1. Borderline Personality Disorder
101
Kiera Van Gelder, MFA

2. Borderline Personality Disorder
is an ILLNESS of
impulsivity and dysregulation.
It is considered a
personality disorder
because
It influences how a
person perceives, relates
to, and thinks about the
environment and oneself.
Kiera Van Gelder © 2009

3. BPD is highly stigmatized and misunderstood. The typical portrayal of
BPD is Glen Close as Alex Forrest in “Fatal Attraction”
Kiera Van Gelder © 2009

4. Clinicians historically have describe BPD traits as being willfully
imposed on others, rather than symptoms of an illness
Fickle Moody
Chaotic
Flighty Possessive
Childish
Fragile Reckless
Clingy
Hostile Seductive
Cranky
Importunate Shallow
Demanding
Inconstant Unpredictable
Desultory
Irritable Unreasonable
Going to Extremes
Manipulative Vehement
Adoring and
Contemptuous Mercurial Volatile
Kiera Van Gelder © 2009
--Michael H. Stone, MD

5. However, this is how people with BPD see themselves:
Helpless
Misunderstood A failure
Incompetent Unlovable
Hopeless Alone
Unsafe
Out of control Defective
Neglected
Kiera Van Gelder © 2009

6. We need to understand the extreme pain of having BPD in order to
make sense of why people behave as they do:
Dr. Mary Zanarini and colleagues identified “BPD Pain” as
involving:
 “Feeling misunderstood,
thinking that no one cares
 “Feeling about them or that they are
overwhelmed, bad, thinking about killing
worthless, very themselves, believing they
angry, empty, are evil, feeling like a small
abandoned, child, and believing they are
furious, enraged” damaged.”
“the overall ‘amplitude’ of this pain may be a
particularly good marker for the borderline diagnosis.”
Zanarini, et al. Harv Rev Psychiatry. 1998 Nov-Dec;6(4):201-7.

7. The American Psychiatric Association’s manual of diagnoses (the DSM IV TR)
defines nine BPD symptoms. These symptoms, you’ll note, are also basic human
experiences, and so, the disorder is best defined by the severity of symptoms and
their duration.
“A pervasive pattern of instability of interpersonal relationships, self-image, affects and control over impulses
beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following
criteria: (5 out of 9)
1. Frantic ef forts to avoid real and 5. Recurrent suicidal behavior, gestures or
imagined abandonment. threats; or self-mutilating behavior.
2. A pattern of unstable and intense 6. Af fective instability due to a marked
reactivity of mo od (e.g. intense episodic
interpersonal relationships dysphoria, irritability or anxiety usually
characterized by alternating between lasting a few hours and rarely more than a
extremes of idealization and few days).
devaluation
7. Chronic feelings of emptiness.
3. Identity disturbance, persistently and
markedly unstable self-image or sense
of self. 8. Inappropriate, intense anger or lack of
control of anger (e.g. frequent displays of
temper, constant anger, recurrent physical
fights).
4. Impulsivity in at least two areas that
are potentially self damaging (e.g.
substance abuse, sex, binge eating, 9. Transient stress related paranoid ideation or
spending, reckless driving). severe dissociative symptoms.”
American Psychiatric Association Dialogistic and Statistic Manual IV TR

8. How to make sense of BPD when everyone
experiences the symptoms to one degree or
another?
And there are so many of them!
Clinicians and researchers continue to struggle with
refining the diagnosis to accurately reflect the experience
of those who suffer from it. The variety of forms it takes,
and the way it borders on average human experience,
makes understanding the disorder difficult.
Additionally, since you only need 5 out of 9 symptoms to qualify, there are a total of 256 different
combinations of BPD. Valarie Porr, MA, often uses the parable of the blind man touching an elephant
when showing people in her workshops how many ways BPD can be perceived. Here are just some of
the ways clinicians explain the core symptoms:
• Dr. John Gunderson:
• Dr. Marsha Linehan: Multiple areas “Phenotypes” that can be traced to
of “Dysregualtion” genetic markers
• Dr. Otto Kernberg: Disordered • Dr. Aaron Beck: “Schema”
“Attachments” and “Defence
Mechanisms” •Dr. Judith Herman: Complex Post
Kiera Van Gelder © 2009 Traumatic Stress Disorder

