Borderline Personality Disorder (BPD)
Borderline personality disorder (BPD) is a complex mental health condition that affects how a person experiences themselves and how they think, feel, and relate to others. Individuals with BPD often struggle with regulating their emotions and maintaining stable relationships. They may experience intense mood swings, fear of abandonment, impulsivity, and unstable self-image. There is also an increased risk of suicide and self-harm associated with BPD.
The development of BPD is believed to be influenced by a combination of environmental, developmental, and social factors. Developmental factors, such as childhood trauma like abuse or neglect, are commonly associated with the development of BPD. While some believe genetic factors also play a role, there is insufficient and inconclusive evidence to support this.
Psychotherapy is considered the first line of treatment for borderline personality disorder. Medication, on the other hand, is generally not used, except for potentially treating co-occurring disorders and symptoms.
It is important to emphasise that diagnosis of borderline personality disorder, as with other personality disorders, is associated with controversies. This is mainly due to stigma associated with it but also due to the influences of cultural factors which may enforce certain personality characteristics.
Characteristics of Borderline Personality Disorder
Mood Swings and Emotional Dysregulation
Borderline personality disorder is characterised by intense mood swings. This means that individuals with BPD may struggle to regulate their emotions effectively, resulting in outbursts of anger or episodes of intense sadness without clear triggers. A person may shift between favourable self-esteem and a cohesive sense of self to feelings of self-devaluation, worthlessness, badness, self-contempt, and self-hate.
These shifts in how a person experiences themselves will also affect how they feel about others, especially in significant relationships, such as with family, friends, colleagues, and romantic partners. For instance, a rupture in a relationship of someone with BPD may trigger feelings of abandonment, as well as feelings of inadequacy or unworthiness. Individuals coping with BPD may struggle with rapid or periodic shifts in their perception of others, moving from seeing them as all-good to all-bad. This can create instability in their relationships and, at times, lead to relationship breakdowns, further exacerbating feelings of unworthiness, self-disdain, and self-blame. Relational instability can result in challenges in maintaining healthy connections with others, often leading to frequent conflicts and misunderstandings.
Identity
A stable and integrated identity is crucial for psychological stability and self-regulation during times of heightened stress. Due to identity diffusion, individuals with BPD lack this function, impairing their ability to self-regulate and leading to fluctuations in their self-esteem.
Impulsivity, affective instability, and shifts in perception of self and others in individuals coping with borderline personality disorder are largely driven by the instability of their identity. In fact, BPD is considered the most typical disorder characterised by identity issues and their impact on relationships (Luyten et al., 2020).
Due to what is known as internal fragmentation or identity diffusion, individuals with borderline personality disorder may perceive themselves differently in various relationships, to the extent of feeling like a different person with different people. They may have multiple social circles but tend to keep them separate. Additionally, they may struggle with dependency, overly adopt others' opinions and struggle with defining their own preferences and beliefs.
Identity diffusion may also be evident through fragmentation of the so-called narrative identity. This means that individuals with BPD, particularly those significantly impacted by it, often perceive their current emotional and cognitive state as totalistic - as if their experience remains unchanged over time. For example, if a conflict arises in one of their close relationships, they may view the other person as entirely negative while disregarding any previous positive perceptions of them as kind and caring.
Risky Behaviour
Reckless spending, substance abuse, or risky sexual activities are often associated with individuals struggling with borderline personality disorder. These behaviours are typically attempts to cope with overwhelming emotions or an experience of emptiness within themselves. However, these actions can have adverse effects on the person’s overall well-being and relationships.
Symptoms of Borderline Personality Disorder
Symptoms of borderline personality disorder may include:
Issues with identity and the sense of self: An individual diagnosed with BPD may struggle with maintaining a stable and coherent sense of self, often characterised by feelings of worthlessness, badness, and low self-esteem. Their experience of themselves tends to be unstable and can shift depending on the dynamics of their significant relationships.
Feelings of internal emptiness: These may involve feelings of a void, fragmentation, non-existence, lack of physical bodily boundaries etc. (Related: Subjective Experience of Emptiness)
Difficulties with life goals and general difficulties with commitments: This may involve difficulties with academic or work commitments, as well as challenges in committing to a romantic relationship. Engaging in professional or personal activities may be perceived as purposeless and meaningless.
Difficulties in recognising the feelings and experience of others: These difficulties often stem from the individual's challenges with mentalisation. Someone with BPD may struggle to differentiate between their own perceptions of others' feelings and thoughts, and the actual experiences of those individuals.
Difficulties with psychological and emotional intimacy: Close relationships, especially romantic ones, are characterised by fears of abandonment and instability, making them volatile and a primary source of distress for individuals dealing with BPD. There is often a fluctuating pattern of clinging (neediness) and distancing (withdrawal) as the individual navigates between feelings of engulfment and abandonment.
