Borderline personality disorder (BPD) is known for being the most disabling of all mental health conditions, but it can be effectively managed through early interventions.
Through this, we can teach interpersonal skills, emotion regulation, mindfulness, problem-solving and more that are crucial to healthy functioning.
The Space Between Us sat down with Tanzanian psychologist Nadia Ahmed to unpack this largely misunderstood disorder.
TSBU: Nadia, let’s start with dissecting what BPD is and what it feels like.
Nadia: BPD affects a person’s ability to regulate their emotions and is marked by unstable moods, behaviours, and relationships.
The person almost always seems to be in a state of crisis. I had a patient with BPD who, whenever she had a small disagreement or fight with her partner, would engage in suicidal gestures and attempts, as a way of getting his attention and care. Sufferers can be depressed at one moment, argumentative the next, and later complain about having no feelings. They detest being alone, leading to frantic searches for companionship no matter how unsatisfactory. The person will distort their relationships by viewing people as either all good or all bad. As a result, their commitment often shifts from one thing to another.
Sufferers will experience extreme fear of either real or imagined abandonment, patterns of unstable and reckless short-lived relationships, alternating between extremes of idealisation and devaluation, unstable self-image, and sense of self, engaging in self-damaging and impulsive sensation-seeking behaviours like sex, drug abuse and reckless spending, repeated self-harm and suicidal behaviours. The fear of rejection leads to projection of this rejection onto a significant other through their behaviour. For example, a person with BPD is unable to face their insecurities in a relationship and may project these onto their partner, leading them to blame or doubt their partner.
TSBU: Have you noticed a trend of BPD emerging in Tanzania?
Nadia: BPD is a growing pandemic in Tanzania. Historically, personality disorders have gone mostly unrecognised in Tanzania because of limited resources, leading to the priority being given to conditions that present with psychosis.
Due to the increased suicide rate in the country and relapse of other mental health conditions, BPD has caught everyone’s attention. There haven’t been any published studies on the prevalence of BPD in Tanzania, but a trend has been observed by clinicians in both private practice and public health facilities. Many inpatients that experience chronic mental illness also screen positively for BPD - this observation has inspired further exploration into this condition.
We are working on a tool to help in the screening of personality functioning in adolescents called the Levels of Personality Functioning Questionnaire, to assess impairments in personality.
TSBU: Would you say it’s just as common in South Africa?
Nadia: It’s just as prevalent in South Africa and goes highly under-reported in men. Research conducted by Paruk and Janse van Rensburg (2016) found that 18.5% of patients admitted at the Helen Joseph Hospital in Johannesburg met the criteria for BPD.
TSBU: What do you think is behind this spike?
Nadia: Rather than a spike it is more a realisation that BPD is prevalent in African contexts. Most research on personality disorders have not focused on low- and middle-income countries like Tanzania and South Africa. Instead, most statistics reflect data of high-income countries.
Disorders like BPD are caused by biological, social, psychological, and environmental factors.
Some African families are emotion dismissing, that is, children from these families may grow up without the skills needed to control their own emotions and others. This can mean not learning the necessary skills to regulate their own emotions. Adverse childhood experiences, like child abuse, neglect, child labour, loss, and deprivation in early childhood are common across the world and also in the African context. These issues disrupt healthy personality development and emotional wellbeing.
TSBU: What is the best way to get help and/or treatment?
Nadia: The first steps are learning more about the disorder to gain essential insights and better understanding. Treatment focuses on dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT).
DBT teaches skills to control intense emotions, manage distress, reduce self-destructive behaviours, and improve relationships. The goal of this therapy is to help the individual to build a life that they find worth living.
MBT is long-term psychotherapy that involves mentalisation, which is the ability to think about thinking. It helps us make sense of thoughts, beliefs, wishes and feelings and to link these to our behaviours and actions.
TSBU: If you have a family member or friend with BPD, how can you offer support?
Nadia: You can help in two main ways.
The first step is preventative and entails becoming emotion coaches for children. Emotion coaching helps the child to understand their emotions by recognising what they are feeling and why this skill helps them develop emotion and behaviour regulation skills which in adulthood help them navigate through social relationships, maximise intellectual success and develop self-confidence.
The second step is to support the individual after receiving their diagnosis. The most important thing is to be non-judgmental, be patient, calm and consistent in your interactions with the individual. Be open minded in learning and understanding more about the disorder and understanding of the individual. It is never too late to be an emotion coach. Families can demonstrate and facilitate healthy ways to regulate emotions and social interactions.
Finally, attending some of The Space Between Us’ practical, expert-led workshops like Building Healthy Relationships to Thrive workshop and Integrating Home, Work and Play Series can get you started on the right foot. .