In my day to day work I meet a lot of people who get the diagnosis of Borderline Personality Disorder. While few of them had ever been party to an in depth discussion about what this diagnosis means, many find that their thoughts and opinions suddenly lose value because they are ill. Now I don’t want to tell anybody how to describe or understand their experiences but if you find that having this diagnosis and being seen as ill causes problems for you (the testimonial injustice that Jay Watts writes about) this might be a useful way to think about how this diagnosis has come about.
Lets start by saying that experiences of neglect, abandonment and abuse are very common amongst people who are given this diagnosis. It would make sense that our minds and bodies adapt to these experiences. Some people with a BPD diagnosis don’t identify with trauma as a part of their lives. Here it might be useful to think about the life of Marsha Linehan, the creator of Dialectical Behaviour Therapy. While she didn’t identify one big event in her life, she did recognise that she was different to how her mum wanted her to be. This meant that she had a lifetime of getting a clear message that she was wrong about who she thought she was, that her achievements were of little value and that praise could only be obtained by denying who you were. Years of this combined with stress around exams and a desire to achieve led to headaches that would not go. When this led to a hospital admission where restrictions were placed on her she became someone who ticked every criteria for BPD in the book. Not everyone I work with has an obvious traumatic event in their lives, but I’ve never met anyone whose difficulties couldn’t be explained in terms of what they had lived through and how they had been shaped to think and behave.
With all this in mind, lets take a look at the BPD criteria. In theory, you will need 5 of these to get the diagnosis.
1 -Frantic efforts to avoid real or imagined abandonment.
This basically means that the idea of people you care about not being in your life is frightening and you’ll do a lot to avoid it happening. This is something most people in the world do. The difference is often that you’ve probably had experiences of people quickly vanishing from your life. It might also be that you’ve not met many people you could count on so losing the ones you’ve got is a huge blow. Equally it could be that you think very badly about yourself and feel that if someone leaves, you’ll be alone forever. For all the above it makes sense that you will do more than the average person to keep people in your life. The reality is that no one wants to be abandoned so there’s nothing odd about wanting to keep people around.
2 - A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Everyone in the world likes some people more than others. It’s not odd for this to be your experience too. You have probably had people in your life who have really let you down and it would make sense that if they did, others will too. Sometimes people will seem alright, but they can do things that remind you of those who have let you down in the past. If you’ve had poor experiences of people in the past, it makes sense that you’ll want to make the most of those who are kind to you. Again, there’s nothing odd about this. We can be pushed into seeing people as absolutes, or that in life there is a binary right and wrong. If these were oure early experiences it makes sense we carry them throughout orur lives.
3- Identity disturbance: markedly and persistently unstable self image or sense of self.
I meet a lot of people who experience this. They tend to have had long periods in their lives where they couldn’t be themselves. They might have been punished for it or not rewarded or accepted for it. Because most of us want to be accepted, we will normally adapt aspects of ourselves to the people we are with. How quickly do we start picking up accents in another part of the country?
If we’ve had prolonged experiences of having to be someone else to avoid pain or to be accepted, then it makes sense that we might not know who we are. We might be extremely different for different people and never feel ‘right’ – like we are always wearing a mask or putting on a performance. It can be exhausting but again, based on previous experiences this isn’t odd.
4 - Impulsivity in at least two areas that are potentially self- damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Pretty much everyone I meet who has been given this diagnosis thinks of themselves in a very negative way. People have generally encouraged them to do this and their worst thoughts about themselves often echo what abusive people have said in the past. This often leads people to feel that they are worthless and that life is not worth living. When you feel either or both of these things it makes sense that doing things that make the moment better are worth doing. If you can’t see a future it makes perfect sense to do whatever makes the now more bearable. When people are given months left to live their lives often change radically. It makes sense that people who don’t see a future live more for the now. It makes sense that people who think they are worthless don’t value themselves enough to take more care of their lives.
5 - Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.
This relates to the above. If you are convinced that life is not worth living, it makes sense that you would do things that might bring life to an end. It’s hard to overcome our instinct to stay alive so it makes sense that something dangerous might be done, then help sought. It might make sense that we do dangerous things again and again and again. Separate to this, it might be that the world has taught us that asking for help is not enough and that people will only help when the volume is at 11. Few people think “I will do x to get y” but life will have shown them that people will only show care when danger levels are high, when blood is flowing or poison ingested. Mental health services are brilliant at giving the message “you’re not bad enough for help” so it makes sense that people respond to that message.
