Borderline personality disorder
Borderline personality disorder | |
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Other names |
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lifetime prevalence)[8] |
Personality disorders |
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Cluster A (odd) |
Cluster B (dramatic) |
Cluster C (anxious) |
Not otherwise specified |
Depressive |
Others |
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD),
The onset of BPD symptoms can be triggered by events that others might perceive as normal,
The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development.
Therapeutic interventions for BPD predominantly involve
BPD has a
Signs and symptoms
![](http://upload.wikimedia.org/wikipedia/commons/thumb/9/98/BPD_1.png/220px-BPD_1.png)
Borderline personality disorder, as outlined in the
- Frantic efforts to avoid real or imagined emotional abandonment.[32]
- Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of idealization and devaluation, also known as 'splitting'.
- A markedly disturbed sense of identity and distorted self-image.[8]
- Impulsive or reckless behaviors, including uncontrollable spending, unsafe sexual practices, substance use disorder, reckless driving, and binge eating.[33]
- Recurrent suicidal ideation or behaviors involving self-harm.
- Rapidly shifting intense emotional dysregulation.
- Chronic feelings of emptiness.
- Inappropriate, intense anger that can be difficult to control.
- Transient, stress-related paranoid ideation or severe dissociativesymptoms.
The distinguishing characteristics of BPD include a pervasive pattern of instability in one's interpersonal relationships and in one’s self-image, with frequent oscillation between extremes of idealization and devaluation of others, alongside fluctuating moods and difficulty regulating intense emotional reactions. Dangerous or impulsive behaviors are commonly associated with the BPD.
Additional symptoms may encompass uncertainty about one's
Mood and affect
Individuals with BPD exhibit emotional dysregulation. Emotional dysregulation is characterized by an inability in flexibly responding to and managing
A core characteristic of BPD is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to psychosocial cues, leading to significant challenges in managing emotions effectively.[39][40][41]
As the first component of emotional dysregulation, individuals with BPD are shown to have increased
A second component of emotional dysregulation in BPD is high levels of negative affectivity, stemming directly from the individual’s emotional sensitivity to negative emotions. This negative affectivity causes emotional reactions that diverge from socially accepted norms, in ways that are disproportionate to the environmental stimuli presented.[42] Those with BPD are relatively unable to tolerate the distress that is encountered in daily life, and they are prone to engage in maladaptive strategies to try to reduce the distress experienced. Maladaptive coping strategies include rumination, thought suppression, experiential avoidance, emotional isolation, as well as impulsive and self-injurious behaviours.[42]
American psychologist
Emotional dysregulation is a significant feature of BPD, yet Fitzpatrick et al. (2022) suggest that such dysregulation may also be observed in other disorders, like generalized anxiety disorder. Nonetheless, their findings imply that individuals with BPD particularly struggle with disengaging from negative emotions and achieving emotional equilibrium.[46]
Moreover, emotional lability, indicating variability or fluctuations in emotional states, is frequent among those with BPD. Emotional lability may imply rapid alternations between depression and elation, mood swings in BPD are more commonly between anger and anxiety or depression and anxiety.[48]
Interpersonal relationships
Interpersonal relationships are significantly impacted in individuals with BPD, characterized by a heightened sensitivity to the behavior and actions of others. Individuals with BPD can be very conscious of and susceptible to their perceived or real treatment by others. Individuals may experience profound happiness and gratitude for perceived kindness, yet feel intense sadness or anger towards perceived criticism or harm.[49] A notable feature of BPD is the tendency to engage in idealization and devaluation of others – that is to idealize and subsequently devalue others – oscillating between extreme admiration and profound mistrust or dislike.[50] This pattern, referred to as 'splitting', can significantly influence the dynamics of interpersonal relationships.[51][52] In addition to this external "splitting,” patients with BPD typically have internal splitting, i.e., vacillation between considering oneself a good person who has been mistreated (in which case anger predominates) and a bad person whose life has no value (in which case self-destructive or even suicidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking.[53]
Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent, or fearfully preoccupied attachment styles in relationships, complicating their interactions and connections with others.[54] Family members, including parents of adults with BPD, may find themselves in a cycle of being overly involved in the individual’s life at times and, at other times, significantly detached,[55] contributing to a sense of alienation within the family unit.[53]
Behavior
Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, self-injury among other self-harming practices.
