Compass

Tag: borderline personality disorder (BPD)

  • Waiting For The Other Shoe To Drop

    Waiting For The Other Shoe To Drop

    Spring Light

    My dearest daughter. I am writing this on the most glorious spring day. The house is full of light for the first time in months. The dog is curled up on top of his crate in a sun patch. Outside, the clematis has erupted into a wall of white flowers. The washing machine is chuntering away. You are fast asleep upstairs. All feels curiously well with the world.

    I am having a delicious week off work. And for the first time in what seems like forever, I find myself able to do things around the house.

    Clearing Out

    I’ve gone through two kitchen cupboards and taken out all the years-old spices, the packets of beans never used, the detritus that has collected over the past years. I’ve taken all my clothes that no longer serve to the charity shop and the tip. I’ve completely cleared the bed in the front garden where the new shed will go — all those pestilential dogwoods, gone at last.

    And you have gone through all your clothes too. A far bigger job than mine. The chaotic floordrobe we’ve both survived with for the past year is no more, the carpet is back and we have functioning wardrobes again.

    Something has shifted. Not dramatically. But enough that we are both, it seems, ready to do some things differently.

    What’s Changed For You

    This week you worked four days in a row — unheard of. In the past you weren’t given that many shifts. I get the impression that you are more confident now and able to do more – I wonder if that’s why you’ve been offered the extra work? Also, you previously turned down shifts you didn’t get plenty of warning on — you’ve needed to know what you’re doing well in advance, which meant you missed out on work. Last night you agreed to another shift for tomorrow! Just working two shifts at the weekend used to be enough to leave you in bed for days, recovering. No wonder you are still asleep upstairs…

    I’d say I’ve noticed a change in you since you started DBT group therapy. You have of course been doing one-to-one DBT for a couple of years, but the group therapy is new. I wonder if you’re getting more out of it because you’ve already gone through a lot of the skills in your individual sessions – you’re not having to learn everything and process the group dynamics at the same time.

    I’d love to understand more about what’s helping. But I’m also scared of somehow spoiling this good thing if I prod at it too much. It feels so young and delicate, this change, and as much as I want to know the inner workings, I get that it’s also personal and private and maybe more for observing than understanding at this stage.

    What’s Changed For Me

    You’ve pointed out that you think I’ve changed too. That I’m “better” now. I’m not sure if I am, exactly, but I am trying.

    I’ve been taking a course called Managing Suicidality and Trauma Recovery, run by NEABPD (an American charity) for parents living with on-going fear about their child’s safety.

    It’s been tough – I’ve felt a bit sorry for myself having to stay up late in the evening because of the time difference (you know how I like an early night), but I haven’t found anything equivalent in the UK. And talking to strangers about something so distressing — trauma, shame, fear, all of it — that’s my idea of hell. A lot of the time I’ve been dissociating, not really taking it in. It’s only now, as the course ends, that I feel more comfortable and able to listen. But something must have been sinking in despite this.

    I’ve also been working on building something — an app to support caregivers of people with BPD. Still very early days, but the process of thinking about what I’d actually want to support me, and trying to apply what I’ve learnt from this course and countless other sources over the years, has been surprisingly helpful. More on that another time.

    The Other Shoe

    As I write this, something has started to tug at me. The fear of jinxing it. It’s not just the changes in you that feel fragile — it’s the changes in me, and in our relationship. Is it right to talk about it all when it is so new?

    I guess I’m waiting for the other shoe to drop. We’ve had peaceful times before — the odd day, even the odd week — and then it all descended into chaos, conflict and distress again. How long have we got this time?

    And yes, I say this fully aware that this ‘easier time’ hasn’t been perfect. We’ve had our descents — times you’ve been dysregulated, times I’ve triggered you by saying or doing something or other — and things haven’t escalated the way they have in the past. Which suggests we may be travelling somewhere new – still a bumpy road, yes, but not the dirt track full of crevasses and jagged rocks we’ve been careening down thus far.

    And yet, and yet… what if it’s not? What if you wake up today and everything goes wrong, reverts back to how it was before?

    OK, I had a bit of a spiral there so I used one of my new found skills… I redirected my attention to my surroundings – the dog in his sun patch, a fly buzzing against the window. And I remembered a slide from the course that has stuck with me: Interrupt fear patterns by gently saying to yourself ‘I don’t know’.

    I don’t know how this will pan out for us, my dearest one. And I’m trying to learn to sit with that.

    One thing is for sure though: Wherever you are, whatever you are going through, I’m still here for you — not perfect, not particularly wise, but trying to do better.

    Crikey – who knew that things feeling a bit easier could be so challenging?

  • Why You Feel Dreadful (When It’s Not You Who’s Ill)

    Why You Feel Dreadful (When It’s Not You Who’s Ill)

    In this article I talk about crisis, but I don’t necessarily mean a medical emergency.  I mean any episode of extreme emotional intensity and dysregulation. In the aftermath of a loved one’s crisis, many caregivers instinctively replay what happened — what was said, what was done, what they should have said instead — to make sense of their distress. But mental replay provides only part of the picture. The body was there too, experiencing all of it, and my theory is that understanding what happens at the body level could be the key to recovery.

    What the Research Tells Us

    There hasn’t been a great deal of research into the physical and mental impact on caregivers who have a loved one with BPD, but what has been done shows that the impact can be profound.

    A systematic review by Bailey & Grenyer (2013), published in the Harvard Review of Psychiatry, found that caregivers of people with BPD experience higher levels of burden and grief than caregivers of other serious mental illnesses, including schizophrenia.

    Their follow-up study (2014) found that BPD caregivers reported symptoms at levels consistent with mood disorders, anxiety, and PTSD.

    More recently, a 2025 study (Tempia Valenta et al.) noted significant psychological and somatic distress in BPD caregivers — physical symptoms caused or worsened by chronic stress, such as headaches, stomach problems, and sleep disruption.

    I haven’t found research that explores why caregivers experience this level of physical and psychological impact. What follows is my attempt to provide one answer to that question — drawing on established science around the body’s stress response and applying it specifically to the experience of caring for someone with BPD.

