Borderline Personality | Personality Couch

Ep 44: The 3 Most Unstable Personalities | Schizotypal, Borderline, & Paranoid

Tue, 30 Dec 2025 02:00:01 +0000

In this episode of the Personality Couch Podcast, we (licensed clinical psychologists Doc Bok and Doc Fish) explore the 3 most unstable personality disorders: schizotypal, borderline, and paranoid. All 3 types are at risk of psychosis. We first discuss historical personality classifications of neurotic, psychotic, and borderline, highlighting that the borderline space between neurotic and psychotic is the most prone to instability. This borderline space is where schizotypal, borderline, and paranoid personalities sit. We discuss the risky traits of each personality, including cognitive slippage, emotional instability, and extreme rigidity. We also discuss some of our thoughts and experiences in diagnosing these rather tricky disorders!

Are you a clinician stuck on a case? To schedule a consultation, please visit the practice website! https://www.questpsych.org/

The 3 Unstable Personalities

Tue, 30 Dec 2025 02:00:00 +0000

The 3 Unstable Personalities

** For this blog, the borderline personality organization (note: this is not BPD!) is super important to understand because Millon noted this is where his structurally defective personalities are found. Please see Understanding Neurotic, Borderline, and Psychotic Personalities for more detail **

Millon’s Structurally Defective Personalities ¹

Millon categorized three personality disorders as more severe than the others because they are “structurally defective,” meaning that the actual architecture of the psyche - not the style/category of personality - is unstable and falling apart. It’s “melting,” like the borderline organization mentioned above. While all humans have survival motives, personalities look differently in regard to balance and conflict of needs (see picture above). These three personality disorders are: Schizotypal, Borderline, and Paranoid.

Schizotypal Personality - Ungrounded ¹

I won’t go into detail about what Schizotypal is here, but if you need a recap on schizotypal personality, check out this blog. The unstable aspect of the schizotypal involves the fragility and disconnection to their survival motives, like a leaf floating all around with no purpose or effectiveness. Thus, their focus on the polarities are easily reversed and always muted and weak.

Some major signs of schizotypal at the borderline organization (aka almost psychotic-ness) include cognitive slippage, odd perceptual experiences (bodily illusions, detachment from body), preoccupation with “other worldly” phenomena (e.g., superstition, magical thinking, telepathy), and ideas of reference (e.g., thinking “They are talking about me because they looked at me as they drove by”). Sometimes, there can be brief steps into actual psychosis, but it doesn’t stay there. It’s their ungroundedness and disconnect from self and the world that leads them to the quasi-psychosis place.

For structurally defective personalities, there is almost always another non-structurally defective personality disorder that goes along with it. Though, it can be difficult to know what the original structure used to be before it started falling apart. For schizotypal, schizoid (passively detached) and avoidant (actively detached) personalities are usually the ones that disintegrate and fall apart into schizotypal.

Borderline Personality - Conflictual ¹

Here, we are discussing borderline personality disorder, not borderline personality organization (though it is at the borderline level of organization - so “double borderline,” if you will). If you need a recap on borderline personality, check out this blog. In regard to the survival motivations in Millon’s theory, borderlines have an average focus on each, but there is a conflict within each domain. There is intense, extreme inconsistency and ambivalence, resulting in emotional lability, unpredictable behaviors, and thoughts/feelings about others that are always changing and inconsistent. They keep switching back and forth between the different survival polarities, which is often why there tends to be push-pull dynamics in borderline personalities (e.g., “Come here - Go away,” “I love you - I hate you,” or “I want help - I don’t need your help”). The bottom line: They are unstable.

Some major signs of a borderline’s almost psychotic-ness include stress-triggered, fleeting dissociation or paranoid ideation, which may or may not briefly cross into actual psychosis with hallucinations and delusions. But they come back to reality quickly and are aware of their brief stay in psychosis. Borderline personalities can be extremely aware of their psychic pain, to a fault. There may be temporary dissociative episodes ranging from wasting the day away in bed to self-harming without feeling pain. There can be short-term paranoia about others being out to get them, resulting in impulsive and reckless decisions like moving to a different state, quitting their job, or leaving a relationship.

For the structurally defective borderline personality, the other personalities that often coexist with it include those historically in Clusters B and C: melancholic (sad), dependent (clingy), avoidant (socially anxious), histrionic (attention-seeking), narcissistic (egotistical), and antisocial (rule breaking).

Paranoid Personality - Rigid ¹

If you need a recap on paranoid personality, check out this blog. For the paranoid, Millon doesn’t focus on the intensity of motives, but the inflexibility and rigidity of the paranoid’s survival aims and motives. Their psychic structure is fixed, so whatever they learned and developed in life is hidden, unchangeable, and not influenced by life circumstances and external experiences. There is an unwillingness to change, even with good reasons to do so or when faced with contradicting information. They will not adapt to external realities, rigidly adhering to their way of viewing the world, which they see as a hostile and threatening place. Paranoids are so afraid of annihilation that they are fixated on surviving, causing them to freeze.

Paranoids dip into brief psychosis is actually super tricky to see because their delusions are systematic, meaning they are logical and comprehensive, but also irrational and untrue. Often, the delusion is persecutory, as they are absolutely convinced someone is out to get them with malevolent intent, despite no evidence or evidence to the contrary. Usually, this is triggered by intolerable, unconscious feelings of guilt that are then projected onto another (“I’m not the bad guy, YOU ARE”). They need to hurt before they are hurt, which can blur the line between self/others and reality/non-reality. It can also result in illusions of enemies, persistently bearing grudges, or believing the other completed an offense against them that did not happen. It’s their paranoia that takes them into possible psychosis.

For the structurally defective paranoid personality, other personality disorders that often coexist include avoidant (socially anxious), negativistic (passive-agressive), compulsive (extra rigid), narcissistic (egotistical), antisocial (rule breaking), and sadistic (dangerous). Because the three structurally defective personalities are falling apart and in a quasi-psychotic space, it can be extra difficult to differentiate them, especially because they usually coexist with a non-structurally defective personality.

Personality dysfunction and disorders can be tricky! If you want to better understand the differences between schizotypal, borderline, and paranoid, therapy and/or psychological testing can help! If you’re in Virginia (or a PsyPact state), check out Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

References

Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc. ↩︎ ↩︎ ↩︎ ↩︎

Understanding Neurotic, Borderline, and Psychotic Personalities

Tue, 30 Dec 2025 02:00:00 +0000

Back in the day, psychologists and psychiatrists categorized individuals as sane or insane, which later changed to neurotic or psychotic, respectively¹. However, not everyone fit neatly into these categories (duhhh), and so the concept of borderline was proposed¹. The borderline space is the space in between neurosis and psychosis, where individuals weren’t insane but also weren’t not insane either

Psychodynamic Personality Organizational Levels

Organizational levels of personality in psychoanalysis include those historical levels of neurotic, psychotic, and borderline. It does not refer to the type or category of personality, but the functioning and stability of one’s psyche. In other words, we are not talking about borderline personality disorder right now. All personality types can technically be found at any organization level, though some personalities tend to live at certain levels. It is also important to note that organization of personality can impact severity, but it does not imply severity¹.

Neurotic ¹

At the neurotic level, reality testing is intact, and there is an integrated, continuous, stable sense of self that can lead to increased insight and ego strength. Problems are pushed outside of the self (ego-dystonic) in order to analyze and fix them. There is an internal, unconscious conflict of acting out unacceptable impulses, resulting in overactive defenses to protect against guilt. This means they are too cold, like a freezerburnt snowman. They are inflexible, rigid, and critical of the self (and sometimes others), avoiding confrontation and conflict. Their defenses are verbal (secondary defenses) stemming from the oedipal stage of childhood (about age 3 to 6) where their struggle with initiative vs. guilt resulted in inhibition due to difficulties accepting their “bad” human instincts (i.e., aggression, libido). Specific defenses include reaction formation, repression, and sublimation. Personalities that tend to be found at the neurotic level include histrionic, obsessive-compulsive, and depressive-manic.

