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Understanding Borderline Personality Disorder

Welcome to Borderline & Welcome to Me!

Kimberly Webb

Salt Lake Community College

PSY 2300: Abnormal Psychology

Dr. Emily Putnam

April 27th 2021

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Borderline personality disorder is a relatively new disorder. It was added to the DSM-III

as a diagnosable disorder in 1980, and there still is quite a bit about it that we do not understand.

What we can say for sure is that borderline personality disorder is one of the most prevalent

personality disorders we see in the western world, with a lifetime prevalence rate of 5.9%

[ CITATION And21 \l 1033 ]. With a cluster of symptoms that make up the diagnosis, borderline

personality disorder is a complex personality disorder that is often misrepresented or

misunderstood by the general public.

The term ‘borderline’ predates its presence as an official diagnosis. We first see the term

borderline used in psychoanalysis in 1938 by Adolph Stern, who would describe individuals as

being part of the ‘borderline group’ [ CITATION Nat09 \l 1033 ]. For many years, borderline was

also treated as a ‘catchall’ diagnosis for individuals who were subthreshold for a different

diagnosis, or didn’t quite fit all the categorical criteria for a diagnosis [ CITATION Opt \l 1033 ].

Individuals presenting with borderline symptoms would be described as having atypical, or

borderline, presentation of anxiety, depression, or bipolar disorder, as well as schizophrenia

[ CITATION Opt \l 1033 ].

This term was most frequently used in relation to schizophrenia. Gregory Zilboorg

described it as a milder form of schizophrenia [CITATION Opt \l 1033 ], and for many years,

borderline personality disorder was considered to be just that. The key difference of the time was

neurosis as opposed to psychosis. A borderline schizophrenic state was a symptom of neurosis,

which was viewed as treatable at this point in history, as opposed to the psychosis identified with

schizophrenia, which was not considered to be treatable [ CITATION Kri20 \l 1033 ].

It was 30 years after the term’s initial introduction, in 1968, that Roy Grinker began

conducting the first research done on borderline personality disorder [ CITATION Opt \l 1033 ].
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Shortly thereafter, in 1975, John Gunderson began publishing research on the disorder, and

published a descriptive set of symptoms for the disorder [ CITATION Nat09 \l 1033 ]. The

symptoms outlined by Gunderson were used as the blueprint for the DSM-III definition.

The symptoms proposed by Gunderson have been updated and adjusted following the

initial introduction of borderline personality disorder 40 some odd years ago. While they have

been updated, the core symptoms of the disorder remain largely the same. Those with borderline

personality disorder are consistent in their inconsistency. These individuals suffer from a myriad

of different symptoms, many of which present differently in different people. What seems to be

constant at the core of this disorder is a mood irregularity and a certain lack of stability. Their

moods rapidly cycle, and those with borderline personality can experience symptoms of euphoria

akin to the hypomania individuals with bipolar experience, extreme and intense anger, and low

pits of depression, all within hours of each other [ CITATION Ame13 \l 1033 ].

The lack of emotional regulation that many of these individuals exhibit is just one of

many symptoms that someone with borderline personality disorder must face. Other frequently

observed symptoms include self-harm or suicidal behavior, instability in their interpersonal

relationships, behavior, and self-concept, and impulsivity [ CITATION VMa161 \l 1033 ].

Ultimately, borderline personality disorder is a cluster of different behaviors or symptoms, the

conglomerate of which warrant the diagnosis.

The Diagnostic and Statistical Manuel of Mental Disorders assert that ultimately, it is a

“pervasive pattern of instability of interpersonal relationships, self-image, and affects, [and]

marked by impulsivity” that defines borderline personality disorder (5th ed.; DSM-5; American

Psychiatric Association; 2013). The DSM-5 then goes on to outline nine different behaviors that

may be indicative of borderline personality disorder. These behaviors include extreme efforts to
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avoid abandonment (either real or imagined), unstable and intense interpersonal relationships,

incongruence with one’s personal identity, impulsivity in at least two ways that can be damaging,

self-mutilation or suicidal behavior, mood instability, feelings of emptiness, intense anger, and

severe dissociative symptoms. In order for an individual to receive a diagnosis of borderline

personality disorder they must exhibit at least five of these behaviors. Unlike with other

disorders, an individual does not have to be distressed by these behaviors in order for them to be

considered for a diagnosis.

