Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD),[16] is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses.[9][17][18] People diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline.[19][20][21] Symptoms such as dissociation (a feeling of detachment from reality), a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.[17]
The onset of BPD symptoms can be triggered by events that others might perceive as normal,[17] with the disorder typically manifesting in early adulthood and persisting across diverse contexts.[9] BPD is often comorbid with substance use disorders,[22] depressive disorders, and eating disorders.[17] BPD is associated with a substantial risk of suicide;[9][17] an estimated 8 to 10 percent of people with BPD die by suicide, with males affected at twice the rate of females.[23] Despite its severity, BPD faces significant stigmatization in both media portrayals and the psychiatric field, potentially leading to its underdiagnosis.[24]
The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development.[8][25] A genetic predisposition is evident, with the disorder significantly more common in people with a family history of BPD, particularly immediate relatives.[8] Psychosocial factors, particularly adverse childhood experiences, have been proposed.[26] Neurologically, the underlying mechanism appears to involve the frontolimbic neuronal network of the limbic system.[26] The American Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies BPD as a cluster B personality disorder, alongside antisocial, histrionic, and narcissistic personality disorders.[9] There is a small risk of misdiagnosis, with BPD most commonly confused with a mood disorder, substance use disorder, or other mental health disorders.[9]
Therapeutic interventions for BPD predominantly involve psychotherapy, with cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) the most effective modalities.[8] This psychotherapy can occur one-on-one or in a group.[8] Although pharmacotherapy cannot cure BPD, it may be employed to mitigate associated symptoms,[8] with quetiapine and selective serotonin reuptake inhibitor (SSRI) antidepressants commonly prescribed even though their efficacy is unclear. A 2020 meta-analysis found the use of medications was still unsupported by evidence.[27] In severe cases, hospitalization may be necessitated, even if for only short periods.[8]
BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population,[9][8][28][29] with a higher incidence rate among women compared to men in the clinical setting of up to three times.[9][28] Despite the high utilization of healthcare resources by people with BPD,[30] up to half may show significant improvement over a ten-year period with appropriate treatment.[9] The name of the disorder, particularly the suitability of the term borderline, is a subject of ongoing debate. Initially, the term reflected historical ideas of borderline insanity and later described patients on the border between neurosis and psychosis. These interpretations are now regarded as outdated and clinically imprecise.[8][31]
Signs and symptoms
[edit]
One of the symptoms of BPD is an intense fear of emotional abandonment.
Borderline personality disorder, as outlined in the DSM-5, manifests through nine distinct symptoms, with a diagnosis requiring at least five of the following criteria to be met:
Frantic efforts to avoid real or imagined emotional abandonment.[32]
Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of idealization and devaluation, also known as 'splitting'.
A markedly disturbed sense of identity and distorted self-image.[8]
Impulsive or reckless behaviors, including uncontrollable spending, unsafe sexual practices, substance use disorder, reckless driving, and binge eating.[33]
Recurrent suicidal ideation or behaviors involving self-harm.
Rapidly shifting intense emotional dysregulation.
Chronic feelings of emptiness.
Inappropriate, intense anger that can be difficult to control.
Transient, stress-related paranoid ideation or severe dissociative symptoms.
The distinguishing characteristics of BPD include a pervasive pattern of instability in one's interpersonal relationships and in one's self-image, with frequent oscillation between extremes of idealization and devaluation of others, alongside fluctuating moods and difficulty regulating intense emotional reactions. Dangerous or impulsive behaviors are commonly associated with BPD.
