Borderline personality disorder (BPD) is a complex mental health condition that adversely affects how people see themselves and the world around them, as well as how they interact with others. It’s estimated that less than 3% of the general population has BPD, but individuals with the disorder comprise about one-fifth of those in inpatient psychiatric treatment.
BPD can be challenging to treat, but several types of therapy can help people manage its complex profile of symptoms, which include emotional regulation, difficulty forming and sustaining relationships, and developing a healthy self-image and healthy behavioral patterns.
What Is Borderline Personality Disorder?
BPD is a type of mental illness characterized by poor self-image and a distorted image or understanding of other people and situations. This condition leads to intense reactions, unstable relationships and job performance, and self-destructive or self-defeating thoughts and behaviors.
“It affects how individuals manage themselves, form their identity, and how they manage relationships,” explains Lois Choi-Kain, MD, MEd, director of the Gunderson Personality Disorders Institute at McLean Hospital.
She adds that, among personality disorders, BPD is the most severe, and yet the most treatable. “It’s the most severe, because people with BPD often have suicidal tendencies,” Dr. Choi-Kain explains. “It’s also a lot more disabling than other personality disorders.”
Among serious mental health conditions, BPD may be most like bipolar disorder, though there are some important distinctions. While BPD and bipolar disorder both cause intense mood swings and impulsive behavior, they have very different patterns, triggers, and treatments. Dr. Choi-Kain notes, for example, that people with BPD tend to have angrier outbursts than those with bipolar disorder.
She also notes that biology plays a greater role in bipolar disorder, which is why it can be treated with a number of medications aimed at stabilizing brain chemical shifts. BPD develops from a combination of both biological and environmental factors, and psychological development. Medications are not proven effective for decreasing its symptoms. Psychotherapy remains the key approach to managing and treating BPD symptoms.
Key Symptoms of Borderline Personality Disorder
One of the main borderline personality disorder symptoms is emotional instability. This instability leads to rapid, sometimes unpredictable, mood swings that often last for hours or days. “People with BPD have higher levels of negative emotions generally,” Dr. Choi-Kain says, though she adds that feelings of optimism, joy, and affection can be among the emotional shifts, especially when a person with the disorder feels connected to someone who cares for them. Some people with BPD can be very charming and come across as energetic and entertaining.
Sometimes extreme emotional reactivity can lead to reckless actions and impulsive behavior. These symptoms can include everything from alcohol or drug misuse to suddenly quitting jobs, dropping hobbies, or cancelling plans. In many cases, self-harm and suicidal thoughts are among the most concerning borderline personality disorder symptoms and the signs that lead family members to seek help for their loved ones.
When it comes to borderline personality disorder and relationships, the emotional highs and lows can lead to a range of problematic behaviors. Fear of abandonment can drive people to cling to a partner, while other feelings and perceptions can cause individuals to push a partner away. Someone seen as a soulmate one day may be viewed the next day as a bad or hurtful person.
While having BPD can lead people to view others through a distorted lens, the condition also causes individuals to view themselves in unrealistic and negative terms. Self-perception can range from all-good to worthless, with no middle ground. Goals, values, priorities, and opinions can change frequently and predictably. Self-esteem and self-image often depend on the reactions and validation of others. And because people with BPD may not understand themselves or know who they are inside, they can often feel a chronic emptiness.
Causes and Risk Factors
It’s not always clear why a person develops BPD, though likely causes of borderline personality disorder include a combination of genetics, brain changes, and environmental factors related to a stressful childhood. Children who experience neglect, abandonment, or abuse are at higher risk of developing BPD. Other types of stress and trauma experienced at a young age also may contribute to BPD risk.
“Kids who are more emotional and impulsive tend to get more harsh parenting and are more likely to get bullied,” Dr. Choi-Kain says. She explains that those kids may respond to anger from others with more emotional and impulsive behavior, thus perpetuating a vicious cycle that may lead young people to develop BPD.
Research has also identified various neurological and genetic factors related to BPD risk.
