and extremes in thoughts or judgement, including episodes of paranoid thinking (e.g., “they actually hate me and are out to get me”, “they’re cheating on me”, “they want to leave me”), and dissociative experiences where events are not remembered or experienced clearly.
An example of this might be someone feeling so overwhelmed by stress and anxiety when a partner is trying to set a reasonable boundary them that they dissociate and their brain doesn’t process or store information from the interaction properly. Later on, they misremember and misbelieve that their partner is really mad at them and blamed, insulted, and hates them.
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These can include a wide range of impulsive, extreme, dangerous, or destructive behaviours. One way of conceptualising these behaviours is that they are often an individual’s dysfunctional attempts to cope with emotional distress by shifting their attention away from activating emotional content (Reitz et al., 2015). This is thought to possibly operate though the behaviour reducing inner tension via distraction, displacement, self-stimulation, self-soothing, and/or self-medication. Behaviours may include deliberate self-harming and suicidal behaviours, disordered eating, substance use, risky sexual behaviours, and a wide range of potentially damaging risk-taking.
An example of this could be self-soothing by binge eating after a stressful day at work, but then engaging in self-harm as a punishment due to feeling so guilty and angry at themself about this. This may then become a decompensating repeated cycle or ‘downward spiral’.
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Also known as Social Dysregulation, this frequently relates to difficulties sustaining meaningful relationships over time due to fear of, real or imagined, abandonment from others. This often results in feelings of anxiety and rapidly switching between extremes of idealisation and devaluation of another person (e.g., “I hate you, you make me sick! Don’t you dare leave me!”, “ I love you more than anything! You disgust me for staying!”). It can also contribute to behaviours desperately attempting to prevent separation or relational distance, including by overpromising change, rapidly developing new intense and chaotic relationships, engaging in interactions which can feel emotionally manipulative or threatening, by self-sabotaging otherwise positive relationships, or not recognising or dismissing abusive behaviours in self or others.
An example of this could be a new partner that is idealised as being “absolutely perfect and the love of my life, who I couldn’t live without”, but when they have to go away for work or there is a disagreement, “they clearly don’t care about me and are probably already cheating on me because they haven’t messaged me back”, so the only solution is to break-up and show them how much they hurt me.
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Also referred to as Identity Dysregulation, this relates to significant difficulties or distress understanding ‘who I am’ and can contribute to a fractured or unstable sense of self. This tends to be pronounced in younger people, possibly because it exacerbates identify confusion commonly experienced as a younger person. It often overlaps with feelings of emptiness inside (e.g., feeling hollow, disconnected, alone, misunderstood, different) and struggling with defining or delineating self from others. This can increase vulnerability to things like peer pressure, imitation of others or social media, coercion, manipulation, subjugation, and people-pleasing. Outcomes from this can frequently include feeling self-disgust, envy, fake, unsatisfied, ambivalent, lost, and like an outsider or imposter.
An example could be a person that never feels certain about what they want to do for a career, so copies someone else’s values and goals, but soon changes their mind and quits their job or study because it isn’t fulfilling and does not genuinely interest them. Afterwards they feel distressed because they don’t know what they should be doing or what they like themselves, so feel overwhelmed and paralysed, before repeating this pattern.
Supporting The Team
Marsha Linehan (2018), the creator of Dialectical Behaviour Therapy which is typically the most common treatment approach for Borderline Personality Disorder, identifies that people with Borderline Personality Disorder can be exceptionally enthusiastic, idealistic, joyful, and loving, while also becoming overwhelmed by uncomfortable or negative emotions. People with Borderline Personality Disorder can experience these negative emotions as ‘coming out of nowhere’ and ‘going from zero to one hundred’ in moments, often leaving themselves and others feeling physically and emotionally exhausted. Like they have been stuck riding an emotional rollercoaster with no way off. As a family member or caregiver supporting someone with a Borderline Personality Disorder diagnosis, these intense emotional changes can be incredibly stressful, concerning, and scary to observe. People will often describe this as feeling like they are “constantly walking on eggshells” around each other.
Emotional dysregulation and fatigue further increase peoples’ vulnerability to acting impulsively or saying or doing hurtful things without thinking. The actions taken are commonly ineffective attempts to have needs met, influenced by emotional urges related to sadness, frustration, anger, anxiety, worry, and jealousy. This can result in a wide range of problems, such as invalidation, withdrawal, avoidance, punitiveness, aggression, excessive reassurance seeking, clinginess, and premature ending of relationships.
It’s important to remember that these actions are not just limited to an individual with a diagnosis, but to all people. They are also possible to see in the people trying to provide support, especially when they are also feeling run down, depleted, or burnt out themselves. It’s easy to understand not only how this can occur, but also the guilt or regret that might accompany it. This is part of what makes us all human and why it is critical for supporters to attend to their own self-care as well, because while the urge to be present to provide social or family support can be overwhelming, so can the stress of this.
Remember, you can’t pour from an empty cup.
What is Self-Care?
Self-care can look different for everybody, but refers to intentional actions taken to improve or maintain physical, mental, and emotional well-being (Virtue et a., 2012; Norcross & Guy, 2018; Posluns & Gall, 2020). I recommend including actions from more than one domain, such as physical (e.g., getting good quality sleep, nutrition, exercise), emotional (e.g., attending therapy, journaling, practising acceptance or self-compassion), psychological (e.g., setting boundaries, practising mindfulness, learning new things), social (e.g., regularly connecting with and nurturing relationships), and spiritual practices (e.g., engaging with personal values or beliefs, practising religion). Simple things like maintaining your own hobbies and interests, catching up with a mate at the gym, spending time outside in nature or with pets, and allocating time for relaxation and play are also fundamental not to overlook.
