What you need to know about borderline personality disorder

Research indicates that 1.4% of the adult U.S. population¹ experiences BPD.

An estimated 75% of those diagnosed with BPD are women. However, an equal number of men may be affected¹ — who have been incorrectly diagnosed with depression or post-traumatic stress disorder instead.

The most common age for a person to first present with BPD is in late adolescence.²

A 10-year follow-up study on recovery from BPD³ found that 93% of patients' symptoms went into remission for two years and 86% had a remission that lasted four years. Only 15% experienced a symptomatic recurrence after a sustained remission.

Not everyone with BPD experiences the same symptoms. However, there are a number of diagnostic criteria that are characteristic of borderline personality disorder. These traits are primarily:

Intense emotions and overwhelming feelings

A core symptom of BPD is extreme mood swings and emotions. Events that other people may seem able to shrug off — for example, being criticized at school or work — can trigger extreme sadness or anger. 

These moods are usually very intense and can last for a few minutes to several hours.

Sometimes people with borderline personality disorder engage in destructive or self-harming behaviors like binge-drinking alcohol or self-injury through cutting in an attempt to cope with their feelings.

Instability in relationships

A common symptom of BPD is intense but unstable, short-lived relationships that are characterized by quickly changing feelings, such as intense love or hate.

Feeling hurt or disappointed can trigger intense feelings of abandonment and other painful emotions.

Impulsive and unwanted behaviors

People with BPD can struggle with impulsive acts that they later regret or have brought unwanted consequences.  These behaviors may include:

• Self-injury

• Gambling

• Binge eating 

• Alcohol and/or drug abuse

• Spending sprees

• Reckless driving

• Engaging in unprotected sex

Deliberate self-harm

Self-injury, such as burning or cutting can also be a symptom of BPD.  Suicidal thoughts may be present (although not all self-harm is associated with thoughts of dying or suicide).

Self-injury may be a temporary distraction from undesirable emotions or a way of stimulating endorphins for temporary pain relief. However, the consequences such as infection, or accidental fatal injury can be severe or irreversible.

So, accessing professional care is vital. If you have BPD, a psychiatrist can help you develop constructive coping mechanisms and reduce harmful urges.

Unclear or shifting self-image

If you have BPD, your sense of self may be unstable. There are times when you feel good about yourself, and other times you experience self-hatred, possibly to the point of believing you are “evil.”

People with BPD may lack a clear idea of who they are or their purpose in life. They may keep changing jobs, friends, lovers, goals, values, sexual identity, and even their fundamental beliefs.

Chronic feelings of emptiness

BPD is often marked by intense feelings of loneliness or emptiness.

Paranoia or dissociation

If you have PBD you may feel disconnected from your body or reality, or experience paranoia (such as intense worry that people don’t want to be around you).

Difficulty managing intense or inappropriate anger

A person with BPD may get into physical fights or have trouble controlling frequent bouts of anger.

Criteria for diagnosis

It is important to note that in order for a clinical BPD diagnosis to be made, you must exhibit five or more of the above-mentioned symptoms, usually from adolescence or early adulthood. These symptoms will have a significant impact on major areas of your life, such as your career, family, and relationships. 

Concurrent disorders

A person with BPD often lives with other disorders as well — which you will sometimes hear described by the medical community as co-occurring or concurrent disorders. That means that they occur at the same time.

For a person with BPD, these simultaneous disorders might include depression, bipolar disorder, substance abuse, eating disorders, or anxiety. When BPD is successfully treated, other disorders can improve substantially.

Complications

BPD can be damaging to important areas of your life. It can negatively impact intimate relationships, jobs, education, social interactions, self-esteem, and socioeconomic status. Untreated, BPD can lead to repeated job loss, poor academic performance, legal issues, conflict-filled relationships, divorce, suicidal ideation, and suicide.

There isn't one main cause of BPD that researchers have identified. Studies indicate that there are a multitude of factors, including genetics, brain differences, environmental factors, and life experiences.

Genetics

Research¹ suggests that BPD could be an inherited genetic condition among family members. If you have a BPD history in your family, you are at a higher risk of developing the condition than someone who doesn't.

Brain factors

Neuroimaging studies show that people with borderline personality disorder can have structural and functional differences in their brains compared with those without BPD.  However, it is not yet fully clear whether this causes the condition or is simply a result of having BPD.  Borderline personality disorder has also been associated with genes that affect the neurotransmitter serotonin. 

Environmental factors

Several environmental factors have been associated with BPD.  There is a strong link between having BPD and having experienced traumatic or major adverse life events, including childhood abuse or parental neglect.

Diagnosis

Currently, there isn't a single “gold standard” test to indicate a BPD diagnosis. However, a trained mental health professional can determine a diagnosis after a comprehensive assessment. 

Assessment

BPD can be diagnosed by professionals, including therapists, psychiatrists, or clinical social workers. Screenings for BPD can be done face-to-face, online or in-person. A complete assessment for BPD includes:

• A comprehensive interview with a candid discussion of past and present symptoms 

• A review of the patient's individual and family medical history

• A physical exam to rule out other causes of symptoms

• Additional interviews with family and friends

Psychiatric evaluation

Psychiatric evaluations follow the official interview guide from the DSM-5 criteria. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)² is a guideline published by the APA to diagnose BPD and other mental health problems. During an evaluation, the clinician will ask you questions related to the DSM-5 criteria for borderline personality disorder.