Additional symptoms may encompass uncertainty about one's identity, values, morals, and beliefs; experiencing paranoid thoughts under stress; episodes of depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or episodes of psychosis. It is also common for individuals with BPD to have comorbid conditions such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder (PTSD), and attention-deficit hyperactivity disorder (ADHD).[34]
Mood and affect
[edit]
Further information: Emotional dysregulation
Individuals with BPD exhibit emotional dysregulation. Emotional dysregulation is characterized by an inability in flexibly responding to and managing emotional states, resulting in intense and prolonged emotional reactions that deviate from social norms, given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli.[35][36][37][38]
A core characteristic of BPD is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to psychosocial cues, leading to significant challenges in managing emotions effectively.[39][40][41]
As the first component of emotional dysregulation, individuals with BPD are shown to have increased emotional sensitivity, especially towards negative mood states such as fear, anger, sadness, rejection, criticism, isolation, and perceived failure.[42][43] This increased sensitivity results in an intensified response to environmental cues, including the emotions of others.[42] Studies have identified a negativity bias in those with BPD, showing a predisposition towards recognizing and reacting more strongly to negative emotions in others, along with an attentional bias towards processing negatively-valenced stimuli.[42] Without effective coping mechanisms, individuals might resort to self-harm, or suicidal behaviors to manage or escape from these intense negative emotions.[44][42] While conscious of the exaggerated nature of their emotional responses, individuals with BPD face challenges in regulating these emotions. To mitigate further distress, there may be an unconscious suppression of emotional awareness, which paradoxically hinders the recognition of situations requiring intervention.[40]
A second component of emotional dysregulation in BPD is high levels of negative affectivity, stemming directly from the individual's emotional sensitivity to negative emotions. This negative affectivity causes emotional reactions that diverge from socially accepted norms, in ways that are disproportionate to the environmental stimuli presented.[42] Those with BPD are relatively unable to tolerate the distress that is encountered in daily life, and they are prone to engage in maladaptive strategies to try to reduce the distress experienced. Maladaptive coping strategies include rumination, thought suppression, experiential avoidance, emotional isolation, as well as impulsive and self-injurious behaviours.[42]
American psychologist Marsha Linehan highlights that while the sensitivity, intensity, and duration of emotional experiences in individuals with BPD can have positive outcomes, such as exceptional enthusiasm, idealism, and capacity for joy and love, it also predisposes them to be overwhelmed by negative emotions.[40][45] This includes experiencing profound grief instead of mere sadness, intense shame instead of mild embarrassment, rage rather than annoyance, and panic over nervousness.[45] Research indicates that individuals with BPD endure chronic and substantial emotional suffering.[34]
Emotional dysregulation is a significant feature of BPD, yet Fitzpatrick et al. (2022) suggest that such dysregulation may also be observed in other disorders, like generalized anxiety disorder (GAD). Nonetheless, their findings imply that individuals with BPD particularly struggle with disengaging from negative emotions and achieving emotional equilibrium.[46]
Euphoria, or transient intense joy, can occur in those with BPD, but they are more commonly afflicted by dysphoria (a profound state of unease or dissatisfaction), depression, and pervasive distress. Zanarini et al. identify four types of dysphoria characteristic of BPD: intense emotional states, destructiveness or self-destructiveness, feelings of fragmentation or identity loss, and perceptions of victimization.[47] A diagnosis of BPD is closely linked with experiencing feelings of betrayal, lack of control, and self-harm.[47]
Moreover, emotional lability, indicating variability or fluctuations in emotional states, is frequent among those with BPD. Although emotional lability may imply rapid alternations between depression and elation, mood swings in BPD are more commonly between anger and anxiety or depression and anxiety.[48]
Interpersonal relationships
[edit]
