Borderline personality disorder (BPD) is a condition characterized by chronic instability in relationships, extreme emotional reactions, and chronic fear of abandonment.
The diagnosis is controversial: BPD is listed in the Diagnostic and Statistical Manual (DSM-5) with other personality disorders. However, some mental health professionals argue that borderline personality is not a mental health condition at all, while others believe 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 DSM-5 establishes criteria for determining whether a person’s symptoms constitute a diagnosable personality disorder. 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 these personality traits across time. A person who temporarily shows symptoms of BPD would likely not qualify for a diagnosis.
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- 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, they must then meet 5 of the following 9 criteria to be diagnosed with BPD. Those include:
- Separation anxiety: BPD is characterized by an intense and chronic fear of abandonment or rejection. Being turned down for a second date, for example, might cause as much distress as a breakup for some people.
- Interpersonal/relationship difficulties: People with BPD may long for close relationships but frequently experience hostile, angry, or resentful feelings toward those they love. They may become disproportionately angry in response to minor slights or alternate between idealizing and devaluing the people they love the most. This is known as splitting.
- Unstable or unclear sense of self: People with BPD may struggle with their identity or frequently appear to modify or alter aspects of their identity. This may be done, consciously or unconsciously, out of a desire to appeal to others, find the love they seek, or discover their true identity or self.
- Impulsive behavior: People with BPD may act impulsively, or without thinking, in ways that can cause harm. They may engage in risky or compulsive behaviors (sex, shopping, reckless driving) or resort to self-harm to express their feelings or cope with emotional distress.
- Suicidal ideation or behavior: This may include thoughts of suicide, suicide attempts, or suicide threats. Some people with BPD may also engage in self-mutilating behavior.
- 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.
- Feelings of emptiness: People with BPD may experience chronic, persistent feelings of emptiness. These feelings may relate to a person’s fear of abandonment or the lack of a clearly defined sense of self.
- Anger issues: Many people who have BPD experience intense anger and/or find it difficult to control their anger.
- Dissociation: Dissociation may occur in some people who have BPD. Others may experience paranoid thinking in relation to stress or other difficulty.
Many people with BPD were abused or abandoned as children. Some estimates suggest as many as 75% of people with BPD have a history of sexual abuse. Thus, many believe the condition may be caused by early environmental factors rather than genetic disposition. 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 have a harmful impact on a child may lead that child to develop unhealthy coping skills that eventually lead to BPD.
Research also has shown that some symptoms of the condition, particularly difficulty regulating emotions and making decisions, may have a neurological cause.
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 skills practice and homework. Participants focus on cultivating stress management, emotion regulation skills, 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. A significant number of mental health professionals, including leading experts in the field, do recognize borderline personality as a mental health condition and believe that an accurate diagnosis can help individuals experience greater success in treatment. Some who support the diagnosis have, however, suggested the possible renaming of this condition.
Although about 75% of people diagnosed with BPD are women, new findings reveal that gender plays little part in the development of the condition. More recent research has found that men experience borderline personality at almost the same rate as women (other genders were not studied). There is little evidence that the condition is caused by biological factors, suggesting that something else may be responsible. 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 posttraumatic 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.
- A.D.A.M. Editor Board. (2000, November 18). Borderline personality disorder. PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001931
- Borderline personality disorder and trauma. (n.d.). Retrieved from http://www.borderline-personality-disorder.com/co-occuring-disorders/trauma
- Borderline personality disorder. (n.d.). Retrieved from http://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
- BPD name change is being considered. (n.d.). Retrieved from http://www.borderlinepersonalitytreatment.com/bpd-name-change.html
- Colman, A. M. (2006). Oxford dictionary of psychology. New York, NY: Oxford University Press.
- Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
- Skodol, A. E., & Bender, D. S. (2003). Why are women diagnosed borderline more than men? Psychiatric Quarterly, 74(4), 349-360. doi:10.1023/A:1026087410516