Point of View: Not All Borderline Personality Disorder is Alike

by Katie Brown
August 17, 2023 at 10:05 AM UTC

Challenging the fixed perceptions and the stigma encircling borderline personality disorder.

Clinical Relevance: A borderline personality disorder can be nuanced and require tailored treatment

  • A clinical psychologist challenges fixed perceptions about borderline personality disorder.
  • Some BPD patients lack whole object relations, the ability to view a subject as having likeable and disagreeable traits at the same time. 
  • Not all BPD cases are “high splash” with all the hallmark symptoms of the disorder that are listed in the DSM-5.

Borderline personality disorder (BPD) is a disorder characterized by unstable relationships and difficulty controlling moods and behavior. It’s one of the most highly stigmatized mental illnesses, according to one Cambridge University study. And, while there are plenty of widely-held misconceptions about BPD that need debunking, clinical psychologist Elinor Greenberg says there’s one in particular that stands out:

BPD is a life sentence.

“You don’t have to stay borderline your whole life,” Greenberg told Psychiatrist.com. As author of Borderline, Narcissistic, and Schizoid Adaptations: The Pursuit of Love, Admisration, and Safety, she has dedicated much of her career to studying and teaching about BPD.

Whole Object Relations

According to Greenberg, it all comes down to a concept known as whole object relations

“Whole object relations means, technically, that you can view somebody in an integrated, realistic, and stable way that includes both the traits you like about them and that you don’t like,” she said. 

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Those who lack whole object relations—as many BPD patients do—instead have a “split” view of those in their lives, seeing only the good in them during happy moments and viewing them as all bad during disagreements. For these patients, “There’s no middle ground; there’s no gray area,” Greenberg said. These individuals lack the ability to integrate these two views of the person.

When most people think of BPD, they typically imagine a patient with no grasp of whole object relations. “The person everybody pictures—the person who called you ten times in a row; who is in the middle of the night texting you; who, after their boyfriend breaks up with them, they’re threatening to commit suicide and making a dramatic scene?” Greenberg emphasized, “The average person with borderline personality disorder isn’t like that.”

The reality is that like every disorder, borderline personality disorder is a spectrum. While some lower-functioning patients may behave similarly to Greenberg’s aforementioned description, most are able to develop some level of object constancy—“the ability to maintain a feeling of positive connection towards someone while you are frustrated by them, disappointed with them, angry with them, saddened by them, or physically distant from them,” she said. 

Most people start cultivating object constancy in their toddler years and have a full grasp of it by adulthood. But others, often those who grew up in abusive or unempathetic environments, never pick up the concept naturally. 

Emotional Splashing

The theory of “emotional splashing” came to Greenberg while watching Michael Phelps swim the butterfly in the Olympics. “He went through the water so smoothly that nobody was splashing,” she noted. A few days later, at a family pool, she noticed children who splashed freely, both intentionally and unintentionally.

She began to picture her borderline patients on a “splash” spectrum, measuring how detectible their disorder is to people in their lives. “The high splashes, they’re unlikely to have whole object relations and they’re not private. They don’t mind their problems being out in public,” Greenberg noted. 

She found that her high-splash patients exhibited self-centeredness, lacked adequate emotional coping tools, and relied heavily on loved ones. The splashiest patients represent the more stereotypical portrayal of BPD. Greenberg said this doesn’t resonate with the majority of her clients.

Low-splash people, on the other hand, tend to be more private, hold onto their jobs for longer, and have developed tools for whole object relations. Why is it, then, that the general view of BPD tends to portray the most extreme manifestation of the disorder?

The answer may lie in the DSM-5, a manual used by physicians to diagnose mental disorders based on observable symptoms, Greenberg speculated. But what about those low-splash individuals without many observable symptoms? “They will not get the diagnosis as easily,” Greenberg said.“They got it right about the lowest-functioning, most obvious group, but they don’t get it right about anybody who has learned to function at a higher level.”

A New Language

The good news, according to Greenberg, is that whole object relations can be learned. She says it’s like learning a new language. “The defining characteristic of any personality disorder is a lack of whole object relations and a lack of object constancy,” she noted. 

Using a few basic techniques, many of her clients have progressed to the point where they no longer qualify as having borderline personality disorder, based on the DSM-5’s description. She describes these individuals as having borderline traits with coping mechanisms to manage them.

The best way to develop whole object relations is through practice and repetition. Greenberg suggests each of her clients make lists, scrapbooks, or other visual reminders related to the people and things in their life that may trigger them. Divide each into two parts. One side should represent the things the patient likes about a subject and the other side should symbolize things the patient dislikes. When they begin to feel triggered, the borderline patient can attempt to calm themselves by referencing the words and symbols they penned while in a more stable state of mind. “Inhibit your mind from going to the place it goes to,” she suggested. “You want to heal the split.”

Greenberg believes that practicing this technique over time can change the brain’s wiring and create better habits. “In your brain, habits are formed by a group of neurons that fire together. And the more times they fire together, the more automatic it becomes,” she said.

To speed this process along, Greenberg suggested borderline clients join a dialectical behavior therapy (DBT) group in their area. Often, this is a form of relatively inexpensive, widely-available group psychotherapy that teaches tools for stress tolerance and management of negative emotions in distressing moments.

Opinions Vary

While Greenberg’s views present the possibility of recovery from BPD, professional opinions on this matter diverge. Factors such as individual history and access to treatment can significantly influence the extent of improvement. Additionally, some critics question whether the concept of whole object relations comprehensively encapsulates the intricate spectrum of challenges associated with BPD. These perspectives highlight the nuanced nature of BPD and its potential outcomes.

But Greenberg said she wants people impacted by BPD to have hope for recovery. “Everybody can improve their functioning,” she said. “That’s the message.”

Original Research

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