Beyond the DSM: Understanding Borderline Personality Disorder
1. The Diagnostic Criteria
Borderline Personality Disorder (BPD) is described in the DSM-5-TR as a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, along with significant impulsivity. The pattern begins by early adulthood and is present across a variety of situations.
For a diagnosis of Borderline Personality Disorder, a person must exhibit five or more of the following nine characteristics:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships, often involving movement between extremes of idealizing and devaluing another person.
Identity disturbance, involving a markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging, such as spending, sexual behavior, substance use, reckless driving, or binge eating.
Recurrent suicidal behavior, gestures, or threats, or self-harming behavior.
Significant emotional instability and reactivity, often involving episodes of intense sadness, irritability, or anxiety that may last several hours and, less commonly, several days.
Chronic feelings of emptiness.
Inappropriate or intense anger, or difficulty controlling anger, which may include frequent displays of temper or persistent anger.
Temporary, stress-related paranoid thinking or severe dissociative symptoms.
Diagnosis Is Not the Same as Understanding
Think about basketball.
A definition might tell us:
Two teams
Five players on each team
Put the ball through the basket
Score more points than the other team
Rules such as:
Traveling — moving illegally with the ball without dribbling
Double dribble — stopping your dribble and then starting it again
Charging — an offensive player illegally running into a defender who has established position
Goaltending — illegally interfering with a shot near or above the basket while it is on its way down
Personal foul — illegal physical contact with another player
It could even give us precise definitions of each of those rules.
Accurate? Yes.
Do you now understand basketball? No.
To understand basketball, you also need to understand:
How the pieces fit together
What players are trying to accomplish
Why they respond the way they do
Patterns that develop during the game
What to do in different situations
The DSM works in a similar way.
It helps us:
Identify BPD
Describe its characteristics
Diagnose it
But a list of characteristics does not necessarily tell us:
What BPD feels like from the inside
Why these reactions occur
How the characteristics fit together
What happens in close relationships
How to respond effectively
2. Understanding BPD
The Leaky Cup
Sense of self connected to the opinions of others.A Unique Picture of the World
Centered around memories of pain.Difficulty Hearing Criticism
A Distorted View of Connection
I’m abandoned. I’m not enough.Splitting
High highs and low lows.Emotional Instability in Reaction to Day-to-Day Events
Anger. Sadness. Withdrawal.Impulsivity
The Punching Bag and the Witness Stand
Learning to Communicate in Terms of Negative Cognitions
What’s the need?The Need for Boundaries
Putting the Pieces Together
The Leaky Cup
Central to understanding BPD is that humans need meaning, and part of that is having a sense of who I am and what value I have. A person with BPD will tend to struggle with feelings that they are not enough, that there is something fundamentally wrong with them, or that no one can really love them.
If we think of having our lives filled with meaning as analogous to “filling our cup,” then one way to understand a borderline characteristic is to imagine a nearly constant need to refill the cup because the cup has a hole at the bottom. As meaning is coming in, it is also draining out.
When the cup reaches empty, that is when negative behavior may emerge, such as:
Panic
Anger
Turning to addictions
Suicidal thinking
Turning on loved ones
Negative sentiment override
A Unique Picture of the World
The unique picture of the world can be understood as emerging, in part, from the panic that comes from the leaky cup. It is miserable, nearly unbearable, to feel that emptiness, so a person can become very self-focused in an effort to overcome it.
They may come to expect others to view the world as they do. Often, those closest to them can begin to adopt some of that distorted view as well, because it can be hard to dismiss a view of reality that is repeated again and again and again by someone we care about.
Difficulty Hearing Criticism
Difficulty hearing criticism is an especially important characteristic to understand in many people with BPD.
The distorted view of reality may have become a piece of psychological survival for the person who developed it, and challenges to that view can therefore be met with great resistance. Moreover, the person's self-esteem may be so weak that criticism is received not simply as criticism of something they did, but as an attack on the core of their being and their sense of value.
A criticism such as:
“I didn't like what you did.”
may be experienced as:
“There is something wrong with me.”
“I'm not enough.”
“I'm unlovable.”
A Distorted View of Connection
A distorted view of connection and what it means is another hallmark of the pattern.
A story sometimes heard from the partner of someone with BPD characteristics is: “Everything was great right up until we got married, and then my partner turned on me.”
One way of understanding this is that enormous hopes have been placed on the relationship. The partner is expected to meet needs that the person has never learned to meet internally, and the day when those needs will finally be met may be anticipated with tremendous excitement. When the partner inevitably fails to meet all of those needs, there can be extreme disappointment.