Psychotic ¹

At the psychotic level, reality testing is defective - like a melted snowman. They might not be sure they are actually alive and exist separate from others, let alone have a cohesive, integrated sense of self. There is an unconscious fear of nonexistence, resulting in underactive defenses to protect against fear of annihilation and dread. Thus, they are super sensitive to authenticity and genuineness in others, especially because they can access things that most other people reject in themselves, such as limitations and flaws. Their defenses are preverbal and prerational (primitive defenses) stemming from the oral stage of childhood (birth to about age 2) where their struggle with trust vs. mistrust resulted in withdrawal due to difficulties trusting what is inside and what is outside of themselves. Specific defenses include acting out, denial, extreme dissociation, omnipotent control, primitive idealization and devaluation, primitive forms of projection/introjection, somatization, splitting, and withdrawal. Personalities that tend to be found at the psychotic level include paranoid, schizoid, antisocial, and schizotypal.

Borderline ¹

At the borderline level, reality testing is inconsistent with brief episodes of being out of touch with reality - like a melting snowman. Unlike those at the psychotic level, they know that they exist, but they experience identity confusion due to having a discontinuous, inconsistent, and unstable sense of self. There is fear of separation and abandonment, resulting in instability. They are impulsive, having difficulty regulating emotions and can be more hostile with outbursts of intense emotion, including anger. The instability makes it difficult to function and can result in push-pull dynamics. Their defenses are pre- and post-verbal (primary and secondary defenses) stemming from the anal stage of childhood (about age 1.5 to 3) where the struggle with autonomy vs. shame/doubt resulted in fear of separation due to difficulties with separation-individuation and attachment. Specific defenses include denial, projective identification, and splitting. Personalities that tend to be found at the borderline level include dependent, avoidant, masochistic, borderline, and narcissistic.

Personality dysfunction and disorders can be tricky! If you want to better understand the differences between personalities at the neurotic, borderline, and psychotic levels, therapy and/or psychological testing can help! If you’re in Virginia (or a PsyPact state), check out Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

References

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

Ep 29: Paranoid Personality or BPD? | The Unstable Duo

Tue, 03 Jun 2025 02:00:01 +0000

In this episode of The Personality Couch Podcast, we (licensed clinical psychologists Doc Bok and Doc Fish) help differentiate between paranoid and borderline personality disorders. We explore the similarities and differences between these two disorders, discussing their core characteristics, emotional responses, symptoms, and how our own intuition helps us more than we realize. We specifically look at the instability unique to these two personality disorders and how both express anger, shame, and fear. As both disorders can have fleeting episodes of psychosis, we also discuss how delusions can show up in each, but how their triggers are vastly different. We further discuss our own personal experiences treating both disorders and ways we use our intuition to guide diagnosis. We end by highlighting the need for empathy in treatment and welcome other providers to reference this information or to contact us directly if in need of a consultation.

To schedule a consultation, please visit the practice website for more information! https://www.questpsych.org

Paranoid Personality or Borderline Personality? | The Unstable Duo

Tue, 03 Jun 2025 02:00:00 +0000

Paranoid personality disorder can often look like borderline personality disorder, and can be extremely tricky to distinguish between the two. Even Millon¹ noted that there are times when the only way to differentiate between paranoid personalities and borderline personalities is to understand their childhoods, attachments, and initial fears. How in the world can two vastly different personality types look so similar? Let’s take a closer look.

Paranoid Personality vs. Borderline Personality Emotions

Photo by mohamed abdelghaffar

Anger

Both paranoids and borderlines can struggle with anger, and both use anger as a protective mechanism. But borderlines use anger to protect themselves from attachment-related distress, and their anger is often triggered by interpersonal stress, as it’s not a core characteristic. They are also more impulsive and self-destructive with their anger. In contrast, paranoids use anger to protect themselves from being destroyed by a world they believe is out to get them. Anger is a core part of the paranoid, along with fear, because they are fighting to survive. Their anger is consistent, not impulsive, and directed towards others instead of being directed toward the self.

Photo by Serje Lahoud

Shame

Both paranoids and borderlines can have intense shame. The main difference is that borderlines consciously feel their shame. They feel like they’re not enough, bully themselves, and have low self-esteem. They can sit in their shame, looking more like Eeyore by sitting in their victimhood and helplessness. In contrast, paranoids use their defenses so strongly that they can’t actually access their shame.² Shame is rejected and projected (put on others). There’s something inauthentic about a paranoid’s expression of pain that lacks shame (because they don’t want you to truly know them), but you can feel the authenticity of a borderline’s shame-related pain.

Photo by Andrea Piacquadio

Fear

Both paranoids and borderlines are fearful, but that fear is quite different. Borderlines fear losing attachments (being abandoned) but also fear being overtaken by others if they are too close.² It’s a difficult conflict. Meanwhile, a paranoid’s biggest fear is annihilation anxiety, or the fear of disappearing, being destroyed, or falling apart.² They feel like they’re always in danger and that the world is out to get them, so they react to that fear with irritability and aggression.

Paranoid Personality vs. Borderline Personality Symptoms and Features

Photo by cottonbro studio

Transient Psychotic Episodes and Paranoia

Both paranoids and borderlines can have some flavors of psychosis and paranoia, but it’s vastly different. Borderline delusions/paranoia happen when there’s a lot of emotional distress but disappear when they can tap back into their logical side. Their delusions are irrational, unconvincing, and time-limited.¹ It reminds me of a child tantruming with intense emotions who cannot hear any adult logic, at least not until their emotions regulate and their attachment is again secured. For example, a borderline might think their partner doesn’t like them, so they impulsively plan to run away, but they don’t because they end up back in their partner’s arms. In contrast, paranoid delusions are rational and convincing because they truly believe them.¹ It’s a consistent delusion that cannot be challenged. A paranoid will leave without a trace and won’t look back, especially if it matches with their delusion.

Photo by Vera Arsic

Dependency and Relationships

Both paranoids and borderlines are able to engage in relationships and attachment. Borderlines are often more favorable to relationships because they crave attachment, as long as it’s not too close. They swing between dependency and avoidance. In contrast, paranoids reject their dependency needs because others could humiliate them. They keep the attachment and can be anxious-ambivalent, but it’s a hesitant, surface level, inauthentic attachment where you never actually get to know them.² Paranoids often don’t have many friends, and if they do have a few, it is a rather limited social circle.

Photo by Yan Krukau

Defenses

Both paranoids and borderlines can use the defense mechanism of projection, borderlines use more lower level defenses in comparison to paranoids.² This is because the borderline’s core wound happened during early attachment, so their defenses are more infantile. Their projection comes off as more pouty and emotional. In contrast, paranoids use projection in a destructive, sophisticated manner that can head into sadistic territory. Because for the paranoid, it’s about surviving the dangerous world, not keeping attachments.

Photo by Natallia Rak

Personality Structure

According to Millon¹, both paranoids and borderlines are more severely disintegrated personalities but in very different ways. Borderlines are very inconsistent and changeable with constant conflicts between being active or passive, pursuing pain or pleasure, and focusing on self or others. In contrast, paranoids are very rigid and inflexible in their conflicts between active/passive, pain/pleasure, and self/others.¹ They cannot take in any outside data because they don’t believe the world is safe. Everything outside of themselves could be a lie. So borderlines are too malleable, and paranoids are not malleable enough.

Paranoid Personality vs. Borderline Personality Treatment and Pain Dynamics

Photo by Ana Bregantin

Dramatics, Pain, and Treatment

Both paranoids and borderlines can be quite dramatic in telling their stories, traumas, and symptoms. However, borderlines over endorse things because everything genuinely hurts. Similar to a child, they will act out, yell, cry, and be intensely dramatic so you understand that they are in pain. They run to treatment like a child runs to a parent when injured. Paranoids are dramatic, but contradictorily, they send you on a wild goose chase about what to believe. They don’t want you to know them because that’s too scary. You could use that information to hurt them, but they also need you to know they’re the victim of the world, since everyone is out to get them. Paranoids usually avoid treatment unless in extreme distress or if someone makes them go. This is because they don’t trust anyone, let alone a therapist. They are afraid a therapist will see who they truly are, and then destroy them.²

Photo by Minja Nim

Countertransference

Countertransference happens with every personality type at any level of severity. It’s the therapists’ reactions to the dynamics that the client brings into the room. With borderlines, there is often a pull to rescue them and attach to them quickly. They need you, so you want to save them. In contrast, paranoids often elicit feelings of anxiety, hostility, and distrust.² They don’t trust you, and you become suspicious of them.

