Borderline personality disorder: a guide to its causes, symptoms and treatment
- Borderline personality disorder, also known as emotionally unstable personality disorder (EUPD), is a serious mental illness characterized by impairments in personality, along with the presence of pathological personality traits
- Statistics show that almost 75 percent of the people diagnosed with BPD are women. Some psychiatrists attribute this gender pattern to genetic or hormonal reasons as well as premenstrual tension
- Although proper diet is far from being a cure to BPD, it may still be helpful in managing your symptoms, improving your mental health and preventing obesity as a complication of impulsive eating habits
- There are no drugs that have been approved to specifically treat BPD. However, some mental health providers may prescribe medications like antidepressants, antipsychotics or mood-stabilizing drugs to help manage co-occurring problems such as depression, impulsiveness or anxiety
Personality refers to the characteristics and traits that people develop as they grow up — it's the way a person thinks, feels and behaves. It affects how an individual interacts with other people, maintains relationships, performs day-to-day activities and handles emotions.
In some cases, people develop personalities that lead to unhealthy thoughts and behaviors, and an inability to control emotions and impulses. Those who are struggling with these characteristics may have a personality disorder, which is recognized as a mental illness.1
One of the most common types of personality disorder is borderline personality disorder (BPD), which affects anywhere from 1.6 to 5.9 percent of the U.S. population, according to the American Psychiatric Association.2
What Is Borderline Personality Disorder?
Borderline personality disorder, also known as emotionally unstable personality disorder (EUPD),3 is a serious mental illness characterized by impairments in personality, along with the presence of pathological personality traits.4
According to the National Institute of Mental Health, people who are struggling with this condition may experience ongoing patterns of varying moods, self-image and behavior, as well as intense episodes of anger, depression and anxiety that could last from a few hours to days, often resulting in marked impulsive actions as well as unstable self-image and interpersonal relationships.5
Borderline Personality Disorder in Women
Statistics show that almost 75 percent of the people diagnosed with BPD are women.6 Some psychiatrists attribute this gender pattern to genetic or hormonal reasons as well as premenstrual tension.7
However, researchers have determined that there may be no differences in prevalence by gender in BPD — it's just that affected men are usually misdiagnosed with other forms of mental illness such as post-traumatic stress disorder (PTSD) or depression. Women with BPD are also believed to be more likely to seek psychological help than men.8
Borderline Personality Disorder in Men
Although BPD in the male population may be just as prevalent as it is in women, there is a notable gender difference in the expression of BPD symptoms. Studies show that men are more likely to exhibit explosive temperament and novelty seeking.
They're also more prone to experiencing substance use disorders and antisocial personality disorder. In terms of treatment utilization, men with BPD are likely to be treated for substance abuse, whereas women receive pharmacotherapy and psychotherapy.9
Borderline Personality Disorder in Children
Many studies over the past years have shown that the pathology of BPD is not exclusive to adulthood and that it may have developmental pathways that begin during childhood. In fact, statistics show that up to 71 percent of adults with BPD have experienced severe abuse as a child, and 30 percent were reported to have self-injurious tendency before the age of 12.10
Previously, the diagnosis of BPD in people below the age of 18 had been controversial because it's not considered a valid illness in youths, as adolescents are still developing their personality and the typical features of BPD are normal during this stage of life. Doctors may also be trying to protect their young patients against the stigma of a mental health issue.11
With the new DSM-5 criteria, the possibility of BPD occurring during childhood has been recognized. The indicators of BPD in children and teenagers are similar to that in adults, which include:12
- Hostile or paranoid view of the world
- Dangerous impulsivity
- Intense, unstable or inappropriate emotion
- Intense but unstable relationships
- Lack of self-image
If you've noticed these notable indicators in your child or have experienced them yourself, you should seek psychological help immediately. Early diagnosis is crucial to determine the best way to control emotions and behaviors, and reduce the risk of self-harm.13
Borderline Personality Disorder Versus Bipolar Disorder
Bipolar disorder is a mood disorder that's characterized by unpredictable and extreme shifts in mood, energy and activity levels. These episodes are categorized into two types: mania and depression.
Both BPD and bipolar disorder can present impulsive behaviors, intense emotions and suicidal tendencies, which is why they're often confused with each other. Here are some of the notable differences between these two mental illnesses:14
- Frequency of mood changes — Mood changes in people with BPD are short-lived, and are usually caused by environmental or interpersonal triggers, unlike that of the mood changes in bipolar disorder, which can last for weeks, months or even years.
