Borderline Personality Disorder, and Why Young People are Falling Through the Cracks

Natasha Swingler has lived with complex mental illness from a young age.

“I didn’t want to be seen, to be heard. I didn’t really want to exist, I didn’t feel that I was deserving of any form of care,” she says.

It would take some time until she would learn of her diagnosis — borderline personality disorder, or BPD.

Even though BPD affects a significant number of people in the community, a large proportion of them having suffered trauma early in life, it remains one of the most misunderstood and stigmatised mental health conditions.

And that stigma extends to the healthcare system, where the enduring myth that it is untreatable prevails and sees many people like Natasha fall through the cracks.

“For me, it saw me believe that this was all my life would ever amount to.

At the age of 10, she started to self-harm.

“At that age, you know that it’s not right, and you know enough to hide it,” she says.

“I started a pattern of utilising self-harm as a way of managing pretty difficult emotions and hiding everything that was going on for me on a really personal level.”

When she was 17, Natasha was sent to an emergency department by a doctor who was concerned for her welfare.

“It was incredibly busy, it was incredibly loud,” she says.

“And I would be discharged that evening with no support for myself, no support for my family, which started pretty much a 24/7 vigil, my family checking that I was still breathing overnight.”

People living with BPD can experience intense and painful emotions, which can make it hard for them to maintain relationships, says Dr Martha Kent, a psychiatrist and advocate for healthcare reform.

They may also be living with, or be at risk of, developing other mental health conditions such as anxiety, depression and psychosis.

“They can shift from intense anger, to sadness, to despair, to mania sometimes, and often there is an underlying sense of emotional pain, which is very difficult to live with,” Dr Kent says.

“They have difficulty containing their impulses, they have a tendency to be attracted to addictive behaviours.

“But I think what BPD is particularly associated with are efforts or the impulse, if you like, to self-harm, and often that is accompanied by suicidal thoughts.”

The enduring stigma surrounding BPD

The complexity of BPD, as well as the stigma surrounding it, means it can often be missed. But even the right diagnosis does not guarantee adequate help and support.

“It’s very confusing for the patient, because the patient usually knows that something is seriously amiss in their lives,” Dr Kent says.

“And I think there is every indication from my experience, and from the literature, that people with BPD are not treated as seriously as people with other mental illnesses.

“There are many examples of people with BPD who are refused admission or treatment because the treating clinician considers that BPD is not a genuine mental illness.”

Professor Andrew Chanen, director of clinical services at youth mental health organisation Orygen, agrees.

“People with severe personality disorder get diminished access to the mental health system. And regrettably, people still experience harm at the hands of some people within the mental health system,” he says.

“So discrimination is a major problem for people with personality disorder.”

Natasha knows that stigma well — it was something she started to internalise early on when she was trying to get help.

“You see young people with BPD in Australia sometimes … discharged from, say, an inpatient stay with no support and still with active plans and intent for their own death, because they are seen as manipulative,” she says.

“When you are continually told that you are manipulative, that you are an inherently bad person, how do you distance that from your own beliefs about yourself?”

What causes BPD?

There is still a lot that is unknown about BPD and its causes. It often begins in adolescence or early adulthood.

Trauma and stress play a role in the development of BPD for many, though not for everyone.

“There’s actually some recent research suggesting that people with this diagnosis are nearly 14 times more likely to report childhood adversity than the average person who doesn’t have BPD, and this is especially true when we are talking about things like emotional abuse and neglect in people with BPD,” Professor Anthony Ruocco from the University of Toronto told The Health Report.

Professor Ruocco studies the neurobiology of the condition and says one of the symptoms of BPD is emotional dysregulation, which can manifest in mood swings and intense emotions like anger and despair.

He says researchers are starting to build a clearer picture of why this occurs.

“Research would suggest that there are disruptions in neural networks in the brain, and these are especially in the frontal brain regions that appear to be involved in regulating one’s emotions,” he says.

“And at the same time, we see potentially deeper regions of the brain such as the amygdala activating differently.”

Therapies that change lives

Despite gaps in our knowledge of BPD, experts say it’s treatable, and it’s time for the stigma to end.

Professor Brin Grenyer is the director of Project Air at the University of Wollongong, which guides an evidence-based strategy to support people living with personality disorders.

He says psychological therapies are incredibly effective.

“Working with a counsellor, working on trying to understand yourself and understand your relationships is very helpful, and people can really develop a lot of skills and strategies to help them when they feel triggered, when they feel unsafe, when they feel like they are losing control.

“In many ways, the diagnosis is actually a hopeful diagnosis because psychological therapies tend to work, and once people get good psychological therapy, they can remain relatively well for most of their life.”

There is also biological proof these treatments work.

“We actually see evidence from brain imaging showing that people with BPD who undergo psychotherapy show not only changes in symptoms of emotion regulation and symptoms of impulse control, we actually also see corresponding changes in frontal regions of the brain,” Professor Ruocco says.

But despite the evidence that therapies do work for people living with BPD, many continue to fall through the cracks.

Skilled care providers that can deliver the right support for people living with BPD can be hard to find — and expensive.

“And a lot of people in the mental health system simply do not feel equipped to offer skilled, compassionate treatment to people with BPD, because they haven’t had the training,” Dr Kent says.

The right treatment finally came for Natasha when by chance, she encountered a health worker she describes as “curious” and “non-judgemental”.

“She quite consistently and gently prodded away at a lot of that self-stigma, and we started to do a lot of work within the DBT (dialectal behaviour therapy) realm about stress tolerance and mindfulness and emotion regulation.

“In the space of probably a couple of months, I’d gone from this individual that was self-harming most days and needing medical attention to manage that, to someone [who] was managing to make it weeks, and then months, without engaging in self-harm at all.”

She says she still has bad days living with BPD — but the difference is she now has the skills to manage.

“We need to understand and recognise that BPD is treatable, that it is manageable,” Natasha says.

“It’s just a matter of finding what it is that works for an individual. And, yes, that takes time.



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