    Your Body Has a Plan

    When your brain perceives a threat — whether a physical danger or your loved one in crisis — it triggers a cascade of changes designed to keep you alive. Adrenaline surges, your heart rate climbs, muscles tense, breathing quickens. Cortisol follows, keeping you alert and mobilising energy. Blood flow redirects away from both digestion and your “thinking brain” toward the systems that help you survive.

    This is the fight-or-flight response. It evolved to handle physical threats requiring immediate action. The stress hormones flood your system, you fight or run, and the exertion uses up that mobilised energy. Then your parasympathetic nervous system kicks in to restore calm. Threat over. Cycle complete. System resets.

    The key word is “complete.” The stress response has a beginning, middle, and end — and researchers like Peter Levine have argued that physical action is what closes the loop, the body’s way of saying: the danger has passed, stand down.

    What Happens When the Cycle Can’t Complete

    When your loved one with BPD is highly dysregulated, or in crisis, your body can experience this as a threat. It then mobilises exactly as it’s designed to, but the context of caregiving — the love, the responsibility, the need to stay in relationship — means the stress cycle may never complete. And this is true regardless of how you respond:

    • Holding everything in. You stay calm on the surface while your nervous system screams underneath. The energy mobilised for action has nowhere to go — it stays in the muscles, the clenched jaw, the tight shoulders, the buzzing restlessness that lingers long after the crisis is over.
    • Fighting back. You shout, argue, match the intensity. It looks like stress is being discharged, but what often follows is guilt and self-recrimination — one incomplete cycle giving way to another.
    • Walking out. You leave the room, drive away. This comes closest to completing the flight response, but worry, guilt, and hypervigilance about what you’ll return to can keep your nervous system activated even though you’ve physically moved away.
    • Shutting down. You go numb, feel detached, experience a strange flatness. This is the freeze response — the nervous system’s last resort when neither fight nor flight seems possible. It can be the hardest state to recognise as stress, because it doesn’t feel like agitation. It feels like nothing.
    • Fawning. You pour all that activated energy into appeasing and accommodating, doing whatever it takes to de-escalate. Outwardly calm, but underneath the nervous system is working overtime.

    There are also approaches that can help people with BPD and their loved ones respond more skilfully in times of crisis, in ways that reduce stress on both sides — and future articles will explore these. But even with better tools, the fundamental challenge remains: your body is likely activating a survival response in a situation where survival instincts aren’t always what’s needed.

    Whatever your response looks like, it’s the situation itself — not a personal failing — that makes the stress cycle so hard to complete.

    What “Stuck Stress” Feels Like

    When a stress cycle doesn’t complete, the after-effects show up in the body in one of two ways:

    Agitation: a restless, buzzing energy that won’t settle. Your body is still primed for action that never happened — the energy sitting in your muscles, waiting to complete a response that got interrupted.

    Crash: a heavy, flu-like exhaustion that descends hours or sometimes days after a crisis. Your body went through a significant physical event, even though from the outside it might have looked like you were just standing in your kitchen.

    Neither is a sign of weakness. Both are signs of a body that has been through something real and hasn’t yet completed its natural recovery.

    Over time, when these cycles repeat without resolution, the effects can become chronic — persistent headaches, stomach problems, disrupted sleep, unexplained aches. I believe this may be the mechanism behind the somatic distress that research is now documenting in BPD caregivers.

    Why the Standard Advice Sometimes Misses the Mark

    If you’ve been told to try yoga, take a bath, go for a walk, or practise deep breathing — and sometimes it helps and sometimes it doesn’t — there are good reasons for that.

    If your body mobilised for a sprint, a gentle stroll doesn’t match the energy that was prepared. When your system is highly activated, stillness can feel like being trapped rather than calm. And when your nervous system is dysregulated, your thinking brain goes partially offline — so strategies that rely on reasoning your way through it may not reach the part of you that needs them.

    These techniques aren’t useless — but they’re not always the right tools for the moment.

    Why This Matters

    Understanding the stress cycle answers a question many caregivers ask: my loved one is the one suffering, not me — so why do I feel physically and mentally dreadful? Because your body has been through something real, repeatedly, and it deserves help completing its natural recovery.

    Where This Takes Us Next

    If stress gets stuck because the cycle can’t complete, the obvious question is: what helps it complete? There’s a growing body of research offering practical answers — and future articles in this series will explore them.

    Sources and Further Reading

    Bailey, R. C. & Grenyer, B. F. S. (2013). Burden and support needs of carers of persons with borderline personality disorder: A systematic review. Harvard Review of Psychiatry, 21(5), 248–258.

    Bailey, R. C. & Grenyer, B. F. S. (2014). Supporting a person with personality disorder: A study of carer burden and well-being. Journal of Personality Disorders, 28(6), 796–809.

    Tempia Valenta, S. et al. (2025). Psychoeducation for caregivers of individuals with borderline personality disorder: A randomized controlled trial of multiple family group therapy. Personality and Mental Health.

    Levine, P. A. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books.

    Porges, S. W. (2011). The Polyvagal Theory. Norton.

    Payne, P., Levine, P. A. & Crane-Godreau, M. A. (2015). Somatic experiencing: using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology.

    Gerritsen, R. J. S. & Band, G. P. H. (2018). Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Frontiers in Human Neuroscience.

    NEABPD (2025). Managing Suicidality & Trauma Recovery (MSTR): A Course for Parents in Distress.

  • They Offered Me Tea

    They Offered Me Tea

    No issue getting there

    Dearest daughter, I don’t remember there being an issue getting you to the appointment that morning. You’d met the mental health nurse a couple of times before and liked her. Vibe is really important to you, and you liked her vibe — easy-going, not one of those hand-wringing types who get emotional over your plight.

    The appointment

    She asked how you were getting on with the increased dose of duloxetine. You said you didn’t think it was working, that you needed something stronger. She told you it takes time to build up in your system, so you needed to give it a few more weeks. I guess this wasn’t what you wanted to hear.

