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Introduction

All humans are social, and one of our deepest needs is to attach to or feel connected to others. We can’t survive without others. When we are young, our most important attachments are to parents and adult caregivers. As we get older, our attachments change to include friends and peers. In adulthood, they change to focus on romantic partners.

Because one of our deepest needs is to attach, it is natural then that one of our deepest fears is lack of attachment, rejection, or abandonment.

Some people are quite sensitive to stress in their relationships. 

The strengths of being sensitive are that sensitive people tend to be thoughtful, conscientious, kind and caring.

However, in some people, their emotional sensitivity can be so extreme that it may be part of 'borderline personality traits...'

Extreme, Intense Emotions May Be 'Borderline Personality Traits' 

In some people with intense emotions, their symptoms are part of a condition known as 'borderline personality traits'. Knowing that someone is struggling with 'borderline personality traits' can be helpful because it can help them receive appropriate support and services. Without this recognition, many people may struggle, feel misunderstood, or even be blamed for their problems by well-meaning family and friends.

Features include:  

• They may have extreme fears of rejection or abandonment and feel easily rejected by others, even when the other person did not intend to reject them.
• They may need excessive reassurance from others.
• When triggered, they may experience strong feelings that are hard to self-regulate.
• They may shift from feeling fine to feeling...
  • Depressed, and may even feel that life is no longer worth living.
  • Anger and hatred of others.
• To cope with their feelings, they may try various coping strategies. Some might be positive (e.g., distraction, reaching out to others, physical activity). However, others might be negative (e.g., self-cutting, using drugs or alcohol to soothe).
• Unfortunately, fears of abandonment and rejection can be a self-fulfilling prophecy. Behaviours (like excessive clinginess and jealousy) can make it hard for others to be around them.
• Friends and family may feel like they are ‘walking on eggshells’.

What Causes Borderline Personality Traits? 

It is likely caused by several factors, such as:

• Genetics and temperament: Some people are born or “hard-wired” with intense emotions and temperament.
• Life events. Many sensitive people have experienced situations that have been overwhelming or stressful for them, contributing to their concerns of rejection or abandonment. This includes stressful situations such as trauma or abuse. It can also include stresses such as parental separation or divorce. It can be bullying from peers. It may also simply be that the person's need for emotional validation/acceptance was higher than what the environment could provide. Some children simply have high emotional / attachment needs, and their well-meaning environment/parent (s) may simply have been unable to meet that need. 

How Common are Borderline Traits?

There are very few studies of borderline traits in youth. Studies suggest that 1-3 out of every 100 youth under 18 may have these traits. Researchers estimate that 1-2 out of every 100 adults have Borderline Personality Disorder (BPD). Recent studies show that the number of women and men in the community with BPD is similar. More women see professionals for treatment compared to men.  

Other Conditions

People with borderline personality traits are at a higher risk of having other conditions, such as:

• Mood disorders (like depression);
  
• Anxiety disorders;
• Substance abuse;
• Eating disorders (usually binge eating or bulimia, but sometimes anorexia nervosa).

When and Where to Find Help?

Ask yourself:

• Have the problems with intense emotions persisted for a long time?
• Are the problems significant enough to cause troubles at home, school or relationships?

If so, then see a health professional such as:

• Your primary care provider (e.g. family physician, nurse practitioner);
• A mental health agency;
• Professional in private practice, such as a psychologist, social worker, psychiatrist or counsellor/therapist;
• Call a crisis support line or visit a mental health walk-in clinic if there are any more pressing concerns about your child’s mental well-being.

• A health professional can explore other contributing issues, such as:
  • Stress, anxiety, depression;
  • Learning issues such as attention deficit hyperactivity disorder (ADHD);
  • Sensory processing issues and self-regulation issues;
  • Emotional intensity disorder (a newer term proposed to replace the older term ‘borderline personality disorder”).

Do Borderline Traits Get Better? 

Most youth who receive appropriate support and services will benefit and show improvement. Youth who don’t get treatment are at higher risk for aggression, criminal behaviour, ongoing mental health problems, suicide, homelessness and problems in their relationships. 

