Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a condition characterized by difficulties regulating emotion. This means that people who experience BPD feel emotions intensely and for extended periods of time, and it is harder for them to return to a stable baseline after an emotionally triggering event.

This difficulty can lead to impulsivity, poor self-image, stormy relationships and intense emotional responses to stressors. Struggling with self-regulation can also result in dangerous behaviors such as self-harm (e.g. cutting).

It’s estimated that 1.6% of the adult U.S. population has BPD, but that number may be as high as 5.9%. Nearly 75% of people diagnosed with BPD are women. Recent research suggests that men may be equally affected by BPD but are commonly misdiagnosed with PTSD or depression.

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Symptoms

People with BPD experience wide mood swings and can display a great sense of instability and insecurity. Per the Diagnostic and Statistical Manual diagnostic framework, some key signs and symptoms may include:

  • 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 that can have dangerous outcomes, such as excessive spending, unsafe sex, substance abuse or reckless driving.
  • Self-harming behavior including suicidal threats or attempts.
  • Periods of intense depressed mood, irritability or anxiety lasting a few hours to a few days.
  • 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.

Causes

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.

Diagnosis

There is no definitive medical test to diagnose BPD, and a diagnosis is not based on one specific sign or symptom. BPD is best diagnosed by a mental health professional following a comprehensive clinical interview that may include talking with previous clinicians, reviewing previous medical evaluations and, when appropriate, interviews with friends and family.

Treatment

There are good long-term outcomes for people experiencing BPD who engage in a comprehensive treatment plan. Most experience the best results using a combination of psychotherapy, peer and family support and medications (when indicated) to address their symptoms. People with BPD often have other co-occurring conditions and their treatment plan should address these as well.

Work with your treatment team to understand the risks and benefits of each of these individual courses of action as well as how they work with each other.

Psychotherapy

Psychotherapy is considered the cornerstone for treating BPD because it aims to address the emotional dysregulation associated with the condition. A hallmark of effective treatment is learning to master dysregulation with coping skills, insight and acceptance. There are several types of psychotherapy that have shown to be effective in doing this:

  • Dialectical behavioral therapy (DBT) focuses on teaching coping skills to combat counterproductive urges, regulate emotions and improve relationships. Involving individual and group work, DBT encourages practicing mindfulness techniques such as meditation, regulated breathing and self-soothing. DBT has been shown to be effective in reducing suicidal behavior, psychiatric hospitalization, treatment dropout, substance abuse, anger and interpersonal difficulties.
  • Cognitive behavioral therapy (CBT) helps address the negative thinking and behaviors associated with BPD. The goal of this therapy is to recognize negative thoughts and learn effective coping strategies.
  • Mentalization-based therapy (MBT) teaches people how to become conscious of their internal states and how to develop empathy for other people’s experiences. This treatment is also used to explore emotions and develop alternative explanations for negative interactions with others.

Medications

There is no singular medication designed to specifically treat the core symptoms of BPD. Medications can be useful in treating certain symptoms associated with BPD, such as depression and anxiety. They can also be used to help increase a person’s ability to engage in psychotherapy.

Level Of Care

While most people can live in the community during their treatment (outpatient), higher levels of care may be useful at moments when more intensive clinical support is needed. For example, a hospital inpatient unit can provide a safe environment for a person with BPD who is actively suicidal.

In the DBT framework, the goal is usually to learn coping skills while in the community; it is not organized around inpatient care. Though, there are some facilities that have a DBT track in inpatient-partial hospital program, which is a model where you sleep at home and attend during the day. It’s important to determine the level of care you or your loved one might require before engaging in (and throughout the duration of) treatment.