Borderline Personality Disorder

Topic Overview

What is borderline personality disorder?

Borderline personality disorder is a mental illness that causes intense mood swings, impulsive behaviors, and severe problems with relationships and self-worth. People with this disorder often have other problems such as depression, eating disorders, or substance abuse.

Most of the time, signs of the disorder first appear in childhood. But problems often don't start until early adulthood. Treatment can be very hard, and getting better can take years. This is because problems with emotions and behaviors are hard to improve. But treatment may work better than experts used to think. Most people with severe symptoms get better over time.¹

What are the symptoms?

Everyone has problems with emotions or behaviors sometimes. But if you have borderline personality disorder, the problems are severe, repeat over a long time, and disrupt your life. The most common symptoms include:

• Intense emotions and mood swings.
• Impulsive behaviors that are self-damaging, such as substance abuse, binge eating, and reckless driving.
• Relationship problems.
• Low self-worth.
• A frantic fear of being left alone (abandoned).²
• Aggressive behavior.

Other symptoms may include:

• Feeling empty inside.
• Problems with anger, such as violent temper tantrums.
• Hurting yourself, such as cutting or burning yourself.
• Suicide attempts and suicidal thoughts.
• Feeling suspicious of others for no reason (feeling paranoid) or losing a sense of reality.

It is easy to confuse this disorder with other mental illnesses such as antisocial personality disorder. So if you think that you or someone you know may have borderline personality disorder, see a doctor. Don't try to diagnose yourself.

What causes borderline personality disorder?

About 2 out of 100 people have borderline personality disorder, but experts don't know exactly what causes it. Problems with chemicals in the brain that help control moods may play a role. The disorder also seems to run in families.³

Often people who get it faced some kind of childhood trauma such as abuse, neglect, or the death of a parent. The risk for getting the disorder is higher when people who had childhood trauma also have problems coping with anxiety or stress.

How is it treated?

The symptoms of borderline personality disorder can be treated, but there is no known cure. Long-term counseling is an important part of treatment, but this can be very challenging. Often, it is hard for people with this disorder to have a good relationship with the counselor.

There are also medicines that can help you cope with the disorder. These medicines can help treat depression or help control moods.

Treatment can be very hard, and getting better can take years. The return of symptoms is a common problem. This is called a relapse. Treatment is even harder if the person has other problems, such as depression or an eating disorder. But most people who are treated improve over time.

Frequently Asked Questions

Cause

The cause of borderline personality disorder is not well-understood. It may be a result of an imbalance of chemicals in the brain called neurotransmitters, which help regulate mood. Mood is also influenced by genetic and environmental influences.

Borderline personality disorder is 5 times more common among people whose parents or siblings have the disorder.⁴ It is also seen more often in families who have other mental health conditions such as antisocial personality disorder, substance abuse problems, and mood disorders like depression.³

People who develop this disorder often have experienced significant childhood trauma, such as sexual, physical, or emotional abuse; neglect; or early loss of or separation from a parent. When this trauma is combined with certain personality traits, such as reacting poorly to stress or having problems with anxiety, the risk for developing borderline personality disorder increases.

Although experts know that people with borderline personality disorder have impaired function in parts of the brain, it is still not clear whether the problems are caused by-or are a consequence of-the disorder.⁵

Symptoms

A person with borderline personality disorder often has unstable relationships, low self-esteem, and problems with impulsive behavior, all of which begin by early adulthood.²

A common feature of this disorder is fear of being left alone (abandoned), even if the threat of being abandoned is not real. This fear may lead to frantic attempts to hold on to those around you and may cause you to become too dependent on others. Sometimes you may react to the fear of being abandoned by rejecting others first before they can reject you. This erratic behavior can lead to troubled relationships in every area of your life.

People who are diagnosed with borderline personality disorder have at least five of the following symptoms. They may:⁴

• Make frantic efforts to avoid real or imagined abandonment.
• Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.
• Have an unstable self-image or be unsure of his or her own identity.
• Act impulsively in ways that are self-damaging, such as extravagant spending, frequent and unprotected sex with many partners, substance abuse, binge eating, or reckless driving.
• Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning himself or herself.
• Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. These mood swings usually only last a few hours at a time. In rare cases, they may last a day or two.
• Have long-term feelings of emptiness.
• Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights.
• Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

Not everyone who has five or more of these symptoms is diagnosed with borderline personality disorder. For a person to be diagnosed with any personality disorder, the symptoms must be severe and must go on long enough to cause significant emotional distress or problems functioning in relationships or at work.⁴

You may have temporary episodes of psychosis (paranoia and a loss of a sense of reality) with borderline personality disorder, especially when you are going through a personal crisis. This psychosis usually does not last very long. But if it continues, your doctor may consider another condition, such as schizophrenia.

Symptoms of borderline personality disorder are not caused by another medical condition or by medicines, and they are not a result of long-term substance abuse problems. Borderline personality disorder may be confused with other conditions with similar symptoms, such as other personality disorders, including antisocial personality disorder and histrionic personality disorder.

Suicidal behavior

Suicidal behavior is common in people with borderline personality disorder, with close to 10% of those with the disorder completing suicide.⁶ Your risk of suicidal thoughts or attempts increases if you have depression along with borderline personality disorder.⁷ But you can reduce your risk for suicide by treating symptoms of both conditions.

Other conditions that commonly occur with borderline personality disorder

Other mental health conditions commonly occur with borderline personality disorder and need treatment also. These additional conditions can make it difficult to distinguish borderline personality and can complicate treatment. Conditions that frequently occur with borderline personality disorder include:^{3, 4}

• Depression or other mood disorders (for example, dysthymic disorder).
• Eating disorders, especially bulimia nervosa.
• Substance abuse problems.
• Bipolar disorder, which is depression with episodes of mania.
• Panic attacks or panic disorder.
• Attention deficit hyperactivity disorder (ADHD).

Other personality disorders can occur in addition to borderline personality disorder. A few of these conditions include:

• Histrionic personality disorder, which causes excessive emotional reactions, attention-seeking behavior, and dramatic behavior.
• Avoidant personality disorder, which causes a person to avoid interaction with other people, especially if the interaction involves a new activity that may prove embarrassing.
• Antisocial personality disorder, a condition that involves a pattern of disregard for or violation of the rights of others.

What Happens

The first signs of borderline personality disorder usually appear by late childhood. The most common early characteristics are impulsive and reckless behavior. The disorder often fully develops between the ages of 18 and 25. The risk of suicide associated with borderline personality disorder is greatest in the young adult years and gradually decreases with age.⁴

In the adult years, the disorder causes intense emotions, impulsive behaviors, and unstable relationships. Uncontrolled emotions and fear of being abandoned often lead to job losses, failed marriages, and uncompleted education. ³

Frequently, other disorders occur along with borderline personality disorder and also need treatment.

Treatment can be difficult, and often people with borderline personality disorder have difficult relationships with their health professionals. People with the disorder often see others as either "good" or "bad". A shift from one view to the other, called splitting, can occur suddenly in any relationship, for minor reasons.

These changes in feeling often are a source of tension between a person with borderline personality disorder and health professionals. Splitting is also a common source of tension in relationships with friends and family members.

Severe symptoms such as self-destructive and suicidal behavior, irrational thinking, and emotional problems related to relationships may improve as you begin treatment. Some symptoms may last longer, such as feelings of anger or emptiness or abandonment, suspiciousness, and difficulty tolerating being alone.¹

Among people with borderline personality disorder, those who are in their 20s are most likely to have thoughts of suicide, and the risk for completed suicide is highest for people in their 30s.⁸

However, the majority of those with this disorder gain more stable emotions, relationships, and employment during their 30s or 40s. Many people who get treatment for borderline personality disorder do decrease destructive behaviors, often within the first year of treatment.⁴ Around half of those diagnosed with borderline personality disorder no longer have many of the behaviors associated with the disorder after about 10 years of treatment.⁴

What Increases Your Risk

Your risk for developing borderline personality disorder increases if you:

• Have a family member with the disorder.
• Have a history of sexual, physical, or emotional abuse during childhood.
• Have difficulty dealing with stress, anxiety, or worry (neurotic personality).

Your risk for relapse of symptoms of borderline personality disorder is greatest when you feel threatened by being left alone (abandonment).

When To Call a Doctor

Call 911 or other emergency services immediately if:

• You think you cannot keep from harming yourself or someone else.
• You hear voices (auditory hallucinations).
• Someone you know attempts suicide or shows warning signs of suicide, such as talking about suicide.
• Someone you know talks about harming you or someone else.
• Someone you know shows signs of detachment from reality (psychosis) or is using alcohol or drugs excessively.

Watchful Waiting

Watchful waiting means taking a wait-and-see approach.

Watchful waiting is not appropriate for borderline personality disorder. If you are concerned about symptoms, contact a health professional.

Who To See

Treatment for borderline personality disorder usually involves professional counseling and sometimes medicine, especially if you have another condition that often responds well to medicine (such as depression). It is important that you establish a long-term and trusting relationship with your health professionals for treatment of this disorder.

Professional counseling can be provided by a:

• Psychiatrist.
• Psychologist.
• Licensed mental health counselor who has special training in treating borderline personality disorder.
• Social worker who has special training in treating borderline personality disorder.

If you need medicine therapy along with professional counseling, it can be prescribed by your:

• Psychiatrist (who can also diagnose mental health conditions).
• Internist.
• Family medicine physician.
• General practitioner.
• Physician assistant.
• Nurse practitioner.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

If you think you may have symptoms of borderline personality disorder, your health professional will do a thorough evaluation of your symptoms. This may include written or verbal tests, a physical exam, and questions about your medical history, which can help rule out other health conditions that might be causing your symptoms. The evaluation may also include a mental health assessment, which involves an interview with a health professional.

Because borderline personality disorder shares symptoms with many other mental health conditions, your health professional may look for signs of another mental health condition in addition to borderline personality disorder.

Treatment Overview

Borderline personality disorder is difficult to treat. Relapse, which is a return of your symptoms, is a common problem, and many people with the disorder have difficult relationships with their counselors or other health professionals. But it is possible to recover from the damaging behaviors associated with borderline personality disorder.

Many people find relief from destructive symptoms within the first year of treatment.⁴ About half of those treated for this condition find that they no longer have most of the behaviors after about 10 years of treatment.⁴

Consistent, long-term treatment of borderline personality disorder is important in improving your symptoms and the quality of your life.

Successful treatment for borderline personality disorder can be more difficult if you have:⁹

• Been abused as a child.
• Experienced symptoms early in life.
• Had continuous symptoms over a long period of time.
• Continued to be unable to control your emotions.
• Experienced problems with aggression, substance abuse, or other mental health conditions, such as depression.

Initial treatment

Initial treatment depends on how bad your condition is. When borderline personality disorder is diagnosed, you most likely will begin treatment with professional counseling (psychotherapy). The first goal of therapy is to help you control destructive behaviors, especially if you are feeling suicidal or self-destructive. When you are less likely to harm yourself and you are able to function more normally, treatment will focus on managing your emotions, such as controlling feelings of anger or unhappiness.⁵

Types of counseling commonly used to treat the disorder include:¹⁰

• Cognitive-behavioral therapy (CBT), which focuses on changing certain thoughts and behavior patterns to control the symptoms of a condition.
• Dialectical behavior therapy, which helps reduce destructive behaviors by teaching healthy ways to adapt to and cope with challenges and feelings of frustration or lack of power.
• Psychodynamic therapy, which focuses on uncovering or understanding your past to gain insight into your actions and current behavior. This technique assumes that problems with behavior are caused by internal conflicts that you are not consciously aware of.
• Family therapy, which can help educate your family about your condition and provide support to you and to those who care about you and are affected by your condition. For example, it is sometimes difficult for a parent with borderline personality disorder to be nurturing, even to his or her own child.
• Support groups, where you and people you care about are able to meet others who share similar challenges.

Techniques that may help you manage symptoms of borderline personality disorder, such as stress and anxiety, include:

• Getting enough sleep and going to bed around the same time every night.
• Eating a balanced diet.
• Getting regular exercise, such as walking or swimming.
• Avoiding alcohol, illegal drugs, and medicines that have not been prescribed to you. These may make your symptoms of borderline personality disorder worse and also may interfere with your prescribed medicines.
• Avoiding any major life decisions (like changing jobs, moving, or getting married or divorced) when you are feeling irritable, anxious, angry, or depressed.
• Building a strong social support system by developing positive relationships with other people, such as family members, friends, and health professionals.

You many need to stay in the hospital if you show warning signs of suicide, such as thoughts or plans of harming yourself or another person, detachment from reality (psychosis), or excessive use of alcohol or drugs.

Any other medical conditions you have may also need to be treated. It is common for other conditions to occur with borderline personality disorder. These may include depression, eating disorders, substance abuse problems, attention deficit hyperactivity disorder (ADHD), or another personality disorder.

Your health professional may prescribe medicines to treat symptoms that can occur with borderline personality disorder, such as impulsive or reckless behavior, uncontrolled anger, thoughts of self-injury, depression, anxiety, and psychosis. Medicines to treat such symptoms include:²

• Antidepressants, which may help to reduce anger, irritability, impulsive behaviors, and depression. Those often used include selective serotonin reuptake inhibitors (SSRIs) or other similar medicines.
• Mood stabilizers, which may help control impulsive behaviors and anger.
• Atypical antipsychotics, which are sometimes used to help reduce impulsive and reckless behavior.

Ongoing treatment

Ongoing treatment for borderline personality disorder includes:

• Long-term professional counseling such as:
  • Cognitive-behavioral therapy (CBT), which focuses on changing certain thoughts and behavior patterns to control the symptoms of a condition.
  • Dialectical behavior therapy, which helps reduce destructive behaviors by teaching healthy ways to adapt to and cope with challenges and feelings of frustration or lack of power.
  • Psychodynamic therapy, which focuses on uncovering or understanding your past to gain insight into your actions and current behavior. This technique assumes that problems with behavior are caused by internal conflicts that you are not consciously aware of.
  • Family therapy, which can help educate your family about your condition and provide support to you and to those who care about you and who are affected by your condition. For example, it is sometimes difficult for a parent with borderline personality disorder to be nurturing, even to his or her own child.
  • Support groups, where you and people you care about are able to meet others who share similar challenges.
• Medicines, which may be used to reduce symptoms that can occur with borderline personality disorder, such as impulsive or reckless behavior, uncontrolled anger, thoughts of self-injury, depression, anxiety, and psychosis. You may have to try several medicines before you find the one(s) that work best for you. Medicines to treat such symptoms include:²
  • Antidepressants, which may help to reduce anger, irritability, impulsive behaviors, and depression. Those often used include selective serotonin reuptake inhibitors (SSRIs) and other similar medicines.
  • Mood stabilizers, which may help control impulsive behaviors and anger.
  • Atypical antipsychotics, which are sometimes used to help reduce impulsive and reckless behavior.

Techniques that may help you manage features of borderline personality disorder include:

• Getting enough sleep and going to bed around the same time every night.
• Eating a balanced diet that is low in saturated fat and contains lots of fresh fruits and vegetables.
• Getting regular exercise, such as walking or swimming.
• Avoiding alcohol, illegal drugs, and medicines that have not been prescribed to you. These may make your symptoms of borderline personality disorder worse and also may interfere with your prescribed medicines.
• Avoiding any major life decisions (like changing jobs, moving, or getting married or divorced) when you are feeling irritable, anxious, angry, or depressed.
• Keeping scheduled counseling appointments and taking your medicines as prescribed.

Treatment if the condition gets worse

If your symptoms associated with borderline personality disorder get worse while you are being treated with professional counseling and medicines, you may need to be hospitalized briefly until serious symptoms (such as intense thoughts of suicide) are reduced.

Your doctor may also prescribe medicines, such as selective serotonin reuptake inhibitors (SSRIs), to help reduce symptoms and prevent relapse (a return of your symptoms). It may take several weeks for these medicines to become effective.

You can help manage symptoms by getting enough sleep regularly, eating a balanced diet, getting regular exercise, avoiding alcohol and medicines not prescribed for you, avoiding big decisions when you are feeling low, keeping scheduled counseling appointments, and taking all medicines as prescribed.

Successful treatment for borderline personality disorder is more difficult if you have:⁹

• Been abused as a child.
• Experienced symptoms early in life.
• Had symptoms over a long period of time.
• Continued to be unable to control your emotions.
• Experienced problems with aggression, substance abuse, or other mental health conditions, such as depression.

Prevention

There is no way to prevent borderline personality disorder. But you may be able to prevent a return of your symptoms (relapse) by going to your counseling appointments and taking medicines as prescribed.

Home Treatment

There are many steps you can take at home to help manage your borderline personality disorder symptoms.

• Get enough sleep, and go to bed around the same time every night.
• Eat a balanced diet that is low in saturated fat and contains lots of fresh fruits and vegetables.
• Get regular exercise, such as walking or swimming.
• Avoid alcohol, illegal drugs, and medicines that have not been prescribed to you. These may make your symptoms of borderline personality disorder worse and also may interfere with your prescribed medicines.
• Avoid making any major life decisions (like changing jobs, moving, or getting married or divorced) when you are feeling irritable, anxious, angry, or depressed.
• Keep scheduled counseling appointments, and take your medicines as prescribed.

If you know someone with borderline personality disorder, you may want to watch for warning signs of suicide, because suicide attempts are common with this disorder. You also may want to seek support for yourself because this condition can be demanding for those who care about the affected person.

Medications

Medicines may be used to try to reduce symptoms of borderline personality disorder, such as impulsive behavior or depression. Often a combination of different medicines may be the best treatment.

Medication Choices

The most commonly prescribed medicines for borderline personality disorder are:^{2, 6}

• Antidepressants, which may help reduce anger, irritability, impulsive behaviors, and depression. Those most often prescribed for these behaviors are selective serotonin reuptake inhibitors (SSRIs) and similar medicines.
• Mood stabilizers, which may help control impulsive behaviors and anger.
• Atypical antipsychotics, which are sometimes used to help reduce impulsive and reckless behavior.

What To Think About

It may take several weeks for medicines to become effective. You may need to try more than one medicine before you find the one that is right for you. Your doctor may also prescribe a combination of medicines to reduce your symptoms.

FDA Advisory. The U.S. Food and Drug Administration (FDA) has issued an advisory to families and health professionals to closely watch for warning signs of suicide in all adults and children taking antidepressants. This is especially important at the beginning of treatment or when doses are changed.

The FDA also advises that people taking antidepressants be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviors in children, who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. If concerns arise, contact a health professional.

Surgery

No surgery is available to treat borderline personality disorder.

Other Treatment

Professional counseling is an important part of treatment for borderline personality disorder. Other therapies, such as relaxation techniques, may also help you recover more quickly and improve your quality of life. Family therapy may help you and those who care about you to deal with borderline personality disorder.

Other Treatment Choices

Borderline personality disorder is often successfully treated with professional counseling such as:¹⁰

• Cognitive-behavioral therapy (CBT), which focuses on changing certain thoughts and behavior patterns to control the symptoms of a condition.
• Dialectical behavior therapy, which helps reduce destructive behaviors by teaching healthy ways to adapt to and cope with challenges and feelings of frustration or lack of power.
• Psychodynamic therapy, which focuses on uncovering or understanding your past to gain insight into your actions and current behavior. This technique assumes that problems with behavior are caused by internal conflicts that you are not consciously aware of.
• Family therapy, which can be helpful in educating your family about your condition and providing support to those who care about you and are also affected by your condition. For example, it is sometimes difficult for a parent with borderline personality disorder to be nurturing, even to his or her own child.
• Support groups, where you and people you care about are able to meet others who share similar challenges.

What To Think About

A critical part of the treatment of borderline personality disorder is long-term professional counseling. It is important that you build a stable relationship with your counselor to successfully continue treatment. Your condition may cause you to go from viewing your counselor as nurturing to cruel, especially when you are asked to try to change a behavior. Try to find a counselor who has special training in treating borderline personality disorder.

Unfortunately, many people don't seek treatment for mental health problems. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

If you need help deciding whether to see your doctor, see some reasonswhy people don't get help and how to overcome them.

Other Places To Get Help

Organizations

Related Information

• Alcohol Abuse and Dependence
• Anorexia Nervosa
• Attention Deficit Hyperactivity Disorder (ADHD)
• Bipolar Disorder
• Bulimia Nervosa
• Depression
• Depression in Children and Teens
• Panic Attacks and Panic Disorder
• Schizophrenia

References

Citations

1. Zanarini MC, et al. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160(2): 274-283.

2. American Psychiatric Association (2001). Practice guidelines for the treatment of patients with borderline personality disorder. American Journal of Psychiatry, 158(10): 1-52.

3. Cloninger CR, Svrakic DR (2000). Personality disorders. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 2, pp. 2063-2104. Philadelphia: Lippincott Williams and Wilkins.

4. American Psychiatric Association (2000). Personality disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 706-710. Washington, DC: American Psychiatric Association.

5. Lieb K, et al. (2004). Borderline personality disorder. Lancet, 364(9432): 453-461.

6. Soloff PH (2000). Psychopharmacology of borderline personality disorder. Medical Clinics of North America, 23(1): 169-192.

7. Soloff PH, et al. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. American Journal of Psychiatry, 157(4): 601-608.

8. Paris J (2005). Borderline personality disorder. Canadian Medical Association Journal, 172(12): 1579-1583.

9. Skodol AE, et al. (2002). The borderline diagnosis II: Biology, genetics, and clinical course. Biological Psychiatry, 51(12): 951-963.

10. Oldham JM (2002). A 44-year-old woman with borderline personality disorder. JAMA, 287(8): 1029-1037.

Other Works Consulted

• Gunderson JG (2001). Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Publishing.

• Phillips KA, et al. (2003). Personality disorders. In RE Hales, SC Yudofsky, eds., Textbook of Clinical Psychiatry, 4th ed., pp. 803-832. Washington, DC: American Psychiatric Publishing.

• Gross R, et al. (2002). Borderline personality disorder in primary care. Archives of Internal Medicine, 162(1): 53-60.

• Reich DB, Zanarini MC (2001). Developmental aspects of borderline personality disorder. Harvard Review of Psychiatry, 9(6): 294-301.

• Sanislow CA, et al. (2002). Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: Findings from the collaborative longitudinal personality disorders study. American Journal of Psychiatry, 159(2): 284-290.

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