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Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and an individual’s sense of identity. It is also known as an emotionally unstable personality disorder (EUPD), is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, an unstable sense of self, and unstable emotions. There is frequent dangerous behavior and self-harm. People may also struggle with a feeling of emptiness and a fear of abandonment.
Causes of Borderline Personality Disorder
The causes of BPD are not fully understood, but scientists agree that it is the result of a combination of factors, including:
- Genetics – While no specific gene or gene profile has been shown to directly cause BPD, studies involving twins suggest this illness has strong hereditary links. BPD is about five times more common among people who have a first-degree relative with the disorder.
- Environmental factors – People who experience traumatic life events—such as physical or sexual abuse during childhood or neglect and separation from parents—are at increased risk of developing BPD.
- Brain function – The emotional regulation system may be different in people with BPD, suggesting that there is a neurological basis for some of the symptoms. Specifically, the portions of the brain that control emotions and decision-making/judgment may not communicate optimally with one another.
- 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.
Symptoms of Borderline Personality Disorder
A borderline personality disorder may be characterized by the following signs and symptoms
- Harmful, impulsive behaviors. These may include things like substance abuse, binge eating, out-of-control spending, risky sexual behavior, and reckless driving.
- Relationship problems. You may see others as either “good” or “bad” and may shift from one view to the other suddenly, for minor reasons. This can make relationships very difficult.
- Markedly disturbed sense of identity
- Frantic efforts to avoid real or imagined abandonment and extreme reactions to such
- Splitting (“black-and-white” thinking)
- Impulsivity and impulsive or dangerous behaviors
- Intense or uncontrollable emotional reactions that often seem disproportionate to the event or situation
- Anxiety about relationships, efforts to avoid being abandoned
- Unstable and chaotic interpersonal relationships
- Self-damaging behavior
- Anger, moodiness, irritability
- Distorted self-image
- Dissociation
- Frantic efforts to avoid real or imagined abandonment by friends and family.
- Unstable personal relationships that alternate between idealization (“I’m so in love!”) and devaluation (“I hate her”). This is also sometimes known as “splitting.”
- Distorted and unstable self-image, which affects moods, values, opinions, goals, and relationships.
- Impulsive behaviors can have dangerous outcomes, such as excessive spending, unsafe sex, substance abuse, or reckless driving.
- Self-harming behavior includes suicidal threats or attempts.
- Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days.
- Feeling empty, low self-esteem
- Paranoia or emotional detachment
- Impulsive, risky behavior
- Self-harm, threatening or attempting suicide
- Chronic feelings of boredom or emptiness.
- Inappropriate, intense, or uncontrollable anger—often followed by shame and guilt.
- Dissociative feelings—disconnecting from your thoughts or sense of identity or “out of body” type of feelings—and stress-related paranoid thoughts. Severe cases of stress can also lead to brief psychotic episodes.
- Frequently accompanied by depression, anxiety, anger, substance abuse, or rage
The most distinguishing symptoms of BPD are marked sensitivity to rejection or criticism, and intense fear of possible abandonment.
Other signs or symptoms may include:
- 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
- Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating. Please note: If these behaviors occur primarily during a period of elevated mood or energy, they may be signs of a mood disorder—not a borderline personality disorder
- Self-harming behavior, such as cutting
- 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 an 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
Criteria for Diagnosing of Borderline Personality Disorder
These are the criteria mental health professionals use to diagnose a borderline personality disorder
- Frantic efforts to avoid abandonment, real or imagined
- A pattern of unstable and intense relationships
- An unstable self-image or sense of self
- Dangerous impulsivity such as unsafe sexual encounters, substance abuse
- Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
- Emotional instability due to high reactivity
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoia or severe dissociative symptoms
International Classification of Disease of Borderline Personality Disorder
The World Health Organization’s ICD-10 defines a disorder that is conceptually similar to borderline personality disorder, called Emotionally unstable personality disorder. Its two subtypes are described below.
- F60.30 Impulsive type
At least three of the following must be present, one of which must be
- marked tendency to act unexpectedly and without consideration of the consequences;
- marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
- liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
- difficulty in maintaining any course of action that offers no immediate reward;
- unstable and capricious (impulsive, whimsical) mood.
- F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present with at least two of the following in addition:
- disturbances in and uncertainty about self-image, aims, and internal preferences;
- liability to become involved in intense and unstable relationships, often leading to emotional crisis;
- excessive efforts to avoid abandonment;
- recurrent threats or acts of self-harm;
- chronic feelings of emptiness.
- demonstrates impulsive behavior, e.g., speeding in a car or substance abuse
The ICD-10 also describes some general criteria that define what is considered a personality disorder.
Millon’s subtypes of Borderline Personality Disorder
Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or more of the following:
| Subtype | Features |
|---|---|
| Discouraged borderline (including avoidant or dependent personality features) | Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless. |
| Petulant borderline (including negativistic features) | Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels “slighted” and quickly disillusioned. |
| Impulsive borderline (including histrionic or antisocial features) | Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal. |
| Self-destructive borderline (including depressive or masochistic and self-defeating features) | Inward-turning, intropunitively (self-punishing) angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide. |
Treatment of Borderline Personality Disorder
Treatment approaches are chosen to fit the goals of the client and the skills base of the clinician. These may include:
Counseling and therapy
It’s important to find a counselor you can build a stable relationship with. This can be hard, because your condition may cause you to see your counselor as caring one minute and cruel the next, especially when he or she asks you to try to change behavior. Try to find a counselor who has special training in dialectical behavioral therapy (DBT) to treat this disorder.
Medicines
Such as antidepressants, mood stabilizers, and antipsychotics. In combination with counseling or therapy, they may be helpful in treating symptoms of borderline personality disorder
Light therapy
The light emitted by conventional fluorescent lamps is deficient in many of the colors and wavelengths of natural sunlight. The basis of light therapy is replacing such lamps with full-spectrum fluorescent lamps whose light (referred to as bright light) is more similar to sunlight.
Psychotherapy
Psychotherapy — also called talk therapy — is a fundamental treatment approach for borderline personality disorder. Your therapist may adapt the type of therapy to best meet your needs. The goals of psychotherapy are to help you:
- Focus on you current ability to function
- Learn to manage emotions that feel uncomfortable
- Reduce your impulsiveness by helping you observe feelings rather than acting on them
- Work on improving relationships by being aware of your feelings and those of others
- Learn about borderline personality disorder
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. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.
Dialectical behavior therapy (DBT)
DBT can include group or individual therapy designed specifically to treat borderline personality disorder. DBT uses a skills-based approach to teach you how to manage your emotions, tolerate distress and improve relationships.
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)
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. MBT emphasizes thinking before reacting.
Systems training for emotional predictability and problem-solving (STEPPS).
STEPPS is a 20-week treatment that involves working in groups that incorporate your family members, caregivers, friends or significant others into treatment. STEPPS is used in addition to other types of psychotherapy.
Transference-focused psychotherapy (TFP)
Also called psychodynamic 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.
- System training for emotional predictability and problem solving
- Transference-focused psychotherapy
- Mentalization-based therapy.
Prevention of Borderline Personality Disorder
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.
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