By addressing sleep disruption—a vulnerability factor for emotion dysregulation and impulsivity—we can reduce the risks of self-harm and suicide for individuals diagnosed with BPD.
by Brian Curtis, PhD, DBSM
For individuals diagnosed with borderline personality disorder (BPD), the relationship between sleep and emotional well-being is particularly pronounced.
Add insomnia and/or recurring nightmares into the mix, and the relationship has life-saving implications.
Emotion regulation difficulties are a hallmark of BPD.
The combination of emotional intensity with a slow return to emotional baseline that individuals with BPD often experience can make adhering to evidence-based recommendations for overcoming chronic sleep disruption, such as Cognitive Behavioral Therapy for Insomnia (CBT-I), uniquely challenging.
The very nature of intense and shifting emotions can complicate efforts to establish a regular sleep-wake pattern that evidence repeatedly suggests is central to our mental and physical health.
When the goal is to improve our sleep, adhering to a routine daily sleep-wake schedule (maintaining a consistent out of bedtime each day in particular) is one of the more powerful tools in the behavioral sleep medicine toolbox.
If a daily diary card is integral to effective Dialectical Behavior Therapy (DBT) for BPD, daily monitoring of sleep-wake behaviors serves as a similar cornerstone for individuals working towards maintaining a consistent sleep pattern.
A routine sleep-wake schedule lends a powerful sense of predictability to our days that can significantly benefit emotional regulation. It also sets the clock of our circadian rhythms and regularizes the buildup of homeostatic sleep pressure so we can fall asleep more easily and wake up less frequently.
Sleep disruption isn't just a minor inconvenience.
For individuals with BPD, ongoing sleep disturbances can intensify emotion dysregulation, potentially escalating impulsive behaviors, including self-harm and suicide.
DBT is unique among cognitive behavioral therapies in its acknowledgement of sleep disruption as a key vulnerability factor for emotion regulation difficulties.
Unfortunately, individuals with BPD and their DBT clinicians are currently left with a one-page sleep hygiene handout and a one-page nightmare protocol handout to address this often-complicated vulnerability factor of sleep.
We need more DBT clinicians competent to assess and treat sleep disruption in the approximately 50% of individuals with BPD struggling with chronic insomnia, recurring nightmares, or both.
Targeting ongoing sleep disruption represents a low-hanging fruit to improve emotion regulation and reduce the risk for suicide for individuals with BPD.
Collaboratively settling on a consistent sleep-wake schedule and monitoring this consistency using a daily sleep diary represents an actionable first step.
Try the following:
1) Choose an ideal bedtime based on your natural waking time and current social commitments.
2) Estimate the total amount of sleep you feel you need to function well during the daytime.
3) Subtract that total sleep time from your out of bedtime each day to get your approximate daily sleep-wake schedule.
For example: You need to be out of bed at 08:00 a.m. each day. You feel you need about 7 hours of total sleep time to function well during the day. Subtracting 7 hours from 08:00 a.m. gives you an approximate bedtime of 01:00 a.m. each day.
Approximate sleep-wake schedule for the upcoming week: 01:00 a.m. to 08:00 a.m.
Start to monitor how effectively you can stick to this sleep-wake schedule for the upcoming week using a daily sleep diary. See if you notice any changes in your emotions, relationships, and overall sense of wellbeing each day.
For bonus points / improved effectiveness: Combine DBT skills of mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation to the evidence-based treatments in behavioral sleep medicine.
If you’ve been diagnosed with BPD and you’re currently struggling with your sleep, please consider asking your therapist or general practitioner for help.
You can find experts in behavioral sleep medicine by visiting the Society of Behavioral Sleep Medicine’s website here.
You can find DBT clinicians here.
You can learn more about the Consensus Sleep Diary for daily monitoring of sleep-wake behaviors here.
Please feel free to email me directly with questions or if I can help in any other way: firstname.lastname@example.org