- Sleeping patterns — People with bipolar disorder are more likely to have interrupted sleeping patterns compared to those with BPD. During a mood episode in bipolar disorder, a person can sleep continuously for days or stay awake for long periods without experiencing fatigue.
- Stability of interpersonal relationships — People with BPD are more likely to have problems with interpersonal relationships due to their tendency to be more emotionally unstable.
Borderline Personality Disorder Symptoms
People with BPD may experience a wide range of symptoms that affects the way they see themselves, how they relate to others and how they behave. It's important to be aware of the varying patterns of behaviors and feelings associated with BPD, as they can easily be misinterpreted or mistaken as a sign of other mental problems.15,16
Borderline Personality Disorder Checklist
In case you're wondering if you or a loved one has BPD, use this checklist to determine if you exhibit the common symptoms associated with this mental illness:17
1. Do you have an intense fear of abandonment that causes you to act frantically to avoid real or imagined abandonment from happening?
2. Do you engage in impulsive and risky behaviors, such as gambling, binge eating or reckless driving?
3. Have you been in unstable relationships that alternate between idealization (strong feeling of love) and devaluation (hatred)?
4. Do you experience rapid changes in self-identity, self-image, and/or goals and values?
5. Do you experience periods of stress-related paranoia?
6. Do you have suicidal tendencies or self-damaging behaviors?
7. Do you get intense and varying mood swings that last from a few hours to days?
8. Do you feel ongoing feelings of emptiness?
9. Do you have a short temper and frequently experience intense outbursts of anger?
If you exhibit five or more of the symptoms mentioned above, then it's possible that you have BPD. Keep in mind that even if you think you know what is causing these symptoms, you still need to consult a mental health provider to get a proper diagnosis.
This checklist is based on the DSM-5 diagnostic criteria for BPD published by the American Psychiatric Association (APA). The APA has released newer diagnostic criteria for BPD in the DSM-5, which features an updated list and classifications of symptoms, including associated features supporting a BPD diagnosis.18,19
Bipolar Disorder Symptoms Based on the DSM-5 Criteria
The more recent DSM-5 criteria state that a person must have pathological characteristics and impairment in personality in order to be diagnosed with BPD. The impairments in personality functioning associated with BPD are:20
- Impairment in self-functioning — Manifested by unstable or poorly developed identity and self-direction.
- Impairments in interpersonal functioning — Characterized by the lack of empathy and/or intense yet unstable intimate relationships that are viewed in extremes of idealization and devaluation (also known as splitting).
Meanwhile, the pathological traits that a person with BPD may experience are grouped into the following categories:21
- Negative affectivity — Characterized by intense emotions that are out of proportion to events and circumstances, anxiousness, separation insecurity or fear of rejection and depression.
- Disinhibition — Characterized by impulsive responses and engagement in potentially harmful and unnecessary activities, without regard to the consequences.
- Antagonism — Characterized by hostility or frequent angry feelings in response to minor slights or insults.
Borderline Personality Disorder Test
To determine if you have BPD, a mental health provider may ask you to answer a questionnaire that contains the questions listed in the checklist above. Additionally, you may undergo a detailed interview to discuss your symptoms and medical history.22
Diagnosing a mental illness like BPD can be difficult. Unlike physical illnesses that can be identified through a series of lab tests, diagnosing BPD requires a lot of observation, since some of the symptoms may not be apparent right away. This is exactly why a misdiagnosis is common in people with BPD.23
For a better chance of getting the correct diagnosis, take note of important information about your health before visiting your doctor, such as:24
- The duration of symptoms you have experienced
- Personal information like traumatic events and current stressors
- All medications you're taking, including supplements and vitamins
Borderline Personality Disorder Causes
The exact cause of BPD has not yet been identified, but research suggests that it may be influenced by the following factors:25,26
- Genetic predisposition — Those who have an immediate family member with BPD or other personality disorders may be at higher risk of developing this condition. In fact, according to the DSM-5, if you have a first-degree relative with BPD, you are about five times more likely to be diagnosed with it yourself.27
- Brain abnormalities — Abnormal changes in the parts of the brain involved in emotion regulation, impulsivity and aggression may lead to the development of BPD.
- Problematic childhood — Many individuals diagnosed with BPD are reported to have experienced sexual or physical abuse during their childhood, while others were neglected by or separated from a parent or guardian. Exposure to unstable family relationships and parents with substance misuse or mental health issues may also trigger BPD.
