Borderline personality disorder (BPD) is a mental health condition that affects mood, behavior, and self-image.
BPD is a type of personality disorder. A person with BPD experiences intense emotions, poor self-image, and impulsive behaviors. Another characteristic symptom of the condition is a lack of stability in personal relationships.
The term borderline originally came into use when clinicians thought of the person as being on the border between having neuroses and psychosis, as people with a diagnosis of BPD experience elements of both.
The National Institute of Mental Health (NIMH) suggest that around 1.4% of adults in the United States have BPD.
Historically, BPD has been difficult to treat. However, the NIMH say that new evidence-based treatments can reduce the symptoms and improve the person’s quality of life.
This article provides an overview of BPD, including its causes, symptoms, diagnosis, and treatment options.
BPD is a complex mental health condition characterized by difficulties with emotion and self-image, unstable personal relationships, and impulsive behaviors.
BPD is a cluster B personality disorder. This is a group of disorders that affect a person’s emotional functioning and lead to behaviors that others see as extreme or irrational.
Common challenges in BPD include:
- instability in relationships with others
- intense emotions, such as anger and low mood
- sudden shifts in self-image (regarding values or career plans, for example)
- impulsive and damaging behaviors, which can include substance misuse or impulsive spending
- self-harm and, for some people, suicidal thoughts or actions
The way a person with BPD interacts with others is closely associated with their self-image and early social interactions.
In most cases, BPD begins in early adulthood. Clinicians will not usually diagnose it in children or adolescents, as their personality is still developing during these years. Symptoms that may look like those of BPD may resolve as children get older.
Clinicians use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose mental health conditions, including BPD. Insurance companies also use the DSM-5 to reimburse for the treatment of this condition.
According to the DSM-5, the following signs and symptoms are characteristic of BPD:
- frantic efforts to avoid being abandoned by friends or family
- unstable and intense personal relationships that shift between extreme adoration and extreme dislike
- a persistently unstable self-image or sense of self, such as sudden shifts in values, career path, types of friends, or sexuality
- impulsive, damaging behaviors, such as substance misuse, sexual activity, unsafe driving, or binge eating
- self-harming behaviors and, for some people, suicidal thoughts or actions
- intense moods, such as extreme low mood, irritability, or anxiety that lasts for a few hours to a few days
- chronic feelings of emptiness
- extreme anger
- difficulty controlling anger
- severe feelings of dissociation, which means feeling disconnected
- stress-related paranoid thoughts
The symptoms of BPD are present in a variety of different situations. They are not consistent with the individual’s developmental stage or place in society, and they are not solely due to the use of drugs or the presence of a medical condition.
The following sections will look at some of the significant symptoms of BPD in more detail.
A main symptom of BPD is difficulty regulating emotions. The person may feel emotions intensely and for long periods, and they may find it more difficult to return to a baseline emotion after experiencing emotional stress.
The person may also have feelings of intense anger or difficulty controlling their anger. This is often followed by shame or guilt, which can impair the person’s self-image. This anger is often in response to a fear of neglect, uncaring, or abandonment.
Self-harm is another common symptom. People with BPD may use this as a means of regulating their emotions, punishing themselves, or expressing their inner pain.
Another symptom of BPD is recurring thoughts of suicide. Some people also engage in suicidal actions. The rates of self-harm and suicide are higher in people with BPD than in people without.
Receiving effective treatment can help people manage their emotions and reduce the frequency or severity of self-harm behaviors and suicidal thoughts.
Another characteristic symptom of BPD is engaging in impulsive behaviors, which may involve:
- risky sexual activity
- substance misuse
- excessive spending
- unsafe driving
- binge eating
People may also feel bored often and have a persistent need to have something to do.
People with BPD often have patterns of intense or unstable relationships. This may involve a shift from extreme adoration to extreme dislike, known as a shift from idealization to devaluation.
Relationships may be marked by attempts to avoid real or imagined abandonment. The perceived threat of being abandoned can have a significant impact on the person’s self-image, moods, thoughts, and behaviors.
For example, the person may feel panicked or angry over minor separations from people they feel close to.
If you know someone at immediate risk of self-harm, suicide, or hurting another person:
- Ask the tough question: “Are you considering suicide?”
- Listen to the person without judgment.
- Call 911 or the local emergency number, or text TALK to 741741 to communicate with a trained crisis counselor.
- Stay with the person until professional help arrives.
- Try to remove any weapons, medications, or other potentially harmful objects.
