Borderline personality disorder

Borderline personality disorder (BPD) (called emotionally unstable personality disorder, borderline type in the ICD-10) is a cluster-B personality disorder whose essential features are a pattern of marked impulsivity and instability of affects, interpersonal relationships, and self image. The pattern is present by early adulthood and occurs across a variety of situations and contexts. Other symptoms may include intense fears of abandonment and intense anger and irritability that others have difficulty understanding the reason for.

People with BPD often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. Self-mutilation and suicidal behavior are common.

This disorder is recognized by the Diagnostic and Statistical Manual of Mental Disorders, which specifies that it "begins by early adulthood". Because a personality disorder is a pervasive, enduring and inflexible pattern of maladaptive inner experience and pathological behavior, there is a general reluctance to diagnose personality disorders before adolescence or early adulthood. Some emphasize, however, that without early treatment, symptoms may worsen.

There is an ongoing debate about the terminology of this disorder, especially the word "borderline". The ICD-10 manual refers to this disorder as Emotionally unstable personality disorder and has similar diagnostic criteria. There is related concern that the diagnosis of BPD stigmatizes people with BPD and supports discriminatory practices because it suggests that the personality of the individual is flawed. In the DSM-5, the name of the disorder remains the same.

Signs and symptoms

The most distinguishing symptoms of BPD are being highly sensitive to rejection and spending a lot of time thinking about and feeling afraid of possible abandonment. Overall, the features of BPD include unusually intense sensitivity in relationships with others, difficulty regulating emotions, and impulsivity. Other symptoms can include feeling unsure of one's personal identity and values, having paranoid thoughts when feeling stressed, and severe dissociation. 

Emotions

People with BPD feel emotions more easily, more deeply, and for longer than others do. Emotions last longer in people with BPD. Moreover, emotions in people with BPD might repeatedly re-fire, or reinitiate, prolonging their emotional reactions even further. Consequently, it can take a long time for people with BPD to return to a stable emotional baseline following an intense emotional experience.

In Marsha Linehan's view, the sensitivity, intensity, and duration with which people with BPD feel emotions have both positive and negative effects. People with BPD are often exceptionally idealistic, joyful, and loving. However, they can feel overwhelmed by negative emotions, experiencing intense grief instead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness. People with BPD are especially sensitive to feelings of rejection, isolation, and perceived failure.

Before learning other coping mechanisms, their efforts to manage or escape from their intense negative emotions can lead to self-injury or suicidal behavior. They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, shut them down entirely. This can be harmful to people with BPD, as negative emotions alert people to the presence of a problematic situation and move them to address it.

While people with BPD also feel joy intensely, they are especially prone to dysphoria, or feelings of mental and emotional distress. Zanarini et al. recognize four categories of dysphoria that are typical of this condition: extreme emotions; destructiveness or self-destructiveness; feeling fragmented or lacking identity; and feelings of victimization.

Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: 1) feeling betrayed, 2) "feeling like hurting myself", and 3) feeling completely out of control. Since there is great variety in the types of dysphoria experienced by people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.

In addition to intense emotions, people with BPD experience emotional lability, or changeability. Although the term suggests rapid changes between depression and elation, the mood swings in people with this condition actually occur more frequently between anger and anxiety, and between depression and anxiety.

Behavior

Impulsive behaviors are common, including: substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending and reckless driving. Treating "sex with multiple partners" as a symptom of mental illness is controversial and might lead to a greater percentage of women receiving a diagnosis of BPD, since having indiscriminate sex with multiple partners contradicts the traditional female gender role (see Gender under Controversies). Impulsive behaviors can also include quitting jobs or relationships, running away, shoplifting, and self-injury.

People with BPD act impulsively because it gives them immediate relief from their emotional pain. However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.

They can also suffer long-term consequences of hospitalization, incarceration, homelessness, and poverty. A cycle often begins in which people with BPD feel emotional pain, engage in impulsive behaviors to relieve that pain, feel shame and guilt over their actions, feel emotional pain from the shame and guilt, and then experience stronger urges to engage in impulsive behaviors to relieve the new pain. As time goes on, impulsive behaviors can become an automatic response to emotional pain.

Self-harm and suicidal behavior

Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM IV-TR. Management of and recovery from this behavior can be complex and challenging. The suicide rate among patients with BPD is 8 to 10 percent.

Self-injury is common, and can take place with or without suicidal intent. The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts. Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances. In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide. Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.

Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.