Interpersonal relationships are significantly impacted in individuals with BPD, characterized by a heightened sensitivity to the behavior and actions of others. Individuals with BPD can be very conscious of and susceptible to their perceived or real treatment by others. Individuals may experience profound happiness and gratitude for perceived kindness, yet feel intense sadness or anger towards perceived criticism or harm.[49] A notable feature of BPD is the tendency to engage in idealization and devaluation of others – that is to idealize and subsequently devalue others – oscillating between extreme admiration and profound mistrust or dislike.[50] This pattern, referred to as "splitting," can significantly influence the dynamics of interpersonal relationships.[51][52] In addition to this external "splitting," patients with BPD typically have internal splitting, i.e. vacillation between considering oneself a good person who has been mistreated (in which case anger predominates) and a bad person whose life has no value (in which case self-destructive or even suicidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking.[53]
Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent, or fearfully preoccupied attachment styles in relationships, complicating their interactions and connections with others.[54] Family members, including parents of adults with BPD, may find themselves in a cycle of being overly involved in the individual's life at times and, at other times, significantly detached,[55] contributing to a sense of alienation within the family unit.[53]
Personality disorders, including BPD, are associated with an increased incidence of chronic stress and conflict, reduced satisfaction in romantic partnerships, domestic abuse, and unintended pregnancies.[56] Research indicates variability in relationship patterns among individuals with BPD. A portion of these individuals may transition rapidly between relationships, a pattern metaphorically described as "butterfly-like," characterized by fleeting and transient interactions and "fluttering" in and out of relationships.[57] Conversely, a subgroup, referred to as "attached," tends to establish fewer but more intense and dependent relationships. These connections often form rapidly, evolving into deeply intertwined and tumultuous bonds,[57] indicating a more pronounced dependence on these interpersonal ties compared to those without BPD.[58]
Behavior
[edit]
Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, self-injury among other self-harming practices.[59] These behaviors are a response to the intense emotional distress experienced by individuals with BPD, serving as an immediate but temporary alleviation of their emotional pain.[59] However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle.[59] This cycle typically begins with emotional discomfort, followed by impulsive behavior aimed at mitigating this discomfort, only to lead to shame and guilt, which in turn exacerbates the emotional pain.[59] This escalation of emotional pain then intensifies the compulsion towards impulsive behavior as a form of relief, creating a vicious cycle. Over time, these impulsive responses can become an automatic mechanism for coping with emotional pain.[59]
Self-harm and suicide
[edit]
Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5.[9] Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method.[60] Other methods, such as bruising, burning, head banging, or biting, are also prevalent.[60] It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.[61]
Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation.[62][53][63] There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD.[64]
The motivations behind self-harm and suicide attempts among individuals with BPD are reported to differ.[44] Nearly 70% of individuals with BPD engage in self-harm without the intention of ending their lives. Motivations for self-harm include expressing anger, self-punishment, inducing normal feelings or feelings of normality in response to dissociative episodes, and distraction from emotional distress or challenging situations.[44] Conversely, true suicide attempts by individuals with BPD frequently are motivated by the notion that others will be better off in their absence.[44]
Sense of self and self-concept
[edit]
Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable self-concept. This instability manifests as uncertainty in personal values, beliefs, preferences, and interests.[65] They may also express confusion regarding their aspirations and objectives in terms of relationships and career paths. Such indeterminacy leads to feelings of emptiness and a profound sense of disorientation regarding their own identity.[65] Moreover, their self-perception can fluctuate dramatically over short periods, oscillating between positive and negative evaluations. Consequently, individuals with BPD might adopt their sense of self based on their surroundings or the people they interact with, resulting in a chameleon-like adaptation of identity.[66]
Dissociation and cognitive challenges
[edit]