The DSM-5 criteria state that five of the nine signs and symptoms should be present for someone to be diagnosed with BPD. You must exhibit at least five out of the following nine symptoms to be diagnosed with BPD:

• Extreme fear of abandonment

• Unstable self-image

• Problems with emotion regulation, including mood swings 

• Problems controlling anger

• Recurring feelings of emptiness

• Self-harming behavior

• Dangerous impulsive behaviors such as reckless driving or unsafe sex

• Unstable self-image

• A long pattern of unstable and intense relationships (associated with idealization and devaluation)

• Dissociative symptoms or transient paranoid thoughts 

The McLean Screening Instrument

The McLean Screening Instrument (MSI-BPD) uses 10 questions to help people identify and self-report their BPD symptoms. It can be an important step in determining whether or not further evaluation for BPD is appropriate. BPD has been described as an underdiagnosed condition, which is part of why an effective screening tool is vital.³

If you or someone you care about are looking to talk about borderline personality disorder, the National Alliance on Mental Illness offers a free NAMI HelpLine⁴ with phone, email, and texting options.

If you are in crisis, you can speak with a trained crisis counselor 24/7 by calling the National Suicide Prevention Hotline⁵ at 1-800-273-TALK (8255).

The cornerstone of BPD treatment is generally psychotherapy, usually delivered on an outpatient basis. Medications may be offered short-term to help control symptoms when they are severe, or to treat comorbid disorders.  Hospitalization may be needed if safety is at risk. However, treatment is generally more effective outside of a hospital.

Psychotherapy Treatments 

Psychological treatments are the best way to treat borderline personality disorder.  Therapy is typically delivered 1:1 but group therapy may be recommended as well.  There are several types of psychotherapy treatments found to be effective with BPD. These include:

Dialectical behavior therapy (DBT) is an evidence-based form of cognitive therapy that focuses on behavioral and mindfulness approaches.

Schema therapy (ST) may take a group therapy format or a combined group-individual format.

Mentalization-based therapy (MBT) helps people develop the capacity to mentalize, which includes ​​how we make sense of each other and ourselves.

Medications

Notably, as of now, there is no drug approved by the FDA for the treatment of BPD. However, certain medications can help with the symptoms and co-occurring problems like depression, impulsiveness, aggression, or anxiety. These medications include mood-stabilizing drugs, antipsychotics, or antidepressants. It is essential to talk to a physician about the benefits and side effects of these drugs.

Since people with BDP require specialized care, it is important that the condition is diagnosed and treated by certified mental health professionals.

Which types of doctors and healthcare professionals are involved in diagnosing BPD?

Psychiatrists, psychologists, and licensed clinical social workers can diagnose BPD. It can also be evaluated by GPs, nurses, social workers, and occupational therapists with special training.

Which types of doctors and healthcare professionals are involved in treating BPD?

Primary healthcare providers (such as family doctors) may not be qualified to diagnose and treat BPD. However, they can refer you to a certified, experienced mental health provider in your area.

When should you get emergency help for borderline personality disorder?

Call 911 if someone you care about is in a crisis which may sound or look like:

• Deliberately injuring themselves

• Acting out aggressively

• Expressing thoughts of suicide 

• Being disoriented about  who they are/where there are

• Hallucinating (hearing or seeing things that are not real)

If you are the person in crisis, you can also call the National Suicide Prevention Hotline at 1-800-273-TALK (8255).

Borderline personality disorder is treatable

The complications of BPD can be painful. Small things often trigger intense reactions, and once upset, you lose control over your emotions and thinking. When you are struggling with overwhelming emotions, you can't think straight or stay grounded. You act dangerous or hurl hurtful words that you feel guilty or ashamed of afterward.

For most people living with BPD, it is a tumultuous disorder that often seems inescapable. However, it is possible to get relief from the excruciating symptoms of BPD with the proper treatment and support.

Why is it called borderline personality disorder?

In 1938, when many other personality disorders were first described, Adolph Stern spoke of patients who were neither precisely psychotic or neurotic¹, which led to the introduction of the word ‘borderline’ — as it ‘bordered’ on other conditions. Modernly, BPD specialist Linehan² suggests that BPD could be best described as an emotional regulation disorder, or simply dysregulation disorder. She also describes that “People with BPD are like people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”³

What is the difference between borderline personality disorder and bipolar disorder?

Bipolar disorder is a type of mood disorder. People with the condition experience episodes of depression (low mood) and also separate episodes of mania or hypomania (high mood) that may last for days to weeks.

Borderline personality disorder is a type of personality disorder, meaning that the symptoms are considered to be a long-term and enduring pattern rather than episodic.

Although the two conditions are distinct, depending on the symptoms you have, it may take some time to make a diagnosis or distinguish between the two. It is also possible to have both conditions together.

What is the best way to communicate with someone who has borderline personality disorder?

If someone you love is struggling with BPD, one way to help them is through robust communication. Understanding the signs and symptoms of BPD is the first step to achieving better communication with a loved one living with the condition. Here are a few tips for communicating with someone with BPD in a healthy,  productive way:

Listen actively

Offer your full attention when a person living with BPD is talking. Ask questions and rephrase what they have said to show that you heard them. Avoid distractions and schedule a time dedicated to talking.

Be patient

Don't get frustrated if you are not getting anywhere communicating with your loved one with BPD. It may be difficult and take ample time for them to open up about their feelings.

Think before responding

Instead of responding promptly to what your loved one has said, take time to offer your response. This way, you find a better way to provide a measured and well-thought-out response that could diffuse the situation.

Provide validation

Many people with BPD were raised in invalidating environments where their feelings, desires, and concerns were dismissed as wrong or unmerited. They may seem irrational and or as though overreacting to a perceived slight. They are quick to misinterpret other people's intentions. Instead of responding to them with invalidating statements such as "don't be ridiculous," "you’re acting weird, stop it," replace such try using statements like " Help me understand why are you feeling this way" or "I understand how that has really upset you."