(See also Overview of Personality Disorders Overview of Personality Disorders Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more .)
Patients with borderline personality disorder have an intolerance of being alone; they make frantic efforts to avoid abandonment and generate crises, such as making suicidal gestures Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more in a way that invites rescue and caregiving by others.
Reported prevalence of borderline personality disorder in the US varies. The estimated median prevalence is 1.6% but may be as high as 5.9%. In patients being treated as inpatients for mental health disorders, prevalence is about 20%. About 75% of patients diagnosed with this disorder are female, but in the general US population, the ratio of men to women is 1:1.
Comorbidities are complex. Patients often have a number of other disorders, particularly depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , anxiety disorders Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more (eg, panic disorder), and posttraumatic stress disorder Posttraumatic Stress Disorder (PTSD) Posttraumatic stress disorder (PTSD) is recurring, intrusive recollections of an overwhelming traumatic event; recollections last > 1 month and begin within 6 months of the event. The pathophysiology... read more , as well as eating disorders Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more and substance use disorders Overview of Substance-Related Disorders Substance-related disorders involve drugs that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific pleasurable... read more .
Etiology of BPD
Stresses during early childhood may contribute to the development of borderline personality disorder. A childhood history of physical and sexual abuse, neglect, separation from caregivers, and/or loss of a parent is common among patients with borderline personality disorder.
Certain people may have a genetic tendency to have pathologic responses to environmental life stresses, and borderline personality disorder clearly appears to have a heritable component. First-degree relatives of patients with borderline personality disorder are 5 times more likely to have the disorder than the general population.
Disturbances in regulatory functions of the brain and neuropeptide systems may also contribute but are not present in all patients with borderline personality disorder.
Symptoms and Signs of BPD
When patients with borderline personality disorder feel that they are being abandoned or neglected, they feel intense fear or anger. For example, they may become panicky or furious when someone important to them is a few minutes late or cancels an engagement. They think that this abandonment means that they are bad. They fear abandonment partly because they do not want to be alone.
These patients tend to change their view of others abruptly and dramatically. They may idealize a potential caregiver or lover early in the relationship, demand to spend a lot of time together, and share everything. Suddenly, they may feel that the person does not care enough, and they become disillusioned; then they may belittle or become angry with the person. This shift from idealization to devaluation reflects black-and-white thinking (splitting, polarization of good and bad).
Patients with borderline personality disorder can empathize with and care for a person but only if they feel that another person will be there for them whenever needed.
Patients with this disorder have difficulty controlling their anger and often become inappropriate and intensely angry. They may express their anger with biting sarcasm, bitterness, or angry tirades, often directed at their caregiver or lover for neglect or abandonment. After the outburst, they often feel ashamed and guilty, reinforcing their feeling of being bad.
Patients with borderline personality disorder may also abruptly and dramatically change their self-image, shown by suddenly changing their goals, values, opinions, careers, or friends. They may be needy one minute and righteously angry about being mistreated the next. Although they usually see themselves as bad, they sometimes feel that they do not exist at all—eg, when they do not have someone who cares for them. They often feel empty inside.
The changes in mood (eg, intense dysphoria, irritability, anxiety) usually last only a few hours and rarely last more than a few days; they may reflect the extreme sensitivity to interpersonal stresses in patients with borderline personality disorder.
Patients with borderline personality disorder often sabotage themselves when they are about to reach a goal. For example, they may drop out of school just before graduation, or they may ruin a promising relationship.
Impulsivity leading to self-harm is common. These patients may gamble, engage in unsafe sex, binge eat, drive recklessly, abuse substances, or overspend. Suicidal behaviors Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more , gestures, and threats and self-mutilation Nonsuicidal Self-Injury (NSSI) Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more (eg, cutting, burning) are very common. Although many of these self-destructive acts are not intended to end life, risk of suicide in these patients is 40 times that of the general population. About 8 to 10% of these patients die by suicide. These self-destructive acts are usually triggered by rejection by, possible abandonment by, or disappointment in a caregiver or lover. Patients may self-mutilate to compensate for their being bad, to reaffirm their ability to feel during a dissociative episode Overview of Dissociative Disorders Everyone occasionally experiences a failure in the normal automatic integration of memories, perceptions, identity, and consciousness. For example, people may drive somewhere and then realize... read more , or to distract from painful emotions.
