Borderline Personality Disorder

Borderline personality disorder affects approximately two percent of adults. It can manifest as mood instability, difficulty with interpersonal relationships, and high rates of self-injury and suicidal behavior.

Definition

Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and an individual’s sense of identity.

People with BPD, originally thought to be at the “border” of psychosis and neurosis, suffer from difficulties with emotion regulation. While less well known than schizophrenia or bipolar disorder, BPD affects two percent of adults. People with BPD exhibit high rates of self-injurious behavior, such as cutting and, in severe cases, significant rates of suicide attempts and completed suicide. Impairment from BPD and suicide risk are greatest in the young-adult years and tend to decrease with age. BPD is more common in females than in males, with 75 percent of cases diagnosed among women.

People with borderline personality disorder often need extensive mental health services and account for 20 percent of psychiatric hospitalizations. Yet, with help, many improve over time and are eventually able to lead productive lives.

Symptoms

A person with borderline personality disorder may experience intense bouts of anger, depression, or anxiety that may last only hours or, at most, a few days. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in thoughts and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, identity, and values.

Sometimes people with BPD view themselves as fundamentally bad or unworthy. They may feel bored, empty, or unfairly misunderstood or mistreated, and they have little idea who they are. Such symptoms are most acute when people with BPD feel isolated or lacking in social support, and they may result in frantic efforts to avoid being alone.

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes toward family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize another person, but when a slight separation or conflict occurs, switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.

Most people can tolerate the ambivalence of experiencing two contradictory states at one time. People with BPD, however, must shift back and forth between good and bad states. If they are in a bad state, for example, they have no awareness of the good state.

Individuals with BPD are highly sensitive to rejection, reacting with anger and distress to mild separations. Even a vacation, a business trip, or a sudden change in plans can spur negative thoughts. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating, and risky sex. BPD often occurs with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Causes

Although the cause of borderline personality disorder is unknown, both environmental and genetic factors are thought to play a role in predisposing people to BPD symptoms and traits. BPD is approximately five times more common among people with close biological relatives with BPD.

Studies show that many individuals with BPD report a history of abuse, neglect, or separation as young children. Forty to 71 percent of BPD patients report having been sexually abused, usually by a noncaregiver.

Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect, or abuse as young children and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victims of violence, including rape and other crimes. These incidents may result from harmful environments as well as the victims’ impulsivity and poor judgment in choosing partners and lifestyles.

Neuroscience is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The brain’s amygdala, a small almond-shaped structure, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal, which may be more pronounced under the influence of stress or drugs like alcohol. Areas in the front of the brain (prefrontal area) act to dampen the activity of this circuit. Recent brain-imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.

Serotonin, norepinephrine, and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much as people manage susceptibility to diabetes or high blood pressure.

Treatments

The recommended treatment for borderline personality disorder includes psychotherapy, medications, and group, peer, and family support. Group and individual psychotherapy have been shown to be effective forms of treatment for many patients. Psychotherapy is the first line treatment for BPD, and several forms of therapy, such as dialectical behavioral therapy (DBT), mentalization based therapy (MBT), cognitive behavioral therapy (CBT), and psychodynamic psychotherapy, have been studied and proven to be effective ways to alleviate symptoms.

Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.

References

• National Institute of Mental Health

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

• US Department of Health and Human Services

• National Alliance on Mental Illness

Last reviewed 03/06/2018

19 Signs You Grew Up With Borderline Personality Disorder

Sarah Schuster

Borderline personality disorder (BPD) is a highly stigmatized and misunderstood mental illness that affects about 14 million Americans, or 5.9 percent of adults in the U.S. But because the symptoms usually first occur while a person is a teenager or in their early 20s, it’s too easy to dismiss those early signs as “bad behavior” or “teenage angst,” when in actuality the person is really struggling.

To find out some ways people knew (in hindsight) they had borderline personality disorder, we asked people who live with it in our community to share what it was like to grow up with undiagnosed, or maybe not-yet-developed, borderline personality disorder.

Here’s what they had to say:

1. “Ever since I can remember, even as far back as first grade, I have always been extremely sensitive to everything. I remember I would always feel different and really alone… Looking back, it really set in around age 14. That’s when the anger started coming out, the abuse of drugs and alcohol, the impulsivity, very rocky relationships — basically all the symptoms of BPD. I’m 20 years old now and I have gotten some aspects under control, but it’s still a battle I fight every day.” — Julia F.

2. “The impulsiveness, reckless behavior and trouble maintaining healthy relationships. The black-and-white thinking, self-harming behaviors… pushing and pulling people in and out of my life.” — Melissa R.

3. “I always thought I just felt everything a lot more than other people. I would get super excited about things other kids didn’t seem to care about. I can remember jumping up and down because my team scored a point and looking around wondering why no one else was as excited as me. I was told over and over to calm down, be quiet and even when I expressed outrage over an injustice, I was told there is nothing I can do.” — Melanie M.

4. “A friend of mine, who I thought was my BFF, wanted to sit next to another girl in class next. When she told me that, I threw myself on the ground and cried my heart out as I thought she hated me. In that moment I hated her with my very soul. I was crying for days because of that.” — Lenka W.

