Quiet BPD: Signs, Symptoms, & Treatments

What Is Quiet Borderline Personality Disorder (BPD)?

Quiet BPD–sometimes referred to as “high-functioning” BPD, Q BPD, or discouraged borderline–is a type of borderline personality disorder (BPD) that involves internalizing the strong emotions associated with general BPD. Individuals direct symptoms toward themselves as opposed to others. These may include feelings of anxiety, sadness, emptiness, intense anger (known as borderline rage), paranoia, or thoughts of self-harm.¹ Although quiet borderline personality disorder is not a recognized mental health diagnosis, it can help professionals quickly explain and understand this cluster of symptoms.

By definition, borderline personality disorder (BPD) is a mental health disorder that usually results in emotional instability and difficulties with overall functioning. Some common signs and symptoms of BPD include intense and unpredictable emotions, impulsivity, urges to self-harm or suicidal ideation/attempts, and unstable self-identity. However, not everyone with BPD will experience the same manifestations and behaviors.¹

Evelyn P. Meier, PhD, Licensed Clinical Psychologist and Director of the Dialectical Behavior Therapy (DBT) Program at Genesee Valley Psychology says, “While Quiet BPD is not an official, diagnosable disorder, it is certainly the case that many folks don’t fit the prototypical BPD mold, yet their suffering is very real. In my experience, these individuals are less likely to meet criteria for uncontrolled anger and aggression. In fact, these folks may be overly passive and people-pleasing, fearful of becoming a burden or taking up too much space.”⁷

Imi Lo, Psychotherapist and Consultant, Eggshell Therapy and Coaching, explains, “People with quiet BPD have an ‘internalized disorder’ rather than the typical ‘externalizing’ tendency of BPD. They may feel intensely lonely, socially isolate themselves, be plagued with self-blame and shame, and dissociate from their feelings. Rather than lashing out, they usually turn anger inward. They may also be socially anxious, assume everything is their fault and feel like they are a burden to others. Just like people with ‘classic’ BPD, they also suffer from fear of abandonment, black-or-white thinking, mood swings, and urges to self-harm.”⁶

Signs & Symptoms of Quiet BPD

While symptoms of quiet borderline personality disorder overlap with other signs and symptoms of BPD, they manifest differently. In typical BPD, a person may show their condition in outwardly powerful ways. Conversely, those with quiet BPD may turn their responses inward. How a person expresses their borderline features will be a unique and individualistic experience.

Common quiet BPD symptoms and signs may include:⁴

• Becoming suddenly quiet and withdrawn
• Feeling any strong emotional expression is wrong, causing shame and guilt
• Extreme people-pleasing
• Engaging in a string of intense and unhealthy relationships
• Constantly feeling one is not good enough for another person
• Fears of abandonment resulting in preemptive termination of a relationship
• Fragile self-esteem
• Feeling numb, cold, empty, or hollow
• Limited interpersonal trust
• Unstable sense of self
• Impulsive or risky behaviors
• Self-harm or suicidal ideation
• Inappropriate displays or outbursts of anger
• Poor emotional regulation
• Temporary dissociative symptoms

Meier further states, “They may be more prone to dissociation or derealization, basically shutting down when emotions become too intense – which makes sense if you believe that you could be harmed or rejected for expressing emotions or needs. They may experience intense fear of abandonment in relationships but rather than pleading, lashing out, or making threats, their responses will be more internal: they may isolate, try to convince themselves not to care about the relationship, or bend over backward to appease the other at the expense of their own needs.”

Kaz J. Nelson, MD, Associate Professor, Department of Psychiatry & Behavioral Sciences at the University of Minnesota Medical School notes, “A person with a ‘quieter’ form of BPD may be experiencing symptoms that seriously interfere with functioning, but might not be as visible to others.” She adds, “On the surface, these symptoms may look like major depressive disorder, or generalized anxiety disorder when the reality is that these symptoms are much more complex to understand and treat. This may lead to undertreatment or ongoing invalidation from others, including care providers, which can worsen feelings of isolation.”⁹

How Is Quiet BPD Diagnosed?