Dissociative episodes, paranoid thoughts, and sometimes psychotic-like symptoms (eg, hallucinations, ideas of reference) may be triggered by extreme stress, usually fear of abandonment, whether real or imagined. These symptoms are temporary and usually not severe enough to be considered a separate disorder.
Symptoms lessen in most patients; relapse rate is low. However, functional status does not usually improve as much as the symptoms.
Diagnosis of BPD
Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])
For a diagnosis of borderline personality disorder, patients must have
A persistent pattern of unstable relationships, self-image, and emotions (ie, emotional dysregulation) and pronounced impulsivity
This persistent pattern is shown by ≥ 5 of the following:
Desperate efforts to avoid abandonment (actual or imagined)
Unstable, intense relationships that alternate between idealizing and devaluing the other person
An unstable self-image or sense of self
Impulsivity in ≥ 2 areas that could harm themselves (eg, unsafe sex, binge eating, reckless driving)
Repeated suicidal behavior and/or gestures Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more or threats or self-mutilation Nonsuicidal Self-Injury (NSSI) Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more
Rapid changes in mood, lasting usually only a few hours and rarely more than a few days
Persistent feelings of emptiness
Inappropriately intense anger or problems controlling anger
Temporary paranoid thoughts or severe dissociative symptoms triggered by stress
Also, symptoms must have begun by early adulthood but can occur during adolescence.
Borderline personality disorder is most commonly misdiagnosed as
Bipolar disorder Bipolar Disorders Bipolar disorders are characterized by episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity... read more : This disorder is also characterized by wide fluctuations in mood and behavior. However, in borderline personality disorder, mood and behavior change rapidly in response to stressors, especially interpersonal ones, whereas in bipolar disorder, moods are more sustained and less reactive and people often have significant changes in energy and activity.
Other personality disorders share similar manifestations.
Histrionic personality disorder Histrionic Personality Disorder (HPD) Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy... read more or narcissistic personality disorder Narcissistic Personality Disorder (NPD) Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for adulation, and lack of empathy. Diagnosis is by clinical criteria. Treatment is with psychodynamic... read more : Patients with either of these disorders can be attention-seeking and manipulative, but patients with borderline personality disorder also see themselves as bad and feel empty. Some patients meet criteria for more than one personality disorder.
Differential diagnosis for borderline personality disorder also includes
Depressive disorders Overview of Mood Disorders Mood disorders are emotional disturbances consisting of prolonged periods of excessive sadness, excessive joyousness, or both. Mood disorders can occur in children and adolescents (see Depressive... read more and anxiety disorders Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more : These disorders can be distinguished from borderline personality disorder based on the negative self-image, insecure attachments, and sensitivity to rejection that are prominent features of borderline personality disorder and are usually absent in patients with a mood or anxiety disorder.
Many disorders in the differential diagnosis of borderline personality disorder coexist with it.
Treatment of BPD
General treatment Treatment Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more of borderline personality disorder is the same as that for all personality disorders.
Identifying and treating coexisting disorders is important for effective treatment of borderline personality disorder.
The main treatment for borderline personality disorder is psychotherapy.
Many psychotherapeutic interventions are effective in reducing suicidal behaviors, ameliorating depression, and improving function in patients with this disorder.
Cognitive-behavioral therapy focuses on emotional dysregulation and lack of social skills. It includes the following:
Dialectical behavioral therapy (a combination of individual and group sessions with therapists acting as behavior coaches and available on call around the clock)
Systems training for emotional predictability and problem solving (STEPPS)
STEPPS involves weekly group sessions for 20 weeks. Patients are taught skills to manage their emotions, to challenge their negative expectations, and to better care for themselves. They learn to set goals; avoid illegal substances; and improve their eating, sleeping, and exercise habits. Patients are asked to identify a support team of friends, family members, and health care practitioners who are willing to coach them when they are in crisis.
