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2 Key Targets for Treating Borderline Personality Disorder

Grant H. Brenner, MD Grant H. Brenner, MD

Key Points


  • BPD is characterized by instability in sense of self and difficulty maintaining relationships.
  • Core features of BPD involve challenges in making use of emotions, self-reflective function, and accurately gauging others’ intentions.
  • Research shows how different features of BPD interact with each other to interfere with function and therapeutic efforts.
  • Treatments for BPD are increasingly effective, improving over time as research, practice and patient understanding deepen.


Borderline Personality Disorder (BPD) is one of several personality disorders, according to the American Psychiatric Association, which describes it as:


“[A] pattern of instability in personal relationships, intense emotions, poor self-image and impulsivity. A person with borderline personality disorder may go to great lengths to avoid being abandoned, have repeated suicide attempts, display inappropriate intense anger or have ongoing feelings of emptiness.”


Though awareness is increasing and stigma decreasing, BPD often is unrecognized and may be associated with great suffering (as well as positive experiences). According to the National Alliance for Mental Illness, about 1.4 percent of people have BPD, 75 percent of whom are women, though estimates of rates change over time with recognition and public awareness.


BPD overlaps with other conditions, including complex Posttraumatic Stress Disorder (cPTSD), and may have dissociative features, while being distinct from Dissociative Identity Disorder. BPD may be associated with depression, eating problems, substance and alcohol use problems, and relationship difficulties.


These conditions share core features, including attachment difficulties and impaired self-awareness, which often interfere with day-to-day function and therapeutic goals. Attachment, the quality of how we relate, whether secure or insecure, is increasingly found to be a core feature in illness and health (Herstell, et al., 2021).


Making Sense of Inner and Social Reality


BPD is associated with insecure attachment, particularly the disorganized subtype, with shifting patterns of approach and avoidance in relationships typically driven by limited self-awareness or the capacity to regulate emotions and behaviors. Core difficulties relate to “social cognition” or “mentalization”—the capacity to, “comprehend and interpret one’s own and others’ behaviors based on underlying mental states” (Pourmohammad et al., 2021). Problems with awareness and naming of emotions (“alexithymia”) coupled with limited capacity for “Theory of Mind” (TOM) characterize BPD. Alexithymia gets in the way of self-understanding and communication with others about feelings and desires.


TOM, a key aspect of social cognition, includes, “two main processes of identifying cues in the social environment and interpreting these cues,” covering both emotional or “affective,” TOM and cognitive TOM, pertaining to grasping others’ motivations and beliefs. The two types of TOM parallel two types of empathy: cognitive and affective. Compassion parallels the capacity to act upon empathic attunement to alleviate one’s own and others’ suffering, also problematic for those with trauma, attachment problems, and difficulty with self-integration, who tend to take in others’ motivations as their own without realizing it.


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Borderline Personality Disorder - Treatment

Borderline Personality Disorder - Treatment

Deepening Our Understanding of BPD to Strengthen Constructive Change


While many of these factors have been studied, a greater understanding of the relationship between TOM and alexithymia would be useful. Recently published work in the Journal of Psychiatric Research (2021) looked at these factors in a group of 50 patients with BPD compared with a matched group of “healthy controls” (HC) without BPD or other significant problems, including women and men.


Several tests were administered: the Reading the Mind in the Eyes Test, which reflects the ability for people to tell mental states from looking at others; the Faux Pas Test, which asks participants to determine intentions based on social gaffes described in test narratives; the Toronto Alexithymia Scale, which looks at three aspects of difficulty identifying feelings, difficulty describing feelings, and externally-oriented thinking; and the Digit Span Test, a measure of attention, categorizing, and auditory processing. The scores on these validated rating instruments were analyzed for significant differences between BPD and the HCs.


First, the BPD group and HCs were found to be similar in all demographic variables (age, gender, employment, marital, etc.) except that HCs had a higher educational level on average. A subset of participants in the BPD group had a history of substance or alcohol use disorders or an additional personality disorder, and about half had another psychiatric condition.


In the Faux Pas Test, BPD patients had difficulty telling which stories were the faux pas ones, with lower affective and cognitive TOM. Interestingly, the two groups were equally able to recognize the stories in which there were not faux pas. The problem was in catching the social gaffes, but BPD patients did not misinterpret proper social behavior as awkward or off in any way.


