Borderline personality disorder (BPD), also known as emotionally unstable personality disorder, is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions.
There is often an extreme fear of abandonment, frequent dangerous behavior, a feeling of emptiness, and self-harm. Symptoms may be brought on by seemingly normal events.
The behavior typically begins by early adulthood, and occurs across a variety of situations.
Substance abuse, depression, and eating disorders are commonly associated with BPD.
About 10% of those with BPD die by suicide.
BPD’s causes are unclear, but seem to involve genetic, brain, environment, and social factors. It occurs about five times more often in a person who has an affected close relative. Adverse life events also appear to play a role.
The underlying mechanism appears to involve the frontolimbic network of neurons. BPD is recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a personality disorder along with nine other such disorders.
Females are diagnosed about three times as often as males. It appears to become less common among older people. Up to half of people improve over a ten-year period. There is an ongoing debate about the naming of the disorder, especially the suitability of the word “borderline”.
Signs and Symptoms
Borderline personality disorder may be characterized by the following signs and symptoms:
- Markedly disturbed sense of identity
- Frantic efforts to avoid real or imagined abandonment and extreme reactions to such
- Splitting (“black-and-white” thinking)
- Severe impulsivity
- Intense or uncontrollable emotional reactions that often seem disproportionate to the event or situation
- Unstable and chaotic interpersonal relationships
- Self-damaging behavior
- Distorted self-image
- 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. Overall, the features of BPD include unusually intense sensitivity in relationships with others, difficulty regulating emotions, and impulsivity.
Other symptoms may include:
- Feeling unsure of one’s personal identity, morals, and values
- Having paranoid thoughts when feeling stressed
- Dissociation and depersonalization
- Stress-induced breaks with reality or psychotic episodes.
People with BPD feel emotions more easily, more deeply, and longer than others do. In addition, emotions may repeatedly resurge and persist a long time. Consequently, it may take more time for people with BPD than others to return to a stable emotional baseline following an intense emotional experience.
They often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment.
With BPD, they are often exceptionally enthusiastic, idealistic, joyful, and loving.
However, they may feel overwhelmed by negative emotions (“anxiety, depression, guilt/shame, worry, anger, etc.”), experiencing:
- Intense grief instead of sadness
- Shame and humiliation instead of mild embarrassment
- Rage instead of annoyance
- Panic instead of nervousness.
People with BPD are also especially sensitive to feelings of rejection, criticism, isolation, and perceived failure. Before learning other coping mechanisms, their efforts to manage or escape from their very negative emotions may lead to self-injury or suicidal behavior.
They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, they shut them down entirely.
While people with BPD feel joy intensely, they are especially prone to dysphoria, depression, and/or feelings of mental and emotional distress.
Since there is great variety in the types of dysphoria experienced by people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.
In addition to intense emotions, people with BPD experience emotional lability; or in other words, changeability. Although the term emotional lability suggests rapid changes between depression and elation, the mood swings in people with this condition actually fluctuate more frequently between anger and anxiety and between depression and anxiety.
Impulsive behavior is common, including substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending, and reckless driving.
Impulsive behavior may also include leaving jobs or relationships, running away, and self-injury.
People with BPD act impulsively because it gives them immediate relief from their emotional pain. However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.
A cycle often begins in which people with BPD:
- Feel emotional pain
- Engage in impulsive behavior to relieve that pain
- Feel shame and guilt over their actions
- Feel emotional pain from the shame and guilt
- Experience stronger urges to engage in impulsive behavior to relieve the new pain.
As time goes on, impulsive behavior may become an automatic response to emotional pain.
The lifetime risk of suicide among people with BPD is between 3% and 10%. There is evidence that men diagnosed with BPD are approximately twice as likely to complete suicide as women diagnosed with BPD. There is also evidence that a considerable percentage of men who complete suicide may have undiagnosed BPD.
Self-harm, such as cutting, is common and takes place with or without suicidal intent. The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts.
Nearly 70% of people with BPD self-harm without trying to end their life. Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.
