Wednesday, February 10, 2016

Subtypes of BPD, Part II

“Your perspective on life comes from the cage you were held captive in.”
― Shannon L. Alder
        The first post provided a brief overview of BPD by way of metaphor. Now, I would like to suggest an original way of viewing BPD from an existential viewpoint. This is not based on any research, but professional experience and observation over time.
Subtypes of BPD
      From professional experience and observation, there tend to be three types of BPD. BPD shares a similar pathology with diabetes: Type I, Type II, and Gestational. Not only does the pathology tend to match, the treatments are similar as well: Maintenance/Life changes, Life changes, and Monitoring; respectively.

Type I
     The first, and most severe, type of BPD is Type I. Many adults with BPD have a history of trauma and abuse. Often times, a history of trauma is evidenced as a previous or current diagnosis of PTSD, RAD, or Disinhibited Social Engagement Disorder (DSED). Nearly 75 percent of clients with BPD report sexual abuse or trauma (Aguirre, 2007, p. 104). This statistic can be somewhat misleading, as many BPD symptoms involve antisocial, impulsive, and risky behaviors. These behaviors can expose people to situations where sexual abuse/trauma is more likely to occur. In addition, research has shown that people with BPD are more susceptible to developing PTSD (Golier, 2003). Etiology research has identified multiple factors involved in the development of BPD, but early trauma is one of the most common factors for people with BPD (Bandelow, 2003). However, meta-analytic study suggests that anywhere from 20-40 percent of people diagnosed with BPD do not report a history of childhood sexual abuse (CSA) (Fossati, 1999).
     Similar to Type I Diabetes, Type I BPD manifests early in life, will impact multiple systems, and requires medical treatment in addition to lifestyle changes. Type I BPD would be present in the 80-60 percent of cases where CSA, trauma, or neglect are reported. These instances will most likely have multiple diagnoses of PTSD, RAD, or DSED along with BPD (Binks, 2006). The proclivity of comorbidity of Type I BPD can muddy treatment goals and overwhelm resources, providers, and family/social supports.
     It is estimated that 90 percent of people with BPD attempt suicide at a 10 percent completion rate (Aguirre, 2007, p. 201). The rate of death due to diabetes is also 10 percent (National Diabetes Statistics Report, 2014). An additional commonality between Type I BPD and Diabetes is neuropathy. With diabetes, weakness, numbness, and pain from nerve damage, usually in extremities occurs. The resulting numbness can prevent people from noticing when they have a wound or injury. These injuries can then fester, become infected, and result in amputations. An emotional and relational equivalent also occurs in people with Type I BPD. They have experienced an emotional numbness that, when not addressed, can exacerbate relational wounds or injuries which fester to the extent the relationship requires amputation. This does not mean relationship repair is impossible. However, there are times when damage sustained from someone with BPD is so severe, the other person in the relationship is unwilling or unable to risk additional harm.

Initial Treatment
     To summarize, Type I BPD is evident in people who have a history of trauma, complex/compound trauma, unhealthy attachments, self-harm, likely multiple acute psychiatric hospitalizations, and symptoms have been pervasive since adolescents. Type I BPD will require long term treatment due to inherent distrust, emotional lability, and difficulty with attachment/joining. Emotional neuropathy may require multiple specialists to address specific symptoms while an overarching therapy is maintained. This could include EMDR, DBT, CBT, or IOP.