When diagnosing quiet BPD, mental health professionals will focus on identifying the standard borderline personality disorder traits to assess the presence of the condition. There are no quiet borderline personality disorder tests, so clinicians and other professionals will interview to evaluate a person’s experience and point of view. Family members’ opinions are considered if present during diagnostic testing.

Meier mentions, “Mental health providers are more familiar with a version of BPD characterized by intense displays of emotional lability, angry lashing out, and behavioral dyscontrol that is harder to miss. Since “quiet BPD” is not an official, diagnosable disorder and there has been little to no research on it to date, many clinicians are less attuned to the more internalized symptom presentation. Though speculative, these individuals are often misdiagnosed with depression and anxiety, which may also be present, but is not the full picture.”

Lo also notes, “It is difficult to identify and diagnose quiet BPD because people with quiet BPD go at length to hide their pain. They often have an ‘over-control’ tendency rather than an ‘under-control’ tendency, which means they tend to suppress their emotions and needs, diminish their distress, and appear ‘stoic’ about things. They usually come across as quiet and reserved, rarely get excited, and are typically polite, in control, and calm. Even when they are highly anxious, they tend not to let others see it on the outside.”

Causes & Risk Factors of Quiet BPD

A combination of factors could contribute to the development of quiet BPD. BPD may be genetic, as people with a family history of BPD are more likely to acquire it themselves. Biological differences in brain structure and functioning may also cause or trigger quiet BPD.⁴

Those with close family members with BPD who have experienced childhood trauma and frequent conflicts have an increased chance of developing quiet BPD. While certain factors make a person more at risk for BPD, these elements do not guarantee that the condition will develop.

Possible causes and risk factors of quiet BPD include:

• Genetic factors: An interplay of genetic and environmental factors is often associated with BPD. People with a family history of BPD are more likely to acquire it themselves.¹
• History of other mental health disorders: Individuals with borderline personality disorder commonly experience co-occurring conditions, such as depression and bipolar, anxiety, substance, or eating disorders.
• Brain development: Differences in brain regions relating to emotional regulation, impulsive behavior, and aggression may contribute to quiet BPD.¹³
• Serotonin levels: Individuals with BPD may experience dysfunction in serotonin levels, a neurotransmitter that helps regulate mood.¹³
• Childhood trauma: Early trauma can initiate the development of BPD symptoms like mood instability, emotion dysregulation, and self-destructive behaviors.¹⁴ Children who experience multiple traumas over developmental periods are at higher risk for more severe symptoms.¹⁴
• Poor child-caregiver relationships: Insecure attachment with caregivers can lead to a negative self-view, mistrust of others, and fears of abandonment that contribute to unstable relationship patterns.¹⁴

What Can Trigger an Episode of Quiet BPD?

For someone with quiet BPD, intense symptoms may occur when relational challenges arise. Experiencing a loss or rejection can also exacerbate symptoms, especially if a person has not yet developed skills to handle these issues.

Possible triggers of a quiet BPD episode include:

• Relationship challenges: Someone with quiet BPD may feel hopeless and isolated if they experience frequent relational issues.
• Experiencing a loss: If a person does not have distress tolerance skills, they likely have difficulty processing emotions related to a significant loss. They may shut down or dissociate to suppress certain feelings.
• Being rejected: Rejection can bring up shame and self-blame for anyone. However, for someone with quiet BPD, rejection may intensify the anger felt toward themselves.
• Intrusive thoughts: Ruminations or intrusive thoughts can create distressing and intense emotions, such as anxiety, that those with quiet BPD may not have the skills to manage.

Complications Related to Quiet BPD

Personality disorders are so detrimental and complicated because they do not only affect one part of life. Quiet BPD negatively influences every facet of a person’s health and well-being.

Lo adds, “The biggest challenge someone with quiet BPD faces is intense loneliness. They may feel trapped in their predicament. They may feel that something is wrong and long deeply for connection, but feel tied up in their fear of losing control. They may be high-functioning on the surface but feel lost and depressed on the inside.”

Meier also mentions, “In my experience, folks with a more internalized BPD symptom presentation will often appear calm, pleasant, and agreeable. This can mask the emotional storm raging inside and result in invalidation from the environment. They may feel bound to maintain this veneer of composure or risk rejection and abandonment. At the same time, they may feel misunderstood and fraudulent, like no one knows the “real” them – so even positive interactions and relationships can feel suspect and unreliable.”

