Open Access Review

Article DOI: 10.7759/cureus.49293

A Comprehensive Literature Review of Borderline

Personality Disorder: Unraveling Complexity
Received 08/21/2023
From Diagnosis to Treatment
Review began 10/11/2023
Review ended 11/16/2023 Sanskar Mishra 1 , Alka Rawekar 2 , Bhagyesh Sapkale 1
Published 11/23/2023

© Copyright 2023 1. Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
Mishra et al. This is an open access article 2. Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha,
distributed under the terms of the Creative IND
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
Corresponding author: Sanskar Mishra, [email protected]
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Borderline personality disorder (BPD) is a severe mental illness marked by unpredictable feelings, behaviors,
and relationships. Symptoms like emotional instability, impulsivity, and poor social connections are the
basis for diagnostic criteria. A noteworthy discovery highlights the clinical overlap between BPD and several
psychotic disorders by arguing that BPD and psychotic symptoms raise the risk of psychopathology.
According to neuroimaging evidence, structural and functional brain changes, notably in regions controlling
affective regulation and impulse control, are seen in BPD patients. Adolf Stern, a psychoanalyst, used the
word "borderline" in 1938 to describe patients who exhibited increased symptoms during therapy and
displayed masochistic tendencies. Modern BPD research has highlighted the complexity of symptoms like
boredom, a former diagnostic criterion associated with feelings of emptiness.

Though there are still unanswered problems regarding its precise, practical components, the treatment
technique known as Schema therapy (ST) has shown promise in treating BPD. It's interesting to note that
BPD displays complex relationships with other illnesses; for instance, some neurochemical pathways
coincide with those in bulimia nervosa, pointing to a deeper level of interconnection. Concerning diagnosis,
BPD's defining symptoms include, among others, the fear of abandonment, identity disruption, and
recurrent suicidal conduct. The range of treatment options includes pharmacological interventions and
psychotherapies like dialectical behavior therapy (DBT). Even though antidepressants like selective
serotonin reuptake inhibitors (SSRIs) are routinely prescribed, research on their efficacy is ongoing,
underlining the significance of thorough treatment planning. In conclusion, BPD continues to be a complex
condition that calls for early detection, especially considering that it usually manifests in adolescence. While
many patients report symptom relief, lingering problems still exist, emphasizing the value of comprehensive
and personalized treatment strategies.

Categories: Psychiatry, Psychology, Medical Education

Keywords: bpd symptoms, bpd treatment, bpd diagnosis, bpd, borderline personality disorder

Introduction And Background

A psychiatric disease known as borderline personality disorder (BPD) is characterized by unpredictable
mood, conduct, and interpersonal interactions [1]. There is uncertainty about BPD's origin. Based on the
symptoms, clinicians form a diagnosis. Emotional instability, worthlessness, insecurity, impulsivity, and
deteriorated social interactions are symptoms. According to studies, 10% of BPD patients also had bipolar I
disease, and 10% had bipolar II disorder. About 10% of individuals with bipolar I had the condition, and
about 20% of individuals with bipolar II had it [2]. BPD is a long-term mental health disorder characterized
by suicidal conduct, unstable mood and relationships, and extreme impulsivity [3]. Typically, BPD patients
attempt suicide three times in their lifetimes, most frequently by overdose; non-suicidal self-injury (NSSI) is
another self-harm activity prevalent in BPD [4]. The Diagnostic and Statistical Manual of Mental Disorders
(DSM), third edition's classification of BPD as an illness of the mind in 1980 brought about clinical and
academic attention [5]. NSSI typically manifests as little wounds on the arms and wrists. NSSI, however,
does not have a suicide motive; instead, BPD patients cut themselves compulsively to cope with
uncomfortable inner states. Cutting is a way to release emotional stress, not a sign of a death wish [4,5].

