Impulsive Behaviors and Borderline Personality Disorder

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If you have borderline personality disorder (BPD), you may find yourself struggling to manage impulsive behaviors. From making hasty decisions to getting into fights, impulsivity can cause harm to yourself and those around you. In addition to undermining relationships and your overall sense of well-being, impulsive behaviors can also lead to financial and legal harm if left unchecked.

Fortunately, there are treatments that can help bring impulsivity under control, including psychotherapy, mindfulness training. and pharmaceutical drugs.

Understanding Impulsivity

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), impulsive behaviors are a hallmark of BPD. Impulsivity is broadly defined as actions without foresight that are poorly conceived, prematurely expressed, unnecessarily risky, and inappropriate to the situation. Impulsivity is associated with undesirable, rather than desirable, outcomes.

People who are impulsive are commonly described as being rash, hot-headed, unpredictable, or unstable. It is, in fact, the instability that best characterizes BPD as a disorder.

People with BPD typically suffer from feelings of inadequacy that manifest with unstable emotions, unstable behaviors, and unstable relationships. They are quick to lash out at anything considered a slight and will often fail to recognize how those emotions are unreasonable or excessive.

In psychological terms, impulsive behaviors are inherently inappropriate either in terms of scale or potential risk. A person with BPD is less likely to take into account potential consequences and will often turn to self-harm behaviors (like binge eating or excessive drinking) as a means to cope.

However, impulsive behaviors are not, in and of themselves, diagnostic of BPD. It only when the behavior is pervasive, detrimental, and interferes with a person's ability to function normally that BPD may be considered.

Impulsivity should not be confused with a compulsion, in which a person recognizes the behavior is abnormal but cannot stop it. With impulsivity, the person will act out without inherently recognizing that the behavior is abnormal.

Examples

There are many different types of behavior that can become impulsive with BPD; each situation is different. There are, however, themes and scenarios that are common among people with BPD:

  • Oversharing of emotions
  • Overspending
  • Over-apologizing
  • Quitting a job suddenly
  • Frequent emotional outbursts
  • Meaningless or risky sex
  • Joining and quitting a lot of groups
  • Jumping to conclusions
  • Clearing out belongings to "start anew"
  • Constantly "turning over a new leaf"
  • Abruptly changing or canceling plans
  • Inability to receive criticism without affront
  • Binge eating or drinking
  • Threatening to harm others
  • Self-harm
  • Self-mutilation
  • Destroying property
  • Escalating confrontations
  • Physical violence

Causes

No one can say for sure what causes BPD and, more specifically, what causes impulsivity in BPD. There is some evidence that BPD is triggered by post-traumatic stress disorder (PTSD), particularly if the trauma occurred in childhood.

Studies into behaviors in twins have suggested that genetics may play a larger role in BPD than imagined. It is believed that a genetic error on chromosome 9 may be linked to features of BPD, including the partial inheritability of impulsive aggression.

Mutations like these may alter the otherwise normal production of serotonin and dopamine, the neurotransmitters associated with mood and cognition. In people with BPD, impulsivity may also be closely tied to dopamine receptors on the brain itself, according to research from Vanderbilt University.

If these receptors are impaired, particularly on the frontal lobe of the brain where logical decisions are made, a person may have less capacity to "think things through" before acting.

The same faulty receptors may explain why people with BPD often have feelings of emptiness and self-loathing characteristic of depression. Without the means to effectively receive and transmit the dopamine signals, a person is less able to achieve self-control or sustain a sense of emotional well-being.

It is this combination of environmental, genetic, and physiological factors that likely create the perfect storm for the development of BPD and BPD-associated impulsivity.

Diagnosis

No single test can confirm whether your impulsive behavior is the result of BPD or some other condition. If BPD is suspected, a doctor will perform a psychological exam to determine whether the body of symptoms are consistent with BPD as outlined in the DSM-5.

To this end, a person must meet the two major diagnostic criteria for the disorder:

  1. An impairment of personality functioning, either in terms of poor self-image and self-criticism or instability of goals, aspirations, values, or career plans
  2. An impairment of interpersonal functioning, either in terms of a lack of empathy (due to negative attitudes and hypersensitivity) or the inability to sustain intimacy (due to mistrust, neediness, or the fear of abandonment)

Both criteria must be met to be diagnosed with BPD. It is a complicated process requiring clinical expertise and one that is prone to misdiagnosis. To avoid this, all other possible causes must be explored and excluded, both psychological and physical.

Differential Diagnoses

Impulsive behaviors are not exclusive to BPD. They are also associated with bipolar mania, often in tandem with grandiosity and a flight of ideas. During an acute manic episode, a person will often act impulsivity with little thought of the consequence. Spending sprees and hypersexual behaviors are two common examples of impulsivity related to bipolar disorder (BD).

Attention-deficit hyperactivity disorder (ADHD) can also manifest with impulsiveness. Known as hyperactive-impulsive ADHD, the behavior is spurred by the child's inability to keep still or control inappropriate behavior. It is this lack of control, combined with a constantly shifting focus of interest, that spurs impulsivity.

A similar thing occurs with substance abuse disorders, although the impulsiveness is typically exhibited under the influence of drugs, when craving drugs, or when actively seeking drugs.

Antisocial personality disorder (ASPD) is closely aligned with BPD but differs in that there is a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others.

With borderline personality disorder, a person will have extreme emotions that they find hard to control. With antisocial personality disorder, there will be a marked lack of emotions.

Physical causes of impulsivity may include an acquired brain injury or a neurodegenerative disease like Alzheimer's disease or Huntington's disease.

Treatment

While impulsive behaviors can be severe and pervasive, these symptoms can often be successfully managed with treatment. Many treatments for BPD have components that specifically target impulsivity.

Dialectical behavior therapy (DBT) focuses on building skills that reduce your impulsive behaviors and increase your ability to think and reflect before acting. By using coping mechanisms to handle intense emotions, a person with BPD is better equipped to face situations without confrontation.

Mindfulness, a skill taught in DBT, encourages you to stay in the moment. This can help you to remain more aware of your actions so you take the time to consider consequences. Practicing this technique can help you to take the time needed to reflect on your options, empowering you to make more rational decisions about how to respond to events around you. Mindfulness meditation is a modality often used to support the training.

Medications like a selective serotonin reuptake inhibitor (SSRI) sometimes combined with a low dose of an antipsychotic may also help. This is especially true if your behavior is extreme and poses a risk to your safety or those around you.

There are a number of drugs that specifically treat impulsive behaviors. Among the atypical antipsychotics, Abilify (aripiprazole) is seen to reduce interpersonal problems and impulsivity. Among the mood stabilizers, Lamictal (lamotrigine) may help reduce impulsivity and anger, while Topamax (topiramate) may ameliorate impulsivity, anger, and anxiety.

Medications are most effective when used in conjunction with psychotherapy with a therapist who specializes in BPD.

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