Understanding impulsivity in borderline personality disorder (BPD)
Like many other people who are reeling from the effects of lockdowns, re-entering society has brought up a truckload of difficult feelings in me like anxiety, burnout, and depression but lately, I’ve been struggling most with impulsivity. After a year-and-a-half of limited opportunities to be impulsive within the confines of my apartment, I’m overcorrecting in my impulsive behaviours, particularly around social drinking. My impulse control issues have led to a struggle to maintain moderation when I’m drinking in social settings, which can trigger other impulsive behaviours and potentially lead to dangerous situations.
Impulsivity in at least two areas that are potentially self-damaging is one of nine criteria listed in the DSM-5 (psychiatry’s bible) related to borderline personality disorder (BPD). Discouraged and to the point of borderline destruction (ha) by my recent failures to manage my impulsivity, I’ve turned to one of my healthier coping mechanisms: “know thy enemy.” I’ve rededicated myself to understanding and researching the personality disorder at the root of my behaviours. Like many mental illnesses, BPD presents on a spectrum and I fall on a place along that spectrum where I’m privileged to be able to take refuge in the sharper parts of my mind and set about working to “solve” troubling symptoms like they were a Rubik’s Cube. I might be setting myself up for disappointment, but having the ability to confront my unstable and emotional responses with logic (or in IFS speak, with my manager “parts”) brings me a lot of comfort.
BPD is one of ten personality disorders listed in the DSM-5. A personality disorder, broadly, is the inability to adjust one’s behaviour, thinking, and pattern of responses in relation to particular situations or feelings (or both). BPD is defined by the DSM-5 as “a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity beginning in early adulthood and present in a variety of contexts.” Of the nine criteria related to BPD, an individual needs to meet five or more of the following symptoms to qualify for a diagnosis, which allows for 256 unique combinations of symptoms by which an individual could receive a BPD diagnosis:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistent unstable self-image or sense of self.
Impulsivity (as discussed).
Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour.
Affective instability due to a marked reactivity of mood.
Chronic feelings of emptiness.
Inappropriate, intense anger, or difficulty controlling anger.
Transient stress-related paranoid ideation or severe dissociative symptoms.
BPD is estimated to occur in about 1.6 per cent of the general population. The causes of BPD are unknown but are thought to be a combination of biological factors like genetics and brain functioning, psychological and social influences, and early attachment patterns. Research indicates that 37 to 69 per cent of BPD diagnosis are related to genetic inheritance. I’m the first in my family with a suggested BPD diagnosis, but I recognize many symptoms of BPD in my matrilineal line. Like 71.1 per cent of people diagnosed with BPD, I experienced childhood trauma like abuse and neglect, and was raised in a generally chaotic environment. People with BPD also tend to show similar brain functioning in areas of the brain that are used to regulate and control emotion. The good news about this confluence of causal factors is that a brain can be trained to change how it functions through strategies like mindfulness, dialectical behaviour therapy (DBT) skills, and more. Unlike other personality disorders, recent research demonstrates that BPD has a positive trajectory over time, particularly in people with BPD who receive specialized treatment.
BPD Attachment Styles
If understanding the biological and environmental factors thought to be behind BPD brings me hope, understanding my attachment style brings me the insight I need to make sense of my impulse control issues. Attachment styles develop in childhood based on how our caregivers behaved toward us and influence how a person sees themselves, the world around them, and how they react to situations. The father of attachment theory, John Bowlby, found that having an insecure attachment style with a caregiver increased a person’s likelihood of developing problems with anxiety, anger, depression, self-worth, self-esteem, and emotional connection and control. This type of early attachment is common in people with BPD, and tends to present in three types of insecure attachment styles.
Preoccupied: Having an intense desire to connect to others.
Dismissing: Disregarding others and their emotions.
Fearful: Wanting to be with others but being afraid one is not worthy of love and affection.
To identify my attachment type, I turned to The Borderline Personality Disorder Workbook: An Integrative Program to Understand and Manage Your BPD by Daniel J. Fox. By completing a simple exercise in the book, I determined I have a fearful and preoccupied attachment style. According to Fox:
People with BPD are likely to develop a preoccupied or fearful attachment type, or both. These two attachment types are similar in that people experience a high degree of anxiety associated with the fear of abandonment, but they differ in how people interact with others in order to feel safe. Individuals with a preoccupied attachment type tend to seek out others to help them feel safe when they’re stressed or afraid, and those with a fearful attachment type tend to distance themselves from others out of fear of not being worthy of taking the other person’s time or attention when they need it. Both of these insecure types create a lot of internal conflict.
