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FAQ

What is histrionic personality disorder?

Traits may include the following. The starred traits overlap with other cluster B disorders in some individuals:
Constantly seeking reassurance or approval **

Having a low tolerance for frustration or delayed gratification **

Needing to be the center of attention (self-centeredness)

Quickly changing emotions, which may seem shallow to others **

Acting or looking overly seductive

Being easily influenced by other people **

Being overly concerned with their looks
Being overly dramatic and emotional **

Being overly sensitive to criticism or disapproval **

Believing that relationships are more intimate than they actually are **
Blaming failure or disappointment on others **
HPD will most likely be dropped in the DSM-5.

What is antisocial personality disorder?

Antisocial personality disorder symptoms may include the following. The starred traits overlap with other cluster B disorders in some individuals:
Child abuse or neglect **
Intimidation of others **

Aggressive or violent behavior **

Lack of remorse about harming others

Impulsive behavior **

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Agitation

Poor or abusive relationships **

Irresponsible work behavior

Disregard for right and wrong

Persistent lying or deceit **

Using charm or wit to manipulate others

Recurring difficulties with the law

Repeatedly violating the rights of others

How common are borderline and narcissistic personality disorders?

According to the largest study ever conducted on personality disorders (PD) by the U.S. National Institutes of Health (NIH), 5.9% of the U.S. population has BPD (Grant et al. 2008) and
6.2% has NPD (Stinson et al. 2008). As some people fit both diagnoses, about 10 percent of the U.S. population has BPD and/or NPD.
Of the people meeting the criteria for a BPD diagnosis, 53 percent were women and 47 percent were men (Grant et al. 2008). Of the people meeting the criteria for NPD, 62 percent were
men and 38 percent were women (Stinson et al. 2008).
Your partner could have either disorderor both. Almost 40 percent of people with one of these disorders also have the other, according to the NIH study (Grant et al. 2008; Stinson et al.
2008). Many more people have traits of a PD, but not the full disorder. Therefore, the number of people with some of these problems may be even higher.
(From Splitting: Protecting Yourself When Divorcing a Borderline or Narcissist by Bill Eddy and Randi Kreger)

What is a high conflict personality (HCP)?

High conflict personalities are people who demonstrate certain personality patterns:
1.
2.
3.
4.
5.
6.
7.

Rigid and uncompromising, repeating failed strategies

Unable to heal or accept a loss
Negative emotions dominate their thinking
Won't reflect on their own behavior
Can't empathize with others
Preoccupied with blaming others
Won't accept any responsibility for problems or solutions

HCP's stay unproductively connected to people through conflict and will continue to create conflict to maintain any sort of relationship, good or bad. Since HCP's undermine all
relationships, they constantly repeat their same patterns and usually end up divorcing repeated times. About 20-30% of all couples getting divorces have at least one HCP spouse.
HCPS are driven by four primary fears:
1. Fear of being ignored
2. Fear of being belittled or publicity exposure

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3. Fear of being abandoned

4. Fear of being dominated, includes fear of losing control over you, the other spouse, their money/assets, or themselves
HCPs often have one or more cluster B personality disorders (which include BPD and NPD) or just have BPD/NPD traits PD traits. However, not all people with BPD/NPS are high conflict
personalities.
From Splitting: Protecting Yourself When Divorcing a Borderline or Narcissist by Bill Eddy and Randi Kreger

What is an Axis ll disorder?

The DSM-IV-TR uses a five level diagnostic system to classify illnesses and disorders. The most important is Axis l and ll.
Axis I is reserved for clinical disorders you're probably familiar with: things like depression, bipolar and schizophrenia. Axis II is for personality disorders. Axis ll disorders are considered
less treatable and insurable, although this is changing. The current proposal for the revision of the DSM does away with this system.

Can someone have both narcissistic personality disorder and borderline personality disorder?

Yes. Many people believe their family member has BPD when they really have traits of both disorders. People with BPD who do not seek treatment are at risk for having NPD traits: the
NPD keeps them in denial. Almost 40 percent of people with one of these disorders also have the other, according to an NIH study (Grant et al. 2008; Stinson et al. 2008).
In addition to these statistics, it's important to know that many more people have traits of a PD, but not the full disorder. Therefore, the number of people with some of these problems may
be even higher.

What is the DSM-IV TR?