The availability of specific efficient psychotherapies, the potential over-prescription of drugs with minimal
benefits, and the danger of medically significant adverse effects make identifying BPD clinically relevant.
BPD's three core symptom domains are impulsivity, affective dysregulation, and cognitive-perceptual
symptoms (paranoia and dissociation). In Western nations, 0.4-3.9% of people suffer from a crippling
psychiatric disease called borderline personality disorder (BPD) [6]. Regulatory bodies have not authorized
any drugs to treat BPD. Despite this, up to 96% of BPD patients take at least one psychotropic drug [6].
Antipsychotics do not significantly affect mood instability, cognitive-perceptual signs and symptoms, or
overall functioning [7]. They also had a minor to moderate impact on rage. The findings could not be used to
evaluate individual antipsychotics because they were combined. People with borderline personality disorder

How to cite this article

Mishra S, Rawekar A, Sapkale B (November 23, 2023) A Comprehensive Literature Review of Borderline Personality Disorder: Unraveling
Complexity From Diagnosis to Treatment. Cureus 15(11): e49293. DOI 10.7759/cureus.49293
 are typically treated with psychotherapy [8]. According to the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) model for personality disorders, high levels of disinhibition are a common
feature of both borderline personality disorder and antisocial personality disorder; high levels of negative
affectivity and elevated levels of antagonism are also associated with BPD and antisocial personality
disorder, respectively [9]. BPD sufferers do engage in self-harming behavior [10]. Among adults, 2.7% have
BPD. Addiction or substance use issues are experienced once in their lifetime by 78% of people with BPD [9].
Those with BPD who use drugs have increased levels of impulsivity and clinical instability. They exhibit
more suicidal behavior, frequently leave treatment, and have shorter abstinence periods [11]. A unique
therapeutic approach is necessary when borderline personality disorder and addiction are present.

Review
Search methodology
The study aimed to conduct an exhaustive literature review on borderline personality disorder (BPD). The
focus was placed on the disease's onset, diagnostic standards, signs, symptoms, treatment, and other
aspects, focusing on its history, neurological foundations, and related comorbidities. Major databases like
PubMed, PsycINFO, Google Scholar, Cochrane Library, and Web of Science were used. Searches included a
variety of terms, including "borderline personality disorder" and "diagnosis,", as well as more specific terms
like "neurological basis" and "adolescent onset". We set the study period between 1990 and 2022 to
thoroughly synthesize historical and modern findings. The inclusion criteria were strict; only research
focusing on BPD symptoms, treatments, historical background, neurological alterations, and comorbidities
was considered. After careful removal of duplicates, non-English entries, opinion-based articles, and
research with hazy procedures from an initial discovery of 1,500 articles, we ultimately selected 400 studies.
The selected papers provide details about the authors, the study's goals, demographic information from the
sample, and the key findings. However, there were certain restrictions. Due to database indexing limitations,
not all pertinent papers may have been included, and there may be publication bias in favor of research with
notable findings. Yet this exacting process resulted in a significant synthesis of BPD. The condensed
information provided a more transparent comprehension of the complexity of BPD, illuminating various
treatment options and pointing out areas that need further research. The Prisma flow diagram is shown in
Figure 1.

2023 Mishra et al. Cureus 15(11): e49293. DOI 10.7759/cureus.49293 2 of 8

 FIGURE 1: Prisma flow diagram
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Borderline personality disorder

A mental illness is marked by unpredictability in mood, behavior, and relationships. Uncertainty surrounds
the origin of BPD. Symptoms are used to form a diagnosis. Emotional instability, worthlessness, insecurity,
impulsivity, and deteriorated social interactions are symptoms [12]. The presence of both BPD and psychotic
signs is an indication of a serious psychopath and a risk for adverse outcomes (such as suicidality), as there
are more similarities than differences between the symptoms in those suffering from psychotic disorders
and auditory verbal illusions, especially in BPD sufferers [13]. BPD patients have structural and functional
brain changes, especially in brain areas related to impulse control and emotional and cognitive regulation
[14]. Specialized psychotherapies have focused on beliefs concerning the causes and variables that maintain
BPD, and they have published thorough protocols on how to treat BPD, use therapeutic methods, and
manage the therapeutic alliance [15]. One of the most common DSM-5 illnesses is post-traumatic stress
disorder (PTSD), with a lifetime prevalence of 10% [16].