Types of Borderline Personality Disorder
Not everyone with BPD experiences the same combination of symptoms. The diverse ways this condition can be manifested suggest that it has subtypes, but there's currently no firm consensus about what these types are. Currently, the most popular and widely recognized classification of BPD is the one created by the American psychologist Theodor Millon in his book, "Disorders of Personality: DSM-IV and Beyond." Millon's four types of BPD include:28,29
- Discouraged borderline — People who have this type of BPD have a strong desire for acceptance and approval, and are needy, dependent and easily disillusioned, with a lot of pent-up anger toward other people. They're more prone to committing self-harm, as they're haunted by feelings of inferiority and inadequacy.
- Impulsive borderline — Characterized by the desire to be the center of attention and a tendency to be easily bored, people who fall under this classification of BPD are more likely to engage in a wide range of risky behaviors without regard to the consequences.
- Petulant borderline — Individuals who have this type of BPD exhibit narcissistic behaviors and are unpredictable, difficult to please, irritable, impatient and prone to outbursts of anger and frustration. Because of their willful and defiant nature, they're often defensive and unwilling to admit if they're wrong.
- Self-destructive borderline — As the name suggests, this type of BPD is characterized by dangerous behaviors that may lead to injuries. Those who fall under this subtype lack a stable self-image and have an intense fear of abandonment.
Another lesser-known type of BPD is quiet borderline, which is characterized by acting-in behaviors. Acting in refers to internalized hostility, anger, aggression and other self-injurious emotions. People with quiet BPD are more likely to hide their unstable emotions and problems from their loved ones.30
There's also a new set of BPD subtypes proposed in the 2017 edition of the journal Borderline Personality Disorder and Emotion Dysregulation, which classifies each type according to the number and severity of symptoms, exposure to trauma, levels of attachment, personality functioning, quality of life, and relationship issues. These classifications include:31
- Core BPD
Borderline Personality Disorder Treatment
BPD is a condition that was previously considered difficult to treat. Today, there are many treatment options that can help patients cope with their condition and lead a more stable and fulfilling life. These treatment plans mostly involve psychotherapy, also known as talk therapy, with the goal of providing ways to manage emotions, reduce impulsivity and improve relationships. Some of the types of psychotherapy that may be helpful for people with BPD include:32,33,34
Dialectical behavior therapy (DBT) — This is a type of therapy specifically designed to help treat people with BPD. The approach focuses on two concepts: validation and dialectics. Its ultimate goal is to help people with BPD to break free of seeing the world as either "black or white."
Schema-focused therapy — Can be done individually or in a group, this method helps identify and fulfill unmet needs that have led to unhealthy behaviors.
Mentalization-based therapy (MBT) — The goal of this approach is to emphasize thinking before acting, helping individuals identify thoughts and feelings to create an alternate perspective at any given moment.
Systems training for emotional predictability and problem-solving (STEPPS) — Often used together with other types of psychotherapy, this method is a 20-week treatment that involves the help of family members, caregivers, friends and significant others.
Transference-focused psychotherapy (TFP) — This method involves developing a relationship between the individual with BPD and the therapist to get a better understanding of emotions and interpersonal difficulties.
Good psychiatric management (GPM) — Less intensive and regulated than other types of psychotherapy, GPM focuses on how an individual with BPD reacts to stressors that may be encountered in their everyday life. It can be done individually or in a group.
Help Manage Borderline Personality Disorder With Proper Nutrition
What you eat has a significant impact on your brain health. Although proper diet is far from being a cure to BPD, it still may be helpful in managing your symptoms, improving your mental health and preventing obesity as a complication of impulsive eating habits.
The first step to managing BPD with proper nutrition is to remove all unhealthy processed foods from your diet, as they may contain ingredients that can promote oxidative stress and disrupt the balance of chemicals in your brain. These include foods that contain:
- Trans fat
- Genetically engineered products like corn and soy
- Added sugar and artificial sweeteners
- Food additives
Instead of eating the foods mentioned above, here are some healthy choices that you should include in your diet to help in the management of BPD as well as other mental disorders:
- Sources of omega-3 fatty acids, including wild-caught Alaskan salmon, anchovies, sardines, avocados, coconuts and coconut oil, and organic egg yolks. Omega-3 fatty acids play a crucial role in brain development and function, and studies35 have shown that they may be a safe and effective natural remedy for BPD.
