Is BPD a mental illness?
Yes. Borderline personality disorder (BPD) is a serious mental illness.
In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness 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 ICD10 description of, ‘Emotionally Unstable Personality Disorder’, two types may be distinguished:
The impulsive type, characterized predominantly by emotional instability and lack of impulse control.
In the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM), Borderline Personality Disorder (BPD) is described as:
The borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts’.
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, 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 criteria is often used in the UK rather than/alongside the ICD10.
What are the symptoms of BPD?
Below are the symptoms of Borderline Personality Disorder according to government guidelines (National Institute for Health and Care Excellence [NICE] 2009).
You have emotions that are up and down (for example, feeling confident one day and feeling despair another), with feelings of emptiness and often anger.
You find it difficult to make and maintain relationships.
you have an unstable sense of identity, such as thinking differently about yourself depending on who you are with.
you take risks or do things without thinking about the consequences.
you harm yourself or think about harming yourself (for example, cutting yourself or overdosing).
you fear being abandoned or rejected or being alone.
you sometimes believe in things that are not real or true (called delusions) or see or hear things that are not really there (called hallucinations).
Information taken from
If you have been diagnosed with borderline personality disorder you may be more likely to experience other mental health related problems, such as depression, anxiety, eating disorders or substance misuse (misusing drugs or alcohol).
What are the disordered traits of BPD?
Every person has a personality: longstanding ways of perceiving, relating to, and thinking about the environment and oneself. However, when these traits are inflexible, maladaptive and cause significant functional impairment or subjective distress, they constitute a personality disorder. (John G. Gunderson, MD).
The 9 diagnostic criteria for BPD consist of the following symptoms: Abandonment Fears, Unstable/Intense Relationships, Identity Disturbance, Impulsivity, Suicidal/Self-injurious Behaviors, Affective (Emotional) Instability, Emptiness, Anger, Transient Stress Related Paranaoia or Psychotic Symptoms. You can read more about these
here in our booklet.
People with BPD are people, so just like all ‘normal’ people, those with BPD have their own unique combination of traits! Below lists some of the ways that these symptoms play out in the form of traits for some individuals.
These descriptions are not intended for diagnosis. Refer to the DSM Criteria for Personality Disorders for clinical diagnostic criteria. Everyone with BPD is different and therefore manifest the symptoms in very different way! No one person exhibits all of the traits and the presence of one or more of these traits is not evidence of a personality disorder.
Some Traits and Behaviours of those with BPD:
Abusive Cycle - This is the name for the ongoing rotation between destructive and constructive behavior which is typical of many dysfunctional relationships and families.
All or Nothing Thinking - Very black and white thinking.
Anger - People who suffer from BPD often feel a sense of unresolved anger or a heightened sense that they have been wronged, invalidated, neglected or abused. This anger can also be self-directed - feeling intense anger towards themselves.
Avoidance - The practice of withdrawing from relationships with other people as a defensive measure to reduce the risk of rejection, accountability, criticism or exposure.
Baiting - A small number of people with BPD engage in a provocative act used to solicit an angry, aggressive or emotional response from another individual.
Blaming - Some poeple with BPD tend to identify a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.
Catastrophizing - The habit of automatically assuming a "worst case scenario" and inappropriately characterizing minor/moderate problems or issues as being catastrophic.
Chaos Manufacture - Some individuals with BPD unnecessarily creating or maintaining an environment of risk, destruction, confusion or mess.
Confirmation Bias - The tendency to pay more attention to things which reinforce your beliefs than to things which contradict them.
Denial - Believing or imagining that some painful or traumatic circumstance, event or memory does not exist or did not happen.
Dependency - An inappropriate and chronic reliance by an adult individual on another individual for their health, subsistence, decision making or personal and emotional well-being.
Depression - When you feel sadder than you think you should, for longer than you think you should - but still can't seem to break out of it - that's depression. People who suffer from BPD are often also diagnosed with depression resulting from mistreatment at the hands of others, low self-worth and the results of their own poor choices.
Dissociation - A psychological term used to describe a mental departure from reality.
Engulfment - An unhealthy and overwhelming level of attention and dependency on another person, which comes from imagining or believing one exists only within the context of that relationship.
Escape To Fantasy - Taking an imaginary excursion to a happier, more hopeful place.