9. As you can see, doctors have many
theories and ways of defining BPD
Chemical
Imbalance
Faulty
Schema
Emotion Dysregulation
Disorder
I’m screwed
Complex Post Traumatic
Reactive Stress Disorder
Attachment
Disorder
Willful
Asshole…
Just needs to
change
No!
Screw
Primitive Thanks to Valarie Porr for
you!
defenses the inspirationfor this slide!
Kiera Van Gelder © 2009

10. Additionally, many clinicians cannot see the disorder because
they focus on the many “Co-Occuring” diagnosis, as BPD
“borders” on and combines with numerous other struggles….
Often, people with BPD will be given other diagnosis and treated specifically for those, but ultimately the core of our
suffering is never healed. This can go on for decades, leading to the conclusion that there are people who are
untreatable and incurable. When, in fact, they have not received the right education and treatment.
PTSD Generalized Anxiety
Disorder Is there
“Ragaholic”
anything I
don’t have?
Depression Bipolar & Bipolar
II
Eating Disorders Substance Abuse
Obsessive Compulsive Disorder
Agoraphobia
Kleptomania
Co-dependence Sex Addiction I’m certain
you don’t
Panic Disorder have BPD!
Personality Disorder Not Otherwise Specified

11. So what is BPD (minus the confusion, stigma,
denial, misinformation and horrible media
portrayals?
Kiera Van Gelder © 2009

12. First, an understanding of what we call
“Psychiatric Disorders”
Mental illness or psychiatric disorder
refers to difficulties (impairments) a person
experiences with thoughts, emotions, behaviors,
perceptions and relationships.
The diagnosis (i.e. depression, addiction,
PTSD) acts as a map that allows us to
understand symptoms that cause misery
and get in the way of good living.
A psychiatric condition is not WHO we are:
no matter if it’s biologically-based or involves
our personality!
However, our language and thinking often
reinforces that concept.
ie “He is a schizophrenic; I am an alcoholic;
Kiera Van Gelder © 2009 she is a borderline.”

13. Why is BPD called a “Personality” Disorder?
Unlike many mood disorders, a personality disorder involves one’s sense of self
and perception of the world. For some of us, our experience of self and other, our
ways of behaving and reacting, become harmful and rigid. It takes great courage
and insight to go beyond our habitual ways to grasp that our personality might be
impaired. Of course, everyone’s personality is disordered to some extent. But with
“Personality Disorder,” it is sever, destructive, incapacitating and often hellish for
ourselves and those who know us.
Personality Development
involves the interaction of
Biological pre-dispositions (nature)
External Environments (nurture)
A Personality Disorder
occurs when personality traits are
inflexible and maladaptive and cause
functional impairment or
subjective distress.

14. Dr. Marsha Linehan suggests that people develop BPD due
to a “biological vulnerability” in combination with a
specific environment:
Those with BPD typically have three vulnerabilities
1) High Quick to
emotional heat up
sensitivity
Slow to
2) High cool down
emotional
reactivity
3) A Slow
return to
emotional
baseline = Symptoms of
Kiera Van Gelder © 2009
Impulsivity and

15. A little Acronym for BPD: RISE
REACTIVITY
 impulsive, out-of-control, overly aggressive, acting without
thinking
INTENSITY
 psychic bleeding, hemorrhaging pain, unable to calm down
SENSITIVITY
 emotional burn victims; thin-skinned; easily disturbed by small
slights
EMOTIONALITY
 Overwhelmed by feelings / dissociated from feelings; thoughts
easily distorted; difficulty seeing beyond present emotional state
Kiera Van Gelder © 2009

16. Before lo oking at the more “intra-psychic” aspects of BPD (like
attachment, rejection sensitivity, and fear of abandonment) let’s focus on
the areas of dysregulation Dr. Marsha Linehan lists as being central to
BPD.
5 Areas of
Emotions
Dysregulation:
Behavior
Relationships
Self-Image
Cognition
Kiera Van Gelder © 2009

