A Scientific Look at Borderline Personality Disorder
Introduction to Borderline Personality Disorder
A borderline personality disorder affects every part of a person’s life by causing extreme emotional and behavioral reactions to mundane occurrences. Because of the intense emotions they feel, people with borderline personality disorder (BPD) can act in ways that lead others to believe they are selfish, manipulative, and volatile.
While a person with untreated BPD can be a difficult partner, parent, or child to understand, there are reasons and pain behind their irrational actions that can be treated. This stigma about BPD is substantial outside and within the mental health community, leading to several complications, including but not limited to; a minority of therapists willing to work with BPD patients, refusal to diagnose BPD to protect a patient from the stigma, loved ones oversimplifying the disorder to such a degree that they dehumanize people with BPD, and misdiagnosing patients if they do not appear explicitly volatile enough to the therapist, even if the said patient meets the diagnostic criteria.
BPD is a cluster B personality disorder. These personality disorders are only related by mutual trouble in emotional regulation and display seemingly irrational behaviors; antisocial personality disorder, histrionic personality disorder, and narcissist personality disorder share this cluster.
Well-known books and internet forums about BPD ignorantly blur the lines between these disorders adding to the confusion and misunderstanding. It is not uncommon to hear people saying that a narcissist trait is actually a BPD trait and vice versa. Despite sharing a cluster, these personality disorders should not be compared or confused. Both disorders need specialized therapy, but each therapy focuses on different thoughts and behaviors.
People with BPD can have comorbid narcissist/antisocial personality disorder, but the gross oversimplification of the probability of comorbidity in common media only makes it harder for people with BPD to get help, and their loved ones to understand their actions.
Despite being a more common illness (1.6% of the population), BPD is less well known than many other disorders such as schizophrenia or psychopathy (Salters-Pedneault, 2020). This may be due to the fact that BPD is often misdiagnosed or portrayed wrongly in common media as bipolar disorder.
With more recognized academics, athletes, and celebrities opening up about their diagnoses, such as Pete Davidson, Brandon Marshall, and Mikaela Spielberg, hopefully, there can be a wider understanding of BPD.
BPD is more commonly diagnosed in women, but it is unknown if this is because more women have the disorder, or if the symptoms of BPD are more likely to be noticed in women. The amount of BPD diagnosis is rising, but the stigma against the disorder is a looming obstacle to diagnosis and treatment options.
Changing the recognition and stigma of BPD through understanding only serves to help patients and their loved ones cope with the disorder and its effects.
Once the psychological, cognitive, and neuroscience aspects of BPD are understood, the inevitable cognitive empathy allows researchers and professionals to create effective therapies for patients and educate those who are affected by a loved one having BPD.
The Psychology of Borderline Personality Disorder
BPD is characterized by dysregulation in four domains: behavioral (e.g. impulsivity, self-harm), emotional (e.g. affective instability, anger issues, “being sensitive”), interpersonal (e.g. unstable relationships, fears of abandonment), and cognitive (dissociation, executive function).
While there are genetic components that make a person more vulnerable to the disorder, BPD symptoms are usually formed as a coping mechanism to adolescent maltreatment and/or trauma. Because of the vast number of symptoms in the four domains of dysregulation that exist under the BPD diagnosis umbrella, people with BPD often have a comorbid disorder (or two or three).
For example, Borderline impulsivity can lead to addiction or also be part of ADHD, fear of abandonment is also very common in PTSD, emotional swings are most commonly associated with bipolar disorder, and dissociation can happen to people with anxiety disorders.
There is a hypothesis that BPD is a chronic implicit shame response (Rüsch et al., 2007) or Complex-PTSD coping mechanism that was internalized into an adolescent’s implicit self-image (Cloitre et al., 2014), but neither of these hypotheses have been fleshed out enough to become a theory. Nevertheless, I am interested to see where the research into these ideas will show us.
Behavioral and interpersonal dysregulations are the most noticeable symptom to people who have a loved one with BPD and are the main symptoms BPD-specific therapies work to regulate.
Behavioral dysregulations are “inappropriate” or “severe” reactions to situations that would not cause a healthy counterpart to react similarly.
Taking from real-life conversations, these reactions can range from feeling suicidal after running out of comfort food (Oreos), self-harming after seeing an ex across the room at a party, yelling at a partner for not noticing a new haircut, dissociating for four days after having lunch with their neglectful mother, etc.