Interpersonal relationships

People with BPD can be very sensitive to the way others treat them, feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative after a disappointment, a perceived threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called splitting or black-and-white thinking, includes a shift from idealizing others (feeling great admiration and love) to devaluing them (feeling great anger or dislike). Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers. Self-image can also change rapidly from very positive to very negative.

While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships, and they often view the world as generally dangerous and malevolent. BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse and unwanted pregnancy. However, these factors appear to be linked to personality disorders in general.


Manipulation to obtain nurturance is considered to be a common feature of BPD by many who treat the disorder, as well as by the DSM-IV. However, some mental health professionals caution that an overemphasis on, and an overly broad definition of, "manipulation" can lead to misunderstanding and prejudicial treatment of people with BPD, particularly within the health care system. (See Manipulative behavior and Stigma under Controversies.)

Sense of self

People with BPD have trouble seeing a clear picture of their identity. In particular, they have a hard time knowing what they value and enjoy. They are unsure about their long-term goals for relationships and jobs. This difficulty with knowing who they are and what they value can cause people with BPD to feel that they are empty and lost.

Cognitions

The intense emotions of people with BPD can make it difficult for them to control the focus of their attention. In other words, it can be difficult for them to concentrate.In addition, people with BPD might dissociate, which can be thought of as an intense form of "zoning out". Dissociation often takes place in response to a painful event, or to a "trigger" that causes someone to recall a painful event, and consists of directing partial or full attention away from that event. Although blocking out painful emotions provides relief from them, it inhibits the natural experience of emotions, and decreases the ability of people with BPD to function in their daily lives. Sometimes it is possible to tell when someone with BPD is dissociating, because their facial or vocal expressions might become flat or expressionless, or they may appear to be very distracted; at other times, dissociation might be barely noticeable.

Diagnosis

Diagnosis of borderline personality disorder is based on a clinical assessment by a qualified mental health professional. The assessment can include a physical exam, laboratory tests to check for thyroid conditions and levels of substance use, and a psychological evaluation. The psychological evaluation includes asking the client about the beginning and severity of symptoms, as well as other information about how symptoms impact the client's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others. Diagnosis is based both on the client's report of his or her symptoms and on the clinician's own observations.

The DSM-IV-TR defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self image, and affects, as well as markedly impulsive behavior. The DSM-5 has the same diagnostic criteria as the DSM-IV-TR.

According to Marsha Linehan, many mental health professionals find it challenging to diagnose BPD using the DSM criteria, since these criteria describe such a wide variety of behaviors. To address this issue, Linehan has grouped the symptoms of BPD under five main areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.

Diagnostic and Statistical Manual

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) has removed the multiaxial system. Consequently, all disorders, including personality disorders, are listed in Section II of the manual. Like the DSM-IV-TR, the DSM-5 states that a person must meet 5 of 9 criteria to receive a diagnosis of borderline personality disorder.

In addition, the DSM-5 proposes alternative diagnostic criteria for Borderline personality disorder in section III, "Alternative DSM-5 Model for Personality Disorders." These alternative criteria are based on trait research and include specifying at least four of seven maladaptive traits.

International Classification of Disease

The World Health Organization's ICD-10 defines a conceptually similar disorder to borderline personality disorder, called (F60.3) Emotionally unstable personality disorder. Its two subtypes are described below.

F60.30 Impulsive type

At least three of the following must be present, one of which must be (2):

1. marked tendency to act unexpectedly and without consideration of the consequences;
2. marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
3. liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
4. difficulty in maintaining any course of action that offers no immediate reward;
5. unstable and capricious (impulsive, whimsical) mood.

F60.31 Borderline type

At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:

1. disturbances in and uncertainty about self-image, aims, and internal preferences;
2. liability to become involved in intense and unstable relationships, often leading to emotional crisis;
3. excessive efforts to avoid abandonment;
4. recurrent threats or acts of self-harm;
5. chronic feelings of emptiness.
6. demonstrates impulsive behavior, e.g., speeding, substance abuse

The ICD-10 also describes some general criteria that define what is considered a Personality disorder.

Millon's subtypes

Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or more of the following:

Subtype	Features
Discouraged (including avoidant features)	Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
Petulant (including negativistic features)	Negativistic, impatient, restless, as well as stubborn defiant, sullen, pessimistic, and resentful; easily slighted and quickly disillusioned.
Impulsive (including histrionic or antisocial features)	Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, becomes agitated, and gloomy and irritable; potentially suicidal.
Self-destructive (including depressive or masochistic features)	Inward-turning, intropunitively angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.