If you or someone you know is having thoughts of suicide, a prevention hotline can help. The National Suicide Prevention Lifeline is available 24 hours per day at 800-273-8255. During a crisis, people who are hard of hearing can call 800-799-4889.
Some people may be genetically predisposed to developing BPD, with certain environmental factors increasing the risk.
Experts have identified three factors as likely to play a part in the development of BPD: genetics, environmental factors, and neurological factors.
The following sections will look at each of these in more detail.
There is a genetic predisposition to developing BPD, with twin studies suggesting over 50% heritability for the condition.
Many people with BPD have an immediate relative who has a mental health condition, which might be bipolar disorder, depression, substance use disorder, or antisocial personality disorder.
Many people with BPD have had experiences of trauma, such as abuse or abandonment in childhood, hostile conflicts, or unstable relationships.
Some sources say that 70% of people with BPD experienced mistreatment during childhood, such as physical abuse, sexual abuse, or neglect.
Some studies have found structural and functional differences in the brains of people with BPD — specifically in brain areas linked with emotion regulation.
However, experts do not know whether these differences were risk factors or developed due to the condition itself.
BPD is difficult to diagnose because its symptoms overlap with those of other mental health conditions. Individual cases can also vary greatly.
Mental health professionals can diagnose BPD following a thorough psychological evaluation during which they ask about the person’s clinical history and their symptoms.
As BPD shares some symptoms with several other conditions, mental health professionals will need to rule these out before being able to make a firm BPD diagnosis.
In addition, BPD often occurs alongside other mental health conditions, such as:
Due to the difficulties in diagnosing BPD, it often goes underdiagnosed or misdiagnosed.
People with BPD who receive effective treatment experience fewer and less severe symptoms, a better ability to function, and an improved quality of life.
Some treatment options for BPD include:
Psychotherapy, or talking therapy, is the first line treatment for BPD.
Several different types of psychotherapy can reduce the impact of BPD, including:
- Cognitive behavioral therapy: Working with a therapist, a person can become aware of any negative or ineffective forms of thinking, allowing them to view challenging situations more clearly.
- Dialectical behavior therapy: People can use a skills-based approach alongside both physical and meditative exercises to learn how best to regulate emotions and tolerate distress.
- Schema-focused therapy (SFT): Based on the idea that BPD comes from a dysfunctional self-image, SFT focuses on reframing how the person views themselves.
- Mentalization-based therapy: This is a form of talk therapy that helps people identify their own thoughts and separate them from those of people around them.
- Transference-focused psychotherapy: This approach uses the developing relationship between the person and their therapist to help the person understand their emotions and interpersonal difficulties.
- Systems training for emotional predictability and problem solving: This is a form of group therapy led by a social worker that is intended to supplement other forms of treatment.
There is no medication currently available that can cure the condition itself, but clinicians can prescribe certain medications to treat issues that occur alongside BPD.
These medications include:
- Selective serotonin reuptake inhibitors: This practice is not supported by clinical trial evidence, but a clinician may recommend this class of drugs if the person also has co-occurring anxiety or depressive disorder.
- Second-generation antipsychotics and mood stabilizers: There is some evidence to suggest that these help manage some symptoms of BPD.
- Omega-3 fatty acids: There is also some evidence to suggest that omega-3 fatty acids, one source of which is fish oil, can help reduce symptoms of aggression and depression in women with BPD. However, further studies are necessary.
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.
In some cases, such as those in which a person has attempted suicide, treatment in specialist environments such as hospitals and psychiatric clinics may be necessary.
Often, inpatient treatment will be a combination of medication and psychotherapy sessions. It is rare for a person to be hospitalized with BPD for a long time. Most people only need partial hospitalization or a day treatment program.
According to the DSM-5, the impacts of BPD and the risk of suicide are highest in early adulthood. However, they gradually reduce with age. Most people achieve greater stability in their relationships and jobs by their 30s and 40s.
Although BPD can be difficult to treat, new evidence-based treatments can reduce the symptoms and improve the person’s quality of life.
People who receive therapeutic treatments often experience improvements during the first year. Studies have reported that after about 10 years, as many as 91% of people achieve remission from BPD.
BPD is a complex mental health condition characterized by instability in a person’s moods, behaviors, and personal relationships.
Receiving effective treatment, such as psychotherapy and social support, can reduce the frequency and severity of the person’s symptoms.
The National Alliance on Mental illness offer advice for family members and caregivers on how to support others with a mental health condition while looking after themselves.