Borderline Personality Disorder (BPD) is a mental health condition that causes emotional instability and difficulties with interpersonal relationships. BPD is a complex condition with various 'sub-types; one of these is 'quiet borderline personality disorder'.

Borderline personality disorder sub-types

Recent research suggests that there are sub-categories within a borderline personality disorder diagnosis, each with slightly different presentations, including ‘discouraged’ or ‘quiet’ BPD, which presents as less outwardly expressive, with more internalized emotional dysregulation [1].

This is a fairly new discovery, which hasn’t yet been confirmed or agreed upon in the scientific community, and as such, is not yet deemed an official diagnosis. However, ongoing research is taking place, to help build a bigger picture and clearer understanding of BPD and the varying presentations seen in those with the diagnosis [2][3].

Quiet BPD causes

BPD is diagnosed more in females than males, and typically formed in adolescence, although it can affect any gender or age [4]. The exact cause of BPD is not known, but it is often attributed to childhood experiences of neglect, abandonment, abuse, or trauma. It may also be more likely in those with a close family member with the diagnosis or another mental health condition [5].

Quiet BPD symptoms

Unlike BPD, people with quiet BPD are less likely to express their emotions to those around them. This means that the symptoms of quiet BPD can be very different or may even go unnoticed. However, there are currently no official diagnostic criteria for quiet BPD, so if a person is diagnosed, it will likely be with a BPD diagnosis, with no further subtype categorization.

Symptoms of BPD include:

  • Emotional instability, such as mood swings, intense and uncontrollable anger, or periods of depression and feelings of emptiness.
  • Difficulties maintaining interpersonal relationships, including regularly arguing with friends and partners, or rapidly starting and ending relationships, initially idealizing your friend or partner, but quickly changing your view of them to hatred or resentment.
  • A fear ofrejection or abandonment, sometimes with no reason for this, often believing people are upset or angry with you, or thinking they will leave, resulting in desperate behaviors to keep that person close.
  • Low self-esteem, poor sense of self and self-worth, including a feeling of not really knowing who you are, what you enjoy, or what you believe in, and not knowing if you are ‘good or bad’.
  • Thoughts of self-harm and suicide, regularly engaging in self-harming behaviors and expressing a desire to die.
  • Impulsive or reckless behaviors, such as drug use, promiscuity, unsafe driving, or excessive spending.

These symptoms may still be present in a person with quiet BPD, but they may be less obvious [1][6]. For example, emotional instability may be more internalized or hidden, so others will not see bouts of anger or sadness, but they will likely still be present.

It is likely that they will withdraw from others, particularly when feeling sadness, guilt, or hurt, and choose not to talk to anyone about their feelings. Despite still feeling afraid of abandonment, they will be more likely to end a relationship or friendship if they feel hurt or upset because of that person, rather than confronting them.

People with quiet BPD will be more avoidant of social situations and will likely be dependent on one person, whom they will be very attached to, feeling the need to remain in their company in order to feel less vulnerable.

This lack of outward expression has resulted in this subtype of BPD being known as quiet BPD, which can regularly go unnoticed and undiagnosed, as these people are able to continue functioning in their daily life, at school or work, while hiding their symptoms from others.

Quiet BPD diagnosis

Quiet BPD is not currently an officially recognized diagnosis, so, along with the above-mentioned symptoms, it is a challenge to identify, often resulting in no diagnosis or a misdiagnosis. However, a diagnosis of quiet BPD or BPD will likely result in your doctor suggesting a similar treatment plan, so it is important to be clear about your symptoms when seeking professional help.

A mental health professional will conduct an examination with you to determine a diagnosis, depending on your presenting symptoms and mental health history. They will also ask if any of your family members have experienced mental health conditions.

