Borderline personality disorder is a mental health disorder that creates mood, behavioral and relationship instability. The symptoms of the disease have been described in medical literature for over 3000 years, though the disease has only really begun increasing in visibility over the past 30 years.1
The term "borderline" originally came into use when clinicians thought of their patients as being on the border between neurotic and psychotic, having displayed both neurotic and psychotic symptoms. Mental health experts now generally agree that the name "borderline personality disorder" is misleading, but a more accurate term has not yet been created.17
Borderline personality disorder (BPD) was defined as a stand-alone diagnosable illness for the first time in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) in 1980. The DSM is a resource that is widely used by mental health professionals to diagnose mental illnesses.3
The National Institute of Mental Health (NIMH) state that an estimated 1.6% of adults in the US have borderline personality disorder in any given year.17
Contents of this article:
You will also see introductions at the end of some sections to any recent developments that have been covered by MNT's news stories. Also look out for links to information about related conditions.
Here are some key points about borderline personality disorder. More detail and supporting information is in the main article.
- People with BPD have problems regulating thoughts, emotions and self-image, can be impulsive and reckless, and often have unstable relationships with other people.
- Most cases of BPD begin in the early stages of adulthood, seem to be worse in young adulthood, but may get better with age.
- Experts do not yet know what causes BPD.
- Genetics, environmental factors and brain abnormalities are thought to play a role in the development of BPD.
- About 85% of people with BPD also meet diagnostic criteria for another mental illness, such and often suffer from depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.
- BPD and schizophrenia often co-exist, but the two are distinct conditions.
- A person can be diagnosed with BPD if they display at least five of nine recognized symptoms.
- Symptoms of BPD can be triggered by situations others find untroubling.
- As many as 80% of people with BPD go on to develop suicidal behavior, and 4-9% go on to commit suicide.
- BPD is commonly treated with psychotherapy, aided with medication and, occasionally, hospitalization.
- There is no cure for BPD, but symptoms can improve over time and many people with BPD find ways to manage their condition successfully to lead satisfying lives.
What is borderline personality disorder?1,2,5
BPD is a challenging and disruptive illness. People with BPD often have problems regulating their thoughts and emotions and can be prone to impulsive, reckless behavior.
Personality disorders are patterns of behavior and inner experience that deviate from what is normative within the individual's culture. Patterns of behavior and experience within personality disorders are inflexible and prevalent within a wide range of personal and social situations.
BPD often begins in early adulthood and is usually characterized by a distorted image of the self.
The majority of cases of BPD begin to occur in early adulthood. The manner in which a person with BPD interacts with others is closely associated with their self-image and early social interactions.
People with BPD often have a distorted self-image and feel as though they are flawed and worthless.
BPD causes the following behavioral disturbances:
- Distorted perceptions
- Disturbed relationships
- Excessive emotional responses
- Harmful, impulsive actions.
What causes borderline personality disorder?3,6-8
At present, it is not known precisely what causes BPD. Experts believe it is likely that the condition arises through a combination of factors; it appears that people can be genetically predisposed to developing BPD, with environmental factors increasing the risk.
Three factors have been identified as being likely to play a part in the development of BPD:
- Genetics: studies of twins with BPD suggest that a predisposition to the condition is inherited. Research has also shown that certain personality traits such as impulsiveness can also be inherited.
- Environmental (social) factors: unstable family relationships, child abuse and neglect have been associated with an increased risk of BPD. Poor judgement regarding lifestyle choices can also be a risk factor.
- Brain abnormalities: BPD has been associated in studies with changes to certain parts of the brain involved in the regulation of emotion. Improper functioning of certain brain chemicals involved in mood regulation, such as serotonin, may also be involved in BPD.
There is also an established link between BPD and other mental disorders. Many people with BPD have an immediate relative that has a mental illness. Related disorders that people with BPD and their relatives are more likely to develop include ADHD, bipolar disorder, depression and schizophrenia.
A new study recently published in the American Journal of Psychiatry has found an association between child abuse and the reduction of gray matter in the brain that is responsible for information processing.
It is well established that seasons can affect mood. But a new study by researchers from Hungary claims the season during which we are born may influence our risk of developing mood disorders later in life.
Signs and symptoms3,8,9
BPD is not normally diagnosed in children or adolescents as symptoms that suggest such a diagnosis may resolve as children get older.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, is used by mental health providers to diagnose mental health conditions such as BPD, and by insurance companies to reimburse for treatment of the condition.
Unlike the DSM-4, the DSM-5 does not require there to be at least five out of nine specific symptoms present for a diagnosis to be made. Instead the DSM-5 requires that the following criteria be met:18
A. Significant impairments in personality functioning manifest by:
- Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
- Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:
- Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by - and/or separation from - significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
- Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger.
- Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
Symptoms of BPD can be triggered by situations that may seem mundane to those who are healthy. People with BPD often have difficulty accepting gray areas in life, seeing things as either black or white. They can feel distressed over minor separations from people who they feel close to, as a result of business trips or sudden changes of plans, for example.
People with BPD are at an increased risk of substance abuse.
Studies have also found that people with BPD can see anger in emotionally neutral faces or react to words with negative connotations much more strongly than people without the condition.
