Borderline Personality Disorder

Borderline personality disorder (BPD) is a mental health condition that seriously inhibits a person’s ability to manage his or her emotions. Sufferers experience chronic instability in their personal and professional lives, and if the symptoms of BPD remain unaddressed they can significantly impede daily functioning. BPD responds well to a variety of therapies and medications, and with the help of a sustained recovery program sufferers can overcome the most debilitating effects of the disorder and restore their capacity to regulate their emotional lives.

What is Borderline Personality Disorder?


Borderline personality disorder (BPD) is a chronic and life-altering mental health disorder that affects mood, self-image, and relationships. Those who suffer from borderline personality disorder have special difficulties managing their emotions and are subject to sudden shifts in mood that seem to come totally out of the blue.

The mood changes that BPD sufferers experience do have causes. But from the perspectives of most people such provocations would seem minor or insignificant. Individuals with BPD are highly reactive to environmental and social triggers of all types, and their emotional responses tend to be extreme and disproportionate. They experience bouts of intense anger, anxiety, depression, insecurity, paranoia, or frustration that last for extended periods of time, and only occasionally are these episodes triggered by authentically troubling events.

As a side effect of these turbulent and uncontrollable moods, individuals with BPD are prone to impulsive, risky, or self-destructive behavior. Their self-image and self-esteem are often as mercurial as their behavior, and their ability to function and manage their daily lives is often compromised by the extremes of their condition.

People with untreated borderline personality disorder tend to experience constant chaos and uncertainty. They may have trouble holding down a job, sustaining relationships, maintaining their homes, or managing their financial affairs. Rates of suicide are disturbingly high among BPD sufferers (8-10 percent, or 400 times the national average), which indicates how strongly the disorder impacts every area of people’s lives.

In any given year, somewhere between 1.6 and 5.9 percent of the adult population will suffer from borderline personality disorder, and women are diagnosed with BPD three times as often as men. The earliest signs of BPD are often observed during adolescence, but are seldom recognized for what they represent.

The symptoms of BPD are often quite similar to the symptoms of other mental health disorders, which further complicates the picture for mental health professionals, who must accurately diagnosis the disorder before targeted treatment can begin.

Signs and Symptoms of Borderline Personality Disorder


In a very real sense, BPD sufferers wear their emotions on their sleeves. Their often volatile and intense feelings are exhibited in their thoughts, behavior, and communication, and those who live with them or spend time with them will notice—and often be adversely affected by—the consequences of the disorder.

With borderline personality disorder daily reality remains in constant flux, not just for the sufferer but for their loved ones as well.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM 5) lists nine primary symptoms of borderline personality disorder:

  1. Distorted and unstable self-image, often turning extremely negative
  2. Periods of serious depression, anxiety, paranoia, and irritability that last for hours or days
  3. Self-harming behavior that can include attempts at suicide
  4. Chronic feelings of emptiness, meaninglessness, or boredom
  5. Impulsive behaviors: overspending, binge drinking, binge eating, incidents of road rage, fighting, etc.
  6. Excessive fear of abandonment and extreme actions to avoid it
  7. Explosive, often uncontrollable fits of anger, far out of proportion to the situation
  8. Rapid shifts from idealization (excessive love and admiration) to disillusionment (anger, distrust) in relationships
  9. Dissociative symptoms (losing touch with reality, feelings of alienation or separation from the mind or body, possibly psychotic episodes in extreme cases, etc.)

People with borderline personality disorder fluctuate between a variety of emotional states, many of which are extreme and none of which are stable or long-lasting. This affects their expectations and behavior, and they tend to change life plans, relationships, living arrangements, and beliefs frequently and often radically.

Causes and Risk Factors


There are three categories of risk factors for borderline personality disorder:

Genetics. Evidence suggests many people carry a strong genetic disposition for borderline personality disorder. People who have first-generation family members (parents, children, or siblings) with BPD are five times more likely to be diagnosed with the disorder than those with no such connection.

Neural structure and function. Brain examinations have revealed structural and functional variations in individuals diagnosed with BPD. Specifically, the areas involved in emotional regulation and impulse control appear underdeveloped or ineffectual.

Exposure to trauma or severe stress. In various studies, between 40 and 71 percent of individuals with BPD report sexual abuse during childhood, and other types of abuse or childhood loss or abandonment also increase the risk of BPD. Adult trauma is also implicated in the onset of BPD, but not as frequently as with childhood exposures.

Unfortunately, many BPD sufferers come from unstable family situations where caregivers were actually abusers. This is far from universal, but it can complicate recovery since family involvement in the healing process is often beneficial.

Co-occurring Mental Health Conditions


It is common for people suffering from mental illness to be diagnosed with more than one health disorder or condition, and it is an especially frequent occurrence for people with borderline personality disorder.