Type II
     In a minority of BPD cases, clients will present with no identifiable history of trauma, CSA, or familial trauma. Parents and family will state the client was a happy child with little to no mood lability, relational stability, and no history of hospitalizations, suicide attempts, or self-harm. Like Type II Diabetes, Type II BPD occurs when natural attempts to identify meaning and meet existential needs are frustrated. This exacerbation of the natural existential vacuum results in what Frankl identified as noogenic neurosis (Crumbaugh, 1964).
     An existential vacuum, a term created by Viktor Frankl, is defined as an emptiness and lack of meaning in our lives. "Frankl suggests that one of the most conspicuous signs of existential vacuum in our society is boredom" (Boeree, 2006). If this is not filled in a meaningful way, people will tend to settle for anything. People with Type II BPD often want for very few things. They tend to be wealthy with access to various supports and seemingly unlimited resources. This strength becomes the weakness which predisposes individuals to this existential form of BPD.
     When people reach out for meaning, belonging, and purpose, but are provided with resources, directions, and expectations, they end up meeting their "wants" without meeting their "needs". This results in an existential version of "rabbit starvation". This phenomenon occurs when rabbit meat, which is very lean, is the primary food. There are too few fats to make the meat truly beneficial in these circumstances and, though the hunter may be full from consuming massive amounts of rabbit meat, they starve to death.
     In clients with Type II BPD, they may have been "fed" a steady diet of resources, medications, and treatment, but they have been devoid of genuine relationships and meaning. Suddenly, out of relational desperation, these clients begin to panic. They become hypersensitive to abandonment, react strongly to any form of critique, and symptoms escalate rapidly. The crucial component then, is lack of authenticity and genuineness in relationships accompanied with an awareness of what is lacking. Van Deurzen (2007, p. 45) identifies inauthentic living as "a sense of imposed duty or the experience of discontentment with one's fate". The symptoms are exacerbated by a lack of sense of self (Buber, 1996, p. 126).
Initial Treatment
     This form of BPD, in my experience, responds remarkably well to existential psychotherapy, EFT, and the humanistic/experiential aspects of DBT. Like Type II Diabetes, Type II BPD can go into remission with lifestyle changes. Clinicians working with this population must be very intentional to avoid exacerbating symptoms. Preparing the client for successfully handling the necessary anxiety this treatment will produce is critical. Basic coping skills, psychoeducation, and planned gradual exposure, built on a solid foundation of the therapeutic relationship, can provide the necessary safety for someone to overtly and intentionally experience authentic relationship. Prognosis in these cases is very positive and could be completed within 12-20 family and individual sessions. Any hospitalizations should be normalized as part of treatment seeking stabilization. This will help clients avoid feeling shameful about their attempts at growth.
     This information is important to help understand and delineate types of BPD in order to specifically target forms of treatment in order to increase positive prognosis. As with any other diagnosis, knowing severity is important to assist in setting expectations and arranging necessary supports. If providers view every BPD case the same way, they may provide too many, or too few, resources. More research needs to be done to help clinically identify forms of BPD. Gestational BPD, a suggestion on how new research can be done, and how it may impact treatment will be covered in part III.
(C) 2016, Nathan D. Croy


     Aguirre, B. A., M.D. (2007). Borderline Personality Disorder in Adolescents: A complete guide to understanding and coping when your adolescent has BPD (1st ed.). Beverly, MA: Fair Winds Press.
     Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G., & RĂ¼ther, E. (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Research, 134(2), 169-179. Retrieved from
     Binks, C., Fenton, M., Mccarthy, L., Lee, T., Adams, C. E., & Duggan, C. (2006). Psychological therapies for people with borderline personality disorder. Protocols Cochrane Database of Systematic Reviews. Retrieved from LINK.

     Boeree, C. G. (2006). Viktor Frankl. Retrieved February 10, 2016, from

     Buber, M., & Kaufmann, W. A. (1996). I and Thou: Martin Buber; a new translation with a prologue "I and You" and notes. New York, NY: Simon & Schuster.

     Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl's concept of noogenic neurosis. Journal of Clinical Psychology, 20(2), 200-207. Retrieved from

    van Deurzen, E. (2012). Existential counselling & psychotherapy in practice. London: SAGE.
     Fossati, A., Madeddu, F., & Maffei, C. (1999). Borderline personality disorder and childhood sexual abuse: a meta-analytic study. Journal of personality disorders, 13(3), 268.
     Golier, J. A., Yehuda, R., Bierer, L. M., Mitropoulou, V., New, A. S., Schmeidler, J., . . . Siever, L. J. (2003). The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events. American Journal of Psychiatry AJP, 160(11), 2018-2024. Retrieved from

     National Diabetes Statistics Report. (2014). Retrieved from


Sunday, February 7, 2016

Subtypes of Borderline Personality Disorder, Part I

“People with [Borderline Personality Disorder] are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” 
― Marsha M. Linehan

     Let me begin by saying I am not an expert on Borderline Personality Disorder (BPD). The information discussed throughout this post, like all my posts, should not be used to diagnose or treat patients. Instead, I would like to share how I've come to view BPD throughout my career and how my treatment changes based on that understanding. This, the first post of three, will describe a metaphor I use to help explain BPD to clients and families. The last two posts will describe the specific subtypes (I, II, and gestational) and explore existential treatment options.
     The DSM 5 outlines specific symptoms and diagnostic criteria for BPD. Information can be found here. A few theories on subtypes of BPD already exist. Millon has theorized 4 subtypes, and Lawson identified 4 types of borderline subtypes for mothers. All of these suggestions are useful in long-term treatment. However, I would like to suggest a new alternative to identifying subtypes of BPD from an existential and systemic standpoint.
     Lastly, I may not consistently use person first language throughout this post. This is not to say people with BPD are defined by their diagnoses. Rather; it is important to see this post as my clinical view on BPD rather than the people who suffer with it. 