Self-harm and suicide
Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5.[9] Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method.[60] Other methods, such as bruising, burning, head banging, or biting, are also prevalent.[60] It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.[61]
Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation.[62][53][63] There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD.[64]
The motivations behind self-harm and
Sense of self and self-concept
Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable
Dissociation and cognitive challenges
The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function.[65] Additionally, individuals with BPD may frequently dissociate, which can be regarded as a mild to severe disconnection from physical and emotional experiences.[67] Observers may notice signs of dissociation in individuals with BPD through diminished expressiveness in their face or voice, or through an apparent disconnection and insensitivity to emotional cues or stimuli.[67]
Dissociation typically arises in response to distressing occurrences or reminders of past trauma, acting as a psychological defense mechanism by diverting attention from the current stressor or by blocking it out entirely. This process, believed to shield the individual from the anticipated overwhelming negative emotions and undesired impulses that the current emotional situation might provoke, is rooted in avoidance of intense emotional pain based on past experiences. While this mechanism may offer temporary emotional respite, it can foster unhealthy coping strategies and inadvertently dull positive emotions, thereby obstructing the individual's access to crucial emotional insights. These insights are essential for informed, healthy decision-making in everyday life.[67]
Psychotic symptoms
BPD is predominantly characterized as a disorder involving emotional dysregulation, yet psychotic symptoms frequently occur in individuals with BPD, with prevalence estimates ranging between 21% and 54%.
The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD.
Disability and employment
Individuals diagnosed with BPD often possess the capability to engage in employment, provided they secure positions that align with their skill sets and the severity of their condition remains manageable. In certain cases, BPD may be recognized as a
Causes
The
Genetics and heritability
Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel.[76] Estimates suggest the heritability of BPD ranges from 37% to 69%,[77] indicating that human genetic variations account for a substantial portion of the risk for BPD within the population. Twin studies, which often form the basis of these estimates, may overestimate the perceived influence of genetics due to the shared environment of twins, potentially skewing results.[78]
Despite these methodological considerations, certain studies propose that personality disorders are significantly shaped by genetics, more so than many
Research involving twin and sibling studies has shown a genetic component to traits associated with BPD, such as impulsive aggression; with the genetic contribution to behavior from serotonin-related genes appearing to be modest.[80]
A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify
Among specific genetic variants under scrutiny as of 2012[update], the
Psychosocial factors
Adverse childhood experiences
Studies based on empiricism have established a strong correlation between adverse childhood experiences such as child abuse, particularly child sexual abuse, and the onset of BPD later in life.[84][85][86] Reports from individuals diagnosed with BPD frequently include narratives of extensive abuse and neglect during early childhood, though causality remains a subject of ongoing investigation.[87] These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers,[88] alongside a notable frequency of incest and loss of caregivers in early childhood.[89]
Moreover, there have been consistent accounts of caregivers invalidating the individuals' emotions and thoughts, neglecting physical care, failing to provide necessary protection, and exhibiting emotional withdrawal and inconsistency.[89] Specifically, female individuals with BPD reporting past neglect or abuse by caregivers have a heightened likelihood of encountering sexual abuse from individuals outside their immediate family circle.[89]
The enduring impact of chronic maltreatment and difficulties in forming
Invalidating environment
Brain and neurobiologic factors
Research employing
In addition to structural imaging, a subset of studies utilizing
Neurological patterns
Research into BPD has identified that the propensity for experiencing intense negative emotions, a trait known as negative affectivity, serves as a more potent predictor of BPD symptoms than the history of childhood sexual abuse alone.[93] This correlation, alongside observed variations in brain structure and the presence of BPD in individuals without traumatic histories,[94] delineates BPD from disorders such as PTSD that are frequently co-morbid. Consequently, investigations into BPD encompass both developmental and traumatic origins.
