What is Borderline Personality Disorder?

Borderline Personality Disorder (BPD) is a mental disorder characterised by a person having difficulties in regulating their emotions, their moods and how they interact with others. It is denoted by a pattern of emotional instability, impulsive behaviour, distorted self-image and unstable relationships.

People with BPD feel emotions more intensely, for longer periods of time and it is harder for them to return to a stable state following an emotionally triggering incident, for example a memory, experience or event. It is the most commonly recognised personality disorder.

According to the National Institute for Health and Care Excellence (NICE), between 0.7% and 2% of the UK population suffer with borderline personality disorder. BPD appears to be more prevalent in women, with 75% of BPD sufferers being female. However, NICE highlights that one reason why the condition is predominantly seen in females is that women are far more likely to seek treatment.

The prevalence of BPD is particularly high in the prison population; in England and Wales it is estimated to be 23% among male remand prisoners, 14% among sentenced male prisoners and 20% among female prisoners.

How do you know if you have borderline personality disorder?

People with BPD tend to be extremely sensitive. Some people describe it as similar to having an exposed nerve ending. Small things can trigger intense reactions and once you are upset, you have trouble calming down again.

When you are experiencing overwhelming emotions, sometimes called a “crisis”, you are unable to think straight or stay grounded. You may say hurtful things or act in dangerous or inappropriate ways that make you feel guilty or ashamed afterwards. It can be an agonising cycle that can feel impossible to escape.

If you have BPD you may recognise some of the following statements:

• I often feel “hollow”.
• My emotions can swing very quickly.
• I often experience extreme sadness, or anger, or anxiety.
• I am constantly afraid that the people I care about will leave me or abandon me.
• I would describe most of my romantic relationships as intense, but unstable.
• When I’m feeling insecure in a relationship, I tend to lash out or make impulsive gestures to keep the other person close.
• The way I feel about the people in my life can dramatically change from one moment to the next and I don’t always understand why.
• I often do things that I know are dangerous or unhealthy, for example:
  – Driving recklessly.
  – Having unsafe sex.
  – Binge drinking.
  – Binge eating.
  – Using drugs.
  – Misusing other substances.
  – Going on spending sprees.
• I have attempted to hurt myself.
• I have engaged in self-harm behaviours such as cutting.
• I have threatened self-harm and/or suicide.

If you identify with a number of the above statements, you may be suffering from BPD, however, you should seek a correct diagnosis from a mental health professional as some of these feelings can also apply to other similar or co-occurring conditions such as:

• Depression.
• Bipolar disorder.
• Substance abuse.
• Eating disorders.
• Anxiety disorders.

What are the symptoms of borderline personality disorder?

BPD can reveal itself in a variety of ways, however, mental health professionals usually group the symptoms into nine major categories for the purpose of diagnosis. The symptoms must have been experienced by the suffer for some time, usually beginning in adolescence, it must impact a number of areas of their life and sufferers must show signs of at least five of these symptoms to be diagnosed with BPD.

