Detecting Borderline Personality Disorder to Begin TreatmentWritten by: Rob Print This Article
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The first step in helping somebody with BPD is figuring out that they suffer from it. In the article Could it be Borderline Personality Disorder (BPD)?, author Tami Green lists 43 questions to examine your personality or that of somebody close to you to see if you may have Borderline Personality Disorder. The more questions answered “yes”, the more likely a person is to suffer from BPD or a similar mental health problem.
BPD Related to Narcissistic, Histronic, and Antisocial Personality Disorders
An important point to consider is that the DSM-IV Axis II Cluster B personality disorders (Borderline – BPD, Narcissistic – NPD, Histrionic – HPD, and Antisocial – APD or ASPD) share a number of behavioral patterns. It could be that somebody who seems like a Borderline is really a Narcissist if they show a lot of these traits but tend to be more self-absorbed, an Antisocial if they tend to be more lawless and ruthless, and a Histrionic if they tend to be very dramatic.
Stop Stigmatizing Mental Illness
In most cultures, mental illness is stigmatized. People tend to hide it and be in denial that it affects them or a loved one. It is my sincere belief that this societal stigma and resulting individual hiding/denial behavior pattern is highly destructive and irresponsible. Destigmatization of mental illness should be a high priority for all societies because these conditions lead to long-term quality of life problems ranging from depression to domestic violence to suicide, yet many of them are highly treatable. Even in cases which are not treatable, simply knowing what is causing the problems may make it easier for the family of the patient to deal with the behaviors by learning coping and behavior modification skills that help the patient and the family.
Mental illnesses are caused by a variety of factors. There is often a genetic, biochemical, or neurological reason for many cases. In many other cases, it is environmental factors over which the patient has little or no control (child abuse, divorce, crime, etc.) that lead to mental illness. And it is common for both of these types of factors to be involved. For BPD in particular, it is increasingly believed that the brains of Borderlines grow in some way that makes them more susceptible to emotional overload. When they are exposed to too much invalidating and confusing input, the person develops BPD traits. If it continues unabated, full-blown BPD is the result.
Protecting Patients, Families, and Society
Being mentally ill is no more the fault of the patient than having a cold, flu, or cancer is the fault of patients with those diseases. In most societies today, we don’t stigmatize people for having a flu or cold or cancer. For infectious diseases, we may advise that they stay home, get some rest, stay away from other people until they are feeling better to reduce the spread of damage caused by the illness. Mental illnesses should be viewed the same way as biological diseases. Drop the stigma, focus on the solutions for the patient and prophylactic measures to keep other people safe.
Some mental health conditions are “infectious” in the sense that they spread mental health disorders to unprepared people who come into contact with the patient. BPD is one of these “infectious” mental illnesses. I don’t mean that you literally catch it like a viral cold or flu or a bacterial infection. What I mean is that if you are in frequent close contact with a person who has BPD, you are likely to be subjected to stressful and difficult behaviors that will produce mental health problems for you and your family, especially if you are unaware of why the person who is mentally ill treats you as he or she does.
Borderline Personality Disorder in particular has a really bad reputation with many mental health professionals and people who have suffered from what Borderlines have done to them. The reputation is deserved, but it should not deter trying to help patients and their families.
Cancer has a horrible reputation, too, yet doctors try to help cancer patients with great effort rather than run away from them as many mental health care providers do with those suffering BPD. Yet cancer often turns out to be incurable and fatal. While it is true that BPD can lead to fatality, especially by suicide, the death rates from BPD are lower than from many cancers, and many people do improve markedly with treatment. Moreover, their families and communities can be spared great damage and expense if the BPD is acknowledged and handled with sensitivity and caution.
This last point may not make sense if you haven’t been through a family relationship (spouse, child, parent, etc.) with a Borderline or similar personality disorder. Borderlines often do a great deal of damage to themselves and their family members. They may attempt suicide. They may “split” and turn hostile to one or more family members, triggering a high-conflict disputes complete with extensive and expensive involvement of courts, police, and CPS agencies who are woefully untrained and ignorant of this illness. The most common such dispute is probably a divorce, but others are possible, too.
