What is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a mental health issue where individuals often experience unstable moods, unusual self-perceptions, and tumultuous relationships. This may result in having a warped view of themselves and others, creating obstacles in forming and maintaining healthy relationships. People with BPD usually have quick and drastic shifts in emotion, struggle to control their feelings, and may act impulsively. They can often feel empty inside and can experience extreme fear of being abandoned, which may cause harmful behaviors, including self-damage and thoughts of suicide. Other health conditions, such as mood disorders, anxiety, eating disorders, post-traumatic stress disorder, substance abuse, and other personality disorders, can further complicate BPD.
The understanding and classification of BPD have changed over time, reflecting shifts in medical knowledge. Early descriptions of fluctuating, intense moods can be traced back to Hippocrates. BPD-like behaviors were first observed in the 1930s and 1940s, and by the 1950s, borderline conditions were often seen as part of the schizophrenia spectrum. The term “borderline,” used to describe patients with symptoms that did not fall neatly into other categories, began to gain acceptance during the 1960s and 1970s.
BPD was officially recognized as a unique diagnosis after the publication of the third edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. This provided specific criteria for diagnosis and led to increased research and understanding. Later editions of the DSM have refined the diagnostic criteria, aiming to improve the reliability and validity of the diagnosis.
The latest DSM version divides personality disorders into three clusters: A, B, and C. Each cluster groups together personality disorders with similar symptoms. Cluster A includes disorders marked by odd or eccentric behaviors; Cluster B involves disorders characterized by dramatic, emotional, or unpredictable behaviors, like BPD; Cluster C is about disorders associated with anxiety and fear. However, this method of grouping has its limitations, and research does not consistently support it.
What Causes Borderline Personality Disorder?
The current theory suggests that Borderline Personality Disorder (BPD) is caused by a mix of genetic influences and negative experiences during early life that affect how the brain grows and develops. The exact balance between these two factors remains unknown.
Genetic research suggests that personality disorders, including BPD, can run in families. About 40% of BPD cases are believed to be inherited. Among Swedish families studied, identical twins were observed to have the highest risk of both having BPD, followed by non-identical twins, full siblings, and half-siblings. However, it’s worth noting that shared family environments could potentially inflate the perceived role of genetics in these studies. No definitive links have been found between BPD and specific genes.
Social and family factors can also increase the risk of developing BPD. These include factors like being in a low socioeconomic bracket, family adversity, having a parent with a mental illness or substance abuse issue, harsh parenting styles, childhood abuse or neglect, and low mental capabilities. Personality factors, like one’s temperament, might also play a role in the development of BPD.
Other medical conditions associated with personality changes, such as head injuries, brain tumors, epilepsy, multiple sclerosis, hormonal disorders, heavy metal poisoning, and HIV-associated brain disorders, should be ruled out when diagnosing BPD.
Psychological approaches to understanding BPD focus on subconscious mental processes, early life experiences, and internal conflicts. Some people with BPD might use mental defenses like denying their own feelings, shifting feelings onto others, splitting people into ‘all good’ or ‘all bad’ categories, or acting impulsively to manage their internal struggles and anxieties. This last phenomenon — “splitting” — can make it hard for someone with BPD to see other people as a mix of good and bad, which can strain relationships.
Personality, a unique set of behaviors that individuals use to respond to their surroundings, is shaped by a mix of biological, mental, social, and developmental influences. Even among people diagnosed with a personality disorder, each person has a unique personality often described in terms of ‘temperament’, an inborn psychological trait.
A psychological researcher named Cloninger proposed four dimensions of temperament: harm avoidance, novelty seeking, reward dependence, and persistence. BPD is often associated with high levels of harm avoidance, meaning a tendency to avoid risky activities that may not result in a reward, and novelty seeking, meaning a desire to engage in new activities that may lead to rewards.
Life experiences such as trauma and socioeconomic conditions can further shape an individual’s temperament and personality.
