BPD and Comorbid Anxiety

G. Pacana

2/22/20244 min read

"Fear is more of a present-moment emotional experience. Fear is what you experience when you are actually in a stressful or threatening situation. Anxiety, on the other hand, is more of a future-focused emotion. One emotion is about the anticipation of an event, and the other is about the actual experience of that event.”

― Alexander L. Chapman

Anxiety, a pervasive and often debilitating emotional state, affects millions of individuals worldwide. In psychology, anxiety is defined as an intense feeling of worry, fear, or apprehension that can manifest in various forms, which include generalized anxiety disorder, obsessive-compulsive disorder, social anxiety disorder, and panic disorder. However, within the realm of mental health, it is crucial to recognize anxiety not only as a discrete condition but also as a common symptom or characteristic of borderline personality disorder.

Borderline personality disorder frequently coexists with anxiety disorders, complicating the diagnosis and treatment. While BPD and anxiety are distinct entities, their co-occurrence underscores the complexity of mental health and the nuanced approach required for effective intervention. Research findings consistently highlight the intricate relationship between BPD and anxiety disorders.

Studies have demonstrated a significantly higher prevalence of anxiety disorders among individuals diagnosed with BPD compared to the general population. Furthermore, longitudinal research suggests that the presence of anxiety symptoms in adolescence may increase the risk of developing BPD later in life. These findings underscore the intertwined nature of BPD and anxiety, suggesting shared underlying vulnerabilities.

Anxiety disorders are estimated to be three times more frequent in BPD than in the general population (Silverman et al., 2012), with an estimated lifetime prevalence of 48% for panic disorder, 12% for agoraphobia, 46% for social phobia, 32% for simple phobia, 14% for generalized anxiety disorder (GAD), 16% for obsessive-compulsive disorder (OCD) and 56% for post-traumatic stress disorder (PTSD) (Harned and Valenstein, 2013; Zanarini et al., 1998).

Environmental factors play an important role in shaping the development and expression of both BPD and anxiety. Trauma, and in particular early childhood abuse, neglect, or other adverse experiences, have been identified as a significant environmental risk factor for both BPD and anxiety disorders.

Individuals with a history of trauma may exhibit heightened emotional reactivity, difficulty regulating emotions, and a pervasive sense of fear and hypervigilance—core features of both BPD and anxiety disorders. Additionally, childhood experiences characterized by instability, unpredictability, and invalidation can contribute to the development of maladaptive coping strategies and interpersonal difficulties, further exacerbating symptoms of both BPD and anxiety.

Invalidating environments, where emotions are dismissed, ignored, or criticized, can instill a sense of invalidation and self-doubt, amplifying feelings of anxiety and contributing to the development of BPD traits such as identity disturbance and unstable relationships. Understanding the impact of environmental factors is essential for clinicians to effectively assess and address the complex interplay between BPD and anxiety in their clients.

Common treatment approaches for addressing both BPD and anxiety encompass a multidimensional approach, integrating therapy and medication to address the complex needs of individuals. One of the most widely recognized and empirically supported therapies for BPD is dialectical behavior therapy. Research has shown DBT to be effective in reducing symptoms of both BPD and comorbid anxiety disorders, providing individuals with practical tools to manage intense emotions and navigate challenging interpersonal situations.

Medication can also be a valuable adjunct to psychotherapy in managing symptoms of BPD and anxiety. While no specific medication is approved for treating BPD, certain medications, such as selective serotonin reuptake inhibitors (SSRIs), can be effective in alleviating anxiety in individuals with BPD. In addition, benzodiazepines such as ativan, valium, and clonazapen, while very effective in managing anxiety disorders, are not always recommended for patients with BPD. Some research suggests that benzodiazepines can worsen symptoms of impulsivity and suicidal thoughts, gestures, and behaviors in people with BPD.

In addition to therapy and medication, lifestyle modifications and self-care practices play a crucial role in managing the symptoms of both BPD and anxiety. Individuals with BPD and anxiety can greatly benefit from incorporating healthy lifestyle habits and self-care routines into their daily lives. Regular exercise, such as aerobic activities or yoga, has been shown to reduce symptoms of anxiety and improve overall mood and well-being. Physical activity not only helps to alleviate tension and stress but also promotes the release of endorphins, the body's natural enhancers.

Maintaining a balanced diet and prioritizing adequate sleep are also essential components of self-care for individuals with BPD and anxiety. Nutrient-rich foods and adequate hydration support optimal brain function and mood regulation, while establishing a consistent sleep schedule can help regulate emotions and reduce anxiety levels. Avoiding excessive caffeine and alcohol consumption is also important, as these substances can exacerbate anxiety and interfere with sleep quality.

Engaging in activities that promote relaxation and stress reduction, such as mindfulness meditation, deep breathing exercises, or progressive muscle relaxation, can help individuals with BPD and anxiety manage overwhelming emotions and promote a sense of calmness and centeredness. Building a support network of trusted friends, family members, or support groups can provide invaluable emotional support and validation, helping individuals feel less isolated and more understood in their struggles.

Mental health professionals specializing in BPD recognize the unique challenges posed by the co-occurrence of anxiety symptoms, which often complicate the diagnostic process and treatment planning. Clinicians emphasize the importance of adopting a comprehensive and integrative approach that addresses both the core features of BPD and the associated symptoms of anxiety.

One key insight from mental health professionals is the need for a nuanced understanding of the underlying mechanisms driving anxiety in individuals with BPD. While anxiety may stem from a variety of factors, including biological vulnerabilities, environmental stressors, and maladaptive coping strategies, clinicians emphasize the role of emotional dysregulation and fear of abandonment as central contributors to anxiety in BPD. By addressing these core issues through targeted interventions such as dialectical behavior therapy (DBT) and schema therapy, clinicians can help individuals develop more adaptive coping strategies and reduce the intensity of their anxiety symptoms.

Mental health professionals also emphasize the importance of creating a safe and validating therapeutic environment for individuals with BPD and anxiety. Given the heightened sensitivity to interpersonal cues and the fear of rejection characteristic of BPD, clinicians prioritize building a trusting therapeutic alliance based on empathy, validation, and acceptance. Through collaborative exploration and validation of their experiences, individuals with BPD and anxiety can begin to develop a greater sense of self-compassion and self-acceptance, reducing their vulnerability to anxiety triggers and enhancing their overall well-being.