Frequently Asked Questions
Is BPD a mental illness?
Yes. Borderline Personality Disorder (BPD) is classed as a 'serious mental illness'.
In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable condition for the first time.
In the UK, BPD is actually officially called ‘Emotionally Unstable Personality Disorder’ (as it is stated in the UK psychiatric manual: ICD10). However, it is still far more commonly known as/referred to as BPD.
In the most recent American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Health Disorders 5th Edition (DSM-5), Borderline Personality Disorder (BPD) is described as:
A pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the nine stated criteria.
This definition is often used in the UK rather than/alongside the ICD10.
What are the symptoms of BPD?
People with BPD can experience some of the following symptoms:
Feeling very worried about people abandoning you and would do anything to stop that happening.
Experiencing very intense emotions that last from a few hours to a few days and can change quickly (for example, from feeling very happy and confident to suddenly feeling low and sad).
Not having a strong sense of who you are, and it can change significantly depending on who you're with.
Finding it very hard to make and keep stable relationships.
Feeling empty a lot of the time.
Acting impulsively and doing things that could harm you (such as binge eating, using drugs or driving dangerously).
Harming yourself or think about harming yourself (for example cutting yourself, overdosing or making attempts to end your life).
Experiencing very intense feelings of anger, which are really difficult to control.
When very stressed, you may also experience paranoia or dissociation.
Information taken from Mind.
What are some of the common traits of BPD?
Every person has a personality: longstanding ways that we relate to the world, others and ourselves. When our personal traits cause impairments in our relationships and daily functioning, we might meet criteria for having a personality disorder.
Just like everyone, people with BPD will have their own unique combination of personality traits. Below are some of the common traits seen in people with BPD.
Possible traits, thought patterns, and behaviours of those with BPD:
- All or nothing thinking – Sometimes called ‘black and white thinking’, a person may struggle to see things in the 'grey area' between two extremes e.g. failing an exam and thinking “nothing ever goes right for me, I’m a failure at everything”. This can also manifest itself within interpersonal relationships; 'splitting' is a behaviour in which someone will idealise or devalue another person ('put them on a pedestal' or vice versa) based on what may be perceived (whether rightly or wrongly) as something such as a hurtful comment from a co-worker.
- Anger - People who suffer with BPD can experience episodes of intense anger (one of the criteria in the DSM-5), sometimes triggered by what may seem on the outside like a 'minor' event (in DBT language 'unwarranted' or 'unwarranted by degree'!). This anger can be obvious to others sometimes - the stereotype portrayed in the media is usually the 'angry [female] borderline'! - but it can also be internalised and self-directed, and the person will feel intense anger towards themselves rather than others.
- Avoidance - Withdrawing from situations or relationships with other people as a defensive mechanism, perhaps to reduce the risk of rejection or anxiety - "I'll leave them before they inevitably leave me" - or in an effort to 'protect' others from getting close due to feelings of worthlessness.
- Catastrophising - The habit of automatically assuming a 'worst case scenario' and inappropriately characterising problems or issues as being catastrophic e.g. "my friend hasn't replied to my texts today, they must not want to be friends with me anymore... I’m never going to see them again” or "I didn't do as much as I should have done today, I'm completely useless and will never get anywhere in life".
- Confirmation bias - The tendency to pay more attention to things which reinforce already-held beliefs than to things which contradict them e.g. focusing on mistakes made during an interview and not thinking about the questions answered well.
- Denial / minimisation - Believing or imagining that some painful or traumatic circumstance, event, or memory does not exist or did not happen, or remembering it in a skewed way e.g. "[event] happened but they are a good person so it was definitely my fault" or "everyone goes through that, it's not unusual". Sometimes people might do this ‘unconsciously’ to protect themselves. Denial is a coping mechanism that gives a person time to adjust to or survive distressing situations in the short-term, but in the long-term staying in denial can have an extremely detrimental effect on someone's life.
