What is borderline personality disorder

Borderline personality disorder is a mental illness marked by an ongoing pattern of unstable or turbulent emotions, self-image, and behavior. The core features of borderline personality disorder are intense, uncontrollable emotions, a pattern of troublesome interpersonal relationships, unstable behavior, mood and a disturbed sense of self or identity. People with borderline personality disorder may appear to lead chaotic lives, act impulsively or intentionally harm themselves as a method of coping.

People with borderline personality disorder may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.

Abrupt and extreme mood changes, stormy interpersonal relationships, an unstable and fluctuating self-image, unpredictable and self-destructive actions characterize the person with borderline personality disorder. These individuals generally have great difficulty with their own sense of identity. They often experience the world in extremes, viewing others as either “all good” or “all bad.” A person with borderline personality may form an intense personal attachment with someone only to quickly dissolve it over a perceived slight. Fears of abandonment may lead to an excessive dependency on others. Self-multilation or recurrent suicidal gestures may be used to get attention or manipulate others. Impulsive actions, chronic feelings of boredom or emptiness, and bouts of intense inappropriate anger are other traits of this disorder, which is more common among females.

Borderline personality disorder can be difficult for other people to understand, and people with this disorder are often unfairly stigmatized.

Even the name can be confusing, as it was originally named because the symptoms seemed to be ‘on the border’ between psychotic and neurotic disorders. However, many health professionals agree it needs a more appropriate name.

Personality refers to a distinctive set of traits, behavior styles, and patterns that make up your character or individuality. How you perceive the world, your attitudes, thoughts, and feelings are all part of your personality. People with healthy personalities are able to cope with normal stresses and have no trouble forming relationships with family, friends, and co-workers.

Those who struggle with a personality disorder have great difficulty dealing with other people. They tend to be inflexible, rigid, and unable to respond to the changes and demands of life. Although they feel that their behavior patterns are “normal” or “right,” people with personality disorders tend to have a narrow view of the world and find it difficult to participate in social activities.

In general, someone with a personality disorder will differ significantly from an average person in terms of how he or she thinks, perceives, feels or relates to others.

The symptoms of borderline personality disorder can be grouped into four main areas:

• Emotional instability – the psychological term for this is “affective dysregulation”
• Disturbed patterns of thinking or perception – (“cognitive distortions” or “perceptual distortions”)
• Impulsive behavior
• Intense but unstable relationships with others

The symptoms of a personality disorder may range from mild to severe and usually emerge in adolescence (mid to late teens or in early adulthood), persisting into adulthood. Symptoms may get better after middle age.

Between 2 and 5 per cent of the population are affected by borderline personality disorder at some stage in their lives ¹. Women are 3 times more likely to be diagnosed with borderline personality disorder than men.

The good news is that with treatment and understanding, people with borderline personality disorder can lead fulfilling lives.

• If you or someone you know has or is suspected of having borderline personality disorder, it’s important to seek help. There is a high risk of self-harm and suicide associated with borderline personality disorder, although not everyone with the disorder will harm themselves.

If you or someone you know has borderline personality disorder and exhibits any risk of suicide then seek medical attention urgently. This is a serious situation.

Borderline personality disorder outlook (prognosis)

Outlook of treatment depends on how severe the condition is and whether the person is willing to accept help. With long-term talk therapy, the person often gradually improves.

Borderline personality disorder possible complications

Borderline personality disorder can damage many areas of your life.

Complications may include other mental health disorders, such as:

• Depression
• Drug use
• Problems with work, family, and social relationships
• Suicide attempts and actual suicide
• Alcohol or other substance misuse
• Anxiety disorders
• Eating disorders
• Bipolar disorder
• Post-traumatic stress disorder (PTSD)
• Attention-deficit/hyperactivity disorder (ADHD)
• Other personality disorders

Borderline personality disorder can negatively affect intimate relationships, jobs, school, social activities and self-image, resulting in:

• Repeated job changes or losses
• Not completing an education
• Multiple legal issues, such as jail time
• Conflict-filled relationships, marital stress or divorce
• Self-injury, such as cutting or burning, and frequent hospitalizations
• Involvement in abusive relationships
• Unplanned pregnancies, sexually transmitted infections, motor vehicle accidents and physical fights due to impulsive and risky behavior
• Attempted or completed suicide

Borderline personality disorder criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, is often used by mental health providers to diagnose mental health conditions and by insurance companies to reimburse for treatment.

