Borderline personality disorder (BPD) is a serious mental health condition that often causes difficulty with everyday tasks and functioning. People with borderline personality have trouble regulating their emotions, and they experience extreme and intense emotions for a prolonged period.
Experts believe that genetics, environmental factors, and neurological differences may all increase an individual’s risk of developing a borderline personality disorder. Having a family history of the illness, including having a sibling or parent with the condition, is associated with an elevated risk of developing it. In fact, individuals who have a first-degree relative with the condition are five times more likely to develop it themselves than those who do not have first-degree relatives with the illness.
In addition, recent studies have shown that individuals with a borderline personality disorder often have both structural and functional alterations in brain regions responsible for the regulation of impulses and emotions. However, scientists do not yet know if these changes are true risk factors or if they are simply a result of the condition itself. Environmental factors such as childhood trauma, frequent conflict, hostility, and unstable relationships may all increase an individual’s risk of developing a borderline personality disorder.
In the United States, approximately 1.6 percent of the population has been diagnosed with borderline personality disorder. Experts believe that as many as 5.9% of the population may have the condition, and it is commonly misdiagnosed as post-traumatic stress disorder or depression. Nearly 75 percent of individuals diagnosed with this illness are female. Researchers suspect that the male population is equally affected by this condition, and they believe that males are more likely than women to be misdiagnosed.
The symptoms of personality disorders like BPD tend to vary significantly from person to person. Some common symptoms that are suggestive of borderline personality disorder include an extreme, intense fear of being abandoned, persistent feelings of emptiness, and significant mood swings that may last for a few hours or for several days. Patients with BPD may also experience rapid alterations in their sense of identity and self-image. These changes may involve shifts in values or goals, and patients may view themselves in a negative way or as though they do not exist. During times of stress, patients might enter a paranoid state that causes them to detach from reality; this can last for hours or days. BPD frequently causes feelings of extremely intense anger and can lead to physical fights. Instances of impulsive behavior such as gambling, reckless driving, drug use, and out-of-control spending are common.
BPD patients may have suicidal thoughts, and they may also attempt suicide. These patients may engage in self-harm behaviors, including cutting, burning, or scratching. One of the classic symptoms of this condition is a pattern of instability in the patient’s relationships. He or she may rapidly alternate between idolizing a person and then hating him or her, a process that psychiatrists often refer to as splitting. Patients with this condition are extremely sensitive to any form of rejection, including both rejections that are real and those that the patient has imagined.
Researchers who study personality disorders have currently identified four major types of this condition.
The first type of this condition is known as “discouraged borderline.” This form of the illness has many similarities with codependency (dependent personality disorder). Individuals with this form may appear clingy and somber, and they may feel constantly dejected. Inside, they are typically very angry and disappointed with the actions of those around them, and they may be prone to outbursts of explosive anger. This form of the disease is associated with an increased risk of self-harming behaviors and suicidal tendencies.
The second form of this condition is known as “impulsive borderline.” This form shares similarities with a histrionic personality disorder, and patients tend to be flirtatious, charismatic, highly energetic, and thrill-seeking. They crave attention and excitement, and they are likely to act without thinking. Patients tend to engage in impulsive behaviors that may be dangerous, including drug use, reckless driving, expensive shopping sprees, and gambling.
The next type of BPD is known as “petulant borderline.” Patients with this form of the condition may be irritable, unpredictable, impatient, and disgruntled. They tend to complain, and they can also be defiant, stubborn, and resentful. They feel rapidly shifting feelings of wanting to rely on people one minute and keeping their distance the next for fear of being seen as a disappointment. They may feel unworthy one minute and very angry the next. The type of explosive anger they experience can be dangerous and may escalate to physical fighting.
The fourth and final type of this condition that researchers have currently identified is known as “self-destructive borderline.” These patients tend to experience persistent feelings of bitterness and extreme self-hatred that drive them to self-harm. In addition to self-harming behaviors, individuals with this form of the illness may act in self-destructive ways. For example, they may resign from a job that they enjoyed, or they may neglect their health care needs. They might also engage in other risky behaviors such as unsafe sex or dangerous driving practices.
The fifth type is called “Narcissistic Borderline.” People who have bipolar disorder tend to struggle with their sense of self and identity. There is a frequent pattern of confusion and misdiagnosis between BPD and narcissistic personality disorder (NPD). The disorders share many common symptoms, and NPD is one of the possible co-occurring conditions of BPD.
People with NPD and BPD both struggle to deal with their emotions and interact with people around them. Angry outbursts as a result of the conflict, either real or perceived, aren’t uncommon. People with BPD often feel embarrassed, ashamed or guilty after an outburst and apologize, but people with NPD are generally insistent that their responses are always someone else’s fault.
People who classify as having a co-occurring borderline personality disorder and narcissistic personality disorder experience a deep fear of abandonment. They are prone to intense relationships riddled with conflict and judgment.
People with a narcissistic borderline personality disorder lack emotional responses to situations and tend to ignore their responsibility in a relationship. Little research supports an effective treatment for NPD, so patients with a co-occurrence would most likely benefit from a common BPD treatment plan like dialectical behavioral therapy.
Patients who are suspected of having BPD will need to undergo a range of tests to confirm a diagnosis of the disorder. To rule out potential medical causes for symptoms that patients may be experiencing, the clinician will take a complete health history and perform a comprehensive physical examination.
