Do I have Borderline Personality Disorder (BPD)?

BPD and Complex PTSD overlap and may have similar symptoms

Many people come to my Vancouver office seeking mental health counselling wondering: Do I have borderline personality disorder?

You may have googled BPD online and the diagnostic criteria as defined by the DSM-5 seem to fit your experience of the world. 

If you’re curious about the criteria I’ve included it here below for reference : 

DSM-5 diagnostic criteria for Borderline Personality (BPD)

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following:

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

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)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

How Borderline Personality Disorder (BPD) May Fit Your Experience of the World

You find it difficult to sustain interpersonal relationships, you become easily overwhelmed or angered, and find it difficult to “control” your emotions and find yourself acting impulsively and angrily without thinking, which often leads to damage in work and relationships.

You find yourself changing your personality and interests based on the people around you.  You may experience intense paranoia about what others are saying or thinking about you as well as experience dissociative symptoms such as blanking out and losing track of time and not remembering when you have lashed out at others or how you got somewhere.

Do I still have BPD?

You may have been previously diagnosed with BPD as a young adult and wonder if you still “have” BPD.  When you were younger you may have engaged  in periods of self-harm, eating disordered behaviour, excessive substance use and/or suicidal urges but now you only engage in those behaviours on occasion or rarely now.  For example, when you have an episode of emotional intensity you may binge drink or get angry, but this happens less frequently than it used to do when you were younger. 

Now you find yourself parenting, working and/or studying but find the emotional energy to do all of these tasks can be mentally taxing.  Over the years you may have had a lot of counselling sessions or attended DBT groups and feel markedly better but still are set off by rejection by others and have incredibly low feelings of depression and often feeling like you cannot control your emotions.

It could be the case that now you no longer meet the criteria for BPD, as your emotion regulation has stabilized and you have grown a stronger sense of your self and have developed more healthy, supportive and long-lasting relationships. However, it is best to see a mental health professional such as a psychiatrist or a psychologist to be re-assessed.

A Therapist’s Experience Working with BPD and Complex PTSD (CPTSD)

When I worked in a community mental health team Borderline Personality Disorder (BPD) was one of the most common diagnosis given to people (mostly women) who were self-harming, suicidal, depressed, and struggling with intense emotions.  

To a Mental health team this meant that this client had a lot of needs beyond what medications alone and our short-term mental health counselling models could provide.  Psychiatrists often wrote in their reports “needs to develop emotion regulation skills” and recommended DBT.  

Psychiatrists very rarely screened for PTSD and Complex PTSD, unless it was the sole presenting issue (for example a refugee fleeing war or someone who experienced a single incident trauma such as a car accident).  When a client had multiple issues occurring for example: eating disorders and anxiety, and binge drinking and had sought help multiple times from the mental health system they were often also given the diagnosis of BPD, without assessing for co-occurring PTSD or CPTSD.

Being given a label of BPD officially by a psychiatrist could result in discrimination and bias when seeking emergency support from the hospital giving clients negative labels such as “help-seeking” or “frequent flyers”.  Clients told me they could hear nurses talking about their BPD diagnosis negatively and felt they were treated differently.  I did not doubt them, as I had witnessed the same in conversations with other mental health staff.  BPD carried a huge stigma, and still does today.

It was a contradictory experience for clients being told to use a safety plan that told them if they could not cope and felt suicidal that they should go to the hospital but then when they went there they experienced a negative judgements from staff for having come to the hospital in the first place.

I was keenly interested in DBT and so I read and undertook DBT training to work with BPD with suicidal clients.  At the time we did not have a full DBT team, but I tried to use the skills in mental health counselling with my clients and learned as much as I could.  I had the privilege of working with one particular client weekly with DBT who was highly suicidal. I felt it was effective and helped this client improve their coping, and it was very rewarding as a therapist. However when I left for another role they were still suffering- I do wonder how they are doing after all these years.  After learning about the effects of trauma and dissociation I wonder if a trauma-focused lens could have helped her find more relief and healing.

In my later clinical years I came to work with many pregnant and parenting women and people who were using substances.  They had all invariably suffered from intense childhood trauma- many were women of colour, Indigenous, low-income, and had grown up in foster care or abusive homes. In their adolescent and younger adult years some of them had been suicidal or self-harmed and then later ceased suicide attempts and self-harm when they began substance use. Many of these clients were at one point in their lives given the diagnosis of Borderline Personality Disorder (BPD).  

In working with these women I began to hear how their environment (racial discrimination, colonization, poverty) and trauma greatly affected their lives and I began to see that Complex PTSD seemed to fit better for many of these clients who had been diagnosed with BPD previously in their lives.  In that role I began to offer both DBT skills groups as well as EMDR therapy individually and noticed both of these therapies helped these clients greatly- with some clients finding one therapy more beneficial than the others, but often both were helpful.