    Then somehow the conversation turned to your weight. It’s such a blur — I can’t remember exactly how, and I fear I might have brought it up, trying to shift things onto something more positive because you were only a couple of pounds off the target weight the ADHD consultant had said you needed to reach to get back on medication. If it was me who raised it, I’m so sorry.

    The scales

    The nurse asked if you wanted to be weighed — no pressure, just if you wanted to. You said yes. I think you believed you had put on weight.

    You kicked your trainers off and looked at the dial. Bad news. You were actually lighter than when you were weighed at therapy a few days earlier.

    I could feel myself beginning to panic. My body knew we were entering dangerous territory.

    I think the nurse said something about you not being far off target, that it was achievable. And then the escalation started.

    The escalation

    This bit is all very blurry. I think you said something about how unfair it was — how were you supposed to get better? I tried to explain your impossible situation: not allowed ADHD medication because of your low weight, even though the psychiatrist said it would indirectly help with the BPD. And the eating disorder service not seeing you because of your BPD, so how were you supposed to put on weight?

    And then I think you swore and said you just needed help.

    And the nurse told you not to swear.

    And I was thinking: a) I don’t blame you for swearing; b) why is she focussing on the swearing and not on you asking for help; and c) oh no, telling you not to swear is like a red rag to a bull. She’s given you something to be really angry about.

    And now you’re shouting — you have a very powerful carrying voice — and you’re swearing and saying you don’t want to live any more. And she’s saying you’ll have to leave if you don’t stop with the shouting and swearing.

    And I become tearful. I don’t usually burst into tears at your appointments, but I’d just come back from a few days away with work and I was exhausted. So I guess this was me becoming dysregulated too — but in a different way to you. And my tears made you worse, because you hate it when I get upset.

    Suddenly other people rush into the room — a woman I don’t recognise and a receptionist — asking if everything is OK. You’re in tears, shouting about how useless they all are. They say you are upsetting the other patients. I’m scared they’re going to call the police because you’re saying no, you’re not going to leave — not because you want to stay, but because you’re in fight mode.

    I leave the room

    I suggest I leave. I’m hoping that if I make me and my tears the problem, I’ll give you and the nurse a chance at a fresh start.

    The plan seems to work. You agree to stay, the nurse agrees too, and I sit outside in the corridor.

    You’re still shouting, so I can hear what you’re saying. You’re telling her you hate your life, it’s unbearable, you want to die.

    Sweet tea

    The two women sit me down in the corridor, I feel obliged to explain that I don’t usually get tearful but it’s just all too much today. The receptionist offers to make me a cup of tea and insists on putting sugar in it. I say yes even though that’s not how I drink it. The other woman says she’s also a mental health nurse. She says that her colleague is brilliant and she’ll calm you down.

    I’m thinking, I’m not so sure.

    I can hear you begging the nurse to be sectioned, but I can’t hear her answers. I’m guessing she’s saying no, because you’re still shouting and crying.

    The tea comes. It’s actually quite nice. The two ladies are so lovely, saying how hard it must be for me.

    Eventually you stop

    You pretty much stop talking. The door opens and you come out. I say thank you to the nurse. I don’t know what for.

    I don’t remember leaving. I don’t remember driving.

    The next thing I remember is us in the supermarket — we’d driven straight there because it was our weekly shop day. It was our usual routine. We were on autopilot. We’d nearly finished when my phone rings. It’s the nurse, saying she’s made a referral for you to the crisis team and they’ll be calling shortly. I explain we’re in the supermarket, could they wait an hour. I hear her pause — she seems thrown by the fact we’ve gone shopping — and then says yes.

    We get home. There is no call.

    You’ve calmed down by then, and we laugh about how it’s a good thing it’s not an emergency any more.

    The call that came eventually

    They call the next day, in the afternoon. I hand you my phone and listen as you tell the man you’re no longer a threat to yourself. He doesn’t seem to ask any follow-up questions.

    I want to be part of the conversation, but you are avoiding eye contact. You don’t want me involved. And yet I am part of it all, aren’t I? That’s the problem with being so close and bearing so much of the brunt — when it comes down to it, if you don’t want me involved, I can’t be. You’re an adult now.

    A few days later, you get a letter saying you’ve been discharged from the crisis team.

    What I can’t stop thinking about

    Here’s what stays with me from that morning: we were both dysregulated. Both of us. I was crying, you were shouting. Both of us were overwhelmed, both of us struggling to cope.

    But my distress was palatable. Yours was not.

    I got tea. I got kindness. I got sympathy. Two lovely women telling me how hard it must be.

    You got told to stop.

    And I sat there, sipping sweet tea, listening to you beg to be sectioned through a closed door, feeling guilty that they were so kind to me and not to you.

    The zero tolerance problem

    The NHS has a Zero Tolerance Policy. It’s designed to protect staff from violence and abuse — and I understand why it exists. Being shouted and sworn at is horrible and there is never an excuse for violence.

    But here’s what I’ve learned: the NHS policy was never supposed to apply to people who are mentally unwell. The original guidance explicitly says that withdrawal of treatment shouldn’t apply to anyone who is mentally ill. And yet, in practice, shouting and swearing in a GP surgery can get you warned, removed from the patient list, or even threatened with the police — regardless of whether you’re in crisis.

    The frustrating thing is that de-escalation training is apparently mandatory for NHS staff. From my limited experience, I’d say it isn’t fit for purpose.

    A different kind of training

    I’m not singling anyone out for blame because I struggle with this as well – I think most of us do. Our nervous systems are set up to respond to shouting and swearing as a threat, not a cry for help.

    What I wish existed — for NHS staff and the loved ones of people with BPD — is effective training that gives us tools to stay calm and connected when someone is shouting, not tools to shut them down.

    Because the shouting isn’t the problem. The shouting is the symptom. And responding to the symptom while ignoring the cause doesn’t help anyone.

  • When It’s Not Just BPD: What We Know About Overlapping Conditions

    When It’s Not Just BPD: What We Know About Overlapping Conditions

    Introduction

    If you have borderline personality disorder (BPD), there’s a good chance other conditions are part of the picture too. That’s common: it’s having BPD and nothing else that’s relatively unusual.

