Borderline personality disorder: definition, causes, symptoms, types, and treatments

Borderline personality disorder (BPD) is a Cluster B personality disorder indicated by the inability to control emotions, which leads to dramatic and intense behaviors. People with BPD aren’t aware their reactions are unhealthy until they are diagnosed and treated properly. In fact, borderline personality disorder is one of the most disabling mental illnesses.

The causes of BPD include a combination of genetic factors and brain abnormalities. Someone is more likely to develop BPD if their family members also have it. Studies have shown that people with BPD have abnormalities in neurotransmitters and specific brain areas.

Symptoms of BPD include severe fear of abandonment, intense or unstable relationships, changes in self-identity and self-image, stress-related paranoia, and risky or impulsive behaviors.

There are four types of borderline personality disorder. These are discouraged BPD, impulsive BPD, petulant borderline, and self-destructive borderline.

The treatment for BPD includes psychotherapy as the first-line treatment. Medications may also be prescribed to manage symptoms. Most severe cases require hospitalization to reduce the risk of self-harm. While there is no cure that would eliminate BPD entirely, it’s possible to manage the severity of symptoms and improve quality of life.

What is borderline personality disorder?

Borderline personality disorder is a mental illness that affects a person’s ability to control their emotions. For that reason, symptoms of BPD affect someone’s functioning in daily life.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association categorizes BPD among Cluster B personality disorders. As a Cluster B personality disorder, this mental illness involves erratic and dramatic behaviors.

Not every person with dramatic behaviors has BPD. The difference is that someone with borderline personality disorder doesn’t know there’s a healthier way to behave and relate to themselves and other people.

Borderline personality disorder has a long history. For many years psychiatrists have been exploring erratic behaviors and lack of emotional regulation in people. The term borderline personality was proposed in the United States by Adolph Stern in 1938. Stern first described a group of patients whose symptoms didn’t fit into psychotic and psychoneurotic conditions. He came up with the term borderline to describe the condition whose symptoms border on other mental illnesses.

It took a while after 1938 to establish a clear difference between BPD and other mental conditions. For example, back in 1941, psychoanalyst Gregory Zilboorg described borderline personality disorder as a mild version of schizophrenia.

The understanding of borderline personality changed with its introduction to DSM-3 in 1980. The next edition, DSM-4 from 1994, further explained the symptoms of BPD and diagnostic criteria.

How common is borderline personality disorder?

The lifetime prevalence of BPD, according to UpToDate, is around 6%. Numbers show that the prevalence of BPD in the general population is approximately 1.6% and 20% in the inpatient psychiatric population.

The disorder can be diagnosed in patients as young as 11 years old. However, prevalence of BPD in children is unknown. When it comes to adolescents, the prevalence of borderline personality disorder in this population is around 3%, according to a paper from the Adolescent Health, Medicine, and Therapeutics.

The National Alliance on Mental Illness reports that approximately 75% of people with BPD are women. Men may be equally affected by borderline personality disorder, but they are commonly misdiagnosed with depression or post traumatic stress disorder (PTSD).

A paper from Advances in Psychiatric Treatment revealed that the prevalence of personality disorders among older adults in the community had been around 10%. The American Journal of Geriatric Psychiatry confirmed that BPD was among the most prevalent personality disorders in older adults, in addition to narcissistic and dependent traits. More recent evidence, such as a review from the January 2022 issue of Current Opinion in Psychiatry, shows the rates of BPD in older adults are decreasing. For example, a paper from European Psychiatry reported prevalence of BPD in adults older than 55 years is 3.2%, but it is decreasing due to factors such as risky behavior and suicide.

What are the causes of borderline personality disorder?

Several factors may play a role in the development of this disorder rather than a single cause. The causes of borderline personality disorder are listed below:

• Genetic factors
• Brain abnormalities

1. Genetic factors

Genetic factors are gene mutations or variations that make a person more susceptible to developing a borderline personality disorder. They are the main reason why this disorder tends to run in families.

Studies of borderline personality disorder in families reveal that first-degree relatives of people treated for this disorder are 10 times more likely to have been treated for this mental illness themselves than relatives of people with bipolar disorder and schizophrenia. That means a person is more likely to develop BPD if their sibling or parent has it.