Suicidality

Both paranoids and borderlines can have chronic suicidality, but again, it’s vastly different.¹ Borderlines have a depressive, impulsive component to their suicidal ideation and behaviors that stems from intense emotional pain. On the other hand, paranoids can be suicidal to feel power over someone else or over life itself. They will destroy themselves so someone else will not destroy them, for the purpose of hurting the other person. For example, after a breakup, a borderline might express that they want to die, but a paranoid will express that they hope their partner dies (projection). Paranoids are known to have completed suicide to punish others.¹

Photo by Pixabay

On the outside, paranoid personalities and borderline personalities can look very similar, and they are difficult to tease apart. It has taken Doc Bok and me years to understand personality disorders, and we’re still learning!! Constantly! If you’re a clinician who is stuck, and you’re in a PsyPact state, we are here to help you. We provide consultations if you would like help with a challenging case, diagnoses, or case conceptualization.

Photo by Andrea Piacquadio

References

Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎

Ep 17: Quiet Borderline | A Closer Look at BPD Subtypes

Tue, 17 Dec 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we continue to explore the complexities of Borderline Personality Disorder (BPD), particularly focusing on the lesser-known subtype: Quiet BPD. We delve into the historical origins of the term ‘borderline,’ discuss the various subtypes of BPD, and highlight the differences between Quiet and Noisy BPD. The conversation also touches on the lack of recent empirical research on Quiet BPD and the cultural emergence of the term. We further emphasize the importance of understanding the internal versus external presentations of BPD symptoms and the implications for treatment. The discussion emphasizes the importance of recognizing the different types of BPD and the need for nuanced understanding in both clinical practice and societal perceptions.

Quiet Borderline: A Closer Look at Subtypes

Tue, 17 Dec 2024 02:00:00 +0000

Regarding presentations of borderline personality disorder and structures, Theodore Millon states:
“…borderline may be analogized to the dumplings on Chinese menus. They look alike on the outside, but can be filled with any number of inner ingredients, pork, chicken, various vegetables, and so on. So, too, the borderline classification may be composed internally with a wide range of diverse, coexisting other Axis I and II disorders,” (Millon, 2011, p. 891). Gunderson (2010) did the math and reported that because at least 5 out of 9 criteria are required to be diagnosed with borderline personality disorder, there are 256 possible combinations of the criteria at a diagnostic level. No wonder we have an interest in what different borderline personality disorder subtypes there are! It’s extremely diverse! Yet, the DSM-5-TR does not list any subtypes for borderline personality disorder…

Photo by Roméo A. on Unsplash

The Origin of Quiet Borderline

The most common subtype that’s all over the internet right now is Quiet Borderline or Quiet BPD, but where did that term come from? You can look here for a brief description of the history of borderline personality disorder. It actually wasn’t until 1991 (later expanded on in 1994) when Sherwood and Cohen coined the term Quiet Borderline, comparing it to Deutsch’s (1942) proposal of the “As-If patient.” Johnston (2010, p. 242) provides us with an example where nurses in an inpatient setting were distracted by the Noisy Borderlines (i.e. self-harm, outward dramatics) and often forgot the Quiet Borderline who stayed in the bathroom away from the “madness.” But since then, the research about Quiet Borderline has died off in the past 20 years.

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The Current Research on Borderline Personality Disorder Subtypes

So I dug into the current research on borderline personality disorder subtypes. If you want to do the same, I suggest starting with Wolf (2023) and picking out some hallmark articles. Basically, there’s a ton of different ways researchers have done their magical analyses and come up with subtypes. Subtypes have been explored based on things like severity, symptoms, self-harm, co-occurring conditions, features of other personality disorders, internal vs. external factors, etc. The conclusion is: we don’t know. There is not currently any agreement or consensus on borderline personality disorder subtypes. But we have learned some things! Yay research!

Photo by Choong Deng Xiang on Unsplash

My Understanding of Borderline Personality Disorder Subtypes

Based on my look at the research on borderline personality disorder subtypes, I think most can be organized in three categories: Internalized, Externalized, and Mixed-Ambivalent (which also mirrors some previous research outlined in the supplemental materials for Wolf, 2023, as well as their own results). However, there is bound to be overlap and exceptions. It is my opinion that Borderline isn’t really meant to be contained into categories.

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Internalized Borderline Personality Disorder Subtype

The internalized subtype seems to capture the borderline personality disorder presentations that trend toward withdrawing and pulling away from others because of rejection sensitivity. They are schizoid -y (maybe more Cluster A, but not paranoid), hiding in their protective shell like a turtle, and being more passive, conforming, peaceful, and outwardly stable. They can be more “heady” and dissociative, which can make them seem “higher functioning;” thus, their borderline personality disorder symptoms are more likely to come out in their closest relationships. They can easily fall apart and step out of reality because they are extremely sensitive and filled with emptiness and deep emotional pain. They are more depressive, and their impulsivity is directed toward the self, which can result in more self-harm, sabotage behaviors, and self-destruction.

Externalized Borderline Personality Disorder Subtype

In contrast to the internalized subtype, the externalized subtype seems to capture the borderline personality disorder presentations that trend toward intrusiveness and pushing boundaries in their desire to connect to others. Like the lanternfly, they intrude and can be harmful, but maintain their beauty. They tend to have more Cluster B traits like narcissism (self-focused, egotistical), histrionic (showy, flashy, shallow but dramatic emotions), and antisocial (nonconforming, going against social rules). They also are not paranoid, as they are not anxious. Instead, they tend to act against any anxiety they have by “running into the fire,” being “brave,” and “peacocking.” Their anger is overt, and there can be aggressiveness (especially in males). Their impulsivity is also external, as they might abuse substances, drive recklessly, and engage in risky intimate behaviors. The externalized subtype seems to be more in line with the DSM-5-TR criteria.

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Mixed-Ambivalent Borderline Personality Disorder Subtype

The mixed-ambivalent subtype seems to be more of a classic “push-pull” borderline dynamic, like porcupines on a cold night. Snuggling close is prickly and hurtful, but distance is so cold. They have a more “core” borderline presentation with a major conflict between keeping attachments vs. being independent, which can result in an (un)conscious dislike of their attachments and passive-aggressiveness. There are more Cluster C traits, such as going back and forth between avoidance and dependence. There can also be a really strong compulsive “shell,” meaning that this subtype can work SO very hard to keep themselves together and people-please, but there is still deep internal pain and anger that they have to act that way. This results in resentment and repressed anger, which can leak out when their shell starts to crack. Sometimes there might even be a negativistic flavor of this subtype, in which their bitterness toward others for having to be dependent, as well as their own anger and dislike of themself, is turned onto others.

Photo by Kristina Flour on Unsplash

Quiet Borderline’s Subtype

Okay, so I organized things into three categories: Internalized, Externalized, and Mixed-Ambivalent. But where does our current cultural understanding of Quiet Borderline/Quiet BPD fall? Using the above categories, I think Quiet Borderline falls between the internalizing and mixed-ambivalent subtypes. The internalizing subtype of Quiet Borderline makes sense because it’s obviously quieter with more internal chaos and less overt dramatics. But I also think that Quiet Borderline can be a mixed-ambivalent subtype where they are higher functioning with a compulsive shell, allowing them to present as “quieter” (until it cracks).

Photo by Luis Villasmil on Unsplash

So…I believe the term “Quiet Borderline” not only lost its original meaning from 1991, but is being thrown around incorrectly to describe a vast array of borderline personality presentations that aren’t as externalizing and dramatic as the DSM-5-TR criteria portray. Honestly, I think this leads us back to the argument that “borderline” is an organizational level and does not do well as a diagnostic category (see blog/podcast). Regardless, we can still continue to try to understand borderline personality disorder in all the ways!

