Borderline Personality Disorder
The following text is lifted from an article reviewed by Ken Duckworth, M.D.,
and Jacob L. Freedman, M.D., November 2012. The authors would like to thank
S. Charles Schulz, M.D. for his contributions to a prior version of this page.
Borderline personality disorder (BPD) is a serious mental illness marked by impulsivity & instability in mood, self-image, & personal relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time. Because some people with severe BPD have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name ‘borderline personality disorder’ is misleading, a more accurate term does not exist yet.
According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year. BPD usually begins during adolescence or early adulthood. Some studies suggest that early symptoms of the illness may occur during childhood.
Borderline personality disorder is diagnosed by a mental health professional based on sustained patterns of thinking & behavior in an individual. Some people may have “borderline personality traits” which means that they do not meet criteria for diagnosis with BPD but have some of the symptoms associated with this illness.
Borderline personality disorder is marked mood swings with periods of intense depressed mood, irritability, & anxiety that last anywhere from a few hours to a few days (but not in the context of a full-blown episode of major depressive disorder or bipolar disorder); impulsive behaviors that result in adverse outcomes & psychological distress; recurring suicidal threats or self-injury; unstable, intense personal relationships (sometimes alternating between “all good,” idealization, & “all bad,” devaluation); persistent uncertainty about self-image, long-term goals, friendships & values; chronic boredom or feelings of emptiness; frantic efforts to avoid abandonment.
Once an accurate diagnosis is made, developing a comprehensive treatment plan is important. Typically the treatment plan will include psychotherapy strategies, medications to reduce symptom intensity, and group, peer and family support.
Psychotherapy is the cornerstone of treatment for individuals who live with BPD. Dialectical behavioral therapy (DBT) is the most well researched & effective treatment for BPD. DBT focuses on teaching coping skills to combat destructive urges, encourages practicing mindfulness (e.g., meditation, regulated breathing & relaxation), involves individual & group work, & is often quite successful in helping people with BPD to control their symptoms. DBT has been shown to reduce the outcome of suicide in research studies for people who live with BPD.
No medication is specifically approved by the FDA for the treatment of BPD. Medications are however useful in treating specific symptoms in BPD and may support and enhance essential psychotherapy efforts. For example, off label use of a number of medications may manage key symptoms, including
Relief of such symptoms may help the individual change the harmful patterns of thinking and decrease the detrimental behaviors that disrupt their daily activities. Medication treatment of coexisting medical and mental illnesses, such as anxiety or depression, is also very important in the treatment of BPD.
The support of family and friends is of critical importance in the treatment of BPD as many people with this illness may isolate themselves from these relationships in times of greatest need. Family and friends can be most helpful in encouraging their loved one to engage in proper treatment for this complicated illness. With the support of family and friends, involvement in ongoing treatment, and efforts to live a healthy lifestyle—regular exercise, a balanced diet and good sleeping habits--most people with borderline personality disorder can expect to experience significant relief from their symptoms.
Recent research based on long-term studies of people with BPD suggests that the overwhelming majority of people will experience significant and long-lasting periods of symptom remission in the lifetime. Many people will not experience a complete recovery (e.g., problems with self-esteem and the ability to form and maintain relationships may linger), but nonetheless will be able to live meaningful and productive lives. Many people will require some form of treatment—whether medications or psychotherapy—to help control their symptoms even decades after their initial diagnosis with borderline personality disorder.
People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.
According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
A pattern of intense & stormy relationships with family, friends, & loved ones, often veering from extreme closeness & love (idealization) to extreme dislike or anger (devaluation)
Distorted & unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans & goals for the future (such as school or career choices)
Impulsive & often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, & binge eating
Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
Intense & highly changeable moods, with each episode lasting from a few hours to a few days
Chronic feelings of emptiness &/or boredom
Inappropriate, intense anger or problems controlling anger
Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry & distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may have a stronger reaction to words with negative meanings than people who do not have the disorder.