If the illness had been diagnosed and documented, the family been made aware of it, and the government required by law to contact the properly trained mental health care providers involved in the case for consultation, damage could be significantly reduced. Instead of unmitigated destruction, disasters could be averted before they ruin people’s lives far behind any reasonable level of damage. It might sometimes require institutionalizing a BPD victim for a period to get some control over the illness and begin therapy. But a few weeks or months of that is far preferable to years of expensive and emotionally devastating high-conflict litigation, false child abuse allegations resulting in traumatized children and families, and real abuse from the BPD victim with no means to assist the victims and setting them up for their own mental health problems.
It’s true this all sounds really miserable. But it is far less miserable when it is detected early and dealt with appropriately. It is possible for a person with BPD to recover to a level that these severe risks are no longer present.
Even though you may have been attacked and harmed badly by a Borderline and learned to hate the person, you should remember that these people deserve help. If they got the help earlier, you would have already been spared a great deal of misery. If they get the help now, it may still help them and you avoid a lot more misery that would otherwise occur. Borderlines did not cause their core mental health problems and probably in most cases don’t even fully understand that something is wrong with them.
Instead, they often think their close family and friends around them are controlling, paranoid, dishonest, and dangerous and they are the normal ones. Given that they have known themselves all their lives, thinking they are normal and other people are not is not surprising. They need help, and if they don’t get the help they need to recover and ensure they are in safe situations, they are going to hurt themselves and other people. They usually need somebody else to push them towards treatment because of their denial. It is very much like how substance abusers tend to either need to hit absolute rock bottom or somebody else to force them into treatment before they start to acknowledge their problems.
When you think about it, getting them help means you’re also helping protect other people in their lives. It’s conceptually similar to getting help for somebody who has diabetic blackouts or epileptic seizures. Such people need medical treatment and shouldn’t be driving cars if they are prone to blacking out. If you don’t identify them early, start to treat them, and ensure that they stay in safe situations (always passengers when at risk for a blackout and never drivers), they and other people are virtually certain to be hurt badly.
The same goes for Borderlines. If they are not identified and pushed into treatment, they are likely to hurt other people because of their problems.
Personality Disorders Very Common
In recent years, the estimates for the percentage of people suffering from BPD has risen from about 2% of the general population to about 5.9%. For NPD, the percentage is about 6%. Estimates for APD are that is is more common in men than women and overall may affect about 2% to 3% of the population. HPD is less common still, at around 2% of the population with women more often having it.
Interestingly, although personality disorders often severely impact a person’s life, not all are equally disruptive. HPD is considered the least likely of the four Axis II Cluster B personality disorders to severely impact a person’s life and ability to have relationships and employment.
However, Obsessive-Compulsive Personality Disorder (OCPD) is less disruptive still. The approximately 8% of the population that have it tend to work in detail-oriented jobs in accounting, engineering, science, and other areas with “perfectionist” reputations that benefit with the obsession to detail and perfection. Furthermore, people with OCPD generally are not bothered by their condition and often think it has helped them.
Interestingly, Valerie Porr, a BPD advocate whose daughter suffers from the illness, suggests that acting is a great career for Borderlines:
As a child I had seen a film called “Gaslight” in which Ingrid Bergman, an heiress who is newly married, remarks to Charles Boyer, her ne’er-do-well husband, that the gaslights in their home seem to be dimming. “No, they aren’t darling,” says Boyer, as he fawns over her, “You are imagining things.” Ingrid soon feels that she is going mad when, over time, what she perceives as reality is not being validated by her doting husband. The dimming gaslight is the perfect metaphor for the experience of living with someone with borderline personality disorder, and advocating for education, appropriate treatment and research for this painful disorder.
The person suffering from borderline personality disorder, a severe and persistent mental illness, may appear completely “normal” and may often have the ability to act “as if” he or she has no problems. In fact, many people with borderline personality disorder become professional actors. This “as if” ability of people with borderline personality disorder can be particularly devastating to those who love them.
For people ages 19-25 in the US in the general population, it estimated that about 20% suffer from a personality disorder of some kind. When you add in all psychological conditions including substance abuse, about half of the people in this age group suffer from a mental health problem. Yet only about 25% of college aged people with mental health problems receive any type of mental health care.
For the overall US population, the National Institutes of Mental Health estimates that in any one year, about 25% of people have a diagnosable mental health disorder.