Efforts to avoid abandonment.
Emotional volatility and impulsivity.
Anxiety and depression: Individuals with BPD may frequently experience anxiety and depression as co-morbid symptoms. Their anxiety and panic are often linked to their intense focus on close relationships. Depression, conversely, may manifest as feelings of hopelessness and despair, accompanied by self-critical and self-derogatory inner dialogue.
Issues with anger.
Risk-taking.
Self-harming.
Attempts or threats of suicide.
Substance abuse and impulsive sexual behaviour.
A potentially unhealthy relationship with food, such as binge eating and other traits of eating disorders.
Development of Borderline Personality Disorder
The causes of BPD development are diverse. They are thought to stem from developmental, family history, environmental, and social factors. While there is evidence of a higher prevalence of BPD in families with a member already having the condition, the evidence on genetic underpinning remains insufficient and inconclusive (Jang & Vernon, 2001; Kernberg, 2004).
The main causes seem to be related to:
Childhood trauma and adverse childhood experiences (ACEs): Childhood trauma, in various forms, is believed to be one of the most significant causes in the development of BPD. While childhood sexual abuse is most commonly associated with the occurrence of BPD, whether a person who has experienced sexual abuse will develop BPD depends on many factors. Other forms of childhood trauma, such as physical, emotional, and verbal abuse, as well as neglect, are also thought to be linked to the development of BPD. It is important to note that a specific childhood trauma cannot be directly linked to the development of BPD, as individuals may cope with trauma differently. BPD is just one of the trauma-related conditions that can arise.
Family history and parenting patterns: BPD is also closely related to parenting patterns and the unhealthy patterns within the family of origin. This is thought to be related to both the temperamental patterns of the family as well as the family dynamics and trauma experienced within the family (Paris, 2018). Individuals who struggle with BPD have often had parents who struggled with personality disorder themselves.
Other social factors: For example, growing up in a social environment where witnessing violence and abuse was common may contribute to the development of BPD.
Diagnosis of Borderline Personality Disorder
Controversies and Discontents Over Diagnosing BPD
As with any diagnosis of a personality disorder, the diagnosis of borderline personality disorder (BPD) is not without its controversies. These controversies often revolve around the stigma and potential negative impact that such a diagnosis can have on individuals.
Being diagnosed with BPD can lead to feelings of being labelled and pathologised, which can be detrimental to one's self-perception and mental well-being. Individuals diagnosed with BPD may feel labeled and pathologised by the diagnosis as their underlying trauma remains unseen. The diagnosis may be experienced as a focus on pathology rather than seeing one’s struggles and distress as a coping mechanism.
The stigma attached to the diagnosis may also affect how others perceive and interact with those diagnosed with BPD, further exacerbating feelings of isolation and alienation.
Cultural factors often play a role in the development of personality, making the diagnosis of BPD controversial from this perspective. It may impose a mainstream view of what is considered "normal" and what is not.
On the other hand, some individuals find comfort in receiving a BPD diagnosis as it helps them make sense of their experiences and distress that they previously could not understand.
It is crucial to approach the diagnosis of BPD with sensitivity and understanding, taking into account the individual's unique experiences and needs.
Issues With the Categorical Model of Diagnosing Borderline Personality Disorder
While it may seem that borderline personality disorder is a distinct personality disorder, this is not entirely the case. This assumption has historically prevailed the diagnostic classification set in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The types of personality disorders are somewhat arbitrarily determined based on the combination of diagnostic categories present. Research shows that because of this artificial boundaries between types of personality disorders, there is a high co-morbidity between personality disorders diagnosed according to the DSM model (Ofrat, Krueger, & Clark, 2018). This means that a person diagnosed with borderline personality disorder may also present with other types of personality disorder.
Another issue with the categorical model of diagnosis of personality disorders, which is also the case for BPD, is that the threshold for diagnosis is arbitrarily set (Ofrat, Krueger, & Clark, 2018). This implies that a person either meets the criteria and is therefore diagnosed with BPD, or does not meet the criteria and is not diagnosed. In reality, however, personality disorders exist on a continuum from less severe to more severe. Therefore, individuals who do not meet the set diagnostic threshold may still experience significant psychological distress.
Various Ways of Diagnosing Borderline Personality Disorder
The categorical model of diagnosis has been criticised for its inapplicability in clinical settings, particularly in the case of psychotherapy. There have been calls for a dimensional model of diagnosis, which would recognise the level of personality functioning as one of the main factors in determining not only the presence of a personality disorder but also its severity.
