1. What is a personality disorder?

As defined by the American Psychiatric Association Diagnostic and Statistical Manual, a personality disorder is an enduring pattern of inner experience and behavior that deviates significantly from social/cultural expectations, begins in adolescence or early adulthood, is pervasive and inflexible and leads to distress or social/occupational impairment.

2. What are the symptoms of borderline personality disorder and how frequently does this disorder occur?

Nine symptoms of this disorder are described in the Diagnostic and Statistical Manual; you must show five of these to qualify for the diagnosis. To summarize these symptoms, I would say they describe the presence of extremely intense, unstable emotions, including anger, unstable relationships marked by deep fear of abandonment, unstable self-image accompanied by impulsive behaviors in areas like spending, substance abuse or sex, episodes of dissociation, and recurrent suicidal threats or gestures and self-mutilation.

A 2008 study of nearly 35,000 adults found that 5.9% had been given a borderline personality disorder diagnosis. This translates to about 18 million Americans.

3. Why is it called “borderline” personality disorder?

In the 1930’s a psychoanalyst named Adolph Stern created the term borderline to describe patients who appeared to fall between Sigmund Freud’s two main diagnostic categories: psychosis and neurosis. Back at that time, analysts found that such patients would come to their office with what appeared to be neurotic symptoms of anxiety and depression, but as time passed and analysis did not cure these symptoms, psychiatrists began to believe these patients were actually on the psychotic spectrum, or on the borderline between neurosis and psychosis.

4. It has been said that this is the diagnosis most feared by mental health professionals. Why?

Most often it is due to the recurrent suicidal threats and gestures, as well as the self-mutilation. These problems are often resistant to treatment and can feel manipulative to the therapist. In addition, borderline clients have a high suicide rate compared to other diagnoses. Finally, some individuals with this diagnosis have significant problems regulating anger, attacking people they care about, including their therapist.

5. What causes borderline personality disorder?

According to University of Washington psychologist Dr. Marsha Linehan, who is one of the world’s leading experts on borderline personality disorder, it results from an emotionally vulnerable child growing up in a particular set of circumstances that she terms an invalidating environment. By an emotionally vulnerable child Linehan means a child whose autonomic nervous system reacts strongly to even low levels of stress and who takes longer than expected to return to baseline, so the child stays emotionally aroused. Linehan believes that this is a biological predisposition that can arise either from genetic factors or from events occurring in the womb before birth or both. It results in what could be called a sensitive nervous system. The interaction between this biological vulnerability and an invalidating environment produces the symptoms of borderline personality disorder.

6. What exactly is an invalidating environment?

An invalidating environment refers to a situation in which the child’s feelings and statements about feelings are disregarded or labeled as wrong or invalid. For example, a parent might tell a child “Don’t say you hate your brother, you know you love your brother.” Or, “Don’t be stupid, there is nothing scary about the dark.” Or “shut up or I’ll give you something to cry about.” Overall, in an invalidating environment, the child’s feelings and actions are criticized, punished or pathologized, and the child is told to control her emotions without being taught how to do so. Of course, it is also very invalidating to be physically or sexually abused. Individuals with borderline personality disorder frequently describe a history of childhood sexual abuse and this is regarded by Linehan as a particularly extreme form of invalidation.

7. Why does invalidation have such an impact on children (and adults)?

Invalidation keeps the child from accurately labeling her own feelings and she learns that her feelings and responses are wrong and somehow bad. She will not learn how to regulate her emotions because she cannot even identify them accurately and her behavior may then oscillate between opposite poles of emotional inhibition in order to gain acceptance and extreme displays of emotion in order to have her feelings acknowledged. This failure to learn to regulate emotions, combined with a sensitive nervous system, leaves the child with intense emotions she cannot control, which then destabilizes her relationships, her sense of self, and her capacity to go to school or work. And, according to Linehan, it also causes these individuals to try to reduce their great emotional pain with impulsive behaviors, such as drinking or drugging, or self-mutilation, or ultimately suicidal threats or actions. Linehan regards these behaviors, which leave mental health professionals so reluctant to treat borderlines, as the client’s attempt to get rid of emotional misery quickly.

8. How is borderline personality disorder treated?

Generally treatment of this disorder includes both medication from a psychiatrist skilled in treating borderlines, and psychotherapy. Several psychotherapeutic approaches have developed over the last decade or so; the approach I am familiar with is the one developed by Marsha Linehan called Dialectical Behavior Therapy or DBT, and described in detail in the book she published in 1993.

9. What does DBT involve?

DBT is a treatment that combines the benefits of both behaviorism and cognitive behavioral therapy, the radical acceptance strategies including meditation of Zen Buddhism, the warmth and validation of relationship-centered therapies such as that of Carl Rogers, and the perhaps undervalued power of psycho-education. DBT is both structured and flexible; it contains four primary treatment modes: weekly individual therapy, a weekly 2 hour psycho-educational skills training class; telephone contact with the therapist if a crisis occurs, and a weekly consult group for therapists. The overriding goal is to help the borderline client learn how to regulate her emotions, tolerate distress without self-harm or impulsive actions, act interpersonally effective, and focus and control her attention. Individual therapy sessions are directed to helping the client use the skills she is learning in the psycho-educational group, telephone contact is designed to help the client get through a crisis without doing something that makes it worse or sends her to a hospital, and the therapist consult group is to insure therapists are working within the DBT framework. Borderline clients can be difficult and therapists need support.

The core strategies in DBT represent a balance or a synthesis of validation and problem solving. Attempts to help the client change are balanced by interventions that validate her current feelings and actions as completely understandable given her past history and current situation. The opposing points of validation/acceptance of the client as she is and the message she needs to do better and work harder to change runs throughout DBT. Validation is a critical strategy, because invalidation played a significant role in producing the borderline symptoms.

10. How effective is DBT in resolving the symptoms of borderline personality disorder?

DBT is supported by empirical evidence that indicates it is first and foremost successful in reducing suicidal and self-injurious behaviors, and also in reducing time spent in psychiatric in-patient treatment.

11. For what other conditions is DBT effective?

The strongest evidence exists for DBT as a treatment for people with borderline personality disorder.  However, DBT has been found to be effective for a wide variety of other mental health conditions.  Listed below are the conditions for which DBT has been found to be effective through at least one randomized controlled trial (evidence-based mental health care).

  • Borderline personality disorder, including those with co-occurring:
    • Suicidal and self-harming behavior
    • Substance use disorder
    • Posttraumatic stress disorder
    • High irritability
  • Cluster B personality disorders (dramatic, overly emotional or unpredictable thinking or behavior)
  • Self-harming individuals with personality disorder
  • Attention deficit hyperactivity disorder (ADHD)
  • Posttraumatic stress disorder related to childhood sexual abuse
  • Major depression, including:
    • Treatment resistant major depression
    • Older adults with chronic depression and one or more personality disorders
  • Bipolar disorder
  • Transdiagnostic emotion dysregulation (emotion regulation difficulties across different disorders)
  • Suicidal and self-harming adolescents
  • Pre-adolescent children with severe emotional and behavioral dysregulation
  • Binge eating disorder
  • Bulimia nervosa