All to Know About Borderline Personality Disorder

Your emotions, moods, and behaviors are all over the place, and you can’t seem to control or soothe them. To cope with your shifting emotions, you act in self-destructive or impulsive ways. You might want to harm yourself or behave recklessly. Perhaps one day, your best friend seems like the most perfect person in the world, and the next day you suddenly decide that he or she is your enemy. The bottom line is that you may not be able to hold on to stable relationships or even to a reliable sense of yourself.

These are some of the many facets of the complex and often misunderstood mental health condition called borderline personality disorder (BPD). If you have been diagnosed with BPD or feel as if some of these characteristics describe you, there is help available. BPD is now considered a highly treatable condition, and many people with BPD are able to lead happy and productive lives. While the spectrum of BPD varies in severity, with some people needing more intense intervention and others getting better over time, everyone with BPD can greatly benefit from evidence-based treatments.

What Is Borderline Personality Disorder?

The history of how the medical community viewed BPD is a story of misunderstanding, but the story has a happy ending. In the 1960s and 1970s, BPD was a diagnosis given somewhat indiscriminately, often to patients who were considered especially difficult, according to Francis Mondimore, MD, an associate professor in the department of psychology and behavioral sciences at Johns Hopkins Medicine, director of the Mood Disorders Clinic at Johns Hopkins Bayview Medical Center in Baltimore, and the co-author of Borderline Personality Disorder: New Reasons for Hope. “It also acquired this idea that it was something that was basically untreatable, and there was really not much you could do for these patients,” Dr. Mondimore says.

The decades that followed came with a surge of research that cleared up many of the misunderstandings surrounding BPD and the people living with it. “The thinking of borderline personality disorder went from ‘these are the worst of the worst patients that you really can’t do anything for’ to ‘this is a very treatable problem.’ And with treatment, people actually do very well,” says Dr. Mondimore.

Borderline personality disorders tend to emerge during the teen years. Based on studies, we know that BPD patients often seek treatment around age 18, but their symptoms usually begin years before that. As they age, most people with BPD get better. Self-harm and thoughts of suicide are often a more pervasive problems in younger people. The impulsive behaviors that many display early in the course of BPD are considered the most likely or first to fade with age and maturity.

“It’s a condition of youth that usually begins early in adolescence and peaks during late adolescence or the early young adult years,” explains Joel Paris, MD, a professor in the department of psychiatry at McGill University in Montreal, Quebec, Canada. “But by 30 or 35, most people are better—even if they’re untreated—and some people will be able to manage the symptoms and move on to have a good life, although treatment probably makes that go faster.”

Who Gets Borderline Personality Disorder and Why?

About 1.4% of adults in the U.S. are estimated to be affected by BPD. Doctors used to think that BPD affected women more than men, but more recent research has revealed that men and women develop it equally. However, women do make up a greater proportion of the people who seek treatment. Women and men also seem to develop different symptoms. Some studies have found that BPD in men is more likely to reveal itself through anger, violence, and substance use, while in women it’s more likely to cause issues related to emotional eating, changes in mood, depression, and anxiety.

While there aren’t significant differences in the prevalence of BPD among races, there is some evidence that BPD is diagnosed—possibly overly diagnosed—almost twice as often among lesbian, gay, and bisexual people compared to heterosexual people. According to one study, this may be because doctors diagnosing the problem are unable to properly differentiate between the ways that these groups may have to cope with stress surrounding their identity and fitting into society, and legitimate symptoms of BPD.

There is no simple explanation for why people develop BPD. “You’re talking about this collection of problems that grow out of one another and reinforce one another, and to look for simple answers and simple causes is frustrating because they’re not there,” says Dr. Mondimore.

Borderline Personality Risk Factors

Research has found that certain factors may play a role in fueling BPD or raise the risk of getting it:

  • Having a family member with BPD
  • Changes in the brain that affect impulse control and emotional regulation
  • Trauma, including a history of abuse, abandonment, unstable relationships, or other adversities, especially during childhood

While these factors seem to be associated with a higher risk of getting BPD, they are not at all definitive. Many people with these risk factors will not get BPD, and many others get BPD without having them.

