Borderline Personality Disorder (BPD)

Overview

Borderline personality disorder (BPD), is arguably the most common and debilitating of all the personality disorders. It causes chaos and anguish for both the people who suffer from it and those who care about them. It affects how you feel about yourself, how you relate to others and how you behave.

Borderline personality disorder is an often-misunderstood condition that has many challenging aspects, including a pattern of unstable and stormy personal relationships, intense emotions (emotional dysregulation), low self-esteem, self-sabotaging acts and impulsivity. A person with borderline personality disorder may go to great lengths to avoid being abandoned, have repeated suicide attempts, display inappropriate intense anger, or have ongoing feelings of emptiness.

BPD often begins in early adulthood and presents in a variety of contexts. People with BPD have an intense fear of abandonment or instability, yet uncontrollable and inappropriate anger coupled with frequent mood swings can often push others away. They find it hard to manage their emotions which often cause them to feel a great deal of pain.

How common is borderline personality disorder?

BPD is estimated to affect between 2 – 6 per cent of Australians. Although BPD is said to be more common in women, this is probably because it is recognised less frequently in men, who may be less likely to seek treatment.

Symptoms and causes

Symptoms of borderline personality disorder

Borderline personality disorder is a pervasive pattern of unstable interpersonal relationships, self-image and affects, and marked impulsivity that begins in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Intense fears of real or imagined abandonment and/or frantic efforts to avoid abandonment.
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
3. A persistent and unstable self-identity and self-image that includes shifting goals and values, and seeing yourself as bad or as if you don’t exist at all.
4. Impulsive and risky behaviour, such as gambling, reckless driving, unsafe sex, spending sprees, binge eating or drug abuse, or sabotaging success by suddenly quitting a good job or ending a positive relationship.
5. Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour often in response to the fear of separation or rejection.
6. Periods of stress-related paranoia, dissociation and loss of contact with reality, lasting from a few minutes to a few hours.
7. Chronic feelings of emptiness.
8. Intense mood swings lasting a few hours and rarely more than a few days, which can include intense happiness, irritability, shame or anxiety.
9. Inappropriate, intense anger or difficulty controlling anger such as frequent displays of temper, constant anger, being sarcastic or bitter, or getting into physical fights.

Causes of borderline personality disorder

Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for substance use disorders, antisocial personality disorder, and depressive or bipolar disorders.

Although BPD doesn’t seem to have a clear-cut cause , experts agree that there are a number of biological, psychological and social factors that combine in complex ways that aren’t always fully understood. The risk factors include the following:

• Trauma
• Genetics
• Parenting
• Social culture
• Biology

Diagnosis and treatment

How is borderline personality disorder diagnosed?

Diagnosis of a personality disorder requires a mental health professional to evaluate long-term patterns of functioning and symptoms. Diagnosis is only applicable to individuals 18 or older. People under 18 are typically not diagnosed with personality disorders because their personalities are still developing. Some people with personality disorders may not recognise that they have a problem.

Healthcare providers use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-5), to help diagnose Borderline Personality Disorder. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for Borderline Personality Disorder.

Evolving approaches to diagnosing BPD

Great controversy surrounds the diagnosis for all personality disorders. In particular, mental health professionals have long debated how to diagnose BPD since presenting symptoms can vary greatly. Some believe part of the diagnostic problem lies in the term borderline.

Adolph Stern, an early American psychoanalyst coined the term borderline in 1938 to describe patients who sat on the border between neurosis and psychosis.

Neurosis describes a variety of emotions such as anxiety, depression and distress that stem from unconscious conflict. Psychosis, on the other hand, describes a loss of contact with reality such as hallucinations, delusions and serious problems with rational thought.

Dr John Gunderson and Dr Mary Zanari – both BPD experts – together developed an interview to assist with the diagnosis which focuses on the four major categories. Their approach recommends only using the term BPD for those people who exhibit all of these symptom clusters.