The person with BPD may struggle to find fulfillment internally or to self-soothe. They look to other people to help them do that.
On the other hand, just as they may want someone else to be everything for them, they may also want to be everything for someone else. If their spouse doesn't miss them after a short absence, doesn't seem to rely on them, or seems perfectly content without them, that can be devastating and reinforce the negative cognition:
I'm not enough.
Splitting
Splitting is where the person who is looked to for meeting those needs can go from being a hero to a zero.
If the partner is helping fill the cup, everything may feel wonderful. But if something happens and the cup suddenly drains—and what happened may have very little to do with the partner—the partner can suddenly be experienced as failing, uncaring, or unloving.
It becomes difficult to hold both ideas at once:
I'm hurting and my spouse still loves me.
My spouse disappointed me and is still a good person.
I'm angry with my spouse and still deeply connected to them.
Emotional Instability
The emotional instability goes along with the instability of the cup.
Many things can cause the cup to drain, and the hole in the bottom means that refills are constantly needed. But life simply does not operate on the terms that this person desperately wishes it would—where the world is continually functioning in such a way that the cup remains full.
The result can be rapid movement into:
Anger
Sadness
Anxiety
Panic
Withdrawal
Despair
Impulsivity
Impulsivity, addictive behavior, and what would sometimes be called “firefighters” in IFS terminology can be understood as responses that emerge when the cup is drained.
These behaviors can represent desperate efforts to avoid or escape the experience of emptiness or meaninglessness.
The specific behavior varies considerably from person to person.
The Punching Bag and the Witness Stand
If someone repeatedly describes feeling like a punching bag in an important relationship, that tells us something is seriously wrong in the relational pattern. It does not by itself establish that the other person has BPD, but this experience can occur in relationships involving significant BPD characteristics.
Because of the desperate need to have the cup filled, combined with the sense that there is a particular person—often the romantic partner—who has the ability to fill the cup if they were only willing, that partner can come under significant and intense attacks upon their character.
This can be a very lonely experience. Many people will keep it to themselves for a long time. They may begin to believe that the attacks upon their character are true, or they may gradually lose confidence in their own ability to distinguish between what is true and false, real and unreal, what they feel and don't feel. Eventually, some simply become numb.
During these attacks, the person may also feel that they are on the witness stand, being asked to defend themselves against things they supposedly said:
Yesterday
Two months ago
Eight years ago
The underlying accusation is often:
You don't love me.
And it can be extraordinarily difficult to prove to a person whose cup feels completely empty that anyone loves them, that they could ever be loved, much less that the person currently on trial actually loves them.
Learning to Talk About Needs
What is crucial to making progress in a relationship involving BPD characteristics is learning to talk about needs, not only facts.
This is important for both partners.
The person who is attacking needs to learn to recognize that underneath the attack is often hurt, fear, shame, or vulnerability.
They need to learn to speak in those terms:
I feel unloved.
I feel like I'm not enough.
I feel like there is something fundamentally wrong with me.
I feel worthless.
I don't understand why anyone would see value in me.
I'm afraid you're going to leave me.
When the conversation shifts from accusation to what the person is actually feeling, vulnerability emerges.
The partner can feel empathy.
Compromise becomes more possible.
The real need can finally be discussed.
The Need for Boundaries
The last piece is the need for boundaries.
It is simply not helping anyone to keep taking the beatings.
Yes, Christ calls us to turn the other cheek, but did he mean that we should allow people to walk all over us? Did he mean that we should leave someone in torment and make no effort to help them change?
The person with the empty cup who is lashing out is miserable. Loving them means wanting to help them overcome that state, not simply allowing destructive patterns to continue indefinitely.
A person with BPD characteristics needs help, and sometimes that process begins when loved ones call attention to inappropriate behavior and refuse to continue participating in destructive interactions.
A person may be capable of exercising considerably more control in settings where expectations, limits, and consequences are clear. That tells us something important: boundaries matter.
Boundaries might sound like:
I will talk with you about what you're feeling, but I won't continue while I'm being yelled at.
I want to understand what hurt you, but I'm not going to defend myself against accusations for the next three hours.
I love you, but I will not accept being treated this way.
We can come back to this conversation when we're both able to talk respectfully.
The goal of a boundary is not punishment.
The goal is to stop reinforcing destructive ways of seeking connection and make room for healthier ones:
Asking for help
Naming the underlying feeling
Learning to self-soothe
Tolerating disappointment
Communicating needs directly
Accepting responsibility
Developing a more stable sense of self
