Borderline Personality Disorder

Borderline Personality Disorder, or BPD, is a complex condition that affects 1.6% of adults in the U.S. This article will help you recognize its symptoms, understand its challenges (especially in relationships) and find pathways to coping and treatment.

Core Symptoms

Emotional Instability and Intense Mood Swings

People with BPD experience significant emotional instability, leading to episodes of intense mood swings. These can range from feelings of euphoria to deep depression, often triggered by perceived rejections or abandonment. They may yell or scream irrationally, or tell you they love you and you’re the only one who understands them…until you “cross” them, at which time you’re on the “enemy list.”

Fear of Abandonment and Unstable Relationships

One of the most prominent symptoms of BPD is an intense fear of abandonment, which can result in desperate efforts to avoid being left alone. This fear often leads to patterns of unstable interpersonal relationships, swinging wildly between idealization and devaluation of others. again, one minute the new person is the greatest in the world and everyone else stinks, and the next minute the new person stinks too, and in fact, stinks worse than every other person who stinks in the world. In a week or two they may be off the stinker list and back to the list of greatest people in the world. and on and on it goes.

Impulsive Behaviors

Individuals with BPD may engage in impulsive and often dangerous behaviors. These can include reckless or impaired driving, binge eating, alcohol or drug abuse and other negative behaviors which are usually efforts to manage negative emotions. They will minimize these behaviors, using rationalizations that range from the ridiculous to the more ridiculous.

Distorted Self-Image

A fluctuating sense of self is common in BPD. Individuals may struggle with their identity, leading to sudden changes in values, self-image, or aspirations. This instability can cause significant distress or impairment in social or occupational settings. They may grossly overvalue their talent or importance, and lash out in anger when called on their amplifications. These behaviors will often cause people to misdiagnose the BPD patient with narcissistic personality disorder; a mistake that can be costly.

Chronic Feelings of Emptiness

Many people with BPD describe a persistent feeling of emptiness, which they may try to fill with alcohol, drugs, food, or relationships. This symptom is often associated with profound loneliness or boredom, and they may constantly seek friends…friends who will often eventually be rebuffed when they don’t toe the line of expected behaviors of the person with BPD.

Inappropriate Anger

Difficulty controlling anger or experiencing inappropriate, intense anger is another symptom of BPD. This can manifest as temper outbursts, ongoing feelings of resentment, or fights, both physical and verbal. Threats of physical violence are not uncommon.

Self-Harming Behaviors

Self-harm, including cutting or burning, is a common symptom among those with BPD. These actions may be used as a coping mechanism to deal with emotional pain or to feel a sense of control.

Stress-Related Paranoia

Under stress, individuals with BPD may experience paranoia, grandiosity and even dissociative behaviors. They may accuse others of the very behaviors they engage in on a daily basis.

Understanding these symptoms is crucial for recognizing BPD and advocating for proper diagnosis and treatment.

Challenges in Relationships for Those with BPD

Navigating the emotional landscape of relationships can be particularly challenging for individuals with Borderline Personality Disorder (BPD). Here’s a closer look at some of the unique hurdles they might face:

Trust and Hypersensitivity

• Difficulty Trusting Others: For those with BPD, trust doesn’t come easily. This can stem from past experiences or inherent fears associated with the disorder.
• Hypersensitive Reactions: Perceived slights or rejections can trigger intense emotional responses, often leading to conflict or withdrawal.

Emotional Instability

• Constant Emotional Changes: Rapid fluctuations in mood can confuse and alienate partners, friends, and family members, making stable relationships difficult to maintain.
• Perceived Chaos: To outsiders, these emotional peaks and valleys may appear chaotic or unpredictable, adding strain to interpersonal dynamics.

Fear of Abandonment

• Intense Fear: This core symptom of BPD can drive individuals to cling to relationships, fearing isolation and rejection above all else.
• Unrealistic Expectations: Sometimes, the fear of abandonment leads to unrealistic expectations of partners, fostering a codependent dynamic.

Relationship Patterns

• Caring but Sensitive: Individuals with BPD can actually be caring and compassionate, but their sensitivity to abandonment or perceived slights causes conflict and complicates their relationships.
• Codependency Issues: The intense desire to avoid abandonment may lead to relationships where one partner is excessively dependent on the other, which can be both unsustainable and unhealthy.