Like the disorder itself, the cause of borderline personality disorder is complex. The

etiology of borderline personality disorder is multifaceted and multidimensional. It was

originally believed that the development of this disorder was, at least primarily, caused by

environmental factors. We can see that the environment likely does play a major role in its

development: It’s estimated that 70% of those with borderline personality disorder experienced

significant childhood trauma [ CITATION Jen20 \l 1033 ]. Studies have shown that parental

psychopathology, poor familial boundaries, parental substance abuse, and inadequate maternal

relationships, as well as sexual or physical abuse and neglect are all significant precursors to the

development of this personality disorder [ CITATION Jen20 \l 1033 ].

While there clearly is a heavy, environmental influence in borderline personality

disorder, as the multidimensional, integrated approach suggests, it seems that there are multiple

different factors that must be considered to help us truly understand its root cause. Research on

this disorder is fairly new, but numerous studies suggest that there is a strong genetic component

to its development. Various twin studies show over 50% hereditability for borderline personality

disorder [ CITATION Jen20 \l 1033 ], suggesting that is more hereditable than major depressive

disorder. Further research has suggested that there may be differences in the brain structures of
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those with borderline personality disorder. Neuroimaging studies show key differences in the

amygdala, hippocampus, and the medial temporal lobes when comparing the brains of

individuals with borderline personality disorder to those without [ CITATION Jen20 \l 1033 ].

This research shows that its development is not strictly based on environmental influences. Dr.

Marsha Langman suggests that, like in the diathesis-stress model, a certain genetic diathesis or

vulnerability interacts with environmental inputs, specifically with a “chronically invalidating

environment,” to lead to the disorders development [ CITATION Jen20 \l 1033 ].

Because borderline personality disorder is a conglomeration of so many varying

symptoms, there are other diagnosis that an individual may receive or that a clinician may

consider. Other diagnosis’ that one may consider can differ depending on what type of

symptoms the client is presenting. This is why, prior to its own distinction as a disorder, people

were considered ‘borderline schizophrenic’ or ‘borderline depressed’. Many of the symptoms of

borderline personality disorder may resemble schizophrenia, depression, anxiety, bipolar

disorder, post-traumatic stress disorder, or even attention deficit/hyperactivity disorder

[ CITATION Joe18 \l 1033 ].

While borderline personality disorder can present in many different ways, causing

potential mis-diagnosis for a plethora of psychological disorders, it is most frequently confused

with bipolar disorder. This is due to the fact that mood instability is an integral part of both

disorders. The two are very different in actuality, and treatment often differs drastically between

the two disorders, making it important that the correct diagnosis is given. The key way to

distinguish between a patient presenting with bipolar disorder and a patient presenting with

borderline personality disorder, at least when discussing and evaluating mood regularity, is the

frequency of mood disruptions. An individual with borderline personality disorder can switch
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between states of euphoria and depression in a matter of hours, while the intense mood states are

more lasting in an individual with bipolar disorder [ CITATION Joe18 \l 1033 ].

It is important that we assess for possible comorbidities as well as considering the

differential diagnoses when evaluating an individual presenting with borderline personality

disorder. There are frequent comorbidities that occur with this disorder, and it is radically

important that we understand and treat these as well as borderline personality disorder. An

astounding 96% of individuals with borderline personality disorder also suffer from a mood

disorder at some point in their lives [ CITATION Rob13 \l 1033 ]. Other frequent comorbidities

that we need to be aware of include depression, anxiety, eating disorders, substance abuse

disorders, and post-traumatic stress disorder[ CITATION Opt \l 1033 ].