Borderline Personality Disorder
     Often times, clients with BPD are unaware of their diagnosis or they aren't sure what their diagnosis means. The DSM 5 describes symptoms in clinical terms which, to the one receiving the diagnosis, may mean very little. When providing treatment for clients with BPD, a primary goal is to help them understand the diagnosis. Therapists would do the same with depression, addiction, or any other diagnosis. As a way of clarifying some of the clinical jargon, a metaphor has often helped to illustrate the critical aspects of the disorder in an approachable way.

The Window Painter
     Imagine we are all born into a room. The architecture of the room has unique and distinct features setting itself apart from other rooms, and is mostly bare without any furniture, paint, window dressings, or decorations. As we mature, we begin to decorate our room as a reflection of who we believe we are. As others look out their perspective window into ours, and as long as the blinds are open, they will see aspects of how we've decorated our room. We move past other people's windows, and sometimes other people, from within their rooms, move past our windows. Regardless of the external changes, we remain in our rooms.
     People with BPD, tend to spend an inordinate amount of time looking out their window without looking into their room. Eventually, they begin to see other rooms are decorated or designed, and they want to appear the same way. Then, instead of working on interior design, they begin to draw on the windows. The window drawing becomes so effortless that, over time, they can change the entire look of a room, nearly on demand. If, when looking into the surrounding rooms, a person with BPD sees primarily pinks, pastels, bows, and trophies, they will paint their windows to match! Then, if there are a new set of rooms appearing out their windows, the paint quickly disappears and a new set of illusions are constructed and painted to match.
     All the while, the inside of the room, the actual room, is nearly devoid of real substance. There are no chairs to relax on, no beds to provide rest, and few lights to illuminate the recesses of the room. After a time, the energy required to maintain a nearly constant vigilance, begins to consume the window painter. When this happens, they start making errors in dressing the window. Someone notices the mistake and asks a harmless question. The Window Painter panics! They turn to see their room and find it empty, save for dust and cobwebs. Consumed with dread and shame, they enable one of the few design pieces in the room: the blinds.
     With the blinds fully closed, the window painting is still very visible, but the Window Painter is hidden. These are not healthy moments of introspection and solitude. These times are when the Window Painter, looking at the back of the blinds, sees no one, no thing, with which to connect. They are utterly alone. Within that instant, thoughts of self-harm and suicide begin to spiral into perseverating patterns of self-destruction.
     This is often when those on the outside, in their own rooms, feel so disconnected and confused. Loving parents cannot understand the source of the destructive behaviors. Friends and social resources begin to be consumed with drama and crises. People begin to distance themselves from the Window Painter. Then, when they peek through the blinds, their worst fears are confirmed: everyone really was leaving!
    Enraged and unable to engage, the Window Painter scratches and claws at the illusion on the window. They throw the blinds open and show the world the cultivated emptiness of their room. This only happens for a few brief moments before the Window Painter sees into the room of another. The connection becomes a juncture, an opportunity, for the Window Painter to bare their emptiness to another. The alternative is to resume painting, pretending, pantomiming, and hoping others interpret their real needs without risking exposing the bare walls.

     The primary criteria for diagnosing BPD is "frantic efforts to avoid real or imagined abandonment" (Sperry, 2003. p.93). In the metaphor of the Window Painter, there is a dim awareness of the emptiness of the room. The compulsion to look outward, to the exclusion of personal insight, is fed by the overwhelming fear and dread which awaits those who look inward. This places the Window Painter in an existential dilemma: They want nothing more than to connect with others, to see and be seen. However, their greatest fear is abandonment. If the connections they experience are superficial and communication is primarily passive-aggressive manipulation, then very little rejection is risked. After all, how can someone truly reject someone they don't really know?
     The sacrifice for this perceived safety is true intimacy. They are not fully known by anyone and therefore unable to truly connect. Behaviors emerging from fearful attachment (Agrawal, 2004) ultimately serve to confirm the greatest fear: Everyone leaves. This cycle repeats over and over again until the person struggling with BPD is truly alone. The mechanisms by which we come to know our selves (insight), our reactions (awareness), and others (empathy), all interact to help form relationships.