While aiming to find a specific diagnosis, you will be asked questions based on diagnostic criteria and screening tools, such as the McLean Screening Instrument for BPD (MSI-BPD) [7], the Patient Health Questionnaire-9 (PHQ-9) [8] for depression, and General Anxiety Disorder-7 (GAD-7) [9], to determine the severity of your symptoms.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) [10], compiled by the American Psychiatric Association, informs clinicians of how to determine your diagnosis. Within the DSM-V, it states that for a diagnosis of Borderline Personality Disorder, 5 out of 9 criteria must be present and persistent. These criteria are:

  • Fear of abandonment
  • Unstable relationships
  • Poor sense of self or identity
  • Impulsive and damaging behaviors
  • Self-harm and thoughts of suicide
  • Mood swings
  • Feelings of sadness or worthlessness
  • Intense or uncontrollable anger
  • Paranoia, suspicion, or feeling out of touch with reality

Quiet BPD treatment

Therapy

Research suggests that therapy is the best treatment option for BPD [11][12]. There are many useful types of therapy that can help with managing and improving the symptoms of BPD.

Dialectical Behavioral Therapy (DBT) [13], developed by Dr Marsha Linehan, has been found to be a helpful tool for understanding and communicating about BPD and personal triggers, while learning positive coping strategies to manage the condition.

Similarly, Cognitive Behavioral Therapy (on which DBT is based), is also a useful therapy to aid in the development of positive coping strategies and responses to emotional difficulties.

There are various other types of individual therapy available, as well as family therapy, which can help loved ones develop a better understanding, to receive and provide support; and group therapy, which can help provide a support system and reduce feelings of aloneness.

Therapy can help you to identify your own triggers and to develop an understanding of why these triggers exist. This can be hugely important in managing your symptoms, as you may be able to avoid certain situations that could be triggering, learn how to tolerate emotional distress, and recognize when to utilize your coping strategies.

Medication

There is no specific medication for the treatment of BPD, but you may be prescribed a medication to help you manage certain symptoms of the condition [5]. BPD can be challenging to treat, as it presents differently from person to person, and individuals often have different responses to medications.

Your doctor will decide which symptoms or underlying conditions they can treat with medication and prescribe one or more medications for this treatment. This may include an antidepressant, such as sertraline or fluoxetine; anti-anxiety medication, such as diazepam or lorazepam; a mood stabilizer, such as carbamazepine or lamotrigine; or an antipsychotic, such as aripiprazole or risperidone.

It is important to take your medication exactly as prescribed by your doctor, as missing doses, taking extra, or suddenly stopping or starting a medication can negatively impact your physical and mental health.

Quiet BPD self-care

Calming activities

You might find it useful to develop a plan for when you feel triggered. This could involve moving to a ‘safe space’, putting on music, drawing or coloring, meditating or practicing breathing exercises, reading a book, or utilizing specific DBT techniques you have learnt. These actions could help you to manage your emotions and prevent a worsening of your symptoms.

Exercise

Some people find exercise to be a good release of emotion, or a time to reflect on a situation. For example, team sports, going to the gym, yoga, running, or walking, may all be positive outlets for emotional distress or ways to calm the mind. Engaging in regular exercise can also be a positive way to improve physical and mental health in general, thereby reducing emotional difficulties.

Consistent sleep patterns

Having a consistent sleep cycle can provide huge improvements to your mental well-being. Sleep is mentally and physically restorative, so a lack of sleep can contribute to a worsening of mental health symptoms [14].

Aim to go to sleep and wake up at the same time each day. If you struggle to sleep, you can practice good sleep hygiene, by forming routines for bedtime, avoiding caffeine and TV or phone screens, and doing something to help you wind down before bed, such as reading a book, meditating, or other calming activities.

Avoiding unhealthy coping strategies

It is very common for people with BPD to engage in harmful coping strategies, such as drinking alcohol, taking drugs, smoking, and self-harm [5]. While these activities may blunt or mask emotions in the moment, they are ultimately very harmful to your mental and physical health and will only reinforce and worsen unhelpful or damaging emotional responses.

If you need help reducing or managing substance abuse or self-harming behaviors, speak to your doctor or a mental health professional, who can advise on suitable techniques and organizations to assist you in this.

Quiet BPD v normal BPD: What is the difference?

The main difference between quiet BPD and normal BPD is the way in which symptoms present to others. People with BPD may often experience intense anger, lashing out at those around them, which can greatly impact interpersonal relationships.

