borderline personality disorder

Before discussing personality disorders and borderline personality disorder, it is important to understand that the descriptions of personality disorders and a borderline personality disorder described in this article are offered for educational purposes and are not intended to be used for diagnostic purposes.

The only person who can diagnose any psychological/psychiatric disorder, including a personality disorder, is a certified mental health professional. People who are not trained and certified to assess and diagnose these disorders should not attempt to do so and should seek professional assistance.

What Is Personality?

Before discussing the definition of a personality disorder is important to define the term personality in a psychological sense.  Personality comes from the Latin word persona, meaning “mask.” Personality refers to:

“… a set of organized and dynamic characteristics that influence a person’s thinking, emotions, motivations, attitudes, interpersonal relationships, and behavior in a unique manner. “

Thus, according to the definition there were two crucial aspects of the concept of personality:

  • It is consistent.
  • It actually has to perform a function or do something.

By doing something, psychologists mean that the concept of a personality must function to express the person’s needs, define motivations, allows the person  to build relationships, guides behavior, and so forth. If for example, we say that someone is an extrovert (a well-documented personality trait) then most of the time we should be able to correctly predict that the person is going to be outgoing in social situations.

There was a time when many theorists and researchers believed that the concept of personality actually did not exist and that all behavior was driven by situational forces (in fact, some would even argue this now). Today, most psychologists and other researchers accept the notion that the concept of personality is a valid. Just the same, there are many different conceptualizations as to the types of facets that define the psychological aspects of personality.
 

What Is a Personality Disorder?

If a personality must do something, then a personality disorder must also do something except in a dysfunctional manner. The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) is the current clinical diagnostic manual for all psychological/psychiatric disorders. According to DSM-5, a personality disorder is:

“… an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”

Thus, according to the clinical diagnostic criteria, personality disorders:

  • Are stable tendencies that have existed in the person at least since adolescence
  • Go against expectations of the person’s culture
  • Cause the person to experience significant stress
  • Lead to issues with functioning in society in terms of relationships, jobs, or in other areas


It is also important to understand that this particular dysfunctional pattern of behavior cannot be better explained by:

  • The presence of some other mental health disorder (for example, having schizophrenia)
  • By the effects of using a particular drug(s) or medication(s)
  • By the effect of some other medical condition, such as a head injury


What this means is that although any of these other conditions listed above can certainly be present in someone was diagnosed with a personality disorder, the person’s dysfunctional issues cannot be better explained by these conditions alone.

Issues with Personality Disorders as a Diagnostic Category

Some may read the clinical definition of a personality disorder and immediately notice that there is the potential for this definition to be rather subjective in nature.  In fact, the entire diagnostic scheme used in DSM-5 has been sharply criticized because of its potential subjectivity, lack of scientific validation, and other issues regarding its formulation. Many of these critiques became even more public shortly before the release of DSM-5, the latest edition of the manual.

Researchers have suggested a change was needed in the way the different editions described personality disorders for many years; however, in DSM-5, there has been little change to the clinical conceptualization of personality disorders.

Nonetheless, DSM is the diagnostic manual that is used by mental health professionals in the United States today, and a discussion of any psychiatric/psychological disorder should include the DSM diagnostic for that disorder in its description.

Borderline Personality Disorder

bpd and unstable relationshipsBorderline personality disorder (BPD) is a disorder characterized by difficulties with emotional regulation (Cluster C).  BPD is characterized by a longstanding or pervasive pattern of having unstable relationships with others, an unstable personal image, and unstable emotions, as well as displaying significant impulsive behaviors.  These behaviors are often first present during adolescence or early adulthood, and occur in a variety of different situations.

According to DSM-5, there are nine diagnostic criteria that can be used to formally diagnose BPD in a person:

  • 1. Frenzied attempts to avoid abandonment (whether actual or imagined)
  • 2. A pattern of volatile and intense relationships that alternate between poles of idolization and devaluation
  • 3. Markedly and persistently unbalanced sense of self
  • 4. Impulsivity and destructive behavior in two or more areas that are potentially self-harming (e.g., substance abuse, binge eating, and reckless driving)
  • 5. Persistent suicidal behavior, suicidal threats, or self-harming behavior
  • 6. Emotional volatility due to a observable mood reaction
  • 7. Persistent feelings of desolation
  • 8. Inappropriate, passionate anger or trouble managing anger (e.g., recurrent demonstrations of temper, perpetual anger, recurring physical violence, etc.)
  • 9. Fleeting paranoid ideation related to stress or strong dissociative symptoms (these consist of feelings that one is removed or detached from the body, removed or detached from reality, or experiences of severe amnesia)

  • In order to receive a formal diagnosis of BPD, one would have to display at least five of the nine symptoms.