In opening Emotion Wise in Vancouver, BC my goal was to provide high quality mental health counselling. I sought to continue work with those with complex trauma and emotion regulation issues.  In this practice we see many clients who suspect they have BPD, and have been diagnosed in the past, many who have experienced trauma in their childhood. We run trauma-informed DBT Skills groups and provide EMDR therapy.

These clients often share stories of traumatic childhood invalidation which may have included having a parent with intense mental health issues, being verbally abused, being neglected, their needs being dismissed, and not having anyone truly there for them.  Some of the people with CPTSD and BPD who come to us have also experienced sexual and physical abuse, and many have experienced abusive relationships. 

 However the singular thread that ties them together is what Marsha Linehan describes as an “invalidating environment” or “traumatic validation”.

What is Traumatic Invalidation

Traumatic Invalidation is the act of over and over again being dismissed, verbally abused, not believed in or put down.  Examples include repeatedly being yelled at, not being provided with the necessities of life, and/or lack of emotional support. A caregiver may be so busy surviving their own mental health challenges in life that they neglect to be present emotionally to a child and in doing so may actively emotionally harm them.  It could also mean punishing a child for intense emotions or outbursts.  Traumatic Invalidation is often accompanied by a lack of healthy and secure attachment to their parents or caregivers. Marsha Linehan described an invalidating environment as somewhere where you don’t fit and you are not understood, like a square peg in a round hole.

Often these experiences are not seen as not traumatic (enough) by a mental health professional assessing for PTSD  as one’s life wasn’t threatened or there was not physical or sexual violence.  However, constant invalidation, verbal abuse and neglect can have intense ramifications for a child’s developing sense of self and often is the building blocks for later mental health struggles.

If it’s Not BPD, what is it?  

I do not claim to be able to tell you if you have BPD and/or Complex PTSD (see our blog post on what is complex PTSD), or another diagnosis.  However, my experience is that most people with BPD also have Complex PTSD.  Complex PTSD is a relatively new term that acknowledges the deep impact of repeated and chronic trauma in a person’s life. Complex PTSD was coined by Judith Herman who wrote one of the first books on Trauma called “Trauma and Recovery”, though it is not an official diagnosis in the DSM V. People with complex PTSD may have difficulty with emotion regulation and challenges in interpersonal relationships.

For those with Complex PTSD (and often with those with BPD) the foundations of a person's sense of self was developed in response to an invalidating environment.  Their behaviours and emotional intensity are patterned responses that developed to meet their own needs in an environment that failed to protect them and validate them from real emotional wounds. 

For example, if anger was the only way to be noticed and to connect with someone then anger may become a patterned response. A common recurring theme I hear from those I work with is that they were told many times in many different ways that you are “too much”. This feeling that their emotions were too much can create sense of shame and increased sensitivity to their own emotions.

In addition, a person with BPD may also have other conditions such as Autism, ADHD, OCD, or Bipolar disorder, or find that when diagnosed and/or treated for these conditions that BPD doesn’t fit anymore.  

For some people a diagnosis of BPD fits well and feels like a relief as it deeply resonates and for others it doesn't fit and may feel stigmatizing. For many other people- getting diagnosed later with other conditions, such as Complex PTSD, better help them regain a sense of self-understanding, wellness and healing in their lives.

What Therapy Works for Complex PTSD and BPD

People with BPD and Complex PTSD are very diverse and therapy needs may change depending on what a person's needs and which stage of life they are in and what their goals are.

For someone who is actively engaging in self-harm and suicidal I would recommend DBT therapy as it was created to provide practical skills to help cope with distress and build a life worth living.

If you are struggling with your emotional regulation whether with anger or substance DBT skills provide a solid foundation to help you cope in a new way.

However, if you are no longer struggling with the same intensity of emotions I highly recommend a trauma therapy such as EMDR  to help heal experiences of childhood invalidation and trauma.  There are emerging studies that show that treating trauma including with EMDR, can not only treat Complex PTSD and PTSD, but also BPD symptoms.

Additional therapies that have a significant evidence base for BPD include: Schema Therapy, Transference Focused Therapy, General Psychiatric Management and Mentalization Based Therapy. Many emerging therapies such as ego state therapy, Somatic therapy, and Internal Family Systems therapy many find helpful as well for both BPD and CPTSD.

My experience is that healing trauma helps form new positive beliefs in yourself that may decrease the need for previous BPD behaviours that were borne out of a need to avoid abandonment, deep feelings of aloneness, and lack of validation from a traumatic past.

At Emotion Wise Counselling we provide mental health counselling in Vancouver and throughout BC specializing in EMDR and DBT for complex trauma and emotion regulation issues. 

Reach out today for a consultation.