The current American Psychiatric Association (APA) Diagnostic and Statistical Manual (DSM) lists nine criteria that define Borderline Personality Disorder. They are:
Fear of abandonment.
Unstable or changing relationships.
Unstable self-image, including struggles with sense of self and identity.
Stress-related paranoia.
Anger regulation problems, including frequent loss of temper or physical fights.
Consistent and constant feelings of sadness or worthlessness.
Self-injury, suicidal ideation, or suicidal behavior.
Frequent mood swings.
Impulsive behaviors such as unsafe sex, reckless driving, binge eating, substance abuse, or excessive spending.
A person who meets 5 or more of these 9 criteria would meet the diagnosis for Borderline Personality Disorder. It’s important to note, however, that there are 256 possible combinations of very different symptoms for which an individual could receive a BPD diagnosis.
This is just one of many complicated facets of a severe and widespread mental health disorder that has long been misunderstood, misdiagnosed and highly stigmatized.
Stigma and BPD
In a book she co-authored with Dr. John Gunderson of McLean Hospital in Boston, Beyond Borderline: True Stories of Recovery From Borderline Personality Disorder, Perry Hoffman had this to say:
Seldom does an illness, medical or psychiatric, carry such intense stigma and deep shame that its name is whispered, or a euphemism coined, and its’ sufferers despised and even feared. It may actually be the most misunderstood psychiatric disorder of our age.
The high degree of stigma attached to Borderline Personality Disorder has a long history. For decades mental health providers typically avoided treating people with BPD for a number of distorted reasons: they were difficult to deal with, behaved badly to gain attention, were unresponsive to treatment, had a high risk of suicide and overall were just not worth the time and effort.
Fortunately, in recent years, several advocacy efforts have emerged to counter those egregious arguments and attitudes about people with BPD. For the first time, people with BPD began to speak out and share their experiences (good and bad) with others about their lives. “You are not alone” became a popular post on social media, was promoted at awareness walks and proclaimed at fund raising events.
During that same time, more compassionate researchers, academics and providers started chipping away at the unwarranted biases toward people with BPD. Effective behavioral therapies, like Dialectical Behavior Therapy, Cognitive Behavior Therapy, Mindfulness Based Therapy and Schema Based Therapy became available. More powerful imaging technology revealed realtime brain activity in people with BPD, and psychotropic medications were more skillfully applied. At long last, patients, providers, families and friends were speaking openly and honestly about BPD.
Except, perhaps, people who met BPD criteria and yet steadfastly refused to share their suffering, opting to suppress their pain rather than reveal it to anyone.
People who are referred to as having Quiet BPD.,
What Is Quiet BPD?
Theodore Millon, PhD., an influential American psychologist highly regarded for his extensive ideas and insights on personality disorders, proposed that are a number of subtypes of personality disorders, including Borderline, that can develop in people.
Personalities are like impressionistic paintings. At a distance, each person is 'all of a piece'; up close, each is a bewildering complexity of moods, cognitions, and motives.
Dr. Millon identified four possible subtypes of Borderline Personality Disorder:
Discouraged: hopeless, depressed, helpless, and powerless.
Petulant: impatient, stubborn, defiant, pessimistic, and resentful.
Impulsive: magnetic, superficial, agitated, potentially suicidal.
Self Destructive: Inward turning, moody, self-punishing, self-harming and suicidal.
Although it is not considered a distinct mental health disorder, another term for the Self Destructive subtype is “Quiet BPD”
People with BPD typically direct their anger, resentment, negativity, defiance and violent behaviors toward other people. But people with Quiet BPD internalize their emotions, turning their anger and negative thoughts inward, toward themselves, often in undetectable ways. This includes keeping their self harming and suicidal tendencies well hidden. As a result, Quiet BPD tends to go unrecognized and untreated.
Other terms used to describe people who have Quiet BPD include “high-functioning” or “apparently competent”, when in fact they suffer as greatly as anyone else who struggles with BPD. One way to think about a person with Quiet BPD is that they emotionally ‘'implode" as opposed to the way people with with typical BPD 'explode'.
How Prevalent Is Quiet BPD?
Because Quiet BPD is not a recognized disorder, there is little research on the topic to warrant an estimate of how many people fit the description for what is a variant of traditional Borderline Personality Disorder.
How Is Quiet BPD Treated?
In recent years, a number of talk-based therapies have proven to be helpful in the treatment of Borderline Personality Disorder, chief among them Dialectical Behavior Therapy (DBT). A cognitive behavioral treatment originally developed by Marsha Linehan, PhD, to treat chronically suicidal individuals, was, and remains, the ‘gold standard’ of treatment for people with BPD. Yet, DBT wasn’t always helpful for some people with BPD as it was for others.
A research team led by Thomas R. Lynch, PhD, Director of the Duke Cognitive Behavioral Research and Treatment Program at Duke University in the US and, more recently, Professor Emeritus in Psychology at the University of Southampton in the U.K., recognized that anomaly.
Dr. Lynch and his colleagues found that people with BPD who had little control over their emotions benefitted from DBT more than people with BPD who were exceeding good at keeping their emotions under strict control. They surmised that people with BPD who were able to keep their emotions under tight control might have learned early in their chaotic lives not to express their feelings, but rather to internalize them.
People who have Quiet BPD are still sensitive and easily hurt. but they are able to mask their emotions from others. They experience emotional distress but repress their feelings to such a degree that they appear emotionless and socially distant. And they avoid seeking professional help for their pain and suffering.
To better meet their unique needs of people with Quiet BPD,, Dr. Lynch developed a version of DBT he called Radically Open-Dialectical Behavior Therapy or RO-DBT.
Built on the original DBT framework, RO-DBT helps people who, having learned to “control” their emotions, suffer in silence with conditions such as anorexia nervosa, chronic depression and obsessive-compulsive disorder. They are also more vulnerable to self harm and suicide attempts.
The primary goal of RO-DBT is to help people accept their ‘go it alone’ approach is ineffective and that developing more effective social skills such as being more open about their situation and developing a greater social connectivity.
Helpful Resources
If you are interested in learning about living with Quiet BPD, there is a comprehensive explanation of this BPD variant in an article published online by Psychology Today.
You can learn more about Radically Open DBT and how it differs from traditional DBT in the treatment of Borderline Personality Disorder here
For a deeper dive into the symptoms, causes, diagnosis and treatment of Quiet BPD, check out this article in the online health journal VeryWelL
Post Script
Given that the upcoming month of May is dedicated to BPD Awareness in the U.S., Quiet BPD might well be a topic people might want to know more about. So please feel free to share this newsletter.
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