References

Cohen, C. P., & Sherwood, V. R. (1991). Becoming a constant object in psychotherapy with the borderline patient. Jason Aronson.
Deutsch, H. (1942). Some forms of emotional disturbance and their relationship to schizophrenia. The Psychoanalytic Quarterly, 11(3), 301-321. https://doi.org/10.1002/j.2167-4086.2007.tb00257.x
Gunderson, M. D. (2010). Revising the borderline diagnosis for DSM-V: An alternative proposal. Journal of Personality Disorders, 24, 694–708.
Johnston, J. (2010). Being disturbed: Integration and disintegration in the patient and professional relationship. Psychoanalytic Psychotherapy, 24(3), 231-251. https://doi.org/10.1080/02668734.2010.502306
Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc.
Sherwood, V. R., & Cohen, C. P. (1994). Psychotherapy of the quiet borderline patient: The as-if personality revisited. Jason Aronson.
Wolf, K., Scharoba, J., Noack, R., Keller, A., & Weidner, K. (2023). Subtypes of borderline personality disorder in a day-clinic setting—Clinical and therapeutic differences. Personality Disorders: Theory, Research, and Treatment, 14(5), 555–566. https://doi.org/10.1037/per0000624

Ep 16: BPD Part 4: What Therapy Really Looks Like

Tue, 03 Dec 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we dive into the complexities of Borderline Personality Disorder (BPD) treatment, in particular, the healing power of the invisible dynamics in therapy. We discuss the importance of motivation and insight in recovery for BPD, and the significance of the therapeutic relationship. The conversation emphasizes that while BPD is treatable, the journey is often non-linear and requires active participation from the patient. We also highlight the necessity of setting boundaries within therapy to create a safe and effective environment for healing. In this conversation, we discuss the importance of evaluating effort in therapy, the significance of attachment, and the challenges posed by boundary violations. Our conversation also explores the concepts of transference and counter-transference, the process of repairing ruptures in the therapeutic relationship, and the methods of facilitating insight and connections in therapy. Overall, this discussion emphasizes the individualized nature of treatment and the invisible dynamics that play a crucial role in the therapeutic process.

The Invisible Dynamics of Treating Borderline Personality Disorder

Tue, 03 Dec 2024 02:00:00 +0000

Borderline personality disorder is a hot topic recently, and Personality Couch has explored its history and presence in the media, criteria and symptoms, and suicidality/self-harm. It’s a disorder characterized by deep emotional pain…but what about treatment? Is there hope? YES!!! There are actually many treatments for borderline personality disorder, which you can Google and likely find Dialectical Behavior Therapy (DBT) as the evidence-based, gold-star treatment. Instead of telling you about all the information that’s already out there everywhere, I’m going to talk about what isn’t talked about - the unspoken dynamics happening in treatment with borderline personality disorder.

Treating borderline personality disorders is one of my specialties. I enjoy it for many reasons, including the need for an individualized approach to treatment because no two persons with borderline personality disorder are alike. The growth made in treatment is hugely influenced by tricky, unspoken dynamics that are invisible. So what are they?

Photo by Bianca Ackermann on Unsplash

Boundaries

While boundaries can be spoken and visible, they are often unspoken and invisible. Boundaries are involved in all the therapeutic processes throughout the entirety of therapy. Boundaries are important for personality disorders in general, but especially for borderline personality disorder. This is due to the safety and validation that boundaries provide in the chaotic pain of this disorder. We can think of boundaries as the frame of the therapy puzzle.

Boundaries Outside Sessions

Some examples of important boundaries outside of sessions include following rules and policies with paperwork (i.e. must be complete), payment (i.e. must be made the day of session), and communication (i.e. goes through the administration team). The policies are needed to set a professional therapeutic environment, not just an informal conversation with an acquaintance. It’s essentially the groundwork for treatment.

Boundaries Inside Sessions

There are also boundaries that are involved inside of session work, such as attendance, communication during session, and work put into sessions. I always emphasize that the days someone does not want to attend therapy are likely the most important days that they should, since that might be when they’re depressed, angry, avoidant, etc. Not to mention there can be policy-related consequences to not attending. I also highlight that anything can be discussed in therapy (even anger, attraction, fears, aggression desires), but we can’t necessarily behave on it. For example, you can be angry and scream at me, but you can’t knock over the lamp (Please be aware that every therapist sets their own boundaries. It may not be okay to scream at your therapist). Additionally, therapy is the client’s space, and therefore, I cannot do the work for the client.

Photo by Kelly Sikkema on Unsplash

Therapeutic Relationship

(Super important factor!)

Attachment

The relational connection or lack thereof (attachment) between client and therapist is important for treatment. For those with borderline personality disorder, there is often a quick attachment to the therapist because of their high pain, need for help(er), and need for relationship (due to fear of abandonment). The client might view the therapist as a hero, rescuer, or the best thing ever (idealization). Uncommonly, and sometimes fleetingly, the client might view the therapist as a villain, persecutor, or the worst thing ever (devaluation). When either of these happen, providers need to be careful and accept it without reinforcing it.

Because of the pushes and pulls involved in treating personality disorders, boundaries and attachment often overlap and can be quite problematic. My biggest pet peeve is when providers take up the client’s therapeutic space with clinically irrelevant self-disclosure. It’s highly unlikely that the client needs to know about their therapist’s love life, diet, or own struggles with mental health. Therapists can become too involved in their clients’ needs, especially when their client wants them to constantly meet all their needs and tell them what to do. I’ve seen some providers portray a controlling or possessive resistance when a client wants to end therapy, which means something is wrong there. Other big, bad boundary crossings include unsolicited advice regarding nonclinical matters, socialization outside of sessions, physical contact, and romantic intimacy that is acted upon. Honestly, these are all red flags! 🚩🚩🚩

Transference/Countertransference

The attachment in the therapeutic relationship inevitably leads to transference and countertransference. Because the client does not have a full picture of who the therapist is as a human being, the client unconsciously perceives the therapist to be similar to a different attachment they have a map for, usually from childhood, like their mother (transference). The client then unconsciously behaves in similar ways that they acted with their mother, which leads to countertransference. This is when the therapist has their own perceptions, emotions, and reactions to the client that often mirrors what the transferred person (like mother) felt, which is often frustration or pulls to rescue. It’s common for the Drama Triangle (podcast/blog) to show up in these dynamics!

Photo by Tania Melnyczuk on Unsplash

Corrective Experiences

Corrective experiences are difficult to explain because they are extremely individualized. It’s an experience that occurs in the therapeutic relationship that “corrects” or “heals” a traumatic or bad experience that occurred with a different attachment (usually in childhood). While I may celebrate the admission or expression of anger for someone who turns their anger inward, I might celebrate the self-containment or accountability for someone who is outwardly destructive in their anger. A more complex example would be for someone who has been parentified, I can set boundaries to facilitate corrective experiences by making sure I am the “parent” in the therapeutic relationship. I handle tracking the time, making sure we’re scheduled, etc. In contrast, if someone is regressed, I can set boundaries to not play into any dependency or “tantrums.” I might make it the client’s responsibility to make sure we are scheduled or have the boundary that I will not call them if they are late or missing a session, with the purpose of increasing their tolerance of taking responsibility for themselves.

Repairing Ruptures

Corrective experiences can also include repairing attachment ruptures in the therapeutic relationship. A rupture can happen when there is any conflict or potential for conflict between the therapist and client. This is SUPER important in the treatment of borderline personality disorder because of the fear of abandonment. I have to validate the conflict or concern without judgment, allowing the client to be upset in a way where it is also emphasized that I will not abandon the client. Sometimes, this includes me being incongruently excited and celebratory that the client has brought up their concern. Then, the repairing of the rupture includes sitting in the distress, exploring what is happening, taking accountability, and resolving the conflict interpersonally.

Photo by Anne Nygård on Unsplash

Connections & Insight

Making connections and facilitating insight is also an important part of the invisible dynamics of therapy. Making connections involves putting separate pieces of a client’s story together. It’s the middle part of the puzzle, and it is similar to finding all the pieces that make up a certain design, color, or shape, and putting them together. While therapists (should) do this in their own head, it’s important for the client to make and verbalize the connections with guidance (Not rescuing. Not advice. Not answers) from the therapist. Client-led connections are much more powerful and helpful. Facilitating insight includes self-reflection, self-awareness, and looking deep into the self, and then being able to verbalize it. Therapists can call out what’s happening in the room in the moment (immediacy) to help clients with this. For example, a therapist might ask the client what is leading to the clenched fists when discussing their mother or the picking at the couch when discussing their father.

Photo by Anastasiia Ornarin on Unsplash

In sum, treatment for borderline personality disorder is extremely individual with a ton of invisible dynamics. This can actually be pretty frustrating for clients because there’s not necessarily tangible evidence of growth or boxes being checked off like in some manualized treatments. So because the growth is also “invisible,” it can feel like progress isn’t being made, or maybe even feeling “stuck.” However, the healing often occurs over time without realization (ya know, since all these things are frustratingly invisible!). But then, when prompted to explore their progress, clients can usually verbalize their growth, and it can be super powerful!