The 15 most frequently diagnosed co-occurring conditions in BPD sufferers (ranked by percentage of lifetime incidence) include:

  1. Alcohol use disorders: 57.3 percent
  2. Post-traumatic stress disorder (PTSD): 39.2 percent
  3. Specific phobias: 37.5 percent
  4. Drug use disorders: 36.2
  5. Generalized anxiety disorder: 35.1 percent
  6. Major depression: 32.1 percent
  7. Bipolar I disorder: 31.8 percent
  8. Social phobia: 29.3 percent
  9. Unspecified eating disorders: 26.1 percent
  10. Bulimia nervosa: 25.6 percent
  11. ADHD: 25 percent
  12. Anorexia nervosa: 20.8 percent
  13. Panic disorder: 18.8 percent
  14. Obsessive-compulsive disorder (OCD): 15.6 percent
  15. Panic disorder/agoraphobia: 11.5 percent

Either simultaneously or in the future, about three quarters of those diagnosed with borderline personality disorder will also suffer from an anxiety disorder, mood disorder, and/or a substance use disorder.

Borderline personality disorder is part of a larger group of personality disorders, all of which are presumed to be unique conditions. Nevertheless, many people diagnosed with BPD will also meet the criteria for other personality disorders at some point in their lives. BPD sufferers are especially likely to develop symptoms consistent with narcissistic or schizotypal personality disorders, with rates of lifetime incidence approaching 40 percent.

Diagnosing Borderline Personality Disorder


A person must demonstrate five of the nine primary symptoms of borderline personality disorder to be officially diagnosed with the condition. A diagnosis can only be made by a licensed mental health professional, usually a psychologist, psychiatrist, or clinical social worker.

The overall diagnostic process should include:

  • A thorough medical examination to rule out physical causes for possible BPD symptoms
  • A detailed interview to obtain the patient’s medical history, with family members participating if possible
  • A review of symptoms experienced along with any existing risk factors

These procedures are rigorous and comprehensive, and must be if an accurate diagnosis is to be made. If symptoms consistent with other mental or behavioral health disorders are uncovered, the patient may be given a dual diagnosis for BPD plus the additional condition(s). When signs of a substance use disorder are detected, the patient may be referred to an addiction specialist for further evaluation.

Co-occurring disorders can confuse the diagnostic process and cause BPD to be overlooked. Some patients with BPD are initially misdiagnosed, since its symptoms often resemble those associated with other disorders (bipolar disorder in particular).

Despite the complications, mental health professionals are skilled at diagnosing BPD and can usually do so successfully, as long as patients and family members provide them with complete and accurate information.

Treatment for Borderline Personality Disorder


Individualized programs of psychotherapy comprise the core of a borderline personality disorder recovery plan. Individual, group, and family sessions will be included in a patient’s ongoing treatment regimen, which will focus more on their unique personal situation than the personality disorder itself, which affects everyone differently.

There are a variety of evidence-based therapies that work well for individuals with BPD. Some of these promising options include:

  • Dialectical behavior therapy (DBT). Patients in DBT develop cognitive coping skills for controlling destructive impulses, managing emotions, and improving relationships. Traditional therapeutic activities are combined with mindfulness meditation and other similar techniques that can help patients preserve their emotional equilibrium.
  • Cognitive behavioral therapy (CBT). The goal during CBT is to identify and eliminate negative, self-destructive thinking patterns, which are common in BDP sufferers and exacerbate their inability to successfully manage their emotional lives.
  • Mentalization-based therapy (MBT). Patients undergoing MBT become progressively more conscious of their inner emotional states. Their history of unproductive relationships is examined closely, and the ultimate goal is to develop more empathy so future social interactions can be more positive and constructive.
  • Transference-focused psychotherapy (TFP). The emphasis in TFP is on long-term personality reorganization, which is essential to sustainable healing and recovery. The patient-therapist relationship is a vehicle through which the patient can increase self-comprehension and gain greater power of self-determination.
  • Family psychoeducation. Borderline personality disorder is highly stressful and disruptive for families. But specially crafted educational sessions can help parents, children, spouses, and other close relatives of BPD sufferers learn more about the disorder and about how it should be managed. Research shows that healthy family relationships are tremendously beneficial to BPD patients, and family psychoeducation can help produce them.

In addition to therapy, medication is often prescribed to help BPD sufferers manage some of their troubling symptoms. Pharmaceutical drugs will not help individuals with borderline personality disorder cope with their fears of abandonment or sense of alienation, but they can be useful against anxiety, depression, anger, and the various co-occurring disorders that sometimes accompany BPD.

Antidepressants, anti-anxiety drugs, antipsychotics, and mood stabilizers are some of the medications frequently prescribed to BPD sufferers, but they are only given in combination with extensive therapy regimens.

For many individuals with BPD, a short stay (30-90 days) in a residential treatment center is necessary to get their recovery off to a good and sustainable start. If co-occurring disorders are present inpatient treatment should be considered essential, since each condition must be treated comprehensively and simultaneously if true healing is to occur.

Prognosis


Borderline personality disorder is a lifelong condition that can cause tremendous damage if left untreated. Suicide rates among BPD sufferers are an astonishing 10 percent, and those who engage in self-harming behavior often need medical treatment to deal with their injuries. But this cycle of destructiveness can be broken. While BPD cannot be cured, sufferers can gain immense benefit from a sustained, long-term care program that addresses the disorder’s symptoms and remains focused on altering self-destructive thoughts and behavior.

Residential treatment, outpatient treatment, and aftercare can all contribute substantially to the recovery process, and people with BPD who have strong, loving support networks have an especially good chance of overcoming the worst effects of their condition.