Research has shown changes in two
Contrary to earlier findings, individuals with BPD exhibit decreased amygdala activation in response to heightened negative emotional stimuli compared to control groups. John Krystal, the editor of Biological Psychiatry, commented on these findings, suggesting they contribute to understanding the innate neurological predisposition of individuals with BPD to lead emotionally turbulent lives, which are not inherently negative or unproductive.[95] This emotional volatility is consistently linked to disparities in several brain regions, emphasizing the neurobiological underpinnings of BPD.[96]
Mediating and moderating factors
Executive function and social rejection sensitivity
High sensitivity to
Family environment
The family environment significantly influences the development of BPD, acting as a mediator for the effects of child sexual abuse. An unstable family environment increases the risk of developing BPD, while a stable environment can provide a protective buffer against the disorder. This dynamic suggests the critical role of familial stability in mitigating or exacerbating the risk of BPD.[99]
Diagnosis
The clinical diagnosis of BPD can be made through a thorough
An effective approach involves presenting the criteria of the disorder to the individual and inquiring if they perceive these criteria as reflective of their experiences. Involving individuals in the diagnostic process may enhance their acceptance of the diagnosis. Despite the stigma associated with BPD and previous notions of its untreatability, disclosing the diagnosis to individuals is generally beneficial. It provides them with validation and directs them to appropriate treatment options.[53]
The
DSM-5 diagnostic criteria
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has eliminated the multiaxial diagnostic system, integrating all disorders, including personality disorders, into Section II of the manual. For a diagnosis of BPD, an individual must meet five out of nine specified diagnostic criteria.[102] The DSM-5 characterizes BPD as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and a significant propensity towards impulsive behavior.[102] Moreover, the DSM-5 introduces alternative diagnostic criteria for BPD in Section III, titled "Alternative DSM-5 Model for Personality Disorders". These criteria are rooted in trait research and necessitate the identification of at least four out of seven maladaptive traits.[103] Marsha Linehan highlights the diagnostic challenges faced by mental health professionals in using the DSM criteria due to the broad range of behaviors they encompass.[104] To mitigate these challenges, Linehan categorizes BPD symptoms into five principal areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.[104]
International Classification of Disease (ICD) diagnostic criteria
ICD-11 diagnostic criteria
The World Health Organization's ICD-11 completely restructured its personality disorder section. It classifies BPD as Personality disorder, (6D10) Borderline pattern, (6D11.5). The borderline pattern specifier is defined as a personality disturbance marked by instability in interpersonal relationships, self-image, and emotions, as well as impulsivity.[105]
Diagnosis require meeting five or more out of nine specific criteria:
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships, which may be characterized by vacillations between idealization and devaluation, typically associated with both strong desire for and fear of closeness and intimacy.
- Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
- A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).
- Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).
- Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one’s own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.
- Chronic feelings of emptiness.
- Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).
- Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.
Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:
- A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
- An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
- Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.
ICD-10 diagnostic criteria
The ICD-10 (version 2019) identified a condition akin to BPD it termed Emotionally unstable personality disorder (EUPD) (F60.3). This classification described EUPD as a personality disorder with a marked propensity for impulsive behavior without considering potential consequences. Individual with EUPD had noticeably erratic and fluctuating moods and are prone to sudden emotional outbursts, struggling to regulate these rapid shifts in emotion. Conflict and confrontational behavior are common, especially in situations where impulsive actions are criticized or hindered.
The ICD-10 recognizes two subtypes of this disorder: the impulsive type, characterized mainly by emotional dysregulation and impulsivity, and the borderline type, which additionally includes disturbances in self-perception, goals, and personal preferences. Those with the borderline subtype also experience a persistent feeling of emptiness, unstable and chaotic interpersonal relationships, and a predisposition towards self-harming behaviors, encompassing both suicidal ideations and suicide attempts.[106]
Millon's subtypes
Psychologist Theodore Millon proposed four subtypes of BPD, where individuals with BPD would exhibit none, one, or multiple subtypes. The discouraged subtype is characterized by traits such as avoidance, dependency, and internalized anger and emotions. Individuals belonging to this subtype tend to exhibit impulsivity alongside compliance, loyalty, and humility. They often feel vulnerable and perpetually at risk, experiencing emotions such as hopelessness, depression, and a sense of helplessness and powerlessness.[107] The petulant type is characterized by negativism, impatience, restlessness, stubbornness, defiance, angriness, pessimism, and resentment. Individuals of this type tend to feel slighted and disillusioned with ease. The impulsive type is characterized by being captivating, unstable, superficial, erratic, distractible, frenetic, and seductive. When they fear loss, they become agitated, gloomy, and irritable, potentially leading to suicidal thoughts or actions. The self-destructive type is inward-turning, self-punishing, angry, conforming, and displays deferential and ingratiating behaviors. Their behavior tends to deteriorate over time, becoming increasingly high-strung and moody, and they may also be at risk for suicide.[108]
Misdiagnosis
Individuals with BPD are subject to
Critics of the BPD diagnosis contend that it is indistinguishable from negative affectivity upon undergoing regression and factor analyses. They maintain that the diagnosis of BPD does not provide additional insight beyond what is captured by other diagnoses, positing that it may be redundant or potentially misleading.[113]
Adolescence and prodrome
The onset of BPD symptoms typically occurs during adolescence or early adulthood, with possible early signs in childhood.
