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Borderline Personality Disorder - Emotional vulnerability

The term "borderline" was first used by early psychiatrists in the late 19th century to describe people who did not seem to fit into the two broad diagnostic categories being used at the time (psychosis and neurosis). These people were referred to as “borderline”, which meant on the border between the two categories. Today Borderline Personality Disorder, or BPD for short,  is understood in a very different manner, although the term borderline has stuck. Many experts are seeking to have this disorder renamed in keeping with the modern conceptualisation.

Borderline Personality Disorder (BPD) is characterised by intense emotional experiences and consequent instability in relationships and behaviour. Marsha Linehan, an American clinical psychologist, has pioneered modern ways of understanding BPD. She proposed that the main underlying problem is that of emotion dysregulation. Linehan believes that people with BPD have difficulties regulating many, if not all, emotions, and that the far-reaching instabilities in behaviour and relationships are the result of maladaptive and inadequate attempts to regulate emotions.

BPD as emotional vulnerability

 

A helpful way to understand this may be to consider an everyday example. Consider a young boy with a vision impairment. In common with many visually impaired people he has extreme auditory sensitivity. When he goes with his family to a football game at a large stadium, he finds the noise of the crowd, the drums and hooters, and the loud speakers extremely stressful. He may become physically agitated, hyperactive and start making loud noises himself. Alternatively he may become extremely withdrawn, curling up on his seat, unable to engage with others. He may not be aware of why he is feeling so acutely uncomfortable, and he is likely to remain distressed and unsettled for some time after leaving the stadium.  His responses are maladaptive; they impair his capacity to relate to the people around him, may elicit negative reactions from them, and, depending on his age, may cause him to feel shame or embarrassment. He is, however, doing the best he can.

 

With help and support from others, as this boy gets older, he will be more aware of his sensitivity to continual loud noises and will develop strategies to deal with it. If he goes to a game with his friends he may leave the stands intermittently to seek out a quiet spot for a few minutes, he may wear ear plugs or use an ipod playing soothing music, he may arrive at half-time to reduce his exposure, or watch the game at home and meet his friends afterwards to re-hash the game together. He has learnt skills to cope with his underlying sensitivity, and can moderate aspects of his behaviour in ways that do not impair his relationships with others, or interfere with personal goals and self-concept.

We can now consider the parallel with BPD. The boy in our example has a sensory sensitivity, whereas people with BPD have an acute emotional vulnerability. Emotional vulnerability means high sensitivity to emotional situations, intense responses to emotional situations, and a slow return to emotional baseline once emotionally upset. The ability to moderate emotions involves a capacity to control or stop inappropriate or ineffective behaviour related to strong emotions (the so-called “action-urge”), keep behaviour organised during strong emotions, soothe emotions once aroused, and maintain and refocus attention in the presence of strong emotion. According to Linehan, emotion dysregulation in people with BPD is the result of an emotional response system that is oversensitive and over-reactive, with limited or no capacity to modulate the resulting intense emotions and associated behaviours. The human emotion regulation system is very complex and a dysfunction in any part of the system can produce emotion dysregulation.

Emotion dysregulation causes many other problems

 

Struggling with emotion dysregulation can produce many of the behaviours and difficulties associated with BPD, such as unstable mood, inappropriate intense emotions or impaired awareness of emotions, impulsive behaviour, unstable relationships, and recurrent suicidal thoughts. Please refer to my article What are the Criteria for Borderline Personality Disorder? for more information about how core problems in emotion regulation create difficulties in other areas of life.  Like the boy with the sensory sensitivity, people who experience emotional sensitivity and dysregulation have developed behaviours and strategies to help manage their lives. Behaviours such as self-harm, binge eating, drug and alcohol abuse are often used as kind of emotion regulators. They may help moderate strong emotions, and perhaps provide some respite from the ongoing onslaught of dysregulated emotions. However, like the boy’s early attempts to regulate himself at the stadium, these kinds of behaviours, while effective in the short-term, have other clearly negative consequences.

Marsha Linehan has developed a treatment strategy for BPD  called Dialectical Behaviour Therapy, or DBT for short. The core of this therapy is the teaching of skills which are designed to help people with BPD regulate their emotions in ways that have positive consequences in both the short and the longer term, and so allow them to develop a more stable and satisfying life. DBT includes skills to assist with emotion regulation, tolerance of distress, interpersonal effectiveness and mindfulness.

If you think you may have some features of Borderline Personality Disorder, struggle with regulating your emotions or are interested in learning more about DBT, please consider making an appointment with me, so that we can explore your difficulties further and consider whether DBT would be a suitable treatment for you.