A 2005 paper in the American Psychiatric Journal entitled The Prevalence of DSM-IV Personality Disorders in Psychiatric Outpatients studied personality disorders and other common mental health conditions in people who are undergoing outpatient psychiatric health care. Most patients who meet the criteria for one personality disorder are likely to have one or more additional personality disorders. The authors believed that screening for personality disorders should be routinely performed for every patient as they affect more than half of patients and impact treatment of Axis I disorders (anxiety, depression, etc.) for which medications are often prescribed:
In conclusion, personality disorders are frequent in psychiatric settings. A summary of other clinical epidemiological studies using semistructured diagnostic interviews indicated that at least half of the patients had a personality disorder, thus making these disorders, as a group, among the most frequent disorders treated by psychiatrists. Personality disorders should be evaluated in every patient because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.
In psychiatric hospitals, an estimated 20% of adults and about 43% to 53% of teens have been diagnosed with BPD. Part the reason for this is that as a group, Borderlines have a very high suicide rate and because of the suicidal ideation and suicide attempts they are often institutionalized at some time.
As you can see, mental illness and personality disorders are extremely common. If a major fraction of our society has these problems as research shows, then hiding and ignoring them is just going to result in unnecessary suffering and damage. Again, drop the stigma and focus on finding and implementing solutions for those with mental illnesses that help them and their families and communities.
Non-BPs Often Show Some or Many BP Traits
Much of the literature on BPD refers to people with BPD as “BPs” and those in relationships with the BPs who don’t have BPD as “non-BPs”. Being in a close relationship with a BP or a person with another personality disorder is likely to have a profound effect on your emotional health and how you view your life.
What is perhaps unexpected about BPD is that people who are involved in a relationship with someone who suffers from BPD or similar personality disorders (e.g., Narcissistic Personality Disorder) start to develop mental health problems themselves. Don’t be surprised if you can answer quite a few of Tami Green’s BPD questions “yes” yourself, even if it is your loved one you think has BPD and not you.
For instance, if you’ve been through a divorce or break-up with a Borderline, Narcissist, or Antisocial personality, you’re likely to have experienced being personally attacked in extreme ways that make you afraid of being around other people, wondering if any relationship can be safe, and suffering from stress-related mental illnesses especially including ones such as depression and anxiety disorders, including Post-Traumatic Stress Disorder (PTSD). The nature of such attacks is discussed in our article BPD Distortion Campaigns. For a person who has suffered through this kind of experience, it is not be surprising to answer “yes” to 10 or 15 of these 43 questions.
Children of BPs (and other Personality Disorders) Often Develop Mental Health Problems
If you grew up as a child of a Borderline, especially if you didn’t have a mentally healthy parent around defending you, it’s also likely you’ll answer “yes” often. Keep in mind that Borderline mothers in particular tend to pass on BPD to their daughters because of the parentification, invalidation, inconsistent treatment, and often abuse they inflict upon their children.
Just as with an adult in a relationship with a BP, children are also likely to develop depression and anxiety disorders. They may also have problems with interpersonal relationships that look like attachment disorders, substance abuse, eating disorders, or even BPD itself. Andrea Lamont of the Teachers College of Columbia University writes about this in her paper Mothers with Borderline Personality Disorder (PDF):
Researchers have long been interested in examining the familial patterns of BPD. Masterson (1976) once commented that “the mother of any borderline is herself a borderline,” and since then, research in this area has focused on the increased prevalence of psychopathology in biological families (e.g., Links, Steiner, & Huxley, 1988). Family members of those with BPD are at an increased risk for a myriad of psychopathological diagnoses. The prevalence rate of Borderline Personality Disorder is five times greater in first degree relatives of people with BPD than in the general population (APA, 2000; Links et al., 1988; Paris, 1999) with an even higher prevalence of subsyndromal phenomenology of the disorder in first degree relatives (Zanarini et al., 2004). Additionally, Substance Dependence, Antisocial Personality Disorder and recurrent mood disorders (primarily, unipolar depression) are commonly diagnosed within the family of origin (APA, 2000; Links et al., 1988).
