Borderline personality disorder (BPD) is a condition characterized by chronic instability in relationships, difficulty with empathy, extreme emotional reactions, and chronic fear of abandonment. The diagnosis is controversial, with some mental health professionals arguing that borderline personality is not a mental health condition at all, and others arguing that it may be a response to early childhood trauma rather than an actual mental health issue.
To qualify for a diagnosis of BPD, a person must exhibit symptoms on an ongoing basis. Most people exhibit some of the symptoms of BPD at some times, particularly when emotionally distressed. Thus the Diagnostic and Statistical Manual (DSM-5) establishes criteria for determining whether a person’s symptoms constitute a diagnosable personality disorder. According to the DSM-5, a person with BPD must show the following general symptoms of a personality disorder prior to being diagnosed with a specific personality disorder:
- Impairments with self-direction or identity, as well as interpersonal challenges.
- At least one troubling personality trait. For instance, a tendency to frequently lie might qualify.
- Relative stability in personality traits across time. A person who temporarily shows symptoms of BPD would likely not qualify for a diagnosis.
- The challenges in functioning associated with the condition must not be better explained by environmental challenges or normal development. Children show many signs of BPD, but the emotional regulation challenges children experience are part of normal development.
- The challenges associated with the condition are not better explained by a medical condition such as a brain tumor, or by substance abuse.
Once a person meets these diagnostic criteria, he or she must then meet a detailed list of diagnostic criteria for BPD. Those include:
- Emotional instability: People with BPD may experience intense mood swings, as well as emotions that seem unusually intense for the situation. A minor rebuke at work might initiate days of self-loathing. Many people with BPD see the world in terms of black and white, with people, places, and things rapidly alternating between being all good and all bad.
- Anxiety: People with BPD are prone to panic and distress, and feel particularly vulnerable in the face of uncertainty.
- Separation anxiety: BPD is characterized by an intense and chronic fear of abandonment or rejection. For a person with BPD, being rejected for a second date might feel as bad as ending a multi-year relationship.
- Depression: People with BPD often feel depressed or hopeless, and may experience difficulty recovering from setbacks. Shame, guilt, and feelings of inadequacy are common.
- Impulsive behavior: People with BPD often act without thinking. They may engage in compulsive behaviors, or resort to self-harm to express their feelings or cope with pain.
- Risk-taking: BPD results in needless risk-taking. People with this condition may not assess risk, or may be unable to accurately evaluate the danger of a particular decision. Spending $10,000 on a shopping spree might seem like a great idea.
- Interpersonal antagonism: People with BPD may long for close relationships, but often experience hostile, angry, and resentful feelings toward those they love. They may become unreasonably angry in response to minor slights, or alternate between idealizing and devaluing the people they love the most.
Many, though not all, people with BPD were abused or abandoned as children. Thus the condition may be caused by early environmental factors rather than genetic disposition. Some estimates suggest that as many as 75% of people with BPD have a history of sexual abuse, which might help explain why there are so many more women diagnosed with the condition than men. There is some evidence that BPD is an intergenerational disease, with parents passing the condition to their children through environmental exposure, not genetics. A parent whose unstable moods traumatize his or her child may cause that child to develop unhealthy coping skills that eventually lead to BPD.
Until the last decade or two, borderline personality was regarded as one of the most challenging psychiatric conditions to treat. New research, greater empathy for those with BPD, and more effective psychoactive medications have all resulted in better treatment options. Some of the most useful treatments for BPD include:
- Psychotherapy: While any type of psychotherapy may help, dialectical behavioral therapy (DBT) was designed specifically to help those with BPD. This approach blends individual and group therapy sessions with lots of homework. Participants focus on cultivating stress management and interpersonal skills while exploring the ways BPD affects their lives.
- Medication: For people with BPD who struggle with depression or anxiety, antidepressants or anti-anxiety medications can be helpful.
- Social support: People with BPD can behave in ways that can be alienating and even abusive to those around them. The behavior, though, results from intense distress, not a conscious desire to be hurtful. Identifying sources of social support and having allies in one's treatment process can help a person with BPD work through any relationship issues they may experience.
Not everyone agrees that borderline personality is a legitimate medical condition. BPD derives its name from its original diagnostic criteria, which suggested that people with BPD were “on the border” of psychosis. Contemporary mental health experts do not view mental health conditions in this way.
Though 75% of people with BPD are women, there's little evidence that the condition is caused by biological factors, suggesting that something else may be at play. Some feminist groups have pointed out that BPD may be a normal reaction to abnormal circumstances, such as abuse or chronic stress.
A related condition, complex post-traumatic stress (C-PTSD) shares many of the same diagnostic criteria as BPD, but does not come with the stigma of a personality disorder diagnosis. Some advocates argue that the two conditions should be merged, but it's important to note that BPD and C-PTSD are not indistinguishable.
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