An explosive man or woman whose attacks cause great suffering to his wife, girlfriend, or children, marital problems, and the need for intensive counseling.

While this image fits some people with this disorder, many individuals diagnosed with BPD are highly sensitive individuals who experience fear and depression more intensely than anger. Anger may not be the primary feature of the disorder.

The video at this link illustrates the fear and depression experienced by a young man diagnosed with BPD. Unfortunately, help came too late for this beloved young man who committed suicide last year. Many thanks to his friend who sent me the link to the video in a comment in response to one of my previous posts about BPD. The nine-minute video is worth watching to the end.

My professional colleague H.O. has BPD. So H.O. has a professional and personal understanding of the diagnosis of BPD. She recently wrote to me to share her perspectives on BPD. I am glad that H.O. She permitted me to share her writings with my readers.

This is the third in a series of H.O. Insights. The first explained the term “borderline personality disorder” and the second addressed the stigma associated with the term “borderline personality disorder” from its association with terms like “drama queen” for women and “abuser” for men.

The question of diagnostic classification for people with what we commonly call borderline personality disorder is very complex. For a long time, there has been controversy over dropping the term “borderline” as misleading and stigmatizing.

Related : There May Be 3 Types of Borderline Personality Disorder

Concerns have also been raised about placing borderline personality disorder in the group of personality disorders. There appears to be a significant biological overlap between borderline personality disorder and bipolar disorder, for example, which the psychiatric establishment considers biological rather than “bad.” Many of the more negative traits that people often associate with borderline personality disorder may stem from malignant narcissism (the drive to hurt people combined with listening to one’s desires).

When I diagnose a patient with borderline personality disorder, I base my diagnosis on two aspects of the DSM-5 diagnosis:

a) the general criteria for all personality disorders, i.e. impairment and its persistence over time/across situations

b) the specific criteria for borderline personality disorder

What are the specific DSM-5 criteria for borderline personality disorder?

• Significant impairment in personality functioning
• Impairment in interpersonal functioning
• Pathological “personality” traits, i.e. emotional negativity, which consists of emotional instability, anxiety, separation anxiety, and depression.
• Inability to control emotions
• Hostility

Stigma and blame

The term pathological personality traits is particularly unfortunate. It conveys stigma and blame. Now not only is the client unhappy, but it is their fault. This is a term that could benefit from being dropped.

The DSM also unfortunately fails to make clear that emotional negativity (a lot of hurt, anger, depression, and other negative emotions) is a result of vulnerability. Because people with BPD have high emotional sensitivity coupled with poor resilience (the ability to recover from negative emotions), negative emotions tend to occupy a greater share of their time, energy, and relationships.

What is the most helpful perspective for understanding PTSD?

Negative emotions are frequently triggered in people with BPD at least in part because the amygdala, the part of the brain that controls emotional responses, is highly sensitive. That is, the amygdala reads “Danger!” while others do not. The amygdala triggers intense fight-or-flight responses while others cope calmly.

This hyper-reactivity/temperamental intensity may stem from PTSD caused by traumatic childhood experiences including emotional and/or physical abuse in childhood, often by a parent with BPD. These traumatic events trigger amygdala responses. Thus, a person who has experienced childhood trauma functions like a military member with PTSD as a result of being exposed to extremely emotionally distressing negative events in war situations.

Hyperactivity and emotional intensity are the core issues here. All the rest of the symptoms on the diagnostic list are consequences.

From this perspective, I feel that the focus of our articles on psychologytoday.com on emotional hyper-reactivity/hyper-arousal, which has also been the focus of BPD expert Marsha Linehan’s more recent work, is correct.

Hyper-reactivity refers to seeing a threat when there is no threat.

Hyper-arousal refers to responding to actual threats with excessively high levels of emotional arousal, which may take the form of anger or may instead be depression or anxiety.

For example, someone with BPD might hear a comment made by a friend as critical when it was intended to be neutral or positive. “Your hair looks nice” might be interpreted as “Your hair doesn’t usually look nice.” That’s hyper-reactivity.

If the reaction is intense hurt and anger rather than mild anxiety, that’s hyper-arousal.

Hyperactivity/hyper-arousal in experiencing “everyday life violations” leads to “abnormal” behaviors, attitudes, and dysfunctions.

Here’s another example. A person with borderline personality disorder may read a vague expression on a loved one’s face as sarcasm, which in turn provokes anger and hostility or intense rebuke and despair, which in turn undermines the continuity of relationships. This is the chaos that borderline personality disorder causes.

Hyperactivity/hypersensitivity also causes frequent diagnostic confusion about whether a patient has bipolar disorder or borderline personality disorder. The therapeutic efficacy of mood-stabilizing medications (topiramate, lamotrigine) in both bipolar disorder and borderline personality disorder supports a biological/common overlap. In both disorders, the underlying mechanism is something biological that causes hyper-reactivity/hypersensitivity/mood instability.

What causes this type of highly sensitive emotional reactivity?

As I mentioned above, some people with borderline personality disorder, both men and women, have been emotionally reactive and highly sensitive since early childhood, perhaps due to the difficulties they have experienced or perhaps for other reasons.

In both cases, dealing with this hypersensitivity can be difficult for parents. A combination of gentle and firm parenting can make a big difference for such children. Unfortunately, highly sensitive children often have parents with BPD who are emotionally overreactive and/or narcissistic.

Sadly, the spirit of biologically sensitive individuals can be shattered early, especially if their parent, who may also have BPD and narcissism, contributes to their abuse. These individuals then spend most of their lives trying to survive, feeling constantly devastated by the “abuse of everyday life.”

Normal people can brush off or deal with minor conflicts, disagreements, or misunderstandings through cooperative conversation. However, such events lead to disproportionate, overwhelming, and prolonged emotional responses in individuals with BPD.

Diagnosis of Borderline Personality Disorder. Highly Sensitive People
Borderline traits begin in childhood.

In short, all you need to “achieve” the full phenotype of BPD as described in the DSM-5 is to start with a biologically sensitive and vulnerable child who is hyperreactive/extremely intense/unstable. Expose him to an emotionally painful experience that the child, being weak, cannot handle or overcome. Add to this parents who tend to punish more than they tend to parent based on patient instruction, or who are overly lenient instead of training the child in ways that will help him manage his emotional storms more effectively.

Note that a highly sensitive child who exhibits emotional hyper-reactivity/hyper-intensity, has high risk for BPD in adulthood, especially in the absence of a strongly supportive/nourishing environment, even if this environment includes little adversity or trauma. Such extra-supportive environment is unfortunately uncommon, while the vulnerability is quite common. The result is the high incidence of BPD.