Risk Factors and Frequency for Borderline Personality Disorder
Borderline Personality Disorder (BPD) is a mental health condition that affects an estimated 0.7% to 2.7% of the general population. It typically begins to show symptoms in early adulthood. The prevalence of BPD amongst individuals in primary care is around 6%, and for those in outpatient psychiatric clinics, it’s between 11% and 12%. Inpatient psychiatric facilities see a higher rate of 22%. Although it’s slightly more common in women than in men, the rate is significantly higher in women in outpatient psychiatric settings.
- BPD affects an estimated 0.7% to 2.7% of the general population.
- Symptoms typically start to appear in early adulthood.
- The prevalence of BPD is about 6% in primary care.
- In outpatient psychiatric clinics, the rate is between 11% and 12%.
- In psychiatric inpatients, the rate increases to 22%.
- While slightly more common in women, in outpatient psychiatric settings, the rate is significantly higher in women.
Signs and Symptoms of Borderline Personality Disorder
Borderline Personality Disorder (BPD) can present differently in different people. Key to diagnosing BPD is having a detailed understanding of a person’s mental health history, overall health, social relationships, childhood development, and family dynamics. Signs of BPD may become apparent in adolescence and progress into adulthood, often featuring unpredictable and risky behaviors.
One key feature of BPD is emotional instability. Unlike episodes of depression or mania, which are characterized by consistent moods, BPD moods can swing drastically throughout the day based on scenarios and interactions with others. Emotions can range from intense anger to thoughts of suicide.
The way a person with BPD perceives their relationships with friends, family, and partners can provide further clues for diagnosis. A person with BPD can fluctuate between viewing others as “fully good” or “fully bad.” These individuals may cling to relationships, yet also dramatically alter their emotions at the sense of being abandoned or overlooked.
BPD symptoms can also manifest as a persistent sense of emptiness, characterized by feelings of hopelessness, loneliness, and isolation. BPD often leads to harmful coping behaviors like substance use, impulsive spending, risky sexual escapades, binge eating, reckless driving, and self-harm. Changes to the physical appearance through excessive piercings, tattoos, or scars can reflect low self-esteem and indicate BPD.
Self-harming behavior in BPD patients can manifest as non-suicidal acts meant to cause pain, or deliberate attempts at suicide. Non-suicidal self-harm can include habits like cutting or self-abuse, while suicide attempts might involve hanging, gunshots, jumping off heights, drug overdose, or refusal to eat or drink.
Carrying out a mental status examination is essential in assessing potential BPD. This examination can include the following checklist:
- Appearance: Signs like tattoos, piercings, scars, or self-inflicted cuts
- Behavior: Displays of anger, aggression, or contradictory (“splitting”) attitudes.
- Affect: Narrow, unhappy, or angry emotional presentation
- Thought Content: Thoughts of self-harm, suicide, or harming others. Brief instances of psychosis
- Thought Process: Clarity and coherence are standard, but occasional dissociation can occur
- Cognition: Typically, individuals are cognitively sound and oriented
- Insight: There is typically poor understanding of their emotions and how they influence behavior and relationships
- Judgment and Impulse Control: People with BPD often exhibit poor judgment and can’t control impulses
Testing for Borderline Personality Disorder
Diagnosing Borderline Personality Disorder (BPD) often involves monitoring the patient’s behavior over time to gauge their general functionality. There can be some overlap between the symptoms seen in BPD and other mental health conditions, such as mood disorders, so it’s usually best to diagnose BPD when those other conditions aren’t currently causing issues. It’s worth noting that BPD can often worsen other psychiatric illnesses, leading to hospitalization in some cases.
Treating patients with BPD can pose challenges for health professionals. This is due to the fact that interactions with these patients can often be difficult, stemming from behaviors that might include aggression, self-harm, or even suicidal tendencies. Consequently, this can lead to what is known as “countertransference”, which is when the clinician develops a psychological response to their patient. It’s crucial for clinicians to identify these signs as they can negatively impact patient care. Feelings of frustration by clinicians toward their patients can serve as a valuable indicator to guide diagnosis and treatment plans.