Common complications related to quiet BPD include:

• Unhappy or inconsistent relationships: For someone struggling with quiet BPD, relationships are often inconsistent due to extreme people-pleasing tendencies, self-blame, or social withdrawal. They often suppress emotions that emerge from interpersonal struggles, so others have little idea of what’s going on. Those with quiet BPD might have a “favorite person” or someone they tend to idealize/devalue.¹²
• Issues forming loving, trusting relationships: Relationships founded on love and trust require equality and mutual respect. When individuals with quiet BPD brush their emotions aside and focus on others, they may end up in unbalanced relationships that lack space for self-respect.
• Substance abuse: Someone with quiet BPD who has difficulty acknowledging and experiencing their emotions may turn to substances to “escape” feeling emotionally over-controlled.
• Troubles with handling hardships: Quiet BPD typically involves emotional avoidance. When challenges in life occur, the negative emotions that arise may be overwhelming and feel like a “meltdown.”
• Risky sexual behaviors: Risky behavior may not feel as “risky” to someone with low self-worth and a tendency to self-blame. These actions may also function as an escape from suppressing emotions.
• Suicidal ideation and attempts: Individuals with quiet BPD may engage in recurrent suicidal behavior, gestures, or threats of self-harm.
• Difficulties expressing emotions: Someone with quiet BPD struggles with experiencing and expressing their emotions. They may be unable to identify what they feel, let alone put words to this.
• Perfectionism: Those with quiet BPD may hold themselves to much higher standards than they hold everyone else too. Doing so can perpetuate a cycle of self-blame and low self-worth.
• Financial instability: Someone with quiet BPD may use impulsive spending to cope, sometimes leading to financial instability.
• General avoidance of relationships: Someone with quiet BPD may withdrawal from relationships altogether. They may feel hopeless or that relationships are not worth any possible suffering.
• Issues with identity and values: Individuals with quiet BPD may feel a sense of emptiness, numbness, or identity disturbance. They may struggle to identify their values because they dissociate from their feelings.
• Other mental health conditions: Those with quiet BPD may be at a higher risk of developing co-occurring depression, anxiety, and eating disorders.

Treatment Options For Quiet BPD

Borderline personality disorder treatments are constantly improving as experts study, research, and implement new strategies. Many people with BPD are well-managed with only individual therapy, while others will benefit from a combination of individual therapy, group therapy, and medication management.

There are many ways to find the right therapist for BPD, and most clinicians have experience treating the condition. People suffering from BPD should inquire about the specific services and interventions used.⁶ You can start your search now by using an online therapist directory.

Dialectical Behavioral Therapy (DBT)

Dialectical behavior therapy for BPD is an evidenced-based treatment that focuses on mindfulness–paying attention to the present moment without pushing it away or attaching to it–and dialectics–the idea that two seemingly opposite things can be simultaneously true.

DBT teaches emotion regulation, distress tolerance, and interpersonal skills to help individuals with quiet BPD change ineffective behavior patterns. It includes individual and group sessions. Patients record their emotions, skills used, and progress in target behaviors using diary cards.

Mentalization-Based Treatment (MBT)

Mentalization-based therapy is a type of psychotherapy that promotes an understanding of how one’s mental state affects their behavior. Mentalization refers to the ability to understand our own thoughts and feelings, as well as the thoughts and feelings of others. MBT for quiet BPD helps clients develop the ability to mentalize, allowing them to regulate emotions and relate to others.¹⁰

Schema Therapy

Schema therapy was developed for personality disorders and treatment-resistant patients with chronic symptoms.¹¹ It draws on other approaches, including cognitive behavioral therapy, and uses experiential techniques to target long-standing and ineffective thinking patterns.¹¹ This approach helps individuals with quiet BPD learn to self-soothe and regulate.

Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy for BPD helps individuals identify and reframe negative thinking patterns and change ineffective behaviors to improve symptoms. CBT focuses on the present, is very structured, and includes homework.

Medications

Medication management can be an important aspect of coping with the symptoms associated with quiet BPD, such as anxiety, depression, and mood instability. Psychiatrists may prescribe antidepressants, anti-anxiety medication, mood stabilizers or antipsychotic medication depending on symptoms.