Assessment for borderline personality disorder is generally done through a client

interview. Clinician conversation and evaluation of a client’s behavior is the most effective way

to determine whether a diagnosis of borderline personality disorder is warranted. This can be

done can be done through a structured clinical interview. There is not a formal structured

interview for borderline personality disorder, but the DSM-IV axis II Personality Disorder can be

a beneficial tool and in diagnosis.

There are a few other screening instruments that providers can utilize to help aid in

diagnosing borderline personality disorder. The McLean Screening Instrument is a brief, 10

question assessment that can be used to determine whether this is a fitting diagnosis for a patient.

The Personality Diagnostic Questionnaire, 4th edition, is a longer tool, consisting of 99 questions,

but can also be beneficial. Recent studies have indicated that clinical interviews, the MSI-BPD,

and the PDQ-4 are all equally effective in predicting a diagnosis of borderline personality

disorder [ CITATION Kri201 \l 1033 ].

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Psychotherapy the first treatment method that should be explored when treating an

individual with borderline personality disorder. These individuals may benefit from Cognitive-

Behavioral Therapy focused upon influencing the way that they perceive themselves and others.

A main symptom for many individuals with borderline personality disorder is unhealth and

unstable relationships with themselves and others, partnered with an intense fear of

abandonment. CBT can be effective for these individuals if it is able to help identify the root

causes of these the feelings that influence these relationships and address the underlying,

unhealthy beliefs and behaviors [ CITATION Nat17 \l 1033 ]. CBT has also been shown to be

effective in helping individuals cope with and overcome suicidal ideation and tendencies, as well

as self-mutilative behavior.

Another, generally more effective, form of psychotherapy for those with borderline

personality disorder is Dialectical Behavioral Therapy. DBT was created in the 1980s by Dr.

Marsha Linehan, and was specifically developed to help treat individuals with borderline

personality disorder [ CITATION Nat17 \l 1033 ]. Along with the reframing work that is done in

CBT, individuals undergoing dialectical behavioral therapy will be taught a variety of skills

specifically tailored towards individuals with borderline personality disorder. This is done in a

combination of group and individual therapy. DBT focus on teaching individuals to control

impulsivity, cope with intense emotions, and build healthy relationships with others. DBT has

been shown to be immensely effective in treating individuals with borderline personality disorder

and yields high success rates [ CITATION Nat17 \l 1033 ].

While it is not as frequently recommended, some individuals with borderline personality

disorder may benefit from temporary pharmaceutical intervention. Medication can help to

manage intense mood states if it is a major presenting problem. Medicinal intervention may also
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be recommended if an individual is particularly depressed, or has other comorbid disorders that

may be treated well with medication [ CITATION Nat17 \l 1033 ]. All in all, there are many

treatment methods available for individuals suffering from borderline personality disorders and

the disorder generally has a good prognosis with opportunity for improvement if individuals seek

treatment.

There are a few common myths surrounding borderline personality disorder. One of the

most common myths being that it is not treatable. While it is true that personality disorders as a

whole are defined as persistent and pervasive patterns of behavior, that does not mean that they

cannot be treatable. The prognosis for individuals with borderline personality disorder who seek

treatment is actually quite good [ CITATION VMa161 \l 1033 ].

Another common misconception is that borderline personality disorder is simply a

variation of bipolar disorder. This is far from the truth and the two disorders are actually wildly

different. Even though an individual with borderline personality disorder may suffer from mood

instability, the way that they experience shifts in mood is drastically different from the mood

shifts that occur in bipolar disorder. Mood changes in borderline personality disorder can

happen rapidly; an individual may experience multiple, extreme moods within a matter of hours.

An individual with bipolar experiences severe moods, but they remain in an extreme mood state

for an extended period of time, often for a matter of weeks or even longer.

