Borderline personality disorder (BPD) is a condition characterized by difficulties in regulating emotion. This difficulty leads to severe, unstable mood swings, impulsivity and instability, poor self-image and stormy personal relationships. People may make repeated attempts to avoid real or imagined situations of abandonment. The combined result of living with BPD can manifest into destructive behavior, such as self-harm (cutting) or suicide attempts.
It’s estimated that 1.6% of the adult U.S. population has BPD but it may be as high as 5.9%. Nearly 75% of people diagnosed with BPD are women, but recent research suggests that men may be almost as frequently affected by BPD. In the past, men with BPD were often misdiagnosed with PTSD or depression.
People with BPD experience wide mood swings and can display a great sense of instability and insecurity. Signs and symptoms may include:
- Frantic efforts to avoid being abandoned by friends and family.
- Unstable personal relationships that alternate between idealization—“I’m so in love!”—and devaluation—“I hate her.” This is also sometimes known as "splitting."
- Distorted and unstable self-image, which affects moods, values, opinions, goals and relationships.
- Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, substance abuse or reckless driving.
- Suicidal and self-harming behavior.
- Periods of intense depressed mood, irritability or anxiety lasting a few hours to a few days.
- Chronic feelings of boredom or emptiness.
- Inappropriate, intense or uncontrollable anger—often followed by shame and guilt.
- Dissociative feelings—disconnecting from your thoughts or sense of identity, or “out of body” type of feelings—and stress-related paranoid thoughts. Severe cases of stress can also lead to brief psychotic episodes.
Borderline personality disorder is ultimately characterized by the emotional turmoil it causes. People who have it feel emotions intensely and for long periods of time, and it is harder for them to return to a stable baseline after an emotionally intense event. Suicide threats and attempts are very common for people with BPD. Self-harming acts, such as cutting and burning, are also common.
The causes of borderline personality disorder are not fully understood, but scientists agree that it is the result of a combination of factors:
- Genetics. While no specific gene has been shown to directly cause BPD, studies in twins suggest this illness has strong hereditary links. BPD is about five times more common among people who have a first-degree relative with the disorder.
- Environmental factors. People who experience traumatic life events, such as physical or sexual abuse during childhood or neglect and separation from parents, are at increased risk of developing BPD.
- Brain function. The way the brain works is often different in people with BPD, suggesting that there is a neurological basis for some of the symptoms. Specifically, the portions of the brain that control emotions and decision-making/judgment may not communicate well with one another.
There is no single medical test to diagnose BPD, and a diagnosis is not based on one sign or symptom. BPD is diagnosed by a mental health professional following a comprehensive psychiatric interview that may include talking with previous clinicians, medical evaluations and, when appropriate, interviews with friends and family. To be diagnosed with BPD, a person must have at least 5 of the 9 BPD symptoms listed above.
A typical, well-rounded treatment plan includes psychotherapy, medications and group, peer and family support. The overarching goal is for someone with BPD to increasingly self-direct her treatment plan as a person learns what works as well as what doesn’t.
- Psychotherapy, such as dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT) and psychodynamic psychotherapy, is the first line of choice for BPD.
- Medications are often instrumental to a treatment plan, but there is no one medication specifically made to treat the core symptoms of emptiness, abandonment and identity disturbance. Rather, several medications can be used off-label to treat the remaining symptoms. For example, mood stabilizers and antidepressants help with mood swings and dysphoria. Antipsychotic medication may help control symptoms of rage and disorganized thinking.
- Short-term hospitalization may be necessary during times of extreme stress, and/or impulsive or suicidal behavior to ensure safety.
BPD can be difficult to diagnose and treat—and successful treatment includes addressing any other disorders somebody might have. A person with BPD may have additional conditions like:
- Anxiety disorders, such as PTSD.
- Bipolar disorder.
- Eating disorders, notably bulimia nervosa.
- Other personality disorders.
- Substance use disorders.