Family members

People with BPD are prone to feeling angry at members of their family and alienated by them. On their part, the families of people with BPD often feel angry and helpless at the treatment they receive by their loved ones. It is important for clinicians to be mindful of any strains in the relationships between clients with BPD and their family members, because family members often play a central role in providing social and financial support.

A study in 2003 found that family members' experience of burden, emotional distress, and hostility toward people with BPD were actually worse when they had greater knowledge about BPD. These findings indicate a need to investigate the quality and accuracy of the information received by family members.

Parents of adults with BPD are often both over-involved and under-involved in family interactions. In romantic relationships, BPD is linked to increased levels of chronic stress and conflict, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these links may apply to personality disorders in general.

Adolescence

Onset of symptoms typically occurs during adolescence or young adulthood, although symptoms suggestive of this disorder can sometimes be observed in children. Symptoms among adolescents that predict the development of BPD in adulthood include problems with body-image, extreme sensitivity to rejection, behavioral problems, non-suicidal self-injury, attempts to find exclusive relationships, and severe shame.

Many adolescents experience these symptoms without going on to develop BPD, but those who experience them are 9 times as likely as their peers to develop BPD. They are also more likely to develop other forms of long-term social disabilities.

Clinicians are discouraged from diagnosing anyone with BPD before the age of 18, due to adolescence and a still-developing personality. However, BPD can sometimes be diagnosed before age 18, in which case the features must have been present and consistent for at least 1 year.

A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood. Among adolescents who warrant a BPD diagnosis, there appears to be one group in which the disorder remains stable over time, and another group in which the individuals move in and out of the diagnosis. Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent. Family therapy may be an essential component of treatment for adolescents with BPD.

Differential diagnosis and comorbidity

Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD showed a higher rate of also meeting criteria for

• mood disorders, including major depression and bipolar disorder
• anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
• other personality disorders
• substance abuse
• eating disorders, including anorexia nervosa and bulimia
• attention deficit hyperactivity disorder
• somatoform disorders
• dissociative disorders

Comorbid Axis I disorders

Gender differences in Axis I lifetime comorbid diagnosis, 2008 and 1998

Axis I diagnosis	Overall ( % )	Male ( % )	Female ( % )
Mood disorders	75.0	68.7	80.2
Major depressive disorder	32.1	27.2	36.1
Dysthymia	_9.7	_7.1	11.9
Bipolar I disorder	31.8	30.6	32.7
Bipolar II disorder	_7.7	_6.7	_8.5
Anxiety disorders	74.2	66.1	81.1
Panic disorder with agoraphobia	11.5	_7.7	14.6
Panic disorder without agoraphobia	18.8	16.2	20.9
Social phobia	29.3	25.2	32.7
Specific phobia	37.5	26.6	46.6
PTSD	39.2	29.5	47.2
Generalized anxiety disorder	35.1	27.3	41.6
Obsessive-compulsive disorder**	15.6	---	---
Substance use disorders	72.9	80.9	66.2
Any alcohol use disorder	57.3	71.2	45.6
Any drug use disorder	36.2	44.0	29.8
Eating disorders**	53.0	20.5	62.2
Anorexia nervosa**	20.8	_7 *	25 *
Bulimia nervosa**	25.6	10 *	30 *
Eating disorder not otherwise specified**	26.1	10.8	30.4
Somatoform disorders**	10.3	10 *	10 *
Somatization disorder**	_4.2	---	---
Hypochondriasis**	_4.7	---	---
Somatoform pain disorder**	_4.2	---	---
Psychotic disorders**	1.3	_1 *	_1 *
* Approximate values ** Values from 1998 study  --- Value not provided by study

A 2008 study found that at some point in their lives, 75 percent of people with BPD meet criteria for mood disorders, especially major depression and Bipolar I, and nearly 75 percent meet criteria for an anxiety disorder.

Nearly 73 percent meet criteria for substance abuse or dependency, and about 40 percent for PTSD. It is noteworthy that less than half of the participants with BPD in this study presented with PTSD, a prevalence similar to that reported in an earlier study.

The finding that less than half of patients with BPD experience PTSD during their lives challenges the theory that BPD and PTSD are the same disorder.

Major gender differences exist in diagnoses for PTSD, substance abuse, and eating disorders. A higher percentage of male patients with BPD meet criteria for substance abuse and dependency, while a higher percentage of female patients meet criteria for PTSD and eating disorders. In two other studies, 38% of people with BPD met a diagnosis of ADHD and 6 of 41 patients (15%) fulfilled criteria for an autism spectrum disorder, a subgroup that had significantly more frequent suicide attempts.

