Borderline Personality Disorder

Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods,
behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental
Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time. Most
psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.
Because some people with severe BPD have brief psychotic episodes, experts originally thought
of this illness as atypical, or borderline, versions of other mental disorders. While mental health
experts now generally agree that the name "borderline personality disorder" is misleading, a
more accurate term does not exist yet.
Most people who have BPD suffer from:

Problems with regulating emotions and thoughts

Impulsive and reckless behavior

Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression,
anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal
behaviors, and completed suicides.

Causes
Research on the possible causes and risk factors for BPD is still at a very early stage. However,
scientists generally agree that genetic and environmental factors are likely to be involved.
Studies on twins with BPD suggest that the illness is strongly inherited. Another study shows that
a person can inherit his or her temperament and specific personality traits, particularly
impulsiveness and aggression. Scientists are studying genes that help regulate emotions and
impulse control for possible links to the disorder.
Social or cultural factors may increase the risk for BPD. For example, being part of a community
or culture in which unstable family relationships are common may increase a person's risk for the
disorder. Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may
lead individuals to risky situations. Adults with borderline personality disorder are considerably
more likely to be the victim of violence, including rape and other crimes.

Signs & Symptoms

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with
borderline personality disorder, a person must show an enduring pattern of behavior that includes
at least five of the following symptoms:

Extreme reactionsincluding panic,

A pattern of intense and stormy relationships with family, friends, and loved ones, often
veering from extreme closeness and love (idealization) to extreme dislike or anger
(devaluation)

Distorted and unstable self-image or sense of self, which can result in sudden changes in
feelings, opinions, values, or plans and goals for the future (such as school or career
choices)

Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance
abuse, reckless driving, and binge eating

Recurring suicidal behaviors or threats or self-harming behavior, such as cutting

Intense and highly changeable moods, with each episode lasting from a few hours to a
few days

Chronic feelings of emptiness and/or boredom

Inappropriate, intense anger or problems controlling anger

Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling

depression,

rage,

or

frantic

actionsto

Seemingly mundane events may trigger symptoms. For example, people with BPD may feel
angry and distressed over minor separationssuch as vacations, business trips, or sudden
changes of plansfrom people to whom they feel close. Studies show that people with this
disorder may see anger in an emotionally neutral face and have a stronger reaction to words with
negative meanings than people who do not have the disorder.
Suicide and Self-harm
Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors,
described below. As many as 80 percent of people with BPD have suicidal behaviors, and about
4 to 9 percent commit suicide.
Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help
reduce suicidal behaviors in people with BPD. For example, one study showed that dialectical

behavior therapy (DBT) reduced suicide attempts in women by half compared with other types
of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient
services and retained more participants in therapy, compared to other approaches to treatment.
Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some
self-harming behaviors may be life threatening. Self-harming behaviors linked with BPD include
cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with BPD
may self-harm to help regulate their emotions, to punish themselves, or to express their pain.
They do not always see these behaviors as harmful.

Diagnosis
Unfortunately, BPD is often underdiagnosed or misdiagnosed.
A mental health professional experienced in diagnosing and treating mental disorderssuch as a
psychiatrist, psychologist, clinical social worker, or psychiatric nursecan detect BPD based on
a thorough interview and a discussion about symptoms. A careful and thorough medical exam
can help rule out other possible causes of symptoms.
The mental health professional may ask about symptoms and personal and family medical
histories, including any history of mental illnesses. This information can help the mental health
professional decide on the best treatment. In some cases, co-occurring mental illnesses may have
symptoms that overlap with BPD, making it difficult to distinguish borderline personality
disorder from other mental illnesses. For example, a person may describe feelings of depression
but may not bring other symptoms to the mental health professional's attention.
Women with BPD are more likely to have co-occurring disorders such as major depression,
anxiety disorders, or eating disorders. In men, BPD is more likely to co-occur with disorders
such as substance abuse or antisocial personality disorder. According to the NIMH-funded
National Comorbidity Survey Replicationthe largest national study to date of mental disorders
in U.S. adultsabout 85 percent of people with BPD also meet the diagnostic criteria for another
mental illness. Other illnesses that often occur with BPD include diabetes, high blood pressure,
chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity,
which is a common side effect of the medications prescribed to treat BPD and other mental
disorders.

Treatments
BPD can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health
professional may also recommend medications to treat specific symptoms. When a person is
under more than one professional's care, it is essential for the professionals to coordinate with
one another on the treatment plan.
The treatments described below are just some of the options that may be available to a person
with BPD. However, the research on treatments is still in very early stages. More studies are

needed to determine the effectiveness of these treatments, who may benefit the most, and how
best to deliver treatments.
Psychotherapy
Psychotherapy is usually the first treatment for people with BPD. Current research suggests
psychotherapy can relieve some symptoms, but further studies are needed to better understand
how well psychotherapy works.
It is important that people in therapy get along with and trust their therapist. The very nature of
BPD can make it difficult for people with this disorder to maintain this type of bond with their
therapist.
Types of psychotherapy used to treat BPD include the following: Cognitive behavioral therapy
(CBT). CBT can help people with BPD identify and change core beliefs and/or behaviors that
underlie inaccurate perceptions of themselves and others and problems interacting with others.
CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal
or self-harming behaviors.
1. Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of
mindfulness, or being aware of and attentive to the current situation. DBT teaches skills
to control intense emotions, reduces self-destructive behaviors, and improves
relationships. This therapy differs from CBT in that it seeks a balance between changing
and accepting beliefs and behaviors.
2. Schema-focused therapy. This type of therapy combines elements of CBT with other
forms of psychotherapy that focus on reframing schemas, or the ways people view
themselves. This approach is based on the idea that BPD stems from a dysfunctional selfimagepossibly brought on by negative childhood experiencesthat affects how people
react to their environment, interact with others, and cope with problems or stress.
Therapy can be provided one-on-one between the therapist and the patient or in a group setting.
Therapist-led group sessions may help teach people with BPD how to interact with others and
how to express themselves effectively.
Some symptoms of BPD may come and go, but the core symptoms of highly changeable moods,
intense anger, and impulsiveness tend to be more persistent. People whose symptoms improve
may continue to face issues related to co-occurring disorders, such as depression or posttraumatic stress disorder. However, encouraging research suggests that relapse, or the recurrence
of full-blown symptoms after remission, is rare. In one study, 6 percent of people with BPD had
a relapse after remission.
Medications
No medications have been approved by the U.S. Food and Drug Administration to treat BPD.
Only a few studies show that medications are necessary or effective for people with this illness.

However, many people with BPD are treated with medications in addition to psychotherapy.
While medications do not cure BPD, some medications may be helpful in managing specific
symptoms. For some people, medications can help reduce symptoms such as anxiety, depression,
or aggression. Often, people are treated with several medications at the same time, but there is
little evidence that this practice is necessary or effective.
Medications can cause different side effects in different people. People who have BPD should
talk with their prescribing doctor about what to expect from a particular medication.