17. Emotions People with BPD have been described as “emotional burn victims” due
to extreme sensitivity. Their interior world is constantly shifting,
unpredictable and difficult to express to others or understand.
Rages
Chronic anxiety
Despair
Low tolerance to stress
Easily frustrated
Rapidly changing emotions
Overwhelming passion / desire
Extreme sensitivity
Dissociation, being “shut down”
Boredom
Kiera Van Gelder © 2009 Loneliness

18. People with BPD typically use impulsive, self-
Behavior destructive behaviors as a way to regulate intense,
negative emotions and cope with life.
Binging and purging
Drug & Alcohol Abuse
Vandalism
Picking fights
Self- harm: cutting & burning
Impulsive Spending
Thrill-seeking
Suicide Attempts and threats
Shoplifting Geographical cures
Unsafe Sex
Kiera Van Gelder © 2009

19. People with BPD have difficulty tolerating separation
Relationships or perceived rejection from those they are closest
too, and can live in constant fear of abandonment.
Intolerance of
Rejection
Intense Fear of
Abandonment
Other person
becomes focal
point for self
Unstable “Stormy” Conflicts with others
Relationships difficult to tolerate
Need for constant assurance
Difficulty internalizing
Trust is given
love or remembering
indiscriminately or
positive connections
not at all
Need for closeness pushes
Frantic Attempts
Kiera Van Gelder © 2009 others’ boundaries
to Avoid Being Left

20. Cognition People with BPD can have impaired and distorted
thinking, especially under stress or when triggered.
Black and White
Thinking
Paranoia when
under stress
Difficulty holding
onto positives
Inability to recognize
consequences of behavior
“Emotional information Hyper-vigilant to
processing” impairment possible threats
Interprets neutral
faces as hostile Alternately see others as
all good or all bad
Overly Jealous or
Suspicious
Kiera Van Gelder © 2009

21. People with BPD have a fragile and shifting sense of self. A sudden
Self-Image change, even a good one, can destabilize a person’s sense of
themselves and their place in the world.
Sense of being bad or wrong
Emptiness
Deep Insecurity
Rapidly Changing
Identity
Confused sexual orientation
Depersonalization / feeling unreal
Annihilation of self by others through
abandonment or engulfment
Sense of self dependant on others
Environment determines self-worth
Shifting and contradictory
Kiera Van Gelder © 2009 goals or values

22. Common beliefs researchers discovered those with BPD
have about themselves and the world, in addition to
“dysregulation”
 I am endangered  The world is dangerous and
malevolent
 I am like a small child
 I am powerless and vulnerable
 I am uncared for
 Zanarini, (1988)  I am inherently unacceptable
 Beck and Freeman (1990)
These very much contribute to our
personality and how we interact with
ourselves and the world!

23. There are recognized biological
components to BPD
Research shows abnormalities in the neural systems that
regulate emotions, impulsivity and thinking
Emotions Perception and
Regulation is Reasoning disortions
impaired Dorsolateral prefrontal system
Amygdala system
Impulsivity control problems
Anterior Cingulate
Orbitomedial Prefrontal Systems
The Best and Most Up to Date information on this is
found in Valarie Porr’s Book: Overcoming Borderline
Personality Disorder: A Family Guide for Healing and
Change

24. How biological vulnerabilities and environment interact:
Linehan’s Bio-social model of BPD Development
Dr. Marsha Linehan proposes that it’s
within a specific “person/environment”
interaction that BPD develops
Biological Invalidating
Vulnerability Environment:
1. High emotional 1. Indiscriminately
sensitivity rejects private experience
2. High emotional 2. Punishes emotional
reactivity displays while
intermittently reinforcing
3. Slow return to emotional escalation
emotional baseline
3. Oversimplifies ease of
problem solving and
meeting goals
Kiera Van Gelder © 2009