The many, shifting Axis I disorders in people with BPD can sometimes cause clinicians to miss the presence of the underlying personality disorder. However, since a complex pattern of Axis I diagnoses has been found to strongly predict the presence of BPD, clinicians can use the feature of a complex pattern of comorbidity as a clue that BPD might be present.

Mood disorders

Borderline personality disorder and mood disorders, such as major depressive disorder and bipolar disorders, are often comorbid. Some characteristics of BPD are similar to those of mood disorders, which can complicate the diagnosis. It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder, or vice versa. For someone with bipolar disorder, behavior suggestive of BPD might appear while the client is experiencing an episode of major depression or mania, only to disappear once the client's mood has stabilized. For this reason, it is ideal to wait until the client's mood has stabilized before attempting to make a diagnosis.

At face value, the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar. It can be difficult even for experienced clinicians, if they are unfamiliar with BPD, to differentiate between the mood swings of these two conditions. However, there are some clear differences.

First, the mood swings of BPD and bipolar disorder have different durations. In some people with bipolar disorder, episodes of depression or mania last for at least two weeks at a time, which is much longer than moods last in people with BPD. Even among those who experience bipolar disorder with more rapid mood shifts, their moods usually last for days, while the moods of people with BPD can change in minutes or hours. So while euphoria and impulsivity in someone with BPD might resemble a manic episode, the experience would be too brief for a manic episode. 

Second, the moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD do respond to changes in the environment.That is, a positive event could not lift the depressed mood caused by bipolar disorder, but a positive event could potentially lift the depressed mood of someone with BPD. Similarly, a negative event could not dampen the euphoria caused by bipolar disorder, but a negative event could dampen the euphoria of someone with borderline personality disorder.

Third, people with BPD usually experience euphoria without the racing thoughts and decreased need for sleep that are typical of hypomania. Bipolar disorders generally involve high levels of sleep and appetite disturbance, but severe sleep disturbance is rarely seen among the symptoms of BPD.

Due to the similarity of the two conditions, BPD was once considered to be a mild form of bipolar disorder, or to exist on the bipolar spectrum. However, this would require that the underlying mechanism causing these symptoms be the same for both conditions. Differences in phenomenology, family history, longitudinal course, and responses to treatment indicate that this is not the case. Researchers have found "only a modest association" between bipolar disorder and borderline personality disorder, with "a strong spectrum relationship with [BPD and] bipolar disorder extremely unlikely."

Benazzi et al. suggest that the DSM-IV BPD diagnosis combines two unrelated characteristics: an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) occurs in 3–8 percent of women. Symptoms begin 5–11 days before a woman's period and cease a few days after it begins. Symptoms include: marked mood swings, irritability, depressed mood, feeling hopeless or suicidal, a subjective sense of being overwhelmed or out of control, anxiety, binge eating, difficulty concentrating, and substantial impairment of interpersonal relationships. PMDD typically begins in patients' early twenties, but many women wait until their early 30's to seek treatment. The timing and duration of symptoms is a major distinguishing characteristic between BPD and PMDD, as the symptoms of PMDD only take place during the luteal phase of a woman's menstrual cycle, whereas BPD symptoms occur persistently at all stages of the menstrual cycle. In addition, the symptoms of PMDD do not include impulsivity.

Comorbid Axis II disorders

Percentage of people with BPD and a lifetime comorbid Axis II diagnosis, 2008

Axis II diagnosis	Overall ( % )	Male ( % )	Female ( % )
Any Cluster A	50.4	49.5	51.1
Paranoid	21.3	16.5	25.4
Schizoid	12.4	11.1	13.5
Schizotypal	36.7	38.9	34.9
Any Other Cluster B	49.2	57.8	42.1
Antisocial	13.7	19.4	_9.0
Histrionic	10.3	10.3	10.3
Narcissistic	38.9	47.0	32.2
Any Cluster C	29.9	27.0	32.3
Avoidant	13.4	10.8	15.6
Dependent	_3.1	_2.6	_3.5
Obsessive-compulsive	22.7	21.7	23.6

Comorbid personality disorders are highly common among people diagnosed with BPD. A 2008 study found that at some point in their lives, 73.9 percent of people with BPD meet criteria for a second Axis II disorder.