- Dependency - An over-reliance by an adult individual on another individual for their personal and emotional well-being. This can be due to negative childhood experiences of attachment, and/or a fear of abandonment.
Depression - When someone feels very sad or down for an extended period of time, and knows there is something wrong but can't seem to break out of it. People who suffer from BPD are often also diagnosed with a mood disorder such as depression, due to experiencing chronically low moods and low self-worth. Depression can lead to suicidal thoughts/behaviours.
Dissociation - A psychological term used to describe a mental departure from reality. Someone may feel disconnected from themselves (depersonalisation) or their surroundings (derealisation), and when severe a person can 'lose' periods of time, unable to recall anything that happened during that time. Dissociation in BPD can occur when someone experiences severe stress (criterion 9 in the DSM-5).
Emotional instability - Experiencing rapid and unpredictable changes in mood throughout the day that feel out of the person's control; the emotions are often triggered by external events such as conflict in a relationship or unexpected changes to plans. “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” (quote by Marsha Linehan, creator of DBT).
- Fear of abandonment - An (often) irrational belief that one is in imminent danger of being personally rejected, discarded or replaced. Sometimes this is based on past experiences, and the threat of being abandoned may be either real or imagined.
- Feelings of emptiness - An acute, chronic sense that one's life or who they are has little worth or significance. This may lead to an impulsive appetite for strong physical sensations and experiences ('thrill-seeking' behaviour) in order to feel something different.
- Hypervigilance - When anxious or feeling threatened, individuals may become hyper-aware of certain people or situations and feel overstimulated by their surroundings. This often leads to jumpiness and fight/flight/freeze responses. It is common in those that have experienced trauma.
- Impulsiveness - The tendency to act or speak based on current feelings and urges, often without taking into consideration the consequences. Sometimes people might later regret acting on impulse.
- Invalidation - This is when someone's emotional or life experiences are denied, rejected or dismissed. When someone is consistently made to believe that their subjective thoughts, feelings, emotions or experiences are inaccurate, 'wrong' or unacceptable, they will begin to feel alienated, confused, inferior, problematic and will eventually learn to doubt and second-guess themselves. It is thought that invalidation is a major contributor to certain mental illnesses, and people with BPD might have grown up in ‘emotionally invalidating environments’.
- Isolation - The struggle to manage the emotions that result from relationships might lead someone to reduce contact with others and become socially isolated. Depression and anxiety, amongst other things, might also cause someone to withdraw from others.
- Lack of object constancy - A term used to describe difficulty remembering that people and things are consistent, stable and reliable, especially when they are not physically there. This can lead to a constant fear of abandonment. Object permanence is the understanding that objects continue to exist even when they cannot be seen, heard, or otherwise sensed.
- Loneliness - The sense of feeling alone, which may occur even if you are with other people. This is common in BPD for various reasons, whether it is because of dissociation, depression, low self-worth, paranoid thoughts, feelings of emptiness etc. This feeling is often described by people as "feeling alone in a room full of people".
- Low self-esteem - A common name for a negatively-distorted self-view which is inconsistent with reality (although for the person experiencing it, it feels like it must be reality!). This can cause someone to feel worthless and undeserving of good things.
- Masking - Hiding one's real emotion by portraying another, usually more 'positive', one. This is in an attempt to appear well to others when the person is in reality struggling to cope: 'smiling to hide the pain'. It is mostly used to conceal 'negative' emotions i.e. sadness, frustration, anxiety, anger, by 'acting' in a way that the person thinks is 'acceptable'; masking is often a behaviour learned as a consequence of invalidation.
- Mirroring - Imitating or copying another person's characteristics, behaviours or traits, or adopting the values and beliefs of whoever they are around. Some people may have learnt to do this due to not having a stable sense of self, or due to fearing that others will leave them if they don’t change (or a combination of both). This is also known as 'chameleon' behaviour.
- Panic attacks - Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and stomach upset. These can be very frightening and can appear physical in nature but are caused by an increase in anxiety.