Diagnosing borderline personality disorder in teens or children is often regarded as reckless to do because personalities are not fully formed and many of the problems that Borderlines have with moderating emotional reactions and dealing with being alone are also similar to behaviors that “normal” teens and children may have. If you find that your teen or child seems to get a lot of “yes” answers on these questions and you’re not sure what that means, try to find a control subject such as a similar age child who is generally well-behaved and has little trouble with emotions and try to answer the question list for them as a comparison. It’s by far best if you can get a parent of that comparison child, perhaps a friend or relative of yours, to help you with your attempt to get a comparison set of answers. That’s because many BPD behaviors and symptoms don’t show up much or at all with people who are not part of a person’s emotionally close set of family and friends.
Furthermore, it’s really common for kids and teens to have issues with friends, feeling alone or left out, and to experiment with varying interests and behaviors based upon what friends and classmates are doing. Don’t get overly worried if your child has a lot of “yes” answers for questions in these areas.
List of Questions Commonly Answers “Yes” by Non-BPs
I went through Tami Green’s BPD question list and found that the following ones seem to be likely to be answered “yes” by people with a relationship with a Borderline or Narcissist. The term “relationship” often implies romantic relationships, but for the purposes of these questions it applies to other kinds of close emotional relationships such as parent-child and sibling relationships.
Below I’ve provided reasons for why many of these questions may be answered “yes” for a person in a relationship or who had a relationship with a Borderline or Narcissist who is not suffering from BPD or an Axis II Cluster B personality disorder.
This isn’t the full list of 43 questions. For that, you have to go visit Could it be Borderline Personality Disorder (BPD)?
- Would you say your emotional life has been characterized by anguish?
Being in a relationship like these tends to be very emotionally challenging. You are often attacked for no apparent reason, then your partner will suddenly change moods. You may still be angry about why he or she was screaming at you about being insensitive, controlling, and abusive because you calmly asked if he or she put gas in the car. But he or she doesn’t see why you’d be upset about being treated like that. Such people often show a distinct lack of empathy and rapidly changing emotions. This may appear as a complete lack of guilt or remorse for their actions. It’s quite likely they will never apologize for offending or attacking you, even when it appears self-evident that they were out of line. So it’s no wonder you are going to feel emotional anguish.
- Have you ever been accused of behaving in ways that are all or nothing with nothing in between?
All or nothing thinking is sometimes referred to as “splitting”. It is a behavior of many Borderlines. Borderlines tend to do a lot of projection of their mental health problems onto the people with whom they have relationships. This is often a defensive tactic to hide their own discomfort about themselves.
If you can simultaneously think about good and bad points about the person, you’re probably not splitting and it is probably your loved one projecting it on to you. For instance, if you can think that your loved one’s singing in the shower that provokes your neighbor to bang on the wall is annoying but he or she is really helpful at cleaning up the kitchen, it’s likely you’re not the one with the all or nothing thinking.
A Borderline would tend to either see it as all negative or all positive.
When it is all negative, the singing is really annoying, the neighbor is a jerk but you caused it, and your failure to clean up the kitchen without being asked is because you are a disrespectful aggravating jerk who wants to cause trouble.
When it’s positive, she loves your singing, thinks the neighbor’s percussion assistance is really cool, and moreover it is so wonderful how you clean up the kitchen really well.
- Have you experienced intense episodes of sadness, irritability, and anxiety or panic attacks?
Nearly everybody gets upset for a little while. A rude driver cuts you off, and you shout in your car “jerk!” But it lasts a moment and is common.
You drop your favorite mug on the floor and it cracks. Of course you might feel sad, maybe a bit angry at yourself, too.
Maybe you get cranky when you don’t get enough sleep. That’s not uncommon, either.
Perhaps when you are expected to speak in front of 1000 people and you’re not used to doing it, you get a bit of an anxiety attack. Also not so uncommon.
If you’re a Borderline, all of these examples would be much more emotionally intense and on a frequent basis, something like the following.
“G**damn f*cking asshole! Why can’t you f*cking drive straight! I’m going to follow you home and run you down in front of your family if you do it again! (said after rolling down your window and sticking your middle finger up at the other driver)
Your mug falls, and you drop to the floor crying for 10 minutes.
Your child spills a couple of drops of milk on the table and you respond “You can never do anything right, you’re a loser! Clean it up, you brat!”
