The Fire Within: Exploring Rage In Borderline Personality Disorder

Overview

Borderline personality disorder (BPD) is a mental illness associated with unstable emotions and relationships. Once thought of as untreatable, more talking-based therapies have been developed to treat the condition.

A key feature of borderline personality disorder is anger and uncontrollable rage. In this article, we will look at the features of the illness with a focus on the rage and how these might be managed. 

Definition of Borderline Personality Disorder 

Borderline personality disorder (BPD) is a serious mental illness that severely impacts a person’s ability to regulate their emotions. This loss of emotional control can affect the individual's self-image, increase impulsivity and negatively impact their relationships with others. This can also be known as emotionally unstable personality disorder (EUPD).

Incidence of BPD

The estimated prevalence of borderline personality disorder is around 1.6% in the general population.¹ More women than men have five or more diagnostic symptoms of BPD.² 

Emotional dysregulation in BPD

Emotional dysregulation is a mental health symptom that refers to difficulties controlling emotions and how those feelings are acted upon. Emotional dysregulation significantly predicts proneness to aggression and self-harm.³ This is similar to executive dysfunction. 

Causes of BPD

BPD is thought to be caused by many factors. 

Genetics

There is a genetic predisposition to having a diagnosis of BPD. Twin studies have shown over 50% heritability for BPD and this is higher than the heritability of major depression.⁴ 

Environmental factors

Environmental factors that can contribute to the development of BPD include:

• Childhood abuse 
• Maternal separation 
• Poor maternal attachment 
• Inappropriate family boundaries 
• Parental substance abuse
• Parental psychiatric illness¹ 

The number of BPD symptoms is positively associated with not living with a partner, having no paid job, and/or having a comorbid mood, anxiety or substance use disorder.²

Diagnosis of BPD

BPDis usually diagnosed in late adolescence or early adulthood. It is much rarer for a person under 18 years of age to be diagnosed with the condition.

A psychiatrist can diagnose BPD through interviews and discussions of symptoms and other medical or psychiatric history. A medical exam can help rule out other possible causes of symptoms. 

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)  lists ten personality disorders that are divided into clusters A, B, and C. BPD is a cluster B disorder that is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image and behaviour. 

BPD can cause significant distress and is associated with multiple medical and psychiatric co-morbidities such as depression, eating disorders or bipolar disorder.¹ 

Symptoms or behaviours of BPD

• Efforts to avoid real or perceived abandonment, such as plunging headfirst into relationships or ending them quickly
• Intense and unstable relationships with family, friends, and loved ones
• Distorted and unstable self-image or sense of self
• Impulsive and often risky behaviours, such as spending sprees, unsafe sex, substance abuse and reckless driving
• Self-harming behaviour
• Recurring thoughts of suicide
• Mood swings and rage with episodes lasting from a few hours to a few days
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Feelings of dissociation such as feeling detached from oneself

Rage and anger in BPD

Anger and rage are major and potentially destructive features of BPD. Anger is a strong feeling of annoyance, displeasure, or hostility. Rage is defined as uncontrollable/violent anger.

Understanding rage in BPD

Rage is a common feature of BPD and can be triggered by perceived or real threats. This rage and anger can last for variable lengths of time from hours through to days. This rage can be destructive to interpersonal or even professional relationships. Thus, the condition can negatively impact the quality of life. Individuals with BPD are thought to be able to perceive the variability of their angry feelings.⁵ 

Common emotional triggers in BPD

• Fear of abandonment
• Rejection and criticism
• Perceived threats to self-image or identity
• Perceived loss of control in relationships

Impact of BPD on life and relationships

The unpredictable and explosive nature of the rage and anger outbursts in BPD can have extremely detrimental effects on relationships and can lead to relationship breakdowns. It is also conceivable that anger can lead to criminalization due to assaults and impulsivity, especially in men.⁶ The suicide rate in people with BPD is 50 times higher than in the general population.⁷ 

Treatment of BPD

Effective treatments are available to manage the symptoms of BPD. These tend to be therapy or talking-based as there are currently no effective pharmacological treatments for BPD.

