Decoding Borderline Personality Disorder

What is Borderline Personality Disorder (BPD)?

Borderline personality disorder (BPD) is a mood disorder that affects the way a person thinks, feels and interacts with others. It is the most common personality disorder.

Experts believe that there is no single cause of BPD and it is most likely brought on by a series of factors, including:

Genetics
Problems with neurotransmitters in the brain (especially serotonin)
Issues with brain development
Environmental factors (including childhood abuse, neglect and trauma)

The symptoms of BPD can be grouped into four key areas:

Emotional instability – this is referred to as affective dysregulation in clinical settings
Cognitive or perceptual distortions – this refers to disturbed patterns in thoughts or perceptions
Impulsive behaviour
Relationships with others that are intense but also unstable

The symptoms of BPD vary between patients, with some only experiencing mild symptoms whilst others experience intense or severe indicators of borderline personality disorder.

Most commonly, the signs of BPD begin to show in adolescence and continue into adulthood, although not every case follows this pattern.

BPD can be a serious condition that may coexist alongside other mental health problems such as:

Alcohol or substance misuse / addiction issues
An additional personality disorder (such as anti-social personality disorder)
Bipolar disorder
Depression
Eating disorders (such as anorexia or bulimia)
Generalised anxiety disorder (GAD)

People with BPD often appear to be unstable and they find it hard to cope with stress, or to regulate their emotions. They may also struggle with feelings of isolation or abandonment. BPD is a significant risk factor for self-harm and suicide.

We will look at the symptoms associated with borderline personality disorder in more detail in the next section.

Core Symptoms of BPD

Emotional instability / affective dysregulation

People with BPD will often experience a range of negative emotions such as:

Extreme sadness
Anger
Shame
Serious panic

They may also experience severe mood swings that happen in a short space of time. If you have BPD, you may find yourself feeling extremely low (even suicidal), then relatively positive a few hours later. Patterns vary between patients, but a key indicator of BPD is that mood swings occur in unpredictable ways.

Cognitive distortions

People with BPD can display disturbed patterns of thinking. These thoughts may include:

Persistent disruptive and upsetting thoughts such as thinking you are a bad person or fearing that you will be abandoned and alone forever.
Brief periods of confusion and paranoia. This may include hearing voices that tell you to do bad things such as harming yourself or others.
Longer episodes of cognitive distortion where you may experience hallucinations and severe paranoid thoughts. This may include themes such as believing you don’t exist or that someone is out to get you.

Even though these disturbing thoughts are illogical and have no basis in reality, they can feel very real to the person experiencing them which will leave them distressed, frightened and not sure who to trust.

If you are concerned that you have symptoms of BPD you should make an appointment with your GP to discuss your concerns. They may refer you to a Community Mental Health Team (CMHT) or a specialist who has experience in diagnosing personality disorders.

If you receive a diagnosis of BPD, it is important that your family and wider social support network are informed as the condition usually affects your relationships with others.

Emotional Dysregulation and Mood Swings

The emotional dysregulation and rapid mood swings experienced by some people with BPD can be extremely hard to cope with. People with BPD may exhibit multiple, intense emotions in a short space of time. They may also show evidence of the following:

Low self-worth and a negative self-image
Problems managing anger or other negative emotions
Feeling confused about who they are
An extreme or irrational fear of being abandoned or being alone

People with BPD often have severe and disproportionate reactions to life events which can set off serious depressive episodes and mood swings.

Self-Harm and Suicidal Behaviour

People who have BPD are at risk of self-harm and suicide. Some research suggests that up to 10% of BPD sufferers will die by suicide and even more will die as a result of engaging in risky behaviours, such as an accidental drug overdose.

A unique aspect of BPD is the prevalence of suicidal ideation, with some patients experiencing intense suicidal thoughts in reaction to life’s stressors on a regular basis. These thoughts of suicide may subside over time and recur once another stressful or challenging event presents itself, and does not necessarily indicate an intent to carry out a suicidal act. However, too many people with borderline personality do kill themselves. One study carried out in Canada of 75 males who had died by suicide found 28% of them to have had BPD.

To minimise the chance of a person with BPD harming or killing themselves, early intervention and effective treatment is key.