    This article summarises what we know (and don’t yet know) about comorbidity in BPD, and why it matters when you’re trying to get the right help.

    How common are comorbidities?

    One large American study suggests that 85% of people with BPD have at least one additional psychiatric diagnosis. Over a lifetime, most people with BPD will experience more than one other condition alongside it.

    Commonly co‑occurring conditions include depression, anxiety disorders, post‑traumatic stress disorder (PTSD), attention‑deficit/hyperactivity disorder (ADHD), eating disorders, substance‑use disorders, and autism.

    These conditions don’t just sit side by side. They can amplify each other, complicate diagnosis, and make treatment harder to access or sustain.

    Why does this happen?

    No one knows for sure, but a few well‑supported explanations are often discussed:

    • Shared vulnerability (including genetics). Some people may inherit a higher baseline sensitivity to emotional dysregulation, impulsivity, anxiety, or mood instability.
    • Trauma and chronic invalidation. Adverse experiences can increase risk for multiple mental health difficulties, including BPD traits.
    • One condition can raise the risk of another. For example, untreated ADHD can lead to repeated failures, conflict, and shame, which may increase vulnerability to later difficulties.

    The diagnostic puzzle

    Mental health services often use categories and labels, to help decide treatment.  And many people want a label to make sense of what they’re experiencing. But symptoms rarely fit neatly into one discrete box.

    For example, difficulties with emotion regulation can be seen in BPD, ADHD, autism, bipolar disorder, trauma‑related conditions, and more.

    In one study, 40% of people with BPD had previously been misdiagnosed with bipolar disorder – which suggests to me that the current labelling system faces huge challenges in correctly identifying what’s actually going on.

    The latest NHS mental health report (APMS 23/24) made a point of highlighting the additional issue of diagnostic overshadowing: when having one diagnosis stops a clinician from investigating whether a behaviour may actually be caused by another condition.  The same report also acknowledged that BPD can overlap with autism and complex PTSD.

    Why the system struggles

    In practice, support is often commissioned and organised around single diagnoses (for example, ADHD, autism, eating disorders, or in some areas personality disorder services). People with complex presentations can fall between services, or face eligibility rules that make it hard to get care that matches what they actually need. For example, personality disorder services often exclude people with active substance misuse.

    NHS talking therapies are also generally time‑limited. Specialist treatments like Dialectical Behaviour Therapy (DBT), where available, vary in length depending on where you live, what is available and what is deemed suitable (from skills groups of 2 or 3 months to full programmes lasting roughly a year).

    Transitions between child and adult services can be another weak point. For example, a young person with ADHD does not automatically transfer into adult ADHD care everywhere; reassessment waits can be long. During that gap, distress can escalate and additional problems can develop.

    What does the research suggest about treatment?

    Treating co‑occurring conditions can improve outcomes. For example, someone whose ADHD symptoms are effectively managed may find it easier to engage in therapy for BPD.

    DBT was developed for chronic suicidality and BPD, but it has also been adapted and studied for related problems such as depression symptoms, eating‑disorder behaviours, and PTSD/trauma‑related presentations.

    While DBT has evidence for treating multiple conditions, this doesn’t mean every DBT therapist is equipped to treat every condition. Finding someone with expertise across a specific combination of conditions can be genuinely difficult, and this gap isn’t always acknowledged.

    What does this mean in practice?

    If you’re seeking help for yourself, or for a loved one, it can help to keep these points in mind:

    • BPD alongside other conditions is common. If things don’t add up, consider whether something is being missed.
    • Choose your battles. Pushing for multiple assessments at once can be exhausting; it’s OK to prioritise.
    • ‘Complex needs’ can feel vague, but it often reflects reality—and it usually means there isn’t a quick fix.
    • If a short course of therapy hasn’t touched the surface, it doesn’t mean you’ve failed. It may mean the offer wasn’t matched to the level of need.

    Conclusion

    You’re not imagining it: ‘something else’ may be going on alongside BPD, and that’s common.

    Complexity is hard—but understanding it can help you advocate for the right treatment for you or your loved one.

    There is a growing understanding that BPD often comes with other conditions – and that treatment needs to reflect this. The frustration is that services haven’t caught up with this new understanding – yet.

  • Bold Beautiful Borderline

    Bold Beautiful Borderline

    PODCAST DETAILS

    Title: Bold Beautiful Borderline

    Host: Sara Abbott

    Platform/Availability: Spotify, Apple Podcasts, and all major podcast platforms

    Episode: Borderline Rage “I will ruin your fucking life”

    Year: re-released 7th December 2025

    Host background: Sara is a Licensed Clinical Social Worker with lived experience of BPD.

    1. WHY I CHOSE TO LISTEN TO THIS

    I decided to see if I could find some podcasts about BPD and this was one of the first to come up in the search. A therapist with lived experience is such a powerful combination and I was keen to tap into her wisdom.  

     I picked this recent re-release episode as a starting point because I find rage extremely challenging – both my own and other people’s. And my daughter experiences a lot of rage.

    2. WHAT IT COVERS

    Sara breaks down in detail a recent argument she had with her husband: what she was feeling and why, and how it was resolved. She then goes back and gives examples from her past of when she experienced rage and dealt with it less well. She reads out responses she had from people with BPD as to what rage feels like to them. She goes into some of the theory behind BPD rage, DBT skills and guidance for people who might be on the receiving end of it.

    3. STRENGTHS

    Sara is highly articulate and speaks passionately and with great clarity about her own experience and as a therapist. I loved the ‘case studies’ from her own life.

    4. LIMITATIONS

    FYI there is the occasional swear word – in case you’re thinking of listening to it in a public space!

    Sara does give some brief advice to people who are on the receiving end of BPD rage, but this isn’t the focus of the episode.

    5. TONE AND SENSITIVITY

    She describes her podcast as raw, honest and sometimes humorous and that’s what I got from this episode. She has great empathy for her listeners who have BPD – their strengths and their struggles.

