Borderline Personality: Whims of Mood and Temper

Among patients with various personality disorders, borderline personality disorder (BPD) is currently the most studied, because this personality disorder has the greatest impact on a person's life. The suicide rate among people with borderline personality is 400 times that of the general population. Among all psychiatric illnesses, BPD ranks first in suicide rate: about 10% of adults with BPD attempt suicide; about 33% of young people who commit suicide have BPD; and about 20% of psychiatric inpatients have BPD (a higher proportion than major depressive disorder).

Patients with BPD have the following major features: 1. intense fear of abandonment, both real and imagined; 2. a relationship history too painful to recall, often involving extreme behaviors and attitudes; 3. an absent or unstable self; 4. two or more impulsive and self-destructive behaviors (such as substance abuse, self-injury, eating disorders, promiscuity, reckless driving, etc.); 5. high suicidal risk; 6. emotional instability, irritability, and overly intense and frequent emotional reactions; 7. persistent feelings of emptiness; 8. intense, uncontrollable anger; 9. persistent feelings of alienation.

The causes of BPD include both genetic factors and postnatal environmental factors. In 60% of patients with BPD, other family members have either BPD or narcissistic personality disorder. People with BPD are usually innately more sensitive than average; they react keenly to the outside world—but most of the time their reaction far exceeds normal intensity. Their perception of facts that threaten them is divorced from reality, exaggerating danger manyfold, which leaves them in a constant state of alarm.

Many people with BPD have a childhood history of abuse, abandonment, or emotional neglect: they may have been given up for adoption, abused by a close person, sexually abused, or raised in a detached or overindulgent way. Their parents are usually emotionally unstable, with a poor family environment; the parents may be divorced, constantly quarreling, or one parent may fly into rages and shout at home.

The basic model of a person with BPD is an abused infant placed in a world full of ill will. The patient's mental development is arrested, and the personality splits into multiple facets. During episodes, their mind functions like that of a two- to four-year-old infant. Most of the time, people with BPD are like an unattended two- to four-year-old: they feel all kinds of intense emotions, but no one soothes them.

So they are constantly in states of anxiety, depression, and fear, and they express their needs through angry behavior, just like a two- to four-year-old. Some people with BPD are hypercritical of those close to them, frequently flying into rages. Others turn the aggression inward, relieving their distress through self-harm, binge eating, reckless driving, addictive behaviors, promiscuity, or suicide. But this relief usually brings only short-lived comfort; they soon fall back into emptiness and worthlessness.

At the same time, when in a normal state, people with BPD are extraordinarily kind to those around them. They keenly perceive others' needs and enjoy meeting them, which gives them a brief taste of their own value. So in the eyes of family, friends, or partners, these patients are normally as lovely as angels. But this goodness is usually unsustainable. Once a detail pulls the trigger of someone with BPD, they immediately switch to another mode, loathing those close to them and even using the harshest words to belittle and ridicule them.

If you look closely, the trigger events are usually those that make the person with BPD feel they are in danger of being negated, abandoned, blamed, or judged. Because at the age when caregivers most needed to affirm them and nourish them with love (ages two to four), people with BPD lacked proper care and even suffered physical and emotional abuse, they have lifelong difficulty acknowledging and accepting themselves.

Accordingly, they also have difficulty truly accepting and acknowledging others, and they struggle with intimate and parent-child relationships. They often shout at, blame, and belittle the people who love them. On the surface it looks as though they are driving these loved ones away, but in fact they react this way precisely because they fear that loved ones will leave them. If the loved one actually leaves because of these behaviors, they may escalate their threats to self-harm and suicide.

If the loved one understands their psychology and, at such moments, clearly affirms their feelings and says they will not leave, the person with BPD will gradually calm down on their own. Conversely, if those around them are also agitated and argue right and wrong with the person with BPD, the emotional intensity easily escalates.

In fact, these are behaviors that people with BPD themselves desperately want to avoid; they fear these behaviors in themselves more than anyone else. But their brain is completely beyond their control. Once hijacked by the infant within, they become like a different person. Their perception of others is split; how they see someone depends entirely on their current mood. If their mood is pleasant, they think the person beside them is the best. If their mood is painful, they think that same person is terrible.

They see people in black-and-white terms. Their expectations of lovers or therapists are unrealistic; the standards their ideal lover or therapist must meet are extremely high, and such a person is almost impossible to find in reality. This is also why people with BPD are known as "therapist killers." Once they notice a flaw in their lover, relative, friend, or therapist that they cannot accept, their impression changes drastically; they no longer see that person as their ideal savior but come to loathe them, openly expressing their anger and disgust and wounding them with sharp, bitter words.

So the love affairs and marriages of people with BPD mostly end in failure. They are also patients with very low adherence; during treatment they have difficulty trusting the therapist and frequently drop out (a professional term in psychotherapy meaning a patient stops seeing the therapist treating them). This further worsens their feeling of being traumatized and makes their imagined abandonment repeatedly come true.

More than half of patients with BPD cannot work normally and must be supported by family or partners, but these patients often come across as ungrateful. They attack their family or partners without restraint, finally driving them away too—although this is exactly what they fear most, they cannot control themselves from bringing it about.

If we have such a patient in the family, we must love, tolerate, and accept them with great patience. A person who is emotionally stable, secure, and highly understanding can help a relative with BPD stabilize. But to rescue the person with BPD, long-term professional treatment is needed. Usually this takes over a year; most patients need four to six years, and some need lifelong treatment.

The treatments currently proven effective for BPD mainly include dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), and schema therapy; the three combined give the best results. Schema therapy has the lowest dropout rate and is easiest for patients to accept and sustain. But there are not many psychiatrists who can diagnose and treat these patients; most doctors lack a basic understanding of BPD. So patients and their families must actively study the relevant knowledge to help the patient recover.

At the same time, family members should fully understand and sympathize with the patient. All the patient's harmful behaviors are ones they themselves desperately want to control but cannot. During episodes, they are in fact hijacked by their childhood self, which is why some describe these patients as "an infant wrapped in an adult's shell." Repeated trauma in relationships worsens the condition, but it can also spark the patient's will to save themselves.

Intimate relationships are both the poison and the antidote for patients with BPD. When the most important relationship in their life is threatened, some patients can recognize their own problems and resolve to correct them. From then on they embark on the path of self-healing. Although, because of their illness, progress on that path may be slow, they have real hope of recovery.

Symptoms of BPD usually first appear in early adulthood. At this stage, friendships and romances often do not last, but the person is not yet in particular pain. As life pressures mount and relationship breakdowns recur, their suffering deepens. They begin to realize they need treatment and rehabilitation, which is why the symptoms of some patients who receive treatment after age forty ease markedly.

The following books may be useful for patients with BPD and their families:

Stop Walking on Eggshells (Randi Kreger); The Stop Walking on Eggshells Workbook (Paul T. Mason); The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD (Alexander L. Chapman, Ph.D. & Kim L. Gratz, Ph.D.); Dialectical Behavior Therapy (Matthew McKay et al.); I Hate You—Don't Leave Me: Understanding the Borderline Personality (Hal Straus and Jerold J. Kreisman, Chinese title by Sally Manning); Borderline Personality Disorder: An Acceptance and Commitment Therapy-Based Guide to Recovering from Emotion Dysregulation (Patricia E. Zurita Ona); Schema Therapy: A Practitioner's Guide (Jeffrey E. Young et al.); Cognitive Therapy of Personality Disorders (Aaron T. Beck et al.).