• Unstable relationships – People with BPD tend to be stormy and manipulative, entitled, demanding and switch quickly between idealisation and demonisation.
• Mood instability – People with BPD often display heightened sensitivity and quickly changing moods due to misperceptions of other people’s intentions. The results can lead to feelings of emptiness, anger, anxiety and rage and struggle to bring their emotions back to a normal state once they’ve lost control.
• Impulsivity – Often acting without thinking, someone with BPD may act recklessly, self-mutilate, attempt suicide and/or go sensation seeking.
• Cognitive impairments – The distorted feelings of someone with BPD can lead to intense distrust, hallucinations and delusions.

Differential diagnosis for borderline personality disorder

Differential diagnosis includes:

• Complex post-traumatic stress disorder (C-PTSD)
• Depressive and bipolar disorders
• Other personality disorders
• Personality change due to another medical condition
• Substance use disorders
• Other identity problems

Treatment for Borderline Personality Disorder

Borderline personality disorder is primarily treated with psychotherapy, but medication may also be advantageous in treating some of the symptoms.

Commonly used types of psychotherapy include:

• Cognitive behavioural therapy
• Dialectical behaviour therapy
• Group therapy
• Psychoanalytic/psychodynamic/transference-focused therapy
• Psychoeducation (teaching the individual and family members about the diagnosis, treatment and ways of coping)

Comorbidity

Borderline personality disorder can coexist with other disorders including:

• ADHD
• Anxiety disorders
• Bipolar disorder
• Eating disorders
• Major depressive disorder
• PTSD or complex PTSD
• Substance use disorders
• Other personality disorders

BPD is one of 10 personality disorders, and, according to the DSM-5, people can receive more than one personality disorder diagnosis. People who are diagnosed with a personality disorder most often qualify for more than one diagnosis. A person with a severe personality disorder might meet the criteria for four, five or even more disorders. Alternatively, people can have traits of different personality disorders without meeting the full criteria for any or all of them.

In practice, clinicians usually recognise that meeting more criteria for personality disorders means the disorder is more severe.

Other personality disorders include:

1. Antisocial personality disorder – a pattern of disregarding or violating the rights of others. A person with antisocial personality disorder may not conform to social norms, may repeatedly lie or deceive others, or may act impulsively.
2. Avoidant personality disorder – a pattern of extreme shyness, feelings of inadequacy, and extreme sensitivity to criticism. People with avoidant personality disorder may be unwilling to get involved with people unless they are certain of being liked, be preoccupied with being criticised or rejected, or may view themselves as not being good enough or socially inept.
3. Dependent personality disorder – a pattern of needing to be taken care of and submissive and clingy behaviour. People with dependent personality disorder may have difficulty making daily decisions without reassurance from others or may feel uncomfortable or helpless when alone because of fear of inability to take care of themselves.
4. Histrionic personality disorder – a pattern of excessive emotion and attention-seeking. People with histrionic personality disorder may be uncomfortable when they are not the centre of attention, may use physical appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions.
5. Narcissistic personality disorder – a pattern of need for admiration and lack of empathy for others. A person with narcissistic personality disorder may have a grandiose sense of self-importance, a sense of entitlement, take advantage of others or lack empathy.
6. Obsessive compulsive personality disorder – a pattern of preoccupation with orderliness, perfection and control. A person with obsessive-compulsive personality disorder may be overly focused on details or schedules, may work excessively, not allowing time for leisure or friends, or may be inflexible in their morality and values.
7. Paranoid personality disorder – a pattern of being suspicious of others and seeing them as mean or spiteful. People with paranoid personality disorder often assume people will harm or deceive them and don’t confide in others or become close to them.
8. Schizoid personality disorder – being detached from social relationships and expressing little emotion. A person with schizoid personality disorder typically does not seek close relationships, chooses to be alone and seems to not care about praise or criticism from others.
9. Schizotypal personality disorder – a pattern of being very uncomfortable in close relationships, having distorted thinking and eccentric behaviour. A person with schizotypal personality disorder may have odd beliefs or odd or peculiar behaviour or speech or may have excessive social anxiety.

Outlook and prognosis

The disorder usually begins by early adulthood and the condition is usually worse in young adulthood and may gradually get better with age.

Self-care strategies, psychological therapies, and support in the community can all help people living with BPD. While the symptoms can be confusing and easily misunderstood, it is possible to live a meaningful and happy life.