These reactions are widely misunderstood by loved ones, and this misunderstanding is a significant part of the negative stigma surrounding BPD. Without an understanding of all domains across many levels of analysis, these behaviors are easy to dismiss as an explicit cognitive action taken to hurt another.
All the domains are interconnected, with stress, trauma, or healing in one spreading to affect others. Heightened emotional sensitivity directly correlates with more volatile actions and more severe dissociation symptoms.
The emotional intensity and sensitivity that patients with BPD feel is out of place among healthy people; a constructive criticism comment from a boss can cause panicking that they are going to be fired, running into an ex-friend can cause suicidal thoughts or self-harm actions.
This inability to control the top-down regulation of fear and its connected emotions (shame, embarrassment, etc.) is further discussed in the following neuroscience section.
Emotional dysregulation is the collection of symptoms that is the easiest to measure in neurological studies as brain functions create an emotional intensity that can be measured through fMRI studies.
Despite the stigma, BPD is an illness many people recover from with time and treatment. In a longitudinal study spanning twenty-seven years, a majority of patients (92%) found that they “grew out” of BPD, or their symptoms decreased so they no longer met the criteria for BPD diagnosis (Paris, Zweig-Frank, 2001). One of the most important BPD symptoms to reduce, self-harm, was found in only 17.5% of BPD patients after a ten-year follow-up (Zanarini et al., 2010).
One of the main theories for this healing hypothesis that the brain’s natural plasticity allows it to heal structures and functional dysregulation eventually gaining stronger control over emotional regulation.
Unfortunately, BPD causes an estimated 10% of victims to take their own lives (Zweig-Frank, Paris, 2001), so many people suffering from BPD do not live long enough to find their calm future. To save lives and help recovery begin earlier and act faster, it is crucial we look not just at people with BPDs symptomology and behavioral therapy, but also their neuroanatomy. If BPD can be understood on different levels on analysis, stigma may dissipate, therapies can prove more effective, and neuroanatomy can be brought into clinical mental health.
The Neuroscience of Borderline Personality Disorder
Current fMRI studies show that BPD emotional dysregulation and behavioral extremes are linked with alteration in brain function, specifically in the frontolimbic system.
The frontolimbic system includes several structures and pathways that influence networks supporting reward, self-regulation, fear, and social cognition. Neural connectivity between the amygdala and ventromedial prefrontal cortex (vmPFC), two far-reaching structures, is an important pathway for emotional regulation (Paret et al., 2016; Shulze et al., 2016).
One meta-analysis of BPD functional and structural fMRI’s supports the current hypothesis that frontolimbic abnormalities are a key feature in the brains of people with BPD (Paret et al., 216).
There is extensive evidence that amygdala activation is associated with cognitive emotion dysregulation in patients with BPD (Paret et al., 2016) and specifically hyperactivation in response to negative emotional stimuli (Schulze et al., 2016; Paret et al. 2016).
Amygdala’s in BPD patients also showed a structural difference: smaller gray matter volume than healthy comparisons (Shulze et al., 2016). It is important to note that the smaller gray matter volume in the amygdala was not observed for every patient with BPD, but the difference is significant enough to warrant further research.
During verbally instructed fear (pretend you see your toxic ex across the room, pretend a tiger is attacking you, etc), patients with BPD would show a prolonged amygdala activation as well as a failure of vmPFC to increase its regulation of the active amygdala (Kamphausen et al. 2011). When a patient with BPD sees an emotional stimulus, say an ex-spouse, their amygdala become hyperactive compared to a healthy subject, labeling the ex-spouse as a much larger threat than they are in reality.
This perceived threat may cause the patient with BPD to lash out against their ex-spouse, saying hateful things for “no reason” in the ex-spouse’s eyes, but a very understandable reason when inside an fMRI watching the amygdala react.
Hyperactive amygdala cause many differences from healthy controls, ranging from impulsivity to inability to perform normal top-down regulations once fearful.
There is a lack of amygdala activity decreased with time in response to Threat vs. Safe stimuli as compared to the healthy control group, so people with BPD may need extra time or coping mechanisms to deal with perceived threat their healthy counterparts may barely notice.
Threat-specific amygdala activity in BPD patients positively correlates with the increase in severity of BPD symptoms (Kamphausen et al., 2011) such as dissociation or impulsivity. A study on emotionally modulated impulse control revealed decreased ventromedial prefrontal cortex activity and increased activation of the extended amygdala for behavioral inhibition along with increased failure rates in a go/no go task created specifically to test BPD patient’s top-down amygdala control (Silbersweig et al. 2007).