How to cope with someone with BPD in your life

Coping with someone who has borderline personality disorder involves understanding, patience, and well-defined strategies to maintain a healthy relationship. Here are practical steps to help manage interactions and support your loved one:

1. Establish Clear Boundaries

Set healthy boundaries to protect both your well-being and the relationship. Clearly communicate what behaviors are acceptable and which are not, ensuring these limits are consistent and respectful.

2. Educate Yourself About BPD

Gain a deeper understanding of BPD symptoms and triggers. This knowledge can prevent misunderstandings and equip you with strategies to handle challenges effectively.

3. Practice Active Listening

Show empathy and validation by listening actively. Acknowledge their feelings without judgment, which can help them feel understood and supported.

4. Stay Calm and Patient

During emotional escalations, remain calm and patient. This stability can be reassuring, helping to de-escalate intense situations.

5. Encourage Professional Help

Support your loved one in seeking professional help such as therapy or counseling. Participate in sessions if appropriate, to better understand their experiences and needs.

6. Learn and Apply Mindfulness

Mindfulness techniques can help both you and your loved one manage stress and emotional spikes. Practice these techniques together to encourage a calm environment.

7. Regularly Check-in

Maintain regular communication to help alleviate fears of abandonment. These check-ins can reinforce your support and commitment to the relationship.

8. Respond to Self-Harm Seriously

Always take any self-harming behaviors seriously. Encourage professional intervention and express your concern about their well-being without judgment.

By implementing these strategies, you can create a supportive and understanding environment that helps manage the challenges of BPD while strengthening your relationship.

Is there effective treatment for BPD?

Absolutely, there are effective treatments for Borderline Personality Disorder (BPD), primarily focusing on psychotherapy, with medication playing a supportive role in managing co-occurring conditions. Let’s break down the key components:

Psychotherapy Approaches

• Dialectical Behavior Therapy (DBT): This is the gold standard for BPD treatment, emphasizing mindfulness, emotional regulation, and distress tolerance skills.
• Cognitive Behavioral Therapy (CBT): Helps patients identify and change core beliefs and behaviors that underlie inaccurate perceptions of themselves and others, and problems interacting.
• There are others, including Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP), and Schema-Focused Therapy, all of which can be helpful, but The challenge is in getting the BPD patient to not only recognize that they have a problem but to continue therapy once they do.

Medication and Other Treatments

• While medications do not cure BPD, they can help manage symptoms like depression, anxiety, and impulsivity when they occur alongside BPD.
• Hospitalization might be necessary in cases where there’s a risk to the patient’s safety.

• Regular exercise, adequate sleep, and a nutritious diet can significantly reduce symptoms.
• Mindfulness and stress management techniques are beneficial in managing emotional spikes and fostering emotional stability.

Conclusion

With the right support, people with BPD can have healthy, fulfilling relationships. Without it, and without treatment, they can lead lonely, unfulfilled lives frought with unstable relationships and substance abuse.

Coping with BPD can be very challenging. But if you, a family member or friend is struggling, there is help. The national alliance on mental illess (NAMI) will provide you with support and information about community resources for you and your family.

Contact the NAMI HelpLine at 800-950-NAMI (6264) or info@nami.org with any questions you may have about BPD.

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Abigail Zuger, MD

Both agents are clinically effective, but uncertainties still attend their use.

At the end of December 2021, two novel oral antiviral agents received FDA emergency use authorization for outpatient use in mild-to-moderate COVID-19. Although both agents generated substantial premarketing enthusiasm, they come to market with lingering uncertainties.

Nirmatrelvir (Paxlovid, Pfizer) is a viral protease inhibitor with expected in vitro activity against all clinically significant SARS-CoV-2 variants to date. In an unpublished manufacturer-supported study. opens in new tab, nirmatrelvir boosted with the CYP3A inhibitor ritonavir reduced rates of hospitalization or all-cause death by almost 90% among unvaccinated high-risk adult outpatients with confirmed mild-to-moderate COVID-19. A study involving vaccinated standard-risk adults is ongoing. The drug has also been authorized for unvaccinated children and teens 12 and older. The dosing regimen consists of two 150-mg nirmatrelvir tablets and one 100-mg ritonavir tablet taken together twice daily for 5 days. Renal impairment requires dose reduction; patients with severe liver or kidney disease should not receive treatment. Coadministration with drugs metabolized by CYP3A or those inducing the enzyme may be dangerous. No specific adverse effects have been associated with nirmatrelvir plus ritonavir to date.