Various diagnostic tools can be used when assessing BPD. One such tool is a questionnaire called the McLean Screening Instrument, which patients self-administer. A score of 7 or above on this instrument is typically indicative of BPD. The Zanarini rating scale is another commonly used tool.
Though not always necessary when the patient’s history is well-documented, psychological tests can be handy for diagnosing personality disorders. More specifically, the Minnesota Multiphasic Personality Inventory-2 and the Rorschach Perceptual Thinking Index can verify the presence of a personality disorder. A diagnosis of BPD requires a comprehensive evaluation looking at multiple factors such as personal history, collateral information, and mental status.
The DSM-5-TR outlines a number of criteria for a BPD diagnosis as well, of which a patient must meet five or more. These criteria largely involve a host of behaviors that indicate instability in various aspects of one’s life, such as interpersonal relationships, self-image and emotional state.
The DSM-5-TR also defines an alternative model for diagnosing BPD, encompassing difficulties in personality functioning and certain pathological traits. This model accepts that symptoms aren’t usually confined to just one personality disorder.
Treatment Options for Borderline Personality Disorder
The primary treatment for Borderline Personality Disorder (BPD) is psychotherapy, which involves different types of talking therapies specifically designed for BPD. These therapies have been shown to improve daily functioning, reduce symptoms, and may decrease self-harm and depression. However, the effectiveness of therapy in younger people is still being researched.
Mentalization-based treatment (MBT) is a specific type of therapy that helps people with BPD better recognize and manage their emotions. It does this by helping them understand their own feelings as well as the feelings of others. This therapy involves both one-on-one and group sessions.
An alternative approach is dialectical behavioral therapy (DBT), a structured therapy that uses mindfulness and practical skills based on cognitive behavioral therapy. DBT aims to help patients manage stressful emotions by developing emotional awareness, improving interpersonal relationships, and practicing mindfulness techniques. This type of therapy also includes one-on-one sessions, group therapy, and regular meetings with a team of therapists.
Transference-focused psychotherapy (TFP) involves the therapist and the patient working together to address the patient’s problematic interpersonal relationships. The therapist uses different methods within the therapeutic relationship to help the patient better understand these problems.
Schema therapy (ST) focuses on the development of a healthier self-image. It helps patients address four typical dysfunctional life schemas associated with BPD, namely the feelings of abandonment, impulsivity, detachment, and punishment. This approach draws from a number of different therapeutic styles, including cognitive-behavioral, psychodynamic, attachment, and emotional therapies.
While medication isn’t typically effective in treating the main symptoms of BPD, it’s often prescribed. In fact, up to 96% of patients with BPD receive at least one psychotropic medication, even though these drugs haven’t been approved by the FDA for treating BPD. These medications, which include serotonin reuptake inhibitors, mood stabilizers, and antipsychotics, are only effective in managing temporary symptoms like anxiety and sleep disturbances. Medication is usually only recommended for treating other disorders that often occur alongside BPD, such as severe depression or anxiety.
The use of multiple medications at once, or polypharmacy, is common in BPD treatment. However, polypharmacy carries potential risks, including harmful side effects and functional impairment. Therefore, when considering treatment options, it’s essential to weigh up the risks and benefits of taking multiple medications.
Additional challenges in treating BPD include managing self-harming behaviour, maintaining appropriate personal boundaries, dealing with substance abuse and managing thoughts of suicide.
People with BPD usually don’t need to be hospitalized. However, in certain circumstances, such as when a patient poses an imminent suicide risk, suffers an intense episode of negative thoughts, agitation, or temporary psychosis, or face a sudden increase in the severity of self-harm, hospitalization may be necessary. Inpatient care may also be required if the patient has a worsening of another mental health or substance use disorder.
What else can Borderline Personality Disorder be?
