Borderline Personality Disorder
Borderline Personality Disorder (BPD) is a complex and multifaceted mental health condition that fundamentally alters the lives of those it impacts. With an estimated prevalence of 1.6% worldwide and a notable 20% of individuals in inpatient psychiatric treatment, BPD brings about significant emotional turmoil, distorts self-perception, and disrupts the ability to cultivate and sustain healthy relationships and daily functioning. Despite its prevalence, BPD remains a misunderstood and stigmatised condition, perpetuating myths and exacerbating the isolation experienced by those affected.
Gaining a better understanding of BPD, encompassing diagnostic criteria, treatment efficacy, and effective management strategies, can foster a more empathetic and knowledgeable approach to supporting individuals navigating the complexities of this challenging mental health condition.
What is Borderline Personality Disorder?
Borderline Personality Disorder is a severe mental health condition characterised by a persistent pattern of volatility in mood, self-image and interpersonal relationships. These patterns often lead to impulsive and erratic behaviour, periods of intense emotional experiences and the onset of depression and other mental health issues. This instability can permeate various aspects of an individual’s life including relationships, work and overall well-being. BPD most commonly presents during adolescence or early adulthood but borderline personality symptoms can start emerging in childhood.
The name “borderline personality disorder” comes from the initial belief that the disorder was at the “borderline” between neurosis and psychosis. However, this terminology is somewhat outdated as we now understand BPD as a standalone complex personality disorder, which cannot fit neatly into such categories. BPD is a type of Cluster B personality disorder characterised by dramatic, overly emotional or unpredictable thinking or behaviour, along with other disorders such as narcissistic, histrionic and antisocial personality disorders.
The diagnostic criteria for BPD
Diagnosing Borderline Personality Disorder requires a careful assessment by a qualified healthcare provider, typically involving an extensive interview and a detailed evaluation of an individual’s medical history. The official diagnostic criteria, as stipulated by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), include a pervasive pattern of instability in interpersonal relationships, self-image and emotional regulation, along with marked impulsivity. These borderline personality symptoms must be present in multiple life situations such as work, home and school and cause real suffering and impairment of daily functioning.
1. Frantic efforts to avoid real or imagined abandonment
People with BPD may constantly fear losing people they are close to, and this fear can sometimes be based on unrealistic notions or perceived signs that others may not notice. For example, a person with BPD may react emotionally to a friend being late to meet them, fearing that the delay is a sign of rejection or abandonment. This can lead them to exhibit frantic efforts to avoid abandonment, including pleading, excessive calling or messaging, codependency, or even stalking behaviours.
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
Individuals with BPD often view relationships in black-and-white terms, causing them to shift quickly between idolising someone and viewing them with disdain. This cycle can occur with friends, family, and romantic partners, causing unstable and tumultuous relationships. This can cause social isolation, exacerbating BPD’s mental health symptoms.
3. Identity disturbance with markedly and persistently unstable self-image or sense of self
People experiencing BPD find maintaining a consistent sense of self-challenging. Their self-image, goals and preferences can change abruptly, often influenced heavily by their current relationships or circumstances. For example, someone with BPD may change career paths suddenly or disregard previous passions because a new partner does not share the same interests.
4. Impulsivity in at least two areas that are potentially self-damaging
Individuals with BPD may have a history of suicidal thoughts or attempts or engage in self-harming behaviours to cope with their emotional pain or express their inner turmoil. They may also threaten to harm themselves in moments of extreme emotional distress, potentially using it as a cry for help or as a way to express their despair.
5. Recurrent suicidal behaviour, gestures or threats or self-mutilating behaviour
Individuals with BPD may have a history of suicidal thoughts or attempts, or engage in self-harming behaviours as a way to cope with their emotional pain or to express their inner turmoil. They may also threaten to harm themselves in moments of extreme emotional distress, potentially using it as a cry for help or as a way to express their despair.
6. Emotional instability due to a marked reactivity of mood
People with BPD experience intense emotional shifts, often due to perceived rejections or failures. Their mood swings can be extreme and rapid, oscillating between joy, anxiety, and depression within a short period. For example, a person may start their day feeling upbeat and happy, but a small triggering event could plunge them into a deep sadness or irritation, with their mood continuing to fluctuate throughout the day.
7. Chronic feelings of emptiness
This refers to a persistent feeling of emptiness or void they can’t seem to fill. It is a profound emotional distress characterised by a lack of fulfilment or satisfaction despite the positive aspects of their life. This can include a loving family, a successful job and financial security.
8. Inappropriate, intense anger or difficulty controlling anger
Individuals with BPD often find it extremely challenging to manage their anger and have disproportionate reactions to situations. This uncontrolled anger can lead to conflicts, verbal outbursts, or physical altercations. For example, a minor disagreement with a colleague can escalate quickly, leading the person with BPD to lose their temper and act inappropriately at work.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
During high-stress periods, individuals with BPD may experience paranoid thoughts, fearing that others are out to get them or harbour ill intentions towards them. They may also experience severe dissociative symptoms, feeling detached from themselves or reality.
Identifying and comprehending these Borderline Personality Disorder signs represents the initial step in effectively managing the condition.
Comorbidities associated with BPD
Individuals with BPD often experience other mental health conditions concurrently, which can complicate the diagnostic process and management of BPD. Some conditions frequently seen alongside BPD include:
- Depression: Many individuals with BPD experience periods of depression characterised by persistent sadness, loss of interest in previously enjoyed activities and difficulties concentrating.
