Borderline personality disorder is an illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with borderline personality disorder may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days (NIMH, 2017).
Trauma Response.
Post Traumatic Stress Disorder (PTSD) is defined as a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world (Oxford Languages). Prolonged and severe trauma, particularly trauma that occurs early in the life cycle, tends to result in a chronic inability to modulate emotions. When this occurs, people can mobilize a range of behaviors that are best understood as attempts at self-soothing. Some of these attempts include clinging and indiscriminate relationships with others in which old traumas are re-enacted over time, as well as more self-directed behaviors such as self-mutilation, eating disorders, and substance abuse. Patients with complicated trauma histories often repetitively attempt suicide or engage in chronic self-destructive behavior, and need to address issues of childhood trauma, neglect, and abandonment, both in the past and as re-experienced in current relationships. Therapy must clarify how current stresses are experienced as a return of past traumas and how small disruptions in present relationships are seen as a repetition of prior abandonment. Fear needs to be tamed for people to be able to think and be conscious of current needs. This bodily response of fear can be mitigated by safety of attachments, security of meaning schemes, and by a body whose reactions to environmental stress can be predicted and controlled (Van der Kolk, Hostetler, Fisler, 1994). Trauma experts maintain that BPD might be a complex variation of PTSD where dissociative periods lead to longer treatment timelines.
Signs and Symptoms
People with borderline personality disorder may experience mood swings and display uncertainty about how they see themselves and their role in the world. As a result, their interests and values can change quickly. Clients also tend to view things in extremes, such as all good or all bad. Their opinions of other people can also change quickly. An individual who is seen as a friend one day may be considered an enemy or traitor the next. These shifting feelings can lead to intense and unstable relationships.
· Efforts to avoid real or imagined abandonment, such as rapidly initiating intimate (physical or emotional) relationships or cutting off communication with someone in anticipation of being abandoned.
· A pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation).
· Distorted and unstable self-image or sense of self.
· Self-harming behavior, such as cutting.
· Recurring thoughts of suicidal behaviors or threats.
· Intense and highly changeable moods, with each episode lasting from a few hours to a few days.
· Chronic feelings of emptiness.
· Inappropriate, intense anger or problems controlling anger.
· Difficulty trusting, which is sometimes accompanied by irrational fear of other people’s intentions.
· Feelings of dissociation, such as feeling cut off from oneself, seeing oneself from outside one’s body, or feelings of unreality (NIMH, 2017).
Splitting
Splitting is a term used in psychiatry to describe the inability to hold opposing thoughts, feelings, or beliefs. Some might say that a person who splits sees the world in terms of black or white—all or nothing. It's a distorted way of thinking in which the positive or negative attributes of a person or event are neither weighed nor cohesive (Salters-Pedneault, 2020).
Splitting is considered a defense mechanism by which people with borderline personality disorder (BPD) can view people, events, or even themselves in all or nothing terms. The process of splitting allows them to readily discard things they have assigned as "bad" and to embrace things they consider "good," even if those things are harmful or risky (Salters-Pedneault, 2020).
Splitting can interfere with relationships and lead to intense and self-destructive behaviors. A person who splits will typically frame people or events in terms that are absolute with no middle ground for discussion. Examples include:
Things are either "always" or "never."
People can either be "evil" and "crooked" or "angels" and "perfect."
Opportunities can either have "no risk" or be a "complete con."
Science, history, or news is either a "complete fact" or a "complete lie."
When things go wrong, a person will feel "cheated," "ruined," or "screwed."
What makes splitting all the more confusing is that the belief can sometimes be iron-clad or shift back-and-forth from one moment to the next (Salters-Pedneault, 2020).
People who split are often seen to be overly dramatic or overwrought, especially when declaring that things have either "completely fallen apart" or "completely turned around." Such behavior can be exhausting to those around them (Salters-Pedneault, 2020).
By itself, splitting may seem almost commonplace, a behavior easily attributed to any number of individuals we know and maybe even ourselves. However, splitting in BPD is considered a consistent and distorted behavior usually accompanied by other symptoms, such as:
· Acting out (acting without consideration to consequences)
· Passive aggression (an indirect expression of hostility)
· Denial (consciously ignoring a fact or reality)
· Projection (assigning an undesirable emotion to someone else)
· Omnipotence (the belief that you possess superiority in intelligence or power)
· Emotional hypochondriasis (trying to get others to understand how severe your emotional pain is)
· Projective identification (denying your own feelings, projecting them onto someone else, and then behaving toward that person in a way that forces them to respond to you with the feelings you projected onto them) (Salters-Pedneault, 2020)
Rage splitting Sudden anger that courses through the body, sometimes without warning. Chest tightens and vision may tunnel. A burning, aching feeling usually blossoms in the rib cage, like the heart is trying to break out and attack. Generally, the primary emotion felt is anger. The client becomes downright infuriated at someone or something for what could be no reason at all. This kind of split usually causes the client to act impulsively, saying things they should not, and lash out violently. It is almost cathartic in that it is a release of emotions or just one overwhelming emotion. Sometimes the client cannot remember what they did or said during the split and looking back the memory is usually a blur.