In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide. Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.
People with BPD can be very sensitive to the way others treat them, by feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.
Their feelings about others often shift from admiration or love to anger or dislike after a disappointment, a threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called “splitting”, includes a shift from idealizing others to devaluing them.
Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers. Self-image can also change rapidly from healthy to unhealthy.
While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships.
BPD, like other personality disorders, is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction on the part of romantic partners, abuse, and unwanted pregnancy.
They often view the world as dangerous and malevolent.
People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.
They are often unsure about their long-term goals for relationships and jobs. This difficulty with knowing who they are and what they value can cause people with BPD to experience feeling “empty” and “lost”.
The often intense emotions experienced by people with BPD can make it difficult for them to control the focus of their attention—to concentrate. In addition, people with BPD may tend to dissociate, which can be thought of as an intense form of “zoning out”.
Dissociation often occurs in response to experiencing a painful event (or experiencing something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event, presumably to protect against experiencing intense emotion and unwanted behavioral impulses that such emotion might otherwise trigger.
Although the mind’s habit of blocking out intense painful emotions may provide temporary relief, it can also have the unwanted side effect of blocking or blunting the experience of ordinary emotions. This reduces access to the information contained in those emotions, which helps guide effective decision-making in daily life.
The DSM-5 defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self image, and affect, as well as markedly impulsive behavior.
The World Health Organization’s ICD-10 defines a disorder that is conceptually similar to borderline personality disorder, called (F60.3) Emotionally Unstable Personality Disorder.
F60.3 is categorized by two subtypes – Impulsive and Borderline.
- F60.30 Impulsive Type
At least three of the following must be present, one of which must be (2):
- 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 [see above], 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, substance abuse.
Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD showed a higher rate of also meeting criteria for:
- Mood disorders, including major depression and bipolar disorder
- Anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
- Other personality disorders
- Substance abuse
- Eating disorders, including anorexia nervosa and bulimia
- Attention deficit hyperactivity disorder
- Somatoform disorders
- Dissociative disorders
A 2008 study found that at some point in their lives, 75 percent of people with BPD meet criteria for mood disorders, especially major depression and Bipolar I, and nearly 75 percent meet criteria for an anxiety disorder.
Nearly 73 percent meet criteria for substance abuse or dependency, and about 40 percent for PTSD.
There are marked gender differences in the types of comorbid conditions a person with BPD is likely to have. A higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.
In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD. In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had significantly more frequent suicide attempts).
Many people with borderline personality disorder also have mood disorders, such as major depressive disorder or a bipolar disorder. It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa.
The mood swings of BPD and bipolar disorder tend to have different durations. In some people with bipolar disorder, episodes of depression or mania last for at least two weeks at a time, while the moods of people with BPD can change in minutes or hours.
The moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD do respond to changes in the environment. That is, a positive event would not lift the depressed mood caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD.
Similarly, an undesirable event would not dampen the euphoria caused by bipolar disorder, but an undesirable event would dampen the euphoria of someone with borderline personality disorder.
Long-term psychotherapy is currently the treatment of choice for BPD. There are six such treatments available:
- Dynamic Deconstructive Psychotherapy (DDP)
- Mentalization-Based Treatment (MBT)
- Transference-Focused Psychotherapy
- Dialectical Behavior Therapy (DBT)
- General Psychiatric Management
- Schema-Focused Therapy.
Medications are useful for treating comorbid disorders, such as depression and anxiety.
- Haloperidol may reduce anger
- Flupenthixol may reduce the likelihood of suicidal behavior.
- Aripiprazole may reduce interpersonal problems and impulsivity
- Olanzapine may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety.
- Valproate semisodium may ameliorate depression, interpersonal problems, and anger
- Lamotrigine may reduce impulsivity and anger
- Topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger, and general psychiatric pathology.
- Amitriptyline may reduce depression.
With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. In addition to recovering from distressing symptoms, people with BPD also achieve high levels of psychosocial functioning.