In adults, the symptoms of Borderline Personality Disorder (BPD) are worse in early adulthood and the young adult years. But most have more stable lives and emotions in their 30’s and 40’s. Newer, more effective therapies, like Dialectical Behaviour Therapy (DBT), outlined below, can help youth recover more quickly. With this therapy, youth learn skills to help them build a life they feel is well worth living. 

Self-Help: Supporting Your Loved One

Is Your Loved One in a Calm, Logical, Rational State? (aka Green Zone)

People in the "green zone" can reason, talk about things, and be rational (at least more than in other states). In this state, you can try some of the following things:

Do's

• Try to understand what helps your loved one be in a good place.
  • Physical needs include regular routines, getting enough sleep, healthy nutrition, physical activity, and outdoor time.
  • Higher needs include having people and activities in our routines that give purpose, belonging, hope and meaning.
• Do schedule regular, one-on-one time with your loved one. Go for a walk, watch a movie, play a board game, bake, or build something together. When you plan for regular ‘special time’ with just you and your loved one, you show that person you value them.
  
• Do you find that your loved one is expecting too much of you?
  • If so, gently set clear expectations with your loved one about what you can and cannot do to avoid burnout. For example, you may need to clarify that you need a little time to recharge. 
  • Start with a loved one's perspective
    • You: "I know you want me to spend time with you on Wednesday evenings. I enjoy those times very much."
    • You: "I'm starting a yoga class on Wednesday evenings. I'll be away from 6-8 PM. We can make sure we spend special time together before or after. What do you think?"
• Do try to understand what triggers your loved one.
  • Typical triggers include times when our loved one might want validation/acceptance, but we happen to give them invalidation, criticism, or non-acceptance.
    • When your loved one tries to do something nice for you (e.g., vacuum, or make you dinner), they start by criticizing it.
    • Your loved one tells you something, and they want validation of their feelings, but you start by giving them advice or criticizing them.
• Are there problems or stresses? In this zone, you can talk to them and try to problem-solve -- at least more easily than in other zones.

Is Your Loved One Emotionally Upset? (aka "Yellow Zone")

Life is stressful, and sensitive people can become easily triggered into a "yellow zone." During these times, they may be upset and need emotional support -- they need "support, not solutions" (aka "connection before direction").

Do's

• Do start with "support not solutions" (aka "connection before direction".
• Support
  • Support is about giving empathy, validation and acceptance, as opposed to starting with "solutions", which is giving advice.
    • Empathy is one of the most powerful ways to support an emotionally sensitive individual.
    • Your loved one: "I can't believe my friend was so mean to me today."
    • You: "I'm so sorry to hear that!" "I'm here for you... Do you want to tell me more? Or we can do something together to get your mind off it."
    • Do ask your loved one how they would like to be supported. You might say: “I’m here for you. How can I support you?” Your teen might respond in many ways, for example, “I just need someone to listen to me”, or “Let’s go out for a walk” or “I need a hug…” or “I need your advice…”.The key is to follow your loved one's lead. If your loved one can’t tell you what support would help, you might make a suggestion.
      
    • Don't start with advice, i.e. "Have you tried doing __?"
• Is your loved one upset with you?
  • This might be hard, but try your best to see their perspective.
  • Example
    • You are busy with your work, and your loved one is upset that you can't spend time with them.
    • Your loved one: "You just don't care!"
    • You: "I'm so sorry. You want to spend time with me, and it feels like I don't care because I'm busy with work right now..."
    • Don't get upset or critical when they are upset. You may be absolutely correct in saying certain things, but if you do say something, it's better to say those things when your loved one is calmer and in the "green zone."

Don'ts

• Don't give advice unless your loved one is calm and ready to receive it. Or until your loved one is asking for advice. All of us need to be accepted and validated. When you give someone advice without being asked, they get the message that you don’t accept them and want them to change. 
• Do you feel a need to give advice? Ask for permission: “I am worried about you. Can I give you some advice?”

Is Your Loved One Overwhelmed in Fight/Flight/Freeze (aka "Red Zone")?

