Borderline personality disorder
Borderline personality disorder is
Onset of symptoms can be triggered by events others perceive as normal, with the disorder typically manifesting in early adulthood and persisting across diverse contexts. BPD is often comorbid with substance use disorders, depressive disorders, and eating disorders. Studies estimate up to 10 percent of people with BPD die by suicide. BPD faces significant stigmatization in media portrayals and the psychiatric field, leading to underdiagnosis and insufficient treatment.
Causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development. The current hypothesis suggests BPD is caused by an interaction between genetic factors and adverse childhood experiences. BPD is significantly more common in people with a family history of BPD, particularly immediate relatives, suggesting genetic predisposition. There is a risk of misdiagnosis, with BPD commonly confused with a mood disorder, substance use disorder, or other mental health disorders.
Therapeutic interventions predominantly involve psychotherapy, with dialectical behavior therapy and schema therapy being the most effective. Although pharmacotherapy cannot cure BPD, it may be employed to mitigate symptoms, with atypical antipsychotics and selective serotonin reuptake inhibitor antidepressants commonly prescribed. Medications are used cautiously, show limited efficacy, and have minimal impact on neural function. Despite the high utilization of healthcare resources by people with BPD, up to half may show significant improvement over ten years with appropriate treatment.
Estimation of BPD's prevalence varies. In the US, around 1% of the population are diagnosed with it. BPD is more prevalent among adolescents and young adults than elderly, and symptoms may remit with age. The term ‘borderline’ is debated, as it referred to concepts of borderline insanity and patients on the border between neurosis and psychosis, which are now considered clinically imprecise.
Signs and symptoms
The distinguishing characteristics of borderline personality disorder 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 BPD.Additional symptoms may encompass uncertainty about one's identity, values, morals, and beliefs; experiencing paranoid thoughts under stress; episodes of depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or episodes of psychosis. It is also common for individuals with BPD to have comorbid conditions such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder, and attention deficit hyperactivity disorder.
Emotional dysregulation
is a core feature of BPD and it is characterized by a difficulty in effectively managing emotional states.It may involve high sensitivity to emotional stimuli, heightened emotional intensity, large and rapid mood shifts, tendency for negative emotions, and a slow return to baseline after emotional arousal. Emotional dysregulation extends beyond emotions, affecting cognition, relationships, and behaviour.Deficits in emotion regulation strategies are observed in BPD. These include resistance to accepting emotional responses, low flexibility to changing strategies, difficulty in identifying emotions, as well as a deficit in goal-directed behaviour, and in using healthy coping strategies. Maladaptive strategies to regulate their emotions include self-harm, rumination, avoidance, and thought suppression.
Emotional dysregulation is thought to be caused by an imbalance in the limbic system and the prefrontal cortex, particularly in the amygdala. Dialectical behaviour therapy can be employed to help with emotional dysregulation.
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. 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. This pattern, referred to as "splitting", can significantly influence the dynamics of interpersonal relationships. 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 and a bad person whose life has no value. This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking.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. 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, contributing to a sense of alienation within the family unit. Anthropologist Rebecca Lester argues that BPD is a disorder of relationships and communication, namely that a person with BPD lacks the communication skills and knowledge to interact effectively with others within their society and culture given their life experience.
Personality disorders, including BPD, are associated with an increased incidence of chronic stress and conflict, reduced satisfaction in romantic partnerships, domestic abuse, and unintended pregnancies. Research indicates variability in relationship patterns among individuals with BPD. A portion of these individuals may transition rapidly between relationships, a pattern metaphorically described as "butterfly-like," characterized by fleeting and transient interactions and "fluttering" in and out of relationships. Conversely, a subgroup, referred to as "attached," tends to establish fewer but more intense and dependent relationships. These connections often form rapidly, evolving into deeply intertwined and tumultuous bonds. In certain cases, BPD may be recognized as a disability within the workplace, particularly if the condition's severity results in behaviors that undermine relationships, involve engagement in risky activities, or manifest as intense anger, thereby inhibiting the individual's ability to perform their job role effectively. Individuals with BPD express higher levels of jealousy towards their partners in romantic relations.
Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a characteristic of borderline personality disorder. In one research study, 88% of therapists reported that they have experienced manipulation attempts from patient. Marsha Linehan has argued that doing so relies upon the assumption that people with BPD who communicate intense pain, or who engage in self-harm and suicidal behavior, do so to influence the behavior of others. The impact of such behavior on others—often an intense emotional reaction in concerned friends, family members, and therapists—is thus assumed to have been the person's intention. 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.
Behavior
Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, and self-injury, among other self-harming practices. These behaviors are a response to the intense emotional distress experienced by individuals with BPD, serving as an immediate but temporary alleviation of their emotional pain. However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle. This cycle typically begins with emotional discomfort, followed by impulsive behavior aimed at mitigating this discomfort, only to lead to shame and guilt, which in turn exacerbates the emotional pain. This escalation of emotional pain then intensifies the compulsion towards impulsive behavior as a form of relief, creating a vicious cycle. Over time, these impulsive responses can become an automatic mechanism for coping with emotional pain. Interventions such as dialectical behavior therapy and schema therapy aim to disrupt this cycle by improving emotional regulation, distress tolerance, and adaptive coping strategies.Self-harm and suicidality
Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5. Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method. Other methods, such as bruising, burning, head banging, or biting, are also prevalent. It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.The motivations behind self-harm and suicide attempts among individuals with BPD are reported to differ. Nearly 70% of individuals with BPD engage in self-harm without the intention of ending their lives. Motivations for self-harm include expressing anger, self-punishment, inducing normal feelings or feelings of normality in response to dissociative episodes, and distraction from emotional distress or challenging situations. Conversely, true suicide attempts by individuals with BPD are frequently motivated by the notion that others will be better off in their absence.