It is particularly important to recognize that childhood trauma is not the main or only cause of BPD, according to D. Bradford Reich, MD, the assistant medical director of The Pavilion at McLean Hospital in Belmont, Massachusetts, and assistant professor of psychiatry at Harvard. “I’ve seen the evolution of the way that these patients see themselves, and I think to understand themselves as being borderline is in some ways more helpful to them than seeing themselves as trauma victims,” Dr. Reich says. “And some are, but there are plenty who’ve never been traumatized. They were just born with this really hypersensitive temperament that they had difficulty regulating from day one.”

Borderline Personality Disorder Symptoms

There are many possible symptoms of BPD, and their frequency and severity can all vary from person to person. Some people may be able to prevent symptoms or keep them at bay by staying away from circumstances that trigger their symptoms, while unavoidable occurrences may trigger others.

BPD symptoms include:

  • Mood swings
  • Uncertainty surrounding one’s identity
  • Unpredictable or erratic shifts in interests, values, or opinions
  • Narrow-minded views, such as seeing things or people as entirely positive or entirely negative
  • Unstable relationships with friends, family, and romantic partners
  • Fear of abandonment and coping with abandonment fears by impulsively entering into or withdrawing from relationships
  • Engaging in impulsive and risky behaviors like abusing substances, lavish spending, unsafe sex, or driving recklessly
  • Self-harming behaviors such as cutting or self-inducing pain
  • Suicidal ideation
  • Threatening suicide
  • Feeling empty, alone, or disassociated from reality or oneself
  • Intense anger displayed in inappropriate ways
  • Trust issues

Holding extreme and volatile views on people or things is sometimes referred to as “splitting.” According to Dr. Reich, splitting describes an inability to “simultaneously hold in mind positive and negative images of yourself and other people,” resulting in views or feelings that are either black or white, all or nothing, or good or bad. For example, someone with BPD may rapidly swing from liking a person to intensely disliking them. “The same thing can happen in relation to images of yourself,” Dr. Reich says. “You may go from feeling sort of OK about yourself to intense self-hatred if you have a borderline personality disorder.”

Two other terms that may come up in relation to BPD are insomnia and hypersexuality. However, according to experts, neither of these symptoms are a core facet of BPD. Unsurprisingly, insomnia is a common and frustrating affliction for some people with BPD, just as it is common in many other mental health conditions. For people with BPD, insomnia and other sleep problems can exacerbate existing symptoms, like difficulty regulating emotions.

Hypersexuality is less common, experts say, but for some people with BPD, compulsive sexual behavior may be an outgrowth of their impulsivity or unstable relationships. “There’s a certain subset of borderline patients who may use sexual impulsivity as a way of soothing themselves or feeling better,” says Dr. Reich. “But I wouldn’t say it’s a hallmark of borderline personality disorder. There’s certainly some patients who engage in it, but there are plenty who have very impoverished social and romantic lives.”

How is BPD Diagnosed?

If you are concerned you may have BPD, the first step is to make an appointment with a doctor trained in treating mental health disorders, like a psychiatrist or psychologist. At the appointment, the doctor will:

  • Conduct an interview with you, asking a variety of questions about your symptoms.
  • Learn about your personal and family history of mental illness and other medical problems.
  • Perform a physical exam to see if you have any other conditions or issues that may be causing your symptoms.
  • Utilize diagnostic measurements such as standardized tests.