You think about the speaking engagement tomorrow and have a panic attack, unable to do anything but sob.
- Have you often felt raw? exhausted? in despair?
- Do you have trouble sleeping?
Being around a Borderline can be exhausting, but at the same time leave you so wound up from being attacked and worried about what the Borderline will do next that you may have trouble sleeping. Exhausted people can become very cranky and feel hopeless.
I know this from personal experience when I don’t get enough sleep. A lot of my sleep problems come from the anxiety of being frequently threatened and lied about by a person from my past whom I believe has Borderline Personality Disorder, even though like many Borderlines she’s never been formally diagnosed with it.
- Have you experienced intense relationships?
It’s common for young people to have more intense relationships, so you have to judge by comparison. If you feel calm and content with your relationship and that you can count on the person being around, then the person is probably not a Borderline. If you feel a mixture of being pushed away, pulled back, beaten up, and adored and this variation occurs frequently, that’s what is meant by an “intense” relationship in the Borderline sense.
- Does your partner accuse you of having a double standard about the relationship?
For instance, BPs and NPs often expect you to do things for them that they consider beneath themselves and you don’t deserve any thanks for doing them. If you don’t do them, they will often criticize you for being uncooperative, unhelpful, or some other complaint to make you feel bad about yourself or try to play you with guilt.
If you request a small favor of them after this, they may refuse and say they are always helping you and you never do anything for them.
People who do this are often projecting their attitudes on to you, and that’s a sign of a BP or NP.
If you call them on it and point out their double standard, you may be completely accurate about it but you’re not likely to get an apology or agreement or willingness to change. It is as if your feelings do not matter.
- Have you said you feel “unsafe” in your relationship?
Borderlines can strike terror into the hearts of others with their intense verbal, emotional, and even physical abuse. Of course you would feel “unsafe”.
“Unsafe” to Borderlines is more likely to mean they are afraid you might leave the relationship when they want you to stay. Then they act as if they must control you through intimidation, blackmail, or brown-nosing such appealing to your vanity or ego to get your compliance.
- Are you often afraid that the world is going to cave in on you… that your life is going to collapse if you aren’t in control of everything?
BPs may feel like this because you said you can’t make it to dinner with them.
Non-BPs may feel like this because the BP threatened to report you to the police as an animal abuser if you don’t walk the dog, something they don’t have time to do since it’s time to leave for work.
- After a relationship has ended, have you felt like you’re experiencing Post Traumatic Stress Syndrome?
For a BP, a “yes” might mean having abandonment fears resulting in severe anxiety and memories of what was lost.
For a non-BP, the flashbacks and fears might be triggered from hearing a loud knock on your door when UPS drops off a package. You’re feeling afraid because the last time that happened, it was the cops there to investigate yet another false accusation against you and they cuffed you and made you face the wall in your own home.
- Have others commented or complained you work too much?
A BP might answer “yes” and it’s because the BP claims to be working all night, but really is having an affair for the 3rd or 4th time this year and doesn’t want you to ever find out.
A non-BP might answer “yes” because when the non-BP goes home it’s just going to start more fights, arguments, verbal abuse, or even physical attacks. So the non-BP works late to avoid the BP at home out of fear.
- Has anyone ever accused you of being paranoid?
BPs are accused of being paranoid because they often are, thinking that a compliment you give is a tactic to manipulate them or that you’re having an affair because you came home 30 minutes late.
Non-BPs may answer “yes” because the start to be afraid to come home, afraid to answer the phone, and afraid to open their email lest there be another rage from the BP.
- Have you ever cut yourself?
This really is a question about intentional self-harm. If you have intentionally harmed yourself by cutting, slashing, smashing, or otherwise mutilating your body and find that it is somehow a relief to do so, it’s a sign you may have BPD.
The key seems to be that BPs are more likely to self-mutilate to get an endorphin reaction that reduces stress and pain, whereas others are more likely to do it because of severe depression.
- Have you ever experienced so much emotional pain that you felt like you wanted to die?
For a BP, that might happen from getting ditched on a date.
For a non-BP, it might happen from being verbally abused on a daily basis for months or years.
- Do social engagements and vacations often end up in turmoil?
