Borderline Personality Disorder
Borderline personality disorder (BPD) is a serious mental illness that can be challenging for everyone involved, including the individuals with the illness, as well their friends and family members. BPD is characterized by impulsivity and instability in mood, self-image, and personal relationships. The treatments and longer-term studies of BPD offer hope for good outcomes for most individuals who live with BPD. Ideas to name the condition in a manner that better describes the pattern of concerns (e.g., Emotion Dysregulation Disorder) have been advanced but no name change to the condition is planned for the release of DSM-5.
What is borderline personality disorder (BPD) and how is it diagnosed?
Borderline personality disorder is diagnosed by mental health professionals following a comprehensive psychiatric interview that may include talking with a person’s previous clinicians, review of prior records, a medical evaluation, and when appropriate, interviews with friends and family. There is no specific single medical test (e.g., blood test) to diagnose BPD and a diagnosis is not based on a single sign or symptom. Rather, BPD is diagnosed by a mental health professional based on sustained patterns of thinking and behavior in an individual. Some people may have “borderline personality traits” which means that they do not meet criteria for diagnosis with BPD but have some of the symptoms associated with this illness.
Individuals with BPD usually have several of the following symptoms, many of which are detailed in the DSM-IV-TR:
- Marked mood swings with periods of intense depressed mood, irritability and/or anxiety lasting a few hours to a few days (but not in the context of a full-blown episode of major depressive disorder or bipolar disorder).
- Inappropriate, intense or uncontrollable anger.
- Impulsive behaviors that result in adverse outcomes and psychological distress, such as excessive spending, sexual encounters, substance use, shoplifting, reckless driving or binge eating.
- Recurring suicidal threats or non-suicidal self-injurious behavior, such as cutting or burning one’s self.
- Unstable, intense personal relationships, sometimes alternating between “all good,” idealization, and “all bad,” devaluation.
- Persistent uncertainty about self-image, long-term goals, friendships and values.
- Chronic boredom or feelings of emptiness.
- Frantic efforts to avoid abandonment.
Borderline personality disorder is relatively common—about 1 in 20 or 25 individuals will live with this condition. Historically, BPD has been thought to be significantly more common in females, however recent research suggests that males may be almost as frequently affected by BPD. Borderline personality disorder is diagnosed in people from each race, ethnicity and economic status.
What is the cause of borderline personality disorder?
The exact causes of BPD remain unknown, although the roles of both environmental and biological factors are thought to play a role in people who develop this illness. While no specific gene has been shown to directly cause BPD, a number of different genes have been identified as playing a role in its development. The brain’s functioning, as seen in MRI testing, is often different in people with BPD, suggesting that there is a neurological basis for some of the symptoms associated with BPD.
Neuroimaging studies are not clinically helpful at this time to make the diagnosis and are research tools. A number of hormones (including oxytocin) and signaling molecules within the brain (e.g., neurotransmitters including serotonin) have been shown to potentially play a role in BPD. People who experience traumatic life events (e.g., physical or sexual abuse during childhood) are at increased risk of developing BPD, as are people with certain chronic medical illnesses in childhood.
The connection between BPD and other mental illnesses is well established. People with BPD are at increased risk for anxiety disorders, depressive disorders, eating disorders, and substance abuse. BPD is often misdiagnosed and many people find they wait years to get a proper diagnosis, which leads to a better care plan.
Many people with borderline personality disorder have a first-degree relative with a serious mental illness (e.g., bipolar disorder or schizophrenia). This is likely due to both genetic and environmental factors.
What are the treatments for borderline personality disorder?
Once an accurate diagnosis is made, developing a comprehensive treatment plan is important. Typically the treatment plan will include psychotherapy strategies, medications to reduce symptom intensity, and group, peer and family support. One overarching goal is for the person with BPD to increasingly direct their care plan as they learn what works and what is counterproductive for them.
Psychotherapy is the cornerstone of treatment for individuals who live with BPD. Dialectical behavioral therapy (DBT) is the most well researched and effective treatment for BPD. DBT focuses on teaching coping skills to combat destructive urges, encourages practicing mindfulness (e.g., meditation, regulated breathing and relaxation), involves individual and group work, and is often quite successful in helping people with BPD to control their symptoms. DBT has been shown to reduce the outcome of suicide in research studies for people who live with BPD. Becoming a DBT therapist requires special training and supervision. If you are interested in DBT, be sure to understand the qualifications of the therapist in this specialized treatment.
While cognitive behavioral therapy (CBT), psychodynamic psychotherapy and certain other psychosocial treatments are useful for some people with BPD, the majority of people with this illness will find dialectical behavioral therapy (DBT) to be the most useful form of psychotherapy.
Medications can be an important component to the care plan, yet is important to know that there is no single medication treatment that can “cure” borderline personality disorder. Furthermore, no medication is specifically approved by the FDA for the treatment of BPD. Medications are however useful in treating specific symptoms in BPD and may support and enhance essential psychotherapy efforts. For example, off label use of a number of medications may manage key symptoms, including valproate (Depakote) that may be useful in decreasing impulsivity, omega-3 fatty acids (fish oil) that may be helpful in decreasing mood fluctuations, and naltrexone (Revia), which has helped some people decrease their urges for self-injury and the use of antipsychotic medication may help with symptoms of disorganized thinking. Relief of such symptoms may help the individual change the harmful patterns of thinking and decrease the detrimental behaviors that disrupt their daily activities. Medication treatment of coexisting medical and mental illnesses, such as anxiety or depression, is also very important in the treatment of BPD.
Co-occuring conditions are common and require attention in the care plan. The use of psychiatric medications should be discussed at length with one’s psychiatrist as individuals with BPD may be at increased risk of experiencing side effects from their medications due to the large number of medications that many people with this illness are prescribed. The use of psychiatric medications should be discussed at length with one’s psychiatrist to understand the risks and benefits of any treatment choice and to get a better sense of the literature upon which the recommendation is based.
While not usually indicated for the chronic symptoms of BPD, short-term inpatient hospitalization may be necessary during times of extreme stress, impulsive behavior, or substance abuse. In other cases however, inpatient psychiatric hospitalization may be paradoxically detrimental for some people with BPD.
The support of family and friends is of critical importance in the treatment of BPD as many people with this illness may isolate themselves from these relationships in times of greatest need. Family and friends can be most helpful in encouraging their loved one to engage in proper treatment for this complicated illness. With the support of family and friends, involvement in ongoing treatment, and efforts to live a healthy lifestyle—regular exercise, a balanced diet and good sleeping habits--most people with borderline personality disorder can expect to experience significant relief from their symptoms.
Will people with borderline personality disorder get better?
Recent research based on long-term studies of people with BPD suggests that the overwhelming majority of people will experience significant and long-lasting periods of symptom remission in the lifetime. Many people will not experience a complete recovery (e.g., problems with self-esteem and the ability to form and maintain relationships may linger), but nonetheless will be able to live meaningful and productive lives. Many people will require some form of treatment—whether medications or psychotherapy—to help control their symptoms even decades after their initial diagnosis with borderline personality disorder.
Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., November 2012
The authors would like to thank S. Charles Schulz, M.D. for his contributions to a prior version of this page.