• Fear of abandonment – People with BPD are often terrified of being abandoned or left alone; something as minor as a loved one arriving home later than expected or going away for a few days may trigger intense fear and this fear can provoke frenzied efforts to keep the other person close. BPD sufferers may become clingy, stalk the other person’s movements, beg them to stay, begin arguments or physically stop the other person from going. Rather than keeping the other person close, this behaviour will usually have the effect of driving them away.
• Unstable relationships – People with BPD tend to have relationships that are intense and short-lived. They may fall head over heels in love often at first sight, feeling that this is “the one”, a “soul mate”, but unfortunately they are often disenchanted as quickly as they have fallen in love. They tend to have relationships that they feel are perfect or dreadful; there never seems to be an in between. The BPD sufferer’s swift swings from perfection to hate and anger can make friends, loved ones and family feel like they are on a constant rollercoaster.
• Unclear or shifting self-image – The sense of self usually tends to be unstable in people with BPD. Sometimes they feel really good about themselves, but at other times they detest themselves and may even go as far as hating themselves. Often, they do not have a clear notion of who they really are or what they want in life. Because of this, they may change jobs, friends, likes, dislikes, ideas, beliefs, and partners very frequently.
• Impulsive, self-destructive behaviours – Many people with BPD engage in harmful, sensation-seeking behaviours. This often happens when they are particularly upset. They may indulge in, for example:
  – Impulse buying, often luxury items they can ill-afford.
  – Driving recklessly.
  – Binge eating or drinking.
  – Unsafe sex.
  – Drugs, alcohol or misuse of other substances.
  – Shoplifting.
  They engage in these risky behaviours to make themselves feel better but this is short-lived and they end up either hurting themselves and/or friends and family.
• Chronic feelings of emptiness – Often people with BPD will say they are feeling empty, as if there is a hole or a void inside them. Nothing they do seems to fill the void; they may try to fill it with food, drugs, alcohol, sex or shopping but none of this satisfies the need. It is a very upsetting experience and BPD sufferers will often say they feel they are worthless or a nobody.
• Extreme emotional swings – Erratic emotions and moods are very common in people with BPD. They may be feeling happy one moment and the next, they are despairing. They are thrown off emotional balance by little things that other people can either ignore or deal with. Although these mood swings are intense, people with BPD tend to get over them fairly quickly and they usually only last a few minutes – sometimes a little longer but they do pass just as swiftly.
• Explosive anger – People with BPD will often struggle with intense anger and a short temper. They often have trouble controlling themselves once the anger rises and they may start shouting and screaming, throwing things around, or becoming completely consumed by rage. Sometimes this anger is directed inwards as well as outwards, and BPD sufferers may experience being angry with themselves for periods of time.
• Feeling suspicious or out of touch with reality – Paranoia or suspicious thoughts about other people’s motives is something that people with BPD often struggle with. They may also feel “spaced out”, vague, confused or as if they are having an out of body experience. When they are anxious or under stress, they may even lose touch with reality completely; this is an experience known as dissociation.
• Suicidal behaviour and/or deliberate self-harm – This is common in people with BPD. Suicidal behaviour includes thinking about suicide, making suicidal threats, or actually attempting suicide. Self-harm includes all other attempts to hurt or harm themselves without a suicidal intent. Common forms of self-harm can include cutting, trichotillomania (hair pulling), skin scratching and burning.

What causes borderline personality disorder?

Unfortunately, as with many other mental health disorders, the causes of BPD are not fully understood at present. Most mental health professionals including MIND believe that BPD is caused by a combination of inherited or internal biological factors and external environmental factors, such as traumatic experiences in childhood.

Research of twins and families suggest that personality disorders may be genetic, that is that they are inherited or strongly associated with other mental health disorders among family members.

Other research has shown that brain abnormalities may be present; that there has been some changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function correctly.

Examples of the environmental factors that are also said to possibly cause BPD, can be people who have experienced traumatic life events such as physical or sexual abuse during childhood or neglect by and/or separation from their parents. These people are said to be at increased risk of developing BPD.

What risks and complications can borderline personality disorder cause?

People with BPD tend to view the world as good or bad, black or white, with no grey areas, and this can cause them complications and issues in life. One of the main areas they experience issues in is relationships – all kinds of relationships with, for example, friends, colleagues, family, partners, neighbours. This is because the person with BPD either loves or hates the people that they have any kind of relationship with and often no two days are the same.

A friend might be the best person in the world one day and the next they are their bitter enemy. Often these feelings stem from the BPD sufferer’s fear of abandonment. The impact is that the person with BPD has difficulties with interpersonal relationships that often leads to conflict and may result in divorce, family disputes, trouble maintaining friendships and clashes at work.

When these interpersonal conflicts arise in the workplace due to the BPD sufferer being unable to regulate their emotions, the impact may well be that they find themselves being disciplined or even losing their job. However, there are some people with BPD who function quite well and do hold down a job successfully.

Another issue that people with BPD experience is potentially having to take time off due to self-harm injuries, consequences of reckless driving, substance misuse, STDs acquired from unsafe sex and hospitalisation due to more serious injuries or suicide attempts. People with BPD will have to face the health and physical repercussions of their erratic behaviours.

How to diagnose borderline personality disorder?

There is no definitive medical test to diagnose BPD, and as referred to above, a diagnosis is not based on one specific sign or symptom but a combination of signs displayed over a period of time.

BPD is not usually diagnosed in children because their personalities and behaviours are still developing, and although some of the behaviours of BPD can be typically seen in young children, most grow out of these. If by adolescence, around the age of 18, a young person is still displaying these symptoms and behaviours and they are affecting their lives significantly, it may be that they are suffering from BPD.

