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Borderline personality disorder

February 16, 2024

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD),[14] is a personality disorder characterized by a long-term pattern of intense and unstable interpersonal relationships, distorted sense of self, and strong emotional reactions.[9][15][16] Those affected often engage in self-harm and other dangerous behaviors, often due to their difficulty with returning their emotional level to a healthy or normal baseline.[17][18][19] They may also struggle with dissociation, a feeling of emptiness, and a fear of abandonment.[15]

Borderline personality disorder
Other names
Despair by Edvard Munch (1894), who is presumed to have had borderline personality disorder[6][7]
SpecialtyPsychiatry, clinical psychology
SymptomsUnstable relationships, sense of self, and emotions; impulsivity; recurrent suicidal behavior and self-harm; fear of abandonment; chronic feelings of emptiness; inappropriate anger; feeling detached from reality (dissociation)[8][9]
ComplicationsSuicide, self harm[8]
Usual onsetEarly adulthood[9]
DurationLong term[8]
CausesGenetics, trauma[10]
Risk factorsFamily history, trauma, abuse[8][11]
Diagnostic methodBased on reported symptoms[8]
Differential diagnosisBipolar disorder, attachment disorder, dissociative identity disorder, identity disorder, mood disorders, post-traumatic stress disorder, CPTSD, substance use disorders, ADHD, histrionic, narcissistic, or antisocial personality disorder[9][12]
TreatmentBehaviour therapy[8]
PrognosisImproves over time,[9] typically after age 30 and some cases are in total remission by 40.[13]
FrequencyEstimation of c. 1.6% of people in a given year[8]

Symptoms of BPD may be triggered by events considered normal to others.[15] BPD typically begins by early adulthood and occurs across a variety of situations.[9] Substance use disorders,[20] depression, and eating disorders are commonly associated with BPD.[15] Some 8 to 10% of people affected by the disorder may die by suicide,[9][15] with the rate being twice as high in males as in females.[21] The disorder is often stigmatized in both the media and the psychiatric field and as a result is often under-diagnosed.[22]

The causes of BPD are unclear but seem to involve genetic, neurological, environmental, and social factors.[8][10] It is five times more likely to occur in a person who has one or more affected immediate relatives.[8] Adverse life events appear to also play a role.[11] The underlying mechanism appears to involve the frontolimbic network of neurons.[11] BPD is classified in the American Diagnostic and Statistical Manual of Mental Disorders (DSM) as a cluster B personality disorder, along with antisocial, histrionic, and narcissistic personality disorder.[9] BPD (and other personality disorders) can be misdiagnosed as a mood disorder, substance use disorder, or other disorder.[9]

BPD is typically treated with psychotherapy, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT).[8] Therapy for BPD can occur one-on-one or in a group.[8] While medications cannot cure BPD, they may be used to help with the associated symptoms.[8] Quetiapine and SSRI antidepressants are widely prescribed for the condition, but their efficacy is unclear. A 2002 study found fluvoxamine (an SSRI) significantly decreased rapid mood shifts in female borderline patients,[23] while more recent meta-analysis found the use of medications still unsupported by evidence.[24] Severe cases of the disorder may require hospital care.[8]

About 1.6% of people have BPD, with some estimates as high as 5.9%.[8][9][25] Women are diagnosed about three times as often as men.[9] Up to half of those with BPD improve over a ten-year period with treatment.[9] Those affected typically use a high amount of healthcare resources.[26] There is an ongoing debate about the naming of the disorder, especially the suitability of the word borderline—the term originally referred to borderline insanity, and later to patients on the border between neurosis and psychosis, an interpretation of the disorder now considered outdated and clinically inaccurate.[8][27]

Signs and symptoms

 
One of the symptoms of BPD is an intense fear of abandonment.

BPD is characterized by nine symptoms according to the DSM-5. To be diagnosed, a person must meet at least five of the following:[28]: 663 

Overall, the most distinguishing symptoms of BPD are pervasive patterns of instability in interpersonal relationships and self-image, alternating between extremes of idealization and devaluation of others, along with varying moods and difficulty regulating strong emotional reactions. Dangerous or impulsive behavior is also correlated with the disorder.

Other symptoms may include feeling unsure of one's identity, morals, and values; having paranoid thoughts when feeling stressed; depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or psychotic episodes. Individuals with BPD may have comorbid conditions, such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder, and attention-deficit/hyperactivity disorder.[28]

Emotions

People with BPD may feel deeper and more intense emotions with greater ease and for a longer time than others do.[31][32] A core characteristic of BPD is affective instability, which manifests as unusually intense emotional responses to environmental triggers, with a slower return to a baseline emotional state.[33][34] According to Marsha Linehan, the sensitivity, intensity, and duration with which people with BPD feel emotions have both positive and negative effects.[34] People with BPD are often exceptionally enthusiastic, idealistic, joyful, and loving,[35] but may feel overwhelmed by negative emotions (anxiety, depression, guilt/shame, worry, anger, etc.), experiencing intense grief instead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness.[35] Studies have shown that borderline patients experience chronic and significant emotional suffering and mental agony.[28][36][irrelevant citation]

People with BPD are also especially sensitive to feelings of rejection, criticism, isolation, and perceived failure.[37] Before learning other coping mechanisms, their efforts to manage or escape from their negative emotions may lead to emotional isolation, self-injury or suicidal behavior.[38] They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, subconsciously shut their awareness down entirely since awareness would only cause further distress.[34] This can be harmful since awareness of negative emotions can alert people to the presence of a problematic situation.[34]

While emotional dysregulation is a key feature of BPD, Fitzpatrick, et al. (2022) argue that the dysregulation itself may not be unique to BPD and be shared by other disorders, such as generalized anxiety disorder. However, their study did suggest that those with BPD may have a harder time disengaging from their negative emotions (using distraction to manage their emotions) and returning to a baseline emotional state.[39]

While people with BPD sometimes feel euphoria (ephemeral or occasional intense joy), they are especially prone to dysphoria (a profound state of unease or dissatisfaction), depression, and/or feelings of mental and emotional distress. Zanarini et al. suggested four categories of dysphoria typical of this condition: extreme emotions, destructiveness or self-destructiveness, feeling fragmented or lacking identity, and feelings of victimization.[40] Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: feeling betrayed, feeling out of control, and feeling like hurting oneself.[40] Since there is great variety in the types of dysphoria people with BPD experience, the amplitude of the distress can be a helpful indicator.[40]

In addition to intense emotions, people with BPD regularly experience emotional "lability" (changeability, or fluctuation). Although that term suggests rapid changes between depression and elation, mood swings in people with BPD more frequently involve anxiety, with fluctuations between anger and anxiety and between depression and anxiety.[41]

Interpersonal relationships

People with BPD can be very conscious of and susceptible to their perceived or real treatment by others, feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.[42] People with BPD often engage in idealization and devaluation of others, alternating between high positive regard for people and great mistrust or dislike for them.[43] Their feelings about others often shift from admiration or love to anger or dislike after a perceived abandonment or perceived loss of esteem in the eyes of someone they value. This phenomenon is sometimes called splitting.[44] This idealization and devaluation can affect interpersonal relationships with those around them.[45]

While strongly desiring intimacy, people with BPD tend toward insecure, avoidant, ambivalent, or fearfully preoccupied attachment patterns in relationships.[46]

People with BPD and members of their family are prone to feeling alienated from and by each other.[47] Parents of adults with BPD are often both over-involved and under-involved in family interactions.[48] Personality disorders in general are linked to increased levels of chronic stress and conflict, decreased satisfaction of romantic partners, domestic abuse, and unwanted pregnancy.[49]

According to some research, some people with BPD tend to move quickly between relationships described in at least one case as "butterfly-like". Other individuals would instead cling closely to very few relationships, becoming reliant on fewer people than those without BPD.[50]

Behavior

BPD is closely linked to impulsive behaviors, which can include substance use disorders, binge eating, unprotected sex, or self-injury, among others.[51] People with BPD might do this because it gives them the feeling of immediate relief from their emotional pain,[51] but in the long term may feel shame and guilt over consequences of this behavior.[51] A cycle often begins in which people with BPD feel emotional pain, engage in impulsive behavior 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 behavior to relieve the new pain.[51] As time goes on, impulsive behavior may become an automatic response to emotional pain.[51]

Self-harm and suicide

Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM-5.[9] Self-harm occurs in 50-80% of people with BPD. The most frequent method of self-harm is cutting,[52] however bruising, burning, head banging or biting are also common with BPD.[52] It is hypothesized that people with BPD may feel emotional relief after engaging in self-harm.[53]

The estimation of lifetime risk of suicide among people with BPD varies—depending on method of investigation—between 3% and 10%.[54][47][55] There is evidence that a considerable percentage of men who die by suicide may have undiagnosed BPD.[56]

The reported reasons for self-harm differ from the reasons for suicide attempts.[38] Nearly 70% of people with BPD self-harm without trying to end their lives.[57] Reasons for self-harm include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.[38] In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide.[38] Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD.[58]

Sense of self

People with BPD tend to have trouble seeing their identity clearly. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.[59] They are often unsure about their long-term goals for relationships and jobs. This can cause people with BPD to feel "empty" and "lost".[59] Self-image can also change rapidly from healthy to unhealthy. People with BPD may base their identity on others, leading to chameleon-like changes in identity.[60]

Cognitions

The often intense emotions people with BPD experience may make it difficult for them to concentrate.[59] They may also tend to dissociate, which can be thought of as an intense form of "zoning out".[61] Others can sometimes tell when someone with BPD is dissociating because their facial or vocal expressions may become flat or expressionless, or they may appear distracted and "numb" to emotional stimuli.[61]

Dissociation most often occurs in response to a painful event (or something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from the current event or situation or blocking it out entirely. This is done presumably to protect against - based on similar or related past experiences - what the mind perceives and forecasts as arousing intense negative emotions and unwanted behavioral impulses that the present emotive event might trigger.[61] The mind's habit of suppressing and avoiding intensely painful emotions may provide some temporary feelings of relief, but dissociation can also lead to unhealthy coping mechanisms, while simultaneously causing the side-effect of blocking out or blunting positive emotions, thereby reducing the access of people with BPD to the valuable information those emotions provide: information that helps to guide effective, healthy decision-making in daily life.[61]

Psychotic symptoms

Though BPD is primarily seen as a disorder of emotional regulation, psychotic symptoms are fairly common, with an estimated 21–54% prevalence in clinical BPD populations.[62] These symptoms are sometimes referred to as "pseudo-psychotic" or "psychotic-like", terms that suggest a distinction from those seen in primary psychotic disorders. Recent research, however, has indicated that there is more similarity between pseudo-psychotic symptoms in BPD and "true" psychosis than originally thought.[62][63] Some researchers critique the concept of pseudo-psychosis for, on top of weak construct validity, the implication that it is "not true" or "less severe", which could trivialize distress and serve as a barrier to diagnosis and treatment. Some researchers have suggested classifying these BPD symptoms as "true" psychosis, or even eliminating the distinction between pseudo-psychosis and true psychosis altogether.[62][64]

The DSM-5 recognizes transient paranoia that worsens in response to stress as a symptom of BPD.[9] Studies have documented both hallucinations and delusions in BPD patients who lack another diagnosis that would better account for those symptoms.[63] Phenomenologically, research suggests that auditory verbal hallucinations found in patients with BPD cannot be reliably distinguished from those seen in schizophrenia.[63][64] Some researchers suggest there may be a common etiology underlying hallucinations in BPD and those in other conditions like psychotic and affective disorders.[63]

Disability

Many people with BPD are able to work if they find appropriate jobs and their condition is not too severe. People with BPD may be found to have a disability in the workplace if the condition is severe enough that the behaviors of sabotaging relationships, engaging in risky behaviors or intense anger prevent the person from functioning in their job role.[65] The United States Social Security Administration acknowledges BPD as a disability, and affected individuals can apply for disability benefits.[66]

Causes

As is the case with other mental disorders, the causes of BPD are complex and not fully agreed upon.[67] Evidence suggests that BPD and post-traumatic stress disorder (PTSD) may be related in some way.[68] Most researchers agree that a history of childhood trauma can be a contributing factor,[69] but less attention has historically been paid to investigating the causal roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.[67][70]

Genetics

Compared to other major psychiatric disorders, genetic research in BPD is still in its very early stages.[71] The heritability of BPD is estimated to be between 37% and 69%.[72] That is, 37% to 69% of the variability in liability underlying BPD in the population can be explained by genetic differences. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment.[73] Even so, the researchers of one study concluded that personality disorders "seem to be more strongly influenced by genetic effects than almost any Axis I disorder (e.g., depression, eating disorders), and more than most broad personality dimensions".[74] Moreover, the study found that BPD was estimated to be the third most-heritable personality disorder out of the 10 personality disorders reviewed.[74] 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.[75]

Families with twins in the Netherlands were participants of an ongoing study by Trull and colleagues, in which 711 pairs of siblings and 561 parents were examined to identify the location of genetic traits that influenced the development of BPD.[76] Research collaborators found that genetic material on chromosome 9 was linked to BPD features.[76] The researchers concluded that "genetic factors play a major role in individual differences of borderline personality disorder features".[76] These same researchers had earlier concluded in a previous study that 42% of variation in BPD features was attributable to genetic influences and 58% was attributable to environmental influences.[76] Genes under investigation as of 2012 include the 7-repeat polymorphism of the dopamine D4 receptor (DRD4) on chromosome 11, which has been linked to disorganized attachment, whilst the combined effect of the 7-repeat polymorphism and the 10/10 dopamine transporter (DAT) genotype has been linked to abnormalities in Inhibitory control, both noted features of BPD.[77] There is a possible connection to chromosome 5.[78]

Brain abnormalities

A number of neuroimaging studies in BPD have reported findings of reductions in regions of the brain involved in the regulation of stress responses and emotion, affecting the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas.[77] A smaller number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of neurometabolites in certain brain regions of BPD patients, looking specifically at neurometabolites such as N-acetylaspartate, creatine, glutamate-related compounds, and choline-containing compounds.[77]

Developmental factors

Childhood trauma

There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD.[79][80][81] Many individuals with BPD report a history of abuse and neglect as young children, but causation is still debated.[82] 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 sex.[83] They also report a high incidence of incest and loss of caregivers in early childhood.[84] 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.[84] Additionally, women with BPD who reported a previous history of neglect by a female caregiver or abuse by a male caregiver were significantly more likely to have experienced sexual abuse by a non-caregiver.[84]

It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.[85] 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.[86]

Neurological patterns

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.[87] This finding, differences in brain structure (see Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history[88] suggest that BPD is distinct from the post-traumatic stress disorder which frequently accompanies it. Thus, researchers examine developmental causes in addition to childhood trauma.

Research published in January 2013 by Anthony Ruocco at the University of Toronto has highlighted two patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder: (1) increased activity in the brain circuits responsible for the experience of heightened emotional pain, coupled with (2) reduced activation of the brain circuits that normally regulate or suppress these generated painful emotions. These two neural networks are seen to be dysfunctionally operative in the limbic system, but the specific regions vary widely in individuals, which calls for the analysis of more neuroimaging studies.[89]

Also (contrary to the results of earlier studies) those with BPD showed less activation in the amygdala in situations of increased negative emotionality than the control group. John Krystal, editor of the journal Biological Psychiatry, wrote that these results "[added] to the impression that people with borderline personality disorder are 'set-up' by their brains to have stormy emotional lives, although not necessarily unhappy or unproductive lives".[89] Their emotional instability has been found to correlate with differences in several brain regions.[90]

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.[91] 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.[91] This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.[91] A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.[92]

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 predicts a lower risk. One possible explanation is that a stable environment buffers against its development.[93]

Self-complexity

Self-complexity, or considering one's self to have many different characteristics, may lessen the apparent discrepancy between an actual self and a desired self-image. Higher self-complexity may lead a person to desire more characteristics instead of better characteristics; if there is any belief that characteristics should have been acquired, these may be more likely to have been experienced as examples rather than considered as abstract qualities. The concept of a norm does not necessarily involve the description of the attributes that represent the norm: cognition of the norm may only involve the understanding of "being like", a concrete relation and not an attribute.[94]

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.[87] 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.[95]

Developmental theories

Marsha Linehan's biosocial developmental theory of borderline personality disorder suggests that BPD emerges from the combination of an emotionally vulnerable child and an invalidating environment. Emotional vulnerability may consist of biological, inherited factors that affect a child's temperament. Invalidating environments may include contexts where a child's emotions and needs are neglected, ridiculed, dismissed, or discouraged, or may include contexts of trauma and abuse.[96]

Linehan's theory was modified by Sheila Crowell, who proposed that impulsivity also plays an important role in the development of BPD. Crowell found that children who are emotionally vulnerable and are exposed to invalidating environments are much more likely to develop BPD if they are also highly impulsive.[97] Both theories describe an interplay between a child's inherited personality traits and their environment. For example, an emotionally sensitive or impulsive child may be difficult to parent, exacerbating the invalidating environment; conversely, invalidation can make an emotionally sensitive child more reactive and distressed.

Diagnosis

Diagnosis of borderline personality disorder is based on a clinical assessment by a mental health professional. The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them.[47] Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it.[47] Some clinicians prefer not to tell people with BPD what their diagnosis is, either from concern about the stigma attached to this condition or because BPD used to be considered untreatable; it is usually helpful for the person with BPD to know their diagnosis.[47] This helps them know that others have had similar experiences and can point them toward effective treatments.[47]

In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others.[98] Diagnosis is based both on the person's report of their symptoms and on the clinician's own observations.[98] Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or a substance use disorder.[98] The ICD-10 manual refers to the disorder as emotionally unstable personality disorder and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in the previous editions.[9]

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. A person must meet five of nine criteria to receive a diagnosis of borderline personality disorder.[99] The DSM-5 defines the main features of the condition as a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as markedly impulsive behavior.[99] In addition, the DSM-5 proposes alternative diagnostic criteria for BPD 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.[100] 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.[101] 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.[101]

International Classification of Disease

ICD-11

The World Health Organization's ICD-11 completely restructured its personality disorder section. It classifies BPD as personality disorder, borderline pattern, described as the following:

The Borderline pattern specifier may be applied to individuals whose pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by many of the following:

  • Frantic efforts to avoid real or imagined abandonment;
  • A pattern of unstable and intense interpersonal relationships;
  • Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self;
  • A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours;
  • Recurrent episodes of self-harm;
  • Emotional instability due to marked reactivity of mood;
  • Chronic feelings of emptiness;
  • Inappropriate intense anger or difficulty controlling anger;
  • Transient dissociative symptoms or psychotic-like features in situations of high affective arousal.

Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:

  • A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
  • An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
  • Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.[102]

ICD-10

In the previous edition of the ICD, the ICD-10, it defined a disorder that was conceptually similar to BPD, called (F60.3) Emotionally unstable personality disorder. Its two subtypes are described below.[103]

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. liable 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 in a car or substance use.[104]

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

Millon's subtypes

American psychologist Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or multiple of the following:[105]

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

Misdiagnosis

Main article: Misdiagnosis of borderline personality disorder

People with BPD may be misdiagnosed for a variety of reasons. One reason for misdiagnosis is BPD has symptoms that coexist (comorbidity) with other disorders such as depression, post-traumatic stress disorder (PTSD), and bipolar disorder.[106][107]

According to critics of the diagnosis, BPD cannot be distinguishable from negative affectivity when subjected to regression and factor analyses. They argue that BPD diagnosis does not seem to add anything to other diagnoses, and may be unnecessary or even misleading.[108]

Adolescence

Onset of symptoms typically occurs during adolescence or young adulthood, although symptoms suggestive of this disorder can sometimes be observed in children.[109] Symptoms among adolescents that predict the development of BPD in adulthood may include problems with body-image, extreme sensitivity to rejection, behavioral problems, non-suicidal self-injury, attempts to find exclusive relationships, and severe shame.[47] 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.[47]

BPD is recognised as a valid and stable diagnosis during adolescence.[110][111][112][113] The diagnosis of BPD (also described as "personality disorder: borderline pattern qualifier") in adolescents is supported in recent updates to the international diagnostic and psychiatric classification tools including the DSM-5 and ICD-11.[28][102][114] Early diagnosis of BPD has been recognised as instrumental to the early intervention and effective treatment for BPD in young people.[112][115][116] Accordingly, national treatment guidelines recommend the diagnosis and treatment of BPD among adolescents in many countries including Australia, the United Kingdom, Spain, and Switzerland.[117][118][119][120]

The diagnosis of BPD during adolescence has been controversial.[112][121][122] Early clinical guidelines encouraged caution when diagnosing BPD during adolescence.[123][124][125] Perceived barriers to the diagnosis of BPD during adolescence included concerns about the validity of a diagnosis in young people, the misdiagnosis of normal adolescent behaviour as symptoms of BPD, the stigmatising effect of a diagnosis for adolescents, and whether personality during adolescence was sufficiently stable for a valid diagnosis of BPD.[112] Psychiatric research has since shown BPD to be a valid, stable and clinically useful diagnosis in adolescent populations.[110][111][112][113] However, ongoing misconceptions about the diagnosis of BPD in adolescence remain prevalent among mental health professionals.[126][127][128] Clinical reluctance to diagnose BPD is a key barrier to the provision of effective treatment in adolescent populations.[126][129][130]

A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood.[123][131] Among individuals diagnosed with BPD during adolescence, 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.[132] Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent.[123][131] Family therapy is considered a helpful component of treatment for adolescents with BPD.[133]

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:[134]

A diagnosis of a personality disorder should not be made during an untreated mood episode/disorder, unless the lifetime history supports the presence of a personality disorder.[136]

Comorbid Axis I disorders

Sex differences in Axis I lifetime comorbid diagnosis, 2008[137] and 1998[134]
Axis I diagnosis Overall (%) Male (%) Female (%)
Mood disorders 75.0 68.7 80.2
Major depressive disorder 32.1 27.2 36.1
Dysthymia 09.7 07.1 11.9
Bipolar I disorder 31.8 30.6 32.7
Bipolar II disorder 07.7 06.7 08.5
Anxiety disorders 74.2 66.1 81.1
Panic disorder with agoraphobia 11.5 07.7 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 non-alcohol substance use disorder 36.2 44.0 29.8
Eating disorders** 53.0 20.5 62.2
Anorexia nervosa** 20.8 07 * 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** 04.2 --- ---
Hypochondriasis** 04.7 --- ---
Somatoform pain disorder** 04.2 --- ---
Psychotic disorders** 01.3 01 * 01 *
* Approximate values
** Values from 1998 study[134]
--- Value not provided by study

A 2008 study found that at some point in their lives, 75% of people with BPD meet criteria for mood disorders, especially major depression and bipolar I, and nearly 75% meet criteria for an anxiety disorder.[137] Nearly 73% meet the criteria for a substance use disorder, and about 40% for PTSD.[137] 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.[134] 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.[134]

There are marked sex differences in the types of comorbid conditions a person with BPD is likely to have[134]—a higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.[134][137][138] In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD.[135] In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had significantly more frequent suicide attempts).[139]

Regardless of the fact that it is an infradiagnosed disorder, a few studies have shown that the "lower expressions" of it might lead to wrong diagnoses. The many and 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.[134]

Mood disorders

Many people with borderline personality disorder also have mood disorders, such as major depressive disorder or a bipolar disorder.[45] Some characteristics of BPD are similar to those of mood disorders, which can complicate the diagnosis.[140][141][142] It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa.[143] For someone with bipolar disorder, behavior suggestive of BPD might appear while experiencing an episode of major depression or mania, only to disappear once mood has stabilized.[144] For this reason, it is ideal to wait until mood has stabilized before attempting to make a diagnosis.[144]

At face value, the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar.[145] It can be difficult even for experienced clinicians, if they are unfamiliar with BPD, to differentiate between the mood swings of these two conditions.[146] However, there are some clear differences.[143]

First, the mood swings of BPD and bipolar disorder tend to 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.[143] 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.[146] So while euphoria and impulsivity in someone with BPD might resemble a manic episode, the experience would be too brief to qualify as a manic episode.[144][146]

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.[144] That is, a positive event would not lift the depressed mood caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD. Similarly, an undesirable event would not dampen the euphoria caused by bipolar disorder, but an undesirable event would dampen the euphoria of someone with borderline personality disorder.[144]

Third, when people with BPD experience euphoria, it is usually without the racing thoughts and decreased need for sleep that are typical of hypomania,[144] though a later 2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were associated with chronic sleep disturbances, including difficulty initiating sleep, difficulty maintaining sleep, and waking earlier than desired, as well as with the consequences of poor sleep, and noted that "[f]ew studies have examined the experience of chronic sleep disturbances in those with borderline personality disorder".[147]

Because the two conditions have a number of similar symptoms, BPD was once considered to be a mild form of bipolar disorder[148][149] 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 suggest that this is not the case.[150] 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".[151] 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.[152]

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) occurs in 3–8% of women.[153] Symptoms begin during the luteal phase of the menstrual cycle, and end during menstruation.[154] Symptoms may 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.[155][156] People with PMDD typically begin to experience symptoms in their early twenties, although many do not seek treatment until their early thirties.[155]

Although some of the symptoms of PMDD and BPD are similar, they are different disorders. They are distinguishable by the timing and duration of symptoms, which are markedly different: the symptoms of PMDD occur only during the luteal phase of the menstrual cycle,[155] whereas BPD symptoms occur persistently at all stages of the menstrual cycle. In addition, the symptoms of PMDD do not include impulsivity.[155]

Comorbid Axis II disorders

Percentage of people with BPD and a lifetime comorbid Axis II diagnosis, 2008[137]
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

About three-fourths of people diagnosed with BPD also meet the criteria for another Axis II personality disorder at some point in their lives. (In a major 2008 study—see adjacent table—the rate was 73.9%.)[137] The Cluster A disorders, paranoid, schizoid, and schizotypal, are broadly the most common. The Cluster as a whole affects about half, with schizotypal alone affecting one third.[137]

BPD is itself a Cluster B disorder. The other Cluster B disorders, antisocial, histrionic, and narcissistic, similarly affect about half of BPD patients (lifetime incidence), with again narcissistic affecting one third or more.[137] Cluster C, avoidant, dependent, and obsessive–compulsive, showed the least overlap, slightly under one third.[137]

Management

Main article: Management of borderline personality disorder

Psychotherapy is the primary treatment for borderline personality disorder.[11] 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.[157] 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.[158]

Psychotherapy

Long-term psychotherapy is currently the treatment of choice for BPD.[159] While psychotherapy, in particular dialectical behavior therapy (DBT) and psychodynamic approaches, is effective, the effects are slow: many people have to put in years of work to be effective.[160]

More rigorous treatments are not substantially better than less rigorous treatments.[161] There are six such treatments available: dynamic deconstructive psychotherapy (DDP),[162] mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy.[47][163] Long-term therapy of any kind is better than no treatment, especially in reducing urges to self-injure.[159]

Transference-focused therapy aims to break away from absolute thinking. In this, it gets the people to articulate their social interpretations and their emotions in order to turn their views into less rigid categories. The therapist addresses the individual's feelings and goes over situations, real or realistic, that could happen as well as how to approach them.[164]

The dialectical behavior therapy (DBT) components are interpersonal (communication), distress tolerance, emotional regulation and mindfulness. In doing this, it helps the individual with BPD gain skills to manage symptoms.[164] Since those diagnosed with BPD have such intense emotions, learning to regulate them is a huge step in the therapeutic process. Some components of DBT are working long-term with patients, building skills to understand and regulate emotions, homework assignments, and strong availability of therapist to their client.[165] Patients with borderline personality disorder also must take time in DBT to work with their therapist to learn how to get through situations surrounded by intense emotions or stress as well as learning how to better their interpersonal relationships.[163]

 
The stages used in dialectical behavior therapy

Cognitive behavioral therapy (CBT) is also a type of psychotherapy used for treatment of BPD. This type of therapy relies on changing people's behaviors and beliefs by identifying problems from the disorder. CBT is known to reduce some anxiety and mood symptoms as well as reduce suicidal thoughts and self-harming behaviors.[8]

Mentalization-based therapy and transference-focused psychotherapy are based on psychodynamic principles, and dialectical behavior therapy is based on cognitive-behavioral principles and mindfulness.[159] General psychiatric management combines the core principles from each of these treatments, and it is considered easier to learn and less intensive.[47] Randomized controlled trials have shown that DBT and MBT may be the most effective, and the two share many similarities.[166][167] 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.[159][167]

Some research indicates that mindfulness meditation may bring about favorable structural changes in the brain, including changes in brain structures that are associated with BPD.[168][169][170] Mindfulness-based interventions also appear to bring about an improvement in symptoms characteristic of BPD, and some clients who underwent mindfulness-based treatment no longer met a minimum of five of the DSM-IV-TR diagnostic criteria for BPD.[170][171]

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.[172] A 2017 review examined evidence published since the 2010 Cochrane review and found that "evidence of effectiveness of medication for BPD remains very mixed and is still highly compromised by suboptimal study design".[173] A 2020 review found that research into pharmacological treatments had declined, with more results confirming no benefits. The review found "moderate to large, statistically significant effects for both doses of quetiapine (150 mg/day and 300 mg/day) regarding BPD severity, psychosocial impairment and aggression, and an additional effect for the higher dose regarding manic symptoms." Despite lack of evidence of efficacy, the review stated that SSRI antidepressants continue to be widely prescribed to people with BPD.[24]

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, one trial found that aripiprazole may reduce interpersonal problems and impulsivity.[172] Olanzapine, as well as quetiapine, may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but a placebo had a greater benefit on suicidal ideation than olanzapine did. The effect of ziprasidone was not significant.[172][173]

Mood stabilizers are anticonvulsant drugs used for both epilepsy and reduction in mood variations in patients with excessive and often dangerous mood variabilities. Often, the goal of the anticonvulsants is to bring certain areas of the brain to equilibrium and control outbursts and seizures. Of the mood stabilizers studied, valproate semisodium may ameliorate depression, impulsivity, interpersonal problems, 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 2017, trials with these medications had not been replicated and the effect of long-term use had not been assessed.[172][173] Lamotrigine showed no benefit in a large randomized clinical trial.[24] A case study on a male patient with borderline personality disorder found IV ketamine treatments, typically used for the treatment of unresponsive depression, drastically decreased anxiety, depression, and suicidal behaviors.[174]

Chen and associates (2022) studied the effect of IV ketamine on adults with major depressive disorder (MDD) and borderline features compared to those with MDD without borderline features. Those with borderline features tend to be harder to treat and are more likely to suffer from suicidal ideation. They found that IV ketamine was more effective at treating those with borderline features 14 days after treatment, as compared to the MDD without borderline features group. While this study looked at those with MDD and borderline features, further studies are needed to see if the results will be the same for those with a diagnosis of BPD. In particular, those with BPD may experience episodes of psychosis and dissociation, which can also be brought on by the use of ketamine. However, in this study, those with borderline features did not show increased signs of dissociation or psychosis, suggesting that ketamine may eventually prove to be an effective treatment for those with MDD and BPD.[175]

Because of weak evidence and the potential for serious side effects from some of these medications, the United Kingdom (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".[176] Cattarinussi (2021) stated medication for treatment of borderline personality disorder should be used at very low doses and for minimal amounts of time.[177] Crawford (2018) found that despite mood stabilizers being prescribed frequently for BPD patients, they are neither cost effective or medically effective in treating BPD as whole after performing a year long study.[178]

Services

There is a significant difference between the number of those who would benefit from treatment and the number of those who are treated. The so-called "treatment gap" is a function of the disinclination to submit for treatment, an underdiagnosing of the disorder by healthcare providers, and the limited availability and access to state-of-the-art treatments.[179] There are also ongoing problems with creating clear pathways to services and medical care, with many people with BPD finding it difficult to access treatment. Even when medical providers try to help, many are not trained or equipped to help severe BPD, which is a problem that has been recognized by both those affected by BPD and doctors.[180]

Nonetheless, individuals with BPD accounted for about 20% of psychiatric hospitalizations in one survey.[181] The majority of individuals with BPD who are in treatment 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.[182]

Experience of services varies.[183] 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.[184] 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.[185]

After a patient with BPD died, the National Health Service (NHS) in England was criticized by a coroner in 2014 for the lack of commissioned services to support those with BPD. Evidence was given that 45% of female patients had BPD and there was no provision or priority for therapeutic psychological services. At the time, there were only a total of 60 specialized inpatient beds in England, all of them located in London or the northeast region.[186]

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.[187][188] 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.[187] 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 a stable recovery from symptoms.[189][190]

Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing dialectical behavior therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient, compared to 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.[191]

In addition to recovering from distressing symptoms, people with BPD can 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.[192]

Epidemiology

The prevalence of BPD was estimated in the mid-2000s to be 1–2% of the general population[188] and to occur three times more often in women than in men.[193][194] However, the lifetime prevalence of BPD, as defined in the DSM-IV, in a 2008 study was found to be 5.9% of the American population, occurring in 5.6% of men and 6.2% of women.[137] The difference in rates between men and women in this study was not found to be statistically significant.[137]

Borderline personality disorder is estimated to contribute to 20% of psychiatric hospitalizations and to occur among 10% of outpatients.[195]

29.5% of new inmates in the U.S. state of Iowa fit a diagnosis of borderline personality disorder in 2007,[196] and the overall prevalence of BPD in the U.S. prison population is thought to be 17%.[195] These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD, which is estimated at 38%.[195]

History

 
Devaluation in Edvard Munch's Salome (1903). Idealization and devaluation of others in personal relations is a common trait in BPD. The painter Edvard Munch depicted his new friend, the violinist Eva Mudocci, in both ways within days. First as "a woman seen by a man in love", then as "a bloodthirsty and cannibalistic Salome".[197] In modern times, Munch has been diagnosed as having had BPD.[198][199]

The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates, and Aretaeus, the latter 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,[200] described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity".[201] In 1921, Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.[202]

The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s.[203] The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938.[204][205] He described a group of patients who he felt to be on the borderline between neurosis and psychosis, who very often came from family backgrounds marked by trauma. He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques.

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).[123] 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[202] between neurosis and psychosis.[206]

After standardized criteria were developed[207] 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.[188] The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder".[206] 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-5 today.[9] However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.[208]

Etymology

Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis.[209] The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s.[210][211] Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.[212]

Controversies

Credibility and validity of testimony

The credibility of individuals with personality disorders has been questioned at least since the 1960s.[213]: 2  Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition.[214]

Dissociation

Researchers disagree about whether dissociation, or a sense of emotional detachment 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.[215] The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid episodic information that would evoke acutely negative affect'.[215]

Lying as a feature

Some theorists argue that patients with BPD often lie.[216] However, others write that they have rarely seen lying among patients with BPD in clinical practice.[216]

Gender

Joel Paris states that "In the clinic ... Up to 80% of patients are women. That may not be true in the community."[217] He offers the following explanations regarding these sex discrepancies:

The most probable explanation for gender differences in clinical samples is that women are more likely to develop the kind of symptoms that bring patients in for treatment. Twice as many women as men in the community [have] depression (Weissman & Klerman, 1985). In contrast, there is a preponderance of men meeting the criteria for substance use disorder and psychopathy (Robins & Regier, 1991), and males with these disorders do not necessarily present in the mental health system. Men and women with similar psychological problems may express distress differently. Men tend to drink more and carry out more crimes. Women tend to turn their anger on themselves, leading to depression as well as the cutting and overdosing that characterize BPD. Thus, anti-social personality disorder (ASPD) and borderline personality disorders might derive from similar underlying pathology but present with symptoms strongly influenced by gender (Paris, 1997a; Looper & Paris, 2000). We have even more specific evidence that men with BPD may not seek help. In a study of completed suicides among people aged 18 to 35 years (Lesage et al., 1994), 30% of the suicides involved individuals with BPD (as confirmed by psychological autopsy, in which symptoms were assessed by interviews with family members). Most of the suicide completers were men, and very few were in treatment. Similar findings emerged from a later study conducted by our own research group (McGirr, Paris, Lesage, Renaud, & Turecki, 2007).[56]

In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology); more likely to wind up in the correctional system due to criminal behavior; and, more likely to commit suicide prior to diagnosis.

Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide.[21]

There are also sex differences in borderline personality disorder.[218] Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have (especially) antisocial narcissistic, passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones[218]). Women with BPD are more likely to have eating disorders, mood disorders, anxiety and post-traumatic stress.[218]

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.[219] In one research study, 88% of therapists reported that they have experinced manipulation attempts from patient(s).[220] 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.[221] 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.[221]

According to Linehan, 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, however, making their assumed manipulative behavior an involuntary and unintentional response.[222]

One paper identified possible reasons for manipulation in BPD: identifying others feelings and reactions, a regulatory function due to insecurity, to communicate ones emotions and connect to others, or to feel as if one is in control, or to allow them to be "liberated" from relationships or commitments.[223]

Stigma

The features of BPD include: emotional instability, intense and 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 negative treatment of these individuals may trigger further self-destructive behavior.[224]

Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers.[225] One camp[who?] argues that it would be better to diagnose these men or women with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior.[citation needed] Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.[226] Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see brain abnormalities and terminology).

Physical violence

The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others.[227] 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.[227] Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.[228]

One 2020 study found that BPD is individually associated with psychological, physical and sexual forms of intimate partner violence (IPV), especially amongst men.[229] In terms of the AMPD trait facets, hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.[229]

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.[228] Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs.[228] This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others.[228][38][227]

Mental health care providers

People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment.[230] A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups.[231] This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed.[232] With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features.[232] Efforts are ongoing to improve public and staff attitudes toward people with BPD.[233][234]

In psychoanalytic theory, the stigmatization among mental health care providers may be thought to reflect countertransference (when a therapist projects his or her own feelings on to a client). 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.[235]

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 health care.[236] Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.[237]

Terminology

Because of concerns around stigma, 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,[238] since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate.[238][239] 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".[240]

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 G. Gunderson of McLean Hospital in the United States.[241] 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.[81] 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.[88]

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.[242]

Society and culture

Fiction

Literature

In literature, characters with behavior consistent with borderline personality disorder include Catherine in Wuthering Heights (1847), Smerdyakov in The Brothers Karamazov (1880), and Harry Haller in Steppenwolf (1927).[243][244][245]

Film

Films attempting to depict characters with the disorder include Margot at the Wedding (2007), Mr. Nobody (2009), Cracks (2009),[246] Truth (2013), Wounded (2013), Welcome to Me (2014),[247][248] and Tamasha (2015).[249]

Robert O. Friedel has suggested that the behavior of Theresa Dunn, the leading character of Looking for Mr. Goodbar (1975) is consistent with a diagnosis of borderline personality disorder.[250]

The films Play Misty for Me (1971)[251] and Girl, Interrupted (1999, based on the memoir of the same name) both suggest the emotional instability of the disorder.[252]

The film Single White Female (1992) suggests characteristics which are typical of the disorder: the character Hedy had markedly disturbed sense of identity and reacts drastically to abandonment.[251]: 235 

Multiple commenters have noted that Clementine in Eternal Sunshine of the Spotless Mind (2004) shows classic borderline personality disorder behavior.[253][254]

In a review of the film Shame (2011) for the British journal The Art of Psychiatry, another psychiatrist, Abby Seltzer, praises Carey Mulligan's portrayal of a character with the disorder even though it is never mentioned onscreen.[255]

Psychiatrists Eric Bui and Rachel Rodgers argue that the Anakin Skywalker/Darth Vader character 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.[256]

Television

On television, The CW show Crazy Ex-Girlfriend portrays the main character, played by Rachel Bloom, with borderline personality disorder,[257] and Emma Stone's character in the Netflix miniseries Maniac is diagnosed with the disorder.[258] Additionally, incestuous twins Cersei and Jaime Lannister, in George R. R. Martin's A Song of Ice and Fire series and its television adaptation, Game of Thrones, have traits of borderline and narcissistic personality disorders.[259] In The Sopranos, the character of Dr. Melfi diagnoses Livia Soprano with BPD[260] and the character of Bruce Wayne/Batman, as portrayed in the show Titans, is said to have it too.[261] The titular character in the adult animation series Bojack Horseman also exhibits many symptoms of BPD.[262]

Awareness

In early 2008, the United States House of Representatives declared the month of May Borderline Personality Disorder Awareness Month.[263][264]

In 2020, South Korean singer-songwriter Lee Sunmi spoke out about her struggle with borderline personality disorder on the show Running Mates, having been diagnosed 5 years prior.[265]

See also

Citations

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February 16, 2024
borderline, personality, disorder, also, known, emotionally, unstable, personality, disorder, eupd, personality, disorder, characterized, long, term, pattern, intense, unstable, interpersonal, relationships, distorted, sense, self, strong, emotional, reactions. Borderline personality disorder BPD also known as emotionally unstable personality disorder EUPD 14 is a personality disorder characterized by a long term pattern of intense and unstable interpersonal relationships distorted sense of self and strong emotional reactions 9 15 16 Those affected often engage in self harm and other dangerous behaviors often due to their difficulty with returning their emotional level to a healthy or normal baseline 17 18 19 They may also struggle with dissociation a feeling of emptiness and a fear of abandonment 15 Borderline personality disorderOther namesEmotionally unstable personality disorder impulsive or borderline type 1 Emotional intensity disorder 2 Hysteria 3 Hysteric personality Hysteroid 4 Negative affectivity neuroticism 5 Despair by Edvard Munch 1894 who is presumed to have had borderline personality disorder 6 7 SpecialtyPsychiatry clinical psychologySymptomsUnstable relationships sense of self and emotions impulsivity recurrent suicidal behavior and self harm fear of abandonment chronic feelings of emptiness inappropriate anger feeling detached from reality dissociation 8 9 ComplicationsSuicide self harm 8 Usual onsetEarly adulthood 9 DurationLong term 8 CausesGenetics trauma 10 Risk factorsFamily history trauma abuse 8 11 Diagnostic methodBased on reported symptoms 8 Differential diagnosisBipolar disorder attachment disorder dissociative identity disorder identity disorder mood disorders post traumatic stress disorder CPTSD substance use disorders ADHD histrionic narcissistic or antisocial personality disorder 9 12 TreatmentBehaviour therapy 8 PrognosisImproves over time 9 typically after age 30 and some cases are in total remission by 40 13 FrequencyEstimation of c 1 6 of people in a given year 8 Symptoms of BPD may be triggered by events considered normal to others 15 BPD typically begins by early adulthood and occurs across a variety of situations 9 Substance use disorders 20 depression and eating disorders are commonly associated with BPD 15 Some 8 to 10 of people affected by the disorder may die by suicide 9 15 with the rate being twice as high in males as in females 21 The disorder is often stigmatized in both the media and the psychiatric field and as a result is often under diagnosed 22 The causes of BPD are unclear but seem to involve genetic neurological environmental and social factors 8 10 It is five times more likely to occur in a person who has one or more affected immediate relatives 8 Adverse life events appear to also play a role 11 The underlying mechanism appears to involve the frontolimbic network of neurons 11 BPD is classified in the American Diagnostic and Statistical Manual of Mental Disorders DSM as a cluster B personality disorder along with antisocial histrionic and narcissistic personality disorder 9 BPD and other personality disorders can be misdiagnosed as a mood disorder substance use disorder or other disorder 9 BPD is typically treated with psychotherapy such as cognitive behavioral therapy CBT or dialectical behavior therapy DBT 8 Therapy for BPD can occur one on one or in a group 8 While medications cannot cure BPD they may be used to help with the associated symptoms 8 Quetiapine and SSRI antidepressants are widely prescribed for the condition but their efficacy is unclear A 2002 study found fluvoxamine an SSRI significantly decreased rapid mood shifts in female borderline patients 23 while more recent meta analysis found the use of medications still unsupported by evidence 24 Severe cases of the disorder may require hospital care 8 About 1 6 of people have BPD with some estimates as high as 5 9 8 9 25 Women are diagnosed about three times as often as men 9 Up to half of those with BPD improve over a ten year period with treatment 9 Those affected typically use a high amount of healthcare resources 26 There is an ongoing debate about the naming of the disorder especially the suitability of the word borderline the term originally referred to borderline insanity and later to patients on the border between neurosis and psychosis an interpretation of the disorder now considered outdated and clinically inaccurate 8 27 Contents 1 Signs and symptoms 1 1 Emotions 1 2 Interpersonal relationships 1 3 Behavior 1 4 Self harm and suicide 1 5 Sense of self 1 6 Cognitions 1 7 Psychotic symptoms 1 8 Disability 2 Causes 2 1 Genetics 2 2 Brain abnormalities 2 3 Developmental factors 2 3 1 Childhood trauma 2 4 Neurological patterns 2 5 Mediating and moderating factors 2 5 1 Executive function 2 5 2 Family environment 2 5 3 Self complexity 2 5 4 Thought suppression 2 6 Developmental theories 3 Diagnosis 3 1 Diagnostic and Statistical Manual 3 2 International Classification of Disease 3 2 1 ICD 11 3 2 2 ICD 10 3 2 2 1 F60 30 Impulsive type 3 2 2 2 F60 31 Borderline type 3 3 Millon s subtypes 3 4 Misdiagnosis 3 5 Adolescence 3 6 Differential diagnosis and comorbidity 3 6 1 Comorbid Axis I disorders 3 6 2 Mood disorders 3 6 3 Premenstrual dysphoric disorder 3 6 4 Comorbid Axis II disorders 4 Management 4 1 Psychotherapy 4 2 Medications 4 3 Services 5 Prognosis 6 Epidemiology 7 History 7 1 Etymology 8 Controversies 8 1 Credibility and validity of testimony 8 1 1 Dissociation 8 1 2 Lying as a feature 8 2 Gender 8 3 Manipulative behavior 8 4 Stigma 8 4 1 Physical violence 8 4 2 Mental health care providers 8 5 Terminology 9 Society and culture 9 1 Fiction 9 1 1 Literature 9 1 2 Film 9 1 3 Television 9 2 Awareness 10 See also 11 Citations 12 General bibliography 13 External linksSigns and symptoms nbsp One of the symptoms of BPD is an intense fear of abandonment BPD is characterized by nine symptoms according to the DSM 5 To be diagnosed a person must meet at least five of the following 28 663 Frantic efforts to avoid real or imagined abandonment 29 Unstable and chaotic interpersonal relationships often characterized by alternating between extremes of idealization and devaluation also known as splitting Markedly disturbed sense of identity and distorted self image 8 Impulsive or reckless behaviors e g uncontrollable spending unsafe sex substance use disorders reckless driving binge eating 30 Recurrent suicidal ideation or self harm Rapidly shifting intense emotional dysregulation Chronic feelings of emptiness Inappropriate intense anger that can be difficult to control Transient stress related paranoid or severe dissociative symptomsOverall the most distinguishing symptoms of BPD are pervasive patterns of instability in interpersonal relationships and self image alternating between extremes of idealization and devaluation of others along with varying moods and difficulty regulating strong emotional reactions Dangerous or impulsive behavior is also correlated with the disorder Other symptoms may include feeling unsure of one s identity morals and values having paranoid thoughts when feeling stressed depersonalization and in moderate to severe cases stress induced breaks with reality or psychotic episodes Individuals with BPD may have comorbid conditions such as depressive or bipolar disorders substance use disorders eating disorders post traumatic stress disorder and attention deficit hyperactivity disorder 28 Emotions People with BPD may feel deeper and more intense emotions with greater ease and for a longer time than others do 31 32 A core characteristic of BPD is affective instability which manifests as unusually intense emotional responses to environmental triggers with a slower return to a baseline emotional state 33 34 According to Marsha Linehan the sensitivity intensity and duration with which people with BPD feel emotions have both positive and negative effects 34 People with BPD are often exceptionally enthusiastic idealistic joyful and loving 35 but may feel overwhelmed by negative emotions anxiety depression guilt shame worry anger etc experiencing intense grief instead of sadness shame and humiliation instead of mild embarrassment rage instead of annoyance and panic instead of nervousness 35 Studies have shown that borderline patients experience chronic and significant emotional suffering and mental agony 28 36 irrelevant citation People with BPD are also especially sensitive to feelings of rejection criticism isolation and perceived failure 37 Before learning other coping mechanisms their efforts to manage or escape from their negative emotions may lead to emotional isolation self injury or suicidal behavior 38 They are often aware of the intensity of their negative emotional reactions and since they cannot regulate them subconsciously shut their awareness down entirely since awareness would only cause further distress 34 This can be harmful since awareness of negative emotions can alert people to the presence of a problematic situation 34 While emotional dysregulation is a key feature of BPD Fitzpatrick et al 2022 argue that the dysregulation itself may not be unique to BPD and be shared by other disorders such as generalized anxiety disorder However their study did suggest that those with BPD may have a harder time disengaging from their negative emotions using distraction to manage their emotions and returning to a baseline emotional state 39 While people with BPD sometimes feel euphoria ephemeral or occasional intense joy they are especially prone to dysphoria a profound state of unease or dissatisfaction depression and or feelings of mental and emotional distress Zanarini et al suggested four categories of dysphoria typical of this condition extreme emotions destructiveness or self destructiveness feeling fragmented or lacking identity and feelings of victimization 40 Within these categories a BPD diagnosis is strongly associated with a combination of three specific states feeling betrayed feeling out of control and feeling like hurting oneself 40 Since there is great variety in the types of dysphoria people with BPD experience the amplitude of the distress can be a helpful indicator 40 In addition to intense emotions people with BPD regularly experience emotional lability changeability or fluctuation Although that term suggests rapid changes between depression and elation mood swings in people with BPD more frequently involve anxiety with fluctuations between anger and anxiety and between depression and anxiety 41 Interpersonal relationships People with BPD can be very conscious of and susceptible to their perceived or real treatment by others feeling intense joy and gratitude at perceived expressions of kindness and intense sadness or anger at perceived criticism or hurtfulness 42 People with BPD often engage in idealization and devaluation of others alternating between high positive regard for people and great mistrust or dislike for them 43 Their feelings about others often shift from admiration or love to anger or dislike after a perceived abandonment or perceived loss of esteem in the eyes of someone they value This phenomenon is sometimes called splitting 44 This idealization and devaluation can affect interpersonal relationships with those around them 45 While strongly desiring intimacy people with BPD tend toward insecure avoidant ambivalent or fearfully preoccupied attachment patterns in relationships 46 People with BPD and members of their family are prone to feeling alienated from and by each other 47 Parents of adults with BPD are often both over involved and under involved in family interactions 48 Personality disorders in general are linked to increased levels of chronic stress and conflict decreased satisfaction of romantic partners domestic abuse and unwanted pregnancy 49 According to some research some people with BPD tend to move quickly between relationships described in at least one case as butterfly like Other individuals would instead cling closely to very few relationships becoming reliant on fewer people than those without BPD 50 Behavior BPD is closely linked to impulsive behaviors which can include substance use disorders binge eating unprotected sex or self injury among others 51 People with BPD might do this because it gives them the feeling of immediate relief from their emotional pain 51 but in the long term may feel shame and guilt over consequences of this behavior 51 A cycle often begins in which people with BPD feel emotional pain engage in impulsive behavior 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 behavior to relieve the new pain 51 As time goes on impulsive behavior may become an automatic response to emotional pain 51 Self harm and suicide Self harming or suicidal behavior is one of the core diagnostic criteria in the DSM 5 9 Self harm occurs in 50 80 of people with BPD The most frequent method of self harm is cutting 52 however bruising burning head banging or biting are also common with BPD 52 It is hypothesized that people with BPD may feel emotional relief after engaging in self harm 53 The estimation of lifetime risk of suicide among people with BPD varies depending on method of investigation between 3 and 10 54 47 55 There is evidence that a considerable percentage of men who die by suicide may have undiagnosed BPD 56 The reported reasons for self harm differ from the reasons for suicide attempts 38 Nearly 70 of people with BPD self harm without trying to end their lives 57 Reasons for self harm include expressing anger self punishment generating normal feelings often in response to dissociation and distracting oneself from emotional pain or difficult circumstances 38 In contrast suicide attempts typically reflect a belief that others will be better off following the suicide 38 Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD 58 Sense of self People with BPD tend to have trouble seeing their identity clearly In particular they tend to have difficulty knowing what they value believe prefer and enjoy 59 They are often unsure about their long term goals for relationships and jobs This can cause people with BPD to feel empty and lost 59 Self image can also change rapidly from healthy to unhealthy People with BPD may base their identity on others leading to chameleon like changes in identity 60 Cognitions The often intense emotions people with BPD experience may make it difficult for them to concentrate 59 They may also tend to dissociate which can be thought of as an intense form of zoning out 61 Others can sometimes tell when someone with BPD is dissociating because their facial or vocal expressions may become flat or expressionless or they may appear distracted and numb to emotional stimuli 61 Dissociation most often occurs in response to a painful event or something that triggers the memory of a painful event It involves the mind automatically redirecting attention away from the current event or situation or blocking it out entirely This is done presumably to protect against based on similar or related past experiences what the mind perceives and forecasts as arousing intense negative emotions and unwanted behavioral impulses that the present emotive event might trigger 61 The mind s habit of suppressing and avoiding intensely painful emotions may provide some temporary feelings of relief but dissociation can also lead to unhealthy coping mechanisms while simultaneously causing the side effect of blocking out or blunting positive emotions thereby reducing the access of people with BPD to the valuable information those emotions provide information that helps to guide effective healthy decision making in daily life 61 Psychotic symptoms Though BPD is primarily seen as a disorder of emotional regulation psychotic symptoms are fairly common with an estimated 21 54 prevalence in clinical BPD populations 62 These symptoms are sometimes referred to as pseudo psychotic or psychotic like terms that suggest a distinction from those seen in primary psychotic disorders Recent research however has indicated that there is more similarity between pseudo psychotic symptoms in BPD and true psychosis than originally thought 62 63 Some researchers critique the concept of pseudo psychosis for on top of weak construct validity the implication that it is not true or less severe which could trivialize distress and serve as a barrier to diagnosis and treatment Some researchers have suggested classifying these BPD symptoms as true psychosis or even eliminating the distinction between pseudo psychosis and true psychosis altogether 62 64 The DSM 5 recognizes transient paranoia that worsens in response to stress as a symptom of BPD 9 Studies have documented both hallucinations and delusions in BPD patients who lack another diagnosis that would better account for those symptoms 63 Phenomenologically research suggests that auditory verbal hallucinations found in patients with BPD cannot be reliably distinguished from those seen in schizophrenia 63 64 Some researchers suggest there may be a common etiology underlying hallucinations in BPD and those in other conditions like psychotic and affective disorders 63 Disability Many people with BPD are able to work if they find appropriate jobs and their condition is not too severe People with BPD may be found to have a disability in the workplace if the condition is severe enough that the behaviors of sabotaging relationships engaging in risky behaviors or intense anger prevent the person from functioning in their job role 65 The United States Social Security Administration acknowledges BPD as a disability and affected individuals can apply for disability benefits 66 CausesAs is the case with other mental disorders the causes of BPD are complex and not fully agreed upon 67 Evidence suggests that BPD and post traumatic stress disorder PTSD may be related in some way 68 Most researchers agree that a history of childhood trauma can be a contributing factor 69 but less attention has historically been paid to investigating the causal roles played by congenital brain abnormalities genetics neurobiological factors and environmental factors other than trauma 67 70 Genetics Compared to other major psychiatric disorders genetic research in BPD is still in its very early stages 71 The heritability of BPD is estimated to be between 37 and 69 72 That is 37 to 69 of the variability in liability underlying BPD in the population can be explained by genetic differences Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment 73 Even so the researchers of one study concluded that personality disorders seem to be more strongly influenced by genetic effects than almost any Axis I disorder e g depression eating disorders and more than most broad personality dimensions 74 Moreover the study found that BPD was estimated to be the third most heritable personality disorder out of the 10 personality disorders reviewed 74 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 75 Families with twins in the Netherlands were participants of an ongoing study by Trull and colleagues in which 711 pairs of siblings and 561 parents were examined to identify the location of genetic traits that influenced the development of BPD 76 Research collaborators found that genetic material on chromosome 9 was linked to BPD features 76 The researchers concluded that genetic factors play a major role in individual differences of borderline personality disorder features 76 These same researchers had earlier concluded in a previous study that 42 of variation in BPD features was attributable to genetic influences and 58 was attributable to environmental influences 76 Genes under investigation as of 2012 update include the 7 repeat polymorphism of the dopamine D4 receptor DRD4 on chromosome 11 which has been linked to disorganized attachment whilst the combined effect of the 7 repeat polymorphism and the 10 10 dopamine transporter DAT genotype has been linked to abnormalities in Inhibitory control both noted features of BPD 77 There is a possible connection to chromosome 5 78 Brain abnormalities A number of neuroimaging studies in BPD have reported findings of reductions in regions of the brain involved in the regulation of stress responses and emotion affecting the hippocampus the orbitofrontal cortex and the amygdala amongst other areas 77 A smaller number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of neurometabolites in certain brain regions of BPD patients looking specifically at neurometabolites such as N acetylaspartate creatine glutamate related compounds and choline containing compounds 77 Developmental factors Childhood trauma There is a strong correlation between child abuse especially child sexual abuse and development of BPD 79 80 81 Many individuals with BPD report a history of abuse and neglect as young children but causation is still debated 82 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 sex 83 They also report a high incidence of incest and loss of caregivers in early childhood 84 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 84 Additionally women with BPD who reported a previous history of neglect by a female caregiver or abuse by a male caregiver were significantly more likely to have experienced sexual abuse by a non caregiver 84 It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder 85 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 86 Neurological patterns 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 87 This finding differences in brain structure see Brain abnormalities and the fact that some patients with BPD do not report a traumatic history 88 suggest that BPD is distinct from the post traumatic stress disorder which frequently accompanies it Thus researchers examine developmental causes in addition to childhood trauma Research published in January 2013 by Anthony Ruocco at the University of Toronto has highlighted two patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder 1 increased activity in the brain circuits responsible for the experience of heightened emotional pain coupled with 2 reduced activation of the brain circuits that normally regulate or suppress these generated painful emotions These two neural networks are seen to be dysfunctionally operative in the limbic system but the specific regions vary widely in individuals which calls for the analysis of more neuroimaging studies 89 Also contrary to the results of earlier studies those with BPD showed less activation in the amygdala in situations of increased negative emotionality than the control group John Krystal editor of the journal Biological Psychiatry wrote that these results added to the impression that people with borderline personality disorder are set up by their brains to have stormy emotional lives although not necessarily unhappy or unproductive lives 89 Their emotional instability has been found to correlate with differences in several brain regions 90 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 91 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 91 This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD 91 A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD 92 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 predicts a lower risk One possible explanation is that a stable environment buffers against its development 93 Self complexity Self complexity or considering one s self to have many different characteristics may lessen the apparent discrepancy between an actual self and a desired self image Higher self complexity may lead a person to desire more characteristics instead of better characteristics if there is any belief that characteristics should have been acquired these may be more likely to have been experienced as examples rather than considered as abstract qualities The concept of a norm does not necessarily involve the description of the attributes that represent the norm cognition of the norm may only involve the understanding of being like a concrete relation and not an attribute 94 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 87 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 95 Developmental theories Marsha Linehan s biosocial developmental theory of borderline personality disorder suggests that BPD emerges from the combination of an emotionally vulnerable child and an invalidating environment Emotional vulnerability may consist of biological inherited factors that affect a child s temperament Invalidating environments may include contexts where a child s emotions and needs are neglected ridiculed dismissed or discouraged or may include contexts of trauma and abuse 96 Linehan s theory was modified by Sheila Crowell who proposed that impulsivity also plays an important role in the development of BPD Crowell found that children who are emotionally vulnerable and are exposed to invalidating environments are much more likely to develop BPD if they are also highly impulsive 97 Both theories describe an interplay between a child s inherited personality traits and their environment For example an emotionally sensitive or impulsive child may be difficult to parent exacerbating the invalidating environment conversely invalidation can make an emotionally sensitive child more reactive and distressed DiagnosisDiagnosis of borderline personality disorder is based on a clinical assessment by a mental health professional The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them 47 Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it 47 Some clinicians prefer not to tell people with BPD what their diagnosis is either from concern about the stigma attached to this condition or because BPD used to be considered untreatable it is usually helpful for the person with BPD to know their diagnosis 47 This helps them know that others have had similar experiences and can point them toward effective treatments 47 In general the psychological evaluation includes asking the patient about the beginning and severity of symptoms as well as other questions about how symptoms impact the patient s quality of life Issues of particular note are suicidal ideations experiences with self harm and thoughts about harming others 98 Diagnosis is based both on the person s report of their symptoms and on the clinician s own observations 98 Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms such as thyroid conditions or a substance use disorder 98 The ICD 10 manual refers to the disorder as emotionally unstable personality disorder and has similar diagnostic criteria In the DSM 5 the name of the disorder remains the same as in the previous editions 9 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 A person must meet five of nine criteria to receive a diagnosis of borderline personality disorder 99 The DSM 5 defines the main features of the condition as a pervasive pattern of instability in interpersonal relationships self image and affect as well as markedly impulsive behavior 99 In addition the DSM 5 proposes alternative diagnostic criteria for BPD 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 100 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 101 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 101 International Classification of Disease ICD 11The World Health Organization s ICD 11 completely restructured its personality disorder section It classifies BPD as personality disorder borderline pattern described as the following The Borderline pattern specifier may be applied to individuals whose pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships self image and affects and marked impulsivity as indicated by many of the following Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships Identity disturbance manifested in markedly and persistently unstable self image or sense of self A tendency to act rashly in states of high negative affect leading to potentially self damaging behaviours Recurrent episodes of self harm Emotional instability due to marked reactivity of mood Chronic feelings of emptiness Inappropriate intense anger or difficulty controlling anger Transient dissociative symptoms or psychotic like features in situations of high affective arousal Other manifestations of Borderline pattern not all of which may be present in a given individual at a given time include the following A view of the self as inadequate bad guilty disgusting and contemptible An experience of the self as profoundly different and isolated from other people a painful sense of alienation and pervasive loneliness Proneness to rejection hypersensitivity problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships frequent misinterpretation of social signals 102 ICD 10 In the previous edition of the ICD the ICD 10 it defined a disorder that was conceptually similar to BPD called F60 3 Emotionally unstable personality disorder Its two subtypes are described below 103 F60 30 Impulsive type At least three of the following must be present one of which must be 2 marked tendency to act unexpectedly and without consideration of the consequences marked tendency to engage in quarrelsome behavior and to have conflicts with others especially when impulsive acts are thwarted or criticized liability to outbursts of anger or violence with inability to control the resulting behavioral explosions difficulty in maintaining any course of action that offers no immediate reward 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 disturbances in and uncertainty about self image aims and internal preferences liable to become involved in intense and unstable relationships often leading to emotional crisis excessive efforts to avoid abandonment recurrent threats or acts of self harm chronic feelings of emptiness demonstrates impulsive behavior e g speeding in a car or substance use 104 The ICD 10 also describes some general criteria that define what is considered a personality disorder Millon s subtypes American psychologist Theodore Millon has proposed four subtypes of BPD He suggests that an individual diagnosed with BPD may exhibit none one or multiple of the following 105 Subtype FeaturesDiscouraged borderline including avoidant and dependent features Pliant submissive loyal humble feels vulnerable and in constant jeopardy feels hopeless depressed helpless and powerless Petulant borderline including negativistic features Negativistic impatient restless as well as stubborn defiant sullen pessimistic and resentful easily feels slighted and quickly disillusioned Impulsive borderline including histrionic and antisocial features Captivating capricious superficial flighty distractable frenetic and seductive fearing loss the individual becomes agitated gloomy and irritable and potentially suicidal Self destructive borderline including depressive or masochistic features Inward turning intropunitive self punishing angry conforming deferential and ingratiating behaviors have deteriorated increasingly high strung and moody possible suicide Misdiagnosis Main article Misdiagnosis of borderline personality disorder People with BPD may be misdiagnosed for a variety of reasons One reason for misdiagnosis is BPD has symptoms that coexist comorbidity with other disorders such as depression post traumatic stress disorder PTSD and bipolar disorder 106 107 According to critics of the diagnosis BPD cannot be distinguishable from negative affectivity when subjected to regression and factor analyses They argue that BPD diagnosis does not seem to add anything to other diagnoses and may be unnecessary or even misleading 108 Adolescence Onset of symptoms typically occurs during adolescence or young adulthood although symptoms suggestive of this disorder can sometimes be observed in children 109 Symptoms among adolescents that predict the development of BPD in adulthood may include problems with body image extreme sensitivity to rejection behavioral problems non suicidal self injury attempts to find exclusive relationships and severe shame 47 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 47 BPD is recognised as a valid and stable diagnosis during adolescence 110 111 112 113 The diagnosis of BPD also described as personality disorder borderline pattern qualifier in adolescents is supported in recent updates to the international diagnostic and psychiatric classification tools including the DSM 5 and ICD 11 28 102 114 Early diagnosis of BPD has been recognised as instrumental to the early intervention and effective treatment for BPD in young people 112 115 116 Accordingly national treatment guidelines recommend the diagnosis and treatment of BPD among adolescents in many countries including Australia the United Kingdom Spain and Switzerland 117 118 119 120 The diagnosis of BPD during adolescence has been controversial 112 121 122 Early clinical guidelines encouraged caution when diagnosing BPD during adolescence 123 124 125 Perceived barriers to the diagnosis of BPD during adolescence included concerns about the validity of a diagnosis in young people the misdiagnosis of normal adolescent behaviour as symptoms of BPD the stigmatising effect of a diagnosis for adolescents and whether personality during adolescence was sufficiently stable for a valid diagnosis of BPD 112 Psychiatric research has since shown BPD to be a valid stable and clinically useful diagnosis in adolescent populations 110 111 112 113 However ongoing misconceptions about the diagnosis of BPD in adolescence remain prevalent among mental health professionals 126 127 128 Clinical reluctance to diagnose BPD is a key barrier to the provision of effective treatment in adolescent populations 126 129 130 A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood 123 131 Among individuals diagnosed with BPD during adolescence 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 132 Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent 123 131 Family therapy is considered a helpful component of treatment for adolescents with BPD 133 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 134 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 including schizotypal antisocial and dependent personality disorder substance use disorder SUD eating disorders including anorexia nervosa and bulimia attention deficit hyperactivity disorder ADHD 135 somatic symptom disorders formerly known as somatoform disorders a category of mental disorders included in a number of diagnostic schemes of mental illness dissociative disordersA diagnosis of a personality disorder should not be made during an untreated mood episode disorder unless the lifetime history supports the presence of a personality disorder 136 Comorbid Axis I disorders Sex differences in Axis I lifetime comorbid diagnosis 2008 137 and 1998 134 Axis I diagnosis Overall Male Female Mood disorders 75 0 68 7 80 2Major depressive disorder 32 1 27 2 36 1Dysthymia 0 9 7 0 7 1 11 9Bipolar I disorder 31 8 30 6 32 7Bipolar II disorder 0 7 7 0 6 7 0 8 5Anxiety disorders 74 2 66 1 81 1Panic disorder with agoraphobia 11 5 0 7 7 14 6Panic disorder without agoraphobia 18 8 16 2 20 9Social phobia 29 3 25 2 32 7Specific phobia 37 5 26 6 46 6PTSD 39 2 29 5 47 2Generalized anxiety disorder 35 1 27 3 41 6Obsessive compulsive disorder 15 6 Substance use disorders 72 9 80 9 66 2Any alcohol use disorder 57 3 71 2 45 6Any non alcohol substance use disorder 36 2 44 0 29 8Eating disorders 53 0 20 5 62 2Anorexia nervosa 20 8 0 7 25 Bulimia nervosa 25 6 10 30 Eating disorder not otherwise specified 26 1 10 8 30 4Somatoform disorders 10 3 10 10 Somatization disorder 0 4 2 Hypochondriasis 0 4 7 Somatoform pain disorder 0 4 2 Psychotic disorders 0 1 3 0 1 0 1 Approximate values Values from 1998 study 134 Value not provided by studyA 2008 study found that at some point in their lives 75 of people with BPD meet criteria for mood disorders especially major depression and bipolar I and nearly 75 meet criteria for an anxiety disorder 137 Nearly 73 meet the criteria for a substance use disorder and about 40 for PTSD 137 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 134 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 134 There are marked sex differences in the types of comorbid conditions a person with BPD is likely to have 134 a higher percentage of males with BPD meet criteria for substance use disorders while a higher percentage of females with BPD meet criteria for PTSD and eating disorders 134 137 138 In one study 38 of participants with BPD met the criteria for a diagnosis of ADHD 135 In another study 6 of 41 participants 15 met the criteria for an autism spectrum disorder a subgroup that had significantly more frequent suicide attempts 139 Regardless of the fact that it is an infradiagnosed disorder a few studies have shown that the lower expressions of it might lead to wrong diagnoses The many and 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 134 Mood disorders Many people with borderline personality disorder also have mood disorders such as major depressive disorder or a bipolar disorder 45 Some characteristics of BPD are similar to those of mood disorders which can complicate the diagnosis 140 141 142 It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa 143 For someone with bipolar disorder behavior suggestive of BPD might appear while experiencing an episode of major depression or mania only to disappear once mood has stabilized 144 For this reason it is ideal to wait until mood has stabilized before attempting to make a diagnosis 144 At face value the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar 145 It can be difficult even for experienced clinicians if they are unfamiliar with BPD to differentiate between the mood swings of these two conditions 146 However there are some clear differences 143 First the mood swings of BPD and bipolar disorder tend to 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 143 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 146 So while euphoria and impulsivity in someone with BPD might resemble a manic episode the experience would be too brief to qualify as a manic episode 144 146 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 144 That is a positive event would not lift the depressed mood caused by bipolar disorder but a positive event would potentially lift the depressed mood of someone with BPD Similarly an undesirable event would not dampen the euphoria caused by bipolar disorder but an undesirable event would dampen the euphoria of someone with borderline personality disorder 144 Third when people with BPD experience euphoria it is usually without the racing thoughts and decreased need for sleep that are typical of hypomania 144 though a later 2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were associated with chronic sleep disturbances including difficulty initiating sleep difficulty maintaining sleep and waking earlier than desired as well as with the consequences of poor sleep and noted that f ew studies have examined the experience of chronic sleep disturbances in those with borderline personality disorder 147 Because the two conditions have a number of similar symptoms BPD was once considered to be a mild form of bipolar disorder 148 149 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 suggest that this is not the case 150 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 151 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 152 Premenstrual dysphoric disorder Premenstrual dysphoric disorder PMDD occurs in 3 8 of women 153 Symptoms begin during the luteal phase of the menstrual cycle and end during menstruation 154 Symptoms may 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 155 156 People with PMDD typically begin to experience symptoms in their early twenties although many do not seek treatment until their early thirties 155 Although some of the symptoms of PMDD and BPD are similar they are different disorders They are distinguishable by the timing and duration of symptoms which are markedly different the symptoms of PMDD occur only during the luteal phase of the menstrual cycle 155 whereas BPD symptoms occur persistently at all stages of the menstrual cycle In addition the symptoms of PMDD do not include impulsivity 155 Comorbid Axis II disorders Percentage of people with BPD and a lifetime comorbid Axis II diagnosis 2008 137 Axis II diagnosis Overall Male Female Any cluster A 50 4 49 5 51 1Paranoid 21 3 16 5 25 4Schizoid 12 4 11 1 13 5Schizotypal 36 7 38 9 34 9Any other cluster B 49 2 57 8 42 1Antisocial 13 7 19 4 9 0Histrionic 10 3 10 3 10 3Narcissistic 38 9 47 0 32 2Any cluster C 29 9 27 0 32 3Avoidant 13 4 10 8 15 6Dependent 3 1 2 6 3 5Obsessive compulsive 22 7 21 7 23 6About three fourths of people diagnosed with BPD also meet the criteria for another Axis II personality disorder at some point in their lives In a major 2008 study see adjacent table the rate was 73 9 137 The Cluster A disorders paranoid schizoid and schizotypal are broadly the most common The Cluster as a whole affects about half with schizotypal alone affecting one third 137 BPD is itself a Cluster B disorder The other Cluster B disorders antisocial histrionic and narcissistic similarly affect about half of BPD patients lifetime incidence with again narcissistic affecting one third or more 137 Cluster C avoidant dependent and obsessive compulsive showed the least overlap slightly under one third 137 ManagementMain article Management of borderline personality disorder Psychotherapy is the primary treatment for borderline personality disorder 11 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 157 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 158 Psychotherapy Long term psychotherapy is currently the treatment of choice for BPD 159 While psychotherapy in particular dialectical behavior therapy DBT and psychodynamic approaches is effective the effects are slow many people have to put in years of work to be effective 160 More rigorous treatments are not substantially better than less rigorous treatments 161 There are six such treatments available dynamic deconstructive psychotherapy DDP 162 mentalization based treatment MBT transference focused psychotherapy dialectical behavior therapy DBT general psychiatric management and schema focused therapy 47 163 Long term therapy of any kind is better than no treatment especially in reducing urges to self injure 159 Transference focused therapy aims to break away from absolute thinking In this it gets the people to articulate their social interpretations and their emotions in order to turn their views into less rigid categories The therapist addresses the individual s feelings and goes over situations real or realistic that could happen as well as how to approach them 164 The dialectical behavior therapy DBT components are interpersonal communication distress tolerance emotional regulation and mindfulness In doing this it helps the individual with BPD gain skills to manage symptoms 164 Since those diagnosed with BPD have such intense emotions learning to regulate them is a huge step in the therapeutic process Some components of DBT are working long term with patients building skills to understand and regulate emotions homework assignments and strong availability of therapist to their client 165 Patients with borderline personality disorder also must take time in DBT to work with their therapist to learn how to get through situations surrounded by intense emotions or stress as well as learning how to better their interpersonal relationships 163 nbsp The stages used in dialectical behavior therapyCognitive behavioral therapy CBT is also a type of psychotherapy used for treatment of BPD This type of therapy relies on changing people s behaviors and beliefs by identifying problems from the disorder CBT is known to reduce some anxiety and mood symptoms as well as reduce suicidal thoughts and self harming behaviors 8 Mentalization based therapy and transference focused psychotherapy are based on psychodynamic principles and dialectical behavior therapy is based on cognitive behavioral principles and mindfulness 159 General psychiatric management combines the core principles from each of these treatments and it is considered easier to learn and less intensive 47 Randomized controlled trials have shown that DBT and MBT may be the most effective and the two share many similarities 166 167 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 159 167 Some research indicates that mindfulness meditation may bring about favorable structural changes in the brain including changes in brain structures that are associated with BPD 168 169 170 Mindfulness based interventions also appear to bring about an improvement in symptoms characteristic of BPD and some clients who underwent mindfulness based treatment no longer met a minimum of five of the DSM IV TR diagnostic criteria for BPD 170 171 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 172 A 2017 review examined evidence published since the 2010 Cochrane review and found that evidence of effectiveness of medication for BPD remains very mixed and is still highly compromised by suboptimal study design 173 A 2020 review found that research into pharmacological treatments had declined with more results confirming no benefits The review found moderate to large statistically significant effects for both doses of quetiapine 150 mg day and 300 mg day regarding BPD severity psychosocial impairment and aggression and an additional effect for the higher dose regarding manic symptoms Despite lack of evidence of efficacy the review stated that SSRI antidepressants continue to be widely prescribed to people with BPD 24 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 one trial found that aripiprazole may reduce interpersonal problems and impulsivity 172 Olanzapine as well as quetiapine may decrease affective instability anger psychotic paranoid symptoms and anxiety but a placebo had a greater benefit on suicidal ideation than olanzapine did The effect of ziprasidone was not significant 172 173 Mood stabilizers are anticonvulsant drugs used for both epilepsy and reduction in mood variations in patients with excessive and often dangerous mood variabilities Often the goal of the anticonvulsants is to bring certain areas of the brain to equilibrium and control outbursts and seizures Of the mood stabilizers studied valproate semisodium may ameliorate depression impulsivity interpersonal problems 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 2017 update trials with these medications had not been replicated and the effect of long term use had not been assessed 172 173 Lamotrigine showed no benefit in a large randomized clinical trial 24 A case study on a male patient with borderline personality disorder found IV ketamine treatments typically used for the treatment of unresponsive depression drastically decreased anxiety depression and suicidal behaviors 174 Chen and associates 2022 studied the effect of IV ketamine on adults with major depressive disorder MDD and borderline features compared to those with MDD without borderline features Those with borderline features tend to be harder to treat and are more likely to suffer from suicidal ideation They found that IV ketamine was more effective at treating those with borderline features 14 days after treatment as compared to the MDD without borderline features group While this study looked at those with MDD and borderline features further studies are needed to see if the results will be the same for those with a diagnosis of BPD In particular those with BPD may experience episodes of psychosis and dissociation which can also be brought on by the use of ketamine However in this study those with borderline features did not show increased signs of dissociation or psychosis suggesting that ketamine may eventually prove to be an effective treatment for those with MDD and BPD 175 Because of weak evidence and the potential for serious side effects from some of these medications the United Kingdom 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 176 Cattarinussi 2021 stated medication for treatment of borderline personality disorder should be used at very low doses and for minimal amounts of time 177 Crawford 2018 found that despite mood stabilizers being prescribed frequently for BPD patients they are neither cost effective or medically effective in treating BPD as whole after performing a year long study 178 Services There is a significant difference between the number of those who would benefit from treatment and the number of those who are treated The so called treatment gap is a function of the disinclination to submit for treatment an underdiagnosing of the disorder by healthcare providers and the limited availability and access to state of the art treatments 179 There are also ongoing problems with creating clear pathways to services and medical care with many people with BPD finding it difficult to access treatment Even when medical providers try to help many are not trained or equipped to help severe BPD which is a problem that has been recognized by both those affected by BPD and doctors 180 Nonetheless individuals with BPD accounted for about 20 of psychiatric hospitalizations in one survey 181 The majority of individuals with BPD who are in treatment 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 182 Experience of services varies 183 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 184 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 185 After a patient with BPD died the National Health Service NHS in England was criticized by a coroner in 2014 for the lack of commissioned services to support those with BPD Evidence was given that 45 of female patients had BPD and there was no provision or priority for therapeutic psychological services At the time there were only a total of 60 specialized inpatient beds in England all of them located in London or the northeast region 186 PrognosisWith 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 187 188 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 187 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 a stable recovery from symptoms 189 190 Patient personality can play an important role during the therapeutic process leading to better clinical outcomes Recent research has shown that BPD patients undergoing dialectical behavior therapy DBT exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient compared to 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 191 In addition to recovering from distressing symptoms people with BPD can 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 192 EpidemiologyThe prevalence of BPD was estimated in the mid 2000s to be 1 2 of the general population 188 and to occur three times more often in women than in men 193 194 However the lifetime prevalence of BPD as defined in the DSM IV in a 2008 study was found to be 5 9 of the American population occurring in 5 6 of men and 6 2 of women 137 The difference in rates between men and women in this study was not found to be statistically significant 137 Borderline personality disorder is estimated to contribute to 20 of psychiatric hospitalizations and to occur among 10 of outpatients 195 29 5 of new inmates in the U S state of Iowa fit a diagnosis of borderline personality disorder in 2007 196 and the overall prevalence of BPD in the U S prison population is thought to be 17 195 These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD which is estimated at 38 195 History nbsp Devaluation in Edvard Munch s Salome 1903 Idealization and devaluation of others in personal relations is a common trait in BPD The painter Edvard Munch depicted his new friend the violinist Eva Mudocci in both ways within days First as a woman seen by a man in love then as a bloodthirsty and cannibalistic Salome 197 In modern times Munch has been diagnosed as having had BPD 198 199 The coexistence of intense divergent moods within an individual was recognized by Homer Hippocrates and Aretaeus the latter describing the vacillating presence of impulsive anger melancholia and mania within a single person The concept was revived by Swiss physician Theophile Bonet in 1684 who using the term folie maniaco melancolique 200 described the phenomenon of unstable moods that followed an unpredictable course Other writers noted the same pattern including the American psychiatrist Charles H Hughes in 1884 and J C Rosse in 1890 who called the disorder borderline insanity 201 In 1921 Kraepelin identified an excitable personality that closely parallels the borderline features outlined in the current concept of BPD 202 The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s 203 The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938 204 205 He described a group of patients who he felt to be on the borderline between neurosis and psychosis who very often came from family backgrounds marked by trauma He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques 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 123 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 202 between neurosis and psychosis 206 After standardized criteria were developed 207 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 188 The diagnosis was distinguished from sub syndromal schizophrenia which was termed schizotypal personality disorder 206 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 5 today 9 However the term borderline has been described as uniquely inadequate for describing the symptoms characteristic of this disorder 208 Etymology Earlier versions of the DSM before the multiaxial diagnosis system classified most people with mental health problems into two categories the psychotics and the neurotics Clinicians noted a certain class of neurotics who when in crisis appeared to straddle the borderline into psychosis 209 The term borderline personality disorder was coined in American psychiatry in the 1960s It became the preferred term over a number of competing names such as emotionally unstable character disorder and borderline schizophrenia during the 1970s 210 211 Borderline personality disorder was included in DSM III 1980 despite not being universally recognized as a valid diagnosis 212 ControversiesCredibility and validity of testimony The credibility of individuals with personality disorders has been questioned at least since the 1960s 213 2 Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition 214 Dissociation Researchers disagree about whether dissociation or a sense of emotional detachment 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 215 The researchers found that decreased ability to recall specifics was correlated with patients levels of dissociation which may help them to avoid episodic information that would evoke acutely negative affect 215 Lying as a feature Some theorists argue that patients with BPD often lie 216 However others write that they have rarely seen lying among patients with BPD in clinical practice 216 Gender Joel Paris states that In the clinic Up to 80 of patients are women That may not be true in the community 217 He offers the following explanations regarding these sex discrepancies The most probable explanation for gender differences in clinical samples is that women are more likely to develop the kind of symptoms that bring patients in for treatment Twice as many women as men in the community have depression Weissman amp Klerman 1985 In contrast there is a preponderance of men meeting the criteria for substance use disorder and psychopathy Robins amp Regier 1991 and males with these disorders do not necessarily present in the mental health system Men and women with similar psychological problems may express distress differently Men tend to drink more and carry out more crimes Women tend to turn their anger on themselves leading to depression as well as the cutting and overdosing that characterize BPD Thus anti social personality disorder ASPD and borderline personality disorders might derive from similar underlying pathology but present with symptoms strongly influenced by gender Paris 1997a Looper amp Paris 2000 We have even more specific evidence that men with BPD may not seek help In a study of completed suicides among people aged 18 to 35 years Lesage et al 1994 30 of the suicides involved individuals with BPD as confirmed by psychological autopsy in which symptoms were assessed by interviews with family members Most of the suicide completers were men and very few were in treatment Similar findings emerged from a later study conducted by our own research group McGirr Paris Lesage Renaud amp Turecki 2007 56 In short men are less likely to seek or accept appropriate treatment more likely to be treated for symptoms of BPD such as substance use rather than BPD itself the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology more likely to wind up in the correctional system due to criminal behavior and more likely to commit suicide prior to diagnosis Among men diagnosed with BPD there is also evidence of a higher suicide rate men are more than twice as likely as women 18 percent versus 8 percent to die by suicide 21 There are also sex differences in borderline personality disorder 218 Men with BPD are more likely to recreationally use substances have explosive temper high levels of novelty seeking and have especially antisocial narcissistic passive aggressive or sadistic personality traits male BPD being characterised by antisocial overtones 218 Women with BPD are more likely to have eating disorders mood disorders anxiety and post traumatic stress 218 Manipulative behavior This section may lend undue weight to a single source s interpretation of manipulative behavior as unintentional implying that this correctly describes all people with BPD Please help to create a more balanced presentation Discuss and resolve this issue before removing this message June 2023 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 219 In one research study 88 of therapists reported that they have experinced manipulation attempts from patient s 220 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 221 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 221 According to Linehan 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 however making their assumed manipulative behavior an involuntary and unintentional response 222 One paper identified possible reasons for manipulation in BPD identifying others feelings and reactions a regulatory function due to insecurity to communicate ones emotions and connect to others or to feel as if one is in control or to allow them to be liberated from relationships or commitments 223 Stigma The features of BPD include emotional instability intense and 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 negative treatment of these individuals may trigger further self destructive behavior 224 Since BPD can be a stigmatizing diagnosis even within the mental health community some survivors of childhood abuse who are diagnosed with BPD are re traumatized by the negative responses they receive from healthcare providers 225 One camp who argues that it would be better to diagnose these men or women with post traumatic stress disorder as this would acknowledge the impact of abuse on their behavior citation needed Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society 226 Regardless a diagnosis of PTSD does not encompass all aspects of the disorder see brain abnormalities and terminology Physical violence The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others 227 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 227 Although people with BPD often struggle with experiences of intense anger a defining characteristic of BPD is that they direct it inward toward themselves 228 One 2020 study found that BPD is individually associated with psychological physical and sexual forms of intimate partner violence IPV especially amongst men 229 In terms of the AMPD trait facets hostility negative affectivity suspiciousness negative affectivity and risk taking disinhibition were most strongly associated with IPV perpetration for the total sample 229 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 228 Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs 228 This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others 228 38 227 Mental health care providers People with BPD are considered to be among the most challenging groups of patients to work with in therapy requiring a high level of skill and training for the psychiatrists therapists and nurses involved in their treatment 230 A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups 231 This largely negative view of BPD can result in people with BPD being terminated from treatment early being provided harmful treatment not being informed of their diagnosis of BPD or being misdiagnosed 232 With healthcare providers contributing to the stigma of a BPD diagnosis seeking treatment can often result in the perpetuation of BPD features 232 Efforts are ongoing to improve public and staff attitudes toward people with BPD 233 234 In psychoanalytic theory the stigmatization among mental health care providers may be thought to reflect countertransference when a therapist projects his or her own feelings on to a client 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 235 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 health care 236 Indeed mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis 237 Terminology Because of concerns around stigma 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 238 since many who are labelled with borderline personality disorder find the name unhelpful stigmatizing or inaccurate 238 239 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 240 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 G Gunderson of McLean Hospital in the United States 241 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 81 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 88 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 242 Society and cultureFiction Literature In literature characters with behavior consistent with borderline personality disorder include Catherine in Wuthering Heights 1847 Smerdyakov in The Brothers Karamazov 1880 and Harry Haller in Steppenwolf 1927 243 244 245 Film Films attempting to depict characters with the disorder include Margot at the Wedding 2007 Mr Nobody 2009 Cracks 2009 246 Truth 2013 Wounded 2013 Welcome to Me 2014 247 248 and Tamasha 2015 249 Robert O Friedel has suggested that the behavior of Theresa Dunn the leading character of Looking for Mr Goodbar 1975 is consistent with a diagnosis of borderline personality disorder 250 The films Play Misty for Me 1971 251 and Girl Interrupted 1999 based on the memoir of the same name both suggest the emotional instability of the disorder 252 The film Single White Female 1992 suggests characteristics which are typical of the disorder the character Hedy had markedly disturbed sense of identity and reacts drastically to abandonment 251 235 Multiple commenters have noted that Clementine in Eternal Sunshine of the Spotless Mind 2004 shows classic borderline personality disorder behavior 253 254 In a review of the film Shame 2011 for the British journal The Art of Psychiatry another psychiatrist Abby Seltzer praises Carey Mulligan s portrayal of a character with the disorder even though it is never mentioned onscreen 255 Psychiatrists Eric Bui and Rachel Rodgers argue that the Anakin Skywalker Darth Vader character 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 256 Television On television The CW show Crazy Ex Girlfriend portrays the main character played by Rachel Bloom with borderline personality disorder 257 and Emma Stone s character in the Netflix miniseries Maniac is diagnosed with the disorder 258 Additionally incestuous twins Cersei and Jaime Lannister in George R R Martin s A Song of Ice and Fire series and its television adaptation Game of Thrones have traits of borderline and narcissistic personality disorders 259 In The Sopranos the character of Dr Melfi diagnoses Livia Soprano with BPD 260 and the character of Bruce Wayne Batman as portrayed in the show Titans is said to have it too 261 The titular character in the adult animation series Bojack Horseman also exhibits many symptoms of BPD 262 Awareness In early 2008 the United States House of Representatives declared the month of May Borderline Personality Disorder Awareness Month 263 264 In 2020 South Korean singer songwriter Lee Sunmi spoke out about her struggle with borderline personality disorder on the 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Edvard Munch The Life of a Person with Borderline Personality as Seen Through His Art Edvard Munch et livslob af en graensepersonlighed forstaet gennem hans billeder Danmark Lundbeck Pharma A S ISBN 978 8798352419 Wylie HW Jr 1980 Edvard Munch The American Imago A Psychoanalytic Journal for the Arts and Sciences Baltimore Maryland Johns Hopkins University Press 37 4 413 443 JSTOR 26303797 PMID 7008567 a b c d e f g h i j k l m n o p q Borderline Personality Disorder NIMH Archived from the original on 22 March 2016 Retrieved 16 March 2016 a b c d e f g h i j k l m n o p American Psychiatric Association 2013 pp 645 663 6 a b Clinical Practice Guideline for the Management of Borderline Personality Disorder Melbourne National Health and Medical Research Council 2013 pp 40 41 ISBN 978 1 86496 564 3 In addition to the evidence identified by the systematic review the Committee also considered a recent narrative review of studies that have evaluated biological and environmental factors as 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