Ep 15: BPD Part 3: Suicidal Behavior and Self-Injury

Tue, 19 Nov 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we delve into the complexities of Borderline Personality Disorder (BPD), focusing on the themes of suicidal ideation and self-harm. We explore the DSM criteria for BPD, the motivations behind self-harming behaviors, and the stigma associated with these actions. The conversation emphasizes the importance of understanding the emotional pain experienced by individuals with BPD and the impact on their relationships. We provide insights into navigating these dynamics, the need for professional help, and the significance of setting boundaries.

Additioanl Podcast Resources

CRISIS RESOURCES

Text Line: Text HOME to 741-741; a trained crisis counselor receives the text and responds quickly.
National Hopeline Network: https://www.thehopeline.com/
National Suicide Prevention Lifeline @ 988 or https://988lifeline.org/
American Foundation for Suicide Prevention @ https://afsp.org/
https://www.mentalhealthishealth.us/better-together-summit/

Psychoeducation

Suicidal Ideation, Self-Injurious Behavior, and Suicidal Threats

Tue, 19 Nov 2024 02:00:00 +0000

Discretion is advised due to the heavy topics addressed below that may not be appropriate for everyone.

Check out the and channel for more in depth information on borderline personality disorder criteria.

Borderline personality disorder is the only personality disorder that has suicidal behaviors/self-harm listed as a criterion, but it’s not necessarily the personality disorder that is at the highest risk for these behaviors. Because of the intense emotional pain experienced by those with borderline personality disorder, self-injurious behaviors are commonly why those with this condition seek help. Unfortunately, this contributes to some of the associated with borderline personality disorder. So let’s unpack this heavy topic and discuss the DSM criteria of suicidal ideation, behavior, threats, and self-harm. We’ll uncover what self-harm looks like, why individuals with borderline personality disorder self-harm, the stigma about these behaviors, and what loved ones can do.

The DSM-5-TR Criterion

Note: Text in these boxes are the exact words from DSM-5-TR¹

5. “Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior¹.” (p. 752)

The fifth criterion under borderline personality disorder addresses suicidality and self-injurious behaviors, which are often why those with borderline personality disorder seek help. The “Diagnostic Features” section in the DSM-5-TR’s borderline personality disorder also notes that is very common, and might even happen during times of , because it can bring relief by atoning for being “bad” ( ) or by helping the person understand they’re alive and can feel something. The “Associated Features” section in the DSM-5-TR’s borderline personality disorder discloses that while death by suicide can occur, especially when borderline personality disorder is paired with depressive disorders or substance disorders, “deaths from other causes, such as accidents or illness, are more than twice as common as deaths by suicide in individuals with borderline personality disorder (Temes et al. 2019).” There is also risk for permanent harm like physical handicaps due to self-mutilation or impulsive, risky behavior.

Remember: This ONE criterion is not sufficient for a diagnosis of borderline personality disorder. While it’s the only personality disorder with suicidal behaviors listed as a criterion, it’s not the only one with correlations for risk for suicide. Suicidal behaviors come up in other diagnoses. Also, not every individual with a diagnosis of borderline personality disorder engages in self-injurious behavior.

The Spectrum of Self-Injurious Behavior

The whole continuum of self-injurious behaviors are an outward expression of inward pain - a way to have pain seen. It can include physical behaviors, such as cutting, burning, choking, head banging, and punching. It can also include risky or reckless behaviors with intent to harm, including unsafe sexual encounters, risky meetups, substance abuse, reckless driving (i.e. driving too fast, intoxicated, unsafely), binge eating, restrictive eating, or excessive exercise.

Triggers and Causes

Because of the intense emotional pain experienced by those with borderline personality disorder, major stressors and/or changes can lead to self-injurious behavior. Losses and separations like job loss, divorce, and difficulties in school - basically when facing a threat of abandonment or rejection - can commonly lead to hopelessness and thus self-injurious behavior. Additionally, facing increased responsibility can lead to intense pain because there’s a threat to their dependence, and dependence ensures they stay connected to someone. They might feel like they can’t do something on their own and need to be taken care of; therefore, if they don’t have someone to care for them, they’ll feel alone, which is intolerable. This can make it seem like and feel like the motivation behind the self-injurious behavior is consciously manipulative (it can be in rare cases), but more than anything it’s an outward expression of an inner self-loathing: an external extension of internal pain.

Motivations & Stigma

There’s some pretty intense stigma around self-harm in those with borderline personality disorder that their self-harm is only manipulative or only for attention. I think this stigma stems from a help-seeking/help-rejecting dynamic in which those harming themselves can unconsciously do so to punish themselves but also to punish the person who “failed” to help them. It’s anger turned toward the self, and it’s often quite impulsive and reflexive. (Remember borderline personality impulsivity damages the self, while antisocial personality impulsivity damages the world). The primary motivation underlying self-injurious behavior in those with borderline personality disorder is a cry for help. It’s an unspoken, “See my pain. I can’t be alone. Save me.” Now there is also a secondary motivation that consists of distraction from pain.

Purpose

So what is the purpose of self-injurious behavior? It serves as a solution to decrease pain, like a coping mechanism. It’s a cry for help. It can help relieve internal pain or negative emotions, transferring the inner pain to physical pain. It results in eliciting responses from the environment that are reinforcing and soothing (i.e. utilizing beta endorphins, dopamine, serotonin), or even addictive. It can help someone feel alive, like they exist, grounding them in their physical self, though it could also increase numbness and dissociation. It can serve as a sense of control, to punish the self, to express self-hatred, or to express anger at others. All of these are based in deep and intense inner pain.

What Can Loved Ones Do?

It’s super scary to know someone you love is hurting themselves, and it might make you feel helpless or even guilty. So what do you do? Understand you don’t have to be alone in this. Seek professional help! You can also encourage your loved one to seek treatment, but you can’t make them go. You’re not responsible if they don’t go to treatment. Take care of yourself and your needs. Take responsibility for your own behavior but also keep yourself in reality. Don’t get sucked into the pull to take their actions personally. Increase your awareness of any behaviors you’re engaging in that are reinforcing or enabling their self-injurious behavior. Gently and clearly, without defensiveness, communicate, set, and keep boundaries.

Sometimes safety planning is needed, especially if there are episodes of rage (both toward self and others). Keep boundaries! If necessary, leave to a designated safe space or call the authorities. Remember:

Don’t ignore the person. You can say, “I will talk with you when you’re calm.”
Don’t respond with your own rage. Stay calm.
Don’t hurt the other person. Refrain from fueling the fire.
Don’t take responsibility for their actions!

While the spectrum of self-injurious behavior may or may not show up in someone diagnosed with borderline personality disorder, it’s notable enough to be its own criterion in the DSM-5-TR. There’s a lot of stigma associated with it, and it spans a whole continuum. It can be triggered by many different things and motivated by pain. It can feel manipulative, but most times that’s not the intent. Regardless, remember to seek professional help and maintain boundaries! It’s easier said than done, but see below for some helpful resources. You’re not alone.

RESOURCES

Crisis and Suicidal Ideation

(Text HOME to 741-741)

Mental Health Resources with Multiple Domains

Additional References

Temes, C. M., Frankenburg, F. R., Fitzmaurice, G. M., & Zanarini M. C. (2019). Deaths by suicide and other causes among patients with borderline personality disorder and personality-disordered comparison subjects over 24 years of prospective follow-up. Journal of Clinical Psychiatry, 80(1).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th edition, text revision.). ↩︎ ↩︎

Ep 14: BPD Part 2: Fear of Abandonment, Psychosis, and Dissociation

Tue, 05 Nov 2024 02:00:01 +0000

In our second episode of the Borderline Personality Disorder (BPD) series, we discuss how this condition manifests in relationships and clinical practice. We explore the pervasive patterns of instability, fear of abandonment, and the role of attachment theory in understanding BPD, while also touching on psychosis and dissociation. Our conversation highlights the challenges faced by individuals with BPD in their relationships and the dynamics that arise in therapeutic settings. We further emphasize the importance of understanding the multifaceted nature of BPD and the need for compassionate approaches in treatment.