When people are emotionally overwhelmed, they cannot access their logical brain, perhaps not even their emotional brain. They may be in a primitive "reptilian" brain.

Do's

• Do give them time and space so that their brain can calm back down into an emotional zone ("yellow zone.")
• Provide a calm, soothing environment and reduce sensory overload, e.g., reduce sound if it's too loud or dim the lights if it's too bright.
• Do talk in a calm, reassuring voice.
• Make gentle and calm eye contact, and try your best not to look aggressive or upset.
• Focus on doing whatever you need to help the person calm down.

Don'ts

• Don't talk too much when people are overwhelmed -- their brains can't process too much. 
• Don't give consequences when your loved one is overwhelmed, as they may feel threatened by it. 
• Are you upset with your loved one's behaviours?
  • Don't focus on punishment or consequences when your loved one is overwhelmed. Threatening punishment or consequences will make them feel threatened, worsening the situation. Focus on calming everyone down, and logical consequences can be discussed when everyone is calm.
• Don't be a therapist. Remember that you are not the therapist (even if you happen to be a therapist, your role is to be a supportive family or friend in this situation). Avoid trying to ‘analyze’ your loved one. And if you’re asked for advice, just share some suggestions. Don’t be too forceful in telling your loved one what to do.

• Support your loved one's treatment. Family and friends can play an essential role in effective treatment. Help your loved one get to appointments and take part in family education and group sessions.

Supporting a Loved One Who Self-Injures

Youth with borderline personality traits often self-injure as a way of coping, however this can be very stressful for their family and friends.

Do's:

• Do remember that your loved one is simply trying to self-regulate and cope with intense emotional pain.
  

• Do ‘Connect before Directing’. You might be tempted to start with giving your loved one advice, like "You shouldn't cut, try your coping strategies instead", but it is better to connect first. Connect by asking how your loved one teen is feeling. You could also observe out loud that your teen must be in a lot of emotional pain and are trying to cope (“I see that you’re hurting and trying to cope”).

  • ​If your loved one responds, express how you care and gently offer your support in helping them find other ways to cope. If your teen is seeing a therapist, ask if the therapist has suggested things to do in times of intense emotional distress.
    

• Do understand that while it’s ideal if your loved one can confide in you, s/he may not always be able to.

  • If your loved one just can’t share thoughts or feelings with you, do remind him/her about other family members/friends, professionals (e.g., therapists), or a crisis line.
  • Let your loved one know that you care and will be there to help with the problem when she’s ready. When your loved one is self-injuring, focus on what is causing the most immediate stress. For example, “What’s causing you to feel upset?” “What stresses are you under?” You can then help resolve some of those stresses.
    

• Do understand that if your loved one has self-injured and needs to require medical attention for the injuries (like stitches for self-cutting), then bring your loved one to medical attention, such as an emergency department.

Don'ts

• Do not simply tell your loved one to stop self-injuring or make them feel guilty about it. This doesn’t help and will probably make things worse in the long run because your loved one may feel worse and be less likely to turn to you or share feelings with you. Besides, if your loved one could simply stop injuring himself or herself, then s/he would have done so by now.
  

• Don't blame or make them feel guilty.

  • Avoid saying things like: “How can you do this to me?” 
  • Don’t take your loved one's behaviour personally because it’s not about you.

Treatment

1. Dialectical Behaviour Therapy (DBT) 

In DBT, youth learn to accept themselves without judgment. At the same time, they learn to find ways to change problem behaviours in ways that bring them closer to their own ultimate goals. This therapy includes education for parents and family members. In DBT, youth learn many skills to help them handle their intense emotional system including: 

• Mindfulness; 
• Interpersonal effectiveness; 
• Distress tolerance; 
• Emotional regulation.

2. Psychodynamic and interpersonal therapies

It can be hard to find a therapist who is trained in DBT. However, other types of therapy can also be helpful for youth with borderline personality traits. In practice, most therapists will use a combination of therapies depending on their training and the teen’s situation. 

3. Medications

There are no medications that treat borderline personality traits specifically. But medications may be helpful for anxiety or depression that is not getting better with talk therapy. 

