That’s a question frequently asked by people who meet the diagnostic criteria and by people who have a loved one with this confusing mental health condition.

No one is born with borderline personality disorder. Rather, it’s a slow developing and ongoing saga, marked by many challenging episodes that occur well before “full blown” BPD is revealed. And as with any story, there is a beginning.

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The first element in the development of BPD is a genetic variation that expresses itself as a tendency to be highly sensitive. Of course being highly sensitive does not mean a person will develop BPD. Far from it. High sensitivity is related to creativity, empathy and intuitive thinking. But it can have a down side under certain circumstances.

The second element has to do with the way the brain handles emotions. Emotions originate in the oldest part of the brain, the area that interprets sensory information coming in from the outside environment by the eyes, ears, nose and tour. This was a critical function in pre-historic times when surviving an untamed and unpredictable world relied on split second recognition and response to threats, i.e., the ‘fight or flight’ response. No time to think, only to react.

As humans evolved, their brains grew in size and complexity, allowing for more thoughtful consideration before responding to emotions. This newer, more reflective area of the brain- the forebrain- never lost contact with the older reactive area. Emotions sparked deep in the old brain were filtered through the newer areas allowing emotions to be examined and responses contemplated.

Using imaging technology, like MRI’s, researchers have recently discovered that in people who have BPD the emotion generating part of the brain (AKA the amygdala) is structurally different than it is in others and reacts more emotionally to outside stimuli. In addition, the emotion filtering part of the brain (AKA the pre-frontal cortex) isn’t as active in these people. As a result they have difficulty keeping their emotions under control. The combination of highly reactive emotions and an inability to put the brakes on them can nurture the development of BPD over time.

How is that? You might imagine how an emotionally volatile child can have a devastating effect on the family unit, especially if the home environment is not equipped to handle it. Many parent/child interactions, even the most benign, can be interpreted as a personal attack. The child reacts in a dramatically negative way, in turn triggering an elevated response from the parent. These conflicts rarely go well for either the parent – “Why does she behave this way?” or the child -“Why don’t they understand me?”.

In addition, the child never learns to understand or trust their own emotions; often seeing themselves as the source of all the problems. This leads to feelings of shame and guilt, compounding the emotional turmoil and creating an endless cycling of negative emotions.

Then you can add on the ‘normal’ turmoil of the teenage years and the considerable social pressures outside the home. Eventually, the emotional pain becomes unbearable and the young person may take on some of the destructive behaviors and psychological problems associated with BPD- self-harm, impulsive behaviors, relationship problems, depression, anxiety, dissociation and other difficulties.

Family and others don’t appreciate that this emotional pain is every bit as real as physical pain, and often believe all the symptomatic behaviors are intentional, attention seeking and selfish. This only serves to reinforce the cycle of emotions and negative beliefs. It can get so bad that some people conclude that their only course of action to find relief from their pain is to end their life.

You can read about this process in more detail in a paper written by BPD researchers Ryan Carpenter and Timothy Trull.

Of course that’s not the whole saga of BPD. Next time, we’ll look at the other side of the story and talk about how people enmeshed in this emotional quagmire can learn to extract themselves from the pain shame and grief they feel and develop a more positive and productive life.