Therapies

Dialectical behavioural therapy (DBT)

DBT aims to help individuals with BPD become better at managing their sensitivities and interactions with others by learning skills that enhance mindfulness and enable them to tolerate distress and regulate their emotions. 

Mentalisation-based treatment (MBT)

Mentalisation refers to human beings’ ability to understand the thoughts and feelings in their and others’ minds to understand interpersonal interactions. MBT aims to improve the individual’s ability to mentalize under stress. 

Transference-focused psychotherapy (TFP)

TFP aims to help individuals with BPD achieve more balanced ways of thinking about themselves and others by freely talking about what's on their mind allowing the therapist to link together commonalities

Schema-Focused Therapy (SFT)

SFT is an integrative cognitive therapy focused on facilitating changes to an individual’s personality. Behavioural, cognitive, and experiential techniques used focus on the therapeutic relationship, daily life outside therapy and past traumatic experiences. SFT encourages an attachment between the therapist and patient to challenge negative patterns of thinking, feeling, and behaving and develop healthier alternatives to replace them.

Medications 

Mood stabilisers and antidepressants

There is currently no effective medication for treating  BPD. Some sedatives may be useful on one-off occasions during rage to calm a person. There may be co-existing illnesses such as bipolar disorder, anxiety, or depression and these may need to be treated with medication such as mood stabilisers, antidepressants, or anxiolytics. 

Medications for other illnesses

Many people with BPD may also have a higher rate of co-existing physical illnesses such as musculoskeletal issues, cardiovascular disease, and fibromyalgia.⁸ They also visit their general practitioner more often than the general population and require medication for those illnesses. As a result of these medical issues, people with BPD may be on many other medications, which would need to be accounted for when prescribing psychiatric medication in case of any drug interactions. 

Collaborative approach to treatment

BPD is complex and there must be a collaborative approach between all and any people involved in treatment. There may be people with BPD who have no medical or psychiatric input but there also may equally be people who have input from therapists, psychiatrists, mental health teams, medical teams, and others.  

As BPD affects relationships and everyday life, it is vital that treating clinicians collaborate to provide consistency and build trust with the affected individual. 

Coping strategies for individuals with BPD

There are ways that the individual with BPD can attempt to manage their impulsivity and anger with self-awareness.  

• Grounding exercises
• Relaxation techniques 
• Building emotional regulation skills
• Identifying triggers and early warning signs

Managing anger in the moment

There are ways to help individuals with BPD manage anger at the moment once they have found ways to identify triggers and develop some awareness of their emotions.

• Acknowledge to themselves that they feel angry
• Remove themselves from the triggering situation
• Focus on what is around them
• Focus on their breath
• Use a grounding object

Future directions in research and treatment

There is some evidence that anger/hostility associated with alterations in the prefrontal and subcortical regions of the brain could be a factor explaining aggressive reactions in response to perceived provocation. Findings indicate that proneness to act aggressively may be linked to a reduced ability to differentiate (at a neural and behavioural level) between threatening and non-threatening interpersonal cues. However, this idea needs to be studied further in a large group of individuals across specific personality disorders and genders.⁹ 

Further research in this area may help develop more targeted interventions and treatments to address actual abnormalities that lead to the disturbing features of the condition such as rage. 

FAQs

Can individuals with BPD take specific medication for BPD?

There is no medication specifically for BPD but individuals may be prescribed medications for other illnesses to help manage symptoms

Can BPD be treated?

BPD can be treated with various psychological therapies and self-management of anger and rage, alongside psychiatric medication if a physician deems it necessary

Is BPD dangerous?

BPD is a complicated condition which can increase one’s risk of self-harm and suicide which is why it should be identified and managed as soon as possible. 

Summary

BPD is a complex disorder associated with significant physical and psychiatric comorbidity. It is a treatable condition associated with persistent problems with personal and occupational relationships. These challenges can often be overcome by adopting a collaborative treatment approach and boundary setting.¹⁰

Earlier intervention, focus on functional rehabilitation, and anger management are new directions that hold the potential to curb the detriments of the disorder throughout a patient’s lifetime to enable more stable engagement in the usual life-building activities.¹¹