Fear of Abandonment - An (often) irrational belief that one is imminent danger of being personally rejected, discarded or replaced.
Feelings of Emptiness - An acute, chronic sense that daily life or who they are has little worth or significance, leading to an impulsive appetite for strong physical sensations and dramatic relationship experiences.
High and Low-Functioning - A High-Functioning Personality-Disordered Individual is one who is able to conceal their dysfunctional behavior in certain public settings and maintain a positive public or professional profile while exposing their negative traits to family members behind closed doors. A Low-Functioning Personality-Disordered Individual is one who is unable to conceal their dysfunctional behavior from public view or maintain a positive public or professional profile.
Hoarding - Accumulating items to an extent that it becomes detrimental to quality of lifestyle, comfort, security or hygiene.
Holiday Triggers - Mood Swings in Personality-Disordered individuals are often triggered or amplified by emotional events such as family holidays, significant anniversaries and events which trigger emotional memories.
Hyper Vigilance - Maintaining an unhealthy level of interest in the behaviors, comments, thoughts and interests of others.
Identity Disturbance - A psychological term used to describe a distorted or inconsistent self-view
Impulsiveness - The tendency to act or speak based on current feelings rather than logical reasoning.
Invalidation - Most people with BPD experience feelings of invalidation, believing that their thoughts, beliefs, values or physical presence are inferior, flawed, problematic or worthless.
- Isolation - The struggling to cope with social situations or to find motivation to go out and about can lead many people with BPD to become incredibly isolated.
Lack of Object Constancy - An inability to remember that people or objects are consistent, trustworthy and reliable, especially when they are out of your immediate field of vision.
Low Self-Esteem - A common name for a negatively-distorted self-view which is inconsistent with reality.
Masking - Covering up one's own natural outward appearance, mannerisms and speech in dramatic and inconsistent ways depending on the situation. Also to appear well to others when you're really struggling to cope - smiling to hide the pain.
Mirroring - Imitating or copying another person's characteristics, behaviors or traits.
Mood Swings - Unpredictable, rapid, dramatic emotional cycles.
Obsessive-Compulsive Behavior - An inflexible adherence to arbitrary rules and systems, or an illogical adherence to cleanliness and orderly structure.
Panic Attacks - Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.
Perfectionism - The maladaptive practice of holding oneself or others to an unrealistic, unattainable or unsustainable standard of organization, order, or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in other areas of living.
Self-Harm - Self Harm, also known as self-mutilation, self-injury or self-abuse is any form of deliberate, premeditated injury inflicted on oneself. The most common forms are cutting and poisoning/overdosing.
Self-Loathing - An extreme hatred of one's own self, actions or one's ethnic or demographic background.
Self-Shaming - The difference between blaming and shaming is that in blaming, you're telling yourself that you did something bad, in shaming you're telling yourself or that you are something bad.
Silent Treatment - Some people with BPD may adapt this passive-aggressive form of emotional abuse in which displeasure, disapproval and contempt is exhibited through nonverbal gestures while maintaining verbal silence.
Sleep Deprivation - Having a routinely interrupted, impeded or restricted sleep cycle.
Splitting - The practice of regarding people and situations as either completely "good" or completely "bad".
Stunted Emotional Growth - Struggle to emotionally cope with situations in the same way healthy adults can, due to parts of the brain not developing normally in childhood.
Testing - Repeatedly forcing another individual to demonstrate or prove their love or commitment to a relationship.
Tunnel Vision - A tendency to focus on a single concern, while neglecting or ignoring other important priorities.
What are the positive traits of BPD?
We are extremely loyal and have a keen sense of connection with others despite a social norm of individual disconnectedness. BPDs can teach that we’re all deeply connected.
We love deeply. We have the ability to relate deeply and intensely to others. We have a keen awareness of the creative and destructive traits of others and self. We see both the positive and negative of all things. BPDs can teach about the light and shadow in both themselves and others and share this knowledge with many people.
We are not afraid to change and adapt to our environment. We are fluid in our identities and open to new experiences. We have a self that is highly adaptive in order to facilitate relations with more rigidly defined others. We are able to build ties with people even in unfamiliar environments. BPDs can teach that ‘self’ exists in relation to ‘other’.
