Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations, and impulsivity. Diagnosis is by clinical criteria. Treatment is with psychotherapy and sometimes medications.
(See also Overview of Personality Disorders.)
Patients with borderline personality disorder have an intolerance of being alone; they make frantic efforts to avoid abandonment and generate crises, such as making suicidal gestures in a way that invites rescue and caregiving by others.
Reported prevalence of borderline personality disorder in the United States varies. The estimated median prevalence is 2.7% but may be as high as 5.9% (1). In patients being treated as inpatients for mental health disorders, prevalence is about 20%. About 75% of patients diagnosed with this disorder are female, but in the general US population, the ratio of male to female is 1:1.
Comorbidities are common. Patients often have mood disorders, somatic symptom disorder, gambling disorder, or substance use disorders (2).
General references
1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 752.
Etiology of Borderline Personality Disorder
Stresses during early childhood may contribute to the development of borderline personality disorder. A childhood history of physical and sexual abuse, neglect, separation from caregivers, and/or loss of a parent is common among patients with borderline personality disorder.
Certain people may have a genetic tendency to have pathologic responses to environmental life stresses, and borderline personality disorder clearly appears to have a heritable component. First-degree relatives of patients with borderline personality disorder are 5 times more likely to have the disorder than the general population (1).
Disturbances in regulatory functions of the brain and neuropeptide systems may also contribute but are not present in all patients with borderline personality disorder (2).
Etiology references
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 755.
2. Stanley B, Siever LJ: The interpersonal dimension of borderline personality disorder: Toward a neuropeptide model. Am J Psychiatry 167(1):24-39, 2010. doi: 10.1176/appi.ajp.2009.09050744
Symptoms and Signs of Borderline Personality Disorder
When patients with borderline personality disorder feel that they are being abandoned or neglected, they feel intense fear or anger. For example, they may become panicky or furious when someone important to them is a few minutes late or cancels an engagement. They think that this abandonment means that they are bad. They fear abandonment partly because they do not want to be alone.
These patients tend to change their view of others abruptly and dramatically. They may idealize a potential caregiver or lover early in the relationship, demand to spend a lot of time together, and share everything. Suddenly, they may feel that the person does not care enough, and they become disillusioned; then they may belittle or become angry with the person. This shift from idealization to devaluation reflects black-and-white thinking (splitting, polarization of good and bad).
Patients with borderline personality disorder can empathize with and care for a person but only if they feel that another person will be there for them whenever needed.
Patients with this disorder have difficulty controlling their anger and often become inappropriate and intensely angry. They may express their anger with biting sarcasm, bitterness, or angry tirades, often directed at their caregiver or lover for neglect or abandonment. After the outburst, they often feel ashamed and guilty, reinforcing their feeling of being bad.
Patients with borderline personality disorder may also abruptly and dramatically change their self-image, shown by suddenly changing their goals, values, opinions, careers, or friends. They may be needy one minute and righteously angry about being mistreated the next. Although they usually see themselves as bad, they sometimes feel that they do not exist at all—eg, when they do not have someone who cares for them. They often feel empty inside.
The changes in mood (eg, intense dysphoria, irritability, anxiety) usually last only a few hours and rarely last more than a few days; they may reflect extreme sensitivity to interpersonal stresses.
Patients with borderline personality disorder often sabotage themselves when they are about to reach a goal. For example, they may drop out of school just before graduation, or they may ruin a promising relationship.
Impulsivity leading to self-harm is common. These patients may gamble, engage in unsafe sex, binge eat, drive recklessly, abuse substances, or overspend. Suicidal behaviors, gestures, and threats and self-mutilation (eg, cutting, burning) are very common. Although many of these self-destructive acts are not intended to end life, risk of suicide in these patients is 40 times that of the general population. About 8 to 10% of these patients die by suicide (1). These self-destructive acts are usually triggered by rejection by, possible abandonment by, or disappointment in a caregiver or lover. Patients may self-mutilate to compensate for their being bad, to reaffirm their ability to feel during a dissociative episode, or to distract from painful emotions.
