Borderline Personality Disorder (BPD)
Borderline personality disorder (BPD) has long been misunderstood. Even its name reflects early beliefs about BPD that proved to be wildly inaccurate. Psychiatrists in the 1930s thought people who presented with symptoms of BPD were on the border between the two primary categories of mental illness: psychosis and neurosis. This meant they saw BPD as a thought disorder that approached the delusional thinking associated with schizophrenia but did not quite reach it.
Understanding the condition has improved in the last several decades. Psychologists now know borderline personality disorder is completely unrelated to schizophrenia. Rather than a disorder of thought, BPD is a disorder of emotional regulation.
Unfortunately, despite advances in clinical insight, the perception of borderline personality disorder remains distorted, and stigma persists. People who are “difficult” or “resistant” are often said to have BPD even when their symptoms suggest another disorder.
However, knowledgeable clinicians understand that BPD is linked with trauma and is as treatable as other trauma-related conditions, like post-traumatic stress disorder (PTSD) and dissociative disorders.
What Is Borderline Personality Disorder?
Borderline personality disorder is one of ten personality disorders listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Personality disorders usually develop prior to adulthood and manifest as more ingrained expressions of identity than other mental health conditions. This is why people often refer to the criteria for personality disorders as “traits” rather than symptoms. For example, when a person has symptoms of borderline personality disorder but does not meet the criteria for a full diagnosis, clinicians often describe that person as having BPD traits.
Mental health professionals define borderline personality disorder by considering its effects on emotional regulation, impulse control, and interpersonal relationships. To be diagnosed with the disorder, a person must have at least four of the following BPD traits listed in the DSM-5:
- Frantic avoidance of real or imagined abandonment
- Significant and persistent identity disturbance or an unstable sense of self
- Recurrent suicidal or self-harming behavior, including suicidal gestures and threats
- Disproportionate or inappropriate anger, rage episodes, or difficulty controlling temper
- Emotional instability and reactivity as exhibited by intense episodic dysphoria, anxiety or irritability
- Impulsivity in at least two areas with a significant risk of danger, such as substance use and unprotected sexual activity
- A pattern of unstable and intense relationships in which another person is alternately idealized and devalued
- Transient stress-induced paranoid ideation or dissociative symptoms
- Chronic feelings of emptiness
Borderline personality traits have some similarities to symptoms of PTSD, another trauma-related disorder. Just as people with PTSD are often easily startled by sudden environmental changes than others, people with BPD usually react more intensely to emotional stimuli than people without BPD. For example, a person with BPD is more likely to experience intense distress in response to an interpersonal conflict and may engage in self-destructive or self-harming behavior to express or manage the overwhelming emotional pain they feel.
Living with borderline personality disorder requires weathering emotional storms. People with BPD who do not get treatment are at an increased risk of both intentional and unintentional suicide as well as a host of other negative outcomes. However, those who receive the right treatment for BPD can learn how to manage their symptoms.
Types of Borderline Personality Disorders
While there are no official subtypes of BPD listed in the DSM-5, many people have classified subtypes of borderline personality disorder based on a wide variety of ways individuals express BPD traits. For example, some people with BPD are less outwardly expressive and more prone to feelings of emptiness and identity disturbance, while others are more demonstrative and engage in impulsive and self-harming behavior.
One recent analysis split people with borderline personality disorder into three categories. Smits, Feenstra, Bales and others performed a cluster analysis on nearly 200 people with BPD and identified three types of borderline personality presentations:
- The core BPD type has the most severe symptoms and most impaired functioning of the three types, particularly when it comes to mood stability and identity integration. These individuals have high rates of self-harm and a more dependent interpersonal style.
- The extrovert or externalizing type has the least severe symptoms, with higher functioning in domains of self-control, effective stability and identity integration. However, these individuals tend to be lower functioning in domains of responsibility and social skills and have a more domineering interpersonal style.