Like many other mental health conditions, BPD may be diagnosed, in part, by comparing one’s symptoms to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Borderline Personality Disorder DSM-5 Criteria

To be officially diagnosed with BPD, one typically has to meet five or more of the following nine criteria:

  1. Intense fear of abandonment leading one to take frantic or extreme measures to avoid feeling or being abandoned
  2. Continuously engaging in unstable and intense relationships and experiencing shifting and extreme feelings toward people (like switching between loving and hating someone)
  3. Uncertain and unstable self-image or sense of self
  4. Engaging in at least two types of impulsive behaviors or activities that may be damaging to oneself (such as reckless spending, unsafe sex, abusing substances, binge eating)
  5. Repeated threats of suicide, suicide attempts, or self-harm
  6. Intense mood swings (like a period of depression, anxiety, and irritability that lasts for a few hours to a few days)
  7. Continuously feeling empty
  8. Difficulty keeping anger under control and sudden, inappropriate, and intense bouts of anger or aggression without cause
  9. Feeling paranoid or disassociated from the world and oneself in stressful situations

The variability of the DSM-5’s criteria for BPD shows how this mental disorder can look very different from one individual to the next.

Experts have different opinions on whether there are distinct categories or “types” of BPD, and research reveals a similarly mixed bag.

For example, Dr. Mondimore generally categorizes BPD cases by severity. “There’s a wide variation in severity such that some people with the problem are extremely impaired and can’t work, can’t maintain relationships, and sometimes can’t even support themselves,” Dr. Mondimore says. “And then there are other people who are functional and have less severe behavioral problems, so can be self-sufficient.”

Read more : Mood Disorders

Borderline Personality Disorder Treatment

Several evidence-based treatments for BPD have been proven to help people manage or eliminate symptoms and lead happier, more productive lives.

Treatment can vary in intensity depending on the individual and the severity of their condition and symptoms. Some people do well with therapy sessions at their practitioner’s office, while some with more severe symptoms may need inpatient care in a hospital setting.

While some people can get better without treatment, and not everyone with BPD needs intensive treatment, treatment can benefit anyone with BPD as long as they’re open to accepting help and their provider is a mental health professional with expertise in providing BPD therapy. One reason that provider experience is so important is that people with BPD often have other mental illnesses or their BPD symptoms may be confused with another mental illness, and treatments that are best for one condition or one person may not work for another. BPD treatment “is not a one-size-fits-all problem,” says Dr. Mondimore.

Also, people with BPD who don’t get appropriately treated may face higher risks of developing other medical or mental illnesses.

Some of the mental health conditions that sometimes overlap or become a co-morbidity with BPD include:

Getting treatment is particularly important in light of the link between BPD and self-harm or suicide. The right treatment helps reduce self-harming behaviors and lowers the number of emergency room visits related to suicide attempts or thoughts of suicide.

What Are the Best Borderline Personality Disorder Treatment Options?

Talk therapy, also called psychotherapy, is the primary treatment for BPD. This can be done in a group or one-on-one sessions with a mental health professional who specializes in treating BPD. These specific forms of psychotherapy can be particularly beneficial:

Dialectical behavior therapy (DBT)

DBT is a form of psychotherapy specifically aimed at treating BPD. Through structured therapy sessions and/or doing specific exercises, DBT can help people become more aware of their emotions, of what may be triggering them, and how to be more in control of these emotions. DBT can also help people avoid self-destructive and self-harming behaviors and create better, more stable relationships.

Cognitive behavioral therapy (CBT)

CBT is a form of talk therapy that helps many different types of mental health issues. For people with BPD, it can help them identify and understand the thoughts and feelings at the root of many of their dysfunctional views and actions and then change them to reduce anxiety, mood swings, thoughts of suicide, self-harming, and more.

Schema-Focused therapy

This therapy helps people identify negative views they may hold or negative patterns they may engage in and shift them to be more positive and healthier.

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

STEPPS shows people how to build the skills to control their reactions to triggering situations. Family and friends are also involved in the STEPPS process.

Unlike some other mental health conditions, BPD is not treated with medication alone. Medication is often used in addition to psychotherapy to target specific symptoms like anxiety, depression, and mood swings. Possible medications include antidepressants, antianxiety, antipsychotics, or mood stabilizers.