- Dark leafy vegetables such as spinach, kale and Swiss chard — these greens are rich in vitamins and phytochemicals that may help fight brain inflammation.36
- Antioxidant-rich vegetables and fruits like cranberries, blueberries and strawberries, which may help alleviate depression and anxiety, if consumed in moderate amounts.37
- Fermented foods like kimchi, sauerkraut, grass fed yogurt, tempeh and natto, which contain probiotics that may help optimize your gut health to improve the production of important brain chemicals.38
Are Medications for Borderline Personality Disorder Effective?
There are no drugs that have been approved to specifically treat BPD. However, some mental health providers may prescribe medications like antidepressants, antipsychotics or mood-stabilizing drugs to help manage co-occurring problems such as depression, impulsiveness or anxiety.39
Think twice before you take any of these medicines, as they can cause serious side effects. For instance, antipsychotics may cause drowsiness, dizziness, restlessness, dry mouth, constipation and seizures, whereas mood stabilizers can cause tremors, seizures, hallucination, loss of coordination and irregular heartbeat.40
Antidepressants, on the other hand, are shown to have the clinical effectiveness of a placebo. What's worse is that they can cause nausea, vomiting, weight gain, diarrhea, sleepiness and reproductive health problems.41
Borderline Personality Disorder Prevention
According to the 2014 study published in the journal Current Treatment Options in Psychiatry, indicated prevention is the only form of prevention that's feasible for BPD. This refers to an approach that targets adolescents and young adults exhibiting early features of this disorder.
Indicated prevention may be recommended for subsyndromal cases, wherein individuals exhibit less than five of the hallmark symptoms of BPD. For those who experience more than five symptoms, early intervention may be recommended to lessen the risk of developing this condition.
Indicated prevention and early intervention involves a variety of psychosocial treatments, including cognitive analytic therapy (CAT), emotion regulation training (ERT) and mentalization-based treatment for adolescents (MBT-A). It also involves omega-3 fatty acid supplementation which, as mentioned above, has been shown to help improve functioning and reduce psychiatric symptoms.
However, even though these approaches appear to be effective for reducing the symptoms of BPD in adolescents and young adults, it's important to note that they're not guaranteed to prevent the onset of this illness. Currently, there is still no surefire way to prevent BPD.42,43
Relationship Cycle in People With Borderline Personality Disorder
Being in a relationship with a person who has BPD can subject you to a rollercoaster of emotions — one moment you feel loved, and the next you're abandoned and hated. Because of their tendency to see things as either "all good" or "all bad," relationships with someone who has BPD often alternate between these two cycles:44,45,46
- Idealization — An individual with BPD usually begins a relationship in this phase, wherein they view their partner in a perfect and picturesque way. During this "honeymoon period," the relationship may feel exciting and passionate.
- Devaluation — As the person with BPD realizes that their partner is not faultless, they immediately switch to devaluing their partner, suddenly viewing them as all bad. During this period, the relationship may spiral downward because of accusations, anger, jealousy and bullying. It may also lead to a break up, which could trigger suicidal tendencies in people with BPD.
The shifts between these two cycles may occur sporadically throughout the day, which could make the partner of a person with BPD feel emotionally manipulated. However, it's important to understand that these behaviors are not done out of malice — they're actually a desperate way to cope with fears of abandonment and rejection.
Frequently Asked Questions (FAQs) About Borderline Personality Disorder
Q: How do I know if I have BPD?
A. According to the DSM-5 criteria, you may have BPD if you experience impairments with self and interpersonal functioning, along with pathological traits like impulsiveness, excessive emotional responses, constant feelings of emptiness and intense anger, to name a few.
Use the checklist above to determine the hallmark symptoms of BPD that you've been exhibiting. If you answer yes to five or more of the symptoms, then it's possible that you may have BPD, and should consult a mental health provider right away.47,48
Q: Is BPD genetic?
A. Yes, genetic predisposition is one of the potential risk factors of BPD.49
Q: Is BPD a disability?
A. Yes, BPD is considered a disability, and those who have it are eligible to apply for social security disability income (SSDI).50
Q: How do you handle someone with BPD?
A. If you're close to someone with BPD, chances are you've been on the receiving end of their emotional outbursts. In order for you to learn how to react to a person with BPD, you have to remind yourself that they're suffering from a mental illness, so they may not be able to control their behaviors. Learn more about the illness to better understand what they're going though. Here are some other tips to help you interact a person with BPD:51
Do not dismiss their emotions. Rather, validate their feelings without agreeing with them.
When talking to them, make your messages short, simple and direct to avoid misinterpretation.
Encourage them to be more responsible so you won't fall into a caretaking role.
Set boundaries and stick to them.
Don't ignore threats of self-harm.
Help them find treatment.
Find support for yourself.
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