The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function.[65] Additionally, individuals with BPD may frequently dissociate, which can be regarded as a mild to severe disconnection from physical and emotional experiences.[67] Observers may notice signs of dissociation in individuals with BPD through diminished expressiveness in their face or voice, or through an apparent disconnection and insensitivity to emotional cues or stimuli.[67]
Dissociation typically arises in response to distressing occurrences or reminders of past trauma, acting as a psychological defense mechanism by diverting attention from the current stressor or by blocking it out entirely. This process, believed to shield the individual from the anticipated overwhelming negative emotions and undesired impulses that the current emotional situation might provoke, is rooted in avoidance of intense emotional pain based on past experiences. While this mechanism may offer temporary emotional respite, it can foster unhealthy coping strategies and inadvertently dull positive emotions, thereby obstructing the individual's access to crucial emotional insights. These insights are essential for informed, healthy decision-making in everyday life.[67]
Psychotic symptoms
[edit]
BPD is predominantly characterized as a disorder involving emotional dysregulation, yet psychotic symptoms frequently occur in individuals with BPD, with prevalence estimates ranging between 21% and 54%.[68] These manifestations have historically been labeled as "pseudo-psychotic" or "psychotic-like", implying a differentiation from symptoms observed in primary psychotic disorders. Studies conducted in the 2010s suggest a closer similarity between psychotic symptoms in BPD and those in recognized psychotic disorders than previously understood.[68][69] The distinction of pseudo-psychosis has faced criticism for its weak construct validity and the potential to diminish the perceived severity of these symptoms, potentially hindering accurate diagnosis and effective treatment. Consequently, there are suggestions from some in the research community to categorize these symptoms as genuine psychosis, advocating for the abolishment of the distinction between pseudo-psychosis and true psychosis.[68][70]
The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD.[9] Research has identified the presence of both hallucinations and delusions in individuals with BPD who do not possess an alternate diagnosis that would better explain these symptoms.[69] Further, phenomenological analysis indicates that auditory verbal hallucinations in BPD patients are indistinguishable from those observed in schizophrenia.[69][70] This has led to suggestions of a potential shared etiological basis for hallucinations across BPD and other disorders, including psychotic and affective disorders.[69]
Disability and employment
[edit]
Individuals diagnosed with BPD often possess the capability to engage in employment, provided they secure positions that align with their skill sets and the severity of their condition remains manageable. In certain cases, BPD may be recognized as a disability within the workplace, particularly if the condition's severity results in behaviors that undermine relationships, involve engagement in risky activities, or manifest as intense anger, thereby inhibiting the individual's ability to perform their job role effectively.[71] The United States Social Security Administration officially recognizes BPD as a form of disability, enabling those significantly affected to apply for disability benefits.[72]
Causes
[edit]
The etiology, or causes, of BPD is multifaceted, with no consensus on a singular cause.[73] BPD may share a connection with post-traumatic stress disorder (PTSD).[74] While childhood trauma is a recognized contributing factor, the roles of congenital brain abnormalities, genetics, neurobiology, and non-traumatic environmental factors remain subjects of ongoing investigation.[73][75]
Genetics and heritability
[edit]
Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel.[76] Estimates suggest the heritability of BPD ranges from 37% to 69%,[77] indicating that human genetic variations account for a substantial portion of the risk for BPD within the population. Twin studies, which often form the basis of these estimates, may overestimate the perceived influence of genetics due to the shared environment of twins, potentially skewing results.[78]
Despite these methodological considerations, certain studies propose that personality disorders are significantly shaped by genetics, more so than many Axis I disorders, such as depression and eating disorders, and even surpassing the genetic impact on broad personality traits.[79] Notably, BPD ranks as the third most heritable among ten surveyed personality disorders.[79]
Research involving twin and sibling studies has shown a genetic component to traits associated with BPD, such as impulsive aggression; with the genetic contribution to behavior from serotonin-related genes appearing to be modest.[80]