- Bipolar disorder: Fluctuations between periods of depression and mania can occur, presenting an additional layer of emotional instability.
- Generalised Anxiety Disorder (GAD): Individuals with BPD may constantly feel worried and find it extremely hard to control their anxiety.
- Panic Disorder: Episodes of intense fear characterised by palpitations, sweating and feelings of impending doom can be prevalent.
Substance abuse and addiction
Individuals with BPD are more susceptible to substance abuse issues, including alcoholism and drug addiction, often using substances to cope with their emotional distress.
Up to 54% of those with BPD also experience an eating disorder at some point. This can include:
- Anorexia Nervosa: Restricting food intake due to a fear of gaining weight or a distorted body.
- Bulimia Nervosa: Engaging in cycles of binge eating followed by purging behaviours.
Attention-Deficit/Hyperactivity Disorder (ADHD)
There can be an overlap in the impulsivity seen in both BPD and ADHD, leading to difficulties in maintaining attention and a tendency toward hyperactivity. The two conditions can also be misdiagnosed as each other.
Self-harm and suicidal behaviours
Apart from being a diagnostic criterion for BPD, self-harming behaviours and suicide attempts can often signify co-existing psychiatric disorders.
Individuals with BPD may also present symptoms of other personality disorders, such as narcissistic, avoidant or dependent personality disorders, making the diagnostic process more complex.
Aetiology and risk factors
The origin and risk factors associated with Borderline Personality Disorder are multifaceted and include a combination of genetic, neurobiological, environmental and psychological components:
Research indicates that Borderline Personality Disorder (BPD) is notably more prevalent among individuals with a close family member, such as a parent or sibling, who also has the disorder, suggesting a genetic predisposition. Twin studies have further highlighted this genetic influence, estimating heritability at approximately 37% to 69%, underscoring the substantial genetic contribution to BPD development.
While the exact neurobiological mechanisms underlying BPD remain somewhat unclear, several avenues of research are illuminating potential contributors:
- Brain abnormalities: Imaging studies have indicated that individuals with BPD may exhibit abnormalities in brain regions involved in emotion regulation and impulse control, including the prefrontal cortex and amygdala.
- Neurotransmitter dysfunctions: There’s also evidence to suggest that imbalances in neurotransmitters such as serotonin, dopamine and noradrenaline play a role in the emotional dysregulation seen in individuals with BPD.
- Hormonal factors: Research has also begun into the role of hormonal imbalances, including dysregulations in the stress hormone cortisol, which might be involved in the disorder’s pathology.
Certain environmental factors appear to elevate the risk of developing BPD significantly:
- Adverse childhood experiences: Individuals with BPD have also commonly had adverse childhood experiences such as physical, sexual or emotional abuse, neglect or the loss of a parent.
- Parental separation or divorce: Early separation from caregivers or growing up in a disrupted family environment can potentially increase the risk.
- Bullying: Being subjected to bullying during childhood and adolescence can also contribute.
Psychological elements can also play a significant role in the development of BPD, including:
- Personality and temperament: Certain personality traits, such as impulsivity and emotional sensitivity, could predispose individuals to BPD.
Cognitive factors: Difficulty interpreting social cues correctly and a tendency towards black-and-white thinking, also known as split thinking, are common psychological traits in individuals with BPD.
Borderline personality treatment and management
Borderline Personality treatment requires a comprehensive and multipronged approach to address individuals’ various symptoms and challenges adequately. These include:
Therapy for Borderline Personality Disorder
Therapy remains the cornerstone in UKAT London Clinic’s treatment of BPD, with several therapeutic approaches proving effective, including:
- Cognitive Behavioural Therapy (CBT): This therapy helps individuals address and change negative thought patterns and behaviours, reducing impulsivity, self-harm tendencies and relationship difficulties.
- Dialectical Behaviour Therapy (DBT): Developed specifically for treating BPD, DBT combines cognitive-behavioural techniques with mindfulness strategies. It teaches individuals how to manage emotions, tolerate distress and improve relationships.
- Family therapy: This involves educating family members about the disorder and fostering a supportive environment at home.
Medication for Borderline Personality Disorder
Although no medications are specifically approved to treat BPD, doctors often prescribe medicines to manage certain symptoms. These might include:
- Antidepressants: To manage symptoms of depression and mood swings.
- Mood Stabilisers: To help reduce mood fluctuations and impulsivity.
- Antipsychotics: Occasionally used in low doses to help with disorganised thoughts or paranoia.
Supporting individuals with BPD
Besides the primary treatment modalities mentioned above, individuals with BPD may benefit from various supportive measures, including:
- Support groups: Safe spaces where individuals can share experiences and gain insights from others with similar experiences.
- Lifestyle modifications: Encouraging regular physical activity, a balanced diet and sufficient sleep can be instrumental in managing symptoms of BPD.
- Holistic approaches: UKAT London provides a range of holistic therapies and activities, including mindfulness, meditation and art therapy. These practices can help individuals develop greater self-awareness and emotional regulation skills.
At UKAT London Clinic, our support of individuals with BPD involves thoroughly understanding the disorder and fostering an environment of patience and empathy. Our BPD experts and industry-leading therapists provide a full medical assessment and tailor treatment and timetables to fit our client’s needs and support them.
Call UKAT London Clinic today to learn how we can help you manage your BPD.