BPD is recognized as a stable and valid diagnosis during adolescence, supported by the DSM-5 and ICD-11.[115][116][117][118] Early detection and treatment of BPD in young individuals are emphasized in national guidelines across various countries, including the US, Australia, the UK, Spain, and Switzerland, highlighting the importance of early intervention.[117][119][120][121]
Historically, diagnosing BPD during adolescence was met with caution,[117][122][123] due to concerns about the accuracy of diagnosing young individuals,[124][125] the potential misinterpretation of normal adolescent behaviors, stigma, and the stability of personality during this developmental stage.[117] Despite these challenges, research has confirmed the validity and clinical utility of the BPD diagnosis in adolescents,[115][116][117][118] though misconceptions persist among mental health care professionals,[126][127][128] contributing to clinical reluctance in diagnosing and a key barrier to the provision of effective treatment BPD in this population.[126][129][130]
A diagnosis of BPD in adolescence can indicate the persistence of the disorder into adulthood,[131][132] with outcomes varying among individuals. Some maintain a stable diagnosis over time, while others may not consistently meet the diagnostic criteria.[133] Early diagnosis facilitates the development of effective treatment plans,[131][132] including family therapy, to support adolescents with BPD.[134]
Differential diagnosis and comorbidity
Lifetime
Comorbid Axis I disorders
Axis I diagnosis | Overall (%) | Male (%) | Female (%) |
---|---|---|---|
Mood disorders | 75.0 | 68.7 | 80.2 |
Major depressive disorder | 32.1 | 27.2 | 36.1 |
Dysthymia | 9.7 | 7.1 | 11.9 |
Bipolar I disorder | 31.8 | 30.6 | 32.7 |
Bipolar II disorder | 7.7 | 6.7 | 8.5 |
Anxiety disorders | 74.2 | 66.1 | 81.1 |
Panic disorder with agoraphobia | 11.5 | 7.7 | 14.6 |
Panic disorder without agoraphobia | 18.8 | 16.2 | 20.9 |
Social phobia |
29.3 | 25.2 | 32.7 |
Specific phobia | 37.5 | 26.6 | 46.6 |
PTSD | 39.2 | 29.5 | 47.2 |
Generalized anxiety disorder | 35.1 | 27.3 | 41.6 |
Obsessive–compulsive disorder** | 15.6 | – | – |
Substance use disorders | 72.9 | 80.9 | 66.2 |
Any alcohol use disorder |
57.3 | 71.2 | 45.6 |
Any non-alcohol substance use disorder | 36.2 | 44.0 | 29.8 |
Eating disorders** | 53.0 | 20.5 | 62.2 |
Anorexia nervosa** | 20.8 | 7 * | 25 * |
Bulimia nervosa** | 25.6 | 10 * | 30 * |
Eating disorder not otherwise specified ** |
26.1 | 10.8 | 30.4 |
Somatoform disorders** | 10.3 | 10 * | 10 * |
Somatization disorder** | 4.2 | – | – |
Hypochondriasis** | 4.7 | – | – |
Somatoform pain disorder** | 4.2 | – | – |
Psychotic disorders ** |
1.3 | 1 * | 1 * |
* Approximate values ** Values from 1998 study[136] – Value not provided by from both studies |
A 2008 study stated that 75% of individuals with BPD at some point meet criteria for mood disorders, notably major depression and bipolar I, with a similar percentage for anxiety disorders.