- Perfectionism - The practice of holding oneself or others to an unrealistic, unattainable or unsustainable standard. Perfectionism may give someone a sense of control, when other areas of life feel out of their control. This is also a trait seen in other mental illnesses such as anorexia and OCD, common co-morbid diagnoses.
- Self-harm - Also known as self-mutilation or self-injurious behaviour, self-harm is any form of deliberate injury inflicted on oneself. Some people do this as a coping strategy to reduce feelings of distress, or to ground themselves when feeling disconnected or unreal (see dissociation). Psychological therapy, such as DBT, can teach people to cope in other ways.
- Unstable relationships - Someone with BPD may struggle to keep stable and healthy relationships that are supportive, have healthy boundaries, and have a positive impact on their wellbeing. They may have grown up in an unstable environment, and as a result do not know what a healthy relationship looks like. Relationship instability can present in a multitude of ways from one end of the spectrum to another e.g. people-pleasing and conflict avoidant, or consistently involved in volatile and dramatic relationships.
- Unstable sense of self - Struggling to know who you are and lacking a strong sense of identity. This is linked to ‘mirroring’ as people might adapt who they are depending on who they are with, but then may feel they don’t know who they are when they are alone. Someone may adopt different values, beliefs, goals, tastes and styles depending on who they are with or where they are.
What are some positive traits found in those with BPD?
What are the BPD diagnostic criteria?
What is it like living with BPD?
Living with BPD can vary drastically from person to person (despite the classic stereotype often portrayed in the media) and so no two people's experiences will be the same. It is important to remember that people with BPD are people first and foremost, and are NOT defined by the diagnosis/label!
How common is BPD?
BPD is thought to affect approximately 1% (1 in 100) of the general population in the UK. It's been estimated that three-quarters of those given this diagnosis are women. It's a condition that is usually diagnosed in adults only, however in recent years emerging traits of BPD are being recognised and treated in child and adolescent mental health services (CAMHS).
Why do some people develop BPD?
Researchers and mental health professionals widely agree that mental health difficulties develop through a combination of biological factors (such as genetic vulnerability and stress responses), psychological factors (such as coping skills and emotions) and social factors (such as abuse, family environment and culture). This is often referred to as the Biopsychosocial Model of mental health.
Borderline Personality Disorder, like other mental health difficulties, is likely to result from a complex combination and interaction of these factors.
Some theories suggest people with BPD are born with an inbuilt tendency to experience heightened sensitivity to their emotions, which for some people might cause them to experience their emotions more intensely than others. In addition, theories also suggest that people with BPD have an increased tendency towards acting impulsively.
Along with biological factors, psycho-social factors such as coping skills, family environment and experience of trauma can also play a role in the development of BPD. It is understood that a high proportion of people with BPD have experienced trauma with 83% of people with BPD experiencing an interpersonally traumatic event such as physical or sexual abuse. Neglect is also a significant distressing experience that can occur in childhood, which can often go unnoticed. This can lead to a sense that no one understands you and your needs, and this sense of disconnection might also be present throughout other relationships in your life.
However, this is not the case for everyone with BPD and so does not explain the full picture.
Another theory of how BPD develops is through the combination of biological sensitivities and growing up in an emotionally invalidating environment. This theory is called the Biosocial Theory and was developed by Marsha Linehan (1993; those of you reading closely will remember she was the person who created DBT). She suggests that emotionally invalidating environments are those where a child grows up believing that their emotions should be coped with alone and should not be shared with their family or friends. They may also have experienced other moments where their displays of emotion were attended to and therefore had mixed messages about appropriate ways to manage their emotions, leaving the child feeling confused and alone. It is important to note that this might not be the ‘fault’ of the child’s parents, as they may have tried their best, or felt that they were parenting their child in the best way they knew how, however the combination of this approach, and the child’s own biological sensitivities may have influenced the child becoming an adult who developed BPD or symptoms of BPD.
Of course, other factors may also contribute to the development of BPD, such as difficult life events like the early loss of a parent or the lack of availability of a parent (due to work, or perhaps their own mental health or substance use difficulties). Stressful experiences such as a break-up of a relationship or the loss of a job role may also lead to symptoms of BPD feeling more intense and unmanageable. Difficult life events can lead people to feel a sense of alienation and a desperate search for close relationships to feel protected and safe. Traumatic experiences may also lead to a sense of mistrust towards other people, leading to a confusing experience of wanting close relationships with others to feel protected and safe and also wanting to put up walls/barriers to not let people get too close.
Research is continuing to look into the causes of Borderline Personality Disorder and other mental health disorders, so by no means is this an exact science. However, hopefully the above summarises some of the current thinking.
Do I have BPD?
As with all mental health difficulties everything is on a continuum. Most people will notice some of the symptoms of BPD within themselves and so you should be wary of making a self-diagnosis. If after reading any of the information we've shared, you feel you may have BPD and that this is causing significant distress to your life, you may want to talk to someone who is medically qualified or a mental health professional. Initially start with your GP and request a referral to the community mental health services.
What mental health treatment is out there for those with BPD?
In the past few decades, treatment for Borderline Personality Disorder has changed radically, and, in turn, the prognosis for improvement and/or recovery has significantly improved. We now have a variety of interventions specifically designed for BPD, which can have significant and enduring benefits.
Under the NHS, specialised personality disorder services have been set up with a range of professionals to provide evidence-based treatment. Speak to your GP to ask about services in your local area. Many services also provide support for family members and carers of people with BPD.
Dialectical Behaviour Therapy (DBT)
DBT is a therapy developed by Marsha Linehan (1993), who is widely known to have also struggled with BPD. DBT is an extension of Cognitive Behavioural Therapy (CBT) developed specifically for individuals with BPD. DBT uses a combination of individual and group work facilitated by specialist mental health professionals. The therapeutic approach involves a mix of change orientated and acceptance strategies. DBT teaches skills in how to manage interpersonal relationships, regulate emotions and tolerate distress. Mindfulness also plays a role in the therapy – i.e., learning to pay attention to the present moment, rather than focusing on the past or the future. The full DBT treatment offers a combination of group and individual work, however some services offer individual DBT or group DBT skills, which is drawn from the same principles.
Mentalisation Based Therapy (MBT)
Mentalisation involves making sense of our thoughts, feelings and behaviours and also the thoughts, feelings and behaviours of others. When we are under stress, we can struggle to mentalise and understand our own behaviour or the behaviour of others. MBT helps people to develop skills in mentalising in order to understand how our thoughts relate to our behaviours which may also influence our relationships.
This therapy is particularly useful for people who experience difficulties in their relationships with others which then may also cause intense emotional experiences that they struggle to control. This approach also usually involves both individual and group work.
Schema therapy was also developed as an extension of CBT to treat people with BPD. In this therapy an individual is helped to identify early patterns of thoughts or beliefs that were created in their childhood. It can be helpful to understand why these beliefs about the self, others and the world might have formed as perhaps they were useful in childhood but might be contributing to difficulties in an individual’s current life. Schema therapy helps individuals to understand the link between these longstanding beliefs and current difficulties navigating intense and changing emotions.
Cognitive Analytic Therapy (CAT)
Cognitive Analytic Therapy (CAT) is a time limited therapy, typically lasting between 16-24 sessions. It is a therapy that integrates several other therapeutic approaches and focuses on the relationships in the individual’s life and patterns of relating that they can fall into. Due to the focus on relationships, CAT also focuses on the relationship between the therapist and patient as exploring this might also aid understanding in other relationships in the individual’s life.
As you may have noticed above, some therapies, such as DBT and MBT offer group-based therapeutic work. Many people with BPD are reluctant to take part in group therapy, as it can feel anxiety-provoking to talk about your difficulties in a group with others. It is completely understandable that you might have concerns about this, but please bear in mind, it can also be helpful to hear from others who have experienced similar thoughts and feelings as you as it can reduce thoughts that you are alone, and that no one can understand you. People with BPD have spoken about it being powerful and healing when they experienced understanding and support from others who have also experienced similar things to them.
Another benefit of group therapy is, due to the interpersonal nature, it can help to shine a light on how you interact with others which might support you to understand some of your patterns of relating to others and how you can make positive changes to this.
Currently, there is no single recommended medical approach to treat BPD, with psychological therapy being found to be more effective. However, medication is sometimes prescribed for co-existing mental health conditions e.g. depression, bipolar, anxiety.
For some people medication may be helpful, however this is something that is individual and should be discussed carefully with a GP, psychiatrist or medical professional.
Family and partners of those with BPD may struggle to cope with looking after a loved one with BPD and may need some support for themselves and their own emotions. If they are struggling to cope with difficult thoughts, feelings or behaviours and feel they would benefit from speaking to a professional they should speak to their GP to see what is available in their local area.
If their loved one is involved in an NHS personality disorder service, they can make enquiries as to what support is offered for family/carers. Psychoeducation can be helpful for family/carers – i.e., specific teaching from mental health professionals about BPD and how they can support the person with BPD. Some services may also offer family therapy sessions; however, this will be recommended on case-by-case basis.
In some areas, crisis teams form part of the mental health provision. These are services that provide short-term support to people who are experiencing a crisis in relation to their mental health. They are often needed when someone is experiencing thoughts of harming themselves and feels they cannot keep themselves safe.
Crisis teams can help the person by providing a 24/7 access to support, usually via the phone. They may also help the person to draw up a safety plan with information on what to do if you feel you cannot keep yourself safe.
At times, people with BPD feel unable to keep themselves safe, even with the support from a community crisis team. When this happens, a mental health professional or team might think the safest option is to spend some time in an inpatient environment, where they can be looked after and kept safe.
Inpatient units often have a range of mental health professionals, including nurses, occupational therapists, health care assistants, psychiatrists and psychologists.
Having some time in an inpatient unit may provide someone with a safe place where they can have the opportunity to be supported by professionals to understand the triggers (or what led up to) their current crisis and how to begin to feel safe again.
Hospitalisations are often short in duration as their intention is to keep someone safe until support can be found in the community.
What is the prognosis for those with BPD?
Signs of Borderline Personality Disorder usually become apparent in early adulthood, but symptoms of it (e.g. self-harm) can also be noticed for some in early adolescence.
Shockingly, as many as 1 in 10 of those diagnosed with BPD tragically die from suicide. But it's not all doom and gloom. There IS hope!
As people with BPD get older, their symptoms and/or the severity of the illness usually reduces over time. One study has found that after a period of 27 years only 8% of people still met the criteria for BPD.
It is worth noting that many people with BPD go on to have stable relationships and employment. Whilst in the past BPD was thought of as a chronic, life-long condition, we now know with treatment people can go on to live healthy, happy lives.
What is it like to have a loved one with BPD?
Family members, partners, and friends are, understandably, concerned for the safety and wellbeing of their loved one with BPD. They might feel fearful and helpless and unsure how to best support the person with BPD.
Are there any famous people with BPD?
Chicago Bears player, Brandon Marshall, is quoted on NBC Sports as saying "I was diagnosed with Borderline Personality Disorder a few years ago and got the right help, the right treatment, and now I'm advocating for it. Mental health in itself is just so stigmatized, it's a taboo topic in our homes, in our communities, and we need more people to talk about it and not make people like myself or others who can't fight for themselves a national punchline."
Marshall is one of the only celebrities we know of who is openly diagnosed with BPD and we would like to commend his bravery in being open about his diagnosis and his role in bringing BPD into the public eye. There are of course others who exhibit traits and behaviours, although have not been open as to whether or not they have received a diagnosis.
This only goes to show how much stigma and lack of understanding still surrounds having a diagnosis of BPD. Other mental health difficulties such as depression and anxiety are beginning to be spoken about in the media yet BPD remains relatively unknown.
