High-Functioning BPD: Definition, Symptoms, & Treatments

What Is High-Functioning Borderline Personality Disorder (BPD)?

The non-official subtype of “high-functioning BPD”, sometimes called “quiet BPD”,  describes someone whose symptoms of BPD are typically well-managed. Borderline personality disorder (BPD) involves a pervasive pattern of impulsivity and instability of interpersonal relationships, self-image, and affect. However, these symptoms are typically less observable in those with high-functioning BPD.^1,2 These individuals are more likely to internalize their distress than they are to present extreme outbursts of anger, observable mood swings, and suicide attempts, which are more characteristic of low-functioning BPD.

In this case, high-functioning refers both to one’s ability to navigate their life fairly effectively (for example, without constantly losing jobs and burning bridges), as well as to their quieter symptom expression. “Quieter” doesn’t necessarily mean the person isn’t suffering or in pain; rather, this refers to a tendency to direct emotions and behaviors inward, such as through self-criticism or rumination. A person with high-functioning BPD may be perceived by others as emotionally stable, which may or may not be the case.³ Compared with those with low-functioning BPD who tend to be under-controlled and dysregulated, those with high-functioning BPD are more likely to exhibit overcontrolled tendencies.

High-Functioning BPD Symptoms

Those experiencing high-functioning BPD often alternate between pushing people away and pulling them in closer, and may similarly fall into patterns of idealizing and then devaluing others. They tend to exhibit quick switches in emotions, such as going from very happy to very irritated. What others see may not accurately reflect what a person is truly feeling. While someone with high-functioning BPD may feel intense anger suddenly, their frustration may display as one appearing tired and in need of some time alone.

High-functioning BPD tends to leave a person feeling chronic emptiness, uncertainty about their identity, insecurity, and dissatisfaction with themself. Someone experiencing the disorder may ruminate, fear rejection, or perseverate on things they wish they never said (or should have said).

In relationships, the extreme emotions and unstable moods characteristic of high-functioning BPD may lead partners to feel confused. It can seem as though nothing they do or say is enough, or like they are being depended on for too much. Partners may at first tolerate the hot-and-cold nature of someone with BPD but ultimately decide that this behavior is not conducive to a healthy, nurturing relationship. At school and work, those with high-functioning BPD may set high expectations of themselves. When these expectations are inevitably not met or one receives constructive criticism, one may experience helplessness and self-criticism.

Signs of high-functioning BPD may include:

• Depression
• Feelings of emptiness
• Difficulty setting and observing healthy boundaries
• Unstable sense of self
• Fear of rejection
• Self-harm and suicidality
• Dependency in relationships
• Isolation and social withdrawal
• Self-destructive tendencies
• Internalized intense emotions such as anger, loneliness, anxiety, guilt, and shame
• Rumination

High-Functioning BPD Causes

Just like there is no singular cause for severe BPD symptoms, there is likely not a singular pathway for developing high-functioning BPD. Generally, persons with BPD have suffered with instability and trauma in their childhood.⁴ However, they may still have experienced  positive support or attachments in life. They may have been born with a gentle temperament that has mitigated some of the heightened emotions experienced with BPD. Additionally, there may be a level of inherent resiliency that has propelled them beyond their symptoms.

It is common for us to hear about those struggling with BPD and their “problems”. However, there may be more persons with BPD that are well-functioning than we think. Across most diagnoses, there is a classification of mild to moderate to severe.⁴ While BPD does not currently have this stratification process in the DSM-5-TR, it may very well be on the horizon as more is understood about “quiet BPD” and high-functioning persons with BPD.