Mood disorders
Seventy-five percent (75%) of individuals with BPD concurrently experience mood disorders, notably major depressive disorder (MDD) or bipolar disorder (BD),
Differences between BPD and BD mood swings include their duration, with BD episodes typically lasting for at least two weeks at a time, in contrast to the rapid and transient mood shifts seen in BPD.[145][146][147] Additionally, BD mood changes are generally unresponsive to environmental stimuli, whereas BPD moods are. For example, a positive event might alleviate a depressive mood in BPD, responsiveness not observed in BD.[146] Furthermore, the euphoria in BPD lacks the racing thoughts and reduced need for sleep characteristic of BD,[146] though sleep disturbances have been noted in BPD.[148]
An exception would be individuals with rapid-cycling BD, who can be a challenge to differentiate from the affective lability of individuals with BPD.[149][147][145]
Historically, BPD was considered a milder form of BD,[150][151] or part of the bipolar spectrum. However, distinctions in phenomenology, family history, disease progression, and treatment responses refute a singular underlying mechanism for both conditions.[152] Research indicates only a modest association between BPD and BD, challenging the notion of a close spectrum relationship.[153][154]
Premenstrual dysphoric disorder
BPD is a psychiatric condition distinguishable from premenstrual dysphoric disorder (PMDD), despite some symptom overlap. BPD affects individuals persistently across all stages of the menstrual cycle, unlike PMDD, which is confined to the luteal phase and ends with menstruation.[155][156] While PMDD, affecting 3–8% of women,[157] includes mood swings, irritability, and anxiety tied to the menstrual cycle, BPD presents a broader, constant emotional and behavioral challenge irrespective of hormonal changes.
Comorbid Axis II disorders
Axis II diagnosis | Overall (%) | Male (%) | Female (%) |
---|---|---|---|
Any cluster A | 50.4 | 49.5 | 51.1 |
Paranoid | 21.3 | 16.5 | 25.4 |
Schizoid | 12.4 | 11.1 | 13.5 |
Schizotypal | 36.7 | 38.9 | 34.9 |
Any other cluster B | 49.2 | 57.8 | 42.1 |
Antisocial | 13.7 | 19.4 | 9.0 |
Histrionic | 10.3 | 10.3 | 10.3 |
Narcissistic | 38.9 | 47.0 | 32.2 |
Any cluster C | 29.9 | 27.0 | 32.3 |
Avoidant | 13.4 | 10.8 | 15.6 |
Dependent | 3.1 | 2.6 | 3.5 |
Obsessive–compulsive | 22.7 | 21.7 | 23.6 |
Approximately 74% of individuals with BPD also fulfill criteria for another
Management
The main approach to managing BPD is through psychotherapy, tailored to the individual's specific needs rather than applying a one-size-fits-all model based on the diagnosis alone.[26] While medications do not directly treat BPD, they are beneficial in managing comorbid conditions like depression and anxiety.[158] Evidence states short-term hospitalization does not offer advantages over community care in terms of enhancing outcomes or in the long-term prevention of suicidal behavior among individuals with BPD.[159]
Psychotherapy
Available treatments for BPD include dynamic deconstructive psychotherapy (DDP),[162] mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy.[53][163] The effectiveness of these therapies does not significantly vary between more intensive and less intensive approaches.[164]
Transference-focused psychotherapy is designed to mitigate absolutist thinking by encouraging individuals to express their interpretations of social interactions and their emotions, thereby fostering more nuanced and flexible categorizations.[165] Dialectical behavior therapy (DBT), on the other hand, focuses on developing skills in four main areas: interpersonal communication, distress tolerance, emotional regulation, and mindfulness, aiming to equip individuals with BPD with tools to manage intense emotions and improve interpersonal relationships.[165][166][163]
Cognitive behavioral therapy (CBT) targets the modification of behaviors and beliefs through problem identification related to BPD, showing efficacy in reducing anxiety, mood symptoms, suicidal ideation, and self-harming actions.[8]
Schema-focused therapy considers early maladaptive schemas, conceptualized as organized patterns that recur throughout life in response to memories, emotions, bodily sensations, and cognitions associated with unmet childhood needs. When activated by events in the patient's life, they manifest as schema modes associated with responses such as feelings of abandonment, anger, impulsivity, self-punitiveness, or avoidance and emptiness. Schema therapy attempts to modify early maladaptive schemas and their modes with a variety of cognitive, experiential, and behavioral techniques such as cognitive restructuring, mental imagery, and behavioral experiments. It also seeks to remove some of the stigma associated with BPD by explaining to clients that most people have maladaptive schemas and modes, but that in BPD, the schemas tend to be more extreme, while the modes shift more frequently. In schema therapy, the therapeutic alliance is based on the concept of limited reparenting: it does not only facilitate treatment, but is an integral part of it as the therapist seeks to model a healthy relationship that counteracts some of the instability, rejection, and deprivation often experienced early in life by BPD patients while helping them develop similarly healthy relationships in their broader personal lives.[169]
Additionally,
Medications
A 2010
Specific medications have shown varied effectiveness on BPD symptoms:
Given the weak evidence and potential for serious side effects, the UK
Health care services
The disparity between those benefiting from treatment and those receiving it, known as the "treatment gap," arises from several factors. These include reluctance to seek treatment, healthcare providers' underdiagnosis, and limited availability and accessibility to advanced treatments.[181] Furthermore, establishing clear pathways to services and medical care remains a challenge, complicating access to treatment for individuals with BPD. Despite efforts, many healthcare providers lack the training or resources to address severe BPD effectively, an issue acknowledged by both affected individuals and medical professionals.[182]