However, first-degree relatives don’t share genes only. They also share the environment, which is why genetic predisposition is not the only cause of BPD. Twin studies have shown that 42% of the variation in borderline personality disorder resulted from genetics, whereas 58% occurred due to other factors such as the environment.

The journal Translational Psychiatry identified two genes, DPYD and PKP4, that play a role in the development of BPD. These particular genes are also associated with some other mental illnesses. Further research is necessary to identify other genes that play a role in the onset of BPD. It’s highly likely that multiple genes are involved rather than one or two variations.

Keep in mind that while genetic factors play an important role in BPD, as they’re passed from parents to children, they don’t tell the whole story. Heredity is combined with other factors in the development of this mental illness.

2. Brain abnormalities

Brain abnormalities are changes in specific areas of the brain that contribute to the onset of BPD symptoms. More precisely, these abnormalities are in regions that participate in emotion regulation, aggression, and impulsivity.

According to a paper from the Journal of Psychiatry and Neuroscience, BPD has been associated with the amygdala and limbic systems of the brain, the centers that regulate emotion, especially rage, fear, and impulsive, automatic reactions. In people with BPD, the hippocampus and amygdala are about 16% smaller, which could result from traumatic experiences.

Additionally, the same paper explains people with BPD exhibit reduced metabolism of glucose in the prefrontal cortex and limbic system. This suggests the disorder could occur due to a failure of the rational prefrontal cortex to control the impulsive limbic system.

Cranial trauma (traumatic brain injury) sustained during childhood may lead to permanent functional abnormalities that result in symptoms of borderline personality disorder.

Hypoactivity in some parts of the brain and hyperactivity in other areas contribute to a failure of rational thought to control emotional thought. These activities result in emotional instability and impulsivity associated with BPD.

A paper from Psychiatry Research found that people with BPD have a decreased grey matter. This brain abnormality was particularly present in victims of child abuse. Diminished grey matter in the prefrontal cortex and medial temporal cortex could mediate the dysregulation of affection and impulse in BPD. This is yet another mechanism through which changes in the structure and function of the brain contribute to symptoms of this disorder.

Many people with borderline personality disorder have problems with neurotransmitters, especially serotonin. Evidence shows dysfunctions in both dopaminergic and serotonergic neurotransmitter systems play an important role in the etiology of BPD.

What are the symptoms of borderline personality disorder?

Symptoms of borderline personality disorder are behaviors and thoughts that change how a person feels about themselves, other people, and how they behave. The symptoms usually start in late adolescence or early adulthood.

Stressful experiences or troubling events can trigger the onset of these symptoms or worsen their intensity. The severity of symptoms goes from manageable to very severe. People with BPD have a combination of symptoms listed below:

• Severe fear of being abandoned
• Unstable, intense relationships frequently
• Self-identity and self-image change quickly
• Stress-related paranoia and periods of losing touch with reality
• Risky and impulsive behavior

1. Severe fear of being abandoned

Severe fear of being abandoned is the overwhelming worry by a person that someone close to them will leave. In most cases, the fear of abandonment is unwarranted but persistent. Many people with borderline personality disorder have a fear of abandonment and are uncomfortable being alone. When someone with BPD feels lonely, abandoned, or neglected, they also develop symptoms such as intense anger or fear, which they can’t control.

Physical effects of fear of abandonment range from nausea and vomiting to headache and stomachache. People with this symptom are too focused on others and whether they’re going to leave, which is why they pay less attention to their health. This can lead to problems with hygiene, overeating, weight gain, and associated risks.

Behavioral effects of fear of abandonment include tracking someone’s whereabouts to stop them from leaving, constantly confronting a person and accusing them of wanting to or preparing to leave, and other suspicious behaviors. These people may even deliberately push someone away just to avoid being rejected or abandoned. People with this symptom find it difficult to have healthy relationships. Their self-esteem worsens, and trust or anger issues become more intense, which can lead to irrational behaviors.

2. Unstable, intense relationships frequently

Unstable, intense relationships refer to relationships that are unhealthy, toxic, and even dangerous for one or both people. Patients with borderline personality disorder find it difficult to maintain healthy personal relationships mainly because they quickly change their views of others. For instance, a person with BPD idealizes someone one moment and quickly devalues them, and vice versa.