People often tend to believe that every individual with borderline personality disorder

experienced intense childhood trauma. While we can see that many individuals with this

disorder did experience trauma, we know that not all of them did. Recent research has shown

that there are other factors, not just environmental factors, that contribute to the development of

this disorder. An individual can experience trauma and still not develop borderline personality
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disorder, and an individual who did not have a traumatic childhood can develop the disorder.

Abuse is not a necessary precursor to the development of borderline personality disorder as we

once thought.

In the film Welcome to Me, Alice Klieg wins the lottery, buys a reality TV show, goes off

her medication, and stops receiving treatment for her borderline personality disorder. Throughout

the film we are able to see instances of Alice’s poor relationship with herself and others, as well

as her impulsive and erratic behavior. As the film progresses, Alice begins to lose further touch

with reality in various ways. You can see her perception of reality alter as her TV show becomes

more popular, and you can see her begin to experience withdrawal symptoms from suddenly

stopping her medication.

In many ways, Welcome to Me provided an excellent illustration of an individual with

borderline personality disorder, and portrayed the disorder in ways you don’t often see in the

media. Alice’s relationships with those close to her provided a good example of patterns of

instability that is often present in those interpersonal relationships. Alice’s behavior towards her

friends is incredibly inconsistent. For much of the film, she completely devalues and dismisses

her friendship with her best friend, Gina. It is only when Gina tells her that she has been an

awful friend that Alice’s behavior switches and she treats Gina with near ideation. On both sides

of the spectrum, Alice’s behavior is incredibly intense and is not indicative of a healthy pattern

of relationship. We see this with Alice’s other friends as well.

Alice also shows immense reckless impulsivity throughout the film. This is seen through

excessive sex throughout the film. You can see that this behavior is impulsive as it seems to be

something done with little thought and that ultimately hurts her other relationship. Alice also

shows excessive spending and nearly spends her entire lottery winnings by the end of the film.
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Another aspect of borderline personality disorder that is accurately depicted in the film is

the intense feelings of anger that many of these individuals experience. There are many

instances where Alice succumbs to her anger and begins screaming. She does this at

reenactment actors who are portraying previous parts in her life at many instances. At one point,

her anger becomes so out of control that while she is screaming at people, she spills hot liquid on

herself and ends up with second degree burns all over her body.

For the things that the movie did well, there were many more things that they did wrong.

One of the most blaring issues with the film is the reference to medication. Early on in the film,

Alice’s therapist asks her why she stopped taking her medication. Alice has been taking Abilify.

While Abilify can be used in some ways to manage mood disorders, it is primarily an

antipsychotic medication. Medication in general is seldom used in the treatment of borderline

personality disorder, and if Alice were to be prescribed a medication to help treat her disorder it

likely would be something that is more primarily utilized for mood regulation.

Many of the other symptoms and problem behaviors that Alice exhibits are not

necessarily characteristics of borderline personality disorder. There are many instances where

her behavior seems to be more indicative of histrionic personality disorder or another disorder.

Alice’s constant need to be the center of attention is one key feature of histrionic personality

disorder. Her excessive self-dramatization is also more representative of histrionic personality

disorder than it is of borderline personality disorder.

All in all, I think that Welcome to Me shows how misunderstood borderline personality

disorder still is today. It felt as though they used an arbitrary label, but then created symptoms as

they saw fit in order to propel their story. It felt similar to the historic use of the term, when

borderline simply was used as a catchall for a symptomatic presentation that didn’t quite fit into
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the categorical requirements for a diagnosis of a given disorder. While the film was entertaining,

it certainly doesn’t do anything to dispel the myths surrounding borderline personality disorder.

If anything, it will only increase confusion and misunderstanding in those individuals who don’t

know much about the disorder as it stands. Ultimately, I feel that the best way for us to reduce

the stigma surrounding this disorder is to educate others about it. It seems that very few people

know much about the disorder itself, and those who do tend to clump it in categorically with

bipolar disorder. One of the greatest ways to reduce stigma is to increase understanding, and we

clearly have a lot of education to do regarding borderline personality disorder.

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