What is Borderline Personality Disorder?

According to the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM-5), the fifth and most recent edition of the manual used by mental health professionals to diagnose psychiatric conditions, borderline personality disorder (BPD) is one of six personality disorders. The manual defines a personality disorder as a condition that causes pathological personality traits and impairs the way a person functions with the self and with others. The general criteria for being diagnosed with a personality disorder include:

• Impairment in self-identity and the ability to function with and around other people
• Consistency in impairments over time
• One or more pathological personality traits
• Impairments or pathological traits that cannot be explained by developmental issues, environmental factors, a physical medical condition, or substance abuse.

BPD is one of the six recognized personality disorders that meet the general criteria. Borderline personality disorder criteria are more specific and are also outlined in the DSM-5. BPD is a mental illness that is characterized by these criteria and symptoms related to self-identity, mood swings, extreme emotions, turbulent relationships, fear of abandonment, and even psychosis. To be diagnosed with BPD, a person must show at least five of the nine symptoms or diagnostic criteria, and these must be persistent, long-lasting and must interfere with normal activities; they cannot be explained by substance use:

• Difficulty creating a self-identity, an unstable self-image, or chronic feelings of emptiness or of being nobody, as well as unstable self-direction—shifting goals, values, careers, aspirations
• Intense and unstable relationships with others, which may be characterized by an inability to empathize with or recognize the feelings and needs of others
• Unstable emotional states, extreme emotional responses, and frequent and extreme changes in mood
• Extreme and illogical fears of being abandoned by others
• Depression symptoms, including shame, worthlessness, hopelessness, inferiority
• Suicidal thoughts and behaviors or non-suicidal self-harm, such as cutting or burning
• Impulsive, risky, and self-destructive behaviors with little regard for consequences
• Extreme anger and hostility either directed at others or at oneself
• Symptoms of psychosis, such as paranoia or suspicion, or even dissociation, a feeling of being outside one’s body

There is no borderline personality disorder test, but a trained mental health professional can perform a psychiatric evaluation and use these criteria to determine if someone is struggling with BPD. In addition to experiencing five or more of these borderline personality disorder symptoms, there are other factors that contribute to a diagnosis.

It is often easier to recognize the symptoms of BPD in someone else. It is much more challenging to recognize them in oneself, and especially to realize when it is time to ask for help. For anyone uncertain of what their troubling feelings or thoughts mean, if these thoughts are normal, or if they indicate a need for professional help, it may be useful to learn what it feels like to have BPD. It helps to know what the internal signs are that indicate there may be a diagnosable condition causing these uncomfortable emotions and thoughts. These internal signs include:

• A persistent feeling of emptiness, of not existing, or of not knowing one’s own identity
• Feeling like one’s personality is always changing, along with goals and pursuits
• Being extremely sensitive and overreacting emotionally
• Feeling as if everything is always changing, and that this is frightening
• Constantly needing reassurance that loved ones care and won’t leave
• Taking drastic steps to try to prevent someone from leaving
• Feeling intensely passionate about someone one day and feeling done with them the next
• Constantly having short, turbulent relationships
• Feeling explosions of anger that are hard to control
• Persistent thoughts of self-loathing or of being broken
• Feeling outside one’s body

These are just some examples of what it feels like to live with this condition. Each person may describe the experience a little differently, but the overall symptoms and feelings are similar.

Borderline personality disorder traits can make it difficult for a person to live a normal life and can result in a number of complications. Symptoms like extreme emotions, mood swings, unstable relationships, and a shifting self-identity make it more challenging to hold down a job, for instance, or to maintain a healthy relationship with a partner. Other potential complications of BPD include:

• Physical injuries from self-harm
• Physical injuries from fights or impulsive and risky behaviors
• Financial difficulties, including unemployment or even homelessness
• Academic struggles
• Substance abuse
• Social isolation
• Legal problems
• Incarceration
• Suicide

A person with BPD is also at an increased risk for being diagnosed with other psychological disorders. These include bipolar disorder with bipolar depression and periods of mania, as well as major depression. Anxiety disorders, such as generalized anxiety or obsessive compulsive disorder, are also possible in someone with BPD. Some people with BPD may also struggle with eating disorders.

Borderline personality disorder causes are not fully understood, but there is evidence that abnormalities in the structure of the brain and in the neurotransmitters that act in the brain may be related to how the condition develops and the symptoms it produces. There may also be triggering factors that play a role in the development of BPD, such as trauma experienced during childhood.

There are some known risk factors for BPD as well. These are factors or conditions that make it more likely, although not guaranteed, that someone will be diagnosed with borderline personality disorder. These include a family history of the condition, traumatic experiences or extreme stress, and a natural tendency to be impulsive, angry, or aggressive.

The main strategy used for treating and managing borderline personality disorder symptoms is therapy. Several different types of therapy may be used depending on how each individual responds. These include cognitive behavioral therapy, schema-focused therapy, Systems Training for Emotional Predictability and Problem Solving, and dialectical behavior therapy (DBT).

While any type of therapy has the potential to help a patient manage moods and emotions, DBT was developed specifically for patients with BPD. It is considered an effective and evidence-based approach to helping patients manage symptoms and live a more normal life. A therapist uses DBT to help a patient achieve symptom management by:

• Regulating and controlling strong emotions
• Using mindfulness techniques, such meditation and other self-soothing strategies
• Reducing self-destructive behaviors
• Improving relationships with others
• Developing stress tolerance
• Balancing acceptance of symptoms and the need to change behaviors

Borderline personality medications do not exist specifically, but there are drugs that may help a patient struggling with the symptoms of BPD or co-occurring conditions. For instance, antidepressants or anti-anxiety medications can help relieve some of the troubling emotions that come with BPD, while mood stabilizers may help to even out mood swings. For someone experiencing the symptoms of psychosis, like those seen in paranoid schizophrenia, antipsychotic medications may be useful. No single medication can treat every patient with BPD and for many, medications won’t help at all. This is why sticking with therapy is so important.

Another evidence-based management strategy for BPD treatment is called family psychoeducation. This refers to involving the family of the patient, not so much in therapy but in learning more about how to create a supportive and healing environment for the patient. The family also learns how to set boundaries with their loved one and how to take care of themselves and manage stress. Having healthy relationships with others is one of the biggest challenges of living with BPD, and when family or friends don’t understand the condition and how it makes the patient feel, those relationships become even more challenging.

Family psychoeducation gives a patient’s loved ones the knowledge and the tools needed to provide useful and effective support. Research has found that when the family is involved in this way, learning more about the condition and developing strategies for coping with stress and maintaining relationships with the patient, outcomes are better for everyone, including the patient with BPD.

Borderline personality disorder is a very serious mental health condition. It is disruptive to living a normal life, holding down a job, and having healthy and stable relationships. As a chronic mental illness there is no known cure for BPD, but it is a treatable, manageable condition. It is crucial to get a professional diagnosis from a psychiatrist, to be part of developing a treatment plan, to get effective therapy, and to stick with it along with the support of family in order to be able to manage symptoms and live a more normal life.