Cluster A disorders, which include paranoid, schizoid, and schizotypal, are the most common, with a prevalence of 50.4 percent in people with BPD. The second most common are another Cluster B disorder, which include antisocial, histrionic, and narcissistic. These have an overall prevalence of 49.2 percent in people with BPD, with narcissistic being the most common, at 38.9 percent; antisocial the second most common, at 13.7 percent; and histrionic the least common, at 10.3 percent.

The least common are Cluster C disorders, which include avoidant, dependent, and obsessive-compulsive, and have a prevalence of 29.9 percent in people with BPD. The percentages for specific comorbid Axis II disorders can be found in the table below.

Causes

As is also the case with other mental disorders, the causes of BPD are complex and not fully understood. Evidence suggests that BPD and post-traumatic stress disorder (PTSD) are closely related. However, research also suggests diverse possible causes of BPD, including a history of childhood trauma, brain abnormalities, genetic predisposition, neurobiological factors, and environmental factors.

Genetics

The heritability of BPD is estimated to be 65%. That is, 65 percent of the variability in symptoms among different individuals with BPD can be explained by genetic differences; note that this is different from saying that 65 percent of BPD is caused by genes. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment.

Twin, sibling and other family studies indicate partial heritability for impulsive aggression, but studies of serotonin-related genes have suggested only modest contributions to behavior. 

Brain abnormalities

Hippocampus

The hippocampus is smaller in people with BPD. This trait is shared by individuals with post-traumatic stress disorder. However, only in BPD are both the hippocampus and the amygdala smaller.

Amygdala

The amygdala is smaller and more active in people with BPD. Decreased amygdala volume has also been found in people with obsessive-compulsive disorder. One study has found unusually strong activity in the left amygdalas of people with BPD when they experience and view displays of negative emotions. As the amygdala is a major structure involved in generating negative emotions, this might explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.^[ Prefrontal cortex

The prefrontal cortex is less active in people with BPD, especially when recalling memories of abandonment. This relative inactivity occurs in the right anterior cingulate (areas 24 and 32). Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties people with BPD experience in regulating their emotions and responses to stress.

Hypothalamic-pituitary-adrenal axis

The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production is elevated in people with BPD, indicating a hyperactive HPA axis in these individuals.This causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability.

Since traumatic events can increase cortisol production and HPA axis activity, the unusual activity in the HPA axis of people with BPD may be related to the traumatic childhood and maturational events that correlate with this condition. Conversely, by heightening their sensitivity to stressful events, increased cortisol production may predispose those with BPD to experience stressful childhood and maturational events as traumatic.
Increased cortisol production is also associated with suicidal behavior.

Neurobiological factors

Estrogen

Individual differences in women's estrogen cycles may be related to the expression of BPD symptoms in female patients. A 2003 study found that women's BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.

Symptoms experienced due to disturbed levels of estrogen are often misdiagnosed as BPD, like extreme mood swings and depression. As endometriosis is an estrogen responsive disease, severe PMS and PMDD symptoms are observed, that are both physical and psychological in nature. Hormone-responsive mood disorders also known as reproductive depression are seen to cease only after menopause or hysterectomy. Psychotic episodes treated with estrogen in women with BPD show considerable improvement but must not be prescribed to those with endometriosis as it worsens their endocrine condition. Mood stabilizing drugs used for bipolar disorder do not help patients with disturbed estrogen levels. A correct diagnosis between endocrine disorder and psychiatric disorder must be made.

Adverse childhood experiences

There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD. Many individuals with BPD report a history of abuse and neglect as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender. They also report a high incidence of incest and loss of caregivers in early childhood.

Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have neglected their child's physical care. Parents of both sexes were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently.

Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were consequently at significantly higher risk of reporting sexual abuse by a non-caregiver. It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.

Other developmental factors

The intensity and reactivity of a person's negative affectivity, or tendency to feel negative emotions, predicts BPD symptoms more strongly than does childhood sexual abuse. This finding, differences in brain structure (see Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history, suggest that BPD is distinct from the post-traumatic stress disorder that frequently accompanies it. Thus researchers examine developmental causes in addition to childhood trauma.
Writing in the psychoanalytic tradition, Otto Kernberg argues that a child's failure to achieve the developmental task of psychic clarification of self and other and failure to overcome splitting might increase the risk of developing a borderline personality.

A child's ability to tolerate delayed gratification at age 4 does not predict later development of BPD.