Studies have shown that certain brain regions in people with BPD are often smaller than normal. These regions include the hippocampus, which is involved in memory and spatial relations, and the amygdala, which processes emotions (including fear) and survival responses.
Dysfunction affecting two key brain networks also may explain the development of BPD. One is the default mode network, which manages self-awareness, social cognition, and emotional assessment or interpretation. The other is the central executive network, which is involved in high-level cognitive tasks, working memory, inhibition, and decision-making. When faced with stress, individuals with BPD may have trouble with inhibiting impulses and activating self-direction, while ramping down preoccupation with self-consciousness and social sensitivity. And difficulties holding information in their working memory can make stressful situations even more problematic.
Researchers are also learning that there may be a much stronger genetic component involved in BPD cases than previously thought. Dr. Choi-Kain notes that multiple genes have been implicated in elevating BPD risk. “The genes associated with BPD are also associated with depression and PTSD,” she adds.
How Is Borderline Personality Disorder Diagnosed?
There is no simple blood test or other screening to diagnose BPD. Instead, a healthcare professional may start with a comprehensive assessment to rule out other causes of symptoms.
The diagnosis of borderline personality disorder primarily comes down to a review of symptoms shared by the individual and by observations made by loved ones. The conversation with a healthcare professional will cover issues such as behaviors and impulse control, emotional regulation and how stress is handled, and relationship history, in addition to personal and family medical history, including a discussion about any mental health conditions.
Dr. Choi-Kain says that even though more obvious BPD symptoms emerge in adolescence and young adulthood, individuals with the condition can sometimes point to a lifetime of emotional and behavioral struggles. “People with BPD often say things like, ‘I’ve had depression since I was 5,’” she says.
Dr. Choi-Kain also notes that a diagnosis of BPD or other personality disorders is often processed differently than a diagnosis of depression, for example. Telling someone their personality is the issue and needs to change can be hard for many people to hear, she says, but this focuses the problems to the way they manage themselves and their relationships with others.
Common Co-Occurring Conditions
As if having BPD wasn’t complicated and challenging enough, it is often accompanied by other serious mental health conditions. Dr. Choi-Kain says that between 50% and 80% of people with BPD also have major depression, which makes someone much less likely to respond well to treatment.
Other common BPD comorbidities/co-occurring disorders include substance use disorder and alcohol use disorder, as well as posttraumatic stress disorder, anxiety disorders, and eating disorders.
Effective Treatment Options
Unlike a condition such as depression, which has symptoms that can often be treated effectively with medications, there are no drugs like antidepressants to manage BPD.
Borderline personality disorder treatment relies primarily on psychotherapy. “All psychotherapies focus on personality change,” Dr. Choi-Kain says, adding that among the effective approaches for BPD is dialectical behavior therapy (DBT).
DBT is a type of talk therapy based on the principles and practices of cognitive behavioral therapy (CBT), but DBT is especially appropriate for people who experience intense emotions. The goal is to help people accept the reality of their lives and behaviors, while also trying to help them change their unhelpful emotions, perceptions, and behaviors. Group therapy can sometimes be helpful, too.
It’s important to understand that BPD is a chronic condition with no actual “cure,” yet. That means living with borderline personality disorder requires a lifetime of management. Building a stable social network of support is helpful. Parents and partners who can defuse stressful situations and help their loved ones handle upsetting episodes may help keep symptoms from getting worse, Dr. Choi-Kain says.
When to Seek Help
Because personality styles and traits tend to become more entrenched over time, seeking treatment for BPD when a person is young may offer the best chance for a desired outcome. When an individual’s concerning mood swings, reactions, and interactions with others become more intense and more frequent, it may be time to talk with a primary care physician or seek out a mental health professional.
Dr. Choi-Kain cautions that BPD remains one of the more stigmatized mental health conditions among medical professionals, so be prepared for some pushback or misunderstandings about BPD in your search for help. She recommends taking the time to find a therapist with experience in treating BPD and who has a real interest in helping this population.
