Borderline Personality Disorder

“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”

― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook

Borderline Personality Disorder

Image: "BPD Focus" by CMEarnest

CC BY-SA 3.0

Borderline personality disorder (BPD) is frequently comorbid with dissociative identity disorder (DID). It's been found that between 48.5-70% of those with DID also meet the criteria for BPD, that 26-76% of those with BPD meet the criteria for a dissociative disorder, and that 2.5-27% of those with BPD meet the criteria for DID. However, care must be taken to distinguish between BPD and DID.

The DSM-5 gives the following criteria for a diagnosis of borderline personality disorder: 

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. (Note: Do not include 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, sex, substance abuse, reckless driving, binge eating). (Note: Do not include 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 (American Psychiatric Association, 2013).1

Criterion 1 refers to intense fears regarding rejection, separation, or abandonment by friends, family, lovers, or even near strangers. Perceived impending separation can lead to changes in self-image, affect, cognition, and behavior. Individuals with borderline personality disorder are highly sensitive to these perceptions and may react to even temporary and necessary separation or changes in plans with intense fear or anger. Perceived abandonment may be taken as a sign of their own low worth. Individuals with borderline personality disorder often cannot tolerate being alone. This is often seen as the defining or main symptom of borderline personality disorder.

Criterion 2 refers to idealizing potential caregivers or lovers at the first or second meeting, believing that their relationship will be perfect and eternal before the other individual has come to view them as more than an acquaintance. The individual with BPD may share intimate details early in the relationship and want to spend as much time as possible with the other person. However, seemingly without warning, idealization can change into devaluation, and the individual with BPD will be left feeling that the other person does not care enough, give enough, or spend enough time with them. Individuals with BPD can be highly caring, sensitive, and nurturing, but they are often easily hurt when they feel that others are not extending the same consideration to them. Their views of others are often extreme and black or white, and they may switch to devaluation of individuals that fail to live up to their standards of caregiving or who they perceive as likely to soon abandon them.

Criterion 3 refers to sudden and dramatic shifts in self image. These shifts may be associated with changing goals, values, opinions, sexualities, and types of desired friends. The entire personality of the individual may seem to suddenly change. Self-image for those with BPD is usually negative, but in unstructured environments or when without meaningful relationships, individuals with BPD may feel as if they do not exist at all.

Criterion 4 refers to engagement in impulsive and damaging behaviors such as shopping, gambling, unprotected or promiscuous sex, substance use, driving far over the speed limit or while distracted, or binge eating.

Criterion 5 refers to acts of self harm (cutting, burning, picking at scabs, picking at skin or hair, starvation, etc.) and suicidal threats, gestures, or attempts. 8-10% of individuals with borderline personality disorder successfully complete suicide attempts, and threats or unsuccessful attempts are very common. These threats or attempts are often responses to real or perceived rejection or to expectations of increased responsibility. Self harm may be used as a form of self punishment or to ward off dissociation.

Criterion 6 refers to intense mood swings that interrupt periods of dysphoria with episodes of anger, panic, or despair or episodes of satisfaction, energy, and childish joy and wonder. Negative episodes are often reactions to relationship-related stressors.

Criterion 7 refers to frequently feeling empty, bored, and unfulfilled. This might be connected to risk-seeking behaviors and result from feelings of not having meaningful relationships.

Criterion 8 refers to outbursts of temper that are intense and may be perceived as uncontrollable. This may manifest as strong sarcasm, bitterness, or verbal or physical outbursts. Anger is often directed at caregivers who are currently being devalued by the individual with BPD. However, once the outbursts are over, the individual often reacts with strong and unproportionate shame, guilt, and a sense of being evil.

Criterion 9 refers to dissociative symptoms such as derealization that are often not severe or frequent enough to warrant a dissociative disorder diagnosis. These symptoms are most often a response to abandonment. Hallucinations, body-image distortions, or paranoia are also possible reactions to extreme stress.

Individuals with BPD often self sabotage, especially once a goal is directly in reach or has been acknowledged by others.  They may be more comfortable with animals or objects than with other people. They may struggle to retain a job, complete their education, or enter into and remain in a stable relationship or marriage (American Psychiatric Association, 2013).1

Borderline personality disorder is associated with childhood abuse, neglect, hostile households, or parental abandonment. Co-morbid depressive and bipolar disorders, substance use disorders, feeding and eating disorders, posttraumatic stress disorder, and attention-deficit/hyperactivity disorder are common, as are other personality disorders. BPD is 5 times more common in first-degree relatives of others with the disorder and is also more likely in families with individuals with substance use disorders, anti-social personality disorder, and depressive or bipolar disorders (American Psychiatric Association, 2013).1

BPD is estimated to affect between 1.6-5.9% of the population. According to the DSM-5, "[t]he prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients" (American Psychiatric Association, 2013).1 It may be more common among younger individuals and is often most severe during early adulthood.  75% of individuals diagnosed with borderline personality disorder are female (American Psychiatric Association, 2013),1 though some speculate that males with the disorder are under-diagnosed or instead diagnosed with other personality disorders.

Treatment for BPD is possible. Improvements are often visible within the first year of therapy, and after 10 years in therapy, about half of individuals who were diagnosed with BPD no longer meet the full criteria for the disorder. Increased stability often comes naturally with advancing age (American Psychiatric Association, 2013).1

Borderline personality disorder should be distinguished from depressive and bipolar disorders, other personality disorders, personality changes due to another medical condition, substance use disorders, and identity problems associated with adolescence (American Psychiatric Association, 2013).1

1 American Psychiatric Association. (2013). Personality Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.).