We have a wide-ranging approach to life and don't live boxed into various categories. We are open-minded to new experiences. Life is never boring. We are not afraid to live on the edge and release childish inhibitions in order to have a full life. We have a deep urge to explore the ecstatic heights and depths of human experience even at the expense of personal risk. BPDs can teach that ecstatic experience is a fundamental part of human existence.
We feel and express our feelings strongly. We find release for our emotions. BPDs can teach about the importance of healthy release of emotions.
We are open to feelings and experiences. We are not static beings. We are able to experience the full emotional spectrum more than nearly anyone. We have heightened sensitivity to atmospheric shifts in the environment and within the individual. BPDs can teach how to tune in to the surroundings on an emotional level.
We are in touch with the existential darkness. We have a deep-seated thirst for meaningful relationships and experiences that is not easily satisfied with artificial substitutes. We realize that there are times we have needs that need emotionally filled. We realize that we as human beings are not complete, and that this is unable to be changed. BPDs can teach that the soul needs nourishment beyond what mainstream society has to offer.
We express our feelings strongly. We have strong reactions to injustice or abuse that sometimes transfers across time and place or individual boundaries. BPDs can teach that anger is an appropriate reaction to injustice and oppression.
We are very sensitive to our environment. We have a connection to realms of experience outside of prescribed "normality" that is cherished and revered in other cultural contexts. We realise that one’s idea of reality is often subjective, and that the world around us is all designed by our perception. BPDs can teach that experience is not limited to the five senses and can offer insight into realms beyond the obvious.
What is the BPD diagnostic criteria?
DSM-IV-TR Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5].
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, promiscuous sex, eating disorders, substance abuse, reckless driving, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
You can read more about these criteria
here in our booklet.
What is it like living with BPD?
Living with BPD can vary drastically from person to person, for several reasons people vary drastically, and people with BPD are people first and foremost!
To be diagnosed, an individual must present with 5 of the listed symptoms. Because there are nine possible symptoms there exist over 200 different ways for the disorder to present itself.
Also, people with BPD usually have one or more other mental health diagnoses and issues alongside BPD e.g eating disorders, OCD, substance abuse etc.
But below you can read Sarah's story, to get a glimpse into one individual's experience:
Sarah’s Story (2013 Article)
For 16 years, Sarah has been fighting anorexia and a condition called borderline personality disorder (BPD). It is a daily battle.
"Most friends and family only see me when I'm having a fairly good day," she says. "When it's bad, I shut myself away from the world.
"People who don't know me see me as an able, intelligent articulate girl. They don't understand or even believe that I have such a debilitating condition”.
What is important is that the brave and brutally honest young woman is sharing her story. She wants people to read what she is going through and how she copes.
Anorexia, suicidal thoughts, self-harm and manic moods are what Sarah has to cope with in her life. Sarah was just a teenager when she tried to take her own life. And between suicide attempts, she was severely self-harming and restricting her food-intake as a form of self-punishment.
Sarah was a teenager when her mum first noticed the wounds on her arms. She took her to the doctor and was referred to the Child and Adolescent Mental Health Services.
Sarah left school with a bunch of GCSEs but when her health took a serious dip, she was forced to drop out of education. Struggling to maintain her weight, she spent time some time at home with her parents.
"I had chronic feelings of emptiness and a complete lack of self-worth," she says.
"I had distortion of reality and had started to self-harm. I'd been restricting my eating and would only allowed myself a cold shower as punishment. I must have had BPD then, but as the personality is not yet fully developed, it isn't diagnosed until adulthood.”
"It was well over a year later when I started to eat better. My parents were distraught to see how poorly I had become.
"These days, on bad days, I just go to bed," she says. "I take my pills which knock me out and I try and sleep it off. I can be in bed for days but I think that's the safest place for me when I'm feeling bad.”
Today is a good day for Sarah. She has got out of bed and is dressed. She is bright, bubbly and chatty. But tomorrow, things could be very different. She may not be able get up. She could feel low and depressed and be too frightened to leave her little bungalow. A slight change in mood or a tiny (real or imagined) incident can trigger her off. Her day can quickly get worse.
Mood swings, from suicidal to manic, can pose real dangers for Sarah – and paranoia simply consumes her. "I have severe mood swings, can have no rational thinking and experience dangerous psychotic episodes. I self-harm, hear voices in my head and feel very insecure. When you're faced with these problems, simple things can prove hugely difficult. My head is always full of stuff. I nap all the time because I'm so tired." Her mood changes and lack of stability make it impossible for her to get a job. She would like to join a choir or an orchestra but she lacks the drive to do it.