If you are experiencing suicidal thoughts, you should reach out for help immediately:

Call your GP and request an urgent appointment
Speak to a trusted part of your support network
Call the Samaritans on 116 123 to speak to a trained adviser. Help is available 24/7
In an emergency, always dial 999 to get immediate help

Impulsivity and Risky Behaviours

BPD carries a risk of engaging in risky, reckless and dangerous behaviours such as spending large sums of money, having unprotected sex with strangers or driving recklessly. This behaviour can put you at additional risk of harm, such as:

Getting into debt
Contracting a sexually transmitted disease (STD)
Hurting or killing yourself or others by getting into a car accident

Broadly speaking, impulsive behaviour related to BPD falls into two categories:

An impulse to hurt yourself (such as self-harm behaviour including cutting) which can escalate to feeling suicidal or attempting to commit suicide
An impulse to engage in dangerous or risky behaviour despite potentially disastrous consequences

Challenges in Relationships

There are often some contradictory messages in relationships with people who have BPD and there may be a dynamic of ‘Go away and leave me alone’ juxtaposed with ‘Don’t abandon me’. This dynamic often extends beyond romantic relationships to friendships, family relations and even relationships with healthcare workers or therapists.

These contradictions can be extremely confusing and difficult to navigate and often result in the breakdown of relationships, which may then reinforce the patient’s feelings of abandonment.

Additionally, people with BPD often tend to think about life in a very rigid way and view people or situations as either all good or all bad, failing to see the nuances and grey areas in between.

People with BPD typically have a history of erratic and intense relationships that are characterised by:

Instability
Intense fear of abandonment
Fear of being controlled/smothered

These intense emotions can lead to people with BPD exhibiting behaviours that can be alarming and overwhelming to others such as:

Constantly calling or texting them
Clinging on to people to prevent them from leaving
Making threats to harm themselves if their partner leaves them

They may exhibit needy and intense traits in addition to contradictory behaviours such as:

Becoming withdrawn
Pushing people away
Rejecting others

Co-occurring Disorders and Dual Diagnosis

Both borderline personality disorder (BPD) and bipolar disorder (BD) are mental health conditions that are characterised by impulsivity and extreme mood swings. The two are sometimes confused, although they are different disorders with different treatments. In some cases, the two disorders can coexist, meaning a patient has enough of the traits of BPD and BD to be diagnosed with both.

With BD, you are more likely to suffer from other mental health conditions and often experience problems such as:

Anxiety and depression
Addiction
Eating disorders

We know that rates of mortality amongst people with eating disorders are among the highest of any mental health problem. NHS research suggests that in cases where disordered eating (specifically anorexia nervosa or bulimia nervosa) co-occurs with BPD, the risks of suicide may be even higher. This highlights just how crucial it is to receive the correct diagnosis and engage with the correct treatment for all co-occurring disorders in order to minimise harm to the patient.

Coping Strategies and Treatment

With the correct interventions, many people with borderline personality disorder will be able to manage their symptoms and some may fully recover. In times of relapse or when faced with stress, seeking additional treatment is always a good idea.

Your treatment will usually be overseen by members of your Community Mental Health Team (CMHT). Your CMHT is made up of different professionals who are there to provide support, treatment and resources. The team may be made up of:

Community mental health nurses
Counsellors or therapists
Pharmacists
Psychologists
Psychiatrists
Social workers
Occupational therapists

If you show signs of BPD that are on the more extreme end then you will often be given a special type of treatment plan, known as a care programme approach (CPA). The CPA is made up of four steps:

An assessment of your needs (both medical and social)
A care plan that matches your needs
You are assigned a keyworker (usually a nurse or social worker)
Regular reviews to check your progress and how treatment is going or if any changes need to be made

Psychotherapy is considered the most effective treatment for BPD. There are different types of psychotherapy available for BPD and they should be delivered by a trained professional such as a psychiatrist or psychologist. You may be able to choose the type of psychotherapy you receive or you may be advised which one would be most suited to your specific needs. The therapies available to you may depend on which area you live in.

