4 Types of Borderline Personality Disorder

[Music] hi i'm kyle kiddleson with med circle joined by clinical psychologist dr romney love seeing you again today thank you so much for having me kyle where you've talked about borderline personality disorder in the past and if you're watching this right now and want a general overview of bpd use the links below to access that content because right now we're gonna dive into the four subtypes dr romney let's start with the high functioning high functioning internalizing slash quiet subtype of bpd so borderline personality disorder sort of again in its wider spectrum is a very very

heterogeneous personality disorder which is why it's so tricky even people out there experiencing borderline personality will say how come my experience is so different than other things that i've read about borderline personality what is heterogeneous different it's different it's so scattered like it's it's not just one thing it's almost like saying i want cereal i'd be like you're a granola person you're a cheerio person like what are we talking about here borderline personality is that mixed up in a way and because we have this one umbrella term that's used but these four subtypes are very

different so it's important for us to distinguish so as we start with the high functioning internalizing sort of quiet borderline to me this is something we could almost term as a more pure borderline personality in this way that this is a style of borderline personality where we see a tremendous amount of despair of of fragility of you know tremendous abandonment crises when when there is an when there is a trigger or an activation such because of an abandonment crisis or a triggering of a prior trauma or a stress that feels that it can't be managed

the person will rage it themselves right so they will internalize it they will talk about themselves horribly they might even have suicidal thoughts about themselves believing passively the world will be better off without them but the key piece in this quiet borderline distinction is that they are high functioning many people who fit this high functioning internalizing quiet borderline descriptor have very high power jobs they're often in jobs where they're giving to others nursing teaching mental health so there's a natural draw of this particular style of borderline personality to a helping profession to give to others

where they might get challenged in a professional arena is that if they even make a small error and i mean it could be small they will have a very strong reaction to it and that strong reaction will be very self-blaming and sometimes even self-harming so the person who presents with quiet borderline personality styles or disorder is somebody who's much much more likely to have co-occurring depression or an anxiety disorder that also makes the symptomatology almost sometimes feel worse because there can be this real these these negative mood states that accompany this particular style in fact

many mental health practitioners may miss the borderline piece and focus more on the depression or the anxiety piece and treatment until over time they see that the patient sort of cell style of self-talk is so self-harming and that individuals with quiet or this sort of high-functioning internalizing borderline personality while they are high functioning it's not a very stress resistant pattern so when there is stress something shifts at work something shifts in a relationship there's a there is a um a tremendous difficulty in being able to tolerate the distress associated with those times but that distress

instead of lashing out and yelling at somebody else or making that kind of a gesture they're very quick to almost rage quietly at themselves self-harm self-destruction people might starve themselves may not get enough food may try to almost break themselves trying to maintain a household or be all things to all people so it's a very self-destructive disorder but it's done in such a quiet way that a lot of people don't even identify it classically as borderline personality disorder which is traditionally thought of to be as a much more chaotic externally dysregulated pattern these subtypes are

they in the dsm and recognized in the mental health community or is it just what laymen have come up with in the dsm they have not recognized the subtypes these subtypes represent a mashup over the years of different sources of research theodore milan was a major player in coming up with these subtypes of borderline personality in fact his scale the milan clinical multi-axial inventory which is a personality assessment tool he i give you if you're ex more expert in scoring it you can actually look at the scoring and sort of break some of that down

and he is opined on these sorts of sub types of borderline personality it's absolutely a anyone who's in practice who's ever worked with somebody with borderline personality knows that this is it is it's like a stone with money facets right it when some you tell me somebody's got borderline personality i'm saying that's not enough you got to give me more tell me a little bit more about this client because i am going to have an incredibly different treatment approach or recommendation based on the kind of subtype but no this has not officially elevated itself into

the diagnostic manuals before we move on to the second sub subtype how prevalent is bpd prevalent the prevalence of bpd is widely disputed okay so the estimates of bpd in the population range probably i've seen estimates anywhere from two to six percent two to seven percent that kind of thing part of the reason it's there's so so much variation is that it's not easy to assess many clients who present with borderline personality disorder in sort of non-research studies like just sort of in traditional clinical evaluation what they show how they show up in sort of

chart data at clinics or hospitals is they're often more likely to be diagnosed with mood disorders anxiety disorders bipolar disorder but not borderline personality disorder part of that is a training issue people are less likely to give that diagnosis out they want to subsume it under under other things part of it is a i guess i don't know how we call it sort of a marketplace issue borderline personality disorder is viewed as something that's difficult to treat and takes a very long time to treat and because of that just to not get pushed back from

insurers or spaces like that there may be more of a tendency to use some of the neighboring or co-occurring some dermatology in that person oftentimes the way these patterns are medicated or similar there's no pill for borderline personality per se you're often sort of working on it symptomatically so i think that we still haven't seen that study that gives us the optimal prevalence number if i were to spitball a guess i would say it's probably somewhere between three and five percent tonight we'll be having a live panel with dr romney and other med circle doctors