Effective amygdala top-down control is a neural mechanism associated with the recovery from emotional dysregulation symptoms that usually involves mindfulness training which utilizes physical and mental mechanisms to calm physical and emotional reactions. That being said, amygdala top-down control is much easier with a visual representation of amygdala action in front of the patient, not just for people with BPD but also for healthy counterparts (Paret et al., 2016).
When patients in a real-time fMRI machine were shown a visual representation of their amygdala activity in the form of an animated thermometer, BPD participants could see changes in the neural network between the amygdala and ventromedial prefrontal cortex, which helped participants decrease amygdala hyperactivity response to negative emotional stimuli that would normally cause hyperactivity and extension of amygdala activity (Paret et al., 2016).
The ability of BPD patients to down-regulate their amygdala activity with a simple animation fits well with mindfulness techniques that are already used in the most common BPD therapy; dialect behavioral therapy. The simple awareness of one’s current emotional state, such as a fear response from the amygdala activating, allows a moment of reflection before action.
Mindfulness has an extensive history in the research of improving healthy and neurodivergent people’s emotional reactivity, but with the harsh emotional dysregulation in BPD, it is a necessity.
After four trials in a real-time-fMRI neurofeedback training where people with BPD were told to down-regulate their emotions using mindfulness techniques and visual representations of their amygdala activity, participants were able to successfully down-regulate amygdala activation after little practice.
Said patients also saw an increase in amygdala-vmPFC connectivity to more closely resemble their healthy counterparts as well as a decrease in their dissociative symptoms and modest improvement in emotional regulation. This frontolimbic pathway is increasingly becoming a standard in BPD neuroscience research.
BPD Neuroscience: Neural Pathway
Abnormalities in the neural pathway between the amygdala and vmPFC play a role in emotional dysregulation (Paret et al., 2016), not allowing the amygdala to measure danger accurately and down-regulate after the danger has passed.
In patients with BPD, the hyperconnectivity in this neural pathway decreases the vmPFC ability to mediate the amygdala’s response to emotional stimuli, especially fear and anger (Kamphausen et al., 2012). Adding evidence to behavioral studies showing that BPD patients perceive threat differently than healthy control.
Since the vmPFC also helps in regulating self-control, BPD symptomology of impulsivity and anger explosions is also hypothesized to come from dysregulation in this area (Nopoulos et al., 2010).
Patients with BPD have reduced brain activity in the vmPFC when they see negative emotional stimuli such as a photo of an ex-partner, dead animal, or a person in pain, compared to healthy controls (Shultz et al., 2016), and decreased vmPFC activity happens when BPD patients were told to expect adverse/fear-inducing images once inside the fMRI machine (Kamphausen et al., 2012).
Just the implied threat of a negative stimulus was enough to have BPD brains function in a significantly different pattern than their healthy controls, even when the stimulus was revealed to not be adverse.
A person with BPD not only reacts to perceived fear faster and more strongly they may also have a harder time self-soothing and letting go of fear than their healthy counterparts, who have more vmPFC inhibitory control.
With vmPFC’s decreased ability in helping the amygdala down-regulate, the enhanced fear response positively correlates in behavioral and emotional dysregulation BPD symptoms, such as inappropriate anger, paranoia, frantic efforts to avoid perceived abandonment, and dissociation.
People with BPD are not volatile or selfish, their brains are creating a perceived reality where daily interactions carry extreme danger.
Luckily, research shows that the amygdala-vmPFC pathway can be improved, and people with BPD can decrease their fear responses in several different ways.
When electrical stimulation was applied to the vmPFC, patients had decreased freezing response to stress, because of the vmPFC’s ability to inhibit the fear-promoting amygdala (Adhikari, 2015).
Decreasing the amygdala’s freezing response is an important step in vmPFC-amygdala regulation, and there is evidence that the connectivity can also advance, leading to a decrease in symptomology beyond fear freezing.
These symptoms are a natural reaction to extremely fearful circumstances, but only get in the way when they appear during normal life activities. “Having to walk on eggshells around [them]” is a common phrase used by people whose loved ones have BPD, but now that researchers can show why a person with BPD may be volatile, the development of more effective therapies and lifestyles commences.
How Can We Help People With Borderline Personality Disorder?
BPD, and all personality disorders, are difficult to treat. The largest hurdle is that many people with BPD do not want to seek help or are resistant to common treatments.
Many patients are not diagnosed until they are admitted to a mental hospital after a suicide attempt or severe self-mutilation, often brought on by emotional dysregulation related to fear and shame.
