Borderline Personality Disorder (BPD) – Pathological personality traits in Disinhibition – impulsivity: acting on a momentary basis without a plan or consideration of outcomes (DSM5).

The Problem

As mentioned in previous blogs, over 2% of the population have some degree of Borderline Personality Disorder (BPD). Of this population 8 to 10% of us commit suicide – this rate is more than 50 times the rate of suicide in the general population and 10 times the rate in people diagnosed with Depression, and that does not even include those of us who depart because of drug overdoses. One of the defining traits that is connected with suicide attempts is impulsivity. We often engage in these harmful, behaviors to ease distress in the short-term, despite the possible serious negative consequences in the long-term. In this blog we are going to focus on developing plans and strategies with due consideration of outcomes. First let’s take a look at the science to see what we are up against.

The Science

Cackowski and others(1) used self-reporting to study 31 unmedicated women with BPD and 30 healthy matched women controls on behavioral tasks measuring response inhibition under resting conditions and after experimental stress induction. Patients with BPD reported higher impulsivity under both conditions and a significantly stronger stress-dependent increase in state impulsivity. They concluded that there is a significant impact of stress on self-perceived state impulsivity and on response disinhibition in females with BPD.

So what is happening in the brain? Leyton and others(2) studied 13 medication-free men and women with borderline personality disorder and 11 healthy controls using positron emission tomography (PET Scans) during go/no-go commission error activities. In both men and women, negative correlations with impulsivity scores were identified in the medial frontal gyrus, anterior cingulate gyrus, temporal gyrus, and striatum. They concluded that synthesis capacity in corticostriatal pathways may contribute to the development of impulsive behaviors in persons with borderline personality disorder. In the male subjects, low trapping was also observed in the medial frontal cortex extending into the orbitofrontal cortex, as well as in the corpus striatum. These sites correspond to regions that seem to be involved in mediating the planning, initiation, and inhibition of goal-directed behaviors, working memory, and emotional affect.

What it Means

So what does this mean in plain English? Well friends, we have a problem. Not only do we engage in risky behavior, not only do we seem to intentionally neglect to plan ahead, but under stress, we seem to forget all the plans that have been planted in our brains by past experiences and the good intentions of therapists. There is a reason for this. It is the way we are wired. Because of our genetic predisposition to be over sensitive and the environmental factors that have shaped our behavior patterns, we now have a brain that says run like hell under stress and to hell with the consequences. The brain scans indicate that both men and women have difficulty reacting to sensory information to controlling emotions (corticostriatal pathway). Women seem to rely more on an emotional response whereas men run into further difficulty when we try to organize that information for decision making (frontal cortex extending into the orbitofrontal cortex). We both end up in the same place with seeking emotional relief usually by avoiding pain and seeking pleasure regardless of the consequences (temporal cortex, limbic areas). This seems to be particularly relevant under stress. So how do we combat our natural reactions, especially under stress?

Here are my five suggestions for borderliners:

1. First line of attack is to control your stress and anxiety levels. To do that you have to learn to read our body signals and stop the anxieties in their early stages before they blow up and you lose control. After that – game over until next time.

2. The best way to relieve anxiety is to get out of your emotional mind (corticostriatal pathway). The best way to that is to shut down all thought because at this stage thought leads back to emotion. You can do this by deep breathing. By concentrating on your breathing you interrupt the flow of negative energy into your brain. I recommend the thirty second breathing activity (in the past I said eight for anxiety relief, but science now suggests we need thirty for healing and changing brain patterns). Take a deep breath and then slowly let it all out (I recommend a stop watch rather than counting). When there is no air left, hold that until the 30 seconds are up. Keep doing this until you feel a sense of peace, calmness and control.

3. Once you have achieved this sense of peace, you are now free to confront your emotions. Self-talk your way through the process. I recommend doing this out loud as this will engage more of your brain and bring some organization patterns to the emotional center. Tell yourself why exploding or going off into a pity party is not helping. Women are naturally good at this whereas men need practice. As a men you may wish to ask a female friend or partner for help with this (sexist, I know, but there is some truth in it).

4. Now that your emotions are under control, you are ready to tackle the problem that caused the emotional reaction. This is where your orbitofrontal cortex comes in. You can do this in two parts. First see where the event fits into your life story. You may gain insight into what has happened in the past to cause you to react this way. You can then go on to making a plan and putting gates and strategies in place for when these kinds of situation occur in the future. Men are good at this; it’s the emotions that they cannot handle. Women tend to digest the emotional part and then think the problem is fixed. It isn’t. You need a plan. You need to build new behavior patterns. You may wish to ask a male friend or partner for help with this (sexist, I know, but there is some truth in it). If your plan does not seem to be working, you may need to seek professional help with this.

5. Build some cues into your plan, some automatic responses or checks and balances to deal with future situations. One I had to use when I was having difficulty during the early stages on my new relationship (seven years tomorrow) was to simply shut down my mind and turn off my mouth until my wife said what she felt she had to say. Then I would excuse myself and go for a walk, do deep breathing exercises until I felt calm, and then come back and give my side of the situation. At first it was difficult and emotional but I had already enlisted the support of my wife in dealing with my emotions. She knew my emotions were about my issues and not about her so she was willing to give me some clues and ignore my emotional reaction to being reminded that I was being an ass again. But I got better at it with practice. Now I do not even need the walk. I catch that first flutter of emotion, take a deep breath, and I’m ready to deal with the situation rationally before it triggers an emotion. I still fall off the wagon from time to time but we both look at each other, smile, and laugh at it for what it is. Just emotion. Whatever strategies you put in place don’t give up on them. It took me sixty years to develop my self-defeating thought and behavior patterns; it took me two full years to change them. Just keep believing in yourself, learn to say you are sorry (including to yourself), learn from the experience, and reset your goals and strategies if needed. Remember that you are a beautiful and powerful spiritual creature. You can do this.

1. Cackowski, S.; Reitz, A.; Ende, G.; Kleindienst, N.; Bohus, M.; Schmahl, C.; and Krause-Utz, A.. Impact of stress on different components of impulsivity in borderline personality disorder. Cambridge University Press. March, 2014.
https://www.cambridge.org/core/journals/psychological-medicine/article/abs/impact-of-stress-on-different-components-of-impulsivity-in-borderline-personality-disorder/E8AF2E2CB9606F30E1F3AA9EF7F12679

2. Leyton, Marco; Okazawa, Hidehiko; Diksic, Mirko; Paris, Joel; Rosa, Pedro; Mzengeza, Simon N.; Blier, Pierre; Benkelfat, Chawki. Brain Regional α-[11C]Methyl-L-Tryptophan Trapping in Impulsive Subjects With Borderline Personality Disorder. The American Journal of Psychiatry. Vol 158, Issue 5, 2001
Published Online:1 May 2001 https://doi.org/10.1176/appi.ajp.158.5.775