- The schizotypal or paranoid type has less severe symptoms, higher functioning in domains of responsibility and social skills, and a socially inhibited interpersonal style.
An American psychologist named Theodore Millon created a similar classification system for borderline personality disorder, placing people with BPD in one of four subtypes: discouraged borderline, impulsive borderline, petulant borderline and self-destructive borderline.
Discouraged borderline personality disorder is a subtype that most closely resembles the “core BPD” subtype identified by Smits and associate researchers. People that fit the criteria for this subtype are often less assertive, more compliant, and more likely to feel depressed and powerless. They are prone to self-harm. People with this subtype tend to exhibit characteristics of dependent personality disorder and major depressive disorder.
Borderline impulsive type is a subtype of BPD characterized by impulsivity, distractibility, irritability and thrill- and attention-seeking behavior. People with this type of BPD are often charming and seductive and are prone to suicidality and self-harm. Impulsive borderline disorder shares traits in common with other “cluster B” personality disorders, characterized by overly emotional, dramatic or unpredictable behavior or thoughts, including antisocial and histrionic personality disorders.
People with petulant borderline personality disorder tend to be pessimistic, resentful, critical, indirectly aggressive, restless, and easily disappointed. They may quickly feel insulted and react in defiant and stubborn ways to perceived slights. People with this subtype are often unpredictable in their relationships, often engaging in a “push-pull” dynamic in which they feel a deep need for others, then push them away. These individuals normally exhibit characteristics of paranoid personality disorder and depressive disorders.
Self-destructive borderline personality disorder also shares features of depressive disorders. People who fit the description of this subtype of BPD may be masochistic, self-punishing, moody and introverted. They often exhibit a pattern of conforming to the expectations of others and then acting out angrily. They also tend to have an increased risk of suicide.
Symptoms of Borderline Personality Disorder
Given the wide range of ways people can express borderline personality disorder traits, the symptoms of borderline personality disorder can vary. Some people with BPD are elaborately and dramatically self-destructive, with visible scars from self-harm and frequent hospitalizations. Others are quiet, melancholy, and creative, more likely to suffer from BPD symptoms like feelings of emptiness, an unstable sense of self, dissociative episodes and dysphoria. People who don’t know them well often don’t have any idea of the intensity of their emotional states.
Still, borderline personality disorder symptoms share a common pattern. The disorder affects relationships, emotions and behavior in ways that are linked. The intense emotions that come with the disorder primarily arise in response to interpersonal conflict. Many, but not all, people with BPD cut or harm themselves when they are overwhelmed to distract from their emotional pain with physical pain or to show others how much they are hurting.
Common borderline personality disorder signs and symptoms include the following:
- Sudden outbursts of disproportionate rage or other intense emotions
- Dramatic and frequent changes in interests, hobbies and sources of enthusiasm
- Descriptions of loved ones that alternate between excessive praise and condemnation, and relationships that follow this pattern of idealization and devaluation
- Rapidly cycling moods that do not follow a typical pattern of manic and depressive episodes, such as elation and dejection alternating several times throughout the day
- Dissociative symptoms ranging from severe depersonalization and dissociative fugue states to mildly escapist or numbing behaviors
- Preoccupation with obtaining a sense of safety or comfort, especially through close relationships
The connection between these symptoms can be better understood when borderline personality disorder is considered in light of its roots in childhood and adolescent trauma.
Causes of Borderline Personality Disorder
The causes of borderline personality disorder can be grouped into three different categories:
- Genetic factors and inherited traits
- Biology and differences in brain function
- Psychosocial experiences and stressors
People with borderline personality disorder can usually trace the origins of their disorder to all three of these areas. A family history of mental illness, especially of BPD or related conditions, is a major factor. People with first-degree relatives who have BPD or BPD traits are five times more likely to have BPD. They were also more likely to have had an emotionally sensitive temperament and issues with impulse control at a young age.