For a BP, it may happen because they want to make somebody else look bad or get attention.
For a non-BP, it may happen because the BP intentionally embarrassed you in front of your friends to make you look like a fool or completely changed the plans without even telling you and then acting like you should have known thereby making you look like an idiot.
- Do you feel like your partner isn’t telling you everything?
For a BP, this can again be tied back to abandonment issues. They may wrongly suspect you of having affairs or of hiding money or or plotting to leave the relationship. They suspect that because they would do these things to you if they felt like it.
For a non-BP, this can be tied back to the BP really is having affairs, hiding money, or plotting to leave the relationship. You wouldn’t do it to the BP, but he or she has done it to you before so it feels like the BP can’t be trusted and is keeping secrets.
- Do you often feel lonely even when you are in a relationship?
For a BP, a “yes” to this may mean they can’t get enough of you even when they call you fourteen times per day at your work.
For a non-BP, it may be because you realize you can’t say anything much without risking a tirade and wish you had a relationship with somebody stable enough you could say “hello” when you walk in the door without it provoking a fight about why you said “hell no” indicating you are a disrespectful and verbally abusive person who should be raged against.
If you’ve gotten the sense that BPs tend to answer these questions “yes” when they have extreme interpretations and non-BPs tend to answer “yes” because of extreme behaviors towards them, you are on the right track. BPD tends to make the BP overreact, and the overreaction tends to make the non-BP distrustful and fearful of the BP.
Somebody who has BPD would likely answer “yes” to 20 or more of these questions if they are being honest with themselves. As many Borderlines have trouble with honesty and tend to do a lot of denial, it may help to both have them answer the questions and one or two people with whom they are close answer the questions about them, too. This way you get multiple viewpoints that might help cut through the denial.
The more “yes” answers there are, the more likely it is the person has BPD. Anything more than about 15 and it’s reasonable to consult a therapist who is experienced in treating people with BPD. Anything more than about 5 and you should probably be seeing a therapist for something as you’re likely to have some mental health problem from whatever your situation is.
If in doubt, talk it over with close family members or friends who seem emotionally stable, rational, and like to help other people. Ask them if they would be willing to spend some time learning about BPD because you think you or a loved one might have it but aren’t sure and need some help figuring out what to do. You can possibly motivate them by saying that even if you or your loved one don’t have BPD, it would still help you to figure that out and that with 6% of the population having it, it’s important to know at least a little bit about it because they will meet people who have it if they haven’t already.
Borderline Personality Disorder Treatment Centers and Resources
If after doing this exercise you suspect that you or a loved one may have BPD or a related personality disorder, it’s important to pick a therapist who is capable of treating such mental health care problems. Many therapists regard Borderlines as “untreatable” and lack the knowledge and skills to help them. They may do more harm than good.
It’s generally best to look for therapists who practice Cognitive Behavioral Therapy (CBT) or better yet Dialectical Behavior Therapy (DBT). A list of therapists who have trained in and practice DBT is available from the Behavioral Tech DBT Therapist Directory.
Unless you can get a solid referral from somebody else who has BPD and is recovering, you should interview multiple therapists. Before you do the interviews, learn more about DBT via our previous article BPD Treatment: Free Dialectical Behavior Therapy Audio Tracks and the articles and audio recordings to which it links.
Ask about their experiences treating people with BPD and what they think is reasonable to expect for progress. You want to find somebody who won’t write off the BPD patient as a lost cause. For instance, claiming they can really never get much better but maybe with five years weekly therapy it might be a little better is probably not a good sign. At the same time, you should be skeptical of promising too much progress. A reasonable response would be that they can’t be sure until they work with the patient for a while, but if a patient is willing to be honest and work at it then weekly sessions for one or two years are likely to produce some good progress.
Ask for some examples of common problems for BPD patients and how they worked on helping the patients with those problems.
Try to get a sense of their attitude towards those with BPD. You really have to get a therapist who isn’t easily riled up even when personally attacked.
It’s also a very good idea to get a therapist who would not be sexually appealing to your suspected Borderline and who would be unlikely to have any interest in your Borderline, also. This is because patient-therapist sexual misconduct or false accusations of such misconduct are unfortunately more common with BPD patients than many other mental health patients.