Psychoanalyst Adolf Stern used the term "borderline" for the first time in 1938. The word was used to
characterize a group of individuals whose problems became worse while they were receiving therapy,
exhibiting a rigid mentality and masochistic behavior, suggesting an attempt to defend against any
imagined changes in the outside world or within the person [17]. BPD discusses boredom reactivity and its
relationship with emptiness. DSM previously linked boredom reactivity to BPD but later removed it [18].
Research has discovered that Schema therapy (ST) successfully treats BPD [19]. However, very little is
known about how treatment works for people with BPD, mainly which specific ST components are effective
or ineffective in their eyes. Adolescents with BPD do not always recover, even if they frequently shed certain
BPD-related features with time. Any personality disorder with high levels of adolescent symptoms will
negatively impact functioning over the course of the next ten to twenty years; these consequences are
frequently more pronounced or persistent than those associated with disorders associated with Axis I [20]. A
spectrum connection between borderline personality disorder and schizophrenia was implausible. Except for
the periodic lapses in reality testing, borderline patients were intensely emotional and interpersonally needy
[21]. Compared to women with borderline personality disorder (BPD) or bulimia nervosa/bulimia spectrum
disorder (BN/BSD-BPD), women with BN/BSD-BPD showed significantly lower levels of serotonin and
monoamine oxidase activity (HC). When compared to women with BN/BSD and HC, women with BN/BSD-

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 BPD also showed higher levels of brain-derived neurotrophic factor, alterations in the methylation of the
glucocorticoid receptor gene promoter (NR3C1), and dopamine receptor gene promoter methylation [22].
Both complex post-traumatic stress disorder (cPTSD) and perinatal BPD are linked to severe impairments in
interpersonal functioning and an increased likelihood of psychopathology being passed down through
generations [23].

Diagnosis of borderline personality disorder

BPD, a mental health disease that begins in early adulthood, is characterized by chronic instability in
relationships, one's self-image, emotions, and impulsive conduct. At least five of the given nine signs must
be present for a person to be diagnosed with the condition: ongoing empty feelings, intense or inappropriate
anger, fear of abandonment, unstable interpersonal relationships, identity confusion, impulsivity, recurrent
suicidal thoughts, emotional instability, and occasionally psychotic-like thinking or dissociation [24]. BPD
covers a wide range of emotional and social difficulties. The dread of abandonment, unstable interpersonal
connections that oscillate between idealization and devaluation, a shaky self-image, impulsive behaviors,
and frequent suicidal thoughts are among its main symptoms. Rapid mood swings, emptiness, unrestrained
wrath, and occasionally skewed perceptions or dissociation are additional symptoms that BPD sufferers may
encounter [25]. These symptoms highlight the difficulties BPD sufferers have. Symptoms of BPD are shown
in Table 1.

Symptoms of BPD

Symptom number Description of symptom

i Fear of abandonment

ii Unstable intimate relationships

iii Identification disorder

iv Impulsivity

v Repeated suicide attempts

vi Emotional instability

vii Feelings of desolation that persist

viii Severe, unreasonable rage

ix Extreme dissociation or quasi-psychotic thoughts

TABLE 1: Symptoms of BPD

BPD: borderline personality disorder

Treatment of borderline personality disorder

The most commonly given drugs for BPD are fluoxetine, selective serotonin reuptake inhibitors (SSRIs), and
citalopram, despite a shortage of research to support their usage [26]. It was shown that the most common
correlation between giving antidepressants to individuals with BPD is comorbidity for affective disorders
[26]. Early childhood impacts on the development of BPD's psychopathology include parenthood-related
issues such as dysfunctional parenting, parenting philosophies, and parenting psychopathology [27]. Staged
therapy designs, additional treatments, and technology-based interventions could be beneficial in cases
where developing cost-effective interventions is necessary when people are newly diagnosed or are awaiting
full-package therapy (or both) or when a particular deficit needs to be addressed in the context of ongoing
treatment [28]. Furthermore, considering the growing body of research indicating that BPD is a diagnosable
disorder in teenagers, treatments aimed at younger demographics constitute an important and required
step. Table 2 displays the treatments available for BPD.