Her paranoia and psychosis has caused rifts with friends and problems with her family. And maintaining a romantic relationship would be impossible right now. Sarah's deep fear of abandonment and her erratic moods would certainly push someone away.
Sarah admits she struggles to cope on a daily basis. Doing simple tasks like cooking a meal can be impossible. And if she is feeling low, or upset or paranoid, she simply stays under the duvet.
"Imagine waiting for the bus and when it doesn't come, thinking that someone is out to ruin your day and it's all part of the 'conspiracy' against you," says Sarah. "Everything is personal. I can be walking down the street and the voices in my head start telling me that I'm being followed. I 'zone out' and forget what I'm doing.
The psychotic and dissociative episodes are scary and Sarah never knows what she has done until she has come out of one. Once she woke up to find she had cut all her hair off.
Another time, in the middle of the night, she was convinced there were dangerous men in her house forcing her to harm herself. She says, “I ran into town and didn't even have my shoes or coat on." She left her house unlocked and ran off, ending up in a very vulnerable situation.
When times get really back and she is able to recognise her mental health is deteriorating, she calls for help. She has friends who come over and stay at her place. Her parents and one of her sisters also live locally and do all they can to help."I try to contact friends when I'm in a panic. They call for the paramedics if they think I've taken an overdose or harmed myself," she says. "But I find it hard to reach out for help, as I hate being such a burden to people."
When Sarah was rushed to hospital following another suicide attempt in her 20s, the true extent of her problems was revealed. She was in Australia working on community projects, when she took an overdose. "Since then, I've been in and out of hospital for my anorexia but I've not had treatment for Borderline Personality Disorder," she says.
"I spent 11 months in hospital in 2010/11. I am definitely better than I was then. I was admitted to an eating disorder unit in Oxford for a few months, and it helped a lot with the anorexia, they had no expertise with treating BPD. I was discharged once my weight was stable, but my BPD symptoms were rampant."
"Two days later I was admitted to an acute psychiatric unit in Derby. But the problem exacerbated. The team could keep me from self-harming but that was really just by locking me up. They didn't have time, expertise or the staff to actually treat BPD and they had no experience at all of eating disorders and my weight plummeted. I hated my time in the acute psychiatric ward. It was a horrible place to be. I had friends and family to visit me and I made friends with another girl on the ward, which helped. But it was not a nice place to be!”
"After those two months in the acute unit, I was then transferred to another eating disorder unit in Leicester as my weight was getting dangerously low. It was there that I was officially diagnosed with BPD. I had some fantastic sessions with a psychiatrist. He had a good understanding of borderline personality disorder and gave me amazing one-to-one support."
Sarah's weight is stable these days, and her eating habits are better than they were, but when she is having a really bad day, she just feels that she does not deserve food. Fighting that thought and making herself eat is exhausting. She is managing her BPD symptoms as best she can, but it is still a pervasive struggle.
Sarah has her own theories as to why she developed BPD and anorexia. She would like to keep some of the reasons to herself, but she says she has always felt like she is a very needy and insecure person. She describes her childhood as loving, but says she was a little girl who desperately craved love and attention all the time. "I don't blame anyone," says Sarah. "I believe I was born with some of these problems. It's the way I'm wired, but that doesn't mean I don't want to be well. I'd love to lead a normal life".
"It's a difficult condition and I know it's hard for people to get a firm understanding of it. But I am passionate about breaking down the stigma that those with BPD are merely their label! We are people first and foremost!"
"My life is much more than just this condition. I love to sing, hang out with my friends, create art and watch comedies. I love my cats (and animals in general) and I am passionate about collecting and photographing Lego figures During a spell when I was well, I travelled the world and also did a degree in Creative Expressive Therapies."
"Over the past few years, I have not been well enough to hold down a paid job, but that is something I am working towards! I am learning to feel proud of myself for what I achieve whilst simultaneously battling this condition! The illness is something that I have to fight, it is not who I am!”
When this article was originally written in 2013, there were no services available for people with BPD who live in Derby. Thankfully now this has changed. Sarah has accessed Dialectical Behaviour Therapy and is now having therapy to deal with the deeper roots that cause the symptoms.
Sarah still has ups and downs, but the amount of ups are certainly increasing! She had to spend a few months in an acute psychiatric ward in 2016 and had a relapse of anorexia in 2017, but she has also set up a Registered Charity to raise awareness of Borderline Personality Disorder and she is learning British Sign Language.
"I still struggle, but I have more hope and resilience now and I am in a better place to tackle the symptoms and to embrace all the good things in life".
This article is an adapted combination of two stories written by journalist Wendy Roberts, which were published in the Derby telegraph. To read the original articles, see:
This Is Derbyshire
How common is BPD?
BPD is thought to affect less than one per cent of the general population. 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.
Why do some people develop BPD?
The causes of BPD are unclear. Most researchers think that BPD develops through a combination of factors including temperament, childhood and adolescent experiences, difficult life events such as the early loss of a parent, childhood neglect, sexual or physical abuse are common in people diagnosed with BPD, though this is not always the case. Stressful experiences, such as the break-up of a relationship or the loss of a job, can lead to already present symptoms of BPD getting worse.
Borderline Personality Disorder, like all other major psychiatric disorders, is caused by a complex combination of genetic, social, and psychological factors. All modern theories now agree that multiple causes must interact with one another in order for the disorder to become manifest.
There are, however, known risk factors for the development of BPD. The risk factors include those present at birth, called temperaments; experiences occurring in childhood; and sustained environmental influences.
A. Inborn Biogenetic Temperaments
The degree in which Borderline Personality Disorder is caused by inborn factors, called the “level of heritability” is estimated to be 52-68%. This is about the same as for bipolar disorder. What is believed to be inherited are the biogenetic dispositions, i.e. temperaments, (or, as noted above, phenotypes), for Affective Dysregulation, Impulsivity, and Interpersonal Hypersensitivity. For children with these inborn dispositions, environmental factors can then significantly delimit or exacerbate them into adult BPD. But, in addition, some more BPD-specific disposition is inherited that glues these phenotypes together.
Many studies show that disorders of emotional regulation, interpersonal hypersensitivity, or impulsivity are disproportionately higher in relatives of BPD patients. The affect/emotion temperament predisposes individuals to being easily upset, angry, depressed, and anxious. The impulsivity temperament predisposes individuals to act without thinking of the consequences, or even to purposefully seek dangerous activities.
The interpersonal hypersensitivity temperament probably starts with extreme sensitivity to separations or rejections. Another theory has proposed that patients with BPD are born with excessive aggression which is genetically based (as opposed to being environmental in origin). A child born with a cheerful, warm, placid or passive temperament would be unlikely to develop BPD.
Normal neurological function is needed for such complex tasks as impulse control, regulation of emotions, and perception of social cues. Studies of BPD patients have identified an increased incidence of neurological dysfunctions, often subtle that are discernible on close examination. The largest portion of the brain is the cerebrum, where information is interpreted coming in from the senses, and from which conscious thoughts and planned behavior emanate.
Preliminary studies have found that individuals with BPD have a diminished response to emotionally intense stimulation in the planning/organizing areas of the cerebrum and that the lower levels of brain activity may promote impulsive behavior. The limbic system, located at the center of the brain, is sometimes thought of as “the emotional brain”, and consists of the amygdala, hippocampus, thalamus, hypothalamus and parts of the brain stem. There is evidence that in response to emotional arousal, the amygdale is particularly active in persons with BPD.
B. Psychological Factors
Like most other mental illnesses, Borderline Personality Disorder does not appear to originate during a specific, discrete phase of development. Recent studies have suggested that pre-borderline children fail to learn accurate ways to identify feelings or to accurately attribute motives in themselves and others (often called failures of “mentalization”). Such children fail to develop basic mental capacities that constitute a stable sense of self and make themselves or others understandable or predictable.
One important theory has emphasized the critical role of an invalidating environment. This occurs when a child is led to believe that his or her feelings, thoughts and perceptions are not real or do not matter.
About 70% of people with BPD report a history of physical and/or sexual abuse. Childhood traumas may contribute to symptoms such as alienation, the desperate search for protective relationships, and the eruption of intense feeling that characterize BPD. Still, since relatively few people who are physically or sexually abused develop the borderline disorder (or any other psychiatric disorder) it is essential to consider temperamental disposition. Since BPD can develop without such experiences, these traumas are not sufficient or enough by themselves to explain the illness. Still, sexual or other abuse can be the “ultimate” invalidating environment. Indeed, when the abuser is a caretaker, the child may need to engage in splitting (denying feelings of hatred and revulsion in order to preserve the idea of being loved).
Approximately 30% of people with BPD have experienced early parental loss or prolonged separation from their parents, experiences believed to contribute to the borderline patient’s fears of abandonment. People with BPD frequently report feeling neglected during their childhood. Sometimes the sources for this sense of neglect are not obvious and might be due to a sense of not being sufficiently understood. Patients often report feeling alienated or disconnected from their families. Often they attribute the difficulties in communication to their parents. However, the BPD individual’s impaired ability to describe and communicate feelings or needs, or resistance to self-disclosure may be a significant cause of the feelings of neglect and alienation.
Where its etiology was once thought to be exclusively environmental, we now know it is heavily genetic.
DBT Self Help)
Do I have BPD?
If after reading any of the information we've shared, you feel you may have BPD, you may want to talk to someone who is medically qualified. Initially start with your GP.
Be very wary of making a self-diagnosis.
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. Where once it was thought to require heroic commitments to undertake BPD treatment, we now have a variety of interventions specifically designed for BPD, which can have significant and enduring benefits.
One of the preliminary questions confronting families/friends is how and when to place confidence in those responsible for treating the patient. Generally speaking, the more clinical experience the treater(s) have working with borderline patients, the better. In the event that several professionals are involved in the care of a borderline individual, it will be important that they are compatible in their approaches and are communicating with one another. Support by family members of treatment is equally important.
Psychotherapy is the cornerstone of most treatments of borderline patients. Although development of a secure attachment to the therapist is generally essential for the psychotherapy to have useful effects, this does not occur easily with the borderline patient, given his or her intense needs and fears about relationships.
Moreover, many therapists are apprehensive about working with borderline patients. The symptomology of the borderline patient can be as difficult for professionals as it is for family members. The treater may assume the role of protective caretaker, and then experience feelings of anger and fear when the patient engages in dangerous and maladaptive behaviors. Even very able, motivated therapists are sometimes abruptly terminated by borderline patients. Often, however, though experienced as a failure, these brief therapies turn out to have served a valuable role in helping the patient through an otherwise insurmountable situation and in making the patient more amenable to subsequent therapists.
The standard recommendation for individual psychotherapy involves one to two visits a week with an experienced clinician for a period of one to six years. Good therapists need to be active and maintain consistent expectations of change and patient participation.
Essential to successful therapy for a borderline patient is the development of feelings of trust and closeness with the therapist (which may have been missing from the patient’s life to that point) with the expectation that this would enhance the ability of the patient to have relationships of this nature with others. Validation, including being listened to, helps individuals develop recognition and acceptance of their self as unique and worthy.
Multiple forms of psychotherapy have been shown by research to be effective. All of them decrease self-harm, suicidality, and use of hospitals, emergency rooms, and medications. The best known and most widely practiced of the empirically validated therapies is Dialectical Behaviour Therapy. Three other effective therapies for BPD are psychodynamic (psychoanalytic): Arts Therapies, Transferance Focussed Psychotherapy (TFP) and Mentalization Based Therapy (MBT). These alongside other therapies sometimes offered are described below:
Dialectical Behavior Therapy (DBT)
DBT combines individual and group therapy modalities and is directed at teaching the patient skills to regulate intense emotional states and to diminish self-destructive behaviors. DBT includes the concept of mindfulness, including self-awareness and balancing cognitive and emotional states, resulting in “wise mind.” DBT also emphasizes regulating emotions; distress tolerance skills and effective interpersonal skills. This therapy’s proactive, problem-solving approach readily engages borderline patients who are motivated to change.
Arts or creative therapies may be offered individually or with a group as part of a treatment programme for people with BPD. Therapies may include: art therapy, dance movement therapy, dramatherapy and music therapy. Sadly these are not often offered on the NHS for those with BPD, as they are incredibly powerful.
Arts therapies aim to help people who are finding it hard to express their thoughts and feelings verbally. The therapy focuses on creating something as a way of expressing your feelings. The arts therapists can help you to think about what you've created and whether it relates to your thoughts and experiences.
* Read about
here and find a local private therapist
* Read about
here and find a local private therapist
* Read about
here and find a local private therapist
* Read about
Dance and Movement Therapy
here and find a local private therapist
Transference Focused Psychotherapy (TFP)
This is a twice-weekly individual psychotherapy that emphasizes the interpretation of the meaning for the patient’s behaviors within relationships, most notably the relationship with the therapist. TFP also emphasizes the importance of experiences of anger.
Mentalization Based Therapy (MBT)
This combines individual and group therapy. It emphasizes learning to recognize one’s own mental states (feelings/attitudes) and those of others as ways of explaining behaviors. This capability is called mentalizing, and is a capacity that all effective therapies try to enhance.
Selective serotonin reuptake inhibitors and other antidepressants have frequently been prescribed to patients with BPD, but they are only modestly useful. Randomized controlled trials now suggest that atypical antipsychotics or mood stabilizers may be better choices. These studies also show that no type of medication is consistently or dramatically effective.
Benzodiazepines are the one class of medications shown to make patients worse, though even here, there are exceptions. Thus medications should be initiated with the full understanding by the borderline patient that they have an adjunctive role to psychotherapy in treatment. In practice, prescribing medications may help to facilitate a positive alliance by concretely demonstrating the physician’s wish to help the borderline patient feel better; but unrealistic expectations of the benefits of medication can undermine work on self-improvement.
Common concerns when prescribing medication to these patients include risks of overdosing and non-compliance, but experience suggests that medications can be used with much reduced risk as long as a patient is regularly seeing and communicating with his or her provider.
Another common problem in practice is polypharmacy, which may occur when patients want to continue or add medications despite a lack of demonstrable benefit; eighty percent of borderline patients are taking three or more medications. Consequences include side effects such as obesity (especially with antipsychotic agents) and associated problems such as hypertension and diabetes. When the benefit of a medication is unclear, patients should be urged to discontinue it before initiating a new one.
Parents and spouses often bear a significant burden. They usually feel misjudged and unfairly criticized if the person with BPD blames them for their suffering. Suffice it to say, that for both the borderline patient, and those who love them, living with this disorder is challenging.
Family members are usually grateful to be educated about the borderline diagnosis, the likely prognosis, reasonable expectations from treatment, and how they can contribute. Such interventions often improve communication, decrease alienation, and relieve family burdens. Conjoint sessions with parents and the BPD offspring should be offered both the borderline patient and their parents need to be motivated to participate, to have established an ability to communicate with words (rather than actions) and to willing listen to each other.
Group therapies include those led by professionals, with selected membership, and self-help groups, comprised of people who gather together to discuss common problems. Both are effective treatments.
DBT skills groups are often like classrooms with much focus and direction offered by the group leader and with homework between sessions. MBT groups offer a form for recognizing misattributions and how one affects others. Borderline patients may be resistant to interpersonal or psychodynamic groups which require the expression of strong feelings or the need for personal disclosures. However, such forums may be useful for these very reasons. Moreover, such groups offer an opportunity for borderline patients to learn from persons with similar life experiences, which, in conjunction with the other modalities discussed here, can significantly enhance the treatment course.
Many borderline patients will find it more acceptable to join self-help or support groups. Such self-help groups that provide a network of supportive peers can be useful as an adjunct to treatment, but should not be relied on as the sole source of support.
Hospitalisation in the care of borderline patients is usually restricted to the management of crises (including, but not limited to, situations where the individual’s safety is precarious). Hospitals provide a safe place where the patient has an opportunity to gain distance and perspective on a particular crisis and where professionals can assess the patient’s psychological and social problems and resources. It is not uncommon for medication changes to take place in the context of a hospital stay, where professionals can monitor the impact of new medications in a controlled environment. Hospitalisations are usually short in duration.
What is the prognosis for those with BPD?
Borderline Personality Disorder usually manifests itself in early adulthood, but symptoms of it (e.g. self-harm) can be found 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 individuals with BPD age, their symptoms and/or the severity of the illness usually diminish. Indeed, about 40-50% of borderline patients remit within two years and this rate rises to 85% by 10 years. Unlike most other major psychiatric disorders, those who do remit from BPD don’t usually relapse!