Additional Podcast References

Books

1984 Borderline Book- John Gunderson, M.D.: https://www.amazon.com/Borderline-Personality-Disorder-John-Gunderson/dp/0880480203

Other Resources

Borderline Personality Disorder (F60.3) Diagnostic Criteria

Tue, 05 Nov 2024 02:00:00 +0000

Check out the and channel for more in depth information on borderline personality disorder criteria.

The most recent (2022) criteria of can be found in the (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision¹). The criteria are nicely organized and concise, BUT even since 1980 when the DSM-III first published borderline personality disorder as a categorical diagnosis, there has been much controversy about putting such a dynamic, moving disorder into a box of criteria. See the and the for a deeper dive about the differences. Regardless, let’s take a closer look into the actual criteria of this often misunderstood disorder.

Note: Text in these boxes are the exact words from DSM-5-TR¹

“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) of the following¹:” (p. 752)

Before we look at the individual criteria, the DSM-5-TR gives a framework about borderline personality disorder disorder. The patterns of borderline personality disorder have to be , meaning spread across the person, time, and settings. This is further explained by noting the patterns of borderline personality disorder must begin by early adulthood (18 to 25) AND be present in a variety of settings (e.g. home, school, work). Basically, borderline personality disorder doesn’t just show up one day in the work environment when you’re 45 years old. It’s been threaded throughout your life from early on and touches multiple parts of your story.

Then we have the actual pattern of borderline personality disorder. There is instability in , (view of self/sense of self), AND (moods). It’s not only one of these areas; it’s all of them. The unstable dynamics of borderline personality disorder are widespread - internal, external, and everywhere in between. PLUS we have (aka obvious) . But that’s not all, folks! We still have the specific criteria that needs to be checked off, and we need FIVE OR MORE of the following noted in the boxes below.

1. “Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5¹.)” (p. 752)

This is where we overtly see a fear of abandonment most commonly associated with borderline personality disorder. I think it’s super important to understand that a fear of abandonment can exist in anyone, and a person with borderline personality disorder technically doesn’t need to check this box if they check five other ones. The tricky part about this criterion is that the abandonment doesn’t have to be real; it can be imagined or anticipated. Abandonment doesn’t have to be actual abandonment. It can be when a therapist goes on a planned vacation, when a friend is a couple minutes late, or when a spouse takes a walk during/after a conflict. There’s a strong need for others and difficulty being alone. The “ ” avoidance of this cannot include criterion 5 (“Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior¹” p. 752), but may include impulsive action fueled by anxiety.

For example, someone with borderline personality disorder might bring up intense topics in the last 2 minutes of the therapy session; cancel immediately on the friend running late so they abandon the friend and not the other way around; or consume six shots of liquor while they call their spouse at work 27 times. This can also look like self-sabotage. For example, leaving a relationship because it could be stable, dropping out of school days before graduation, or regressing after being aware of progress. It is also possible that those with borderline personality disorder attach to less threatening objects like pets or possessions to avoid abandonment.

2. “A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation¹.” (p. 752)

Not only do relationships have to be up and down with pushing and pulling (aka unstable), they have to be intensely rollercoaster-y. How do we know if it’s intense or unstable enough? Well, because there’s idealization and devaluation. is when a person is viewed as “all good,” as they can basically do no wrong and are the best thing ever. is when a person is viewed as “all bad,” because everything they do is wrong and they’re the worst thing ever. It’s hard for a person with borderline personality disorder to handle the (assumingly) flawed but safe nature of an attachment figure, so they protect the self by swinging to extreme views of others. This can lead to patterns of relationship and job ruptures/terminations.

3. “Identity disturbance: markedly and persistently unstable self-image or sense of self¹.” (p. 752)

Here we need to have a super noticeable ( ) AND long-lasting ( ) feeling of personal identity ( ) OR that fluctuates and shifts (unstable). I’ve seen this range from just adapting and being a chameleon in social situations to shifting all around the drama triangle ( / ) to having different parts that come out (e.g. child, teacher, bully). A (more extreme) example of this might be someone with borderline personality disorder needing their partner’s help with dinner because they love them so much and they’re so good at cooking… but upon a 0.021 second hesitation from said partner, the individual with borderline personality disorder states they “don’t need anyone’s help ever because people suck and no one loves them.”

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 behavior covered in Criterion 5¹.)” (p. 752)

is often a big thing in borderline personality disorder, but the impulsivity has to be at a level where it could be harmful, though it excludes any self-harm or suicidal behaviors. Examples of specific impulsive behaviors the DSM-5-TR highlights are spending (i.e. irresponsibility, gambling, excessiveness), sex (i.e. unsafe sexual encounters, risky meetups), substance abuse, reckless driving (i.e. driving too fast, intoxicated, unsafely), and binge eating (which can also lead to restricting and compensatory behaviors). Other impulsive behaviors I’ve seen are hobby-jumping, job-hopping, and partner-swapping. A lot of times, these impulsive, possible harmful behaviors serve a purpose of filling up the empty spot identified in criterion 7. Also, don’t forget this has to show up in at least TWO areas.

5. “Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior¹.” (p. 752)

This criterion is pretty self-explanatory, but if you want more information on suicidal behavior, ( , , ), suicidal threats, , or , our Borderline series goes deeper into this topic! The behaviors captured in this criterion are commonly why those with borderline personality disorder seek help. Unfortunately, this contributes to some of the associated with borderline personality disorder, as there is risk associated with this for providers. These behaviors usually happen after an individual with borderline personality disorder faces a threat of abandonment, rejection, or increased responsibility (because dependence ensures attachment). However, self-harm can also happen during . The can help them feel something or be . Note that borderline personality disorder is the only personality disorder that has suicidal behaviors/self-harm listed as a criterion, but it’s not necessarily the only personality disorder at risk for these behaviors.

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 days¹).” (p. 753)

instability just means unstable emotions. The rollercoaster-y emotions are due to an obvious ( ) reaction of . Often, individuals with borderline personality disorder have a baseline of discontent ( ) that can then be disrupted by short periods of , , or (or another intense emotion). It’s notable that these periods “usually [last] a few hours and only rarely more than a few days¹,” (p. 753) which is NOT sufficient to meet any or criteria found in . Further, the periods of intense emotion often stem from experiencing stress on the relationship front.

7. “Chronic feelings of emptiness¹.” (p. 753)

Feelings of emptiness can be hard to explain. It’s like there’s an empty spot or void inside that is painful and distressing. Sometimes it can feel like disconnectedness, numbness, nothingness, meaninglessness, and purposelessness². This might lead to impulsivity or recklessness to avoid the feelings of emptiness or to attempt to fill the void. Also, these feelings need to be felt over a long period of time ( ).

8. “Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights¹).” (p. 753)

Anger is stereotypically associated with borderline personality disorder, but I think it’s important to note there are those with borderline personality disorder who turn their anger inward or express hurt instead of anger. When angry, it can feel uncontrollable and intense, and it can be out of proportion to the situation or simply inappropriate. Yet, anger tends to be triggered when an attachment figure doesn’t provide the love, nurturance, care, or security needed. The anger can be passive-aggression like intense sarcasm or bitterness, but it can also be verbal or physical aggression. Because anger can threaten the attachment relationship, any anger outburst is often followed by shame or guilt or anger turned inward.

9. “Transient, stress-related paranoid ideation or severe dissociative symptoms¹.” (p. 753)

When experiencing high stress, those with borderline personality disorder can experience or intense disconnectedness ( ). Paranoid ideation can include feeling like others are against you or even after you. It might feel like all your coworkers are talking trash about you or like your boss is actively trying to fire you, but that’s unlikely to be what’s happening. The dissociation can include disconnection from the self ( ) or disconnection from the word/reality ( ). You might not feel real, or things around you might not feel real. Again, this is usually following the intense emotion spurred by real or imagined abandonment, and if resolved, the symptoms may go away. It is absolutely necessary to understand that these symptoms tend to last minutes or hours ( ) and aren’t usually severe or longlasting enough for an additional diagnosis. However, it is possible that some people with borderline personality disorder experience psychotic-like symptoms (like or ) during high stress periods (e.g. , , ).

