People with borderline personality disorder (BPD) experience intense, unstable emotions, stormy relationships, deep insecurity, and a lack of a strong identity. They often have an intense fear of abandonment but are triggered and angered by seemingly insignificant things, making it difficult to maintain relationships.

To learn what separates a “difficult” personality from a personality disorder, Bottom Line Health spoke with Jerold J. Kreisman, MD, a psychiatrist, BPD expert, and author of Talking to a Loved One with Borderline Personality Disorder.


BLH: What are some common characteristics of BPD?

Dr. Kreisman: Some of the defining characteristics of BPD are a history of unstable relationships and a problem with abandonment. You may have a partner who is clingy, who is very insecure about the relationship, or whose attitude about the relationship is very changeable.

For example, for someone with BPD, people in their lives may be idealized one moment but, after a minor disappointment (you didn’t call back early enough, you couldn’t give me a ride), that person is suddenly demonized. It can change immediately.

Another trait that makes BPD recognizable is that there’s a chameleon effect. There isn’t a strong consistent sense of identity. Someone with BPD is a Democrat when they’re with Democrats and a Republican when they’re with Republicans, but when it’s 2 a.m. and they’re alone, they don’t know what they believe or who they are.


BLH: What is the difference between a personality disorder and a mood disorder?

Dr. Kreisman: BPD is often confused with bipolar disorder because people with both conditions have tremendous mood changes, as well as impulsivity and difficulty dealing with interpersonal relationships.

The difference is that in mood disorders, the mood changes often last for extended periods. In bipolar disorder, for example, people go through high or low moods that last for days or even weeks. Importantly, there are periods between those extremes when the person’s moods are fairly stable.

In people with BPD, however, mood changes are usually stimulated by some environmental stimuli and they change on a dime. A person with BPD could be walking down the street and get a compliment that makes them feel really good and positive. But if they then hear a derogatory remark, they can suddenly become depressed, angry, or even suicidal.

This tendency is an ongoing thing. They don’t have extended periods where their moods remain stable.


BLH: What treatment is available for people with BPD?

Dr. Kreisman: There are no medications specifically available for BPD yet, but there is a European company with a drug in phase 3 studies.

Medications can, however, help comorbid conditions. BPD rarely stands alone: It often accompanies another disorder, such as depression, anxiety, or substance abuse. There is a role for medication for many of those accompanying symptoms.

The primary treatment for BPD is therapy. Over the years, several treatment approaches have been developed that are manualized, which means you can “go by the book”:

  • Dialectic behavioral therapy is a form of cognitive therapy that teaches group skills, such as what to do when you feel a sense of abandonment, when you get angry, or when you feel lost and empty.
  • Mentalization-based therapy teaches people how to think through what they are feeling underneath the problematic emotions and to empathize more with the person on the other end of the relationship.
  • Transference focus therapy is more psychodynamic and analytic. It looks into past relationships and the therapeutic relationship to understand and improve current relationships.
  • Schema-focused therapy also has to do with past experiences growing up.

The problem with a lot of these formalized treatment approaches is that they usually require a lot of training for a therapist and they’re not readily available. Overall, mental health treatment isn’t readily available in this country. There’s a terrible shortage of professionals.

So the best approach may be another manualized program called Good Psychiatric Management. It’s more informal and it focuses on understanding BPD and addressing a person’s symptoms.


BLH: What is the prognosis for people with BPD?

Dr. Kreisman: In the past, BPD was stigmatized. Patients had a reputation for being demanding and difficult. Further, there was a belief that “this is your personality: You’re never going to get better.”

But research shows otherwise. Studies have shown that, over time, BPD tends to even out. The good news is that more than 90 percent of people get better over time—even without treatment. And those same studies have provided insights that can make treatment more effective.

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