    6. PERSONAL REFLECTION

    I think I’m going to re-listen to this episode as there was so much for me to digest. Listening to her journey – things she did when she experienced rage when she was younger, to how she handled it in this recent argument with her husband left me with hope. My daughter is working so hard in therapy, but it’s a long, slow haul and sometimes it’s hard to see the progress, so it’s heartening to hear from someone who has stuck with it and is now in such a different place.

    7. WHO IT IS FOR

    I think it’s primarily for people with lived experience of BPD, but as someone supporting a loved one with it I also found it really useful.

    8. STANDOUT QUOTE

    It’s OK to feel anger for longer periods of time, it’s OK for all of those things to live there, it’s just simply what we do with it.

    9. FINAL THOUGHTS

    This podcast is now on my subscribed list!

    LINKS

    🎧Listen to the Podcast
    📷Sara on Instagram

  • The Pecking Order of Distress

    The Pecking Order of Distress

    I keep thinking about a conversation we had earlier, dearest daughter. The one where I told you about the recent NHS survey suggesting that as many as 1 in 10 young women may have Borderline Personality Disorder (BPD).

    I’m not sure how I was expecting you to react – I think I hoped it would make you feel less alone. But your initial reaction was disbelief. You pointed out that you don’t see hordes of young women having episodes out in public — and surely you would, if there were really 10% young women out there with the condition.

    I got defensive

    I’d spent so long looking at the report, trying to understand what it was saying, how the screening for BPD worked, that you refusing to believe it felt like you were saying my article was wrong — even though I was just reporting the results.

    And I got that familiar feeling of frustration that has come from many years of me saying something and you automatically saying the opposite. Like disagreement is your reflex — even when I’m not arguing, just reporting.

    Athough, in this instance, I think you have a point. One in ten young women potentially having BPD does seem impossibly high. But even it’s an overestimate and the real number is closer to one in twelve, or one in fifteen, that’s still a huge number of people.

    Quiet suffering still counts?

    Wanting to defend the statistic, I suggested that maybe some had a different, quieter form. After all, there are many different “flavours” of BPD — not everyone explodes in public.

    You replied with your trademark bluntness: then they don’t really have a problem and shouldn’t count.

    TikTok and self-diagnosis

    You talked about TikTok and how frustrating you find it, seeing people doing posts, self-diagnosing themselves with serious mental health conditions like BPD — the “oh I get anxious and I wanted to kill myself once so I must have BPD” brigade.

    I can see why this would irritate you. The not understanding. The seeming desire to jump on a bandwagon. The undeserving taking a slice of your pie.

    But I also hate pecking orders of distress. The way people like to judge suffering and decide whether it is ‘better’ or ‘worse’ than an imaginary legion of others. It wouldn’t be so bad if these judgements were kept private, but they never are. People feel honour-bound to tell you your suffering isn’t as bad as someone else’s. You get put in your place — usually to shut you up.

    I say this because it’s definitely not just you who judges, I do it — we all do. It has been part of society since forever. Perhaps it’s worse now because of social media. I don’t know. What I do know is that it needs to stop. There has to be another way.

    A spectrum, not a tick box

    I reflected on this new way of thinking about personality disorder — how it is now to be seen as a spectrum, not a tick box. This new framework may be more accurate but I fear it will turn people’s suffering into one long pecking order of distress.

    Given that the NHS has limited resources, how will decisions be made as to whether you qualify for treatment for a personality disorder? How far down the continuum will you need to be? Will there be a magic algorithm that sifts through all the crisis team referrals and the hospitalisations and decides who is deserving? Not saying the system is any better now of course, but if the system is going to change, I’d like it to be for the better.

    TikTok and your diagnosis

    But then you talked about how TikTok was useful in your own journey to diagnosis.

    You were at college and struggling and saw all these videos where people were describing what they felt and did. They called it BPD and you thought they meant bipolar. But when you looked up bipolar specifically, you thought: this isn’t me. So you were confused, and you talked to me about it.

    I said BPD stands for Borderline Personality Disorder, not bipolar. That you having a BPD diagnosis was something I’d discussed with CAMHS a few years before, but they were reluctant to assess you at that age because emotional intensity and instability can look like ‘normal teenage’ stuff. But that maybe it was time to get you properly assessed – you were 19 at the time.

    So I found a psychiatrist privately. Things were so bad I didn’t want to wait months or possibly years to find this out. And hey presto, we’d both been correct. Or rather, the psychiatrist agreed with us. She diagnosed you as having BPD.

    Diluting the experience

    The other thing you said that gave me pause: you refused to believe the 1 in 10 statistic because if it was true, it would give people an excuse to treat it as less serious. Like the volume somehow diluted the severity of experience.

    And maybe what you were really reacting to wasn’t the statistic at all, but the risk that other people would use it against you. That they’d hear “mainstream” and translate it as: Not that bad. Not that urgent. Not worth resources.

    Bandages

    It made me think of the times we used to go to therapy after I adopted you. When we got ready for the journey home, you’d sometimes fake a fall and insist on bandages for an “injured” limb.

    Even when we all knew what you were doing, you still needed it. Because pain that can’t be seen has a habit of being doubted.

    Mental ill-health and trauma can feel brutally lonely for that reason: it’s invisible. And you found a clever way of making the invisible visible.

    You’ve fought so hard to get me — and others — to understand how serious your pain is. So I can see why anything that hints your suffering is now commonplace might feel like it’s pushing you back into being unseen.

    But what if….

    … there are hundreds of thousands of young women like you out there — suffering and not being understood?

    Maybe at the heart of this is a dialectical truth: you can be desperately unwell — and you can be one of many. Both things can be true at the same time.

    If 1 in 10 young women do have BPD, that statistic doesn’t make it trivial. It makes it very, very urgent.

  • A Dive Into The APMS

    A Dive Into The APMS

    The Adult Psychiatric Morbidity Survey (APMS) 2023/4 is a large NHS survey that gives a “snapshot” of adult mental health in England. It follows the same basic approach as the last APMS in 2014, so we can make some comparisons over time.

