Borderline personality disorder (BPD) is a serious mental health condition that causes patients to have unstable personal relationships, intense anger, emotional emptiness and fears of abandonment. About 2 percent of the general population has BPD, according to the American Psychiatric Association (APA). However, this is based on limited information.
Borderline personality gets its name from an earlier belief that the disorder shared characteristics of psychotic and neurotic (disturbed mental health) conditions. However, experts no longer view this definition as accurate. Instead, patients with BPD are said to have a problem regulating emotions, and are in a constant state of emotional turmoil. They may be calm and rational for long periods of time before experiencing sudden feelings of rage.
People with BPD sometimes view themselves as bad or unworthy, and tend to see themselves as misunderstood or mistreated. They may deny responsibility for their feelings and actions by using defense mechanisms such as “splitting.” During splitting patients elevate some people in their lives to a high status while totally devaluing others. Patients may also use a defense mechanism called “projective identification,” in which they deny their own feelings and instead attribute them to someone else.
BPD affects people of all ages, but most often is diagnosed in adolescents and young adults. Women are far more likely to be diagnosed with BPD than men, and account for 75 percent of all cases, according to the APA.
People with BPD often show a lifelong tendency toward impulsiveness, strong emotions and intense relationships. In many cases, BPD that develops during young adulthood gradually diminishes as patients grow older. Greater stability frequently begins to appear in a patient’s 30s or 40s, particularly in those who seek treatment.
Many other mental health disorders are associated with BPD, particularly mood disorders (e.g., major depression, bipolar disorder).
- Anxiety disorders (e.g., post-traumatic stress disorder)
- Substance abuse
- Other personality disorders
- Attention deficit hyperactivity disorder(ADHD)
The cause of borderline personality disorder (BPD) remains unclear. The disorder appears to have a genetic component because BPD is about five times more common in people who have a family medical history of the disorder. In addition, scientists believe that chemical imbalances in the brain and other biological factors may play a role in the disorder. For example, research has revealed that people prone to impulsive aggressiveness – such as appears in emotional outbursts associated with BPD – may have impaired neural circuits in the brain. These impairments may leave the person unable to properly control behavior and emotions.
Some experts also believe that abuse, neglect or other childhood traumas may lay the groundwork for the development of BPD. For example, 40 to 71 percent of BPD patients report having been sexually abused, according to the National Institute of Mental Health. According to this theory, events later in life trigger the onset of BPD in adults who experienced this type of stress as children. Personal histories of neglect, hostile conflict, and early parental loss or separation are closely associated with BPD later in life. Children who have head injuries also appear to have a greater risk of developing BPD.
Unlike other mental health disorders that cause symptoms for long periods of time, patients with borderline personality disorder (BPD) typically experience their symptoms in intense bouts that last from just a few hours to weeks or months. Patients with BPD may share characteristics associated with other mental disorders, including other personality disorders, anxiety disorders and schizophrenia. They have great difficulty controlling emotions and impulses and may experience frequent mood swings. Because their emotions are so unstable, they may experience disruptions in family, work life and long-term planning.
The instability associated with BPD may also disrupt the patient’s sense of self-identity. Marked impulsiveness is a hallmark of the disorder, and it is not unusual for people with BPD to suddenly shift their goals, values and opinions. They also may alter plans regarding their career or type of friends. Patients with BPD have a habit of undermining their efforts just as they are about to reach a goal. For example, they may drop out of school before graduating or quit therapy after making substantial progress. Patients with BPD may engage in risky behaviors, such as excessive spending, binge eating and unsafe sex.
People with BPD desperately need love and fear abandonment, but their regular, explosive mood changes make it difficult to maintain close relationships. They often have intense and stormy relationships in which they initially idealize potential caregivers and lovers, sharing intimate details of their lives early in the relationship. However, this may change quickly later on, and the patient tends to believe their loved one does not care enough about them. For example, a person with BPD may take a spouse’s late arrival for a prearranged meeting as a sign of the spouse’s abandonment. This may send the patient into rage or despair. The belief that the patient may have been abandoned can lead to dramatic shifts in self-image, thought, emotions and behavior.
When people with BPD feel isolated, they may undertake extreme efforts to avoid being alone. Patients with BPD can engage in self-destructive behavior, particularly when feeling abandoned. They have high rates of self-injury, such as cutting or burning themselves, though whether these are true attempts at suicide is still uncertain. Severe cases of BPD result in significant rates of suicide attempts and completed suicide.