The full name of the DSM-IV TR is"Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision." Mental health professionals use the DSM (also dubbed the"psychiatric
bible") to diagnose psychiatric illnesses. The stated purpose of the DSM is threefold: to provide "a helpful guide to clinical practice"; "to facilitate research and improve communication
among clinicians and researchers"; and to serve as "an educational tool for teaching psychopathology."
Each cluster B psychiatric disorder (antisocial personality, histrionic personality, borderline personality, and narcissistic personality) has a numerical code clinicians put on charts and use
to bill insurance companies.

What is "narcissistic supply" and "narcissistic injury"?

Narcissists have a sense of superiority ("I don't need anyone; I'm special"), and believe they're entitled to special treatment and recognition (whether or not they deserve it). At the same
time, they're hypersensitive to criticism and disrespect. They survive through "narcissistic supply" from others, which comes in the form of attention, being put on a pedestal, adoration,
praise, and so forth. These soothe his or her fragile ego.
If the NPD is deprived of these thingsor worse, receives criticism and no special treatmentthe result is a narcissistic injury, which may show itself in rage or sulking. On some level,
NPs know how desperately they need others, which is why they can be so controlling and angry.
It doesn't take much to trigger narcissistic supply. A simple difference of opinion can do it.

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Do people with narcissistic personality disorder have empathy for others?

No. This is one of the most characteristic aspects of the disorder. Read Randi Kreger's blog post about this at Psychology Today.

What causes borderline personality disorder?

According to the National Institute of Mental Health, both environmental and genetic factors are thought to play a role. BPD results from a combination of individual vulnerability to
environmental stress and possible neglect or abuse as young children (or their perception of such).

Why are more women diagnosed with BPD than men?

No one knows, but several theories have arisen:

Sexual abuse, which is common in childhood histories of borderline patients, happens more often to women than men. Women experience more inconsistent and invalidating messages in this society.

Women are more vulnerable to BPD because they are socialized to be more dependent on others and more sensitive to rejection.

Clinicians are biased. Studies have shown that mental health professionals tend to diagnose BPD more often in women than men, even when patient profiles are identical except
for the gender of the patient.
Men seek psychiatric help less often.

Men are more likely to be treated only for their alcoholism or substance abuse; their borderline symptoms go unnoticed because BPD is assumed to be a woman's disorder.
Female borderlines are in the mental health system; male borderlines are in jail.
Also see this blog post by Randi Kreger at Psychology Today.
From Stop Walking on Eggshells by Randi Kreger and Paul Mason

Are people with BPD mostly women and NPD mostly men?
Not really. This is an outdated notion no longer supported by the statistics.
Some statistics
According to the largest study ever conducted on personality disorders (PDs) by the U.S. National Institutes of Health (NIH), of the people meeting the criteria for a BPD diagnosis, 53
percent were women and 47 percent were men (Grant et al. 2008). This is contrary to the old DSM-IV statistic of 75% women.
Of the people meeting the criteria for NPD, 62 percent were men and 38 percent were women (Stinson et al. 2008). But college students' scores on the Narcissistic Personality Inventory
indicate that young women are increasingly narcissistic and closing the gap with men (Twenge and Campbell 2009), so these gender percentages are not statistically significant enough to
make any assumptions about men or women predominantly having one or the other disorder.
Your partner could have either disorderor both.

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Almost 40 percent of people with one of these disorders also have the other, according to the NIH study (Grant et al. 2008; Stinson et al. 2008).
From Splitting: Protecting Yourself When Divorcing a Borderline or Narcissist by Bill Eddy and Randi Kreger.
From Stop Walking on Eggshells

Are people with BPD usually victims of abuse?

We don't really know how many people with BPD have been abused because our measuring tools are not very dependable and we can't measure the backgrounds of people with BPD not
in treatment. However, we do know that a person's poor environment while growing up is certainly a risk factor of BPD. But that could be anything from abuse to divorce or even a
displacement by a new baby.
From The Essential Family Guide to Borderline Personality Disorder by Randi Kreger.

What is the difference between bipolar disorder and borderline personality disorder?

See this blog post about the difference between bipolar disorder and borderline personality disorder at my blog on Psychology Today.

Why do some people with BPD seek treatment and others don't?
See this answer about the overlapping two types of BPD.

Why do people with BPD act so differently?

People with BPD have similar thoughts and emotions, but their behavior differs depending on how they cope and what other co-occurring disorders might be present.
The overlapping types are lower-functioning conventional, higher-functioning invisible, and combination.
Characteristics of lower-functioning,"conventional" BPs:
1.
2.
3.
4.
5.