8 Ways to Cope With Quiet BPD

Personality disorders are pervasive conditions. However, when people put effort and energy into treating their symptoms, their situations can improve.

Here are eight ways to cope with quiet BPD:

1. Be Honest About Your Symptoms & Experience

Dealing with quiet BPD starts with being insightful and clear about your life, relationships, and feelings. Knowing that the issues stem from quiet BPD will help the next steps fall into place.

2. Seek Support From Trusted Loved Ones

Sharing personal struggles can be beneficial especially if you use self-harm to cope with quiet BPD symptoms. Consider reaching out to caring and reliable loved ones willing to provide moral support when feeling internally overwhelmed. Discuss how to connect with them when you’re going through a rough patch. This emotional buffer can be instrumental in stabilizing you mentally and keeping you safe through a crisis.

3. Focus on Physical Health

Physical health and mental wellness are intricately related. Poor health can lead to psychological issues and vice versa. Thus, having good physical health is vital, particularly for people who internalize their stress and frustrations, like in cases of quiet BPD. For this reason, focus on appropriate forms of self-care such as eating nutritiously, engaging in regular physical movement, getting plenty of sleep, attending doctor appointments, and managing stress. Nurturing your physical wellness can keep you balanced and preserve your overall well-being.

4. Take a Relationship Break

Many people with BPD move quickly between relationships hoping to repair the damage of the last, but this pattern only perpetuates problems. If your relationships have been chaotic, take a break to make yourself the priority.

5. Practice Mindfulness

Different therapies often employ mindfulness skills because of their efficacy in calming the mind, regulating emotions, and enhancing overall wellness. Incorporating mindfulness practices can be particularly beneficial in reducing symptoms for those living with quiet BPD. Mindfulness for BPD helps you be fully present in joyful moments and provides mental clarity, emotional stability, and adaptive responses during stressful situations.

6. Check Your Coping Skills

Intense and uncomfortable conditions like Q BPD can result in unhealthy methods of self-medication. Using drugs, drinking alcohol, overspending money, and having casual sex will only provide temporary comfort for a long-term problem.

7. Practice Your Communication

Quiet BPD encourages you to keep feelings inside. Starting to slowly but consistently share your thoughts and feelings can result in excellent results. Initally, journaling offers a safe and subtle way to build your ability to communicate effectively.

8. Talk To Professionals

Managing a personality disorder alone is too much for anyone–call in professionals, therapists, or psychiatrists with experience to lead the way. Coping methods for quiet BPD are endless, so follow your treatment team’s individualized recommendations and suggestions for the best results.

How to Help Someone With Quiet BPD

Chances are you wonder how you can help a friend, family member, or loved one with quiet BPD. Even if you come from a loving place, there is no way to guarantee that someone else is willing or ready to receive help. However, there are ways you can support them without pushing for change, which may come across as invalidating or unsupportive.

Below are some tips for helping someone with quiet BPD:

• Listen to and empathize with them: even if you have never struggled with the same challenges that your loved one is going through, by actively listening and empathizing, you can make them feel less alone and build a connection.
• Validate their experience: Validation can go a long way for someone struggling with mental health. You can validate someone else by being present when they are talking (putting your phone down), reflecting back what they are saying, imagining what they might be feeling, and sharing insight.
• Consider seeking family or couples counseling: Family or couples therapy might be a helpful way for you and your loved one to gain more insight into each other’s experience and improve communication.
• Encourage them to continue treatment: It is normal for someone struggling with quiet BPD to want to quit treatment sometimes. Remaining encouraging and highlighting the progress you see can be a helpful way to support a loved one.
• Celebrate small victories: Change is hard for anyone, especially for someone with deeply-rooted patterns of ineffective behavior. Celebrating the small moments of progress goes a long way–point out that you can see your loved one trying and showing a willingness to heal.
• Maintain your self-care: One of the best ways to stay present for others is to take care of yourself. Taking a break when you feel overwhelmed, scheduling an hour alone to do nothing, or spending time on a hobby you enjoy are all examples of healthy self-care.
• Set boundaries when necessary: Boundaries help us support a loved one through a challenging time without becoming burnt out. These could include compassionately redirecting a loved one to discuss a particular topic with their therapist instead of with you.