What is borderline personality disorder (BPD)?
The symptoms of the disease have been described in medical literature for over 3,000 years, but the disease has only really begun increasing in visibility over the past 30 years.
The term "borderline" originally came into use when clinicians thought of patients as being on the border between neurotic and psychotic - having displayed both neurotic and psychotic symptoms.
- People with BPD have problems regulating thoughts, emotions, and self-image. They 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 symptoms may get better with age.
- Experts do not know what causes BPD. Genetics, environmental factors, and brain abnormalities are thought to play a role.
- BPD is commonly treated with psychotherapy, aided with medication in some cases.
- There is no cure for BPD, but symptoms can improve over time.
What is borderline personality disorder?
Borderline personality disorder is a very specific condition that is difficult to diagnose.
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. BPD causes the following behavioral disturbances:
- distorted perceptions
- disturbed relationships
- excessive emotional responses
- harmful, impulsive actions
People with BPD often have a distorted self-image and may feel as though they are flawed and worthless.
Experts believe it is likely 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.
- Environmental (social) factors: Unstable family relationships, child abuse, and neglect have been associated with an increased risk of BPD.
- Brain abnormalities: BPD has been associated in studies with changes to certain parts of the brain involved in the regulation of emotion.
Signs and symptoms
BPD is not normally diagnosed in children or adolescents as personality is still developing during these years. Symptoms which may look like borderline personality disorder 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 to diagnose mental health conditions such as BPD, and by insurance companies to reimburse for treatment of the condition.
Unlike the DSM-4 (an earlier version), 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:
Impairments in self functioning
- Identity: Poorly developed or unstable self-image, often very self-critical; feelings of emptiness; dissociative states under stress.
- Self-direction: Changing goals, values, aspirations, or career plans.
Impairments in interpersonal functioning
- Empathy: Not able to recognize the feelings and needs of others.
- Intimacy: Intense and unstable close relationships, marked by mistrust, conflict, neediness, and concerns about being abandoned. Close relationships fluctuate between over-involvement and withdrawal.
Pathological personality traits
- highly changeable emotions
- separation insecurity
- often depressed mood
Disinhibition, characterized by:
- act impulsively
- take risks
Antagonism, characterized by:
Also, the impairments in personality and personality traits are:
- fairly constant at different times and in different situations
- not consistent with the individual's developmental stage or place in society
- not solely due to the use of drugs or other substances, or a medical condition
Symptoms of BPD can be triggered by situations that healthy people would find normal. People with BPD have difficulty accepting gray areas in life, often 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.
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 percent of people with BPD develop suicidal behaviors, with 4-9 percent 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.
Diagnosis is achieved by a thorough examination from a mental health professional.
BPD is difficult to diagnose because the condition's symptoms overlap with other mental illnesses, and individual cases can vary greatly.
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.
Due to the difficulties in diagnosing BPD, it is often underdiagnosed or misdiagnosed.
Treatment options include:
There are different forms available:
- 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.
- Dialectical behavior therapy (DBT): Patients 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 patients view themselves.
- 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): This uses the developing relationship between patient and therapist to help the individual understand their emotions and interpersonal difficulties.
- 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.
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. Medications include:
- Selective serotonin reuptake inhibitors (SSRIs): This practice is not supported by clinical trial evidence, but this class of drugs may be used if the person also has co-occurring anxiety or depressive disorder.
- Second-generation antipsychotics and mood stabilizers: There is some evidence that these help manage some symptoms of BPD.
- Omega-3's: There is some evidence that omega-3 fatty acids - commonly found in fish oil - help stabilize mood, reducing symptoms of aggression and depression in BPD, however, further studies are needed.
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 attempted suicide), 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.