Borderline Personality Disorder (BPD)

BPD is strongly associated with childhood trauma, abuse, or neglect, and many people with BPD also experience other mental health issues. Treatment is primarily through psychotherapy, although medication may help reduce the symptoms of other mental health problems.

Key takeaways

• Borderline personality disorder is a long-term mental health condition characterized by powerful emotions and difficulty maintaining healthy relationships

• BPD affects approximately 1.8% of the population and is more common among women. It has a genetic component, but is also heavily influenced by environmental factors, especially childhood trauma

• Doctors used to think that borderline personality disorder was untreatable, but new evidence shows that therapy can reduce the symptoms and severity of the condition

Understanding borderline personality disorder

Like all personality disorders, borderline personality disorder affects patients’ thoughts, beliefs, character traits, and mindset. It is a long-term condition that usually first appears during puberty.^[3]

BPD is a Cluster B personality disorder, which means that it is characterized by dramatic, emotional, or erratic behaviors.^[4]People with this condition typically have difficulty building strong, stable relationships with others and have an unstable perception of themselves.

BPD was once considered untreatable, but more recent investigations suggest that it can respond to treatment, and approximately 85% of people diagnosed with BPD achieve remission within 10 years of diagnosis.^[5]

Prevalence of BPD

Borderline personality disorder is one of the least common personality disorders in the general population, affecting around 1.8% of people during their lifetime.^[6][7]

Around 75% of people diagnosed with BPD are female, but some researchers suggest that this may not reflect the true gender balance of the disorder.^[2][8][9]Women may be more likely to seek a diagnosis, and doctors may find it easier to recognize the symptoms of BPD in women.^[10]

Although BPD is comparatively rare, it is the most common personality disorder found in people attending the emergency room or presenting to primary care physicians.^[11]This is even more marked when considering inpatients receiving psychiatric treatment, where up to 20% of patients have a diagnosis of BPD.^[12]

BPD symptoms

People with borderline personality disorder think, feel, and behave differently from others.^[13]It’s also possible to see symptoms of their disorder in their relationships. Relationship issues often stem from other symptoms, but it’s helpful to understand them as symptoms as well.

Many of these symptoms are things that many people without BPD might also experience sometimes. For people with BPD, these are persistent traits, rather than rare instances.

Cognitive symptoms of BPD

Cognitive symptoms of BPD are those affecting someone’s thought processes. These include^[4]

• Paranoid thoughts, such as believing that others are trying to hurt you without any evidence. These occur for brief periods, often associated with stress.

• Thoughts that seem to come from outside yourself, or that you can’t get rid of. These can feel like instructions.

• Thinking that you are not fully connected to your body.

• Rapid changes in how you think about yourself, for example, moving quickly between thinking of yourself as a good person and believing that you are inherently bad or “evil.”

• A sensation that nothing is real or that you don’t exist.

• Sudden, unexplained changes in beliefs, opinions, or values.

• In rare cases, hallucinations.

• Thinking about death and suicide (suicidal ideation).

Emotional symptoms of BPD

Emotional symptoms of borderline personality disorder are those that impact how someone feels. Emotional instability is characteristic of people with BPD, meaning that emotional symptoms may change rapidly.^[4]

Common emotional symptoms of BPD include

• Rapid changes of mood and extreme mood swings.

• Powerful feelings that are disproportionate to the situation.

• Intense experiences of rage, sorrow, shame, panic, or terror.

• Feeling profoundly lonely or emotionally ‘empty.’

• Feeling suicidal or as if you would be better off dead.

Behavioral symptoms of BPD

Some of the symptoms of borderline personality disorder are things the person says or does. These are the behavioral symptoms. They include^[14]

• Reckless health decisions, for example, binge drinking, drug abuse, or engaging in high-risk, unprotected sex.

• Reckless financial decisions, including excessive spending, gambling, or suddenly quitting a job.

• Frequently making choices that offer short-term rewards, despite potential long-term costs.

• Physical self-harm, including cutting or burning themselves.

• Suicide attempts.

Relationship-focused symptoms of BPD

People with BPD experience difficulties with their close relationships. Many of these symptoms stem from cognitive, emotional, or behavioral symptoms. For example, impulsive sexual behavior can threaten long-term romantic relationships.

Here are some common symptoms of BPD that occur within relationships^[4]

• Intense fear of abandonment.

• Excessive need for reassurance.

• Requests for high levels of contact, for example, constant messages or phone calls.

• A belief that life will not be worth living without their partner.

• Intense relationships, characterized by ‘black or white’ thinking. For example, thinking that a relationship is either perfect or doomed.

How BPD affects others

Borderline personality disorder can have a strong effect on other people who are close to a patient. Loved ones may struggle to cope with the more extreme behaviors someone with BPD displays, especially aggression, self-harm, and suicidal behaviors.^[15][16]

During a period of mental health crisis, someone with BPD may have psychotic symptoms, including hallucinations and hearing voices. Again, friends and family can be afraid of what is happening or struggle to know where to turn for help. If the person with BPD requires hospitalization, this can bring additional guilt and shame to their loved ones for not being able to cope alone.