Preparation splitting This is a split that usually is not acted on. A scenario is imagined of what someone might say and how the client would respond. The client starts to gear up for this situation as if it is actually going to happen. They begin to hate the person in question, despite the fact that what the other party did or said was purely made up. When the time comes for the confrontation, nothing happens and the client feels disappointed. Mostly importantly, however, the feelings of imagined anger and betrayal linger.
Isolation splitting This spilt is brought on by an extreme fear of abandonment and usually blindsides the client unexpectedly out of nowhere. They could be at home, school, work or even with friends and have the overwhelming feeling that everyone hates them. Not only that, the client has the desire to prove themselves wrong so they do the most rational (or in this case, irrational) thing they can think of in an effort to get someone to notice them: the client cuts themselves off. For some clients, this is actually cutting people out of their life aggressively and then wondering why no one is checking on them. For others, this might be a casual withdrawing from social groups and conversations desperately hoping for someone to notice and ask if the client is “okay.” In both cases, the client is either noticed which brings a sort of euphoria or is unnoticed and will rage split on themselves (self harm, suicide attempts, risky behaviors, etc).
Sadness splitting A sudden feeling that the world has gone cold and empty and that nothing will bring joy ever again. This could be mistaken as a symptom of depression but these smaller splits typically resolve themselves in a matter of days or even hours.
Apathy splitting The client no longer feels any emotion whatsoever; for many clients, this a bit of heaven that quickly turns into hell. Since the client is so accustomed to experiencing everything at once, the numbness is overwhelming. In an effort to force emotions again the client creates chaos (self harm, danger activities, etc).
Silent splitting Similar to a rage split, which is anger fueled, this split is characterized by the same anger but actions are controlled. This is more common in quiet clients with borderline personality disorder.
Euphoria splitting This is a sudden “Everything is good and wonderful! Nothing will ever make me sad again!” kind of emotion that results from getting the attention craved. The client will then become so wrapped up in the feeling of elation that they neglect their real responsibilities, convinced they will be okay and lacking the ability to remember the consequences of their actions.
Treatment
Psychotherapy
Psychotherapy is the first-line treatment for people with borderline personality disorder. A therapist can provide one-on-one treatment between the therapist and patient, or treatment in a group setting. Therapist-led group sessions may help teach people with borderline personality disorder how to interact with others and how to effectively express themselves.
It is important that people in therapy get along with, and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with the disorder to maintain a comfortable and trusting bond with their therapist.
Dialectical Behavior Therapy (DBT) was developed for individuals with borderline personality disorder. DBT uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help:
· Control intense emotions
· Reduce self-destructive behaviors
· Improve relationships
Cognitive Behavioral Therapy (CBT) can help people with borderline personality disorder identify and change core beliefs and behaviors that underlie inaccurate perceptions of themselves and others, and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors (NIMH, 2017). It should be noted, however, that prolonged exposure CBT where the focus is primarily on the processing of traumatic memories is not appropriate for chronic traumatic individuals (Safarabad, Farid, Gharraee, and Habibi, 2018).
Eye Movement Desensitization and Reprocessing (EMDR) is a trauma-focused method of therapy, whose effectiveness in reduction of PTSD symptoms in controlled studies has been proved (Safarabad, Farid, Gharraee, and Habibi, 2018). A secure attachment with the therapist and resource building with the client is imperative for positive results regarding EMDR and BPD. A therapist’s deep understanding of complex trauma and the power of EMDR’s ability to unlock early childhood memories is the baseline for qualifications to work with this population. Clinicians should be highly trained in dissociation and assessing Window of Tolerance for clients. This stage-oriented model of therapy is useful for clients and therapists to track progress and provide structure to sessions.
Therapy for Caregivers and Family Members
Families and caregivers of people with borderline personality disorder may also benefit from therapy. Having a relative or loved one with the disorder can be stressful, and family members or caregivers may unintentionally act in ways that can worsen their loved one’s symptoms.
Some borderline personality disorder therapies include family members, caregivers, or loved ones in treatment sessions. This type of therapy helps by:
· Allowing the relative or loved one develop skills to better understand and support a person with borderline personality disorder.
· Focusing on the needs of family members to help them understand the obstacles and strategies for caring for someone with borderline personality disorder. Although more research is needed to determine the effectiveness of family therapy in borderline personality disorder, studies on other mental disorders suggest that including family members can help in a person's treatment (NIMH, 2017).
Sources
The National Institute of Mental Health. (2017, December). Borderline personality disorder. Retrieved April 28, 2020 from: https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Salters-Pedneault, K. (2020, March 5). Splitting and borderline personality disorder: a defense mechanism where everything is black and white. Retrieved April 28, 2020 from: https://www.verywellmind.com/what-is-splitting-425210