Borderline personality disorder

Definition

Borderline personality disorder (BPD) is an emotional disorder that causes emotional instability, leading to stress and other problems.

With borderline personality disorder your image of yourself is distorted, making you feel worthless and fundamentally flawed. Your anger, impulsivity and frequent mood swings may push others away, even though you desire loving relationships.

If you have borderline personality disorder, don't get discouraged. Many people with borderline personality disorder get better with treatment and can live happy, peaceful lives.

Symptoms

Borderline personality disorder affects how you feel about yourself, how you relate to others and how you behave.

When you have borderline personality disorder, you often have an insecure sense of who you are. That is, your self-image or sense of self often rapidly changes. You may view yourself as evil or bad, and sometimes may feel as if you don't exist at all. An unstable self-image often leads to frequent changes in jobs, friendships, goals and values.

Your relationships are usually in turmoil. You often experience a love-hate relationship with others. You may idealize someone one moment and then abruptly and dramatically shift to fury and hate over perceived slights or even minor misunderstandings. This is because people with the disorder often have difficulty accepting gray areas — things seem to be either black or white.

Borderline personality disorder symptoms may include:

• Impulsive and risky behavior, such as risky driving, unsafe sex, gambling sprees or illegal drug use
• Strong emotions that wax and wane frequently
• Intense but short episodes of anxiety or depression
• Inappropriate anger, sometimes escalating into physical confrontations
• Difficulty controlling emotions or impulses
• Suicidal behavior
• Fear of being alone

When to see a doctor
People with borderline personality disorder often feel misunderstood, alone, empty and hopeless. They're typically full of self-hate and self-loathing. They may be fully aware that their behavior is destructive, but feel unable to change it. Poor impulse control may lead to problems with gambling, driving or even the law. They may find that many areas of their lives are affected, including social relationships, work or school.

If you notice these things about yourself, talk to your doctor or a mental health provider. The right treatment can help you feel better about yourself and help you live a more stable, rewarding life.

If you notice these things in a family member or friend, talk to him or her about seeing a doctor or mental health provider. But keep in mind that you can't force someone to seek help. If the relationship is causing you significant stress, you may find it helpful to see a therapist yourself.

Causes

As with other mental disorders, the causes of borderline personality disorder aren't fully understood.

Factors that seem likely to play a role include:

• Genetics. Some studies of twins and families suggest that personality disorders may be inherited.
• Environmental factors. Many people with borderline personality disorder have a history of childhood abuse, neglect and separation from caregivers or loved ones.
• Brain abnormalities. Some research has shown changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.

Most likely, a combination of these issues results in borderline personality disorder.

Risk factors

Personality is shaped by both inherited tendencies and environmental factors, or your experiences during childhood. Some factors related to personality development can increase your risk of developing borderline personality disorder. These include:

• Hereditary predisposition. You may be at a higher risk if a close family member — a mother, father or sibling — has the disorder.
• Childhood abuse. Many people with the disorder report being sexually or physically abused during childhood.
• Neglect. Some people with the disorder describe severe deprivation, neglect and abandonment during childhood.

Also, borderline personality disorder is diagnosed more often in women than in men.

Complications

Borderline personality disorder can damage many areas of your life. Intimate relationships, jobs, school, social activities and self-image all can be negatively affected. Repeated job losses and broken marriages are common. Self-injury, such as cutting or burning, can result in scarring and frequent hospitalizations. Suicide rates among people with BPD are high.

In addition, you may have other mental health disorders, including:

• Depression
• Substance abuse
• Anxiety disorders
• Eating disorders
• Bipolar disorder

Because of risky, impulsive behavior, you are also more vulnerable to unplanned pregnancies, sexually transmitted diseases, motor vehicle accidents and physical fights. You may also be involved in abusive relationships, either as the abuser or the abused.

Preparing for your appointment

If you have a pattern of difficult relationships or personality traits that seem common to borderline personality disorder, call your doctor. After an initial appointment, your doctor may refer you to a mental health provider, such as a psychiatrist.

Use the information below to prepare for your appointment and learn what to expect from your doctor.

What you can do:

• Write down any symptoms you or people close to you have noticed, and for how long.
• Write down key personal information, including traumatic events in your past and any current, major stressors.
• Make a list of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications or supplements you're taking.
• Take a family member or friend along, if possible. Someone who has known you for a long time may be able to ask questions or share information with the doctor that you don't remember to bring up.
• Write down the questions you want to be sure to ask your doctor so that you can make the most of your appointment.

