Ep. 005 - What is borderline personality disorder?

This week’s podcast episode focuses on borderline personality disorder.

Borderline personality disorder is a common condition

Borderline personality disorder is relatively common. It’s a condition that currently affects about 1 out of every 60 people (Lenzenweger, 2007). Up to 1 of every 20 people may be diagnosed with borderline personality disorder at some point in their lives (Grant, 2008).

“Borderline personality disorder” is a terrible name

Dr. Messamore starts off by pointing out that the name of this condition – “borderline personality disorder” – is long overdue for change. It is based on 1930s-era psychological concepts. The psychological concepts have been updated over the past 90 years. Tragically, the name of this condition has not.

Modern neuroscience has revealed a lot about the underlying causes of borderline syndrome. Biochemical studies, genetic studies, and brain imaging studies point to biological and neurological factors as the primary cause of “borderline” symptoms.

Considering all that we’ve learned about this condition, it would be easier to understand – and scientifically more accurate – if we retired the term “borderline personality disorder” and replaced it with “emotion regulation disorder.”

What causes borderline personality disorder?

You can think of the brain as having an emotion-generating part and an emotion-checking part. The “borderline” syndrome happens because the engine and the brake are out of balance.

The engine

Emotions are your brain’s way of influencing your behavior or decisions in ways that the brain thinks will benefit your survival. The job of the limbic system is to generate emotional reactions to events (or ideas). The limbic system is just the generator. It does not have the ability to decide if its reactions are useful or not. That’s the job of the prefrontal cortex.

The brake

The part of your brain that does the things you recognize as thinking… that region is called the pre-frontal cortex – the PFC. One of the many important functions of the PFC is to analyze whatever situation you find yourself in. (For us human beings, creating an explanation is as fundamentally important as food or water). Whenever the limbic system generates an emotion, the PFC is supposed to check it out. (Remember the limbic part is just the generator – not the evaluator). The PFC is supposed to determine of the emotional response is appropriate for the event. If the emotional response is out-of-proportion to the event (or if the emotional response is interfering with other important decisions), then the PFC can talk back to the limbic system.

Overactive engine, inefficient brake

Numerous studies have shown overactivity in parts of the emotion-generating limbic system among people with borderline personality syndrome. Meanwhile, studies have also shown that the activity in the PFC braking region is under-active, or that its connections with the limbic system are inefficient.

The result: the brain generates emotion signals that are either not needed in response to some events, or that are unnecessarily strong. That’s why I think that “emotion regulation disorder” would be a better term for this condition.

How overcharged emotions are at the heart of many “borderline” symptoms

So now consider what happens when you, or someone you know, is feeling extremely uncomfortable. The strong emotion constrains your options. You can’t think about things that are not in line with what your emotion makes you think is true. You’ll do almost anything to feel better. Maybe even things that others would call “reckless” or “impulsive.”

In fact, most of the symptoms of borderline personality can be easily understood as attempts to change emotions that feel too strong.

What are the symptoms of borderline personality disorder?

The diagnostic criteria for psychiatric conditions are listed in the DSM-5, which is published by the American Psychiatric Association.

The DSM-5 describes borderline personality disorder as “a pervasive pattern of instability of interpersonal relationships, self-image, and emotions, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:”

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships
• Identity disturbance: markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• 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).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.

Calling it a “personality disorder” slowed down biological research about borderline personality syndrome

I think that coming up with “borderline personality disorder” as the name for the syndrome of emotion regulation struggle was a horrible idea from the very beginning. One of the many very negative effects from this naming decision is that the American Psychiatric Association seemed to be telling the world that we’re confident that we know the cause is “personality.”

This declaration apparently signaled to the world of biomedical scientists that there is little point in studying its biochemistry. I think that’s the reason why borderline personality has been so poorly studied (from a biochemical basis) compared to other major psychiatric conditions.

Take a look at the number of scientific articles from 1946 to 2015 that address the possible biological causes of schizophrenia, depression, bipolar disorder, and borderline personality (BPD).

 

What’s the best treatment for borderline personality disorder?

While biologically-focused scientists seemed to stay away, the psychologically-focused scientists have done a lot of very good work understanding how emotions work and how they can be harnessed.

As a result, we now know about the important connections between the emotion-generating limbic system and the emotion-regulating prefrontal cortex. Not only do we know about these connections, we also have ways to strengthen them.

It turns out that learning to regulate emotion is a skill that can be taught and learned, pretty much exactly the way that learning to play the piano or to speak a foreign language can be taught and learned. The process is the same. You show the brain what it needs to do. You practice it, step by step. You make mistakes. You practice some more. You get a teacher, a coach, some fellow learners to help you practice, keep you on track, applaud your progress, and inspire you with theirs. You do this week after week and after a while, you start to get good at it. You keep practicing. You keep getting better.

Whether it’s learning to speak Swedish, learning to play harmonica, or learning to recognize and regulate emotion, the process is the same. They all rely on the brain’s remarkable and ever-present ability to literally re-wire itself to make easier any task we ask it to do for us.

Emotion regulation training works for people with the emotion regulation issues that are regrettably today still called “borderline personality disorder.” It sucks to have any sort of mental struggle. But the good news for people with emotion regulation struggles is that there are well-studied and effective training-type therapies that get close to correcting a root cause. Numerous modern brain-imaging studies have shown that these types of training therapies reduce the overactive limbic system and strengthen its connections with the emotion-regulating prefrontal cortex.

The silver lining of borderline personality

The thing with human beings is that our greatest vulnerabilities often provide clues about our greatest potential strengths.

Up to this point, I’ve been focused on the problems of intense or reactive emotion – about how the emotion engine revs too easily or to rapidly. On some levels, the brain is like a car. It has a lot of complicated parts that work together (behind the scenes, usually far outside of our awareness) to get us where we would like to be.

If the brain were a car, though, it would be a very high-performance vehicle – like a Lamborghini. The problem is – for all of us – we’re not given instructions about how to operate that magnificent machine. So most of us spend a good part of our lives driving from ditch, to post, to wall, to ditch – getting where we want to go in a halting, jerky way… and crashing quite often.

But once you understand how your brain really works – particularly the emotion pieces – and learn how to regulate it, you’ll find that it takes you far and fast, wherever you decide to steer it.

So you can think of emotion regulation therapy as a driver’s course.

The other thing about “borderline personality” is this: the ability to experience deep emotion is also a gift. It becomes possible to experience life in ways that are more vivid and more beautiful than others may ever have access to. When such a person is healthy, they can use their depth of experience to drive really great thought and have truly rich experience. The capacity for strong emotion can be difficult to live with, but it can also be a treasure.