They cope with pain mostly through self-destructive behaviors such as self-injury and suicidality. The term for this is"acting in."
They acknowledge they have problems and seek help from the mental health system, often desperately. Some are hospitalized for their own safety.
They have a difficult time with daily functioning and may even be on government disability. This is called low functioning.
If they have overlapping, or co-occurring, disorders, such as an eating disorder or substance abuse, the disorder is severe enough to require professional treatment.
Family members' greatest challenges include finding appropriate treatment, handling crises (especially suicide attempts), feelings of guilt, and the financial burden of treatment.
Parents fear their child won't be able to live independently.

Because lower-functioning conventional BPs seek mental health services, unlike the higher-functioning invisible BPs we'll talk about next, they are subjects of research studies about BPD,
including those about treatment.
Higher-functioning, invisible BPs:

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1. They strongly disavow having any problems, even tiny ones. Relationship difficulties, they say, are everyone else's fault. If family members suggest they may have BPD, they
almost always accuse the other person of having it instead.
2. They refuse to seek help unless someone threatens to end the relationship. If they do go to counseling, they usually don't intend to work on their own issues. In couple's therapy,
their goal is often to convince the therapist that they are being victimized.
3. They cope with their pain by raging outward, blaming and accusing family members for real or imagined problems.
4. They hide their low self-esteem behind a brash, confident pose that masks their inner turmoil. They usually function quite well at work and only display aggressive behavior toward
those close to them. Family members say these people bring to mind Dr. Jekyll and Mr. Hyde.
5. If they also have other mental disorders, they're ones that also allow for high functioning, such as narcissistic personality disorder (NPD).
6. Family members' greatest challenges include coping with verbal, emotional, and sometimes physical abuse; trying to convince the BP to get treatment; worrying about the effects
of BPD behaviors on their other children; quietly losing their confidence and self-esteem; and tryingand failingto set limits. By far, the majority of Welcome to Oz (WTO)
members have a borderline partner.
BPs with overlapping characteristics:
Many BPs (perhaps a majority) possess characteristics of both lower-functioning conventional BPs and higher--functioning invisible BPs. Get Me Out of Here Author Rachel Reiland is
typical of a BP with overlapping characteristics. When she insinuated she was going to shoot herself, her psychiatrist admitted her to a psychiatric hospital. Yet she held a job as a full-time
mother and was active in church. Although she acted out toward her husband and psychiatrist, she was able to appear non-disordered toward most people outside her family.
Summary chart:
Mostly Lower-Functioning Conventional BPs
Coping Techniques

Acting in: Mostly self-?destructive acts such as self-?harm.

Functioning

Low functioning: BPD and associated conditions make it difficult

to live independently, hold a job, manage finances, and so on.
Families often step in to help.

Willingness to Obtain
Help
Co-occurring
(Concurrent) Mental
Health Issues
Impact on Family
Members

Mostly Higher-Functioning Invisible BPs

Acting out: Uncontrolled and impulsive rages, criticism, and blame. These may result less from a lack of
interpersonal skills than from an unconscious projection of their own pain onto others.
High functioning: The BP appears normal, even charismatic, but exhibits BPD traits behind closed
doors. Has a career and may be successful.

Self-?harm and suicidal tendencies often bring these BPs into

the mental health system (both as inpatients and outpatients).
High interest in therapy.

A state of denial much like an untreated alcoholic. The BP disavows responsibility for relationship
difficulties, refuses treatment; when confronted, he or she accuses others of having BPD. May see a
therapist if threatened, but rarely takes it seriously or stays long.

Mental conditions such as bipolar and eating disorders require

medical intervention and contribute to low functioning.

Concurrent illness most commonly a substance use disorder or another personality dis?order,
especially narcissistic personality disorder.

The major family focus is on practical issues such as finding

treatment, ?preventing/
reducing BP's self-?destructive behavior, and providing practical
and emotional support. Parents feel extreme guilt and are
emotionally overwhelmed.

Without the diagnosis of an obvious illness for the BP, family members blame themselves and try to get
their emotional needs met. They make fruitless efforts to persuade their BP to get professional help.
Major issues include high-?conflict divorce and custody cases.

(From The Essential Family Guide to Borderline Personality Disorder by Randi Kreger.)

Can you give me some quick statistics and an overview of borderline personality disorder?