Mediating and moderating factors

Executive function

While high rejection sensitivity is associated with stronger symptoms of borderline personality disorder, executive function appears to mediate the relationship between rejection sensitivity and BPD symptoms.
That is, a group of cognitive processes that include planning, working memory, attention, and problem-solving might be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the relationship between a person's rejection sensitivity and BPD symptoms was stronger when executive function was lower, and that the relationship was weaker when executive function was higher.This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.

A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.

Family environment

Family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment may buffer against it.

Self-complexity

Self-complexity, or considering one's self to have many different characteristics, appears to moderate the relationship between Actual-Ideal self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they hope to acquire, high self-complexity reduces the impact of their conflicted self-image on BPD symptoms. However, self-complexity does not moderate the relationship between Actual-Ought self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they should already have, high self-complexity does not reduce the impact of their conflicted self-image on BPD symptoms. The protective role of self-complexity in Actual-Ideal self-discrepancy, but not in Actual-Ought self-discrepancy, suggests that the impact of conflicted or unstable self-image in BPD depends on whether the individual views self in terms of characteristics that she hopes to acquire, or in terms of characteristics that she should already have.

Thought suppression

A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerability and BPD symptoms. A later study found that the relationship between emotional vulnerability and BPD symptoms is not necessarily mediated by thought suppression. However, this study did find that thought suppression mediates the relationship between an invalidating environment and BPD symptoms.

Management

Main article: Management of borderline personality disorder

Psychotherapy is the primary treatment for borderline personality disorder.Treatments should be based on the needs of the individual, rather than upon the general diagnosis of BPD. Medications are useful for treating comorbid disorders, such as depression and anxiety. Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD.

Psychotherapy

Long-term psychotherapy is currently the treatment of choice for BPD. There are four such treatments available: mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), and schema-focused therapy. Mentalization-based therapy and transference-focused psychotherapy are based on psychodynamic principles, and dialectical behavior therapy and schema-focused therapy are based on cognitive-behavioral principles. All four have been found to reduce some symptoms of BPD, especially self-injury, indicating that long-term therapy of some kind is better than no treatment. Randomized controlled trials have shown that DBT and MBT are the most effective. As of July 2006, DBT was found to have the most empirical support, but DBT and MBT share many similarities.

Researchers are interested in developing shorter versions of these therapies to increase accessibility, to relieve the financial burden on patients, and to relieve the resource burden on treatment providers. From a psychodynamic perspective, a special problem of psychotherapy with people with BPD is intense projection. It requires the psychotherapist to be flexible in considering negative attributions by the patient rather than quickly interpreting the projection.

Medications

A 2010 review by the Cochrane collaboration found that no medications show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment." However, the authors found that some medications may impact isolated symptoms associated with BPD or the symptoms of comorbid conditions.

Of the typical antipsychotics studied in relation to BPD, haloperidol may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, aripiprazole may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology. Olanzapine may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but a placebo had a greater ameliorative impact on suicidal ideation than olanzapine did. The effect of Ziprasidone was not significant.

Of the mood stabilizers studied, valproate semisodium may ameliorate depression, interpersonal problems, and anger. Lamotrigine may reduce impulsivity and anger; topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger and general psychiatric pathology. The effect of carbamazepine was not significant. Of the antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine and phenelzine sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality and improve depression. As of 2010, trials with these medications had not been replicated, and the effect of long-term use had not been assessed.

Because of weak evidence and the potential for serious side effects from some of these medications, the UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends: "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behavior associated with the disorder." However, "drug treatment may be considered in the overall treatment of comorbid conditions." They suggest a "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment."

Services

Individuals with BPD sometimes use mental health services extensively. They accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of patients with BPD continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time. Experience of services varies. Assessing suicide risk can be a challenge for clinicians, and patients themselves tend to underestimate the lethality of self-injurious behaviors. People with BPD typically have a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis. Approximately half the individuals who commit suicide meet criteria for a personality disorder. Borderline personality disorder remains the most commonly associated personality disorder with suicide.

Prognosis

With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. 

A longitudinal study tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission. Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained and stable recovery from symptoms.

Thus contrary to popular belief, recovery from BPD is not only possible but common, even for those with the most severe symptoms. However, it is important to note that these high rates of relief from distressing symptoms have only been observed among those who receive treatment of some kind.

Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients with higher levels of trait agreeableness undergoing Dialectical Behavior Therapy (DBT) exhibited better clinical outcomes than other patients either low in Agreeableness or not being treated with DBT. This association was mediated through the strength of a working alliance between patient and therapist; that is, more Agreeable patients developed stronger working alliances with their therapists which in turn led to better clinical outcomes. 