Dissociative episodes, paranoid thoughts, and sometimes psychotic-like symptoms (eg, hallucinations, ideas of reference) may be triggered by extreme stress, usually fear of abandonment, whether real or imagined. These symptoms are temporary and usually not severe enough to be considered a separate disorder. In most patients, dissociative symptoms lessen over time, and the relapse rate is low. However, functional status does not usually improve as much as the symptoms.
Symptoms and signs reference
1. Pompili M, Girardi P, Ruberto A, et al: Suicide in borderline personality disorder: A meta-analysis. Nord J Psychiatry 59(5):319-324, 2005. doi: 10.1080/08039480500320025
Diagnosis of Borderline Personality Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) criteria
For a diagnosis of borderline personality disorder (1), patients must have
A persistent pattern of unstable relationships, self-image, and emotions (ie, emotional dysregulation) and pronounced impulsivity
This persistent pattern is shown by ≥ 5 of the following:
Desperate efforts to avoid abandonment (actual or imagined)
Unstable, intense relationships that alternate between idealizing and devaluing the other person
An unstable self-image or sense of self
Impulsivity in ≥ 2 areas that could harm themselves (eg, unsafe sex, binge eating, reckless driving)
Repeated suicidal behavior and/or gestures or threats or self-mutilation
Rapid changes in mood, lasting usually only a few hours and rarely more than a few days
Persistent feelings of emptiness
Inappropriately intense anger or problems controlling anger
Temporary paranoid thoughts or severe dissociative symptoms triggered by stress
Also, symptoms must have begun by early adulthood but can occur during adolescence.
Differential diagnosis
Borderline personality disorder is most commonly misdiagnosed as
Bipolar disorder: This disorder is also characterized by wide fluctuations in mood and behavior. However, in borderline personality disorder, mood and behavior change rapidly in response to stressors, especially interpersonal ones, whereas in bipolar disorder, moods are more sustained and less reactive and people often have significant changes in energy and activity.
Other personality disorders share similar manifestations.
Histrionic personality disorder or narcissistic personality disorder: Patients with either of these disorders can be attention-seeking and manipulative, but patients with borderline personality disorder also see themselves as bad and feel empty. Some patients meet criteria for more than one personality disorder.
Differential diagnosis for borderline personality disorder also includes
Depressive disorders and anxiety disorders: These disorders can be distinguished from borderline personality disorder based on the negative self-image, insecure attachments, and sensitivity to rejection that are prominent features of borderline personality disorder and are usually absent in patients with a mood or anxiety disorder.
Substance use disorders: It may be difficult to determine whether impulsivity and marked mood changes are due to substance use disorder or borderline personality disorder. However, the presence of other features of borderline personality disorder (eg, identity disturbance, affective instability), particularly during periods of sobriety, helps distinguish the 2 disorders.
Posttraumatic stress disorder: Although many patients with borderline personality disorder have a history of trauma, patients with posttraumatic stress disorder have recurrent symptoms associated with reexperiencing the traumatic event as well as increased arousal, which are not features of borderline personality disorder. Comorbidity between the 2 disorders is high.
Many disorders in the differential diagnosis of borderline personality disorder coexist with it.
Diagnosis reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 752-757.
Treatment of Borderline Personality Disorder
Psychotherapy
Sometimes medications
General principles for treatment of borderline personality disorder are the same as those for all personality disorders.
Identifying and treating coexisting disorders is important for effective treatment of borderline personality disorder.
Psychotherapy
The mainstay of treatment for borderline personality disorder is psychotherapy.
Several different psychotherapeutic interventions are effective in reducing suicidal behaviors, ameliorating depression, and improving function in patients with this disorder (1).
Cognitive-behavioral therapy focuses on emotional dysregulation and lack of social skills. It includes the following:
Dialectical behavioral therapy (a combination of individual and group sessions with therapists acting as behavior coaches and available on call around the clock)
Systems training for emotional predictability and problem solving (STEPPS)
STEPPS involves weekly group sessions for 20 weeks. Patients are taught skills to manage their emotions, to challenge their negative expectations, and to better care for themselves. They learn to set goals; avoid illicit substances; and improve their eating, sleeping, and exercise habits. Patients are asked to identify a support team of friends, family members, and clinicians who are willing to coach them when they are in crisis.