A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify genetic markers associated with BPD.[81] This research identified a linkage to genetic markers on chromosome 9 as relevant to BPD characteristics,[81] underscoring a significant genetic contribution to the variability observed in BPD features.[81] Prior findings from this group indicated that 42% of BPD feature variability could be attributed to genetics, with the remaining 58% owing to environmental factors.[81]
Among specific genetic variants under scrutiny as of 2012, the DRD4 7-repeat polymorphism (of the dopamine receptor D4) located on chromosome 11 has been linked to disorganized attachment, and in conjunction with the 10/10-repeat genotype of the dopamine transporter (DAT), it has been associated with issues with inhibitory control, both of which are characteristic of BPD.[82] Additionally, potential links to chromosome 5 are being explored, further emphasizing the complex genetic landscape influencing BPD development and manifestation.[83]
Psychosocial factors
[edit]
Adverse childhood experiences
[edit]
Studies based on empiricism have established a strong correlation between adverse childhood experiences such as child abuse, particularly child sexual abuse, and the onset of BPD later in life.[84][85][86] Reports from individuals diagnosed with BPD frequently include narratives of extensive abuse and neglect during early childhood, though causality remains a subject of ongoing investigation.[87] These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers,[88] alongside a notable frequency of incest and loss of caregivers in early childhood.[89]
Moreover, there have been consistent accounts of caregivers invalidating the individuals' emotions and thoughts, neglecting physical care, failing to provide necessary protection, and exhibiting emotional withdrawal and inconsistency.[89] Specifically, female individuals with BPD reporting past neglect or abuse by caregivers have a heightened likelihood of encountering sexual abuse from individuals outside their immediate family circle.[89]
The enduring impact of chronic maltreatment and difficulties in forming secure attachments during childhood has been hypothesized to potentially contribute to the development of BPD.[90] From a psychoanalytic perspective, Otto Kernberg has posited that the child's failure to navigate the developmental challenge of differentiating self from others, or as Kernberg terms it achieve the developmental task of psychic clarification of self and other, and failure to overcome the internal divisions caused by splitting may predispose that child to BPD.[91]
Invalidating environment
[edit]
Marsha Linehan's biosocial developmental theory posits that BPD arises from the interaction between a child's inherent emotional vulnerability and an invalidating environment. Emotional vulnerability is thought to be influenced by biological and genetic factors that shape the child's temperament. Traditional biomedical constructions of BPD often focus solely on biological factors. Though these factors certainly play a role in the development of borderline personality disorder, they do not provide a complete picture. A biosocial approach considers the interplay between genetic predispositions and environmental stressors, such as childhood trauma, invalidating environments, and social relationships, in shaping the course of the disorder. [92]
Invalidating environments are characterized by the neglect, ridicule, dismissal, or discouragement of a child's emotions and needs, and may also encompass experiences of trauma and abuse. [93] Invalidation from caregivers, peers, or authority figures can lead individuals with borderline personality disorder to doubt the legitimacy of their feelings and experiences. This can exacerbate their emotional dysregulation and contribute to a cycle of invalidation, distress, and maladaptive coping strategies. When emotions are consistently dismissed or criticized, individuals with BPD may resort to destructive behaviors such as self-harm, substance abuse, or impulsive actions to cope with their distress, further perpetuating the negative stigma attached to those who suffer from borderline personality disorder.[94]
Clinical and Cultural Perspectives
[edit]
Anthropologist Rebecca Lester raises two perspectives that BPD can be viewed: a clinical perspective where BPD is a “dysfunction of personality”,[95] and an academic perspective that views BPD as a “mechanism of social regulation”.[96] Lester provides the perspective that BPD as a disorder of relationships and communication; that a person with BPD lacks the communication skills and knowledge to interact effectively with others within their society and culture given their life experience. Lester provides the metaphor of the particle-wave duality in quantum physics when dealing with the distinction between cultural and clinical perspectives of BPD. Like the particle-wave-duality, when asking particle-like questions you will get particle-like answers; and if you ask wave-like questions you will get wave-like answers. Lester argues the same applies to BPD; if you ask culturally based questions about the presence of BPD you will get culturally based answers, if you ask clinical personality-based questions it will reinforce personality-based perspectives. Lester advised both perspectives are valid and should work in tandem to provide a greater understanding of BPD culturally and for the individual.[97]
In this light, Lester argues the high diagnosis of women than men with BPD goes towards arguing feminist claims. A higher diagnosis BPD in women would be expected in cultures where females are victimised. In this view BPD is seen as a cultural phenomenon. This is understandable when BPD behaviours are viewed as learnt behaviours as a consequence of their experience surviving environments that reinforce worthlessness and their rejection. To Lester these survival techniques evidence humans “resilience, adaptation, creativity”. Behaviours associated with BPD is therefore an inherently human response.[98]
Brain and neurobiologic factors
[edit]
Research employing structural neuroimaging techniques, such as voxel-based morphometry, has reported variations in individuals diagnosed with BPD in specific brain regions that have been associated with the psychopathology of BPD. Notably, reductions in volume enclosed have been observed in the hippocampus, orbitofrontal cortex, anterior cingulate cortex, and amygdala, among others, which are crucial for emotional self-regulation and stress management.[82]
In addition to structural imaging, a subset of studies utilizing magnetic resonance spectroscopy has investigated the neurometabolic profile within these affected regions. These investigations have focused on the concentrations of various neurometabolites, including N-acetylaspartate, creatine, compounds related to glutamate, and compounds containing choline. These studies aim to show the biochemical alterations that may underlie the symptomatology observed in BPD, offering insights into BPD's neurobiological basis.[82]
Neurological patterns
[edit]
Research into BPD has identified that the propensity for experiencing intense negative emotions, a trait known as negative affectivity, serves as a more potent predictor of BPD symptoms than the history of childhood sexual abuse alone.[99] This correlation, alongside observed variations in brain structure and the presence of BPD in individuals without traumatic histories,[100] delineates BPD from disorders such as PTSD that are frequently co-morbid. Consequently, investigations into BPD encompass both developmental and traumatic origins.
Research has shown changes in two brain circuits implicated in the emotional dysregulation characteristic of BPD: firstly, an escalation in activity within brain circuits associated with experiencing severe emotional pain, and secondly, a decreased activation within circuits tasked with the regulation or suppression of these intense emotions. These dysfunctional activations predominantly occur within the limbic system, though individual variances necessitate further neuroimaging research to explore these patterns in detail.[101]
Contrary to earlier findings, individuals with BPD exhibit decreased amygdala activation in response to heightened negative emotional stimuli compared to control groups. John Krystal, the editor of Biological Psychiatry, commented on these findings, suggesting they contribute to understanding the innate neurological predisposition of individuals with BPD to lead emotionally turbulent lives, which are not inherently negative or unproductive.[101] This emotional volatility is consistently linked to disparities in several brain regions, emphasizing the neurobiological underpinnings of BPD.[102]
Mediating and moderating factors
[edit]
Executive function and social rejection sensitivity
[edit]
High sensitivity to social rejection is linked to more severe symptoms of BPD, with executive function playing a mediating role.[103] Executive function—encompassing planning, working memory, attentional control, and problem-solving—moderates how rejection sensitivity influences BPD symptoms. Studies demonstrate that individuals with lower executive function exhibit a stronger correlation between rejection sensitivity and BPD symptoms.[103] Conversely, higher executive function may mitigate the impact of rejection sensitivity, potentially offering protection against BPD symptoms.[103] Additionally, deficiencies in working memory are associated with increased impulsivity in individuals with BPD.[104]
Family environment
[edit]
The family environment significantly influences the development of BPD, acting as a mediator for the effects of child sexual abuse. An unstable family environment increases the risk of developing BPD, while a stable environment can provide a protective buffer against the disorder. This dynamic suggests the critical role of familial stability in mitigating or exacerbating the risk of BPD.[105]