In addition to recovering from distressing symptoms, people with BPD also achieve high levels of psychosocial functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall.

Epidemiology

The prevalence of BPD was initially estimated to be 1 to 2 percent of the general population and to occur three times more often in women than in men. However, the lifetime prevalence of BPD in a 2008 study was found to be 5.9% of the general population, occurring in 5.6% of men and 6.2% of women.The difference in rates between men and women in this study was not found to be statistically significant.

Borderline personality disorder is estimated to contribute to 20 percent of psychiatric hospitalizations, and to occur among 10 percent of outpatients.

In Iowa, 29.5 percent of new inmates in Iowa fit a diagnosis of borderline personality disorder in 2007, and the overall prevalence of BPD in the U.S. prison population is thought to be 17 percent. These high numbers may be related to the high frequency of substance abuse and substance use disorders among people with BPD, which is estimated at 38 percent.

History

The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates and Aretaeus, the last describing the vacillating presence of impulsive anger, melancholia and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term folie maniaco-mélancolique, described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist C. Hughes in 1884 and J.C. Rosse in 1890, who called the disorder "borderline insanity". In 1921, Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.

The first significant psychoanalytic work to use the term "borderline" was written by Adolf Stern in 1938. It described a group of patients suffering from what he thought to be a mild form of schizophrenia, on the borderline between neurosis and psychosis.

The 1960s and 1970s saw a shift from thinking of the condition as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder), on the fringes of bipolar disorder, cyclothymia and dysthymia. In the DSM-II, stressing the intensity and variability of moods, it was called cyclothymic personality (affective personality). While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization between neurosis and psychosis.

After standardized criteria were developed to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III. The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "Schizotypal personality disorder". 

 The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder," which is still in use by the DSM-IV today. However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.

Controversies

Credibility and validity of testimony

The credibility of individuals with personality disorders has been questioned at least since the 1960s. Two concerns are the incidence of dissociative episodes among people with BPD, and the belief that lying is a key component of this condition.

Dissociation

Researchers disagree about whether dissociation, or a sense of detachment from emotions and physical experiences, impacts the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of autobiographical memory was decreased in BPD patients. The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation. However, a larger study in 2010 found that people with BPD and without depression had more specific autobiographical memory than did people without BPD and with depression. The presence of depression (though not its severity) was the main factor related to a decreased ability to recall the specifics of past events. This decreased ability was found to be unrelated to dissociation and other symptoms of BPD, thus supporting the reliability of the testimony of people with BPD.

Lying as a feature of BPD

Some theorists argue that patients with BPD often lie. However, others write that they have rarely seen lying among patients with BPD in clinical practice. Regardless, lying is not one of the diagnostic criteria for BPD.
The mistaken belief that lying is a distinguishing characteristic of BPD can impact the quality of care that people with this diagnosis receive in the legal and healthcare systems. For instance, Jean Goodwin relates an anecdote of a patient with multiple personality disorder, now called dissociative identity disorder, who suffered from pelvic pain due to traumatic events in her childhood. Due to their disbelief in her accounts of these events, physicians diagnosed her with borderline personality disorder, reflecting a belief that lying is a key feature of BPD. Based upon her BPD diagnosis, the physicians then disregarded the patient's assertion that she was allergic to adhesive tape. The patient was in fact allergic to adhesive tape, which later caused complications in the surgery to relieve her pelvic pain.

Gender

Feminists question why women are three times more likely to be diagnosed with BPD than men, while other stigmatizing diagnoses, such as antisocial personality disorder, are diagnosed three times as often in men.

One explanation is that some of the diagnostic criteria of BPD uphold stereotypes about women. For example, the criteria of "a pattern of unstable personal relationships, unstable self-image, and instability of mood," can all be linked to the stereotype that women are "neither decisive nor constant". Women may be more likely to receive a personality disorder diagnosis if they reject the traditional female role by being assertive, successful, or sexually active. If a woman presents with psychiatric symptoms but does not conform to a traditional, passive sick role, she may be labelled as a "difficult" patient and given a BPD diagnosis.

Since BPD is a stigmatizing diagnosis even within the mental health community (see Stigma), some survivors of childhood sexual abuse who are diagnosed with BPD are thus re-traumatized by the negative responses they receive from healthcare providers. One camp argues that it would be better to diagnose these women with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.

Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see Brain abnormalities and Terminology).