Focus on Dialectical Behaviour Therapy (DBT) Skills

Mindfulness

Highly sensitive youth can become “stuck” in their intense and distressing emotions, “I feel terrible; I’m such a bad person for feeling this way.”

Mindfulness meditation can help youth get “unstuck.” It can help them cope with these feelings and give them more options: “I’m feeling terrible. Anyone would feel terrible in this situation. This is what I’m going to do about it…”

Mindfulness is one of the core strategies in DBT. It is a kind of meditation where youth:

• Practice being in the present moment instead of thinking or worrying about the past or future. Focusing on the body (sights, sounds, body sensations, breathing) while letting other thoughts go can help a lot with worries.
• Learn to look at themselves and the world in a way that helps them to accept themselves without being critical or judgmental.

Distress Tolerance

For highly sensitive youth, everyday conflicts and problems can feel like life-or-death situations. In these situations, these youth tend to react quickly in ways that reduce their emotional distress. Unfortunately, these reactions don’t usually help solve these problems in the long run.

With support, youth can learn to tolerate intense emotional responses without doing things that will worsen the situation.

Emotional Regulation is about:

• Working with emotions so that youth can use them effectively.
• Being able to keep feelings in balance and not let them become overwhelming. This allows youth to stay calm and rational, even when faced with emotionally difficult situations.

Emotional regulation includes:

• Recognizing your feelings
  • E.g. “I’m feeling upset… I’m angry that my sister didn’t say hi to me in front of the other family members.
• Accepting your emotions
  • E.g. "Its natural to feel upset in a situation like this."
• Being able to calm down if you're too upset
  • E.g. "I'm too upset to deal with this right now. I will go to the bathroom and calm down before I do anything rash."
• Choosing how to respond appropriately
  • E.g. “Maybe she’s upset with me or just too busy with the other guests? Either way, the safest thing to do is to be nice. When things are quieter, we can talk alone and see what’s up. Even if she is pissed off now, if I’m kind and helpful, she’ll apologize later. It won't help to get angry and upset at her."

Types of emotional regulation strategies that are taught in DBT:

1. Keeping a healthy ‘emotional bank account’ by doing things that make youth less susceptible to intense and negative emotions (for example, eating well and getting enough sleep).
2. Consider whether feelings “make perfect sense” for the situation at hand. If they do, youth should act on these feelings. But if the feelings aren’t justified by the facts of the situation, youth can learn how to change their feelings by adopting an opposite emotion.

Positive coping

Youth can learn many different ways to handle challenges and problems more positively.

Problem-Solving

• What’s the problem?
• What would I like to see happen (goals)?
• What are possible solutions to reach that goal?
• What are the pros and cons of each possible solution?
• Did it work? Should I try something else?

Grounding exercises

Connecting to the present moment. For example:

• “What day is it? It's Saturday."
• "Where am I? I’m in the living room."
• "What’s in the room? I see the couch, the coffee table, and my cup of tea.”

Keeping busy (behavioural activation)

Being passive and obsessing about stress doesn’t help. Keeping busy with an activity can be a really positive way to handle stress.

Relaxation exercises

• Deep breathing
• Progressive relaxation
• Mindfulness meditation.

Getting social support

• Spending time with family and friends.
• Reaching out to talk with people close to you during rough times. 

Websites for more information 

Behavioural Tech is the website for Marsha Linehan, founder of Dialectical Behaviour Therapy (DBT). 
www.behavioraltech.com

NEA-BPD National Education Alliance for Borderline Personality Disorder
www.borderlinepersonalitydisorder.com 

About this Document 

Written by Dr’s Deanna Mercer (Ottawa Hospital); Dr. Marjorie Robb (CHEO), Dr. Michael Cheng (CHEO) and CHEO’s Mental Health Information Committee. Special acknowledgements to the Ottawa BPD Network for their comments and suggestions. 

License

Under a Creative Commons License. You are free to share, copy and distribute this work as in its entirety, with no alterations. This work may not be used for commercial purposes. View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/ 

Disclaimer

Information in this fact sheet may or may not apply to your child. Your health care provider is the best source of information about your child’s health.