The effects of unstable, intense relationships are largely behavioral. People tend to have chaotic relationships where they exhibit behaviors such as anger, frustration, desperation, and impulsiveness. They may also lose motivation for work and school, which leads to impaired productivity or even job loss.

3. Self-identity and self-image change quickly

Self-identity and self-image changes are impaired beliefs about oneself. People with BPD often develop unclear or distorted self-images as they feel guilty or ashamed of their impulsiveness. Many of them start considering themselves “bad.” In addition to changing their perception of themselves, people with BPD may also change other aspects of their personality. For instance, their goals and interests may change abruptly.

Physical effects of this symptom could be a lack of care for one’s appearance, hygiene, and health in moments when a person considers themselves bad or undeserving of love and success. Lack of care about the body and health may contribute to various problems, including weight gain and the risks that come with it.

Behavioral effects of self-identity and self-image changes include changing social circles and careers out of the blue. In many cases, a person with this symptom sabotages their progress. For example, they may fail something on purpose to get fired. They may also ruin a relationship with someone that could be good for them.

4. Stress-related paranoia and periods of losing touch with reality

Stress-related paranoia is a common symptom of BPD, and it involves impaired perception of reality in times of stress or anxiety. It is also known as paranoid ideation, this symptom is transient and involves feelings of being threatened, conspired against, and persecuted.

The effects of stress-related paranoia are largely behavioral and psychological. They include difficulty maintaining relationships, social isolation, and bizarre behaviors, as a person may keep accusing others of wanting to harm them.

5. Risky and impulsive behavior

Risky and impulsive behaviors refer to participating in actions that put a person in danger of injury and other catastrophic scenarios. This symptom is common in patients with borderline personality disorder.

The physical effects of these symptoms are injuries and complications that occur due to these impulsive behaviors. Behavioral effects include impulsiveness, getting into conflicts with friends and family due to risky activities, and constantly seeking more thrill.

What are the types of borderline personality disorder?

Types of borderline personality disorder are listed below:

• Discouraged borderline personality disorder
• Impulsive borderline personality disorder
• Petulant borderline
• Self-destructive borderline

1. Discouraged borderline personality disorder

A discouraged borderline personality disorder is a type of BPD that describes a person who is very dependent on others to the point they are perceived as clingy or needy. This type of BPD represents a mixed dependent/avoidant pattern where the submissiveness/attachment is strongly represented. It is particularly noticeable when a person becomes overly dependent on a person with whom it’s inappropriate such as a boyfriend/girlfriend they just started dating.

The specific cause of discouraging borderline personality disorder is unknown. Several factors could play a role, including genetics, PTSD, childhood trauma, congenital brain abnormalities, hormonal imbalances, family and social instability, and negative social experiences in childhood.

The main symptoms of discouraged BPD are loyalty to an excessive degree, avoiding competition, humble behavior, being constantly preoccupied with insecurity, self-doubt, and helplessness. People with this condition have a follower type of mentality and they are easily swayed by others. They tend to be submissive and passive while being vulnerable and weak. Other symptoms include tearful episodes, feelings of emptiness, self-victimization, reliance on fantasy as a means to escape, and self-deprivation.

The effects of discouraged borderline personality disorder on a person’s life are numerous. The biggest effects are a high risk of substance abuse, unhealthy relationships, problems with other people, and missing out on opportunities in life.

Unlike other types, discouraged BPD involves a more submissive behavior where a person is too dependent on someone. Other types are more associated with anger and impulsiveness.

What makes discouraged BPD similar to other types is the inability to control one’s emotions and behavior patterns. A person with this type of BPD can become selfish and angry as well.

2. Impulsive borderline personality disorder

Impulsive borderline personality disorder, as its name suggests, is a subtype of BPD characterized by difficulty with impulse control. People with this disorder lack impulse control in interpersonal relationships, self-image, and affect. They often seek a way to satisfy their urges. Of all four types of BPD, this one is the most charismatic.

Causes of impulsive BPD could be a combination of neurobiological factors, childhood trauma, genetics, brain abnormalities, and social, psychological, and environmental factors.

The main symptoms of impulsive BPD include manipulative and attention-seeking behaviors, high energy levels, getting bored easily, and being charismatic, dramatic, flirtatious, and superficial. People with impulsive BPD easily entertain others but tend to avoid meaningful interactions and relationships.