it's a great chance for you to ask questions directly to these doctors it is not treatment or therapy it is education and a great chance for you to really understand whatever mental health topic you need clarification on you can sign up to join us tonight or get the replay sent to you at a later date using the links below this video uh dr romney what is the second sub type of bpd the second subtype has been termed petulant or histrionic i don't like the term histrionic as a feminist i don't like that term because it

really carries this implication it builds on the term hysteria and the term hysteria is really sort of pathologizing of female sexuality so let's stick with petulant but just so people know because this term histrionic is thrown around histrionic means somebody who is very superficially attention seeking and emotionally dysregulated so a person who's like almost seductive in their presentation they are they will be almost coy and little girl and it's very it's very female oriented to get attention um but it's very much an attention seeking kind of a pattern very and very a socially immature pattern

but if we focus on the petulant piece associated with that the petulant part is again it's this sort of acting out if i don't get my way and so a petulant person can be experienced as manipulative they could be experienced as a victimized um petulant people will have a they'll be a sort of a little bit of a through note of entitlement in fact there's a fair amount of overlap of what we call covert narcissism and what we some of the patterns we see in petulant borderline personality and here's where borderline personality gets super super

tricky we've talked about this on med circle before and i know we have a series on cluster b personality disorders there are multiple personality disorders in that set borderline and narcissistic are two of that set when we look at some of the theorists who've studied personality disorders otto kernberg being one of the most primary what we see there is that there is a view of borderline and narcissistic personality disorder as almost being slight variations on a theme so it's no wonder that at times they overlap we just talked about the quiet high functioning internalized borderline

person there we see very few almost no narcissistic personality whatsoever in fact the people in that quiet borderline group really don't have a lot of ego strength which is why they tend to devalue themselves and really fall apart and can't tolerate in the stress in their lives especially around abandonment because there's almost no sense of worthiness but when we slide over into spaces like the more petulant traditionally called hysterionic now we're looking at more the attention seeking now we're seeing the sense of some sort of passive low-grade entitlement why am i not getting my way

i'm going to get my way and if i don't get my way i can't tolerate the abandonment feelings and the stress feelings that come out of that disappointment so people might experience a sort of petulant borderline pattern as one that's more of sort of an attention seeking acting out kind of a pattern and will feel that this is somebody who throws tantrums a lot it'll have that kind of flair in a very disregulated way but as i said here now you're in an area of the borderline personality where we're seeing an overlap with narcissistic personality

if you want to view it this way there's they sit right next to each other so one is going to bleed over into the other just like i'd argue in covert narcissism some of that borderline symptomatology has bled over into there so these are things that sit right next to each other and things that sit next to each other are going to be we're going to see observe observe similar patterns in them so how is this subtype of bpd different than histrionic personality disorder in histrionic personality disorder we won't see the same level of triggered

activation in the face of things like disappointment and especially abandonment and abandonment and disappointment maybe experience is similar like if a person doesn't get i don't know an opportunity or they don't get to go on a um the date gets cancelled or something like that that is a disappointment but if you perceive it as an abandonment you can see how the reaction to it would escalate a lot more than just like something times things don't work out in what was traditionally termed histrionic personality disorder in the dsm that's much more of a superficial attention-seeking um

a superficial attention-seeking style where the person actually becomes visibly uncomfortable if they're not the center of attention so again you can see that overlap with the narcissistic style it's also in cluster b the need for attention the need for validation but what you don't see in the histrionic personality is as strong as a bent and a tendency towards the manipulation you'll see some of it but mostly i would say with the histrionic personality style it's like a baby and an adult in the same person that's what that feels like yeah all right let's move to

the third subtype that would be what we call the angry externalizing impulsive borderline personality honestly this presentation is where borderline personality kind of got its bad name clinically and it's definitely only a sub a percentage of people with borderline personality this is my speculation this is not a accepted fact i'm going to share it here it is my belief that when we see the angry externalizing impulsive borderline style that's likely actually almost a complete overlap of borderline and narcissistic personality it's probably where those two things almost are 50 50 together and this is again what

which is a bummer because so much of borderline personality gets its bad name just from this one presentation and people view this as unhinged and unmanageable now people who have the angry angry externalizing impulsive borderline presentation are exactly what it sounds like there is a lot of very disregulated rage that comes up very quickly that is very discontrolled which can be very unsettling for people around the person and it can mean it can often be triggered by things like abandonment crises or significant um significant disappointment there's major difficulties with distress tolerance so anything that bad

that's happening can't tolerate the distress but instead of turning inward they turn outward you could be yelling it could be screaming it could be breaking objects it could be blaming other people but it's very externalized it's it's targeted at all the other things and people in the environment there's also a lot of impulsivity here impulsive acting out that can actually be dangerous so in the midst of the distress like i said instead of it being turning inward and harming oneself there can be impulsive acting out like using drugs and alcohol driving dangerously having dangerous sexual