To begin the health history, patients will be asked about their personal or family history of diseases, including any history of depression, borderline personality disorder, anxiety, schizophrenia, or other mental health disorders. Patients will also be asked about smoking and alcohol use, and they should bring along a list of all of the medications that they take, including herbal supplements, vitamins, and over-the-counter medicines.
The physical examination will include a neurological assessment that checks the cranial nerves, sensations, reflexes, and grip strength. The physician may also listen to the patient’s heart, lung, and bowel sounds using a stethoscope. If the physician feels that the patient may need to be prescribed medication, he or she will check the patient’s blood pressure and other vital signs to make sure that it is safe to prescribe pharmaceuticals. Patients may also need blood tests to check liver and kidney function.
Since borderline personality disorder may occur alongside bulimia, post-traumatic stress disorder, depression, bipolar disorder, unsafe sex, and substance or alcohol use, the doctor may ask the patient about his or her eating habits, sexual history, and substance use during the physical exam.
If the physician is concerned that a patient may have some underlying health issues related to these symptoms, he or she may perform additional tests during the exam. For example, patients who have engaged in unsafe sex may need to have pregnancy tests or screenings for sexually transmitted diseases. Individuals who have used alcohol or drugs may have tests for these substances, and the doctor may perform a more thorough examination of the liver and kidneys, testing for the presence of pain and enlargement of these organs.
After the physical examination, the patient will have psychological interviews with several health care professionals, including psychiatrists and other mental health experts. In addition to interviewing the patient, mental health professionals may ask the patient to complete questionnaires about several aspects of mental well-being. With the patient’s permission, a mental health professional may also interview the patient’s family, friends, and doctors to obtain information that will aid in reaching a diagnosis.
Following a diagnosis of BPD, patients are usually treated with psychotherapy as the first and preferred treatment option. Peer support, group support, and family support may all be provided as part of psychotherapy treatment. Examples of standard psychotherapy approaches used in the treatment of borderline personality disorder include cognitive behavioral therapy, dialectical behavioral therapy, and psychodynamic psychotherapy.
Through these therapeutic methods, patients learn how to manage and appropriately respond to the emotional regulation difficulties that are characteristic of this condition. They explore healthy coping strategies and ways to reframe their thoughts so that they can build more positive relationships with others. Patients are taught tools that can reduce anxiety, impulsivity, and other symptoms that they may be experiencing. For example, patients are taught to observe their feelings of impulsivity. Over time, they learn that they do not need to act on these feelings; they can simply let these go.
While there are currently no medications that directly treat borderline personality disorder, patients may be given medications that can make it easier to manage the symptoms caused by the condition. For example, antidepressants, antipsychotics, and drugs that stabilize the mood may all be beneficial for patients.
When prescribing an antidepressant, doctors typically start with a selective serotonin reuptake inhibitor. Examples of these drugs include fluoxetine, paroxetine, sertraline, and citalopram. Commonly prescribed antipsychotics include aripiprazole, cariprazine, lurasidone, olanzapine, and quetiapine. These drugs are given in the lowest possible effective doses, and many patients find that the medications enable them to think more clearly.
Patients taking any of these medications will need to be monitored closely by their medical team. They should be alert for potential side effects, including weight gain, blurry vision, dry mouth, and muscle spasms or tremors. Some of these medications may also cause dizziness, headache, diarrhea, insomnia, and agitation. If patients experience any side effects that are particularly disruptive or bothersome, they may be able to be switched to another type of medication that is more tolerable.
Patients with BPD who are prone to dangerous, self-destructive, or self-harming behavior may need to be hospitalized for a short time. For example, this type of hospitalization may be needed if patients are experiencing suicidal thoughts or actions or if they are extremely agitated or stressed. Hospitalization is done to ensure the safety of the patient, and it may be forced against the patient’s will if he or she is in imminent danger.
Most patients will be hospitalized in the psychiatric ward of the hospital, and they will receive intensive inpatient psychotherapy and medication during their stays. Patients will be released from the hospital as soon as it is safe to do so, and they will be discharged with detailed instructions about the next treatment steps. For example, these might include referrals for additional evaluation or information about sources of mental health support.
If you have been diagnosed with BPD, the most important thing to remember is that you can recover from this illness and that you will feel better. Understand that recovering from this condition takes time, and you should be gentle with yourself. Try to work with your family, friends, and mental health providers to take small steps each day, and focus on celebrating each small victory.
If you can, try to develop a structured routine that includes some time for activities that you enjoy. For example, try to go to bed and get up at the same time every day. If you enjoy reading or watching television or movies, try to read one new article or watch one new television episode each day. Above all, try to avoid isolating yourself; interacting with others can help improve your mood and self-image. Just be sure to take things at your own pace.
To help give yourself the best chance of symptom management and recovery, prioritize your health. Always attend any appointments you have made with your physician or mental health providers, and take any medication that has been prescribed. Be open with your health care team about any unpleasant side effects or health changes that you may notice so that steps can be taken to address these and manage your condition in the most effective way possible. Try to educate yourself as much as you can about BPD and any related conditions you may have, and always reach out for support and information from your family, friends, and health care professionals. It will be a long, hard road, but it is possible to get better and lead a full life.