The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts. Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1) ².

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) . (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline personality disorder causes

As with many personality disorders, the causes of borderline personality disorder aren’t fully understood. However, most professionals think that borderline personality disorder is caused by a combination of things, such as:

• genes past abuse or trauma a dysfunctional family life negative or difficult interactions with others during childhood.
• brain abnormalities. Some research has shown changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.

Keep in mind that not all people who have borderline personality disorder experience these things, just as not everyone will develop borderline personality disorder because of them. It’s different for everyone.

Risk Factors for borderline personality disorder

The cause of borderline personality disorder is not yet clear, but research suggests that genetics, brain structure and function, and environmental, cultural, and social factors play a role, or may increase the risk for developing borderline personality disorder.

• Family History. People who have a close family member, such as a parent or sibling with the disorder may be at higher risk of developing borderline personality disorder.
• Brain Factors. Studies show that people with borderline personality disorder can have structural and functional changes in the brain especially in the areas that control impulses and emotional regulation. But is it not clear whether these changes are risk factors for the disorder, or caused by the disorder.
• Environmental, Cultural, and Social Factors. Many people with borderline personality disorder report experiencing traumatic life events, such as sexual, physical, or emotional abuse, either real or fear of abandonment in childhood or adolescence, or adversity during childhood. Others may have been exposed to disrupted family life, poor communication in the family, unstable, invalidating relationships, and hostile conflicts.

Although these factors may increase a person’s risk, it does not mean that the person will develop borderline personality disorder. Likewise, there may be people without these risk factors who will develop borderline personality disorder in their lifetime.

Borderline personality disorder signs and symptoms

People with borderline personality disorder may experience mood swings and display uncertainty about how they see themselves and their role in the world. As a result, their interests and values can change quickly.

People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their opinions of other people can also change quickly. An individual who is seen as a friend one day may be considered an enemy or traitor the next. These shifting feelings can lead to intense and unstable relationships.

Other signs or symptoms of borderline personality disorder may include:

• Extreme or unstable emotions. Their moods are so intense that they interfere with everyday life. Someone with borderline personality disorder might feel fine one second and then really angry or upset the next.
• Efforts to avoid real or imagined abandonment, such as rapidly initiating intimate (physical or emotional) relationships or cutting off communication with someone in anticipation of being abandoned
• A pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
• Distorted and unstable self-image or sense of self
• Deep insecurity. People with borderline personality disorder often feel like they don’t really know who they are, or what their place in the world is. They might also experience intense fears of abandonment.
• Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating. People with borderline personality disorder will often find it hard not to act on their urges. Alcohol and drug abuse are common symptoms, as well as reckless spending, unsafe sex and dangerous driving. Please note: If these behaviors occur primarily during a period of elevated mood or energy, they may be signs of a mood disorder—not borderline personality disorder
• Self-harming behavior, such as cutting. The reasons why a person self-harms can vary, but generally it’s a way of coping with strong feelings and emotions, and of expressing emotional pain.
• Recurring thoughts of suicidal behaviors or threats
• Intense and highly changeable moods, with each episode lasting from a few hours to a few days
• Chronic feelings of emptiness
• Inappropriate, intense anger or problems controlling anger
• Difficulty trusting, which is sometimes accompanied by irrational fear of other people’s intentions
• Feelings of dissociation, such as feeling cut off from oneself, seeing oneself from outside one’s body, or feelings of unreality
• Constant changes of mind. People with borderline personality disorder might find that they constantly change their mind about things, whether it’s their feelings towards the people around them, or other areas of their life, such as their goals, ambitions or sexuality.