While I feel it’s unfortunate that borderline was categorized and put into a checklist of diagnostic criteria, there are definitely some benefits. Having structured criteria can help with identifying the struggles of those with borderline personality disorder, and it can assist in knowing the areas to treat. If you or anyone you know are experiencing any of these symptoms, please seek professional help! You can look on or if you’re in Virginia, check out our private practice, for available services.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th edition, text revision.). ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Miller, C. E., Townsend, M. L. & Grenyer, B. F. S. (2021) Borderline Personality Disorder and Emotion Dysregulation, 8(24). ↩︎

Ep 13: BPD Part 1: History, the Media, and the DSM Symptoms

Tue, 22 Oct 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we delve into the complexities of Borderline Personality Disorder (BPD). We discuss the stigma and misinformation surrounding BPD, the media’s misrepresentation of the disorder, and the need for a more nuanced understanding of its symptoms and diagnosis. The conversation highlights the emotional experiences of individuals with BPD, the criteria for diagnosis, and the importance of recognizing the spectrum of presentations within the disorder. We advocate for a reboot in the classification of personality disorders to better reflect the lived experiences of those affected by BPD.

Where Did "Borderline" Even Come From?

Tue, 22 Oct 2024 02:00:00 +0000

Why focus on Borderline? In clinical practice, borderline personality disorder is common, as the pain these individuals experience often leads them to treatment. Outside of clinical practice, every time I open social media, there’s a hot topic of “borderline-this” or “borderline-that.” It’s one of the most researched of all the personality disorders, yet there is a high level of misinformation online about borderline. Not too long ago, there was intense stigma regarding borderline personality disorder. Currently, the stigma seems to have lessened, but it still exists. It’s hard to squash a stigma that’s been around for almost a century.

Photo by Alexander Shatov on Unsplash

Stigma and Borderline in the Media

Because of the unstable nature of borderline types, it can be a good fit for dramatic TV shows and movies. But such theatrical depictions actually eclipse what borderline looks like in reality. Can you think of any classic movies or shows that portray a character with borderline personality disorder? If so, the character you’re thinking about is quite likely the villain of the story, maybe even murderous or psychopathic. That is NOT your average borderline case. There’s an episode in Daredevil … maybe season 3 episode 5, and they worked really hard to try to have a character named Dex portray borderline personality disorder. But he ended up killing his coach because his coach pulled him out of a game. Dex saw a therapist when he was a child, and the therapist wrote down “borderline personality disorder” and then later, “psychopathic tendencies.” While the writers put in some good effort, they missed the mark. It’s a great example of the exaggerated and dramatized portrayal of borderline in the media. Individuals with borderline are more apt to harm themselves, not others. Remember the Personalities that Kill episode/blog? Borderline individuals are at medium risk, not high.

Photo by Limor Zellermayer on Unsplash

Okay, so what if you just quickly Google “characters with borderline personality disorder?” The Hulk comes up a lot. Why? Because he has two “personalities?” He doesn’t remember what happens when he becomes the Hulk, so this fits much better with dissociative identity disorder and not borderline. Is it because he’s angry? Anger is part of many personalities. The Hulk does not likely meet criteria for borderline personality disorder. I also saw Elsa come up a lot. But based on what? There’s no push-pull in her relationships. She withdraws to protect herself and others (Schizoid type maybe?), and she’s not fearful of being alone. My hypothesis is that characters viewed as “crazy” are likely to be labeled borderline, and this absolutely contributes to the stigma around this condition.

Photo by Lydia Turner on Unsplash

History of Borderline

To understand the history of where the psychological term “borderline” came from, we have to look back to the time when the psychological field split patients into two categories: psychotic (out of touch with reality, needing hospitalization) and neurotic (too rigid and anxious, needing outpatient treatment). Psychotic diagnoses would include schizophrenia, hallucinations, and delusions. Neurotic diagnoses would include obsessive compulsive conditions and those with high anxiety.* But, alas, not all people fit into one of these categories. Some patients were outside of psychotic or neurotic categories- somewhere in the “Borderland,” - since they were bordering on both categories. They also didn’t respond to the standard treatment for either psychoticism or neuroticism. The Borderland space eventually became understood as a borderline organizational level of personality (Kernberg) somewhere around 1967. Kernberg viewed psychotic and neurotic to be on a continuum, calling the space in between: “borderline.” From that time until 1980 when the DSM-III was published, there was significant controversy about the term borderline. Some in the psychological field wanted to create a categorical diagnosis to capture the movement of borderline organization, and some were adamantly against it. Obviously, and unfortunately, the categorical diagnosis of borderline won out and was published in the DSM-III (1980), and it is the same concept we use today. Some professionals still oppose using borderline as a diagnostic category, but the widespread acceptance of such has overshadowed the history of the term.

*In our episode on Psychodynamic Personality Classifications (as Ice Cream Flavors), you can read or listen (5:17) to learn more about this original classification system.

Photo by Ahmad Odeh on Unsplash

All of this history leads me to…. How can we actually capture a dynamic movement and put it in a box? It’s a hindrance that has resulted in chaotic information regarding what we currently understand borderline personality disorder to be. In the earlier days of this disorder, it was essentially a “trash can diagnosis,” - a label to describe the numerous patients whose acuity was too severe to be in outpatient treatment, but too high functioning to be psychiatrically hospitalized. The unfortunate irony in not “belonging” to a category is that at the core of the borderline condition is fear of rejection. The name itself thus reinforces the symptoms of this disorder. Further, the essence of borderline means that there’s movement. For example, patients can be in reality at breakfast time and out of reality from lunch to dinner time. Borderline patients have constantly shifting presentations. The varying display of borderline symptoms has likely led to a lot of the misinformation that’s out there, especially on social media.

My own preference to view borderline as an organizational level and not a category puts me on the losing side of the “borderline battle.” However, the DSM-5-TR does include a proposed dimensional model for the future, placing personality disorders on a severity continuum versus a static, categorical box. This gives me hope. Because there are many things that don’t fit in boxes, least of these, people.

Ep 07: Personalities That Kill

Tue, 30 Jul 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we discuss personality darkness and specifically focus on personalities that are prone to violence and extreme behavior. We also discuss two important research studies, the Milgram study and the Stanford prison experiment, that shed light on the capacity for humans to engage in harmful acts. We then delve into the different personality types within Cluster A (schizoid, schizotypal, and paranoid); Cluster B (borderline, histrionic, and narcissistic); and Cluster C (avoidant, dependent, obsessive-compulsive) and discuss their risk levels for violence and murder. In this conversation, we also explore sadistic personalities, a category not included in the DSM, but included in multiple other personality theories. We highlight the characteristics and behaviors associated with each type and discuss the potential for violence and destructive behavior. The conversation emphasizes the importance of understanding these personalities and their potential risks in order to promote awareness and better understanding of human behavior.

Personalities That Kill

Tue, 30 Jul 2024 02:00:00 +0000

One of my favorite topics to dive into is the darkness of humanity and thus the darkness of personalities. Harm to others surrounds us in a ridiculous amount of ways, which makes many people think about not only what others around them are capable of, but of what they, themselves are capable of. The popularity of true crime, dark genres, horror media, etc., provides evidence that people are interested in this topic. And of course, there’s always some recent event that can remind us of the darkness people have in them. There is SO much I could say about this topic (Listen to podcast episode 07 for much more information), but for now, I’m just going to address the question:

🚩What personalities are at the most risk to kill? 🚩

In my opinion, there are three main personality types that fall into the high risk category. I’m going to start with the “least” risky and end with the “most” risky, though please remember that all still are at high risk.

Narcissistic Personalities

Medium Risk to High Risk

Photo by Lance Reis on Unsplash

The thing to remember about narcissism is that those who kill are quite likely to at least have high narcissistic traits, but not necessarily a narcissistic personality structure/disorder. Narcissistic personalities are all about image, ego, and the self, needing admiration and presenting with superiority, grandiosity, and charm (see Episode 04 podcast/blog for more info on narcissistic personalities). They value image so much that they can harm others in their pursuit and maintenance of it. However, there are some types of narcissistic personalities that are at higher risk for actually killing. While some narcissistic personalities are “more pure,” their focus on image is mostly about climbing the social ladder (e.g. Elitist subtype from Millon, p. 397). Now, they’ll react with anger, hostility, and even emotional/verbal abuse, but they’re not apt to physically kill. In contrast, there are some types who connect power with image, resulting in destruction. Millon’s “Unprincipled” subtype of narcissistic personality (Millon, p. 402) is at high risk for killing due to lack of remorse, lack of social conscience, vengefulness, and maliciousness. This subtype includes antisocial features, seen in their desire to humiliate and dominate others. Millon’s “Unprincipled” narcissist seems to be similar to the PDM-2’s mention of the “Malignant” narcissist (PDM-2, p. 46), whose narcissism is combined with sadistic aggression… 🚩Yikes!!