    Many of the researchers, such as the eminent psychiatrist Otto F. Kernberg, consider that the first of the criteria – pervasive feelings of loneliness that result in the need to feel wanted or to belong to someone/something – is the driving force behind this particular disorder. However, BPD is a disorder that can present in many different ways.

    Interestingly the way that the diagnostic criteria are arranged (one must have at least five of nine symptoms for a formal diagnosis) allows for 126 different combinations of five symptoms of the criteria that can result in a formal diagnosis of BPD.  Of course, the total number of different symptom combinations that can result in a diagnosis of BPD is somewhat higher, as a person could also be diagnosed with BPD having six, seven, eight, or all nine of the diagnostic criteria. Thus, the disorder can present in a number of different ways.

Other Features of BPD 

There are many different studies on the prevalence of BPD; however, the most up-to-date figures place the prevalence in the general population to be anywhere between 1.6 percent and 5.9 percent. 

The prevalence of BPD in psychiatric inpatient groups is estimated to be about 20 percent; however, the prevalence of BPD probably decreases in older groups of people. The male to female ratio of people diagnosed with BPD is 1:3.

Being physically or sexually abused, neglected, coming from home with domestic violence, or having lost a parent in childhood appear to be relatively common occurrences among people diagnosed with BPD. It is about five times more common in first-degree biological relatives, indicating that a potential genetic component contributes to the probability of having the disorder. However, like all personality disorders, there is no distinct cause associated with the development of BPD in anyone, and it is believed that this disorder results from an interaction of genetic and environmental factors.

Subtypes of BPD

Due to the manner in which BPD is diagnosed and the potential for many different presentations of the disorder, there have been several attempts to identify different subtypes of BPD. Some say that the work of the late personality psychologist Theodore Millon is the most recognized.

Millon identified four distinct subtypes of BPD that have endured over many years.  Other empirical research has suggested there are more or fewer subtypes of BPD, but even then, these research findings are in general agreement with the patterns of the subtypes that were described by Millon:

Impulsive

An issue with controlling impulses is often a problem for anyone with BPD; however, in this subtype of BPD, it is the major feature of the presentation. As a result, this subtype is at a very high risk for attempted suicide or self-mutilation. The impulsive subtype of BPD is also often prone to becoming very bored and restless, getting involved in reckless and thrill-seeking activities, and demonstrating drastic mood changes, such as being bubbly and full of energy at one moment and then turning hostile and cold in the next.

Discouraged

This BPD subtype often presents as clingy, reliant on others, and very passive.  Feelings of anger or abandonment are often focused inward, and this subtype is also at risk for suicide tempts or self-mutilating behavior.  Their need for dependence on others, which never seems to be satisfied for long, leads to chronic feelings of emptiness or intolerance with relationships.

Petulant

This subtype of BPD often vacillates between feelings of unworthiness and explosive outbursts of anger (it is sometimes referred to as the angry BPD subtype). These individuals are fearful of being abandoned or rejected, and this leads to issues with jealousy, controlling and manipulating other people, possessiveness, anxiety, and irritability.  Individuals with this subtype of BPD feel a need to control others to keep them close, and because of this need, they are often overprotective of people in their lives. A the same time, they do not experience satisfaction with relationships. This leads to the potential to develop issues with substance abuse.

Self-destructive

People with this subtype may harbor intense feelings of self-loathing, bitterness, and self-hatred. They may express a chronic need for attention from others and, if not satisfied, turn to self-destructive behaviors that can include substance abuse, eating disorders, risky sexual activities, or thrill-seeking  behaviors, such as reckless driving.

Comorbidity of Other Disorders with BPD

Research findings indicate that there are numerous disorders that co-occur with BPD. The most common co-occurring disorders include:

  • Mood disorders

    Mood disorders are the most commonly co-occurring group of disorders associated with a diagnosis of BPD. These disorders include depression and bipolar disorder. The most common co-occurring disorder with BPD is major depressive disorder.

  • Anxiety disorders

    These include disorders, such as panic disorder and phobias.

  • Post-traumatic stress disorder

    This disorder was previously listed as an anxiety disorder but now is classified in a new category named Trauma and Stressor-Related Disorders.

  • Substance use disorders or alcohol use disorder

    Issues with substance abuse and addiction occur frequently in individuals diagnosed with BPD. Research indicates that half to nearly large-8 medium-12 columns of individuals with a BPD diagnosis will also have a substance abuse or addiction issue.