Not everyone with borderline personality disorder experiences every symptom. Some individuals experience only a few symptoms, while others have many. Symptoms can be triggered by seemingly ordinary events. For example, people with borderline personality disorder may become angry and distressed over minor separations from people to whom they feel close, such as traveling on business trips. The severity and frequency of symptoms and how long they last will vary depending on the individual and their illness.

Borderline personality disorder diagnosis

A licensed mental health professional—such as a psychiatrist, psychologist, or clinical social worker—experienced in diagnosing and treating mental disorders can diagnose borderline personality disorder by:

• Completing a thorough interview, including a discussion about symptoms
• Performing a careful and thorough medical exam, which can help rule out other possible causes of symptoms
• Asking about family medical histories, including any history of mental illness

Borderline personality disorder often occurs with other mental illnesses. Co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder. For example, a person with borderline personality disorder may be more likely to also experience symptoms of depression, bipolar disorder, anxiety disorders, substance use disorders, or eating disorders.

A diagnosis of borderline personality disorder is usually made in adults, not in children or teenagers. That’s because what appear to be signs and symptoms of borderline personality disorder may go away as children get older and become more mature.

Borderline personality disorder treatment

Borderline personality disorder has historically been viewed as difficult to treat. But, with newer, evidence-based treatment, many people with the disorder experience fewer or less severe symptoms, and an improved quality of life. It is important that people with borderline personality disorder receive evidence-based, specialized treatment from an appropriately trained provider. Other types of treatment, or treatment provided by a doctor or therapist who is not appropriately trained, may not benefit the person.

Many factors affect the length of time it takes for symptoms to improve once treatment begins, so it is important for people with borderline personality disorder and their loved ones to be patient and to receive appropriate support during treatment.

The treatments described here are just some of the options that may be available to a person with borderline personality disorder.

Psychotherapy

Psychotherapy is the first-line treatment for people with borderline personality disorder. A therapist can provide one-on-one treatment between the therapist and patient, or treatment in a group setting. Therapist-led group sessions may help teach people with borderline personality disorder how to interact with others and how to effectively express themselves.

It is important that people in therapy get along with, and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with the disorder to maintain a comfortable and trusting bond with their therapist.

Types of psychotherapy used to treat borderline personality disorder include:

• Dialectical Behavior Therapy (DBT): This type of therapy was developed for individuals with borderline personality disorder. Dialectical behavior therapy (DBT) uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. Dialectical behavior therapy (DBT) also teaches skills that can help:
  • Control intense emotions
  • Reduce self-destructive behaviors
  • Improve relationships
• Cognitive Behavioral Therapy (CBT): This type of therapy can help people with borderline personality disorder identify and change core beliefs and behaviors that underlie inaccurate perceptions of themselves and others, and problems interacting with others. Cognitive behavioral therapy (CBT) may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.
• Schema-focused therapy. Schema-focused therapy can be done individually or in a group. It can help you identify unmet needs that have led to negative life patterns, which at some time may have been helpful for survival, but as an adult are hurtful in many areas of your life. Therapy focuses on helping you get your needs met in a healthy manner to promote positive life patterns.
• Mentalization-based therapy (MBT). Mentalization-based therapy (MBT) is a type of talk therapy that helps you identify your own thoughts and feelings at any given moment and create an alternate perspective on the situation. Mentalization-based therapy (MBT) emphasizes thinking before reacting.
• Systems training for emotional predictability and problem-solving (STEPPS). Systems training for emotional predictability and problem-solving (STEPPS) is a 20-week treatment which involves working in groups that incorporate your family members, caregivers, friends or significant others into treatment. Systems training for emotional predictability and problem-solving (STEPPS) is used in addition to other types of psychotherapy.
• Transference-focused psychotherapy (TFP). Also called psychodynamic psychotherapy, transference-focused psychotherapy (TFP) aims to help you understand your emotions and interpersonal difficulties through the developing relationship between you and your therapist. You then apply these insights to ongoing situations.
• General psychiatric management. This treatment approach relies on case management and focuses on making sense of emotionally difficult moments by considering the interpersonal context for feelings. It may integrate medications, groups, family education and individual therapy.