Manipulative behavior

Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder. However, Marsha Linehan notes 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 with the intention of influencing 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.

However, since people with BPD lack the ability to successfully manage painful emotions and interpersonal challenges, 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. Linehan notes that if, for example, one were to withhold pain medication from burn victims and cancer patients, leaving them unable to regulate their severe pain, they would also exhibit "attention-seeking" and self-destructive behavior in order to cope.

Stigma

The features of BPD include emotional instability, intense unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult," "treatment resistant," "manipulative," "demanding" and "attention seeking," are often used, and may become a self-fulfilling prophecy as the negative treatment of these individuals triggers further self-destructive behavior.

Physical violence

The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others. While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others. Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves. One of the key differences between BPD and antisocial personality disorder (ASPD) is that people with BPD tend to internalize anger by hurting themselves, while people with ASPD tend to externalize it by hurting others. In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind. Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs. 

This is one way in which people with BPD choose to harm themselves over potentially causing harm to others. Another way in which people with BPD avoid expressing their anger through violence is by causing physical damage to themselves, such as engaging in non-suicidal self injury.

Mental healthcare providers

People with BPD are considered to be among the most challenging groups of patients, requiring a high level of skill and training in the psychiatrists, therapists and nurses involved in their treatment. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups. Efforts are ongoing to improve public and staff attitudes toward people with BPD.

In psychoanalytic theory, the stigmatization among mental healthcare providers may be thought to reflect countertransference (when a therapist projects their own feelings on to a client). Thus a diagnosis of BPD "often says more about the clinician's negative reaction to the patient than it does about the patient" and "explains away the breakdown in empathy between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon". This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation.

Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who have developed helpful coping mechanisms. However, others experience the term "Borderline Personality Disorder" as a pejorative label rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative, and that the stigma surrounding this disorder limits their access to healthcare. Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.

Terminology

Because of the above concerns, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming Borderline Personality Disorder. While some clinicians agree with the current name, others argue that it should be changed, since many who are labelled with "Borderline Personality Disorder" find the name unhelpful, stigmatizing, or inaccurate. Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma."

Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital in the United States. Another term suggested by psychiatrist Carolyn Quadrio is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) as well as a personality disorder. However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name Borderline personality disorder remains unchanged and it is not considered a Trauma- and stressor-related disorder.

Society and culture

Film and television

There are several films portraying characters either explicitly diagnosed or with traits suggestive of BPD. The films Play Misty for Me and Fatal Attraction are two examples, as is the movie Girl, Interrupted, based on the memoir by Susanna Kaysen, with Winona Ryder playing Kaysen. Each of these films suggests the emotional instability of the disorder; however, the first two cases show a person more aggressive to others than to herself, which is less typical of the disorder. The 1992 film Single White Female suggests different aspects of the disorder: the character Hedy suffers from a markedly disturbed sense of identity and, as with the first two films, abandonment leads to drastic measures.

Psychiatrists Eric Bui and Rachel Rodgers argue that the character of Anakin Skywalker/Darth Vader in the Star Wars films meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity, and dissociative episodes. Other films attempting to depict characters with the disorder include The Crush, Mad Love, Malicious, Interiors, Notes On a Scandal, The Cable Guy, Mr. Nobody and Cracks.

Unfortunately, dramatic portrayals of people with BPD in movies and other forms of visual media contribute to the stigma surrounding borderline personality disorder, especially the myth that people with BPD are violent toward others. The majority of researchers agree that in reality, people with BPD are very unlikely to harm others. See The myth of violence under Stigma.

Literature

The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating is a memoir by Kiera Van Gelder.
Girl, Interrupted is a memoir by American author Susanna Kaysen, relating her experiences as a young woman in a psychiatric hospital in the 1960s after being diagnosed with borderline personality disorder.
Get Me Out of Here: My Recovery from Borderline Personality Disorder is a memoir by author Rachel Reiland, relating her treatment and recovery from borderline personality disorder.

Songs of Three Islands, by Millicent Monks, is a memoir speculating about the impact of BPD upon the Carnegie family. Readers have criticized it for presenting a biased and stigmatizing view of BPD.

In Lois McMaster Bujold's science fiction novel Komarr, Tien Vorsoisson has BPD, per the author; his disorder drives a large part of the story. 

Kreisman, Jerold J MD, I Hate You—Don't Leave Me: Understanding the Borderline Personality

Awareness

In early 2008, the United States House of Representatives declared the month of May as Borderline Personality Disorder Awareness Month.