Borderline personality disorder (BPD) is 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 2 percent of adults. People with BPD exhibit high rates of self-injurious behavior, such as cutting and elevated rates of attempted 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 women than in men, 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, the majority stabilize and lead productive lives.
According to the DSM-5, individuals with BPD exhibit some or all of the following symptoms:
- Efforts to avoid real or imagined abandonment.
- 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.
- Recurrent suicidal behavior.
- Transient, stress-related paranoid thinking, or dissociation ("losing touch" with reality).
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 people when they are physically absent, leaving the individual with BPD feeling lost or worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing people to BPD. The disorder 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, in the prefrontal cortex, 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 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.
The recommended treatment for BPD includes psychotherapy, medication, 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.