Borderline personality disorder (BPD) is a serious personality disorder whose main symptoms include unstable relationships and moods, significant issues with a person’s own self-image, and behavior that reflects this instability and self-image issues. Many psychologists believe this is primarily a disorder of emotional regulation.
These issues impact nearly every aspect of a person’s life, disrupting their family and social relationships, school or work, and the ability to plan for their future. According to the National Institute of Mental Health, “borderline” was coined as a term for this disorder as the person was originally thought to be at the “borderline” of psychosis.
Borderline personality disorder is fairly common as personality disorders go, perhaps affecting up to 2 percent of adults, mostly young women, according to the American Psychiatric Association. There is a high rate of self-injury — usually without suicidal intent. There is, however, also a significant rate of suicide attempts, and even completed suicide in more severe cases. People with BPD often need extensive mental health services. Yet, with help, many improve over time and are eventually able to lead productive lives.
Symptoms of Borderline Personality Disorder
While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse.
Distortions in thinking and a person’s sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, and often empty. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.
Even with family members, individuals with this condition are sometimes highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Treatment of Borderline Personality Disorder
Most treatment for borderline personality disorder tends to focus on weekly group psychotherapy with the individual using an approach called dialectical behavior therapy (DBT). Some people may also benefit from individual DBT treatment. DBT was specifically researched and designed to treat this condition, and has good scientific evidence for its effectiveness and positive outcomes.
A small minority of people may also benefit from psychiatric medications prescribed for BPD. These medications are sometimes prescribed based on specific target symptoms, such as anxiety or a depressed mood. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood.
Recent Research Findings in BPD
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits according to the National Institute of Mental Health. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children. Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.
Researchers who study this condition believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.
Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.
Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.
Studies that translate basic findings about the neural basis of temperament, mood regulation, and cognition into clinically relevant insights — which bear directly on BPD — represent a growing area of research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones.
Still have questions? Please read Frequently Asked Questions about Borderline Personality Disorder.
National Institute of Mental Health. (2018). Borderline personality disorder.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA.