People with Borderline Personality Disorder deal with constantly unstable moods, impulsive actions, and chaotic relationships. They tend to view others as either “all good” or “all bad”, and they switch between these with little warning or cause. Even though they dread abandonment and feel very uncomfortable when they are alone, they suddenly push people away after feeling just minor rejections. Their families and friends ride these waves of emotions with them and feel exhausted trying to support them when depressive moods strike. Their loved ones watch helplessly as these people endanger themselves with impulsive and risky behaviors. At the worst, families suffer the trauma of finding them injured or dead from suicide.
Signs of Borderline Personality Disorder usually first appear in the later teen years. By this point, about 40% have been previously misdiagnosed with Bipolar Disorder, which can delay access to the correct treatment. People in these early years struggle with the increased independence of being a teenager. Problems with self-control and regulating emotions come out as these adolescents seek unhealthy solace in self-injury as well as drugs and alcohol. These issues make the already difficult teenage years even harder, leading people to struggle socially and in school. The years between ages 20 and 30 are the most tumultuous part of the disorder, punctuated by strained relationships, hospital visits, and emotional crises.
On the bright side for most people, treatment is highly effective if people stick with it. Four years after being diagnosed, 65% of people who complete a full course of therapy no longer have for the disorder, and after 10 years, the number jumps to 85%. With treatment, the most difficult years pass, and after age 30, most people function much better and with less severe symptoms than a decade prior.
Causes and Risk Factors
Prevalence and gender
Estimates of the rate of Borderline Personality Disorder in the general population average around 1.5%, and about three-quarters of those are women. In people with mental health issues, this personality disorder is one of the most common, appearing in about one in five people in psychiatric hospitals.
People with a first degree relative (a parent, child, or sibling) with Borderline Personality Disorder have a five-times greater than average risk of also developing the disorder. Tendencies for substance abuse, mood instability, Post Traumatic Stress Disorder, and Attention Deficit/Hyperactivity Disorder also appear in relatives of people with the disorder. Personality traits like impulsivity, aggression, and suicide risk all carry common genetic underpinnings as well.
Abuse or neglect
A difficult upbringing is one of the most common themes for people with Borderline Personality Disorder. Many people recall suffering emotional, physical, or sexual abuse in childhood. Having a parent who struggles with substance abuse or another severe mental issue can also create a similarly chaotic environment. They may also have parents who neglect their children’s needs or dismiss their emotions in tough situations. These strained parent-child relationships set the stage for this disorder.
The brains of people with Borderline Personality Disorder process emotional information differently from those of others. The amygdala, a part of the brain that processes anxiety and fear, is much more reactive to potential threats in these people. Additionally, the prefrontal cortex, which is the brain area that manages conscious information processing, struggles to control this hypersensitivity to danger.
Because of a history of trauma is so common in this personality disorder, Post Traumatic Stress Disorder frequently occurs as well in these people. Many people may turn to alcohol or other drugs to deal with stress, and this can lead to substance abuse disorders. People with eating disorders and Borderline Personality Disorder share similar negative feelings towards themselves, so those disorders appear together often as well. Depression, Bipolar Disorder, and anxiety disorders also commonly accompany Borderline Personality Disorder.
Diagnosing Borderline Personality Disorder
These people display a long-lasting pattern of impulsive behavior and unstable moods. Fear of losing others and being alone are common threads in their lives, and they will take drastic actions when they feel like they are being abandoned. At the same time, however, they have trouble trusting people and may experience minor slights as major betrayals. As a result, they suffer stormy relationships and frequently bounce between idolizing their partners and despising them.
Rejection, loneliness, and relationships
These people struggle to trust in an emotional connection with someone who is not physically with them, even if they are away for a just a short period of time. When a friend or significant other must cancel plans to see them, they will take it as a personal rejection, no matter the true reason. These situations usually lead to angry outbursts and relationship turmoil. When a major relationship ends, they feel very uncomfortable being alone and are prone to jumping quickly into a new one. They will idealize their new partner and try to spend as much time as possible with them. When the new partner can no longer stand the intense closeness or tries to take even a short time to themselves, the person with Borderline Personality Disorder will feel rejected, and the cycle begins again.
They usually view themselves negatively, and many aspects of their identities (such as opinions, values, and goals) change unpredictably and often. These people often act hastily and hurt themselves in the process. They drink or use drugs, spend beyond their means, binge eat, and have impulsive sex. Destructive behavior is a common thread for these people, and, following this pattern, they often try to hurt themselves directly. They cut, burn, and injure themselves in a wide variety of other ways. Suicidal threats and behavior are unfortunately common.
Depression and anxiety
Moods in Borderline Personality Disorder change rapidly and unpredictably. Episodes of anxiety and depression may strike daily. They struggle to control their temper, and violent, excessive outbursts take others by surprise. When they feel most stressed, they become irrational and may dissociate, feeling emotionally distant and separated from their surroundings. At times when the extreme moods subside, these people are left with worrying feelings of emptiness. They feel bored and alone, with few hopes, goals, or motivations.
Treating Borderline Personality Disorder
Dialectical Behavior Therapy
DBT is a modified version of Cognitive Behavior Therapy and is the first-line, best treatment for Borderline Personality Disorder. DBT is exceptionally effective at treating this frustrating condition, and 77% of people who complete a full course of DBT can expect to recover. DBT focuses on helping people build a skillset that enables them to better regulate their emotions.
A full course of DBT includes four modules over at least a year (longer if they repeat any sections) in the form of weekly individual and group therapy sessions. The four sections of treatment are mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation. Mindfulness involves paying attention to and accepting the present (as opposed to letting past events or future worries dominate one’s thoughts). Practicing interpersonal effectiveness requires people to learn how to express their needs and assert their desires in a calm, effective manner, especially in situations where they feel vulnerable. The distress tolerance module emphasizes accepting, without judgement or resistance, emotionally stressful situations. This requires cultivating the ability to tolerate challenging times without searching for some sort of temporary escape. In the final module, emotion regulation, people learn to observe what they are feeling (often a complex variety of competing feelings), prevent those emotions from overwhelming them, and take steps to change those emotions.
Mentalization is the ability to interpret how someone else or oneself is feeling based on their behavior. Mentalization-Based Therapy helps train people to identify and distinguish their emotions from those of others. People with Borderline Personality Disorder have burred boundaries in relationships and often struggle to separate others’ internal feeling states from their own. Practicing mentalization helps people empathize with others and understand how their actions affect those around them.
The foundation of Schema-Focused Therapy is that these people develop fixed, negative views of themselves in childhood that carry over and create a poorly functioning adult. These people vacillate between seeing themselves as isolated and broken; violent and impulsive; distant and dissociated; or harsh and unforgiving. The goal of this therapy type help people build a new, healthier, and more functional self-image, one who is assertive, patient, and ready to form stable relationships with others.
Although there are no medications that directly treat the Borderline Personality Disorder as a whole, several types can help keep some symptoms at bay and may help people engage in therapy more effectively. Unfortunately, these people tend to have strong placebo responses to medication initially, but these effects wear off after a few days or weeks. Antidepressants like Selective Serotonin Reuptake Inhibitors (SSRIs) are the go-to medications for reducing impulsivity and aggression, as well as the severity of the periodic depressive episodes. SSRIs are safer, too, especially in patients who may overdose on their medication as part of a suicide attempt. Antipsychotic medications such as Risperdal (risperidone) offer an alternative if SSRIs are ineffective, but they are more dangerous in overdose situations.
Managing Borderline Personality Disorder
Getting support during a crisis
People with Borderline Personality Disorder most commonly come to medical attention when they are in a crisis. A crisis is a critically difficult emotional time when symptoms are at their worst, and people are at a very high risk of self-harm and suicide. Depending on the situation, the first responders to a crisis might be loved ones, emergency medical personnel, police, the individual’s therapist or doctor, or a crisis team. People access crisis teams via 24-hour help lines, such as the National Suicide Prevention Lifeline (1-800-273-8255) or a local city, county, or state line. The exact parts of crisis teams vary from place to place, but usually include a network of social workers, emergency counselors, walk-in clinics, and connections to police and emergency medical services. Crisis teams assess how severe a crisis is and the level of services that the individual needs. Many people in crisis just need a counselor to talk to on the phone or in person for a short time to get through the worst period, and they follow up with their regular therapist, doctor, or social worker the next day. If this is not enough, the crisis worker will get them to a higher level of care.
Levels of care and hospitalization
Although the ultimate goal with treatment is to foster independence, times like these frequently require higher levels of care for a short time. Crisis respite centers, Extended Observation Units (EOUs), and Crisis Stabilization Units (CSUs) are increasing levels of help and monitoring outside of a hospital. Respite centers are residential locations that offer psychiatric assessment, peer support, emotional skills training, and emergency counseling. EOUs are short term (less than 24 hours) options for close monitoring and are usually located within a larger CSU. The rest of a CSU includes multiple beds for people in psychiatric crisis lasting more than one day. When these options are not enough and someone is a danger to themselves or others, the emergency department is the safest place to go. From there, people may go to a psychiatric hospital, a partial hospital program where they do therapy during the day and go home at night, or go directly home if they are safe to do so. Any long hospital stays can be counter-productive by reinforcing people’s thoughts that they are somehow ‘broken’ or lack autonomy. As a result, care teams must walk a fine line between protecting people in crisis but not so much that it undoes the advances they have made in treatment.
Borderline Personality Disorder leads people to consider suicide with a striking frequency. Emotional frustration and even mild distress can rapidly spiral down this dangerous path. This occurs so often for so long that some people are considered “chronically suicidal,” which leads to many hospital visits. Unfortunately, this high frequency of suicidal behavior and threats can lead those around these people to become complacent and not take the threats seriously. This, in turn, puts them at even higher risk of dying from their suicidal acts. On average, 8-10% of people with Borderline Personality Disorder end up taking their own lives.
People turn to self-injury, such as cutting or burning, as a source of escape in the same kind emotional situations that lead them to threaten or attempt suicide. Up to 80% of these people will intentionally hurt themselves at least once during their illness. People hurt themselves physically as a source of relief from emotions that they cannot tolerate. They do it to relieve anxiety or escape from “numb” or “empty” feelings. Sometimes people intend these angry actions to punish themselves for being “bad”. People also hurt themselves when they feel frustrated and ignored by others. Difficulty communicating about emotions is part of the disorder, and self-harm provides an (albeit unhealthy) way of doing this.
Learning about Borderline Personality Disorder will help the friends, family, and partners of people with the disorder better manage stressful situations. A few educational sessions with a therapist can clarify this complex disorder and teach families how best to support their loved ones. They learn how to reinforce the goals of therapy and avoid playing into the symptoms of the disorder.