Self-care may also extend to accessing your own formal supportive counselling or therapy to be able to provide a space for processing difficult emotions or experiences, and talking through your own challenges without fear of judgement or upsetting the other person. You may wish to consult a mental health care professional, like at Kelly Brooks Psychology, or talk to your local GP for more options about this. This type of formal support can help with learning and practising many different ways of protecting your own mental health while supporting others with theirs.
Helping Support Someone Diagnosed With BPD
Learn about the disorder and how it uniquely affects the other person to gain a better understanding of what they are experiencing. Everyone’s experiences and challenges are different.
Offer emotional support by providing validation, patience, encouragement, attempts to understand, and importantly hope, as change is expected, though can be difficult and confronting at the same time.
Practise listening to and validating the other person’s experience by acknowledging their thoughts and feelings without judgement, then seeking to understand how their perspective makes sense to them, even if you don’t agree or personally think/feel the same way. This is arguably one of the most important skills to learn and use.
While validating emotions, foster accountability by highlighting responsibility for actions and non-judgementally helping to see what can be learnt from mistakes. The focus here is not on blaming, but systematically identifying ways of working through difficulties and barriers to be better able to improve responses to life’s challenges.
Encourage seeking out and sticking with a formal psychotherapy treatment option, such as Dialectical Behaviour Therapy or Schema Therapy, as well as attendance of all appointments and completing skills practise or therapy homework tasks to reinforce taking an active role in their own treatment.
If appropriate, invite discussion to share information, skills, or strategies being learnt in therapy so that these can be reinforced in the home environment and everyone is on the same page.
Learn effective ways to communicate and manage your own distress so that you can increase your ability to function under pressure and model these behaviours by being containing rather than overly emotional or activating.
Try separating the person’s thoughts and feelings from their behaviours so that you can try to understand things like their emotional distress or paranoid thinking as representations of the disorder rather than of them, to reduce the likelihood of getting stuck in a reactive cycle.
Validate yourself that it can feel extremely unfair if accused of something and that it is natural to be defensive, while remembering that being nonreactive in the moment and practising effective communication outside of these emotionally charged moments is most likely going to be much more effective in the long-term.
Set clear boundaries around what is and is not acceptable behaviour and the limits of your responsibility, including for maintaining personal safety. With compassion, be as consistent as you can. If functioning within a partnership, such as two parents supporting a young adult child, uniformity in this consistency and developing strategies everyone can stick to is important to reduce potential division and family conflict.
Provide reinforcement for positive behaviours with acknowledgement of progression (e.g., “I can see that you’re really trying”) and encouragement for continued responsibility for change and self-care. Be mindful not to draw excessive attention to this as it can feel like a pressuring expectation that everything is resolved now.
Try to keep things cool and calm in the home environment while maintaining family routines as much as possible including spending time with extended family and friends, and finding time to talk about everything outside of the diagnosis as well (i.e., including about light-hearted, neutral, and typical age appropriate issues) so life doesn’t just become about appointments and mental health.
Consider developing an agreed upon action or Safety Plan for managing crisis situations to help maintain everyone’s safety, such as with Beyond Now. If there are self-destructive acts or threats, don’t ignore them or keep secrets. Talk respectfully and openly about these and encourage that it’s better to use words to express negative feelings and needs rather than act out on short-term feelings.
Prioritise practising your own self-care and explain the benefit of this for everyone in the long-term while internally preparing for possible abandonment reactions (e.g., “I’m not going anywhere, I just need to get to sleep on time otherwise I get really worn out. Let’s talk again tomorrow.”).
Always maintain a respectful attitude towards the other person, avoiding ultimatums or threats, and let them know that you genuinely value and care about them.
Remember that the other person is not just a diagnostic label, they are another human being. To support this and enhance resilience, it is critical to have life goals beyond therapy. Support identification of values and setting attainable goals that are approached one at a time for the life the person wants to build.
Have You Considered Your Own Supports?
Supporting or caring for a loved one diagnosed with Borderline Personality Disorder can be extremely stressful, and in doing so, caring for the carer is often forgotten about as a priority, especially in emotionally traumatic emergency situations. As we’ve briefly covered, Borderline Personality Disorder can be an extremely challenging diagnosis beyond the reasons inherent in the disorder and caring for yourself is an important part of being able to support those around us. If someone you know is struggling with managing Borderline Personality Disorder and this is having an effect on you, it could be important to consider reaching out for your own professional support. Talking to a psychologist or therapist can be a great first step and working individually with a clinical psychologist could help you learn how to better validate, co-regulate intense emotions, navigate setting appropriate boundaries, increase effective communication, and model adaptive behaviours to manage stress.
It can feel daunting or overwhelming at times, but with the right understanding and tools, it is possible to build stronger, more connected, and supportive relationships. This article offers general practical information and guidance for family members, friends, and carers who want to better understand the diagnosis of Borderline Personality Disorder based on current psychological research and accepted evidence-based therapeutic approaches. Whether you are located in Brisbane or accessing telehealth psychology services, Kelly Brooks Psychology offers professional, compassionate support. If you feel like you could benefit from increasing your psychological skillset, I invite you to reach out today to book an appointment.
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