In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions.[183] While many engage in outpatient treatment consistently over several years, reliance on more restrictive and expensive treatment options, such as inpatient admission, tends to decrease over time.[184]
Service experiences vary among individuals with BPD.[185] Assessing suicide risk poses a challenge for clinicians, with patients underestimating the lethality of self-harm behaviors. The suicide risk among people with BPD is significantly higher than that of the general population, characterized by a history of multiple suicide attempts during crises.[186] Notably, about half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association.[187]
In 2014, following the death by suicide of a patient with BPD, the National Health Service (NHS) in England faced criticism from a coroner for the lack of commissioned services to support individuals with BPD. It was stated that 45% of female patients were diagnosed with BPD, yet there was no provision or prioritization for therapeutic psychological services. At that time, England had only 60 specialized inpatient beds for BPD patients, all located in London or the northeast region.[188]
Prognosis
With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years.[189][190] A longitudinal study tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission.[189] Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained a stable recovery from symptoms.[191][192]
Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing dialectical behavior therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient, compared to patients either low in agreeableness or not being treated with DBT. This association was mediated through the strength of a working alliance between patient and therapist; that is, more agreeable patients developed stronger working alliances with their therapists, which in turn, led to better clinical outcomes.[193]
In addition to recovering from distressing symptoms, people with BPD can also achieve high levels of psychosocial functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall.[194]
Epidemiology
BPD has a
Regarding gender distribution, women are diagnosed with BPD three times more frequently than men in clinical environments.
History
![](http://upload.wikimedia.org/wikipedia/commons/thumb/a/aa/Edvard_Munch_-_Salom%C3%A9.jpg/220px-Edvard_Munch_-_Salom%C3%A9.jpg)
The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates, and Aretaeus, the latter describing the vacillating presence of impulsive anger, melancholia, and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term folie maniaco-mélancolique,[204] described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity".[205] In 1921, Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.[206]
The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s.[207] The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938.[208][209] He described a group of patients who he felt to be on the borderline between neurosis and psychosis, who very often came from family backgrounds marked by trauma. He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques.
The 1960s and 1970s saw a shift from thinking of the condition as
After standardized criteria were developed[211] to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III.[190] The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder".[210] The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder", which is still in use by the DSM-5.[9] However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.[212]
Etymology
Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis.[213] The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s.[214][215] Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.[216]
Controversies
Credibility and validity of testimony
The credibility of individuals with personality disorders has been questioned at least since the 1960s.[217]: 2 Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition.[218]
Dissociation
Researchers disagree about whether dissociation, or a sense of emotional detachment and physical experiences, impacts the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of autobiographical memory was decreased in BPD patients.[219] The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid episodic information that would evoke acutely negative affect'.[219]
Lying as a feature
Some theorists argue that patients with BPD often lie. However, others write that they have rarely seen lying among patients with BPD in clinical practice.[220]
Gender
In a clinic, up to 80% of patients are women, but this might not necessarily reflect the gender distribution in the entire population.[221] According to Joel Paris, the primary reason for gender disparities in clinical settings is that women are more likely to develop symptoms that prompt them to seek help. Statistics indicate that twice as many women as men in the community experience depression. Conversely, men more frequently meet criteria for substance use disorder and psychopathy, but tend not to seek treatment as often. Additionally, men and women with similar symptoms may manifest them differently. Men often exhibit behaviors such as increased alcohol consumption and criminal activity, while women may internalize anger, leading to conditions like depression and self-harm, such as cutting or overdosing. Hence, the gender gap observed in antisocial personality disorder and borderline personality disorder, which may share similar underlying pathologies but present different symptoms influenced by gender. In a study examining completed suicides among individuals aged 18 to 35, 30% of the suicides were attributed to people with BPD, with a majority being men and almost none receiving treatment. Similar findings were reported in another study.[64]
In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology); more likely to wind up in the correctional system due to criminal behavior; and, more likely to commit suicide prior to diagnosis.
Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide.[23]
There are also sex differences in borderline personality disorder.[222] Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have (especially) antisocial, narcissistic, passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones[222]). Women with BPD are more likely to have eating disorders, mood disorders, anxiety and post-traumatic stress.[222]
Manipulative behavior
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According to Linehan, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable, however, making their assumed manipulative behavior an involuntary and unintentional response.[226]
One paper identified possible reasons for manipulation in BPD: identifying others feelings and reactions, a regulatory function due to insecurity, to communicate ones emotions and connect to others, or to feel as if one is in control, or to allow them to be "liberated" from relationships or commitments.[227]
Stigma
The features of BPD include: emotional instability, intense and unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "attention seeking", are often used and may become a self-fulfilling prophecy, as negative treatment of these individuals may trigger further self-destructive behavior.[228]
Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers.[229] One camp[who?] argues that it would be better to diagnose these men or women with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior.[citation needed] Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.[230] Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see brain abnormalities and terminology).
Physical violence
The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others.[231] While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others.[231] Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.[232]
One 2020 study found that BPD is individually associated with psychological, physical and sexual forms of intimate partner violence (IPV), especially amongst men.[233] In terms of the AMPD trait facets, hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.[233]
In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind.[232] Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs.[232] This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others.[232][44][231]
Mental health care providers
People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment.[234] A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups.[235] This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed.[236] With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features.[236] Efforts are ongoing to improve public and staff attitudes toward people with BPD.[237][238]
In psychoanalytic theory, the
Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who have developed helpful coping mechanisms. However, others experience the term "borderline personality disorder" as a pejorative label rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative and that the stigma surrounding this disorder limits their access to health care.[240] Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.[241]
Terminology
Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed,[242] since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate.[242][243] Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma".[244]
Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John G. Gunderson of McLean Hospital in the United States.[245] Another term suggested by psychiatrist Carolyn Quadrio is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) as well as a personality disorder.[86] However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.[94]
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name "borderline personality disorder" remains unchanged and it is not considered a trauma- and stressor-related disorder.[246]
Society and culture
Literature
In literature, characters believed to exhibit signs of BPD include Catherine in Wuthering Heights (1847), Smerdyakov in The Brothers Karamazov (1880), and Harry Haller in Steppenwolf (1927).[247][248][249]
Film
Films have also attempted to portray BPD, with characters in Margot at the Wedding (2007), Mr. Nobody (2009), Cracks (2009),[250] Truth (2013), Wounded (2013), Welcome to Me (2014),[251][252] and Tamasha (2015)[253] all suggested to show traits of the disorder. The behavior of Theresa Dunn in Looking for Mr. Goodbar (1975) is consistent with BPD, as suggested by Robert O. Friedel.[254] Films like Play Misty for Me (1971)[255] and Girl, Interrupted (1999, based on the memoir of the same name) suggest emotional instability characteristic of BPD,[256] while Single White Female (1992) highlights aspects such as identity disturbance and fear of abandonment.[255]: 235 Clementine in Eternal Sunshine of the Spotless Mind (2004) is noted to show classic BPD behavior,[257][258] and Carey Mulligan's portrayal in Shame (2011) is praised for its accuracy regarding BPD characteristics by psychiatrists.[259]
Psychiatrists have even analyzed characters such as Anakin Skywalker/Darth Vader from the Star Wars films, noting that he meets several diagnostic criteria for BPD.[260]
Television
Television series like
Awareness
Awareness of BPD has been growing, with the
See also
- Affective empathy
- Hysteria
- Pseudohallucination
- Obsessive love
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General bibliography
- ISBN 978-0-89042-025-6.
- American Psychiatric Association (2013). ISBN 978-0-89042-555-8.
- Chapman AL, Gratz KL (2007). The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD. Oakland, CA: ISBN 978-1-57224-507-5.
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- Manning S (2011). Loving Someone with Borderline Personality Disorder. The Guilford Press. ISBN 978-1-59385-607-6.
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External links
![](http://upload.wikimedia.org/wikipedia/en/thumb/4/4a/Commons-logo.svg/30px-Commons-logo.svg.png)
- Borderline personality disorder at Curlie
- "Borderline personality disorder". National Institute of Mental Health.
- APA DSM 5 Definition of Borderline personality disorder
- APA Division 12 treatment page for Borderline personality disorder
- ICD-10 definition of EUPD by the World Health Organization
- NHS
- "Borderline Support UK".