Some potential causes of high-functioning BPD include:

• Genetic factors
• Neurobiological factors
• Presence of support network
• Temperamental factors
• Resiliency
• Engagement in extracurricular activities
• Passion for something outside themselves, such as supporting a cause and/or a talent

Treatment for High-Functioning BPD

Treatment for high-functioning BPD is similar to treatments for moderate to severe BPD. Generally, individual and group therapy are essential to symptom management. Psychotropic medication management can help to alleviate the often identified symptoms of depression, anxiety, and/or anger that emerge from a BPD diagnosis.^2,5

Treatment may look different in terms of the number of therapy sessions per week. For moderate to severe BPD cases there will often be at least 3-4 sessions in a week; with at least one individual session and up to 2-3 group sessions. However, for those with high-functioning BPD, they may only have 2 sessions consisting of individual and group therapy. Additionally, persons with high-functioning BPD may not need to spend time in inpatient care for stabilization.

BPD Therapy Types

Therapeutic interventions for BPD work to mitigate different aspects of the diagnosis. The overall goal is the same across therapy types; symptom reduction and improvements in quality of life. The most beneficial evidence-based  treatment for BPD is dialectical behavior therapy (DBT) which has specific and manualized intervention tactics to target symptom reduction. Most treatments have some similarities to DBT as there is a big emphasis on improving the relationship with self and others.

• Dialectical behavioral therapy (DBT):  Dialectical behavior therapy (DBT) is the treatment of choice for individuals diagnosed with BPD. DBT for BPD is a multi-dimensional treatment approach that involves individual and group therapy, phone coaching in-between sessions, and groups that focus on building skills. These groups focus on improving one’s mindfulness, distress tolerance, emotion regulation, and interpersonal challenges.
• Cognitive behavioral therapy (CBT): CBT for BPD helps people change the way they think about experiences by reframing negative thoughts and behaviors with positive actions. CBT encompasses a wide range of techniques that are helpful for many individuals living with BPD symptoms.
• Schema-focused therapy: Schema-focused therapy helps individuals understand maladaptive schema developed in childhood. This approach can help people identify how their unmet needs can lead to unproductive relationship and behavioral patterns.
• Mentalization-based therapy: Mentalization-based therapy is a highly structured and time-limited methodology with the goal of helping people to understand their feelings and thoughts to create an alternative, healthier perspective.

Coping Strategies for BPD

Coping skills are ways in which we manage and work through stress. These skills are self-generated and self-directed which gives a person a sense of control over their symptoms. Many of the coping strategies for BPD emphasize mindfulness and grounding techniques. These skills help to calm the mind-body and bring the self back into the present moment. Self-soothing is especially important given the main BPD symptoms: emotional dysregulation and low frustration tolerance.

Some helpful coping strategies for BPD include:

• Mindfulness: Mindfulness for BPD is particularly helpful in this case, as it increases one’s awareness of the present moment. This allows someone to identify, label, and separate from their thoughts or emotions, rather than attaching to and building them up internally.
• Grounding: These coping strategies emphasize a person’s sense of control over their physical body, mind, and space. They connect directly to their environment and actively recognize what is real and tangible in a thoughtful way.
• Interpersonal skills: These skills focus on communication, empathy, and developing a mutual understanding of others. Assisting those with BPD to better understand how they may be misinterpreting others.
• Distress tolerance: We all experience distress at certain points. For clients with BPD, distress tolerance skills are meant to build up internal resources in the hope of mitigating self-destructive behaviors.
• Emotional regulation skills: These skills target the extremely high and low emotions experienced by those struggling with BPD. There is often a mixture of breathwork, self-soothing, and building up self-awareness. Self-awareness is accomplished by building up one’s ability to acknowledge emotions, name emotions, and respond to them in an adaptive manner.

Medication

While medications to treat BPD don’t exist, several options can be used to treat its symptoms (such as anxiety and depression) that are often recommended to be used in tandem with psychotherapy.⁴

How to Find a Therapist

Whether you’re searching for a therapist for yourself or a loved one, it’s important to find one who has training and experience working with those diagnosed with BPD. There are online DBT therapy providers for those who prefer telehealth options. A great way to find the right therapist is by searching an online therapist directory, where you can sort by a therapist’s specialty.