There are different types of mental health conditions and ways that people can experience mental health issues. Personality disorders can be especially challenging. Unlike conditions such as anxiety and depression, those with personality disorders often do not know that they have these conditions, because it is a part of their “normal” – their reality.
Often, as therapists, we use a person’s own insight into themselves to know more about them and help them get a diagnosis, if needed. But personality disorders can be difficult, because the “symptoms” are not always present, nor is the person always aware of them. In addition, some of the symptoms:
- Manipulation
- Approval Seeking
- Emotional Instability
These are examples of issues that may make it a bit more difficult for a therapist to make a diagnosis and, ultimately, help guide the person get the help they need.
But that doesn’t mean that our therapists cannot do it. It simply means that we have to pay attention to more subtle hints.
An example of this is borderline personality disorder, which we typically refer to as BPD. BPD is a complex mental health condition characterized by emotional instability, impulsive behavior, and difficulty maintaining stable relationships. While BPD can present with obvious symptoms such as self-harm, mood swings, and intense relationship conflicts, many of the signs are more subtle and may not be immediately obvious during a therapy session.
Because BPD symptoms often overlap with other mental health disorders such as depression, anxiety, bipolar disorder, and PTSD – and becomes some complaints made by those with BPD may not tell the whole story, such as issues with intense relationship conflicts – therapists rely on more nuanced behavioral and emotional patterns to make an accurate diagnosis. These subtle hints can emerge over the course of multiple sessions as the therapist builds a deeper understanding of the client’s emotional and relational patterns.
Subtle Hints Therapists May Notice When Assessing for BPD
While no single sign confirms a BPD diagnosis, certain subtle behaviors, emotional responses, and relational patterns may lead a therapist to explore the possibility of BPD more closely. These include, for example:
Inconsistent or Shifting Sense of Self
One of the more subtle signs of BPD is an unstable sense of identity. Unlike more overt symptoms like self-harm or intense mood swings, shifts in identity can be harder to detect without consistent observation.
- The client may describe feeling like a “different person” depending on the situation or who they are around.
- Frequent changes in personal values, goals, career plans, or life direction.
- Adopting personality traits, interests, or even speech patterns from others.
- Struggling to articulate a stable sense of self or identity.
Therapists may notice this instability when the client frequently contradicts themselves or expresses confusion about their personal identity.
Subtle Patterns of Idealization and Devaluation
Clients with BPD often experience rapidly shifting perceptions of other people, but these shifts are not always dramatic.
- Speaking about a friend or romantic partner with intense admiration one session and describing frustration or disappointment the next.
- Alternating between excessive trust and suspicion toward the therapist.
- Expecting constant validation and feeling rejected or abandoned when the therapist sets a boundary or remains neutral.
These patterns of idealization and devaluation are often subtle at first but become more noticeable as therapy progresses.
Hyper-Awareness of Therapist’s Reactions
Clients with BPD often have a heightened sensitivity to perceived rejection or disapproval, even when none is present.
- Closely monitoring the therapist’s tone of voice, body language, or facial expressions.
- Over-interpreting neutral feedback as criticism or disinterest.
- Asking for reassurance about whether the therapist is upset or dissatisfied with them.
- Responding with visible distress when the therapist challenges a thought or behavior.
This sensitivity reflects a deep fear of abandonment, which is a core feature of BPD.
Emotional Intensity That Feels Out of Proportion
While emotional outbursts can be a clear sign of BPD, clients may also express intense emotions in more controlled or subdued ways that are easy to overlook.
- Describing seemingly minor events with exaggerated emotional weight.
- Displaying visible emotional distress (e.g., tearfulness, trembling) even when discussing non-traumatic topics.
- Oscillating between emotional numbness and sudden bursts of emotional intensity.
Therapists may notice that emotional reactions seem inconsistent with the situation or that the client struggles to regulate their emotional state.
Subtle Self-Destructive or Impulsive Behavior
Self-harming behaviors like cutting or substance abuse may be obvious, but more subtle forms of self-destruction or impulsivity can go unnoticed.
- Frequent job changes or unstable work history.
- Financial recklessness (e.g., impulsive spending or gambling).
- Engaging in risky behaviors (e.g., unsafe sex, binge eating) without clear motivation.
- Passive self-harm, such as neglecting self-care or refusing to seek medical help when needed.
Therapists may pick up on patterns of self-sabotage or impulsiveness over time as these behaviors are mentioned in different contexts.
Difficulty Tolerating Ambiguity or Uncertainty
People with BPD often experience distress when they cannot clearly define a situation or relationship.
- Pressing the therapist for definitive answers about their diagnosis or mental state.
- Struggling to cope with uncertainty about relationships or life circumstances.
- Viewing people and situations in black-and-white terms (e.g., someone is “good” or “bad”).
This intolerance for uncertainty often leads to emotional instability and rapid shifts in mood or perception.
Unstable Boundaries in the Therapeutic Relationship
The therapeutic relationship itself can become a subtle diagnostic tool for therapists assessing for BPD.
- Rapidly escalating emotional attachment to the therapist.
- Testing boundaries by contacting the therapist outside of session hours or seeking extra reassurance.
- Reacting strongly to changes in scheduling or therapist availability.
- Expressing feelings of betrayal or abandonment when the therapist sets or reinforces a boundary.
Therapists who notice these patterns often recognize them as a reflection of the client’s broader relational difficulties and emotional dysregulation.
Pattern of Feeling Misunderstood or Alone
Clients with BPD often describe feeling fundamentally misunderstood or emotionally isolated, even when they are surrounded by people.
- Expressing frustration that others “don’t get them” or “can’t handle” their emotions.
- Describing a pattern of intense, short-lived relationships that end with feelings of betrayal or abandonment.
- Frequently feeling emotionally disconnected or “empty.”
Therapists may notice that the client struggles to feel emotionally supported even when others are making an effort to connect with them.
How Therapists Use These Hints in Diagnosis
Diagnosing BPD is rarely based on one or two clear symptoms. Instead, therapists look for patterns of emotional instability, relationship difficulties, identity struggles, and impulsive behavior that emerge over time.
Therapists may suspect BPD when they observe:
- Consistent patterns of emotional intensity and instability across sessions.
- A repeated struggle with interpersonal relationships, including the therapeutic relationship.
- Heightened sensitivity to rejection and perceived abandonment.
- A fragile sense of identity or difficulty defining personal values and goals.
Formal diagnosis typically involves clinical interviews, psychological assessments, and observation of the client’s long-term emotional and behavioral patterns. The therapist also evaluates whether the symptoms meet the official diagnostic criteria outlined in the DSM-5 for BPD.
Why Subtle Signs Matter in Diagnosis
Many individuals with BPD do not immediately present with severe or obvious symptoms. Subtle signs – like emotional intensity, shifting self-image, and interpersonal instability – often surface gradually as the therapeutic relationship deepens.
Recognizing these early patterns allows therapists to:
- Provide targeted, early intervention to improve emotional regulation and coping strategies.
- Develop a therapeutic framework that emphasizes acceptance, emotional stability, and healthy relationship patterns.
- Prevent escalation of more severe symptoms, such as self-harm or suicidal behavior.
While diagnosing BPD requires careful clinical assessment, the subtle hints that emerge in therapy can be a big help. Therapists who recognize these patterns early can guide clients toward evidence-based treatments like Dialectical Behavior Therapy (DBT) and help them build healthier emotional and interpersonal functioning over time.
If you suspect yourself or someone you love may have borderline personality disorder, please reach out to Long Island Counseling Services, today.