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5. “It was like no matter how good things were, I could always find a negative in everything… [it was like the] wall that was up was always getter higher could never reach it.” — Stephen J.

6. “Extreme sensitivity. I would idealize people, then push them away. I had the biggest fear of abandonment. Anger would consume me, and I felt I could not get rid of it unless I self-harmed. Then, I would feel horribly guilty and ashamed about it. I remember scratching at my face and hair as early as 4, I think.” — Amy W.

7. “Going from being best friends with someone to hating their guts, and then going back to being best friends after a while… My self-harm as a teenager… having only two to three close friends growing up. I found it very hard to make and keep friends. I was very emotionally sensitive and would get hurt easily. All these things I can see now as signs of my BPD.” — Michelle M.

8. “I was only diagnosed a year ago, but looking back it all makes sense. As far back as I can remember, I was extremely sensitive, had highly fluctuating moods including intense anger and I would self-harm. I would freak out over any sudden changes in plans, and I was terrified of abandonment. It wasn’t until years later I realized it was something much more than just depression and anxiety.” — Kelsey M.

9. “Making impulsive, life-changing decisions without thinking through the consequences, moving from city to city and job to job thinking my problems would go away if I moved to another city. I now have a very unstable work history and am finding it very difficult to find employment.” — Pam M.

10. “Dissociation. Feeling like you’re out of your body — like it’s not even yours, is the most terrifying feelings ever, and was the main symptom/sign that I had something different from depression. Nobody ever really talks about dissociation, and I have no idea why, it horrified me more than anxiety attacks ever did. It’s like this huge seemingly endless brain fog. You can’t think, you can’t talk, you just can’t function. You feel completely numb from the inside and out. To me it gets so bad it feels like I don’t ‘exist,’ and it’s terrifying. Especially when you think you’re the only one who felt this way (which was the case for me for months).” — Alexis W.

11. “I felt like I’d always be alone, like I was not worthy of having friends. I’m in a better place now and have been in treatment for five months.” — Isobel T.

12. “Being extremely sensitive, wanting to be everybody’s best friend, being insanely hard on myself, thinking everyone was talking about me behind my back, loving people way too much, being co-dependent, thinking in absolutes, being very black and white, constant fear of abandonment.” — Marissa L.

13. “My whole life I have been extremely sensitive. If an adult so much as raised their voice a little, I would burst into tears. I also once I hit puberty could never seem to have a steady relationship with peers. My friendships were always very up and down and one-sided especially as I became a teenager. I never had a self-esteem and I started cutting when I was 13. I was misdiagnosed with depression and anxiety first. I always wondered why I was so different, why weren’t other kids like me? Now it makes perfect sense.” — Jessie B.

14. “Black/white thinking. Am I a good/bad person? I love/hate you. Don’t ever leave me/I want be on my own. With everyone of these issues it is extreme and intense, there is no middle ground, no balance or stability.” — Roma S.

15. “It was a constant up and down. I didn’t have steady friendships. I felt insecure and had a low self-esteem. Oftentimes social interactions induced intense emotions that completely overwhelmed me and made me feel isolated and invisible. I felt anchor-less and didn’t know where I belonged or if I would ever find someone who would love and understand me. I was so afraid of my friends leaving me that I tried everything to make them love me. I started self-harming at 14, desperately trying to keep me grounded and gaining recognition.” — Mona B.

16. “As far back as I can remember as a little kid I’d deliberately push people away to test their limits and kind of prove to myself that I wasn’t a lovable person. As a teenager it mainly showed in my complete inability to handle breakups and extreme impulsivity, self-harm, constant suicidal thoughts, etc. This was all shrugged off by everyone around me as ‘being a teenager’ and ‘attention seeking.’ As a result I struggled for years without treatment. I’m still in shock that I survived that to be honest.” — Lucy R.

17. “I have had a serious problem with overspending money and self-harm. I would get so emotional at things that were not even real (fictional things or playful things) and the constant changes of my moods were hard for me to handle. Now I have been diagnosed with BPD and as I look back I see that I’ve had this for quite some time. It feels good to have a name for it now.” — Mackenzi D.

18. “I felt alone, unwanted and so different.” — Seth B.

19. “Definitely getting overemotional at almost everything. Sensitivity to violence, I couldn’t even handle violent TV shows like CSI. Even reading books would put immediately in a mood related to the book — it would make me happy or sad depending on how it ended. I was and still am more sensitive in my interactions with people. I would get easily upset even if they didn’t mean to upset me. I thought for years that something was wrong with who I am. That everything about me was wrong and it was all my fault. Even at age 9 I was self-harming. I hated myself and had no self-confidence. I was dual diagnosed with borderline and bipolar at age 19, and everything finally made sense. All the things I thought were wrong with myself actually had a name. Not that that made it any easier to accept. I’m now 24, and I’m finally starting to accept this is just how I was made. And it’s not my fault.” — Meghan W.

*Some answers have been edited for length or clarity.

If you or someone you know needs help, visit our suicide prevention resources page.

If you need support right now, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741.