- Extreme sarcasm, bitterness and verbal outbursts, followed by periods of guilt
- Intense anger, including physical fights
- Chronic emotional numbness
- Fears of being alone
- Periods of paranoia
- Symptoms that resemble psychosis (e.g., hallucinations) during periods of stress
Borderline personality disorder (BPD) may not be immediately apparent to patients that have the disorder or to their physicians. Instead, patients may seek help because they are troubled by a pattern of unstable relationships or feeling of anger or emptiness. It is even more likely that someone close to the patient – such as a family member or friend – will recommend that the patient seek help for behaviors related to these feelings.
Before diagnosing BPD, a physician will first compile a thorough medical history. A physical examination will be performed to make sure there is no other potential cause for a patient’s symptoms (although this is rare).
- Do they feel intense fear of abandonment?
- Do they have a pattern of unstable relationships?
- Does their self-image regularly shift?
- Do they engage in impulsive, destructive behaviors?
- Do they have a tendency toward self-mutilation or suicide?
- Do they experience wide mood swings?
BPD may be diagnosed when an individual has a lengthy pattern of instability in interpersonal relationships, self-image and feelings or emotions. These patterns are accompanied by distinctly impulsive behavior beginning in early adulthood.
In addition, five or more of the following characteristics should be present in a patient diagnosed with BPD:
- Frantic attempts to avoid real or imagined abandonment.
- Pattern of unstable, intense relationships in which the patient alternates between idealizing and devaluing the other person.
- Markedly and persistently unstable self-image.
- Impulsiveness in at least two areas of life that may be potentially self-damaging. Examples include spending, sex, substance abuse, reckless driving and binge eating.
- Recurrent suicidal behavior, gestures, threats or self-mutilating behaviors (e.g., cutting, burning).
- Unstable feelings and emotions that are characterized by mood swings.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Stress-related episodes of paranoia or symptoms of extreme dissociation.
If a primary care physician suspects that BPD is present, the patient will likely be referred to a mental healthcare physician, such as psychiatrist, or some other type of mental health professional to confirm diagnosis and provide appropriate treatment. In most cases, physicians are reluctant to diagnose borderline personality disorder in adolescents, as many young people eventually grow out of symptoms and behaviors associated with BPD.
Treatment for borderline personality disorder (BPD) can be a difficult, ongoing process that lasts years. It usually consists of individual or group psychotherapy and use of medications.
In recent years, a form of cognitive behavior therapy known as dialectical behavior therapy (DBT) was developed to treat BPD. This form of therapy concentrates on a patient’s internal experiences and their relationships to other people, and examines self-destructive behavior patterns. Patients are encouraged to learn new coping skills that can help them gain better control of their behaviors and emotions.
Some patients may also benefit from using certain types of medication. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are most often prescribed for patients with BPD. In some cases, monoamine oxidase inhibitors (MAOIs) may be used as a form of therapy.
- Antipsychotics (e.g., haloperidol). Medications that are used to treat psychoses such as schizophrenia.
- Lithium. A chemical element used to stabilize fluctuating moods (mood stabilizer).
- Anticonvulsants. Used primarily to prevent seizures, these drugs may also reduce depression and act as mood stabilizers.
Severe cases of BPD may require hospitalization. Approximately 20 percent of all psychiatric hospitalizations are related to BPD, according to the National Institute of Mental Health.
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or mental health professional the following questions related to borderline personality disorder (BPD):
- What symptoms indicate that I might have BPD?
- How do I know these symptoms are not due to another condition?
- How will you diagnose my suspected BPD?
- Is there anything that may have caused me to develop BPD?
- What are my treatment options?
- Will medication help me? If so, what will you prescribe?
- Should I engage in group therapy for the condition?
- Am I at risk of harming myself or others?
- Will I have BPD my whole life?
- What symptoms indicate the need for immediate medical help?
- Will my children be at higher risk for this mental health condition?
The borderline personality tends to be in a constant state of turmoil. There appears to be a constant and intense quest for support, security and love in their relationships. Complications occur when there is separation from, abandonment by, or disapproval from another person. Coexisting substance abuse, eating disorders, and promiscuity can all lead to complications in the course of the disorder. Other psychiatric disorders associated with the disorder and occurring along with the personality disorder will complicate the course, prognosis and outcome.
Borderline personality disorder has successful outcomes as long as treatment is initiated and maintained. In this scenario, psychotherapy and pharmacotherapy may allow the individual to maintain relationships. Without treatment, the course is usually chronic and the prognosis is poor.
Borderline personality disorder may be thought of as an extreme extension of less severe personality disorders (dependent, histrionic, passive-aggressive, or schizotypical). Associated Axis I disorders include generalized anxiety disorder, panic disorder, brief reactive psychosis, major depression and schizo-affective disorder.
Psychiatrist or psychologist.