Some of these statistics, provided by the National Education Association for Borderline Personality Disorder , were derived through research of borderline individuals within the mental
health system or other institutions. It does not include the hundreds of thousands (probably millions) who do not seek treatment and are a large focus of Randi Kreger's books.

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Prevalence in Adults

Officially, four million American individuals have BPD (2 percent of the general public). Cutting-edge research is showing that it is much higher: 5.9 percent equally divided between
men and women.
BPD is more common than schizophrenia.

BPD is twice as common as the eating disorder anorexia.

Twenty percent of people with psychiatric hospital admissions have BPD (more than for major depression).
Suicide and Self-Injury

Ten percent of adults with BPD commit suicide.

A person with BPD has a suicide rate 400 times greater than the general public.
Thirty-three percent of youth who commit suicide have features of BPD.
Treatment Challenges

No FDA-approved medication exists for BPD (although many medications are used to treat the symptoms).
BPD can co-occur with other illnesses. Most people with BPD also have depression.

An overwhelming number of clinicians do not have the training or experience to effectively treat those with the disorder. Research-based therapies for BPD are not widely available
and are only appropriate for a subsection of those with the disorder. Eighty percent of psychiatric nurses believe that people with BPD receive inadequate care.
A thirty-year-old woman with BPD typically has the medical profile of a woman in her sixties.
Economic Impact

Up to 40 percent of high users of mental health services have BPD.

More than 50 percent of individuals with BPD are severely impaired in employability, with a resulting burden on Supplemental Security Income (SSI), Social Security Disability
Insurance (SSDI), and Medicaid and Medicare.
Twelve percent of men and 28 percent of women in prison have BPD.

(From The Essential Family Guide to Borderline Personality Disorder by Randi Kreger.)

What is borderline personality disorder?

According to the National Institute of Health, people with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their
attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an
immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of
not caring for them at all.
With family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in
plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD
feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

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People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar
disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
People with BPD come in two commonly overlapping categories, and which type you're dealing with determines which struggles you will likely face. To be flip about it, individuals in the
first category seek therapy and individuals in the second category provoke others to seek therapy.

I was told that my family member didn't have BPD because she isn't suicidal and doesn't self harm. Does every person with BPD do those
things?

No! BPs come in two overlapping flavors, and which type you're dealing with determines which struggles you will likely face, including suicidal and self-harming behavior. See this section
about the overlapping two types of BPD.

Can children and adolescents have borderline personality disorder?

The new DSM-IV-TR guidelines say yes. Read this guest blog post in Randi Kreger's blog Stop Walking on Eggshells at Psychology Today.

What is narcissistic personality disorder?

Traits may include the following. Starred traits may overlap with other cluster B disorders:
Self-absorbed and indifferent to the needs of others **
Believe they are superior to others

Very charming, exciting, and persuasive **

Lack of empathy for others (although they may mouth the customary words)
High sensitivity to criticism or perceived insults **
Fear of being seen as inferior or helpless **

A sense of entitlement, or the feeling that theyre owed special treatment for no apparent reason
Demanding of attention and admiration

Demeaning and insulting to people closest to them, sometimes in public

Regularly complaining about being a victim and being taken advantage of **

They usually deny responsibility for any of the preceding behaviors. **

A common BPD trait is impulsive aggression (the border-lion). What is it?

Impulsive aggression is widely acknowledged by Larry J. Siever, MD, professor of psychiatry at Mount Sinai School of Medicine, and others as a core feature of BPD that can be triggered
by immediate threats of rejection or abandonment paired with frustration. Impulsive aggression:

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Comprises verbal hostility, physical hostility, or both, with the purpose of hurting another person or self

Can be turned outward, (such as outbursts, rages, hitting objects, or violence toward others) or inward (such as suicide attempts or self-injury).
Is impulsive, unplanned, and reckless (that is, the person gives no thought to the consequences of his actions)

Is linked to several BPD traits, including rage, emotional instability, impulsivity, suicidal thoughts, and self-injury

Is associated with a biological tug-of-war between the logical and emotional aspects of the brain, in which the logical side loses. These aggressive tendencies can be inherited.
Is not exclusive to BPD, but a component of several impulse control disorders such as intermittent explosive disorder

Think of impulsive aggression as a border-lion, a ferocious beast that is uncaged when BPs emotions are so strong and overwhelming they can no longer be contained. The border-lion
also protects the vulnerable child inside the BP.

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