Other interventions focus on disturbances in the ways patients emotionally experience themselves and others. These interventions include the following:
Mentalization-based treatment
Transference-focused psychotherapy
Schema-focused therapy
Mentalization refers to people's ability to reflect on and understand their own state of mind and the state of mind of others. Mentalization is thought to be learned through a secure attachment to the caregiver. Mentalization-based treatment helps patients do the following:
Effectively regulate their emotions (eg, calm down when upset)
Understand how they contribute to their problems and difficulties with others
Reflect on and understand the minds of others
It thus helps them relate to others with empathy and compassion.
Transference-focused psychotherapy centers on the interaction between patient and therapist. The therapist asks questions and helps patients think about their reactions so that they can examine their exaggerated, distorted, and unrealistic images of self during the session. The current moment (eg, how patients are relating to their therapist) is emphasized rather than the past. For example, when a timid, quiet patient suddenly becomes hostile and argumentative, the therapist may ask whether the patient noticed a shift in feelings and then ask the patient to think about how the patient was experiencing the therapist and self when things changed. The purpose is
To enable patients to develop a more stable and realistic sense of self and others
To relate to others in a healthier way through transference to the therapist
Schema-focused therapy is an integrative therapy that combines cognitive-behavioral therapy, attachment theory, psychodynamic concepts, and emotion-focused therapies. It focuses on lifelong maladaptive patterns of thinking, feeling, behaving and coping (called schemas), affective change techniques, and the therapeutic relationship, with limited re-parenting. Limited re-parenting involves establishing a secure attachment between patient and therapist (within professional limits), enabling the therapist to help the patient experience what the patient missed during childhood that led to maladaptive behavior.
The purpose of schema-focused therapy is to help patients change their schemas. Therapy has 3 stages:
Assessment: Identifying the schemas
Awareness: Recognizing the schemas when they are operating in daily life
Behavioral change: Replacing negative thoughts, feelings, and behaviors with healthier ones
While most types of psychotherapy for borderline personality disorder require specialized training and supervision, "good psychiatric management" is an approach to patients with borderline personality disorder that is designed for the general clinician. It involves a set of principles and practices that include individual therapy once a week; psychoeducation about borderline personality disorder, treatment goals, and expectations; and sometimes medications. It focuses on the patient’s reactions to interpersonal stressors in everyday life.
Supportive psychotherapy is also useful. The goal is to establish an emotional, encouraging, supportive relationship with the patient and thus help the patient develop healthy defense mechanisms, especially in interpersonal relationships.
Medications
Medications are not consistently effective for core symptoms of borderline personality disorder and should be used sparingly. In general, their use should be limited to discrete comorbid psychiatric conditions (eg, major depressive disorder) (2).
When used, selective serotonin reuptake inhibitors (SSRIs) are usually well-tolerated; risk of a lethal overdose is minimal. However, SSRIs are only marginally effective for depression and anxiety in patients with borderline personality disorder. Other medications that may be used to treat comorbid psychiatric conditions include
Mood stabilizers: For depression, anxiety, mood lability, and impulsivity
Atypical (2nd-generation) antipsychotics: For anxiety, anger, mood lability, and cognitive symptoms, including transient stress-related cognitive distortions (eg, paranoid thoughts, black-and-white thinking, severe cognitive disorganization)
Benzodiazepines and stimulants are not recommended because of the potential risks of dependency, overdose, disinhibition, and diversion of medications.
Treatment references
1. Stoffers JM, Völlm BM, Rücker G, et al: Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2012(8):CD005652, 2012. doi: 10.1002/14651858.CD005652.pub2
2. Leichsenring F, Heim N, Leweke F, et al: Borderline personality disorder: A review. JAMA 329(8):670-679, 2023. doi: 10.1001/jama.2023.0589