  • Other personality disorders

    Most often, other personality disorders are diagnosed along with BPD. The most common that co-occur with BPD include avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and paranoid personality disorder.

Thus, the relationship between BPD and addiction or substance abuse is fostered by the difficulties these individuals experience with attachment to others and with their emotional regulation. Drugs and alcohol can represent a sort of substitution for a relationship that also allows individuals to also achieve a perception, albeit a false perception, that by using, they can achieve control over their emotions, their relationships, and their self-image.

When an individual is diagnosed with both BPD and another disorder, it can make the treatment plan for that person all the more difficult, as one might expect. Personality disorders are notoriously difficult to treat as are substance use disorders. When a person is diagnosed with both together, it can make the treatment even more complicated.

Treatment Options for BPD

treatment options for bpdPersonality disorders are notoriously complicated to treat. BPD has received notoriety as being even more difficult to treat than other personality disorders. However, recent research has indicated that BPD can respond to treatment and that individuals diagnosed with BPD can make gains.

There are no specific medications that are designed or approved to treat BPD. There is some research that indicates that certain medications, such as antidepressants, anti-anxiety medications, or even antipsychotic medications, can be used to manage some of the specific symptoms that a person diagnosed with BPD may present with; however, no one medication is used in the treatment of BPD. This results in many individuals with BPD being treated with several medications at the same time, increasing the chance for side effects from medication and other issues to occur.

Individuals with BPD are typically treated with therapy or a combination of medication and therapy. The therapies typically used in the treatment of BPD are most often Cognitive Behavioral Therapies (CBT) that help individuals to identify and change their beliefs, expectations, and attitudes regarding relationships with others and their own personal feelings about themselves. CBT has been shown to be particularly effective in helping to restructure a person’s self-image, reduce issues with mood and anxiety, reduce the tendency towards self-harm, and assist in recovery from substance use disorders.

There are several specialized types of CBT that appear to be especially effective for treating patients with BPD:

  • Dialectical Behavior Therapy concentrates on the concept of mindfulness, which refers to remaining aware and focusing one’s attention on the current situation. This type of therapy helps to teach individual to control their intense feelings, improve their relationships, and reduce self-destructive types of behaviors.
  • Schema-Focused Therapy is useful in changing the self-image of people with BPD, how they react to their interactions with others, and how they cope with problems and stress.
  • Specialized forms of group or family therapy have also been useful in treating the symptoms and self-image of people with BPD.

Treating BPD and Substance Use Disorders Together

Issues with rage, mood swings, impulsivity, unstable relationships, and a dysfunctional self-image are features of BPD that increase the susceptibility to substance use disorders (addiction). The following issues represent complications that BPD patients with substance use disorders or addictions present in treatment:

  • Issues with compliance: BPD patients with substance use disorders are even more demanding in treatment and at the same time demonstrate more resistance to treatment. Having either disorder alone is a notorious issue regarding compliance with treatment; however, having both together complicates this issue.
  • Relationship issues: Because individuals with BPD have issues with relationships, and those with addictions find the relationship with their drug/activity of choice to be the most stable relationship that they have experienced, these individuals are more likely to have difficulties in developing a relationship with a therapist or engaging in group therapy. For example, at first the person may view the therapist or group as a much-needed source of support; however, as soon as the individual perceives criticism or disapproval, the group or therapist/group then becomes the enemy and cannot be trusted. This leads to the person missing sessions, becoming passive or angry, and so forth. Therapists need to have a total understanding of the issues associated with BPD and substance abuse, and to provide consistent and nonjudgmental support to these individuals.


Outside of therapy, individuals with BPD will typically have very unstable interpersonal relationships. It is important to help them to develop social skills to maintain relationships outside of therapy. Using 12-Step groups, group therapy, and other focused groups may help the individual to develop more functional personal relationships.

  • Suicidal behavior: People diagnosed with BPD are at a higher risk of suicide and other forms of self-destructive behavior than other individuals. When these individuals are under the influence of drugs or alcohol, the risks for self-destructive behaviors increase. This issue often complicates therapy, and Dialectical Behavior Therapy appears to be particularly useful in addressing issues regarding feelings of suicide and self-destructive behavior.

Conclusions 

BPD is a severe personality disorder that can present a number of different ways but typically involves feelings of potential loneliness or abandonment, poor emotional regulation, issues with relationships, self-destructive behaviors, and other serious co-occurring disorders, including substance use disorders, which are quite common. Treatment can be complicated but effective in managing the disorder.