According to NIMH, as many as 80% of people with BPD develop suicidal behaviors, with 4-9% committing suicide. Self-harm is another common symptom, used at times by people with BPD as a means of regulating their emotions, punishing themselves or expressing their inner pain.
People with BPD are also at an increased risk of developing eating disorders, substance abuse and being victims of violent crime such as rape.
Tests and diagnosis3,10
BPD can be a tricky condition to diagnose, not only because the condition's symptoms overlap with other mental illnesses, but because individual cases can vary greatly. For the condition to be diagnosed, a person must meet the criteria outlined in the DSM (mentioned in the Signs and Symptoms section).
Mental health professionals can diagnose BPD following a thorough interview, during which they will complete a psychological evaluation where they ask about a patient's clinical history and their symptoms.
As BPD shares symptoms with several other conditions, mental health professionals will need to rule these out before being able to make a BPD diagnosis. In order to do this, they will carefully assess the following:
BPD is usually diagnosed following an interview with a mental health professional.
- Characteristics of other personality disorders
- Cognitive functioning
- Depressive symptoms
- Presence, absence and type of antisocial behavior
- Presence and absence of manic or hypomanic behavior
- Presence and nature of suicidal thinking
- Quality of relationships with others
- Substance abuse.
Due to the difficulties in diagnosing BPD it is often underdiagnosed or misdiagnosed. At present, there is no single test that can diagnose BPD, although scientists are continually looking for ways to improve diagnostic procedures.
Treatment for BPD can be divided into three main forms: psychotherapy; medication; and hospitalization. The patient, primary clinician and the patient's family will work together to decide which form of treatment is most appropriate.
Psychotherapy is often the first choice when it comes to treating BPD. There is a variety of different forms available, and it is important the patient trusts and gets on well with their therapist.
- Cognitive behavioral therapy (CBT): working with a therapist, patients become aware of negative or ineffective forms of thinking, allowing them to view challenging situations more clearly. CBT helps patients with the search for and practice of alternative solution strategies.
- Dialectical behavior therapy (DBT): patients use a skills-based approach alongside both physical and meditative exercises in order to learn how best to regulate emotions and tolerate distress. Specifically developed to treat BPD, DBT seeks to find a balance between change and acceptance of behaviors and beliefs.
- Schema-focused therapy (SFT): based on the idea that BPD comes from a dysfunctional self-image, SFT focuses on reframing the ways in which patients view themselves. SFT combines aspects of CBT with other forms of psychotherapy to identify positive patterns in the patient's life while changing negative ones.
- Mentalization-based therapy (MBT): a form of talk therapy that aids patients in identifying their own thoughts and separating them from those of people around them.
- Transference-focused psychotherapy (TFP): also referred to as psychodynamic psychotherapy, TFP uses the developing relationship between patient and therapist to help the individual understand their emotions and interpersonal difficulties. These findings can then be applied to ongoing situations.
- Systems Training for Emotional Predictability and Problem Solving (STEPPS): a form of group therapy led by a social worker that is intended to supplement other forms of treatment. STEPPS focuses on the symptoms of BPD in a manner that is less time-consuming and labor intensive than other forms of psychotherapy.
Psychotherapy sessions can be held on an individual basis or as part of a group.
Doctors can prescribe medication to treat clinical problems that occur alongside BPD, although there is no medication currently available that can cure the condition itself. The US Food and Drug Administration (FDA) has yet to approve any medication to specifically treat BPD.
Medications prescribed by doctors to treat specific symptoms include antidepressants, antipsychotics and anti-anxiety drugs. Many physicians predominantly prescribe selective serotonin reuptake inhibitors (SSRIs) for BPD, but this practice is not supported by clinical trial evidence.19
There is some evidence for beneficial effects by second-generation antipsychotics and mood stabilizers for managing BPD.19
There is some evidence for beneficial effects of omega-3 fatty acids - commonly found in fish oil - to help stabilize mood, reducing symptoms of aggression and depression in BPD.19,20 Omega-3 may exert these beneficial effects by supporting healthy cell membrane function and helping to regulate cellular signaling.
Preliminary research also suggests that there may be a role to play in BPD treatment for medications that modify glutamatergic, opioid and oxytocinergic neurotransmitter systems.20
In some cases, people with BPD require intense treatment in specialist environments such as hospitals and psychiatric clinics. Often, inpatient treatment will be a combination of medication and psychotherapy sessions.
It is rare for people to be hospitalized with BPD for a long time; most people only require partial hospitalization or a day treatment program. Short-term inpatient treatment allows people with BPD to gain support and structure from a safe environment before returning to their home where they may feel more at ease.
By now, most of us are aware that omega-3 fatty acid in fish offers numerous health benefits. But now, a new study published in the American Journal of Preventive Medicine suggests eating the baked or broiled variety of the gill-bearing creature weekly is good for the brain, no matter how much omega-3 fatty acid it has.
Some people lack self-control. A habit of saying the wrong thing at the wrong time is one example. But now, scientists have developed a way of improving a person's self-control through electrical brain stimulation. This is according to a study published in The Journal of Neuroscience.
Recent research has shown that BPD can be treated effectively and that the situations of people with the condition can improve over time. BPD is a condition that appears to improve with age, particularly around the ages of 30 and 40, allowing people with BPD to continue building relationships and their careers.16