People with quiet BPD will often hide their emotions, so they are less likely to have outward bouts of intense anger or sadness. They may be more likely to internalize these feelings, or only express themselves when they are alone. As such, the symptoms of quiet BPD may not be as clear or noticeable, which is why this subtype of the condition is so challenging to identify.

Quiet BPD complications

As there are no official diagnostic criteria for quiet BPD, one of the biggest complications that can occur is a misdiagnosis, or symptoms that go unnoticed for a long time. Without receiving proper treatment, symptoms may worsen and could potentially result in dangerous consequences, such as harm to others, or suicide attempts.

If you or someone you know is experiencing any of the symptoms of quiet BPD or BPD, it is important to seek professional advice and treatment.

Resources:

  1. Millon, T., Millon, C.M., Meagher, S.E., Grossman, S.D., & Ramnath, R. (2004). Personality Disorders in Modern Life, 2nd Edition. Wiley.
  2. Smits, M.L., Feenstra, D.J., Bales, D.L., de Vos, J., Lucas, Z., Verheul, R., & Luyten, P. (2017). Subtypes of Borderline Personality Disorder Patients: A Cluster-Analytic Approach. Borderline Personality Disorder and Emotion Dysregulation, 4, 16. Retrieved from https://doi.org/10.1186/s40479-017-0066-4
  3. Sleuwaegen, E., Claes, L., Luyckx, K., Wilderjans, T., Berens, A., & Sabbe, B. (2018). Do Treatment Outcomes Differ After 3 Months DBT Inpatient Treatment Based on Borderline Personality Disorder Subtypes? Personality and Mental Health, 12(4), 321-333. Retrieved from https://doi.org/10.1002/pmh.1430
  4. The National Alliance on Mental Illness. (Reviewed 2017). Borderline Personality Disorder.NAMI. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Borderline-Personality-Disorder
  5. The National Institute of Mental Health. (Reviewed 2022). Borderline Personality Disorder. NIMH. Retrieved from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder
  6. Duică, L., Antonescu, E., Totan, M., Boța, G., & Silișteanu, S.C. (2022). Borderline Personality Disorder “Discouraged Type”: A Case Report. Medicina,58(2),162. Retrieved from https://doi.org/10.3390/medicina58020162
  7. Zanarini, M.C., Vujanovic, A.A., Parachini, E.A., Boulanger, J.L., Frankenburg, F.R., & Hennen, J. (2003). A Screening Measure for BPD: The Mclean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Journal of Personality Disorders, 17(6), 568-573. https://doi.org/10.1521/pedi.17.6.568.25355
  8. Kroenke, K. & Spitzer, R.L. (2002). The PHQ-9: A New Depression and Diagnostic Severity Measure. Psychiatric Annals, 32, 509-521. https://doi.org/10.3928/0048-5713-20020901-06
  9. Spitzer, R.L., Kroenke, K., Williams, J.B.W., & Löwe, B. (2006). Generalized Anxiety Disorder 7 (GAD-7)[Database record]. APA PsycTests. https://doi.org/10.1037/t02591-000
  10. American Psychiatric Association. (March 2022). Personality Disorders. In The Diagnostic and Statistical Manual of Mental Disorders(5thed., text rev.). APA. Retrieved from https://doi.org/10.1176/appi.books.9780890425787.x18_Personality_Disorders
  11. Choi-Kain, L.W., Finch, E.F., Masland, S.R., Jenkins, J.A., & Unruh, B.T. (2017). What Works in the Treatment of Borderline Personality Disorder. Current Behavioral Neuroscience Reports, 4(1), 21-30. Retrieved from https://doi.org/10.1007/s40473-017-0103-z
  12. May, J.M., Richardi, T.M., & Barth, K.S. (2016). Dialectical Behavior Therapy as Treatment for Borderline Personality Disorder. The Mental Health Clinician, 6(2), 62-67. Retrieved from https://doi.org/10.9740/mhc.2016.03.62
  13. Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
  14. Blackwelder, A., Hoskins, M., & Huber, L. (2021). Effect of Inadequate Sleep on Frequent Mental Distress. Preventing Chronic Disease, 18. Retrievedfrom http://dx.doi.org/10.5888/pcd18.200573