For symptoms common to borderline personality disorder, some basic questions to ask your doctor or a mental health provider include:

• What is likely causing my symptoms or condition?
• Other than the most likely cause, what are possible causes for my symptoms or condition?
• What treatments are most likely to be effective for me?
• How much can I expect my symptoms to improve with treatment?
• How frequently will I need therapy sessions, and for how long?
• Are there medications that can help?
• If you're recommending medications, what are the possible side effects?
• Do I need to follow any restrictions?
• I have these other health conditions. How can I best manage them together?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared in advance, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
A doctor or mental health provider who sees you for symptoms common to borderline personality disorder is likely to ask a number of questions, including:

• What are your symptoms?
• When did you first notice these symptoms?
• How are these symptoms affecting your life, including your personal relationships and work?
• How often during the course of a normal day do you experience a mood swing?
• How often have you felt betrayed, victimized or abandoned?
• How well do you manage anger?
• How well do you manage being alone?
• Do you get bored easily?
• How would you describe your sense of self-worth? Have you ever felt you were bad, or even evil?
• Have you had any problems with self-destructive or risky behavior, such as reckless driving, wasteful spending, gambling or unsafe sex?
• Have you ever tried to harm yourself or attempted suicide?
• Do you use alcohol or illegal drugs? How often?
• How would you describe your childhood, including your relationship with your parents?
• Were you physically abused or neglected as a child?
• Have any of your close relatives been diagnosed with a mental health problem, including a personality disorder?
• Have you been treated for any other mental health problems? If yes, what treatments were most effective?
• Are you currently being treated for any other medical conditions?

What you can do in the meantime
If you have fantasies about hurting yourself, go to an emergency room or call 911 or your local emergency number immediately.

Tests and diagnosis

Personality disorders are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with borderline personality disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published and updated by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

For borderline personality disorder to be diagnosed, at least five of the following signs and symptoms must be present:

• Intense fear of abandonment
• A pattern of unstable relationships
• Unstable self-image or sense of identity
• Impulsive and self-destructive behaviors
• Suicidal behavior or self-injury
• Wide mood swings
• Chronic feelings of emptiness
• Anger-related problems, such as frequently losing your temper or having physical fights
• Periods of paranoia and loss of contact with reality

A diagnosis of borderline personality disorder is usually made in adults, not in children or adolescents. That's because what appear to be signs and symptoms of borderline personality disorder may go away with maturity.

Treatments and drugs

Borderline personality disorder treatment may include psychotherapy, medications or hospitalization.

Psychotherapy
Psychotherapy is the core treatment for borderline personality disorder. Two types of psychotherapy that have been found effective are:

• Dialectical behavior therapy (DBT). DBT was designed specifically to treat borderline personality disorder. Generally done through individual, group and phone counseling, DBT uses a skills-based approach to teach you how to regulate your emotions, tolerate distress and improve relationships.
• Transference-focused psychotherapy (TFP). TFP centers on the relationship between you and your therapist — helping you understand the emotions and difficulties that develop in that relationship. You can then use what you have learned in other relationships.

Medications
Medications can't cure borderline personality disorder, but they can help associated problems, such as depression, impulsivity and anxiety. Medications may include antidepressant, antipsychotic and anti-anxiety medications.

Hospitalization
At times, you may need more intense treatment in a psychiatric hospital or clinic. Hospitalization can also keep you safe from self-injury.

Because treatment can be intense and long term, you face the best chance for success when you consult mental health providers with experience treating borderline personality disorder.

Coping and support

Living with borderline personality disorder can be difficult. You may realize your behaviors and thoughts are self-destructive or damaging yet feel unable to control them. Treatment can help you learn skills to manage and cope with your condition.

Other things you can do to help manage your condition and feel better about yourself include:

• Sticking to your treatment plan
• Attending all therapy sessions
• Practicing healthy ways to ease painful emotions, rather than inflicting self-injury
• Not blaming yourself for having the disorder but recognizing your responsibility to get it treated
• Learning what things may trigger angry outbursts or impulsive behavior
• Not being embarrassed by the condition
• Getting treatment for related problems, such as substance abuse
• Educating yourself about the disorder so that you understand its causes and treatments
• Reaching out to others with the disorder to share insights and experiences

Remember, there's no one right path to recovery from borderline personality disorder. The condition seems to be worse in young adulthood and may gradually get better with age. Many people with the disorder find greater stability in their lives during their 30s and 40s. As your inner misery decreases, you can go on to sustain loving relationships and enjoy meaningful careers.