Some of the therapy options for the treatment of BPD include:

Dialectical behaviour therapy (DBT)
Mentalisation based therapy (MBT)
Therapeutic communities
Art therapies

Dialectical behaviour therapy

Considered a gold star treatment for BPD, dialectical behaviour therapy aims to teach emotional regulation skills. It is based on similar principles to cognitive behavioural therapy but is specially adapted for people who experience emotions very intensely.

The main goal of DBT is to help you to understand and accept problematic feelings and learn to deal with these in a positive way, rather than resorting to harmful coping mechanisms.

Sessions will be delivered weekly, either on a one-to-one basis or in a group setting. Like CBT, dialectical behaviour therapy requires collaboration and teamwork in order to be most effective.

The National Institute for Health and Care Excellence (NICE) recommends DBT as a go-to treatment for people with BPD and it has been shown to be particularly beneficial in treating women with a history of self-harm.

Mentalisation based therapy

MBT is another long-term psychotherapy that can be used to treat people with BPD. It helps us to think about our own thoughts and how we project these thoughts onto others as well as harmful assumptions we may make.

For example, a person with BPD may view the fact that their partner wants to spend a night alone as meaning that they do not love them and are planning to leave them. This may send them spiralling and catastrophising.

Mentalisation based therapy also teaches us to try to take a moment and distance ourselves from a situation before reacting negatively and disproportionately. In the previous example, the patient would be encouraged to reconsider their reaction and acknowledge that time apart and having your own interests, forms the backbone of most healthy relationships.

A course of MBT may last up to 18 months and you may be required to receive the treatment in a hospital setting as an impatient, at least at first.

Therapeutic communities

Therapeutic communities are a type of residential therapy where people with a range of complex mental health issues live together for one to four weeks and take part in activities and therapy sessions.

They are highly structured environments designed to teach skills around behaviour and social interaction. Everyone in the therapeutic community is responsible for doing chores, cooking and keeping the place clean and each individual may take part in sports or other recreational activities.

Art therapy

Some people with BPD find that they benefit from creative expression. Art therapy can help with relaxation, focus and learning to channel negative emotions into something positive.

Art therapy can include different creative mediums, such as:

Art such as painting or drawing
Dance movement therapy
Drama therapy
Music therapy

Art therapy sessions are run by trained therapists. These sessions may be helpful to people who find expressing their emotions problematic.

Self-help

It is important to find the treatment options that work for you, which may be a combination of any of the above options. To support your recovery, you may also want to use some self-help techniques to deal with overwhelming emotions and stressors:

Try practising mindfulness and/or meditation to quieten your mind and help you feel more focused and relaxed.
Boost your mood by doing things that you enjoy and avoid ruminating. Try exercising, listening to music or journaling.
When you experience upset or stress try to take a step back before reacting.
If you are prone to self-harm, try something less damaging to express yourself such as the elastic band technique (where you wear an elastic band around your wrist and ping it to feel a short, sharp sting as needed) or try some high-impact cardio exercise.

Medication

There are currently no medicines licensed to treat BPD in the UK; however, medication can be used to treat co-occurring mental health disorders, for example:

Depression
Anxiety
Bipolar disorder

Mood stabilising and anti-psychotic medication is sometimes used in cases of BPD to treat symptoms of severe mood swings or psychosis or to reduce impulsivity; however, this is always recommended in conjunction with therapy.

Sometimes, sufferers of BPD may experience a mental health crisis which is a severe type of mental health episode. Often, people with BPD find that speaking to someone who understands their condition, such as a member of the crisis resolution team (CRT), is enough to bring them out of their crisis. In extreme cases, you may be prescribed a short course of medication such as a tranquiliser to calm you down and stabilise your mood.

In conclusion, the following are crucial in ensuring people with BPD have the best outcomes:

Recognising symptoms and accessing treatment
Collaboration between the patient, medical professionals and families
Engaging fully with treatment (which will often be some form of psychotherapy)
Adopting positive coping strategies and recognising negative ones
Self-care and self-help

Reaching out for professional help is key in overcoming the challenges that having BPD poses. If you have concerns about your mental health, talk to someone you trust and make an appointment to see your GP as soon as possible.

Decoding Borderline Personality Disorder: Symptoms and Challenges

In this article

What is Borderline Personality Disorder (BPD)?

Core Symptoms of BPD