Diagnosis
[edit]
The clinical diagnosis of BPD can be made through a psychiatric assessment conducted by a mental health professional, ideally a psychiatrist or psychologist. This comprehensive assessment integrates various sources of information to confirm the diagnosis, encompassing the patient's self-reported clinical history, observations made by the clinician during interviews, and corroborative details obtained from family members, friends, and medical records. It is crucial to thoroughly assess patients for co-morbid mental health conditions, substance use disorders, suicidal ideation, and any self-harming behaviors.[106]
An effective approach involves presenting the criteria of the disorder to the individual and inquiring if they perceive these criteria as reflective of their experiences. Involving individuals in the diagnostic process may enhance their acceptance of the diagnosis. Despite the stigma associated with BPD and previous notions of its untreatability, disclosing the diagnosis to individuals is generally beneficial. It provides them with validation and directs them to appropriate treatment options.[53]
The psychological evaluation for BPD typically explores the onset and intensity of symptoms and their impact on the individual's quality of life. Critical areas of focus include suicidal thoughts, self-harm behaviors, and any thoughts of harming others.[107] The diagnosis relies on both the individual's self-reported symptoms and the clinician's observations.[107] To exclude other potential causes of the symptoms, additional assessments may include a physical examination and blood tests, to exclude thyroid disorders or substance use disorders.[107] The International Classification of Diseases (ICD-10) categorizes the condition as emotionally unstable personality disorder, with diagnostic criteria similar to those in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), where the disorder's name remains unchanged from previous editions.[9]
DSM-5 diagnostic criteria
[edit]
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has eliminated the multiaxial diagnostic system, integrating all disorders, including personality disorders, into Section II of the manual. For a diagnosis of BPD, an individual must meet five out of nine specified diagnostic criteria.[108] The DSM-5 characterizes BPD as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and a significant propensity towards impulsive behavior.[108] Moreover, the DSM-5 introduces alternative diagnostic criteria for BPD in Section III, titled "Alternative DSM-5 Model for Personality Disorders". These criteria are rooted in trait research and necessitate the identification of at least four out of seven maladaptive traits.[109] Marsha Linehan highlights the diagnostic challenges faced by mental health professionals in using the DSM criteria due to the broad range of behaviors they encompass.[110] To mitigate these challenges, Linehan categorizes BPD symptoms into five principal areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.[110]
International Classification of Disease (ICD) diagnostic criteria
[edit]
ICD-11 diagnostic criteria
[edit]
See also: ICD-11 § Personality disorder
The World Health Organization's ICD-11 completely restructured its personality disorder section. It classifies BPD as Personality disorder, (6D10) Borderline pattern, (6D11.5). The borderline pattern specifier is defined as a personality disturbance marked by instability in interpersonal relationships, self-image, and emotions, as well as impulsivity.[111]
Diagnosis require meeting five or more out of nine specific criteria:Frantic efforts to avoid real or imagined abandonment.A pattern of unstable and intense interpersonal relationships, which may be characterized by vacillations between idealization and devaluation, typically associated with both strong desire for and fear of closeness and intimacy.Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one's own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.Chronic feelings of emptiness.Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:A view of the self as inadequate, bad, guilty, disgusting, and contemptible.An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.
ICD-10 diagnostic criteria
[edit]
The ICD-10 (version 2019) identified a condition akin to BPD it termed Emotionally unstable personality disorder (EUPD) (F60.3). This classification described EUPD as a personality disorder with a marked propensity for impulsive behavior without considering potential consequences. Individual with EUPD had noticeably erratic and fluctuating moods and are prone to sudden emotional outbursts, struggling to regulate these rapid shifts in emotion. Conflict and confrontational behavior are common, especially in situations where impulsive actions are criticized or hindered.