There is a hypothesis that BPD is a response to chronic shame and that the self-concept of shame is what differentiates BPD from other similar disorders such as complex-PTSD (Rüsch et al., 2007). Under the shame hypothesis, aversion to treatment would be natural, as having to discuss traumatic events in one’s own life, or the way one’s emotional reactions have hurt loved ones can trigger extreme feelings of shame in anyone during therapy.
Dr. Linehan’s creating of dialect behavioral therapy (DBT) in the early 1980s, cannot be overstated as the single most important creation to help BPD patients survive, and decrease symptomology. Her invention and free distribution of DBT therapy courses have saved countless lives, as it is not only the most effective therapy for suicidal people, but also allows patients to recognize warning signs of suicide ideation and help themselves.
DBT combines behavioral therapy, self-acceptance, mindfulness, and daily goals into a program that both validates the BPD self-image of suffering and makes progress an achievable and necessary goal, a simple, contradictory, and revolutionary idea. DBT has helped treat the most urgent matter of clinical psychology, but it is not an explanation of the disorder or a way to educate loved ones of people with BPD.
Research must go beyond DBT to less pressing, yet still crucial concerns; decreasing the stigma and gathering more insight into how BPD functions. As stated previously, people with BPD who survive their suicide attempts are more likely than not to recover.
It is important to note that recovery does not mean the disappearance of BPD, but rather creating the skills specific to each patient needed to regulate their symptomology.
Time is on our side, as the differences between BPD and healthy brains lesson as patient age. The brain’s natural plasticity appears to learn and heal through experience if a person survives that long.
Age and medication act as mediators to amygdala hyperactivity and gray volume matter differences. Medication-free BPD groups had a significant difference from healthy controls in amygdala activation, but groups with BPD patients on psychotropic medication found few differences (Shulze et al., 2016).
Despite promising results with medication, the United States’ inability to regulate pharmaceutical prices makes prescriptions hard to get and medication absurdly expensive for many patients.
A new therapy, neurofeedback, is becoming more popular as an alternative or add-on to medicine. Real-time-fMRI neurofeedback studies show participants changes in their neural activity with a visual display, usually a screen of their brain or movie. The image will either shrink and grow as the brain’s reactions change, or the machine will make a pleasant noise when the patient’s brain is “acting right”.
rtfMRI has been shown to help improve behavioral issues and enhance patient’s ability to regulate response patterns to emotional stimuli, and dissociative symptoms dropped significantly after only four trials (Paret et al., 2016). Evidence supporting neurofeedback therapy’s ability to improve the amygdala-vmPFC functional connectivity is also growing. The neurofeedback has a quick effect on BPD patients, with most seeing connectivity patterns change during the second session (Paret et al., 2016).
Conclusion and Concerns
While there are brighter futures for people with Borderline personality disorder through a new understanding of the disorder and the creation of Neurotherapy, there are still many obstacles to overcome before treatment can be effective and reachable.
As of current standing, the American Psychological Association believes that every individual exists in an elementary world where they have a personality disorder or do not. This is in direct opposition to basic psychological principles; every person is an individual, disorders rarely match diagnosis criteria perfectly, and all symptoms exist on a continuum.
To help not only BPD patients but many misdiagnosed and “treatment-resistant” people, all disorders should be existing on a spectrum. Scientific ideas spread quickly, but APA’s historical staff of old rich straight white men do not. Luckily, there are trailblazers in the industry, and with the new CEO Dr. Evans bringing diversity into the limelight, there could be much-needed changes in the next decade.
Celebrating how far the understanding of BPD has come is also an important part of knowledge for people with BPD or their loved ones, as encouragement and building positive experiences are two of the easiest DBT skills to master. DBT was a breakthrough understanding created by a person with BPD to address the inherent ambiguity of the disorder, and it has been a huge success. BPD went from one of the most treatment-resistant diagnoses to a disorder that had an effective therapy in the blink of an eye.
Hand in hand with the validation of how far awareness has come is the radical acceptance that research and therapies are still limited in their range, and no progress can be made without the patient’s voluntary, active participation. BPD used to be considered one of the most untreatable disorder, with patients being assigned to solitary confinement and lobotomies,
Dr. Linehan did what thousands of mental health professionals wrote off as impossible and changed everything known about BPD. BPD may still be a vastly misunderstood disorder, but the door Dr. Linehan opened is allowing for a massive increase in empathy and research.
The future for people with BPD has never been brighter. Cognitive neuroscience is pushing the boundaries of what is possible for patients with BPD to heal.