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 Type of
Description Purpose/Outcome
treatment

Psychotherapy

Dialectical A type of cognitive-behavioral therapy explicitly developed for Addresses self-harm behaviours, improves
behavior therapy BPD. It incorporates interdependence, emotion control, emotional regulation and enhances interpersonal
(DBT) awareness, and distress tolerance. relationships.

Mentalization- It helps patients understand their own emotions

It focuses on recognizing and understanding the feelings and
based therapy and the emotions of others, improving
thoughts in oneself and others.
(MBT) interpersonal relationships.

Transference-
focused Focuses on understanding and resolving emotions and It helps individuals understand their emotions
psychotherapy interpersonal issues through the patient-therapist connection. and change problematic patterns of interaction.
(TFP)

Schema therapy Combines elements of cognitive, behavioural, and psychodynamic It aims to identify and change maladaptive life
(ST) therapies. Focuses on changing negative life patterns. patterns.

Medications

Includes selective serotonin reuptake inhibitors (SSRIs) and It can help with mood swings, irritability, and
Antidepressants
others. feelings of emptiness.

It can reduce symptoms of anger, impulsivity,

Antipsychotics They were often used in low doses.
and brief psychotic episodes.

It can help stabilize mood swings and reduce

Mood stabilizers Such as lithium or certain anticonvulsant medications.
impulsivity.

Other treatments

They were often used in severe symptoms or if there's a risk of Provides a safe environment for stabilization and
Hospitalization
self-harm. intensive treatment.

Encourages understanding and support among

Group therapy It provides a place to share experiences and coping techniques.
peers with similar challenges.

TABLE 2: Treatments of BPD

DBT: dialectical behavior therapy; MBT: mentalization-based therapy; TFP: transference-focused psychotherapy; ST: Schema therapy

Psychotherapy, such as dialectical behavior therapy (DBT) for emotional regulation and relationship
improvement and mentalization-based therapy (MBT) to understand one's own feelings as well as those of
others, is the mainstay of treatment for BPD [29]. While Schema therapy targets dysfunctional life patterns,
transference-focused psychotherapy (TFP) uses therapist-patient interaction to gain emotional insight [8].
Antipsychotic drugs control rage and impulsivity; mood stabilizers target mood swings; and antidepressants
handle mood and irritability [8]. Hospitalization guarantees safety and intensive care in severe conditions.
In group therapy, participants foster peer support and develop common coping mechanisms. Before
beginning any treatment, it is essential to seek professional guidance. Borderline personality disorder (BPD)
often manifests throughout adolescence; early identification and treatment are crucial [8,29]. While many
BPD sufferers notice considerable improvements with time, it's essential to remember that a sizable
percentage may continue to struggle with lingering symptoms as they age [30]. For prognosis, treatment
planning, and patient counseling, being aware of these little differences is crucial from a professional
standpoint. The analysis of the studies included is shown in Table 3.

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 Author(s) Year Main characteristics

Mezei et al. [1] 2020 1. Examines BPD through a developmental psychopathology lens.

Zimmerman et al. [2] 2013 2. Investigates the connection and distinctions between BPD and bipolar disorder.

Paris et al. [3] 2005 3. General overview, diagnosis, and management of BPD.

Paris et al. [4] 2019 4. Probes into suicidality and its links with BPD.

Videler et al. [5] 2019 5. Discusses BPD's manifestations across various life stages.

Gartlehner et al. [6] 2021 6. Comprehensive analysis of pharmaceutical interventions for BPD.

Parker et al. [7] 2019 7. Overview of pharmacological strategies for treating BPD.

Stoffers et al. [8] 2012 8. Evaluates the effectiveness of psychological therapies for BPD.

9. Examines how antisocial and borderline personality disorders can coexist with alcohol use
Helle et al. [9] 2019
disorder.