Other Elements of Care

Some people with borderline personality disorder experience severe symptoms and need intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care.

Tips for Family and Caregivers

To help a friend or relative with the disorder:

• Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with borderline personality disorder, but it is possible for them to get better over time
• Learn about mental disorders, including borderline personality disorder, so you can understand what the person with the disorder is experiencing
• Encourage your loved one who is in treatment for borderline personality disorder to ask about family therapy
• Seek counseling for yourself from a therapist. It should not be the same therapist that your loved one with borderline personality disorder is seeing

Therapy for Caregivers and Family Members

Families and caregivers of people with borderline personality disorder may also benefit from therapy. Having a relative or loved one with the disorder can be stressful, and family members or caregivers may unintentionally act in ways that can worsen their loved one’s symptoms.

Some borderline personality disorder therapies include family members, caregivers, or loved ones in treatment sessions. This type of therapy helps by:

• Allowing the relative or loved one develop skills to better understand and support a person with borderline personality disorder
• Focusing on the needs of family members to help them understand the obstacles and strategies for caring for someone with borderline personality disorder. Although more research is needed to determine the effectiveness of family therapy in borderline personality disorder, studies on other mental disorders suggest that including family members can help in a person’s treatment.

Borderline personality disorder medication

Because the benefits are unclear and no drugs have been approved by the Food and Drug Administration specifically for the treatment of borderline personality disorder, medications are not typically used as the primary treatment for borderline personality disorder. However, in some cases, a psychiatrist may recommend medications to treat specific symptoms such as:

• mood swings
• depression
• other co-occurring mental disorders

Medications may include antidepressants, antipsychotics or mood-stabilizing drugs.

Treatment with medications may require care from more than one medical professional.

Certain medications can cause different side effects in different people. Talk to your doctor about what to expect from a particular medication.

Hospitalization

At times, you may need more-intense treatment in a psychiatric hospital or clinic. Hospitalization may also keep you safe from self-injury or address suicidal thoughts or behaviors.

Recovery takes time

Learning to manage your emotions, thoughts and behaviors takes time. You may need many months or years of treatment, and you may always struggle with some symptoms of borderline personality disorder. You may experience times when your symptoms are better or worse. But treatment can improve your ability to function and help you feel better about yourself.

Because treatment can be intense and long term, you have the best chance for success when you consult mental health providers who have experience treating borderline personality disorder.

Coping and support

Symptoms associated with borderline personality disorder can be stressful and challenging for you and those around you. You may be aware that your emotions, thoughts and behaviors are self-destructive or damaging, yet you feel unable to manage them.

In addition to getting professional treatment, you can help manage and cope with your condition if you:

• Learn about the disorder so that you understand its causes and treatments
• Learn to recognize what may trigger angry outbursts or impulsive behavior
• Seek professional help and stick to your treatment plan — attend all therapy sessions and take medications as directed
• Work with your mental health provider to develop a plan for what to do the next time a crisis occurs
• Get treatment for related problems, such as substance misuse
• Consider involving people close to you in your treatment to help them understand and support you
• Manage intense emotions by practicing coping skills, such as the use of breathing techniques and mindfulness meditation
• Set limits and boundaries for yourself and others by learning how to appropriately express emotions in a manner that doesn’t push others away or trigger abandonment or instability
• Don’t make assumptions about what people are feeling or thinking about you
• Reach out to others with the disorder to share insights and experiences
• Build a support system of people who can understand and respect you
• Keep up a healthy lifestyle, such as eating a healthy diet, being physically active and engaging in social activities
• Don’t blame yourself for the disorder, but recognize your responsibility to get it treated

1. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Sep 15;62(6):553-64. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2044500/[↩]
2. American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5. Washington, DC: American Psychiatric Association; 2013.[↩]