25. So what is an Invalidating Environment?
An Invalidating
Environment
Negates
An invalidating Dismisses A person’s
environment can be communication
anything from highly Disregards
abusive to a simple
and behavior
mismatch between Criticizes
(Feelings, thoughts,
caretakers and the
person who is Punishes preferences, beliefs,
sensations) *
vulnerable.
* Linehan, 1991
Kiera Van Gelder © 2009

26. People with BPD and those in relationship to
them will encounter challenges specific to the
disorder
For example, intimate and close relationships are
triggering to a person with BPD
Being with and needing others brings up:
 Emotional reactivity
 Sense of being threatened
 Paranoia and jealousy (especially perception of
betrayal)
 Dif ficulty negotiating boundaries (taking on others
emotions, issues)
 Heightened sensitivity to judgment and criticism
 Polarized thinking / perceptions
 Dif ficulty seeing others’ perspectives
 Taking desperate actions in order to manage pain
of conflicts and to express feelings.
We all need to see these behaviors as “maladaptive” rather than “bad”:
those with BPD can be triggered constantly by those they are closest to ,
therefore it may seem impossible to interact with them without getting hurt
yourself.

27. Despite all this, we now know BPD is treatable!
2 years = 40% Remission
6 years = 68% Remission
10 years = 85% Remission
(Zanarini, 2005, 2006)
Remission is defined as
“no longer meeting 5 of 9
criteria”
However, we must also be aware that remission does
not mean “recovery” or having a good quality of life:
Recovery involves more than the absence of symptoms.
Kiera Van Gelder © 2009

28. Treatment for Borderline Personality Disorder is now
proven effective and available in many places
DBT : Dialectical Behavior Therapy (Marsha Linehan, WA)
www.behavioraltech.org
CBT: Cognitive Therapy (Aaron Beck, PA)
www.academyofct.org
SFT: Schema-Focsued Therapy (Jeffrey Young, NY)
www.schematherapy.com
Mentalization (Andrew Bateman and Peter Fonagey, UK)
www.menninger.edu
TFP: Transference-focused Psychotherapy (Otto Kernberg,
NY)
www.borderlinedisorders.com
STEPPS: Systems Training for Emotional Predictability and
Problem Solving (Nancy Blum et al, IO)
www.uihealthcare.com/topics/medicaldepartments/psychiatry/stepps/index.html

29. Dr. Marsha Linehan specifies 4 Stages of Recovery
from Borderline Personality Disorder
Stage 4: “Incompleteness”
 Capacity for Joy and Freedom:
Love as inter-dependence, internalized mastery, “having Sense of
perspective”, self-management, sense of self is evolving.
Self
Stage 3: “Problems in Everyday Living”
 Ordinary Happiness and Unhappiness:
Rebuilding a life, generalizing skills to Interpersonal
relationships and work, involved with life.
Stage 2: “Overcoming Quiet Desperation”
 Emotional Experiencing: Emotional &
Dealing with PTSD and trauma, fear of emotions, Cognitive
understanding triggers.
Stage 1: Severe Behavioral Dyscontrol
Behavioral
 Behavioral Control:
Reducing self-harm, addictions, dissociation, rage,
suicide attempts, chronic despair.
* Adopted from M.M Linehan, 2004

30. No matter what kind of treatment is done, healing
from BPD involves the cultivation of the following
qualities for ALL involved
Openness: A willingness to Non-judgment:
Mindfulness: Not imposing our
experience the symptoms Developing awareness of own viewpoint but
without shutting down or body, feelings, thoughts,
defending ourselves focusing on facts
reactions, & surrounding
unnecessarily environment
Giving the Benefit of the
Validation: Doubt: Not jumping to
Recognize what
conclusions about other
each person is
people’s behavior
saying and
experiencing,
even if you Curiosity:
disagree. Asking “what is going
on” rather than making
Pausing and imagining judgments and
assumptions
what others are
feeling: Patience:
The pause allows us to Allowing ourselves and Hope:
respond rather than react others to go through the
Believing that recovery
process and accept it
won’t be on our schedule
is possible

31. “Abandon what is unskillful….
Cultivate what is good.”
--The Buddha
Kiera Van Gelder © 2009