Borderline Personality Disorder

By Dr. Cheryl Lane, PhD

Of the 10 different personality disorders listed in the DSM, there is one that stands out from all the others when it comes to frequenting therapists’ offices, doctors’ offices, mental health clinics, and hospital emergency rooms.

Individuals with Borderline Personality Disorder (BPD) struggle with intense negative emotions, frequent personal crises, suicidal thoughts, and self-mutilation – all of which cause them to be high users of the mental health system.

The term "borderline" stems from the early belief that individuals with BPD teetered on the "border line" between neurosis and psychosis. A more appropriate name for this particular personality disorder would be "emotional regulation disorder". Attempts to get the name changed have been unsuccessful thus far.

Symptoms of Borderline PD

Individuals with BPD are not hard to spot. Their complicated lives are marked by telltale symptoms. These symptoms not only make their own lives very difficult, but also have a significant negative impact on those around them. The symptoms of BPD include:

An intense fear of abandonment.

Individuals with BPD have a very difficult time dealing with rejection, separation, and being alone. They can be very manipulative in their frantic attempts to avoid any type of abandonment – real or imagined.

Unpredictable, abrupt, and frequent mood changes.

Individuals with BPD may be in an "okay" or upbeat mood one minute, and then suddenly become upset, sullen, anxious, angry, irritable, sad, or tearful the next. The negative or "dysphoric" mood is reactive in nature, and is often triggered by feelings of abandonment.

A history of intense, unstable, and often volatile relationships.

BPD individuals go back and forth between idolizing and harshly devaluing the people in their lives. This behavior, along with other BPD symptoms, makes relationships very difficult to maintain. Individuals with BPD almost always have a long history of broken relationships.

A fragile sense of self.

Their goals, future plans, values, opinions, and even their sexual identity may change frequently as a result of an unstable self-image. Many BPD individuals also perceive themselves as inherently bad or evil.

A chronic sense of emptiness.

Individuals with BPD get bored very easily, and constantly seek ways to alleviate the boredom and emptiness.

Impulsivity.

Borderline individuals often engage in high-risk, destructive, impulsive behavior such as driving recklessly, having unprotected sex, abusing drugs or alcohol, or gambling.

Inappropriate displays of intense anger or rage, and difficulties controlling their anger.

The angry feelings that are often present with BPD may be expressed via sarcastic remarks, verbal attacks, physical fights, and / or bitterness.

Self-mutilation and / or frequent suicidal gestures, attempts, or threats.

Individuals with BPD are often self-destructive, which leads to many ER visits and inpatient psychiatric hospitalizations. Self-mutilation often involves cutting or burning - often done to punish themselves, alleviate emotional pain, or make themselves feel something. While many suicidal threats and behaviors are manipulative in nature, they are also often in reaction to the chronic emotional pain experienced by borderline individuals. As many as 1 in 10 BPD individuals die from suicide.

Brief instances of paranoia or dissociation when under extreme stress.

These typically occur in response to feelings of abandonment in individuals with BPD.

Treatment

Personality disorders, by their very nature, are inflexible and deeply ingrained. This makes them very difficult to treat and lends to a poor prognosis as a general rule. However, compared to other types of personality disorders, some individuals with BPD respond fairly well to appropriate treatment. This is why BPD is the one personality disorder diagnosis that some health insurance plans do cover. Treatment options include psychotherapy, medication, and hospitalization.

Psychotherapy

Psychotherapy is the best overall treatment for BPD. In recent years, a specific, highly structured type of therapy called "dialectical behavioral therapy" has proven to be quite effective in treating BPD. DBT focuses on helping BPD individuals with emotional regulation, interpersonal relationships, and stress management.

Medication

Medication has very limited effectiveness in treating BPD symptoms. However, since many individuals with BPD often struggle with depression or anxiety, medication may be prescribed to treat symptoms of those disorders.

Inpatient treatment

Inpatient psychiatric treatment is sometimes required for individuals with BPD, with the primary goal being safety. Inpatient treatment typically occurs when the individual is actively suicidal or engaging in dangerous self-mutilation (e.g. deep cutting versus superficial cutting). Approximately 1 in 5 psychiatric inpatients have BPD.

Borderline PD vs. Bipolar Disorder

It’s not uncommon for individuals with BPD to be misdiagnosed with Bipolar Disorder, and vice versa, even though the two disorders are quite distinct. Although both disorders involve "mood swings", individuals with BPD experience mood changes very frequently – such as every few hours or even several times a day. These changes are reactive in nature, with the negative moods in BPD often triggered by feelings of abandonment. Also, individuals with BPD don’t have the distinct periods of mania or hypomania that occur in Bipolar Disorder.*

Impulsive behavior is another overlapping symptom. In Bipolar Disorder, this typically occurs during a manic or hypomanic episode, whereas in BPD impulsivity is not mood-dependent.

*It is possible for someone to have both BPD and Bipolar Disorder, in which case a history of symptoms to adequately warrant both diagnoses would be present. An accurate diagnosis is important, especially since the treatment for these two disorders is quite different.

Borderline PD and Frequent Co-Occurring Disorders

Individuals with BPD often have more than one psychiatric disorder. Common co-occurring disorders include substance-related disorders, major depressive disorder, PTSD, ADHD, and bulimia nervosa. Individuals with BPD may have another personality disorder as well.

It’s estimated that 2% of the U.S. adult population has Borderline Personality Disorder. As individuals with BPD reach middle-age and beyond, it’s not uncommon for their symptoms to gradually become less intense.