The effects of impulsive borderline personality disorder are a high risk of self-harm, including suicide attempts. People with impulsive BPD may engage in risky or thrill-seeking activities.

The main difference between this and other types of BPD is the lack of impulse control whereas other types usually include being submissive, self-hatred, and a combination of explosive anger and feelings of worthlessness.

The similarity between these disorders is the high risk of self-harm. This type is also characterized by impulsivity similar to other personality disorders.

3. Petulant borderline

Petulant borderline is a type of BPD indicated by mood swings and petulant behaviors. People with petulant borderline are difficult to interact with and hard to please. Since a person with petulant borderline personality disorder can be manipulative, they tend to become possessive and dissatisfied with their relationships.

The specific cause of petulant BPD is unknown, but factors that cause borderline personality disorder can also contribute to the development of this subtype. This includes a combination of genetics, social, biological, and environmental factors.

Symptoms of petulant BPD include the inability to express feelings, anger outbursts, feelings of not being worthy or loved, and social anxiety. People with this subtype of BPD have an extreme fear of abandonment, and they tend to become too controlling, suspicious, dissatisfied, moody, and negative.

Effects of the petulant borderline stem from problems in relationships to a high risk of suicide and substance abuse. Intense mood swings that go from being happy to angry can affect the way a person functions in society or at the workplace.

The difference between petulant BPD and other types is in the extreme changes in moods and behaviors. Other personality disorders usually include self-destructive behaviors, discouraging attitudes, and lack of impulse control.

The similarity between petulant BPD and other types is in feelings of not being worthy and dissatisfaction with relationships. Like other types of BPD, petulant borderline includes a dose of manipulative or controlling behavior.

4. Self-destructive borderline

Self-destructive borderline personality disorder is a type of BPD that involves a large amount of self-hatred. People with this type of BPD harbor intense feelings of bitterness and may attempt to find comfort in getting attention from others.

The causes of self-destructive borderline are genetic predisposition, changes in the brain, and growing up in an unhealthy or unstable environment.

The main symptoms of this type of BPD include self-loathing or self-hatred, bitterness, depression, unstable self-image, unstable emotions, and believing nobody cares.

Effects of self-destructive BPD include a high risk of substance abuse, suicidal thoughts and tendencies, reckless behaviors, and sabotaging own happiness.

The difference between self-destructive BPD and other types of this disorder is in the amount of self-hatred. In other disorders, it may be one of the symptoms, but in this condition, it’s the main trait.

Self-destructive BPD is similar to other disorders due to unstable emotions and unhealthy attitudes about oneself, which could lead to seeking attention from others.

Who is affected by borderline personality disorder?

Adolescents in their late teen years and young adults are generally affected by borderline personality disorder, even though this mental illness can affect anyone. The disorder also affects people whose family members have BPD or some other mental illness. This is particularly the case with parents and siblings.

Like other mental illnesses, borderline personality disorder may affect people who already have some other mental health condition such as depression, anxiety, or eating disorder, Cleveland Clinic reports. Borderline personality disorder tends to affect people who have experienced a traumatic event in the past, especially in their childhood.

What are the risk factors for borderline personality disorder?

Risk factors for borderline personality disorder are listed below:

• Family history of borderline personality disorder or similar disorders
• Stressful or traumatic childhood, such as sexual, emotional, or physical abuse
• Poor communication in the family
• Abandonment in childhood or adolescence
• Disrupted family life
• Low family socioeconomic status
• Being bullied or rejected by peers
• Negative emotionality
• Inappropriate anger
• Poor emotional control
• Impulsivity and aggressive behavior

How is borderline personality disorder diagnosed?

A borderline personality disorder is diagnosed after physical and psychiatric evaluation. There is no specific borderline personality disorder test that serves solely for diagnostic purposes.

The process starts with a detailed interview with a healthcare provider or a psychiatrist. The psychiatrist performs a thorough evaluation of the symptoms, thoughts, moods, and behaviors. Patients may need to complete a questionnaire as well. During the process, they may evaluate a patient’s medical history.

A physical exam may be necessary to rule out the physical causes of symptoms. For that purpose, patients may need a blood test, urine test, or imaging test such as MRI.

