- Depression, specifically major depressive disorder, is comorbid in 41 to 83 percent of those with BPD.
- Those with BPD often are misdiagnosed with depression, while BPD goes undetected until much later.
- BPD is often confused as an affective disorder (depressive or bipolar), but proof is in the treatment.
- There are no data to guide clinicians in choosing a specific biological treatment for depression that is comorbid with BPD.
Depression, specifically major depressive disorder (MDD), is comorbid in 41 percent to 83 percent of those with borderline personality (Lieb, et al., 2004). As you can see from this statistic, not all individuals with borderline personality disorder (BPD) will or do qualify for MDD. However, individuals with BPD will have what I call “depressive spirals.” These are instances when the individual experiences symptoms of depression (described below), but to a lesser degree and for a shorter duration. These depressive spirals are often in response to internal (loneliness or abandonment fears) or external (end of relationship or loss of employment) triggers. This post addresses the areas that cause the confusion, discusses treatment approaches, and gives strategies to help you attenuate your depression, whether it’s a depressive spiral or major depressive disorder.
What is the heart of the confusion?
Depression is a complex disorder, even without borderline personality disorder coexisting with it. This confusion arises from the significant overlap of symptoms, which includes (Fox, 2022):
- Sullen presentation
- Suicide risk and self-harm
- Affective instability that can mimic agitated depression
- Feelings of emptiness
- Low energy and volition
- Anhedonia (loss of interest in things you once enjoyed)
- Disrupted sleep patterns
- Sense of worthlessness
- Difficulty concentrating or focusing your attention
- Intense guilt and shame
- Impaired social, academic, or occupational functioning
With all of this overlap, it’s no wonder the confusion persists, and those with BPD often are misdiagnosed with depression, while BPD goes undetected until much later. When undergoing treatment, specifically directed at the depression, individuals with BPD have poor response outcomes (Beatson & Rao, 2012). The first step is to understand what type of disorder BPD is, as this can enhance detection and direct treatment.
Is BPD an affective disorder?
BPD is often confused as an affective disorder (depressive or bipolar disorder), but the proof is in the treatment. When those with BPD, with or without MDD, engage in treatment for depression, the symptoms and course of depression do not lessen the BPD symptoms. However, when treatment is directed at BPD-related core pathology and exhibited symptoms, the depression lessens. Why? This is because the catalyst for the depression tends to be BPD core pathology, which may be emptiness or abandonment fears, and when not recognized and addressed, it continues to cause depressive spirals or MDD episodes. If BPD were an affective disorder, treatments that attenuate affective symptomatology, such as those that originate with, and are directly related to, depression, would be efficacious in remitting it. Another area of concern is early adverse experiences that add to the convolution of these two disorders.
What about early adverse experiences?
Regretfully, the fallacy remains that all individuals with BPD have experienced early adverse experiences. It has been found that 71 percent of those diagnosed with BPD have experienced at least one early adverse experience (Porter, et al., 2020), but this is not 100 percent. This certainly occurs in the preponderance of cases, but most does not mean all.
Research has found that early adverse experiences increase the probability of an individual developing BPD (Carr, et al., 2013; Fonagy, et al., 2003; Kim et al., 2018). These include insecure patterns of attachment, sexual, physical, and or emotional abuse, and physical and or emotional neglect. Early adverse experiences have also been found to increase the probability of MDD. Chu and colleagues (2012) found that childhood adverse experiences, which they called “interpersonal violation,” predicted higher depression and anxiety scores.
This illustrates that early adverse experiences add to the confusion in understanding, managing, and attenuating MDD and BPD. The manner in which these early experiences are processed is a critical component of understanding these two disorders. Individuals with MDD, are likely to see their past experiences as certainly painful and traumatic, as are those with BPD, but they often will not internalize the experiences to be part of their self-conceptualization and personal worth. Many individuals with BPD internalize their past adverse experiences and use them to validate their sense of low self-worth, “brokenness,” and self-hatred; whereas, those with MDD do not. These issues illuminate the importance of exploring and working with core pathological factors, such as abandonment, for example, to help identify if BPD is present as part of the clinical picture. If it is, the treatment approach needs to change from a focus on traditional methods of depression symptom management and attenuation to one on BPD and core pathological factors.