What are the warning signs in someone at risk of suicide?
Please note, if anyone tells you they are having suicidal thoughts you should believe them and take them seriously. If you can, support them to access support through their local GP or A&E. If the person is not cooperating with you, and you feel their life is in imminent danger then call the emergency services on 999.
Some warning signs of suicide include:
- Feelings of despair, pessimism, hopelessness, desperation.
- Recent self-injury behaviours.
- Withdrawal from social circles.
- Sleep problems.
- Increased use of alcohol or other drugs or overeating.
- Winding up affairs or giving away prized possessions.
- Threatening suicide or expressing a desire to die.
- Talking about “when I am gone”.
- Talking about voices that tell them to do something dangerous.
- Having a plan and the means to carry it out.
- Apologising for past mistakes, seeming to say a ‘goodbye’, appearing fine or happy after a period of intense distress.
Why is BPD so highly stigmatised and misunderstood?
There is some controversy about the term ‘personality disorder’. This is because the link between 'what is my personality' and 'what is me' is tricky to define, and therefore might make someone feel there is something wrong with ‘me’. Some people also feel that the use of ‘personality disorder’ ignores that for many people with BPD, the symptoms have formed as a understandable way to cope with distressing emotions and/or experiences.
The name ‘Borderline Personality Disorder’ is also quite confusing, and results from in the past when BPD was thought to be on ‘the borderline’ between neurosis and psychosis. This idea is now outdated; however, the name has stuck. There have been some thoughts about changing the name, with suggestions such as 'Persistent Distress Disorder' and 'Emotional Instability Disorder'. Some have also suggested that those diagnosed with BPD actually have C-PTSD (complex post-traumatic stress disorder), to highlight the role of trauma in the development of BPD. However, as mentioned earlier, not everyone with BPD reports a history of trauma and so this might not be fitting for everyone.
Both historically and presently, BPD has been met with misunderstanding and confusion. People who have BPD can also present in vastly different ways and have very different personalities. With the nine possible symptoms there exist over 250 different ways for the disorder to present itself, and this heterogeneity is further complicated by the fact that BPD rarely stands alone. A high rate of co-occurrence exists with other disorders, which typically include major depression, bipolar disorder, substance abuse, eating disorders, and anxiety disorders. Often people report being diagnosed with another mental health condition first, before later receiving a more fitting diagnosis of BPD.
In the past, people with BPD may have experienced reluctance from mental health professionals to treat them. Thankfully this is changing, and mental health professionals have more knowledge and understanding of BPD and the evidence-based treatments that can help people with BPD.
BPD remains largely unknown in the public and due to this misinformation can spread. Many websites have negative and incorrect information about BPD which can contribute to stigma and misunderstanding.
Lastly, medications are often a source of confusion. It is not uncommon for an individual with BPD to be on a variety of medications. To date, no one medication has been specifically researched and approved for BPD, however, many people with BPD take psychiatric medication for co-existing mental health conditions.
Borderline Personality Disorder statistics
- There are 10 classified personality disorders and of those, Borderline Personality Disorder (BPD) is the most common, most complex, most studied, and certainly one of the most devastating, with up to 10% of those diagnosed committing suicide.
BPD exists in approximately 1% of the UK population.
There are some gender discrepancies in BPD, with 75% of people diagnosed with BPD being female.
- Up to 20% of all psychiatric inpatients and between 10-30% of all psychiatric outpatients have BPD.
- Between 50-80% of people with BPD engage in deliberate self-harming behaviour, such as cutting, which is done without suicidal intent. For some people this is a coping strategy to cope with mood difficulties and reduce distress. At other times it can be a way to feel 'real' when dissociating.
- Many people with BPD also have other mental health difficulties, with almost 85% also meeting criteria for another mental health diagnosis, such as depression, anxiety or eating disorders.
- Approximately 10% of people with Borderline Personality Disorder die by suicide.