Brenda was having excessive panic attacks. The attacks were intense, erratic, and debilitating. They lasted anywhere from brief seconds to a longer incredulous 30 minutes. Worse yet, they came out of nowhere with unknown causes or triggers which kept her from fully functioning at home, work, and socially. She was embarrassed, ashamed, and defeated by the attacks. A normally social person, Brenda found herself withdrawing from the people and things she loved the most as her fear of the panic attacks worsened.
Her predicament was strange because Brenda was a lovely person with a friendly personality and these attacks were so contrary to her nature. She was able to converse with a wide variety of people and unusually comfortable in new environments. She was engaging, delightful, and pleasant to be around making these panic attacks that much more out of the ordinary. The attacks began when she was a teenager and had been getting progressively worse as she aged. To the point that now well into her 30’s, she was unable to hold down a job for longer than a few months, her marriage was on the brinks, and she had few if any friends left.
After ruling out several disorders and medical conditions, Brenda was diagnosed with Borderline Personality Disorder (BPD). But on the surface, she did not look like a person with BPD. She didn’t have emotional outbursts, didn’t openly display any fear of abandonment, never made a suicide attempt, and had a long-term relationship with her husband. However, these symptoms did manifest internally, not overtly or externally.
Brenda did not have typical overt BPD which is obvious and easily demonstrated by behavior, mood, and affect but rather it’s quieter version of covert BPD. It helps to think of overt behavior as an outward appearance. Just by looking at a person, several observations can be made about them based on their façade. But their inward character is not revealed until later when a person talks, acts or interacts with others. This is the covert part. Sometimes external parts of a person are a direct reflection of the internal person and sometimes it is not.
Using the DSM-5 explanation of BPD, here is how the covert side manifested in Brenda.
- Frantic efforts to avoid abandonment. For Brenda, this meant that despite any turmoil in her relationship with her husband, she would not leave. She already felt abandoned by both her parents and formed a strong attachment onto her husband at a young age. So regardless of the state of their marriage, she was not leaving.
- Unstable and intense relationships. This predominately showed up in her relationship with her mother who was verbally abusive. She would set a distance boundary based on the latest text message from her mom and then a couple of weeks later engage and go shopping with her as if nothing happened. Her fear of appearing to “needy” meant that when she felt rejected, she internalized it instead of expressing it.
- Unstable self-image. When Brenda was a young child, she was put in numerous beauty contests by her mother. This environment is a breeding ground for unhealthy body image. Brenda learned that if her external looked good, she didn’t need to tend to her internal emotions. This caused years of stored-up anger, grief, shame, guilt, and sadness.
- Impulsivity and self-damaging behavior. Brenda admitted to several unhealthy patterns in her life including alcoholism, drug use, overspending, skin picking, cutting, and binge eating. Not all of these behaviors would appear at the same time, rather they seemed to shift from one to another. When she stopped using drugs, she would turn to excessive spending. When she would stop picking at her skin, she would transfer to binge eating. The constant shifting makes it difficult to pinpoint consistent self-damaging behavior.
- Recurrent suicidal behavior. On the surface, Brenda did not appear suicidal and indicated that she had no desire to harm herself in that manner. However, her excessive drug use at times which led to overdosing masked an unintentional suicide attempt. Over the years her self-damaging behaviors were so intense and pervasive that it was a type of unconscious suicide threat or attempt.
- Intense anxiety, dysphoria, or irritability. Brenda was taught as a young child that any uncomfortable feelings of anxiety, irritability, or uneasiness were inappropriate and wrong. As such, she was not allowed to show these feelings and therefore learned to internalize them. The result was the panic attacks that she experienced. The consequences of this also manifested in abdominal problems as an adult.
- Chronic feelings of emptiness. Even when things were going well for Brenda, she continually felt unsatisfied. This sometimes led her to “bring others down” in an attempt to fully communicate her feelings of emptiness. However, the resistance from her family and her husband was so bad that she chose to isolate and hide instead.
- Inappropriate, intense anger. Brenda reported very few feelings of intense anger. It wasn’t that she didn’t feel the feeling, it was because she was programmed at a young age never to express it. The suppression of anger over the years mounted and on occasion, she would erupt like a volcano. Embarrassed and ashamed of her reaction, she would retreat and overeat to self-soothe.
- Paranoid ideation. Just going through the process of getting a diagnosis was so terrifying for Brenda that she gave-up and restarted several times. Her thoughts easily bordered on paranoia as she was afraid of what her family would say, what others would think of her and that ultimately, she would be abandoned.
- Dissociative symptoms. Brenda reported “zoning out” and seeing herself from the outside looking in. This is a common explanation of a dissociative event. This often happened just before the panic attacks and following them. Brenda didn’t report this to anyone prior to the testing because she was afraid that she would appear “crazy”.
As with overt BPD, covert BPD is treatable. Many do better with a combination of therapies including dialectical behavioral therapy, schema therapy, and psychoeducation. For Brenda, just understanding what was happening to her helped to minimize the panic attacks and through therapy, she learned new tools to better cope with her intense internal feelings.