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Paranoid Personalities

High Risk

Paranoid personalities are tricky. You never really fully know a paranoid personality since they show different faces to different people, which they do because they are suspicious, distrustful, and fearful of others and the world (see Episode 04 podcast/blog for more info on paranoid personalities). They view the world as threatening and against them, and in their defense against this, they tend to attack before being attacked. They can’t handle their own pain and so they transfer it onto others, often in a dramatic manner. They are at a very high risk for destroying others and then themselves, while projecting their own pain onto the masses - such as in a murder-suicide event. It wouldn’t surprise me if many mass murderers have paranoid personality structures. However, while unhealthy paranoid personalities are dangerous in general, some might be most dangerous to themselves (Millon’s “Insular” subtype, p. 975) or in other ways outside of murder (Millon’s “Fanatic” subtype, p. 983). In contrast, Millon’s “Querulously” subtype (Millon, p. 974) tend to be hostile and have delusions, often erotic ones that can result in behaviors like stalking, killing for their object of infatuation, or even killing their actual object of affection. More concerning is Millon’s “Malignant” subtype (Millon, p. 987) who tend to be previous sadistic types who have “fallen apart.” …🚩🚩No bueno!

Antisocial Personalities

High Risk

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Antisocial personalities are boundary-crossing, as they tend to disregard and violate the rights of others, social norms, and the law. They are often deceptive, sneaky, and charming on the outside, but can also be impulsive, aggressive, and/or reckless (see Episode 04 podcast/blog for more info on antisocial personalities). In my opinion, antisocial personalities can be somewhat less dangerous than sadistic personalities, because there are some types who are more at risk for harm to themselves (Millon’s “Risk-Taking” subtype, p. 451) or just withdrawal from society (Millon’s “Nomadic” subtype, p. 455). In contrast, Millon’s “Reputation-Defending” subtype (Millon, p. 453) is high in narcissism as well, with a focus on looking tough and powerful with high status. They might have positions of power and rule with aggressive leadership, likely finding a place in extremist groups/cultures. They are very likely to engage in violent acts to “confirm” their own strength, viewing their victims/enemies as the wrongdoers, which they feel condones their violence.

Millon’s “Malevolent” subtype (Millon, p. 458) is perhaps one of the most dangerous personality types, especially as they are paired with paranoid or sadistic features. They tend to be revenge-driven, vindictive, hateful, and destructive. Millon’s bone-chilling description of them on p. 458 includes the statement, “Distrustful of others and anticipating betrayal and punishment, they have acquired a cold-blooded ruthlessness, an intense desire to gain revenge for the real or imagined mistreatment to which they were subjected in childhood.” …Even more scary, they can usually grasp the concept of remorse/guilt in their minds and even experience it emotionally, but they disregard it🚩🚩🚩. This type seems to be the one that comes to mind when we hear the word “psychopath,” and interestingly, it seems to correlate with the PDM-2’s “Aggressive” subtype of antisocial personality (PDM-2, p. 50).

Sadistic Personalities

High Risk 🚩🚩🚩🚩

Photo by Kurt Cotoaga on Unsplash

This category of personality is a bit confusing. The DSM-5-TR does not include sadistic personality disorder, but Millon and the PDM-2 separate sadistic and antisocial personalities. The overall core of sadistic personalities is their enjoyment of inflicting pain on others (see Episode 05 podcast/blog on Millon’s types or Episode 06 podcast/blog on Psychodynamic types for more info on sadistic personalities). Some sadistic personalities feel like they are entitled to control or punish others, often taking positions of power in militaries, schools, or legal systems, as they also have some compulsive traits. Their power leads to feelings of arrogance and superiority, resulting in a tendency to view their “victims” as inferior and maybe not even human - but all this is wrapped up in their “righteous” exterior that they portray as moral (Millon’s “Enforcing” subtype, p. 637). Some sadists are actually very fearful and use violence to disguise their fear, moving against it through counterphobic action. They can be quite cruel and often find themselves in groups with a shared victim, like a hate group - somewhere to put their anger about their own weakness (Millon’s “Spineless” subtype, p. 637). Some might possibly kill those closest to them in an uncontrollable and unpredictable rage that tends to not be premeditated but impulsive. (Millon’s “Explosive” subtype, p. 641).

The one I find the most severely brutal and horrifying is Millon’s “Tyrannical” subtype (Millon, p. 642), which can have paranoid and/or negativistic features. They enjoy destroying, abusing, assaulting, and terrorizing. They are the devious, composed predators who seek out weak prey, and when they attack, they do so with no remorse, unable to stop until their rage is exhausted. Millon states, “What is also especially distinctive is the desire and willingness of these sadists to go out of their way to be unmerciful and inhumane in their violence” (Millon, p. 645), adequately describing them as being “distressingly ‘evil’” (Millon, p. 642).

Hopefully, this helps you better understand your true crime shows and villains in the media you consume. I wouldn’t wish a relationship with these risky types on anyone! It gives a bit of a new meaning to the concept of red flag 🚩. Beware and be well!

Borderline Personality | Personality Couch

Ep 44: The 3 Most Unstable Personalities | Schizotypal, Borderline, & Paranoid

The 3 Unstable Personalities

The 3 Unstable Personalities

Millon’s Structurally Defective Personalities 1

Schizotypal Personality - Ungrounded 1

Borderline Personality - Conflictual 1

Paranoid Personality - Rigid 1

References

Understanding Neurotic, Borderline, and Psychotic Personalities

Psychodynamic Personality Organizational Levels

Neurotic 1

Psychotic 1

Borderline 1

References

Ep 29: Paranoid Personality or BPD? | The Unstable Duo

Paranoid Personality or Borderline Personality? | The Unstable Duo

Paranoid Personality vs. Borderline Personality Emotions

Anger

Shame

Fear

Paranoid Personality vs. Borderline Personality Symptoms and Features

Transient Psychotic Episodes and Paranoia

Dependency and Relationships

Defenses

Personality Structure

Paranoid Personality vs. Borderline Personality Treatment and Pain Dynamics

Dramatics, Pain, and Treatment

Countertransference

Suicidality

References

Ep 17: Quiet Borderline | A Closer Look at BPD Subtypes

Quiet Borderline: A Closer Look at Subtypes

The Origin of Quiet Borderline

The Current Research on Borderline Personality Disorder Subtypes

My Understanding of Borderline Personality Disorder Subtypes

Internalized Borderline Personality Disorder Subtype

Externalized Borderline Personality Disorder Subtype

Mixed-Ambivalent Borderline Personality Disorder Subtype

Quiet Borderline’s Subtype

References

Ep 16: BPD Part 4: What Therapy Really Looks Like

The Invisible Dynamics of Treating Borderline Personality Disorder

Boundaries

Boundaries Outside Sessions

Boundaries Inside Sessions

Therapeutic Relationship

Attachment

Transference/Countertransference

Corrective Experiences

Repairing Ruptures

Connections & Insight

Ep 15: BPD Part 3: Suicidal Behavior and Self-Injury

Additioanl Podcast Resources

CRISIS RESOURCES

Psychoeducation

Suicidal Ideation, Self-Injurious Behavior, and Suicidal Threats

The DSM-5-TR Criterion

The Spectrum of Self-Injurious Behavior

Triggers and Causes

Motivations & Stigma

Purpose

What Can Loved Ones Do?

RESOURCES

Crisis and Suicidal Ideation

Mental Health Resources with Multiple Domains

Additional References

Ep 14: BPD Part 2: Fear of Abandonment, Psychosis, and Dissociation

Additional Podcast References

Books

Other Resources

Borderline Personality Disorder (F60.3) Diagnostic Criteria

References

Ep 13: BPD Part 1: History, the Media, and the DSM Symptoms

Where Did "Borderline" Even Come From?

Stigma and Borderline in the Media

History of Borderline

Ep 07: Personalities That Kill

Personalities That Kill

Narcissistic Personalities

Millon’s Structurally Defective Personalities ¹

Schizotypal Personality - Ungrounded ¹

Borderline Personality - Conflictual ¹

Paranoid Personality - Rigid ¹

Neurotic ¹

Psychotic ¹

Borderline ¹