Is BPD on a Spectrum?

Borderline Personality Disorder (BPD) has long been a subject of debate and often misunderstanding within the field of mental health. Historically, it has been viewed as a distinct and often stigmatised diagnosis. However, some recent discussions that I have seen, and my own personal experiences of BPD, have raised questions about whether BPD truly exists on a spectrum, much like many other mental health conditions.

In this piece, we will explore the diagnostic criteria for BPD, the concept of it presenting on a spectrum, and the wide variety of presentations possible within BPD. I’ll also take a more personal look at the historical parallels with diagnoses like hysteria, and delve into my own personal experiences and story of BPD recovery, highlighting the ebb and flow of symptoms, in an effort to break down the stigma surrounding BPD.

Sound like fun? Great, let’s dive in.

Understanding BPD: The Diagnostic Criteria

To grasp the concept of BPD being ‘on a spectrum’, it’s crucial to first understand the diagnostic criteria for BPD.

According to the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition:

Diagnostic criteria of borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Given the complexity and diversity of these symptoms, it’s evident that BPD is a multifaceted condition that can manifest in various ways. This variability initially raises the question: Is BPD on a spectrum?

Exploring the Spectrum of BPD: Examining Symptom Combinations

With the diagnostic criteria stating 5 out of 9 symptoms to be met for diagnosis, that could present as 256 different combinations of symptoms in any given BPD diagnosis.

While the DSM-5 provides a list of distinct symptoms, mental health professionals recognise that individuals living with BPD may not experience the same symptoms in the same way. Some may exhibit a combination of symptoms that form a unique profile, making the disorder inherently variable. This observation suggests that BPD may indeed exist on a spectrum.

Consider the scenario where two individuals both meet the criteria for a BPD diagnosis. Person A may struggle predominantly with impulsive behavior and fear of abandonment, while Person B may grapple with mood swings and self-harm tendencies. The diversity in symptom presentations highlights the spectrum-like nature of BPD. It’s simply not a one-size-fits-all condition.

Breaking Down Stigma: BPD in Historical Context

Historically, mental health diagnoses, including BPD, have faced significant stigma. In the case of BPD, parallels can be drawn with the now-obsolete diagnosis of hysteria. Like BPD, hysteria was a broad and often misunderstood diagnosis applied primarily to women in the past. The stigma associated with hysteria was pervasive, hindering both understanding and compassionate care.

In our modern understanding of mental health, breaking down the stigma around BPD is essential. Recognising it as a spectrum allows for a more nuanced approach to diagnosis and treatment. By acknowledging the individualised nature of symptom expression, we can move away from one-size-fits-all stereotypes and foster a more compassionate and accurate understanding of BPD.

Remember, BPD is often intrinsically related to complex trauma. That can increase the likelihood that this diagnosis comes after prolonged relationships of abuse and other complex traumatic circumstances. The stigma thrown at people labelled with this disorder can very closely be tied to the “diagnosis” of hysteria, in my opinion.

That’s not to say that there’s no value in diagnosis. Not at all.

In fact, in the current world and my circumstances at the time, my diagnosis really did finally give me the support I needed and put me on a path to treatment and, ultimately, recovery.

However, I do think that as time passes our understanding of BPD as a disorder will change. Hopefully for the better, with more recognition of complex trauma and the interplay between the sets of symptoms and causal circumstances.

Related reading & research

The History of Hysteria: Sexism in Diagnosis

The New Hysteria: Borderline Personality Disorder and Epistemic Injustice

Is The Widespread Diagnosis Of BPD The New Freudian Cover-up?

Personal Perspective: Recovery Experiences & The Spectrum of Symptoms

In my own journey with BPD, I have experienced the fluctuating nature of symptoms. Before diagnosis and treatment, I found myself caught in a cycle of intense emotions, unstable relationships, and impulsive, destructive and addictive behaviours. However, as I engaged in therapy and developed coping skills, I noticed gradual shifts.

Now, I would say that I am sensitive. Feeling safe after trauma takes a lot of ongoing work. Triggers have come up, but I am in safe relationships and have built the emotional regulation skills to work through them healthily when they do. (I’m also almost 3 years alcohol-free and over 18 months self-h*rm free!)

I have had panic attacks where I no longer have the urge to self-destruct. I have felt the urge to self-destruct without acting on it. I have felt sadness without feeling a pit of unending grief. I have felt the urge to drink without acting on it.

Clearly, it’s important to recognise that the intensity of BPD symptoms can vary over time.

At times, the symptoms may intensify, however, the intensity of these symptoms will always wane — especially with dedicated effort and support along the path to recovery. Building mindfulness skills, as well as skills in emotional regulation, interpersonal effectiveness, and distress tolerance through DBT skills training was also crucial to my recovery.

Despite significant progress, I guess I will always carry the BPD diagnosis, though I really don’t know if I would meet many of the diagnostic criteria anymore. It doesn’t really matter to me at this point—but it sure was a useful tool along the way; a slow unlearning of coping mechanisms that took me all over a spectrum of symptoms and intensities.

This nuanced aspect of BPD challenges the notion of mental health—or BPD recovery—as a linear journey. Rather, it resembles a series of peaks and valleys, or a spectrum, with recovery characterised by the ability to navigate and manage these fluctuations effectively.

24 DBT Mindfulness Journal Prompts For Deeper Healing (& 9-Page Journal Gallery)

A Call for Understanding and Compassion

In conclusion, Borderline Personality Disorder appears to exist on a spectrum, with individuals exhibiting diverse combinations of symptoms. Recognising this variability is crucial in breaking down the stigma associated with BPD, much like the historical shift in our understanding of hysteria.

It’s essential to view BPD through a compassionate lens, acknowledging that recovery is not a linear process. Personal experiences, like my own, highlight the importance of building coping skills and resilience in managing the ebb and flow of symptoms.

Most notably: we do recover. But that journey will have its ups and downs.

As we strive for a more inclusive and empathetic approach to mental health, let us challenge stigmas, foster understanding, and support individuals on their unique journeys of recovery. By embracing the spectrum of BPD, we pave the way for a more nuanced and compassionate understanding of this complex mental health condition, and cast out any ill-informed, stigma-ridden rhetoric in the world.