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., & Rüther, 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



  1. As I read through your post about BPD types, as a good clinician I began thinking through how I would more quickly differentiate the two types in session. Since most of my work with clients and patients is informed by attachment based interventions and psycho-dynamic theories, I imagine that in addition to gaining a good history of trauma, I might notice stronger emotional lability, more resistance to forming a therapeutic relationship, and/or a severely restrictive affect from a type 1 PBD client. What would you say?

    Another thing that stood out to me in this post is your description of BPD 2 and how many seem "more wealthy." I'm thinking that folks with BPD 2 are more able to mask their attachment issues and minimize the relational consequences. My old supervisor used to say that "wealth is the best enabler" because clients can just keep jumping from therapist to therapist and ignore the attachment issues that arise in session. I also thought of how many of my chemical dependency patients tend to operate in a similar way - using their substance of choice to ignore psychological, social and spiritual health issues. Chemical dependency patients often seem to act in a "borderline way" while they are in the clutches of their addiction. I don't think that's an accident.

    1. Couldn't agree more. In fact, there's a great TED Talk on addiction as it relates to attachment you should check out (link at bottom of this reply). The point, though, is that people are designed for attachment and any attachment will do. If money, drugs, ETOH, or anything else is available and it seems safer or more accessible than healthy/genuine attachment, they will attach. EFT talks about this a great deal! When I reference Frankl's noogenic neurosis/existential vacuum in the above post, this is what I'm referring to. That existential vacuum is universal in humanity! We MUST attach to others because it is in that I-Thou relationship where our "I" is affirmed.

      Thank you so much for the comment and wise words. I miss working with you! Hope you enjoy the linked video.


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