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Borderline Personality Disorder
Borderline personality disorder is a condition characterized by instability and impulsivity. The term originates from being on the “border” of psychosis—those with the condition seem to have a different sense of reality.
Instability manifests in relationships, emotion, and self-concept. Terrified of abandonment, people with BPD cling to those close to them, crave reassurance and validation, and are upset by seemingly small changes. Turbulence in emotion and self-concept can involve angry outbursts, severe mood swings, hopelessness, paranoia, self-harm, and suicidality; 10 percent of those with the condition die by suicide.
BPD often begins in adolescence or early adulthood. It affects around 1.6 percent of U.S. adults, according to the NIMH, although other estimates place the prevalence closer to 6 percent.
Committing to treatment with patience and consistency can help individuals and their loved ones navigate the condition. Various forms of therapy, particularly dialectical behavior therapy, and medications to manage symptoms can help those with BPD lead a fulfilling life.
For more, see the Diagnosis Dictionary.
Contents
To be diagnosed with BPD, a person would have at least five of the following symptoms, as determined by a mental health professional per the DSM-5.
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense relationships characterized by alternat­ing between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, or binge eating).
- Recurrent suicidal behavior or threats, or self-harming behavior.
- Instability of mood (dysphoria, irritability, or anxiety).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
Whether in moods or relationships, instability is a hallmark of BPD. The person may have wide mood swings, switching from effusive praise and love to intense criticism and blame. In moments of anger, they may do things like scream at you in public, hit you, or harm themselves—things that other people wouldn’t do in the same situation. A fear of abandonment may manifest as constant, clinginess or manipulating a relationship you have with someone else. If the person demonstrates these behaviors as a pattern, they may have BPD.
Here are a few more clues to look for in the person’s words, emotions, and behaviors that can identify borderline personality disorder.
Yes, BPD seems to manifest differently in women and men. With regard to impulsive behavior, men tend to demonstrate substance use, antisocial behavior, and intermittent explosive disorder while women more often have eating disorders. With regard to self-harm, men may engage in more varied forms including bruising, head-banging and biting in addition to cutting.
With regard to treatment, women more often seek out therapy and medication while men more often seek substance use treatment. Both men and women enter treatment with equal levels of emotional distress.
Splitting is the black-and-white thinking that can engulf those with BPD. In moments of happiness they can fawn over a friend or partner, calling the person “perfect,” while small setbacks or miscommunications can unleash terror or rage, calling the person “terrible” or “never trustworthy.” The extreme perspectives involved in splitting can also manifest in how people with BPD see themselves.
The terms quiet BPD and high-functioning BPD, which are not diagnostic labels, refer to people who may not have stereotypical symptoms of BPD, such as angry outbursts or self-harming behaviors. Instead, symptoms and emotions are often directed inward or only come out in "pockets," such as when the person is triggered by certain people or situations. These individuals may seem calm and collected on the surface, but in reality they struggle from intense loneliness, shame, and self-criticism.
The roots of borderline personality disorder still aren’t fully understood. As is the case for many mental health conditions, it seems to be caused by complex interactions between one’s biology and environment.
The disorder has a strong genetic component, because the condition is five times more common in people whose first-degree relatives have BPD, according to the DSM-5. The balance of activity in key brain regions—namely the prefrontal cortex and the amygdala—may be shifted in people with BPD. Life circumstances also play an important role, as BPD is more common in those who experienced childhood adversity, such as abuse or abandonment.
Past research has found that BPD occurs three times more in women than in men. Yet newer research suggests that the rates may actually be comparable. Past discrepancies may be due to the condition presenting differently in men and women, diagnostic bias, and more women seeking treatment. Therefore it’s important to remember that men and women, and people of all races, struggle with BPD.
The extreme way people with BPD experience the world may reflect a glitch in brain dynamics. Typically, the prefrontal cortex, the part of the forebrain responsible for self-control and decision-making, governs the limbic system, an evolutionarily ancient set of brain regions that generate primal emotions such as fear, centered in the amygdala. But people with BPD seem to have less input from the prefrontal cortex to the amygdala. This leads to an overactive amygdala—perceiving threat and rejection where others would not.