Borderline Personality Disorder (BPD) often happens along with depression or bipolar disorders. It should only be diagnosed if the patient has shown a long-lasting pattern of behavior, even though the symptoms can sometimes seem like these other mood disorders.
BPD and separation anxiety both include a fear of being left alone, but BPD can also be recognized by problems with reckless behavior, self-identity, and relationships.
Having a personality disorder can sometimes be mistaken for BPD. It’s crucial to correctly identify BPD through its distinct features. If a person matches the criteria for more than one personality disorder, they can be diagnosed with each of them.
Dissociative Identity Disorder is recognized by having two or more distinct personalities, each with its own behavior patterns. In BPD, a person may struggle with their identity and image of themselves, but these issues come and go and are not constant.
Regularly using drugs or alcohol can create symptoms that look similar to BPD.
It’s also important to separate BPD from personality changes that are caused by another medical condition. Examples of these conditions include head injuries, stroke, brain tumors, epilepsy, neurosyphilis, multiple sclerosis, hormone disorders, heavy metal poisoning, and certain mental disorders linked to HIV.
What to expect with Borderline Personality Disorder
People diagnosed with Borderline Personality Disorder (BPD) generally have a good chance of improving their mental health condition, according to research. These studies suggest that while BPD symptoms often get better over time, better than previously thought, the disorder can still limit a person’s overall ability to function and integrate into social contexts. Following people with BPD over 5 to 15 years, research found that, on average, 60% experienced symptom relief.
Although many people with BPD will eventually experience reduced symptoms and remain stable with few relapses, they often continue to have significant difficulties in areas of social interaction and daily living. This fits with the idea that when people with BPD have strong support networks and manage to avoid stressful social interactions, their symptoms can indeed improve. However, those who continue to struggle with BPD symptoms are more likely to require hospital treatment and have more co-existing borderline personality disorder symptoms.
Possible Complications When Diagnosed with Borderline Personality Disorder
Patients dealing with Borderline Personality Disorder (BPD) often face a high risk of suicide, which is significantly higher than individuals with other types of personality disorders. In fact, studies have shown that a large majority of those with BPD have attempted suicide at some point. Besides the mental health struggles, BPD often comes with other health complications. These can include physical conditions like obesity, diabetes, and heart disease, as well as chronic pain and sexually transmitted diseases.
BPD is also often found alongside other mental disorders, from mood and eating disorders to posttraumatic stress disorder and substance use disorders. This multi-layered mix of health challenges can make life particularly difficult for individuals with BPD, and they often have a lower life expectancy than those without BPD. Plus, navigating the health care system can be a struggle for them.
Summarizing these issues, we can list the typical challenges faced by BPD patients as follows:
- High risk of suicide
- Other health complications such as obesity, diabetes, gastrointestinal disease, cardiovascular disease and hypertension
- Chronic pain
- Sexually transmitted diseases
- Association with other personality disorders
- Mood disorders
- Eating disorders
- Posttraumatic stress disorder
- Substance use disorders
- Lower life expectancy
- Difficulty navigating the health care system
Preventing Borderline Personality Disorder
Treating Borderline Personality Disorder (BPD) heavily relies on building and sustaining a trusting relationship between the doctor and the patient. This can sometimes be difficult due to the patient’s unstable emotions, high-demanding nature, and tendency to test boundaries, which can complicate the treatment process.
Patients with BPD may frequently show inconsistent emotional responses, make excessive demands, and push the limits of their relationships. This can make it difficult for the doctor to establish a proper therapeutic relationship, making the treatment even more challenging.
However, making patients feel genuinely cared for through warmth and support can help engage them better. Doctors can reassure patients that they are in a safe and supportive environment and encourage them to openly discuss their symptoms and social stressors.
It’s crucial for clinicians to understand and address the unique problems and hurdles that patients with BPD are dealing with, especially when they’re not in an immediate crisis. Patients can also be encouraged to use their existing social connections and be part of group activities as a part of their support network.