After I sat with knowledge of my attachment styles for a bit, I recognized that in casual relationships I’m more likely to behave in a fearfully attached way, whereas in deeper or more secure relationships I have a more preoccupied attachment style (though it can shift based on mood). When I apply this understanding to my impulse control issues around social drinking, I see that one of the reasons I might turn to impulsive drinking behaviours in social settings is to overcome my fear that I’m not worthy to take another person’s attention and to master my inclination to isolate. It also explains why I don’t seem to have problems with moderation or impulse control when I drink at home or with people who I’m very close to.
Primary Symptoms in BPD
Guided by Fox’s workbook, I was ready to expand my awareness around the constellation of symptoms that were creating the biggest impacts in my life. Using Fox’s Symptom Expression Form, I ranked the following symptoms on a scale of one to ten in terms of the intensity of each symptom within the last two weeks:
Tends to have intense relationships
Quick to intimacy
Speech lacks detail
Feels a strong sense of emptiness
Feels intense anger
Feels paranoid when stressed
Feels deserving of privileges or special treatment
Requires constant admiration
Takes advantage of others for own gain
Easily excited and displays emotions as they occur
Unsure of who I am
Feels intense self-importance
Has fantasies of power
Tends to feel detached when under stress
Needs to be the centre of attention
Sees self as totally unique
Gains attention via appearance
Has superficial emotional expression
Inappropriately sexually seductive or provocative
Engages in self-harm behaviour, gestures, or threats
Any symptoms rated seven or above were considered my primary symptoms—the ones that have the greatest impact on me and those around me. Impulsivity was among the symptoms I ranked highest, but other primary symptoms—like being easily influenced and unsure of who I am—gave me more perspective around how they relate and feed into others. For example, during times when I’m struggling with a poor sense of self, I’m more likely to be influenced by others and turn to impulsive behaviours to deaden the fear around my shaky identity (and overcome my fearful attachment style). Recognizing this gives me the insight I need to make more informed decisions around situations that might aggravate the primary symptoms I’m trying to avoid.
Overcoming Negative Response Patterns and Coping with Emotional Buttons
Negative response patterns, according to Fox, are “groups of behaviours that, over time, become [a person’s] default automatic response to beliefs, other people, and situations.” To grow beyond negative response patterns, a person with BPD has to recognize the short-term benefits these patterns bring, while also identifying the long-term consequences. Using an exercise in The Borderline Personality Disorder Workbook, I identified a negative response pattern driven by my BPD that I call Wince, Retreat, Repeat.
Belief: I identified the negative belief that I’m generally unworthy.
Behaviours: This belief leads me to seek out others to reassure me and engage in impulsive or self-destructive patterns to numb the pain and social anxiety, which leads me to retreat and isolate and feel generally unworthy. Then the pattern begins all over again.
Short-term benefits: The short-term benefits to this pattern are that I feel (briefly) comforted and get to take a break from my feelings through impulsive behaviours.
Long-term consequences: The long-term consequences are that my destructive behaviours scare and alienate me from the people who care about me and I get caught in a cycle of external validation, self-medication, and shame.
Negative response patterns are connected to emotional buttons, defined by Fox as specific situations or events from the past that shape how a person sees and reacts to the world in the present. Emotional button reactions that occur repeatedly create negative response patterns. To avoid activating these buttons, a person has to determine the thoughts, feelings, and memories connected to the emotional buttons, the patterns of beliefs and behaviours they’re pushed to engage in, the experiences that created them, and how these experiences impact them in the present and future.
In the case of my impulsive drinking, my emotional button might simply be being in a group of people I’m not entirely comfortable with, which brings up emotional button thoughts like, “I’m so awkward. I bring nothing to the table. These people must think I’m so foolish.” This makes me feel worthless, unimportant, and uncertain of my identity, which leads to behaviours like impulsive drinking to make me feel more comfortable. My pattern is that when I feel worthless and empty, I act impulsively. To shake off these emotional button patterns, Fox recommends:
Identify associations between emotional buttons, the past, present, and future. Past experiences can influence a person’s perception of the present and future. For example, the emotional button pattern I shared above is tied to past childhood experiences of being verbally berated to keep me compliant, which leads me to think thoughts that probably aren’t accurate or true in the present and informs how I react to and see my future prospects.
Strike when the iron’s cold. Fox writes that the secret to success when it comes to managing emotional button responses is to work on them when they’re not activated. As he notes, “when the ‘iron’ of your emotional reaction is hot, it’s hard to handle. When it has cooled down, it’s manageable—you can ‘touch’ it without getting burned.”
Break time. Fox recommends taking a break from a situation in which emotional buttons have been pushed. In the case of my impulse control issues around social drinking, I could remove myself from the situation by excusing myself to the bathroom, where I could collect my thoughts and recentre in the present to allow my emotional buttons to deactivate.