Reichl et al. [10] 2021 10. Focuses on self-harm behaviours within the BPD context.

Kienast et al. [11] 2014 11. Delves into the epidemiology and treatment of BPD coexisting with addiction.

Cremers et al. [12] 2021 12. Uses brain network measures to classify BPD during emotion regulation tasks.

Cavelti et al. [13] 2021 13. Looks at the emergence of psychotic symptoms in BPD from a developmental perspective.

Guendelman et al. [14] 2014 14. Investigates the neurobiological underpinnings of BPD.

Oud et al. [15] 2018 15. Systematic review of specialized psychotherapies for adult BPD patients.

16. A study comparing the costs and benefits of integrated EMDR-DBT with EMDR for PTSD
Snoek et al. [16] 2020
patients who exhibit characteristics of BPD.

Biskin et al. [17] 2012 17. Discusses the diagnostic criteria and methods for BPD.

Masland et al. [18] 2020 18. Reconsiders the significance of boredom as a potential diagnostic criterion for BPD.

Tan et al. [19] 2018 19. Uses a qualitative approach to understand patients’ perceptions of schema therapy for BPD.

Larrivée et al. [20] 2013 20. Discusses challenges and peculiarities of diagnosing BPD in adolescents.

Gunderson et al. [21] 2009 21. Chronicles the development and changes in the diagnosis of BPD over time.

22. A thorough analysis of the genetics, epigenetics and comorbidity of BPD and bulimia
McDonald et al. [22] 2019
nervosa.

23. Reviews interventions for borderline personality disorder and complex trauma in the
May et al. [23] 2023
perinatal period.

Lekgabe et al. [24] 2021 24. Examines traits of BPD in adolescents suffering from anorexia nervosa.

Symptoms - borderline
25. An online resource detailing the symptoms of BPD.
personality disorder [25]

Pascual et al. [26] 2023 26. Discusses pharmacological approaches to BPD and its frequently co-occurring disorders.

Kaur et al. [27] 2023 27. Investigates the influence of parenting in the onset and development of BPD.

Temes et al. [28] 2019 28. Offers insights into recent advances in psychosocial interventions for BPD.

Mayo Clinic [29] 2022 29. A resource from the Mayo Clinic detailing diagnosis and treatment modalities for BPD.

Biskin et al. [30] 2015 30. Explores the progression and lifetime trajectory of BPD.

TABLE 3: Analysis of the studies included

EMDR: eye movement desensitization and reprocessing; DBT: dialectical behaviour therapy; PTSD: post-traumatic stress disorder

Conclusions

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 Understanding and managing BPD remains one of the most intricate and challenging mental health issues.
Due to its unpredictable moods, behaviors, and interpersonal ties, diagnosis and treatment must take a
multidimensional approach. The interconnectedness of BPD with other diseases, like bipolar disorder and
psychotic symptoms, emphasizes its complexity and necessitates a comprehensive approach to therapy.
Although its origins are unclear, the focus on symptoms provides professionals with a clear path for
diagnosis. Recent developments in psychotherapy approaches, particularly Schema therapy and dialectical
behavior therapy (DBT), have given individuals suffering new hope by uncovering viable routes to recovery.
Although experts frequently recommend some pharmacological therapies, ongoing controversy about their
effectiveness emphasizes the need for further study in this field.

The high rate of self-harming behaviors and suicidal thoughts among BPD patients is an important cause for
concern, underscoring the importance of early detection, particularly in younger groups. Early intervention
can significantly change the trajectory of the condition, which is why the urgency is increased by the fact
that BPD frequently manifests during adolescence. In addition, the historical context, from Stern's 1938
coining of the word “borderline” to the complexity of today's diagnosis and treatment of an illness, has
drawn growing attention over the years. Significant obstacles still exist. A more complex knowledge of BPD
is crucial as we go. To guarantee people afflicted by BPD receive the comprehensive support they require,
ongoing research, interdisciplinary collaboration, and patient-centered care are essential.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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