Childhood experiences of parental neglect and emotional, physical, or sexual abuse are among the most important risk factors for BPD. These circumstances may lead children to frantically keep pace and shift strategies to navigate the unpredictability of parents and caregivers, instilling rejection and distrust in the context of relationships.
Historically borderline was thought to be nearly impossible to treat. But today experts recognize that the condition is treatable with commitment to therapy, greatly improving the lives of those with borderline.
The first-line treatment for BPD is dialectical behavior therapy, which teaches patients to tolerate emotional uncertainty and distress along with coping skills to regulate their emotions and build stable relationships.
Other forms of therapy can be effective as well. Cognitive behavior therapy targets distorted patterns of thought. Transference-focused psychotherapy helps patients work through the emotional challenges that trigger borderline behavior. And mentalization-based treatment helps patients regain curiosity about others’ mental states to leverage another perspective.
In addition to therapy, medications may be prescribed to help address symptoms such as anxiety or depression.
The go-to treatment for BPD has long been dialectical behavior therapy (DBT), an intensive program of group skills training on mindfulness, distress tolerance, conflict management, and emotion regulation, supplemented by psychotherapy and phone coaching.
Developed by University of Washington psychologist Marsha Linehan—herself a BPD sufferer—DBT focuses on controlling the behaviors that characterize the disorder. Clients use techniques of mindfulness and distress tolerance to endure painful emotions instead of acting out through cutting, suicide attempts, unsafe sex, substance abuse, or disordered eating.
Recovery is possible, but it requires long-term treatment; a 10-year study found that 85 percent of those with BPD were in remission by the end of the study. These individuals also showed improved social abilities, although overall they still faced difficulties.
People with borderline personality disorder compulsively test the durability of relationships. If therapists indulge this pressure, therapy aimed at personality change will thereafter seem withholding; if therapists resist the pressure to prove they care, therapy will come to feel like a rejection. Therapists must neither feed or starve abandonment fears; in this way, they can engage the patient in changing how they relate to others.
Close friendships, romance, and family bonds are often what people on the borderline crave the most, and they often move in whirlwind style to win over others. But sustaining intimacy is a colossal challenge, as the disorder embodies a poignant paradox: Sufferers yearn for closeness, but their overriding insecurity tends to drive away those most dear. Despite the self-defeating actions they typically deploy, it is not impossible for them to get beyond the histrionics to maintain closeness—and the very stability of a partner often proves curative.
Instability, volatility, and drama are central features of relationships with borderline individuals. You may feel fantastic when the person is in good spirits and crushed when they are not. People with borderline respond to fears of abandonment with neediness, which may come across as clingy text messages or stalking behaviors, or they may respond with anger and fury. They may be hypervigilant for real or imagined signs of rejection or abandonment should you, for example, be late, cancel an appointment, or talk to someone they see as competition. A continual sense of distrust may lead to a distorted sense of reality and paranoia.
Even those who recover from BPD are unlikely to ever be low-maintenance partners and friends. Loved ones need to develop skills such as stress management, self-care, and maintaining good boundaries so they can look out for themselves while helping their partner.
The following tips can help a loved one with BPD and strengthen bonds:
• Avoid discussions about conflicts in your relationship until your partner feels calm and safe.
• Stay curious and ask your loved one what they are feeling.
• Emphasize that it's okay for both of you to not be perfect.
• People with BPD may threaten suicide or self-harm to keep you close. If you're staying with a partner or a friend only because you're worried he can't survive without you, it's time to seek help. Couples therapy can be a safe environment to express the impact of the person's behavior on your life.
Creating a stable life outside of a romantic relationship is key to healing. Prioritizing work, including small, repeated interactions with coworkers, can help those with BPD achieve a steady routine, both professionally and socially. The same pattern can follow for building relationships with neighbors and friends. With a strong foundation in place, people with BPD may then be ready to take on an intimate relationship.