Other interventions focus on disturbances in the ways patients emotionally experience themselves and others. These interventions include the following:
Mentalization refers to people's ability to reflect on and understand their own state of mind and the state of mind of others. Mentalization is thought to be learned through a secure attachment to the caregiver. Mentalization-based treatment helps patients do the following:
Effectively regulate their emotions (eg, calm down when upset)
Understand how they contribute to their problems and difficulties with others
Reflect on and understand the minds of others
It thus helps them relate to others with empathy and compassion.
Transference-focused psychotherapy centers on the interaction between patient and therapist. The therapist asks questions and helps patients think about their reactions so that they can examine their exaggerated, distorted, and unrealistic images of self during the session. The current moment (eg, how patients are relating to their therapist) is emphasized rather than the past. For example, when a timid, quiet patient suddenly becomes hostile and argumentative, the therapist may ask whether the patient noticed a shift in feelings and then ask the patient to think about how the patient was experiencing the therapist and self when things changed. The purpose is
To enable patients to develop a more stable and realistic sense of self and others
To relate to others in a healthier way through transference to the therapist
Schema-focused therapy is an integrative therapy that combines cognitive-behavioral therapy, attachment theory, psychodynamic concepts, and emotion-focused therapies. It focuses on lifelong maladaptive patterns of thinking, feeling, behaving and coping (called schemas), affective change techniques, and the therapeutic relationship, with limited re-parenting. Limited re-parenting involves establishing a secure attachment between patient and therapist (within professional limits), enabling the therapist to help the patient experience what the patient missed during childhood that led to maladaptive behavior.
The purpose of schema-focused therapy is to help patients change their schemas. Therapy has 3 stages:
Assessment: Identifying the schemas
Awareness: Recognizing the schemas when they are operating in daily life
Behavioral change: Replacing negative thoughts, feelings, and behaviors with healthier ones
Some of these interventions are specialized and require specialized training and supervision. However, some interventions do not; one such intervention, which is designed for the general practitioner, is
General (or good) psychiatric management
Good psychiatric management includes individual therapy once a week, psychoeducation about borderline personality disorder and treatment goals and expectations, and sometimes drugs. It focuses on the patient’s reactions to interpersonal stressors in everyday life.
Supportive psychotherapy is also useful. The goal is to establish an emotional, encouraging, supportive relationship with the patient and thus help the patient develop healthy defense mechanisms, especially in interpersonal relationships.
Drugs work best when used sparingly and systematically for specific symptoms.
Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (SSRIs) are usually well-tolerated; chance of a lethal overdose is minimal. However, SSRIs are only marginally effective for depression and anxiety in patients with borderline personality disorder.
The following drugs may be effective in ameliorating symptoms of borderline personality disorder:
Mood stabilizers Drug Treatment of Bipolar Disorders Choice of drug treatment for bipolar disorders can be difficult because all drugs have significant adverse effects, drug interactions are common, and no drug is universally effective. Selection... read more : For depression, anxiety, mood lability, and impulsivity
Atypical (2nd-generation) antipsychotics Second-generation antipsychotics Antipsychotic drugs are divided into conventional antipsychotics and 2nd-generation antipsychotics (SGAs) based on their specific neurotransmitter receptor affinity and activity. SGAs may offer... read more : For anxiety, anger, mood lability, and cognitive symptoms, including transient stress-related cognitive distortions (eg, paranoid thoughts, black-and-white thinking, severe cognitive disorganization)
Benzodiazepines Anxiolytics and Sedatives Anxiolytics and sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause stupor and respiratory depression, which is managed with intubation and mechanical ventilation... read more and stimulants are not recommended because dependency, overdose, disinhibition, and drug diversion are risks.
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Gunderson JG, Herpertz SC, Skodol AE, et al: Borderline personality disorder. Nat Rev Dis Primers 4: 18029, 2018. 1oi:10.1038/nrdp.2018.29