People with BPD often form very close, intense relationships with one or two specific people and require significant attention and reassurance from those people. For their loved ones, this can result in feeling pressured to tolerate boundary violations and to provide unsustainable levels of attention and support.^[17]

Causes of BPD

Borderline personality disorder does not have a simple cause. Like most other mental health and personality disorders, it appears to result from a combination of factors, including genetic, environmental, and psychological.

Current estimates from genetic analyses and twin studies suggest that BPD is approximately 40% heritable.^[18]The stress-diathesis model suggests that people with BPD have a genetic vulnerability to the condition, which only becomes apparent if they experience childhood trauma.^[19]

Several neurotransmitters and brain regions are significantly different in people with BPD compared with others. For example, one of the genes associated with BPD controls how oxytocin is processed in the brain and may increase how much someone is affected by their childhood environment.^[20]

For most differences, however, it is difficult to know whether they contributed to the development of BPD or whether they are a consequence of BPD or trauma.^[13]For example, glutamate, serotonin, dopamine, and noradrenaline are all essential neurotransmitters affected by childhood trauma, which also appear to play a role in BPD.^[21]

The hypothalamic-pituitary-adrenal (HPA) axis controls responses to stress. People with BPD have hyperresponsive HPA axes and, as a result, high cortisol levels.^[21][22]Another difference in people with BPD is that their hippocampus and amygdala, responsible for memory and fear processing, are typically smaller.^[23][24]This may be due to PTSD, rather than BPD, however.^[21]

Brain regions associated with BPD include the anterior cingulate cortex (ACC), prefrontal cortex, and limbic regions.^[22]These are areas associated with emotional processing and executive control or decision-making.

BPD and childhood trauma

Borderline personality disorder has strong associations with childhood adverse experiences and trauma. Up to 90% of people with BPD have experienced some form of childhood trauma, abuse, or neglect, and 40-70% of those hospitalized with BPD have experienced childhood sexual abuse.^[21][22]

People who have experienced childhood trauma are at increased risk of developing BPD, whether that trauma was due to physical, emotional, verbal, emotional, or sexual abuse or neglect. More recently, researchers have come to understand that sustained bullying from peers poses a similar level of risk.^[9]

Risks and complications

People with BPD often face other difficulties alongside, or as a result of, their condition. Most people with BPD experience other mental health issues, with around 96% experiencing mood disorders, such as depression.^[25]PTSD and substance use disorder (SUD) are also common, and 78% of adults with BPD experience addiction.^[8][26]

The strong emotions and impulsivity that characterize BPD may explain the high risk of suicide among people with the disorder.^[27]Some studies have found suicide rates as high as 8-10% among people diagnosed with BPD.^[28]This is nearly 50 times higher than the rest of the population.^[29]

Borderline personality disorder is also associated with poor social relationships and limited support networks. Only 16% of people with BPD are married or living with a partner, for example.^[30]

Diagnosing BPD

Borderline personality disorder is usually diagnosed by a psychologist, psychiatrist, or other mental health professional. BPD can be difficult to diagnose, so clinicians will sometimes ask for input from the patient’s family and friends to understand the details of their struggles. They will also consider the way the patient responds to them during the interview.^[9]

During the clinical interview, the clinician is looking for evidence that someone meets all of the necessary criteria for BPD. The problems must be long-lasting and have begun by early adulthood. There must be signs of instability in relationships, self-image, and emotions.

This instability must be demonstrated by at least 5 of the following criteria^[31]

1. And intense fear of abandonment (real or imagined), which they frantically try to avoid.

2. Intense but unstable interpersonal relationships with extremes of idealization and devaluation.

3. Unstable sense of self or self-image, for example, rapidly shifting between believing themselves entirely good and inherently evil.

4. At least two types of impulsive and potentially self-damaging behaviors, for example, high-risk sexual behavior, substance abuse, or excessive spending. This does not include physical self-harm or suicidal behaviors.

5. Suicidal behaviors, including gestures or threats, or self-harm.

6. Emotional instability and rapid, intense changes in mood. This can include intense sadness, irritability, or anxiety, which lasts for between a few hours and a few days.

7. Chronic feelings of emptiness.

8. Inappropriately intense feelings of anger, which they may have difficulty controlling. This can include physical fights and displays of temper.

9. Short-duration, stress-related paranoia or severe dissociation.

It can be difficult to obtain an early BPD diagnosis. Doctors can be concerned that^[9][32]

• A diagnosis of BPD may stigmatize young people.

• It is difficult to distinguish between normal teenage behavior and signs of BPD.

• Personality and self-identity can be unstable during adolescence.

BPD can also be misdiagnosed, often as bipolar disorder or PTSD.^[33][34]Unfortunately, a late diagnosis can make treatment more difficult.

When to seek a diagnosis

It can be difficult for people with BPD to recognize that there is a problem. Often, they will either seek treatment for another mental or physical health condition, or they will be encouraged to seek help by close friends and family.