encounters thing spending a lot of money things that could put them in sort of harm's way that sometimes can get so escalated it is in this angry externalizing impulsive subtype you can understand why some mental health practitioners would confuse this with mania because it looks so agitated and so acting out and so in this case you might see a lot of rage a lot of you might even see a lot of manipulation and the same abandonment stuff is there as it always been the same problem the issues with identity are there as they always been

all of these borderline subtypes have those same undercurrents a lot of it is sort of how it's expressed and how the world experiences it so this particular subtype of borderline personality is also potentially quite dangerous i think there's that that potential for suicidal acting out and suicidal um thoughts and and tragically suicidal you know completion of a suicidal act you'll see that here too and it can be in a moment of acting out like i'm gonna go do something dangerous i'll show you and then unfortunately that i'll show you can end up in a very

tragic place so all of these threats have to be taken very seriously but many times people will get very exhausted or even very frightened by this presentation of so much strong rageful emotion but the person with this subtype with the angry externalizing impulsive subtype literally feels out of control with these emotions they do not know what to do with them they're absolutely overwhelmed and and they because they don't know instead of turning in they turn out but it's just like with the quiet borderline person they just don't know what to do with all of this

strong emotion yeah understood let's move into the fourth and final step the the fourth and final one is called the depressing i'm sorry the depressive the four the fourth and final one is called the depressive internalizing subtype sometimes called sort of self self-defeating and self-destructive so in this particular subtype it unlike that first group the quiet high functioning internalizing person with borderline personality here we see an almost uniformly dysphoric and depressive presentation because of that people with this final subtype might not be able to hold and secure employment as well whereas in quiet borderline we'll

see people who are often able to stay in jobs for many many many years but whereas with the depressive internalizing kind of self-defeating and self-destructive you might see somebody where that's a lot harder because the depressive the depressive undercurrents of this form of borderline personality can make it a lot harder to sort of mount the energy and the effort to consistently hold employment or even relationships the depressive symptomatology is going to get much more exacerbated again at times of frustration disappointment and certainly abandonment the self the self-destructive and the self-defeating part can mean that there's

a very high risk of self-harm especially in the face of there being an abandonment or other similar kind of triggering crisis in this particular case the depression will often become the central focus of treatment because that's actually what's putting the this client at risk for suicidal acting out suicidal harm self-harm you know or the risk of of committing suicide so this is actually a relatively high risk group many times people in this last group will also sometimes get missed they'll be they'll be labeled solely as having major depressive disorder and then one might say so

what so what if they only have major depressive disorder it does matter because some of that dysregulated instability can make the lows of the depression even lower so it's as though the dysregulation of this particular form of borderline personality where we're seeing the depressive internalizing style is you might see a typically sort of typical dysphoria and then it'll end even further down when the person is facing a real crisis and that can that can mean that they won't be able to take care of themselves they won't they'll neglect themselves they may neglect others in their

care that they may need a lot more support and help that those times they may not as successfully engage in things out there to help them like psychotherapy so there's a real risk in that as well so this is this is a particular subtype and again we're trying to keep them safe because somewhat similar to the quiet borderlines they're immediately they're going to go right to that passive self-harming i deserve to die i shouldn't be alive i don't even know why i exist i don't know who i am that kind of emptiness they'll go there

but because the depression is such a central core feature of this presentation it's harder for them to remain functioning in the world that in the quiet borderline type one thing that often protects them is because they're in the workplace and functioning quite well there they may have social supports through that in this final form of borderline personality it may be harder for these individuals to access social support because they're so depressed and they may be so isolated as a result you know taking all together kyle as you can see these are actually four different presentations

so you can see how with a therapist we're seeing for these four as four different clients a big four very very different experiences and i've actually had the experience of working with all four of these subtypes of borderline personality it couldn't be more different you know i have to say that in terms of how treatment goes the kinds of outcomes we see the level of engagement um the level of boundary violations in therapy is very very different and so i think though what happens is that the borderline symptomatology can make cutting through the other symptoms

especially anxiety and depression a lot more difficult it creates almost this consistency if you will so even as you're getting through the the issues around distress tolerance and and trauma-informed care become really really important but i think that people who are living with borderline personality or are supporters of people with borderline personality really it's important for them to understand that this can present very differently because so much of our attention is often on the negative stereotypes of borderline personality as being difficult to manage and deeply dysregulated i think we're not seeing a full picture of

it and i think there's a real risk in that because i don't think we can care for clients who are living with this be supporters of people living with this or even if you're living with this trying to help you understand yourself and saying i'm not those things do i not have this i'm actually the person who turns inward and thinks these self-harming thoughts but i've had the same job for 25 years no it may very well fit that pattern and that might mean a slightly different approach in terms of how the dbt is used

with those given clients excellent well for more information on bbt bpd and dbt the standard therapy for bpd use the links below this video dr romney thank you again for the great information i'm kyle kiddleson remember whatever you're going through you got this