Studies of the course of BPD have indicated that the first five years of treatment are usually the most crisis-ridden. A series of intense, unstable relationships that end angrily with subsequent self-destructive or suicidal behaviors are characteristic. Although such crises may persist for years, a decrease in the frequency and seriousness of self-destructive behaviors and suicidal ideation and acts and a decline in both the number of hospitalizations and days in hospital are early indications of improvement. Whereas about 60% of hospitalized BPD patients are readmitted in the first six months, this rate declines to about 35% in the eighteen months to two-year period following an initial hospitalization. In general, psychiatric care utilization gradually diminishes and increasingly involves briefer, less intensive interventions.
Improvements in social functioning proceed more slowly and less completely than do the symptom remissions. Only about 25% of the patients diagnosed with BPD eventually achieve relative stability through close relationships or successful work. Many more have lives that include only limited vocational success and become more avoidant of close relationships. While stabilization is common, and life satisfaction is usually improved, the persisting impairment of social role functioning of the patients is often disappointing.
Where it was thought to be a highly chronic, resistant-to-change disorder, we now know it has a remarkably good prognosis.
What is it like to have someone with BPD in your family?
Family members are, understandably, tormented by the threat and/or carrying out of such acts. Reactions, naturally, vary widely, from wanting to protect the patient, to anger at the perceived attention-demanding aspects of the behavior. The risk of suicide incites fear, anger, and helplessness.
You can Rachel's story
here about having a sibling with BPD.
Is there support out there for friends/family of those with BPD?
Click here for a link to helpful message boards.
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. There are 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 still surrounds having a diagnosis of BPD, as other mental illnesses such as depression, Bipolar disorder and anxiety are beginning to be spoken about in the media yet BPD remains relatively unheard of.
What are the warning signs of suicide?
Some warning signs of suicide include:
feelings of despair, pessimism, hopelessness, desperation.
recent self-injury behaviours.
withdrawal from social circles.
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 him or her to do something dangerous.
having a plan and the means to carry it out.
Why is BPD so highly stigmatised and misunderstood?
The question of 'personality disorders' is controversial. What some experts term as 'personality' others regard as 'the self'; so any suggestion that a person's self is disordered, damaged or flawed can be distressing.
Borderline personality disorder, historically and even presently, is a disorder that has met with widespread misunderstanding. There are many reasons for the confusion. With the nine possible symptoms there exist over 200 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, bi-polar disorder, substance abuse, eating disorders, and anxiety disorders.
To compound the problems, unfortunately another diagnosis is often assessed instead, BPD is often missed or ignored. Data indicate, on average, that five years elapse before BPD is accurately diagnosed in a patient. Lastly, medications are often a source of confusion. It is not uncommon for an individual with BPD to be on three, four, five, six or more medications. To date, no one medication has been specifically researched and approved for BPD.
Even among other mental illnesses, BPD is surrounded by a phenomenon that may be termed "surplus stigma."
Issues that promote stigma and, thus, further the BPD misunderstanding include:
1) Theories on the development of the disorder, with a suspect position placed on parents
similar to the erstwhile schizophrenogenic-mother concept
2) Frequent refusal by mental health professionals to treat BPD patients
3) Negative and sometimes pejorative web site information that projects hopelessness
4) Clinical controversies as to whether the diagnosis is a legitimate one, a controversy that
leads to the refusal of some insurance companies to accept BPD treatment for
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 2-4% of the general population
Up to 20% of all psychiatric inpatients and 15% of all psychiatric outpatients have BPD.
Females predominate (about 75%) within psychiatric settings while males are more common in substance abuse or forensic settings.
8-10% of the individuals with Borderline Personality Disorder commit suicide
approximately 75% of patients having the diagnosis and in an even higher percentage for those who have been hospitalized engage in deliberate self-harm behaviors (sometimes referred to as parasuicidal acts)
About 40% of self-harming acts done by borderline patients occur during dissociative experiences, times when numbness and emptiness prevail.
Approximately 50% of people with BPD are experiencing an episode of major depression when they seek treatment, and about 80% have had a major depressive episode in their lifetimes.
What Informal Support is out there for people with BPD?
If you are experiencing mental health problems or need urgent support, there are lots of places you can go to for help and support.
As Borderline Arts is focusing on challenging discrimination in society, we're not able to provide individual or emergency support for people in crisis. But there are lots of people who can. They are listed on our website