However, these genetic and biological factors alone are not enough to cause the disorder. Life experiences are the major causes of BPD, particularly childhood trauma. People with BPD may have been sexually or physically abused or grown up in chaotic or violent homes. They often have histories of emotional abuse or neglect. Separation from parents is also strongly linked to the development of borderline personality disorder.
How Is Borderline Personality Disorder Diagnosed?
Clinicians diagnose borderline personality disorder through clinical observation and interview. Sometimes, people with BPD seek help themselves to understand what is causing their intense and painful emotional experiences. A therapist will learn more about their history and ask targeted questions to identify BPD traits before making a diagnosis. In some cases, a self-destructive episode or suicidal crisis leads to hospitalization, and a diagnosis is made by clinicians during inpatient treatment.
Borderline personality disorder is frequently misdiagnosed. Some people who do not have BPD are incorrectly diagnosed with it, while people who have BPD are sometimes diagnosed with something else. A careful process of clinical examination and differential diagnosis is required to rule out conditions with overlapping or similar symptoms, including the following disorders:
- Bipolar disorder
- Histrionic personality disorder
- Antisocial personality disorder
- Dependent personality disorder
- Post-traumatic stress disorder (PTSD)
- Attention-deficit hyperactivity disorder (ADHD)
- Substance use disorders
- Anxiety disorders
- Mood disorders
There are telltale differences that distinguish BPD from these alternative diagnoses. For example, mood episodes in bipolar disorder last longer than those in borderline personality disorder and are less clearly linked to external factors.
While people with PTSD and BPD often have exaggerated reactions to environmental and social events, people with PTSD suffer from intrusive trauma symptoms that are not part of BPD. However, it is important to note that people with BPD often have histories of trauma and may have comorbid PTSD or other disorders.
Who Is at Risk for Borderline Personality Disorder?
The following risk factors are the most strongly linked to the development of BPD:
- Emotional neglect or parental abandonment
- A sensitive and emotionally reactive temperament
- A violent or chaotic home environment in childhood
- Episodes of impulsive or explosive behavior in childhood
- A history of trauma or abuse in childhood or adolescence
- A family history of BPD, BPD traits or other personality disorders
Borderline personality disorder often develops by late adolescence or early adulthood and is not linked to any factors that emerge after childhood or early adolescence.
BPD in Men
Recent research shows that previous assumptions that BPD is more prevalent in women than men are wrong. Part of the reason for this historic discrepancy in diagnosis is that borderline personality disorder manifests differently in men than it does in women.
Sansone and Sansone found that men with BPD are more likely to have an explosive temper and to engage in dangerous or risk-seeking behavior than women with the disorder. They are also more likely to have co-occurring substance use disorders.
BPD in Women
Another reason that women may be diagnosed with BPD more frequently than men is that women with the disorder are more likely to have sought psychotherapy or pharmacotherapy for mental health concerns, while men with BPD are more likely to have first received treatment for a substance use disorder. Borderline personality disorder in women is also more likely to be paired with co-occurring PTSD, mood, anxiety or eating disorders.
Borderline Personality Disorder Statistics
Borderline personality disorder statistics include the following:
- The lifetime prevalence of BPD in the general United States population is about 6 percent.
- The prevalence of BPD in people receiving inpatient psychiatric treatment is 20 percent.
- Historically, about 75 percent of people diagnosed with BPD have been women. This likely reflects both overdiagnoses in women and underdiagnoses in men. Recent research suggests there is actually no difference in the prevalence of BPD in men and women.
- About 60 percent of people with BPD have co-occurring anxiety disorders.
- Nearly 50 percent of people with BPD have comorbid mood disorders.
- Approximately half of people with BPD have substance use disorders.
- People with borderline personality disorder have a suicide risk that is 50 times greater than that of the general population.
- Almost 80 percent of people with BPD attempt suicide at least once in their lives.
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