Self-statements of truth: Self-statements of truth are positive and honest things a person can say to themselves when their emotional buttons are pushed. During break time, I could practice this technique by saying things to myself like: “I’m safe. I don’t have to do anything I don’t want to. I’m in control of my choices,” or “I’m worthy. I’m enough exactly as I am. This is my past talking.”
Strategic distraction: Strategic distraction is simply participating in a positive distraction when an emotional button is pushed. When the buttons behind my impulsive drinking are triggered, I could start a conversation with someone who is safe and encouraging (or call a friend who is if there’s no one like that in my current environment). Other examples of strategic distraction include going for a walk, reading a book, playing a game, going to a support group, etc.
Harm Reduction and Impulsive Substance Use
Armed with my newfound knowledge about the relationship between my poor impulse control and my BPD, I turned to one of my best resources: my group of friends who also live with BPD. I don’t know how other people with BPD meet their peers (besides intuition), but I was extremely fortunate to make friends in a DBT skill group. Like me, most of my friends with BPD have struggled with impulse control. When I filled them in on my circumstances, they gave me two additional strategies to manage my impulsive drinking (a big shout and thanks to Jay Austin for this one):
Avoid settings where my fearful attachment styles, negative response patterns, and emotional buttons are likely to be triggered. I know that I’m more likely to engage in impulsive behaviour when these parts of my BPD are triggered, so by surrounding myself with those I’m comfortable with who make up my support network, I’m less likely to feel the need to self-medicate impulsively.
Take a harm reduction approach: Since I’m not content with cloistering myself away from unfamiliar social situations for the rest of my life in fear my impulses might run rampant, another strategy is to reduce the negative consequences of my impulsive drinking. The suggestion that seemed most practical and manageable to me was to alternate between alcoholic and non-alcoholic drinks in social settings. For example, order one beer and then a pop or glass of water for the next round, continuing in this manner. Less alcohol overall means my capacity for impulsivity lowers, the break between drinks provides a pause to be mindful, and I can still engage in social settings with people outside of my comfort zone.
Lately, I’ve been working on being mindful of my triggers and practicing some of the techniques I explored above. During lunch at a brewery with a friend I’m very comfortable with, I was able to successfully alternate between non-alcoholic and alcoholic drinks and, at a different brewery I visited with my partner, I practiced taking a break and strategic distraction. Eventually, I hope to be able to successfully use these techniques even in social settings where I’m uncomfortable. Sometimes, living with BPD can be like trying to solve a complicated math problem: If I can understand and demystify my own behaviours, accept certain ones and change others while planning for variables, I might just be able to resolve some of my more distressing BPD symptoms and find a more fulfilling life.
This issue: The Characters by Theophrastus and personality disorders
Humans love patterns and are constantly trying to detect them everywhere we look. Our personalities are no exceptions. Though the concept of the personality disorder is thoroughly modern, humans have been trying to categorize personality types and identify those that deviate from the social norms since at least the ancient Greeks.
Theophrastus, born c. 371 BC, a Greek philosopher and successor to Aristotle, published numerous writings in his lifetime—among them, The Characters. The Characters is the first recorded attempt at systemic personality type writing. His book contains 30 brief descriptions of personality types that he saw as diverging from “good” conduct. Examples include the “Shameless Man,” defined as someone who neglects “reputation for the sake of base gain” or the “Avaricious Man,” a person with “excessive desire of base gain.”
In a 2013 article in Dialogues in Clinical Neuroscience, Mar-Antoine Crocq analyzes the major historical milestones in the study of abnormal personality beginning with Theophrastus. Crocq makes the case that Theophrastus hit upon the notion that personality is a fixed pattern of reacting to various life circumstances—consistent with the DSM’s definition of personality disorders. Crocq also demonstrates how Theophrastus identified both personality disorders and components of them that we still use today: “For instance, the ‘Suspicious Man,’ is analogous to today’s paranoid personality… The ‘Thankless Man…’ is presenting traits that might be qualified today as anhedonia, resentfulness, and negativism.” I’d personally argue that an early definition of BPD might be found in Theophrastus’ “Reckless Man,” who he defines as a person with a “tolerance of shame in word and deed.”
The Borderline Personality Disorder Workbook: An Integrative Program to Understand and Manage Your BPD
By: Daniel J. Fox
The Borderline Personality Disorder Workbook is an excellent resource for those seeking to better understand their BPD. The workbook takes an integrative and tailored approach to treating BPD by helping its readers identify their unique symptoms, emotional triggers, and personal motivators for positive change. I would recommend coming to this book with a least a cursory understanding of BPD and treatments like dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), cognitive behavioural therapy (CBT), and interpersonal therapy as navigating the first few chapters without them might be a little overwhelming.