Borderline personality disorder (BPD) is a severe mental health condition estimated to affect approximately 1.8 percent of the general population. It is characterized by a pattern of instability in social relationships, self-image, and emotion regulation, as well as a significant increase in impulsivity starting in young adulthood. This elusive question was the focus of a new study led by Christian Moltu of the District General Hospital of Førde in Norway. More specifically, he and his collaborators were interested in how those with BPD experienced relationships with themselves and others. The nature of these relationships has important implications for diagnosis and treatment but is often misunderstood.
To that end, Moltu and his team recruited 12 study participants (all women) recently diagnosed with BPD. They conducted in-depth, face-to-face interviews with them about what it was like to be diagnosed and live with the condition and their experiences in treatment. From there, the research team analyzed participants’ narratives for themes. The results were striking.
The overarching theme of “reaching for firm holdings” emerged, highlighting the ongoing search for stability and security among individuals with BPD. The phrase “reaching for” spoke to the participants’ chronic anxiety over losing what they had fought hard to control. The women’s interior lives were marked by chaos and confusion, as they described feeling fragmented, not knowing who they were, and feeling existentially insecure. Their thoughts and feelings scared them and often proved unbearable.
“Reaching for firm holdings” also encompassed someone or something that could provide an escape from the intensity of their experiences. It could be self-defeating, such as using drugs, drinking alcohol, self-harming or unyielding perfectionism. But it could also tilt towards the positive side, including seeking connection with others and attempting to trust them.
This overarching theme yielded five related sub-themes outlined below:
- Captive of emotions: Participants described their inner lives as a cacophony of voices trying to scream over each other. The intensity of their feelings engulfed them like a tidal wave, leading to mental and physical chaos and desperately driving them to search for calm and escape. Their feelings’ uncontrollable and unpredictable nature was most distressing, as they could also feel intense joy. Consider a participant’s reflection: “I can wake up feeling depressed, and then three days go by, and I’m high up. I have no middle; either I’m down, or I’m up. Either I’m happy and blue-eyed, and the world is really nice, and everything is just ‘yes,’ or it’s death, destruction, war, kill me! I’m like that.”
- Keeping undeservedness at bay: Many women wanted to be perfect but didn’t know what they were trying to achieve or what attaining perfection would actually mean. Their pursuit of flawlessness stemmed from feeling damaged and worthless, and being perfect was a way to fend off these feelings. However, the participants’ efforts at perfection left them “wandering in blindness” and informed their relationships. A participant shared: “I would feel insecure a lot; I still do. I need confirmation several times a day to confirm that I do things right because I will judge myself a lot. I have this perfectionist in me; if it’s not perfect, it’s not good.” This perfectionism was destructive. When they could not reach their impossible standards or didn’t receive validation from others, some women resorted to punishing themselves via self-harm (e.g., self-cutting) or self-talk that could escalate into suicidal ideations.
- Distrusting oneself: The participants described feeling unmoored as if floating around within themselves and among others. They felt unequipped to hold, soothe, and validate themselves. They were confused between self and others and doubted their thoughts, emotions, and perceptions of the social world. Being alone was particularly difficult as if risking the evaporation of self. One participant explained: “I struggle a lot with losing myself when I am alone. Life can become hopeless, and I can’t seem to do anything, even if I would like to draw or something, I rarely manage to do anything when I’m home (…) It’s just about passing the time until it’s time to go to bed.”
- Dependence as stability: Many participants engaged in dependent relationships with both things and other people, including alcohol, drugs, love, exercise or relationships. In this vein, addiction could be depended upon in the storm of inner and outer confusion. It was a predictable known quantity that could at least temporarily fill the lonely void. One participant, for example, found relief from daily challenges in prescription pills: “I have a really addictive personality; I easily get dependent on people. I can become really obsessive and think that ‘If I only have her as a friend, others don’t matter.’ I have been in love with people I don’t even know and respond to that by getting high, drinking alcohol or taking pills. I have been addicted to anxiety pills, using them not to feel the intense feelings inside me or to handle certain situations better. So, I easily get addicted.”
- The uncertainty of reaching out: While the women experienced others as constantly changing and insecure, they also sought relationships for stability and security and to counterbalance the insecure relationship they had with themselves. A bind between self and others arose in which participants reached out to others for security—but that meant they risked losing their hold on themselves. This fear led some participants to “test” their friends and family’s love, tolerance, and security levels. A participant expressed feeling so “unsound” in herself that she urgently wanted to be nurtured by someone reliable and secure: “It might be what this personality disorder entails because all I wanted was that someone would take me home with them, you know (cries). Please take me home and take care of me. That’s what I wanted and still want, but that’s not good, or what I want does not go together with what is good for me.” The women in the study found it intolerable to be with and without others. But despite the overwhelming pain this wrought, reaching out helped them hold on and face the next day.
These findings align with strategies from Dialectical Behaviour Therapy (DBT) which can be helpful for individuals with BPD. DBT focuses on developing skills in four key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. By cultivating mindfulness, individuals can learn to observe their thoughts and emotions without judgment, gaining greater awareness of their inner experiences. Distress tolerance skills help individuals cope with intense emotions without resorting to self-destructive behaviours. Emotion regulation techniques help individuals identify and manage their emotions effectively. Lastly, interpersonal effectiveness skills help individuals navigate relationships and establish healthy boundaries.
Through DBT strategies and therapeutic interventions tailored to address these specific challenges, there is hope for individuals diagnosed with BPD to find stability, security, and healthier ways of relating to themselves and others.
Christian Moltu, Britt Kverme, Marius Veseth & Eli Natvik (2023) How people diagnosed with borderline personality disorder experience relationships to oneself and to others: A qualitative in-depth study. International Journal of Qualitative Studies on Health and Well-being, 18(1), DOI: 10.1080/17482631.2022.2152220