Borderline Personality Disorder Explained

Borderline Personality Disorder (BPD) is a disorder of emotion regulation characterized by rapidly fluctuating mood, behavioral impulsivity, and interpersonal problems. Although most experts agree that the name "Borderline Personality Disorder" is not descriptive of the actual problems associated with the disorder, the name persists in the current version of the Diagnostic and Statistical Manual, the DSM-V.

People with Borderline Personality Disorder often experience the following symptoms:

• Problems with regulating emotions and thoughts

• Impulsive and reckless behavior

• Unstable relationships with other people.

As Borderline Personality Disorder is a problem of emotion regulation, individuals with this diagnosis often have other psychiatric disorders, including anxiety disorders, mood disorders, alcohol and drug abuse, and eating disorders.

Causes of Borderline Personality Disorder

Although research into the possible factors implicated in the development of Borderline Personality Disorder is still at an early stage, researchers agree that both genetic and environmental factors influence the development of the disorder. We know from some studies that Borderline Personality Disorder is strongly genetically loaded, meaning it is inherited. Other research has shown individuals can inherit their temperament and personality traits, specifically aggression and impulsivity. Researchers are currently mapping genes that may aid in emotion regulation and impulse tolerance for additional genetic factors associated with Borderline Personality Disorder. In addition to purely biological or genetic factors, current research suggests social influences likely increase the risk for Borderline Personality Disorder. Being part of a community characterized by unstable or unpredictable relationships likely increases the risk of developing Borderline Personality Disorder. 

Symptoms of Borderline Personality Disorder

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

1. Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived

2. A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)

3. Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)

4. Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating

5. Recurring suicidal behaviors or threats or self-harming behavior, such as cutting

6. Intense and highly changeable moods, with each episode lasting from a few hours to a few days

7. Chronic feelings of emptiness and/or boredom

8. Inappropriate, intense anger or problems controlling anger

9. Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

10. Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.

Suicide and Self-Harm in Borderline Personality Disorder

Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with Borderline Personality Disorder have suicidal behaviors, and about 4 to 9 percent commit suicide. Suicide is one of the most tragic outcomes of any mental illness. Some Borderline Personality Disorder treatments can help reduce suicidal behaviors.  For example, one study showed that Dialectical Behavior Therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy or talk therapy. DBT also reduced the use of emergency room and inpatient services and retained more participants in therapy compared to other approaches to treatment for Borderline Personality Disorder.

Unlike suicide attempts, self-harming behaviors in Borderline Personality Disorder do not stem from a desire to die. However, some self-harming behaviors may be life-threatening. Self-harming behaviors linked with Borderline Personality Disorder include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with Borderline Personality Disorder may self-harm to help regulate their emotions, punish themselves, or express their pain. They do not always see these behaviors as harmful.

Accurate Diagnosis of Borderline Personality Disorder

Unfortunately, Borderline Personality Disorder is often underdiagnosed or misdiagnosed. A psychologist experienced in diagnosing and treating mental disorders can detect Borderline Personality Disorder based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms. The psychologist may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with Borderline Personality Disorder,  making it difficult to distinguish Borderline Personality Disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.

Women with Borderline Personality Disorder are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, Borderline Personality Disorder is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder. According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with Borderline Personality Disorder also meet the diagnostic criteria for another mental illness. Other illnesses that often occur with Borderline Personality Disorder include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat Borderline Personality Disorder and other mental disorders.

DBT Treatment for Borderline Personality Disorder

Although as few as twenty years ago, it was commonly thought Borderline Personality Disorder was untreatable, a flood of new research indicates it can be effectively treated with a special form of Cognitive Behavioral Therapy (CBT) called Dialectical Behavior Therapy (DBT). DBT was developed by a psychologist by the name of Marsha Linehan. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.

In the development of Dialectical behavior therapy (DBT), Marsha Linehan focuses on the concept of mindfulness, or being aware of and attentive to the current situation. DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. DBT differs from traditional CBT in that it seeks a balance between changing and accepting beliefs and behaviors.

DBT can be provided one-on-one between the therapist and the patient and in a group setting. Therapist-led DBT group sessions may help teach people with Borderline Personality Disorder how to interact with others and how to express themselves effectively. Families of people with Borderline Personality Disorder may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.

Some therapies, such as DBT-family skills training (DBT-FST), also developed by Marsha Linehan, include family members of people with Borderline Personality Disorder in treatment sessions. These types of programs help families develop skills to better understand and support a relative with Borderline Personality Disorder.  Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in Borderline Personality Disorder. Studies with other mental disorders suggest that including family members can help in a person's treatment.

Some symptoms of Borderline Personality Disorder may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent. People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder. However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with Borderline Personality Disorder had a relapse after remission.

For a directory of California DBT Programs, visit the DBT California Directory. 

Medications for Borderline Personality Disorder

No medications have been approved by the U.S. Food and Drug Administration to treat Borderline Personality Disorder.  Only a few studies show that medications are necessary or effective for people with this illness. However, many people with Borderline Personality Disorder are treated with medications in addition to psychotherapy. While medications do not cure Borderline Personality Disorder,  some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time, but there is little evidence that this practice is necessary or effective. Medications can cause different side effects in different people. People who have Borderline Personality Disorder should talk with their prescribing doctor about what to expect from a particular medication.

This information is provided courtesy of the National Institute of Health.