For alexithymia, people with BPD in this study had difficulty identifying and describing feelings compared with HCs, but were the same as HCs on externally-oriented thinking. There were no significant differences in Reading the Mind in the Eyes between BPD and HCs. Generally, female gender was correlated with better Reading the Mind in the Eyes performance for people with BPD, as was educational achievement. Lower attention was associated with decreased Reading the Mind in the Eyes, and importantly, higher Reading the Mind in the Eyes was correlated with lower externally oriented thinking (inversely correlated).


Implications and Therapeutic Directions


These findings mirror the present understanding of BPD, where understanding and interpreting one’s own and others’ motives and behaviors are challenging on emotional and cognitive levels, making social decision-making and judgment quite challenging by undermining accurate recognition of both emotional information as well as attributions of intentions and values.

Those familiar with BPD, cPTSD, dissociative disorders, and related conditions are unlikely to be surprised by these findings, but, hopefully, they are useful in further articulating important factors. Furthermore, understanding mentalization and emotional function is broadly important as the same processes which contribute to BPD also underlie human behavior more generally.


Misrecognition, especially in the absence of awareness, but even when people want to be more accurate but don’t quite get how to do it, leads to problems, which in turn tend to make things worse. This is compounded by difficulty recognizing social faux pas, making it more likely for a person to get into problematic social situations, more difficulty in repairing relationship missteps, and easier to throw in the towel in both frustration and out of mistrust or misjudgment of others as being more malevolent or incompetent than they actually are.1


Even more poignant for those with developmental trauma, abuse, and neglect (which overlaps with BPD), treatment requires patience and compassion to distinguish distortions from concrete concerns about people being dangerous. It can be hard to know which red flags are actually signs of danger, and which are not.


When others are consistently misinterpreted, they feel misunderstood—people with BPD may not pick up on or make sense of this as easily—leading to ruptures. Mutuality becomes very difficult when mentalization is diminished, making it very hard to resolve, or live with, conflicts. Making negative attributions of others’ intentions makes it hard to remain stable and present, adding to emotional misinterpretation when things go sideways, careening into painful cycles of mistrust and betrayal, rupture and reunion, and, sadly, often loss.


While the challenges are significant, the situation is hopeful. Understanding the specifics of where things go awry in BPD is useful and may be empowering because efforts to change are more effective when they target key functional areas. Trauma-focused therapies, Dialectical-Behavioral Therapy (DBT), Mentalization-Based Therapy, Relational and Attachment-Based therapies, including longer-term contemporary psychoanalytic approaches, and additional approaches including mindfulness, acceptance, and compassion-based work, have been shown to help people live with and overcome BPD and related problems.


Medications can serve a supportive role, alleviating symptoms of depression and anxiety and improving stability, allowing change efforts to take hold. Treatments for BPD, regardless of the specific type, focus on identifying core problems and practicing specific, targeted skills, as well as working on the overall context of how one relates and self-regulates. Self-care is an important element in tuning up self-concept.


The treatment alliance, sometimes difficult to establish, especially if there are perceived or actual missteps early on, is of critical importance in setting the stage for long-term gain with a safe-enough relationship, as is establishing effective coping strategies to manage distress and hopelessness, which may arise throughout the course of the work.


Originally published in Psychology Today on October 15, 2021



1. Problems with TOM, emotional and cognitive, work in tandem with alexithymia where knowing what one is feeling and describing feelings are reduced in BPD. Communication is undermined without access to both one’s own and others’ emotional states and intentions or beliefs. The inverse relationship between Reading the Mind in the Eyes and the alexithymic Externally-Oriented Thinking style is relevant because being less introspective, less reflective impedes the ability to accurately interpret the important non-verbal communication inherent in eye-gazing. Eye-gazing is important to attachment, starting in early childhood with competent primary caregiver availability, and remains an important part of adult relatedness in casual to intimate settings.


Herstell S, Betz LT, Penzel N, Chechelnizki R, Filihagh L, Antonucci L, Kambeitz J, Insecure attachment as a transdiagnostic risk factor for major psychiatric conditions: A meta-analysis in bipolar disorder, depression and schizophrenia spectrum disorder


Pourmohammad P, Imani M, Goodarzi MA, Sarafraz MR, Impaired complex theory of mind and low emotional self-awareness in outpatients with borderline personality disorder compared to healthy controls: A cross-sectional study, Journal of Psychiatric Research (2021), doi:


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Doctor Profile

Grant H. Brenner, MD


Grant Hilary Brenner, M.D., a psychiatrist and psychoanalyst, helps adults with mood and anxiety conditions, and works on many levels to help unleash their full capacities and live and love well.

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