The first step is to talk to your GP if you are concerned that you may have BPD. They will ask about your symptoms and how they are affecting your quality of life. Your GP will also want to rule out other more common mental health conditions, such as depression, and to make sure there is no immediate risk to your health and wellbeing. If your GP suspects BPD, you will probably be referred to a community mental health team for a more in-depth assessment.

A mental health professional will undertake a comprehensive clinical interview that may include talking with any medical or mental health professional that you may have previously been seen by. They will also review any previous medical evaluations if needed and, if and when appropriate, they may want to interview friends and family.

What treatments are available for borderline personality disorder?

When a diagnosis have been made for BPD, treatment may involve individual or group psychotherapy, carried out by professionals within a community mental health team (CMHT).

If your symptoms are moderate to severe, you will probably be entered into a treatment process known as a care programme approach (CPA). CPA is essentially a way of ensuring that you receive the right treatment for your needs.

There are four stages:

• An assessment of your health and social needs.
• A care plan created to meet your health and social needs.
• The appointment of a care co-ordinator (keyworker), usually a social worker or nurse, and your first point of contact with other members of the CMHT.
• Reviews where your treatment is regularly reviewed and any necessary changes to the care plan can be agreed.

BPD may be treated using psychotherapy, but medication may also be added. Types of psychotherapy that have been found to be effective include:

Dialectical behaviour therapy (DBT). DBT includes group and individual therapy designed specifically to treat borderline personality disorder. DBT uses a skills-based approach to teach you how to manage your emotions, tolerate distress and improve relationships.

Cognitive behavioural therapy (CBT). CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle.

Your doctor may also recommend hospitalisation if your safety is at risk. Consider involving people close to you in your treatment to help them understand and support you.

Self-help for those with borderline personality disorder

People with BPD can spend a lot of time fighting their impulses and emotions; however, if you stop trying to fight, avoid, suppress or deny what you are feeling and give yourself permission to have these feelings, you can take away a lot of their power.

Start by observing your emotions, as if from the outside. Watch as they come and go – it may help to think of them as waves. Tell yourself that you accept what you’re feeling right now and remind yourself that just because you are feeling something doesn’t mean it is reality.

• Do something that stimulates one or more of your senses:
  – If you’re feeling too much and need to calm down, try taking a warm bath or shower, snuggling under the bed covers, or cuddling with a pet.
  – If you’re feeling empty and numb, try sucking on strong-flavoured mints.
  – Focus on an image that captures your attention.
  – Try listening to loud music or, to calm down, turn on soothing music or listen to the soothing sounds.
• Take care of yourself by:
  – Eating a balanced, nutritious diet.
  – Getting plenty of quality sleep.
  – Exercising regularly.
  – Minimising stress.
  – Practising relaxation techniques.
• Distract yourself – Watch TV, choose something that is the opposite of what you are feeling, a comedy if you’re feeling sad or something relaxing if you are angry or agitated.
• Get active – Vigorous exercise is a healthy way to get your adrenaline pumping and let off steam.
• Call a friend – Talking to someone that you trust can be a quick and highly effective way to distract yourself, feel better, and gain some perspective.

How to help a family member or friend with borderline personality disorder

Many people with BPD may choose to isolate themselves from these relationships even when they need them most, so the support of family and friends is crucial in the treatment of BPD.

You can help your friend or family member by:

• Looking for warning signs. Watch out for any erratic behaviours, such as:
  – Shopping sprees.
  – Substance misuse.
  – Fighting and/or arguing.
  – Self-harm.
• Discuss their behaviours with them if your loved one is open to it, so they can recognise the signs early.
• Encourage them to seek treatment. Family and friends can be helpful in encouraging someone to begin and engage in proper treatment for this complicated and frustrating condition.
• Don’t tease or berate your friend or family member for failing to be in control or for making bad choices. Speak honestly and kindly, make specific offers of help and follow through. Tell the person you care about them and ask them how they are feeling.
• React calmly – even if your family member or friend is in crisis, angry or shouting, it is important to remain calm. Listen and make them feel understood, then help them to take the next step toward getting help.

In conclusion

Whilst there is no definitive cure for BPD, and learning to manage your emotions, thoughts and behaviours will take time, most people will improve considerably with treatment. You may always struggle with some symptoms of BPD and you may experience times when your symptoms are better or worse. However, treatment can improve your ability to function and help you feel better about yourself.

Helpful contacts include:

• NHS 111.
• MIND Infoline: 0300 123 3393.
• Emergence supporting all people affected by personality disorder.