    The survey results were published at the end of 2025.

    This wasn’t an online poll. Researchers interviewed a random sample of adults in private households, and people answered the most sensitive questions privately on a laptop. Because it’s a household survey, it doesn’t include people living in settings like prisons or inpatient units, and it’s likely to under-represent people who aren’t in stable housing — all groups where mental illness rates are often higher.

    This post focuses on what the survey suggests about Borderline Personality Disorder (BPD).

    Boxes vs Spectrums

    The report notes that personality disorder diagnosis is changing. Older systems tried to put people into categories (like “BPD”), even though many people don’t fit neatly into one box. Newer thinking treats personality disorder more like a spectrum: traits become a “disorder” when they’re so intense or inflexible that they seriously disrupt everyday life and relationships.

    The APMS sits between the two approaches — it reports both category screens for BPD and antisocial personality disorder (ASPD), and a broader screen for general personality disorder traits.

    The report also notes a debate: critics worry a broad “general personality disorder” label could widen the net and increase stigma and pressure on services, while others argue personality disorder has been underdiagnosed and better recognition could improve care.

    What Screened Positive Means

    The APMS did not check people’s NHS records or diagnose them in clinic. It used questionnaires designed to work out if it’s likely someone has a condition like BPD.

    So these figures do not mean a confirmed diagnosis after a full assessment — they mean screened positive on a questionnaire.

    Key BPD Numbers

    • We can compare data regarding numbers who screened positive for BPD with data from 2014
    Bar chart comparing BPD screen-positive rates in adults aged 16–64: 2.4% in 2014 and 2.5% in 2023/4.
    BPD screening hasn’t budged much in a decade (16–64): 2.4% → 2.5%.
    • If you look at all adults 16 years and older, 1.9% screened positive for BPD
    Infographic showing 1.9% of adults aged 16+ screened positive for BPD, equating to around 900,000 adults in England (illustrated with people icons).
    1.9% sounds small — until you realise it’s about 900,000 adults in England.

    Young Women: A Standout Finding

    One of the most striking sets of results is for women aged 16–24. They suggest that young women are experiencing personality disorder and self-harm (a common feature of BPD) at among the highest rates in the survey.

    Infographic listing women aged 16–24: 35.3% screened positive for general personality disorder traits, 9.8% screened positive for BPD, and 31.7% reported lifetime self-harm without suicidal intent.
    Young women (16–24) are the outlier: PD traits, BPD screening, and self-harm all spike.

    The BPD statistic alone is cause for concern.

    Infographic stating that 9.8% of women aged 16–24 screened positive for BPD (approximately 1 in 10).
    About 1 in 10 young women (16–24) screen positive for BPD.

    The report also notes that some critics see “personality disorder” labels as a way of medicalising understandable responses to trauma, inequality, and social pressure.

    Are we diagnosing a biological disorder — or measuring the weight of modern society on young women?

    A Big Caution: Overlap And “Diagnostic Overshadowing”

    The report points out that BPD and general PD criteria can overlap with autism and complex PTSD, which can contribute to “diagnostic overshadowing” (thinking a symptom is linked to one condition when it’s really caused by a different one).

    However, the report doesn’t publish a breakdown of any overlap between people who screened positive for BPD and autism or complex PTSD. Presumably because only 99 people in the survey screened positive for BPD, which limits how much detail you can reliably analyse.

    For me, this is a key area of concern. How can the right treatment be given, if we don’t fully understand what is causing the behaviour?

    The Soup Of Distress (What Tends To Cluster With PD Traits)

    What the report does show clearly is that people screening positive for general personality disorder traits are more likely to be facing wider pressures — including unemployment and financial hardship, and higher rates of depression/anxiety and limiting physical health conditions.

    The Treatment Gap: Pills vs Therapy

    The report suggests a mismatch between recommended care and what people report receiving.

    Horizontal bar chart for people screening positive for BPD: 47.8% reported no treatment, 43.8% reported medication, and 21.6% reported psychological therapy; note that treatments can overlap
    Nearly half get no treatment — and meds beat therapy by about 2 to 1.

    The report concludes this points to a need to improve treatment and service provision (while also noting the small BPD sample size means we should be careful about over-interpreting).

    One Hopeful Note – And One Hard Reality

    A hopeful note is that the much lower screen-positive rates in older age groups challenge the idea that BPD symptoms must be lifelong for everyone (though the APMS can’t track individuals over time).

    Chart showing BPD screen-positive rates are highest in younger age groups and lower in older age groups.
    BPD screening peaks in young adulthood — then drops with age.

    But the report also notes that this isn’t a trivial condition. It cites earlier UK research in people treated by specialist NHS mental health services (beyond GP care) where life expectancy was estimated around 18 years shorter than the general population, and notes many were likely to have had a BPD diagnosis.

    Conclusions

    My conclusion is that it’s great to have this big-picture overview of mental health in England — but the survey now raises questions that need much more granular research.

    For example, my daughter has first-hand experience of diagnostic overshadowing: there are services for other conditions that won’t engage with her because she has a BPD diagnosis. That has been a major barrier to her getting better. The authors of this report suggest she isn’t the only one — but where is the data to confirm this pattern, measure its impact, and show what improves outcomes? Without clear evidence, it’s harder to push services to change.

    The figure of around 1 in 10 young women screening positive for BPD is a wake-up call. Even allowing for the limits of screening tools, this is too common to ignore. It should trigger urgent research into what’s happening for young women — and why.

    And the treatment picture won’t surprise anyone who has tried to access therapy for themselves or a loved one with BPD. It’s also not surprising that medication is used so often, even though there isn’t a drug that specifically treats BPD. When waiting lists are long and therapy is hard to access, people in crisis understandably want something — anything — that might ease their pain.

    Now that this report is out, the question is: will we treat these findings as a headline, or as a prompt for real change — better data, better access to psychological help, and fewer people falling through the cracks?

  • Handstands

    Handstands

    Trigger Point

    It was 8pm. We were on the sofa, watching television as usual. The dog crouched on the floor, quivering with excitement, waiting for you to throw his ball.