Molnupiravir (Lagevrio, Merck) is a nucleoside analog that induces fatal mutations in the SARS-CoV-2 genome; it too has demonstrated in vitro activity against all clinically significant viral variants. In a manufacturer-supported study of high-risk unvaccinated adult outpatients with mild-to-moderate COVID-19, the drug reduced rates of hospitalization or all-cause mortality by about 30% (N Engl J Med 2021 Dec 16; [e-pub]). Because of concerns about possible mutagenicity, molnupiravir is not recommended during pregnancy; and because of possible toxicity to bone, cartilage, or both, the drug has not been authorized for children or teens younger than 18. The dose is four 200-mg capsules twice daily for 5 days. Side effects have been limited to mild decreases in hemoglobin. opens in new tab. No renal or hepatic adjustments are necessary, and no drug–drug interactions have been identified. An FDA advisory committee also articulated concerns about the drug’s potential ability to generate viral mutants of concern.

COMMENT
Until these two drugs were approved, authorized treatments for outpatients at high risk for severe COVID-19 were limited to parenteral monoclonal antibody preparations. Some recent monoclonals (NEJM JW Infect Dis Nov 2021 and N Engl J Med 2021 Sep 29; [e-pub]; NEJM JW Infect Dis Jan 2022 and N Engl J Med 2021 Oct 27; [e-pub]) have yielded results similar to nirmatrelvir’s — and considerably more impressive than molnupiravir’s — but the practical difficulties of administering monoclonals are considerable, and not all are active against specific SARS-CoV-2 variants. Good data now support the efficacy of the parenteral antiviral remdesivir in at-risk outpatients with COVID-19 (N Engl J Med 2021 Dec 22; [e-pub]), but the same practical difficulties apply.

Although oral antivirals will be far easier on both patients and providers than any of the parenteral agents, clinicians should remember the unknowns attending their use— namely, a full picture of the drugs’ clinical efficacy against current and future viral variants, as well as their real-world toxicities. Molnupiravir particularly worries the FDA and its advisors enough that the agency has directed clinicians to use it only if alternative agents are contraindicated or unavailable. This advice presumably places molnupiravir as the current last choice among available agents. Still, the hierarchy of outpatient COVID-19 treatments is likely to change substantially as new agents emerge, new variants circulate, and more-complete data on these first two drugs’ clinical performance are released.

CITATION(S):
U.S. Food and Drug Administration. Fact sheet for healthcare providers: Emergency use authorization for Paxlovid™. FDA 2021 Dec 22; [e-pub]. (https://www.fda.gov/media/155050/download. opens in new tab)

U.S. Food and Drug Administration. Fact sheet for healthcare providers: Emergency use authorization for molnupiravir FDA 2021 Dec 23; [e-pub]. (https://www.fda.gov/media/155054/download. opens in new tab)

Here are good sources of covid-19 data.

This site, Epiforecasts, has the Rt (effective reproductive number) which will give you some idea of how fast the virus is spreading in your community.

Daniel Stout of StoutLabs has created a site that we have used consistently since the start of the pandemic: covid.stoutlabs.com.

Click here for US Data

And this site has comprehensive data;  it can be overwhelming but is worth the time:  Our World In Data.

Our pal Jake Boisvert turned us on to COVIDestim.org, which tries to paint the most complete, current, and granular picture possible of the U.S. COVID-19 epidemic.

 

If you have other sites you’d like added to the list, please let me know.

Dr Steve interviews electronic musician Metamyther. Topics include Moogfest, breaking into electronic music, performance in the age of COVID-19, vaccine timing, and more.

Check him out: https://www.metamyther.com/

stuff.doctorsteve.com (for all your online shopping needs!)

noom.doctorsteve.com (lose weight, gain you-know-what)

Get Every Podcast on a Thumb Drive (all this can be yours!)

roadie.doctorsteve.com (The ROBOT guitar and bass tuner! And it ain’t expensive!)

simplyherbals.net (for all your StressLess and FatigueReprieve needs!)

BACKPAIN.DOCTORSTEVE.COM – (Back Pain? Check it out! Talk to your provider about it!)

Cameo.com/weirdmedicine (Book your old pal right now while he’s still cheap!)