About the Doodle
      The Greek letter Phi is used to symbolize many things, including the "strength (or resistance) reduction factor in structural engineering, used to account for statistical [variability] in materials and construction methods" (Bulleit, 2008). While it should not be inferred that people with BPD have reduced strength, Phi is ideal to indicate a certain statistical variability in how BPD reacts to attachment and threats to attachment. In regards to the reactivity of those with BPD, there is a level of uncertainty which is almost always certain. Reactivity, self-harm, manipulation, low insight, and various other factors should be taken into consideration when entering into a personal or professional relationship with someone diagnosed with BPD.
     This is not to imply that people with BPD are too unstable to participate meaningfully in relationships. Rather, there is a greater degree of variability in mood, affect, and reactivity, all of which can add stress to any relationship. Therefore, to have successful, healthy, supportive, and strong relationships, we must take into account this variability and anticipate the need for additional supports. These may include therapy, hospitalizations, group therapy, medications, and education.

(c) Nathan D. Croy, 2016


     Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment Studies with Borderline Patients: A Review. Harvard Review of Psychiatry, 12(2), 94–104.

     Bulleit, W. M. (2008). Uncertainty in Structural Engineering. Pract. Period. Struct. Des. Constr. Practice Periodical on Structural Design and Construction, 13(1), 24-30. Retrieved from

     Kreger, R. (n.d.). The World of the Borderline Mother--And Her Children. Retrieved February 06, 2016, from

     Lavender, N. J. (n.d.). Do You Know the 4 Types of Borderline Personality Disorder? Retrieved February 06, 2016, from

     Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. New York, NY: Brunner-Routledge.

Monday, February 1, 2016

The Fantastical Poison

“If you do not express your own original ideas, if you do not listen to your own being, you will have betrayed yourself." -Rollo May
     Fantasy is thinking about what should be. Creativity is thinking about what could be. Neither is inherently destructive or unhealthy. However, fantasy can become poisonous when it usurps reality.
     Many of my clients require encouragement to implement creativity: to experiences their lives as they could be! Creativity is at the core of the miracle question and can be a very healthy skill to develop. Goal setting in this way often requires solitude and meditation. To imagine our life as it could be, and begin to think about what is required to make real what's possible, is crucial to healthy growth. Being able to identify concrete benchmarks helps families and individuals plot their growth and internalize success.
     Fantasy, however, can be incredibly destructive. When clients begin to envision what should be, to the exclusion of what is, imagination becomes an escape. Instead of seeking brief respite through solitude, clients become emotionally, mentally, and socially isolated while perseverating on a world which does not exist. Rather than focus on what is possible, fantasy poisons what already exists, and reality becomes an affront to an internalized sense of entitlement.
     This process of fantasy fosters resentment toward resources the client or family already have. When services, providers, family, friends, or therapists seek to support the client poisoned by their fantasy, the client reacts as if their very life is under attack. In truth, this is the experience! The fantasy they have worked so hard to construct is threatened to evaporate the moment they agree with anyone. Even if the fantastic client is presented with their fantasy, it rarely, if ever, aligns with what should have been. In these moments, the client feels a tremendous sense of betrayal and abandonment. Their defense mechanisms kick into high gear, and a new, complex, perfect, fantasy is constructed to protect them from the onslaught of reality.
     The client suffering with fantasy or delusions can be very resistant to treatment. Existentially, treatment will focus on the powerlessness a client feels when faced with reality. The initial steps of therapy require joining with the client and validating their desire to be in control of their world. After all, who does not want to be in control of their life? Therapists must be careful to only validate the sense of frustration rather than the fantasy.
     By identifying the need, rather than the want, treatment encourages a client to use their creative in healthy, positive ways. The Socratic dialogue is particularly beneficial in helping identify the needs a client believes will be met when their fantasy arrives. The miracle question, while beneficial for creative clients, can serve to foster additional avoidance in clients hyperfocused on fantasy and, as such, should be used with caution.
     Once needs are identified, treatment will use dereflection to facilitate identification of meeting needs rather than wants. Once this occurs, it may be useful to address the loss or the fantasy with interventions aimed at mourning. This can help solidify the new direction clients are going in.
     Do not shy away from the fantasy. Clients will cling tenaciously to these ideals if they feel threatened, isolated, or rejected. These fantasies are probably the closest and most loyal companions ever had by your client. Respect the mourning process as new, more healthy options, are gently offered. If the client accepts, they will require a great deal of patience and encouragement as they progress on this new path.
(c) Nathan D. Croy, 2016