    Fleabag had just said I love you — and goodbye to the hot priest. A lovely end to a brilliant series. I said “all done” to the dog and walked out into the hall to put his ball away.

    When I came back, you were off the sofa and furious.

    The dog had ruined everything, you said. No — I had ruined everything. You’d wanted to do handstands. I’d ignored what you wanted, got the dog’s ball out instead, and now the moment had passed. You’d lost your motivation and it was all my fault, because I always put the dog first.

    You were getting louder and louder. I asked you to stop shouting. You said I only listened when you shouted. You’d asked me nicely to put the dog in his crate so you could do handstands, and I’d ignored you. Why should you make all that effort — keep trying with your DBT skills — if they didn’t even get you what you wanted? If I was going to carry on being so fucking useless?

    I stood there trying to catch up. It all felt like it had come out of nowhere, but it hadn’t.

    The Set Up

    It had started twenty minutes earlier, while you were still eating.

    Or maybe even earlier than that when I decided to eat without you. I was post-migraine hungry and couldn’t wait for your appetite to kick in. So I ate on the sofa alone.

    A Routine Disrupted

    Eating separately shifted the whole rhythm of the evening. It meant I’d already done the after dinner dog routine — ball throwing, kibble hiding, peanut-butter LickiMat — the routine we’d devised to try and put a limit on his relentless demands to play with us in the evening. The routine we usually did together.

    Then I was back on the sofa again, keeping you company while you ate your dinner. Sausages and mash, broccoli and green beans, everything swimming in gravy. One of your favourites.

    The Ask I Missed

    We were watching Fleabag when you said you wanted to do handstands, after you finished eating. These post-dinner handstands were a new thing. You said they gave you that strong feeling in your joints — like when you used to swing from the chin-up bar when you were little.

    You said, basically: he’s had his ball — put him in his crate so I can do handstands in peace.

    But I wasn’t so sure. The dog was staring, fully expecting the ball to appear again. And I wanted a quiet life — because when the dog got frantic, you shouted, I snapped back, and everything went to pot.

    I didn’t say any of that out loud. I just went to the kitchen and came back with the Nutella jar and a big spoon — your favourite pudding — and the dog’s ball.

    The Spiral

    You stared hard at me and silently flicked two middle fingers while you licked your Nutella spoon. I let it slide. I was focused on trying to please both of you: a quick play with the dog, then the handstands.

    Except the dog didn’t want to play with me. He kept delivering the ball to you.

    So I leaned over and picked it out of your lap, trying to save you the trouble of throwing it. You flinched as I got close. That stung, but I ignored it, not wanting to provoke you.

    Eventually I put the ball away. And then I came back to find you furious, and I got that familiar stomach-dropping feeling as your rage ramped up.

    Part of me was cross because it felt like it was over nothing — like I was being attacked out of nowhere.

    I told you I wasn’t a mind reader, and that if I’d known the handstand thing was time-critical, I would have handled the dog differently. You looped through your anger again: I should have known what you needed.

    As you raged I flipped between trying to defend myself and mutinous silence. Eventually I pushed back — telling you it was impossible to be open and reflective about my own actions while you were shouting at me.

    Lessons From Childhood

    You said this was no different from what had been expected of you at school — the teachers had shouted you into overwhelm, and then expected you to reflect on your behaviour and apologise.

    Hearing those words, my heart broke. I knew you’d been challenging at school, but no one should be treated like that, especially a child.

    You said it wasn’t just teachers. It was me too — I always made you apologise and rarely apologised myself.

    It was an uncomfortable truth. For all the stories I could tell myself about your “bad” behaviour, things usually escalated because I lost my temper.

    And then you looped back to the same old point: I never listened.

    The Repair

    You’d said it many times before — the not listening — and it always hit a nerve, because I did listen. I just didn’t always agree. But in a moment of inspiration, I tried something different. I asked if I could repeat back what I thought you’d told me, to check whether I’d understood. You could correct me if I’d got anything wrong.

    I said something like:

    So you were eating your dinner and you decided you wanted to do handstands when you finished. You could see that might be difficult with the dog jumping around, so you suggested putting him in his crate. I ignored that and got his ball instead. He kept bringing it back to you, and then I invaded your body space by leaning over to pick it up, which wound you up even more. And by the time I put the ball away, you’d lost the urge to do the handstands. That was frustrating because you’d genuinely wanted to practise. And it felt like I’d ignored you and put the dog’s needs before yours — and that wasn’t fair.

    As I said it, I could see — and feel — you calm down. And as you calmed, I felt myself shifting too. I could see it more from your point of view. I felt empathy for your frustration. I saw that little girl — taken into foster care — who’d never felt she’d been put first.

    I waited a moment then said that part of me still thought waiting could have worked — but I could see why it hadn’t for you. I was half-expecting you to explode again. You didn’t.

    See Me

    How quickly you calmed down surprised me. It gave me pause. I’d assumed it was obvious that I understood why you were angry, but it wasn’t. I’d already been moving on to the next thing — trying to solve the problem — when what you wanted first was to feel seen.

    You told me how frustrating it was when I looked away, or made what I thought were sympathetic noises while you were trying to explain how you felt. How it made you feel ignored — like I didn’t care or understand.

    I asked if I could do the repeating-back thing again in future — so I could check I’d understood, and you could feel me listening properly. You agreed it might work. It felt important.

    You suggested I write it up as a journal post.

  • Borderline Personality Disorder – What’s In A Name?

    Borderline Personality Disorder – What’s In A Name?

    A look at how one of the most misunderstood mental health diagnoses ended up with multiple names and why the language we use still matters.

    When I first started reading about BPD, I thought the name meant it wasn’t a very serious mental illness — that someone who had it was on the borderline of being mentally ill. Phew, I remember thinking, if that’s what my daughter has, it doesn’t sound too bad.