6 - 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).
If we think about Marsha Linehan again, she would tell us that people who get this diagnosis have 3 features.
1 – They are quicker than the average person to be ‘triggered’. They will be more sensitive to a stimulus that sets off an emotional reaction
2 – It takes longer for the emotion to come back down than the average person
3 – As its coming down its even easier for something to stimulate the response again
Obviously those who get this diagnosis have not had the average experiences of others. People might be triggered more easily because there have been a lot more threats and dangers in their life. If this is the case, it makes sense people would be on extra alert. Nobody in the world wants to be hurt.
People have often been in environments that were threatening to them for a long time. The body had to adapt to danger that didn’t go away, that couldn’t be fought off or run from. It makes sense that it takes a longer time for emotions to settle down
Again, when the danger is ever present, it makes sense that to stay safe the body has that response kick in quicker.
Linehan would also say that because of these early experiences, its harder to keep emotions in check. Its hard to manage anger if your role models didn’t, or if they just told you to feel something different. Many people are taught how to identify and respond to emotions but if you come from an environment where that didn’t happen (or people taught the opposite) it would make sense that this is really hard
7 - Chronic feelings of emptiness.
This is a bit vague and can mean different things to different people. When we lose something, we often feel numb, empty. Nothing. If life has little meaning for us we again feel numb. We might have been punished for ‘feeling the wrong things’ in life meaning that all emotion had to be crushed and hidden and we got good at it. Those I work with can often see the lives of others and understandably compare their own. They feel they have lost out because of either who they are or what has happened to them. They also tend to have lives where they can’t be kind to themselves (as they feel worthless) and can’t make long term plans (I cant picture being here in 2 years). These feelings of emptiness make sense.
8 - Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
The people I work with have a lot to be angry about. Having experienced repeated injustice, they are acutely aware of when it rears its head again. Their role models often haven’t shown how to control anger and have also shown that anger and violence gets things done. When confronted with injustice or when our goals are blocked by others, most people feel angry. Most people when told their anger is inappropriate get angrier. Because most people who get a diagnosis of BPD are women and society does not like seeing women being angry, their anger is often seen as being ‘wrong’. I frequently meet people where, if I had had the same experiences in my life, I would be intensely angry. Services are again excellent at replaying scenarios that occurred earlier in life and its understandable that anger is a response.
9 - Transient, stress-related paranoid ideation or severe dissociative symptoms.
This is probably the least talked about criteria of BPD, possibly because it comes closest to what Mental health services feel they are set up to deal with. Paranoid ideas make sense if people have been repeatedly let down by others, if others have hurt them, lied about them or used them to their own advantage all while telling them that they were wrong to feel what they feel. Paranoia would be a healthy response to these circumstances. Hearing voices always seems to come under this category. The voices people hear are separated from what people experience in something like schizophrenia in that they tend to say what the person thinks about themselves or are connected to previous traumatic events. This doesn’t make them any less terrifying, but it does make sense that trauma embeds itself in many ways. The severe dissociation is something I see less often but can be a total disconnect with reality. Again it makes sense that if people have had experiences that cannot be tolerated, slipping out of reality is a way to cope. If it had to happen a lot in the past it makes sense its likely to happen again. While these experiences look a lot like someone who is outside of our reality, I do want us to hold on to the idea that they all make sense based on previous experiences.
So those are all the criteria for BPD. You need five out of nine to get the diagnosis but if you are female and self-harm, you’ll be lucky to get a different one. We now come to the reason for writing this piece. People who have been given this diagnosis say they get dismissed because they are ill. Their reactions to things are seen as being the result of a disease and thus not valid. What I would really like people to take from this piece is that all the experiences listed above can make perfect sense based on what people have lived through. We could see this as an adaptive response to what has gone before. We don’t need to see this as illness and we certainly don’t need to say someones personality is disordered. BPD is definitely something you can write on a benefit, housing or insurance form, but if you don’t like being seen as “ill” then there’s lots above that might challenge that way of people seeing you. It’s certainly a label that can be used to invoke use of the mental health act, but we might take time to pause before we brand it as an illness. We all experience emotions, our emotions tell us something important about what is going on. We are never wrong to feel what we feel. We might want to think about the extent to which we express and react to our emotions, but the feelings themselves make sense. My preference is always to understand people in terms of how their experiences have shaped them. Others might feel differently and no one way is right for everything. If you work with people who get this diagnosis this might help provoke some thought about how to discuss the things they find difficult.
Keir