As a result, it’s helpful to seek a medical opinion if you start to think you might have symptoms of BPD, especially given the risks it brings. Earlier treatment may be more effective.^[35]

Treatment for BPD

Until relatively recently, the consensus was that personality disorders were lifelong conditions with few, if any, options for successful treatment.^[36]Borderline personality disorder, in particular, was seen as untreatable, given the complex difficulties patients face and the frequent co-occurrence of other physical and mental health conditions.^[37]

More recent research has found several interventions that can reduce symptoms of BPD, helping patients develop a more robust sense of self and strengthening their relationships. Even now, however, about half of the people receiving psychotherapy for BPD don’t achieve full remission.^[38]People with BPD often have other mental health conditions, which can make their recovery more complicated.

Therapy

Psychotherapy, sometimes known as ‘talking therapy’, is the first-line treatment for borderline personality disorder.^[36]Patients work with a trained therapist to explore thought patterns, learn new skills, and find new ways to interact with the world.

There are several different types of therapy offered to people with BPD, and it’s normal to respond better to some therapeutic approaches than others. Patients receiving treatment for BPD in the US receive care from an average of 6 different therapists.^[39]

Dialectical behavior therapy (DBT)

One of the most common types of therapy offered to people with BPD is DBT.^[8]This aims to help patients improve their self-regulation, motivation, and practical skills.^[22]It also looks at the patient’s environment to find ways to support learning new skills.

DBT is the most-studied psychotherapy option for BPD, but there is limited evidence to suggest that it is more effective than other types of therapy.^[8]

Mentalization-based treatment (MBT)

MBT is another popular kind of therapy used for BPD, which focuses on helping patients make sense of their emotions and stabilize their sense of self. MBT has similar effectiveness to other psychotherapies for treating BPD.^[8]

Other approaches

Schema-focused therapy is designed to help people with BPD explore alternative ways of understanding the world around them and to replace the unhelpful ones they learned in childhood with ones that support their relationships.^[40]

Systems training for emotional predictability and problem solving (STEPPS) is highly skills-focused and has a similar effectiveness profile to other approaches.

Psychotherapy can reduce the severity and symptoms of BPD, but the type of therapy may not be critical.^[8]Given the difficulty patients with BPD face in building stable relationships, finding a therapist they trust may be more important than the approach.

Medication

There are no medications currently approved for the treatment of borderline personality disorder itself. Despite this, 96% of patients seeking help for BPD are given medication. These are usually intended to treat other mental health conditions patients are also experiencing, rather than BPD itself.^[41]Treating these other conditions can make it easier to deal with BPD in therapy.

Alternative

Given the persistence and impact of BPD, new treatments are being explored. Transcranial direct current stimulation (tDCS) uses electrodes placed on the scalp and low electrical currents to alter brain activity. This may reduce impulsivity and aggression in patients with BPD.^[42]

Repetitive transcranial magnetic stimulation (rTMS) uses magnetic fields instead of electricity to alter brain activity. There is some evidence that it may reduce feelings of abandonment, suicidality, and anger in patients with BPD.^[43]

These potential treatments are still in the early stages, and more research is needed to determine whether they can be effective. Current evidence is promising but weak.^[44]

Self-management for BPD

Self-management for borderline personality disorder is difficult, particularly because many people with BPD are unaware that they have a problem. Professional support is highly recommended, and early treatment can improve outcomes.

Despite this, there are some important steps anyone with BPD can take to reduce their symptoms and develop stronger and more stable relationships.

Learn emotional regulation skills

Learning to regulate their emotions allows people with BPD to cope better with the strong feelings they experience. This could mean finding ways to comfort yourself when you are feeling sad or safe ways to express yourself when you’re feeling angry.

Create a support network

People with BPD struggle to form secure relationships, but it’s helpful to have people around to confide in. Where possible, work on building a network of people to rely on, rather than focusing all of your attention and trust on one person.

One particularly difficult situation for many people with BPD is when the person they want to turn to is unavailable. Consider having a list of people or organizations to contact when things are difficult. Helplines, such as the988 Suicide and Crisis Lifeline, can be a valuable resource.

Have a safety plan

The symptoms of BPD usually vary over time. During times when you are feeling well, create a plan and find resources for the next time things become more difficult. Think about common problems you tend to face and look for ways to make them easier.

This should include a list of names and numbers that may be useful during a crisis, including medical practitioners, helplines, and friends and family. It might also help to think about how you will know that you’re experiencing a crisis and have a step-by-step list of how to manage it.

Meet others who understand

Peer support allows you to talk to other people who also have BPD. This can help you feel less judged, and you can learn from ways other people have tried to manage the same challenges. Peer support groups can be chat-based, video calls, or face-to-face meetings.

Final thoughts

Borderline personality disorder can be a difficult diagnosis to receive. With the right treatment and skills, it is possible to reduce or eliminate the symptoms, allowing you to form healthy, fulfilling relationships and develop a more stable sense of self.