    It soon became clear that it was, in fact, a serious and complex condition. And the confusion deepened when I realised that it’s also called Emotionally Unstable Personality Disorder (EUPD) in some places. Other names cropped up too — Emotional Intensity Disorder, Emotional Dysregulation Disorder — leaving me wondering: Why does this one condition have so many different names? 

    A Bit of History

    The term borderline was coined in 1938 by an American psychiatrist named Adolph Stern. He used it to describe patients he believed sat on the borderline between neurosis and psychosis. 

    At that time, mental illness was largely seen as falling into one of two camps: 

    • Psychosis — where people lost touch with reality, seeing or hearing things that weren’t real and often requiring hospital care. 
    • Neurosis — conditions such as anxiety or depression, which could be treated through psychoanalysis. 

    Stern realised he had patients who didn’t fit neatly into either category. When distressed, they could temporarily lose touch with reality, but most of the time they weren’t psychotic. They were highly anxious, emotionally volatile, but often didn’t respond well to traditional psychoanalytic therapy. These were the people he described as being on the borderline. 

    How Mental Illnesses are Classified

    Agreeing on what to call diseases and symptoms has always been a challenge. The first International Classification of Diseases (ICD) was created in the 1890s to standardise how illnesses were recorded across countries. 

    Mental disorders were added in 1949, when the system came under the administration of the World Health Organization (WHO), which has managed it ever since. 

    A few years later, in 1952, the American Psychiatric Association produced its own manual — the Diagnostic and Statistical Manual of Mental Disorders (DSM) — based on the ICD’s classification of mental illness. Over time, however, the DSM evolved into its own separate system. 

    Although both systems still cross-reference one another, they now differ in the way some conditions are described and named. This is the main reason why mental illnesses can end up with multiple names.

    It’s also worth noting that while the DSM and ICD dominate psychiatric diagnosis globally, they’re not the only systems that exist. For example, China has its own manual — the Chinese Classification of Mental Disorders (CCMD). 

    A Bit More History – When Personality Disorders Entered the Picture

    As psychiatry moved away from thinking about mental illness purely in terms of psychosis and neurosis, both the ICD and the DSM introduced a new group of conditions called Personality Disorders. These described long-term patterns of behaviour and emotion that caused significant distress or difficulties in relationships and daily life.

    By the late 1960s, both manuals included a category for Emotionally Unstable Personality, but neither yet used the term borderline. Although it was being used out in the field – some influential psychiatric researchers had started repurposing this old psychoanalytic term and using it in their own work.

    Over time, the two manuals developed their own versions of the diagnosis: the DSM settled on the name Borderline Personality Disorder (BPD) in 1980, while the ICD updated its terminology in 1992 to Emotionally Unstable Personality Disorder, borderline type (EUPD).

    So What is it Currently Called in the UK?

    At the moment most UK clinicians still use the term Emotionally Unstable Personality Disorder (EUPD) but this is changing.

    The latest version of the International Classification of Diseases — ICD-11 — began rolling out internationally in 2022 and is gradually being adopted across the NHS. In this new version, the old term Emotionally Unstable Personality Disorder (EUPD) has been replaced by “Personality Disorder,” rated by severity (mild, moderate, or severe) with an optional trait description.

    This means the language in clinical notes will eventually shift from EUPD to something like:

    “Personality Disorder, moderate severity, with borderline pattern.”

    The transition to ICD-11 will take some time. It’s expected to replace ICD-10 in England over the next few years. Scotland has already begun using ICD-11 in some mental health settings, while Wales and Northern Ireland look like they are still in the planning stages.

    No Wonder It’s Confusing

    If you live in the UK, this can all feel like a right mess. If you go to your GP, they’ll probably use the term EUPD, because that’s the official language of ICD-10, still in use across most of the NHS.

    Over the next few years, as ICD-11 is implemented, this will change — most likely to simply “Personality Disorder (borderline pattern)” — though no national guidance has yet been issued.

    Meanwhile, my daughter calls it BPD, because that’s the term she sees on TikTok, where most of the content is made by American creators.

    UK charities such as Mind currently try to bridge the gap by saying:

    “Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD).”

    Although this sort of description will presumably have to be updated now that the term EUPD is being phased out.

    Adding to the confusion, you might also come across terms like Emotional Intensity Disorder or Emotional Dysregulation Disorder. These aren’t official diagnoses in either the DSM or the ICD, but they’re used informally by some clinicians, advocates, and people with lived experience who feel the phrase “personality disorder” is stigmatising.

    The Problem with Personality Disorder

    For many people, the term personality disorder itself is painful. It can sound as though there’s something wrong with their core self, rather than describing how trauma, neurodiversity, or emotional dysregulation affect them. 

    The name can also carry stigma and people often report feeling judged or dismissed once that label appears in their records. 

    The Problem with Borderline

    It’s essentially a legacy label, a term that comes from a time when mental illness was understood very differently.

    When the DSM formally introduced Borderline Personality Disorder in 1980, it kept the word borderline simply because it had already been informally used for decades — and no one could agree on a better name.

    Today, it no longer refers to people being in a “borderline” state between anything. Now, clinicians use it as shorthand for a pattern of emotional and relational instability, but there’s nothing in the word itself that explains what it actually means.

    Further Reading

    If you’d like to explore more about how people feel about this diagnosis, I recommend the excellent report BPD Voices by CAPS Independent Advocacy. 

    It shares the wide range of feelings, experiences, and perspectives from people who have been diagnosed with BPD — including how they relate to (or reject) the label itself. 

    In Summary

    The story of BPD/EUPD is as much about language and culture as it is about psychiatry. 

    The name has shifted across decades, continents, and classification systems — and so has our understanding of what it means. 

    As more people with lived experience help shape the conversation, perhaps we’ll see new ways to describe this condition that are less blaming, more accurate, and more compassionate. 

    However, given that both the DSM and ICD tend to evolve slowly and conservatively I’m not expecting an official name change any time soon.

    Perhaps the best we can hope for in the short term is that a two-tier system gets created: one set of clinical terms used by professionals, and another set of names and descriptions used by people to explain their own experiences. Or will that just create even more confusion?

    Sources and Further Reading