The dimensional model of diagnosis is predominantly used in psychotherapeutic settings, particularly with approaches rooted in psychoanalytic and psychodynamic principles. Dimensional models assess personality disorders based on the level of personality functioning, making these models more suitable for psychotherapy by focusing on evaluating intrapsychic and interpersonal dynamics rather than rigid trait-based categories. This enables psychotherapists to address the underlying issues of a BPD diagnosis rather than just its symptoms. Additionally, dimensional models facilitate tracking of psychotherapeutic progress over time.
Misdiagnosis of Borderline Personality Disorder and Co-morbidity with Other Mental Health Conditions
Borderline personality disorder, as is common with any personality disorder, often comes with other co-morbid conditions. These may range from anxiety and eating disorders (see also Shah & Zanarini, 2018), PTSD (Pagura et al., 2010), complex PTSD (Ford & Courtois, 2014), depression (Yoshimatsu & Palmer, 2014), addiction (Kienast et al., 2014), etc. However, because of the similarity between some disorders, such as bipolar disorder and complex PTSD, it is important to attend to differential diagnosis at the time of diagnosing BPD in order to prevent misdiagnosis.
For instance, in practice we often see a misdiagnosis of BPD with complex PTSD. These two disorders, whilst having many shared characteristics, also have some distinct differences.
Psychotherapy for Borderline Personality Disorder
Psychotherapy is the primary, or first-line, treatment for borderline personality disorder. While in the past BPD was considered untreatable, this is no longer the prevailing view. Recent advances in psychotherapeutic treatments and research suggest that psychotherapy can be effective in treating BPD.
Whilst clinical treatment guidelines, such as NICE guidelines and APA guidelines, refer to various treatment approaches in the treatment of BPD, there are four main approaches (also known as a the big four) that are generally considered as the standard. These approaches are:
Dialectical Behaviour Therapy (DBT)
Mentalisation-Based Treatment (MBT)
Schema-Focused Therapy (SFT)
Transference-Focused Therapy (TFP)
The treatment of borderline personality disorder will also depend on the severity of the symptoms and the level of impairment in a person's general functioning. Some individuals may require more intense treatment, which may include inpatient care, while others may find outpatient support or psychotherapy alone to be sufficient.
The treatment of BPD may also involve informing and educating the family members of the individual diagnosed with borderline personality disorder. This is mainly because BPD can significantly impact the individual's relationships, making it essential to manage these relationships and create a supportive, non-judgmental environment as an integral part of the individual's treatment plan.
Ales Zivkovic, MSc, Psychotherapist
Related:
Resources:
McLean Hospital: Borderline Personality Disorder (BPD)
NHS: Overview - Borderline personality disorder
References:
Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1(1), 9–9. https://doi.org/10.1186/2051-6673-1-9
Jang, K. L., & Vernon, P. A. (2001). Genetics. In W. J. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treatment (pp. 177–195). The Guilford Press.
Kernberg, O. F. (2004). Borderline Personality Disorder and Borderline Personality Organization: Psychopathology and Psychotherapy. In J. J. Magnavita (Ed.), Handbook of Personality Disorders: Theory and Practice (pp. 92–119). John Wiley & Sons Inc.
Kienast, T., Stoffers, J., Bermpohl, F., & Lieb, K. (2014). Borderline personality disorder and comorbid addiction: epidemiology and treatment. Deutsches Arzteblatt international, 111(16), 280–286. https://doi.org/10.3238/arztebl.2014.0280
Luyten, P., Campbell, C., & Fonagy, P. (2020). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of Personality, 88(1), 88–105. https://doi.org/10.1111/jopy.12483
Ofrat, S., Krueger, R. F., & Clark, L. A. (2018). Dimensional approaches to personality disorder classification. In W. J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., pp. 72–87). The Guilford Press.
Pagura, J., Stein, M. B., Bolton, J. M., Cox, B. J., Grant, B., & Sareen, J. (2010). Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. Journal of psychiatric research, 44(16), 1190–1198. https://doi.org/10.1016/j.jpsychires.2010.04.016
Paris, J. (2018). The relationship between childhood adversity and borderline personality disorder. In B. Stanley & A. S. New (Eds.), Borderline personality disorder (pp. 71–81). Oxford University Press.
Shah, R., & Zanarini, M. C. (2018). Comorbidity of Borderline Personality Disorder: Current Status and Future Directions. The Psychiatric clinics of North America, 41(4), 583–593. https://doi.org/10.1016/j.psc.2018.07.009
Yoshimatsu, K., & Palmer, B. (2014). Depression in patients with borderline personality disorder. Harvard review of psychiatry, 22(5), 266–273. https://doi.org/10.1097/HRP.0000000000000045