The ICD-10 recognizes two subtypes of this disorder: the impulsive type, characterized mainly by emotional dysregulation and impulsivity, and the borderline type, which additionally includes disturbances in self-perception, goals, and personal preferences. Those with the borderline subtype also experience a persistent feeling of emptiness, unstable and chaotic interpersonal relationships, and a predisposition towards self-harming behaviors, encompassing both suicidal ideations and suicide attempts.[112]
Millon's subtypes
[edit]
Psychologist Theodore Millon proposed four subtypes of BPD, where individuals with BPD would exhibit none, one, or multiple subtypes. The discouraged subtype is characterized by traits such as avoidance, dependency, and internalized anger and emotions. Individuals belonging to this subtype tend to exhibit impulsivity alongside compliance, loyalty, and humility. They often feel vulnerable and perpetually at risk, experiencing emotions such as hopelessness, depression, and a sense of helplessness and powerlessness.[113] The petulant type is characterized by negativism, impatience, restlessness, stubbornness, defiance, angriness, pessimism, and resentment. Individuals of this type tend to feel slighted and disillusioned with ease. The impulsive type is characterized by being captivating, unstable, superficial, erratic, distractible, frenetic, and seductive. When they fear loss, they become agitated, gloomy, and irritable, potentially leading to suicidal thoughts or actions. The self-destructive type is inward-turning, self-punishing, angry, conforming, and displays deferential and ingratiating behaviors. Their behavior tends to deteriorate over time, becoming increasingly high-strung and moody, and they may also be at risk for suicide.[114]
Misdiagnosis
[edit]
Main article: Misdiagnosis of borderline personality disorder
Individuals with BPD are subject to misdiagnosis due to various factors, notably the overlap (comorbidity) of BPD symptoms with those of other disorders such as depression, PTSD, and bipolar disorder.[115][116] Misdiagnosis of BPD can lead to a range of adverse consequences. Diagnosis plays a crucial role in informing healthcare professionals about the patient's mental health status, guiding treatment strategies, and facilitating accurate reporting of successful interventions.[117] Consequently, misdiagnosis may deprive individuals of access to suitable psychiatric medications or evidence-based psychological interventions tailored to their specific disorders.[118]
Critics of the BPD diagnosis contend that it is indistinguishable from negative affectivity upon undergoing regression and factor analyses. They maintain that the diagnosis of BPD does not provide additional insight beyond what is captured by other diagnoses, positing that it may be redundant or potentially misleading.[119]
Adolescence and prodrome
[edit]
The onset of BPD symptoms typically occurs during adolescence or early adulthood, with possible early signs in childhood.[120] Predictive symptoms in adolescents include body image issues, extreme sensitivity to rejection, behavioral challenges, non-suicidal self-injury, seeking exclusive relationships, and profound shame.[53] Although many adolescents exhibit these symptoms without developing BPD, those who do are significantly more likely to develop the disorder and potentially face long-term social challenges.[53]
BPD is recognized as a stable and valid diagnosis during adolescence, supported by the DSM-5 and ICD-11.[121][122][123][124] Early detection and treatment of BPD in young individuals are emphasized in national guidelines across various countries, including the US, Australia, the UK, Spain, and Switzerland, highlighting the importance of early intervention.[123][125][126][127]
Historically, diagnosing BPD during adolescence was met with caution,[123][128][129] due to concerns about the accuracy of diagnosing young individuals,[130][131] the potential misinterpretation of normal adolescent behaviors, stigma, and the stability of personality during this developmental stage.[123] Despite these challenges, research has confirmed the validity and clinical utility of the BPD diagnosis in adolescents,[121][122][123][124] though misconceptions persist among mental health care professionals,[132][133][134] contributing to clinical reluctance in diagnosing and a key barrier to the provision of effective treatment BPD in this population.[132][135][136]
A diagnosis of BPD in adolescence can indicate the persistence of the disorder into adulthood,[137][138] with outcomes varying among individuals. Some maintain a stable diagnosis over time, while others may not consistently meet the diagnostic criteria.[139] Early diagnosis facilitates the development of effective treatment plans,[137][138] including family therapy, to support adolescents with BPD.[140]
Differential diagnosis and comorbidity
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Lifetime co-occurring (comorbid) conditions are prevalent among individuals diagnosed with BPD. Individuals with BPD exhibit higher rates of comorbidity compared to those diagnosed with other personality disorders. These comorbidities include mood disorders (such as major depressive disorder and bipolar disorder), anxiety disorders (including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)), other personality disorders (notably schizotypal, antisocial, and dependent personality disorder), substance use disorder, eating disorders (anorexia nervosa and bulimia nervosa), attention deficit hyperactivity disorder (ADHD),[141] somatic symptom disorder, and the dissociative disorders.[142] It is advised that a personality disorder diagnosis should be made cautiously during untreated mood episodes or disorders unless a comprehensive lifetime history supports the existence of a personality disorder.[143]