Healthcare professionals diagnose BPD when a patient meets diagnostic criteria from DSM-5. Diagnosis requires meeting at least five criteria, such as the chronic feeling of emptiness, emotional instability, fear of abandonment, impulsiveness, intense anger, identity disturbance, unstable relationships, recurrent suicidal behavior, and paranoid ideation.

How to prevent borderline personality disorder?

There is no foolproof way to prevent borderline personality disorder. The causes of BPD are still largely unknown, which explains the lack of exact formula to prevent it.

However, a paper from the British Journal of Psychiatry explains that early intervention strategies could be helpful. The goal of early intervention is to change the life-altering trajectory of young people with BPD by attenuating or averting adverse outcomes linked to this mental illness. This is particularly important because BPD can be reliably diagnosed in its early stages, and it’s one of the most disabling mental disorders.

Individual and group psychotherapy are important aspects of early intervention that may prevent the severe complications of BPD.

When it comes to the prevention of BPD, the things that can help lower the risk in people who are more susceptible to developing it, include validating their emotions, keeping stable schedules, and being present. It is also important to reinforce positive behaviors and show support.

What are the treatments for borderline personality disorder?

Treatments for borderline personality disorder are focused on helping patients learn skills and cope with their condition. The main goal is to help patients live a more stable life, which is why underlying mental illnesses are also managed. Treatments for borderline personality disorder are listed below:

• Psychotherapy: first-line treatment for patients with BPD. Therapy is patient-centric, meaning the therapist chooses the type that suits a patient’s needs and symptoms the most. The main objectives of psychotherapy in the treatment of BPD, Mayo Clinic reports, are to focus on a patient’s current ability to function, help them learn emotions that feel uncomfortable, reduce impulsiveness, improve relationships, and educate about BPD. Different types of psychotherapy in the treatment of BPD include cognitive-behavioral therapy (CBT), psychodynamic therapy, dialectical behavior therapy (DBT), schema-focused therapy, mentalization-based therapy, and transference-focused psychotherapy. Since CBT is a goal-oriented therapy, patients learn to take a close look into their thoughts and emotions in order to understand how they affect their actions. The main objective is to identify negative thought patterns and replace them with positive alternatives, which would lead to healthier behaviors. On the other hand, DBT was developed specifically for borderline personality disorder and it focuses on helping patients accept reality and learn to change life, including negative behaviors. Psychodynamic therapy helps by focusing on the psychological roots of emotional suffering and promoting self-reflection and self-examination. A growing body of evidence confirms the effectiveness of psychodynamic therapies in the treatment of BPD. When it comes to psychotherapy, patients usually attend individual sessions, but group therapy is also helpful. The exact number of sessions depends on the severity of symptoms, but patients may need one to two therapy sessions for at least six months.
• Medications: at this point, there is no specific FDA-approved medication for borderline personality disorder. Doctors may prescribe drugs to manage symptoms and co-occurring problems such as impulsiveness, depression, anxiety, or aggression. Examples of these medications include antidepressants, antipsychotics, and mood-stabilizing drugs.
• Hospitalization: this treatment approach is only recommended in most severe cases when no other option helps. Hospitalizing patients is necessary to prevent self-injury or address their suicidal thoughts and tendencies. This more intense treatment is provided in a psychiatric hospital or clinic.

Do borderline personality disorders have a cure?

No, borderline personality disorders don’t have a cure. There is no quick fix or solution that would eliminate mental illness entirely. That being said, it’s possible to manage symptoms of BPD and reduce their intensity. The only way to make that happen is to adhere to the treatment recommended by the doctor. By managing symptoms and lowering their intensity, the quality of life among patients improves. Many people with BPD go on to have satisfying lives.

What is the difference between borderline personality disorder and schizophrenia?

The difference between borderline personality disorder and schizophrenia is that the latter is not a personality disorder. Instead, schizophrenia is a psychotic disorder.

People with BPD find it difficult to control their emotions and behaviors. On the other hand, individuals with schizophrenia have an impaired perception of reality. Schizophrenia includes symptoms such as hallucinations, delusions, disorganized speech, movements, or behaviors.

While psychosis can occur in both disorders, in people with BPD, the episodes are short, fleeting, and stress-related. In people with BPD, psychosis isn’t accompanied by negative symptoms such as disorganization, PsychCentral reports.

Even though they’re different disorders, BPD and schizophrenia frequently coexist.