A common treatment intervention for depression, and BPD, is medication. This is an often utilized adjunctive approach. Medication can illuminate a lot about MDD and BPD, and help discern confusing overlap and presentation of symptoms.
What about medication?
There are no data to guide clinicians in choosing a specific biological treatment for depression that is comorbid with BPD, but there is increasing worldwide pressure to limit the use of medication for BPD because of its limited effectiveness and concerns about the obesity-related health problems that can occur, particularly with simultaneous use of multiple drugs to treat a single ailment or condition, this is also called polypharmacy (Gunderson, et al., 2004).
Polypharmacy tends to occur because the distress is so intense that clinicians feel driven to try to alleviate it, by whatever means are available. Bender and colleagues (2001) found that people with BPD were two times as likely to have taken antidepressants and two times as likely to have received anti-anxiety medication, more than six times as likely to have received mood stabilizers, and more than ten times as likely to have used antipsychotics when compared to those with MDD alone.
That doesn’t mean don’t take medication, it means exploring options with your doctor and doing your best to have a treatment team that can interact and be aware of your medication and progress in therapy.
What about medication and therapy?
Gunderson and colleagues (2004) recommend that psychotherapy should take priority when BPD co-occurs with depression because once the BPD is addressed and subsides, the depression will follow. This is because MDD is not a significant predictor of treatment outcome for BPD, but BPD is a significant predictor of the outcome for MDD; the core pathology related to BPD is the driver for the depressive symptoms, not the depression alone.
Several types of psychotherapy for BPD have been shown in randomized controlled trials to result in lowered levels of co-occurring depression. These include DBT, metallization-based treatment, transference-focused therapy, schema-focused therapy, and supportive psychotherapy (Choi-Kain, et al., 2017).
Psychotherapies that are helpful for the treatment of depression alone include cognitive behavioral therapy, mindfulness-based approaches, and interpersonal therapy, to name a few. These approaches entail promoting your capacity to reflect on your own mind and that of others (Bateman & Fonagy, 2015; Kernberg, et al., 2008; Levy, et al., 2019). These are critical skills that can help build awareness of core pathology associated with BPD, but they need to be directed at the BPD and not only the depression. These skills help provide a pathway for a lowered rate of relapse of symptoms after psychotherapy, as they enhance the client’s newfound ability to reflect on the thoughts, feelings, and behaviors associated with or leading to their BPD and depressive symptomatology.
This shows that knowledge about the self, others, and your surroundings is crucial to getting the most out of therapy and controlling your issues pertaining to BPD that co-occurs with MDD. To help you get started, or strengthen, your journey to grow beyond your BPD I’ve listed some strategy steps for you to incorporate into your daily routine. Like all skills, the more you do them the stronger they become.
BPD and depression strategy steps
The treatment steps outlined below help build insight, as well as adaptive and healthy strategies, to control BPD and MDD symptoms and issues.
- Identify the symptoms related to BPD outside of depressive symptomatology. Do your depressive symptoms remain even when the trigger has been removed or ended?
- Find the underlying driving force for the BPD symptoms; this is your “core pathology” (abandonment).
- Determine how your core pathology is driving your BPD symptoms? For example, if you have abandonment issues, how do you think, feel, and behave when perceived abandonment occurs?
- Can you recognize the connection between perceived abandonment, BPD, and depressive symptom expression?
- Learn adaptive coping strategies, such as mindfulness, relaxation, or healthy distraction, when core pathology is triggered.
- Address the fear of letting go of old maladaptive patterns; “no one will love me if I’m not depressed or broken.”
- Learn new ways to see yourself and your world without your core pathology, fear, and maladaptive strategies.
Many of these steps may seem very difficult or unattainable; push back on that initial assumption. These thoughts are common, and they can be frightening. However, these strategy steps can help you build insight followed by behaviors that increase the probability of success and healthy relationships. It is possible.
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