Understanding Borderline Personality Disorder

The understanding of borderline personality disorder (BPD) has been steadily improving since the term was first used in the 1930s. Its name reflected early psychologists' perception that it was a disorder of thought with symptoms that fell on a "borderline" between the two major categories of mental illness they used at the time: neurosis and psychosis.

Clinicians and researchers now know that BPD is not a thought disorder, but a disorder of emotional regulation. International clinicians now sometimes use the terms "emotionally unstable personality disorder" or "emotional dysregulation disorder" interchangeably with "borderline personality disorder" when diagnosing people with the condition.

Insight into BPD has advanced even further in the last few decades. Once believed to be extremely difficult, if not impossible to treat, it is now better understood as a trauma-related disorder that responds well to the right treatment. Recent research shows that most people with BPD experience a remission of symptoms, especially when they receive treatment for it.

What Is Borderline Personality Disorder?

Borderline personality disorder is one of ten personality disorders listed in the fifth and most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In general, personality disorders are mental health conditions that form during childhood and early adolescence and emerge by late adolescence or early adulthood. They are caused by a combination of biological and environmental factors, particularly a mix of temperament and childhood experiences. They feel more like an identity than a transient condition. This is one reason their characteristics are commonly called "traits" instead of "symptoms."

Borderline personality disorder is defined by factors affecting emotional regulation, identity, and interpersonal functioning. To be diagnosed with BPD, a person must have four or more of the following traits listed in the DSM-5:

• An unstable sense of self
• Chronic feelings of emptiness
• Frantic efforts to avoid abandonment
• Episodes of inappropriate anger and rage
• Transient experiences of paranoia or dissociation
• Self-harming or suicidal behavior including suicidal gestures and threats
• Emotional instability as exhibited by episodes of dysphoria, anxiety, and irritability
• Impulsivity in potentially self-damaging areas, such as substance use or reckless driving
• Unstable and intense interpersonal relationships that involve patterns of alternating idealization and devaluation

In cases where a person has some of these traits, but not enough to be diagnosed with BPD, clinicians say that they have "BPD traits."

Due to the variance in these traits, there are a wide range of ways people can manifest the disorder. Some clinicians use subtypes to delineate between people who have more passive symptoms and people who are more demonstrative or extraverted in their expression of BPD.

For example, some people with borderline personality disorder frequently engage in acts of self-harm and are hospitalized on a regular basis, including medically for accidents incurred during episodes of high-risk behavior. Others tend to experience more frequent dissociation and dysphoria and keep their emotional intensity mostly hidden. Some people with BPD are more assertive in relationships, while others are more dependent.

What connects all people with BPD is that their emotional reactions are intense and often painful. One of the reasons people with the disorder harm themselves is that physical pain can distract from, diminish, or express the more intense emotional pain they feel. This pain is typically triggered by interpersonal conflict, especially in intimate partner relationships.

Causes of Borderline Personality Disorder

Borderline personality disorder is usually caused by a combination of the following factors:

• An emotionally sensitive and reactive temperament
• A family history of mental illness, especially of BPD
• Growing up in a violent or chaotic home environment
• Experiences of childhood neglect or abandonment
• One or more episodes of trauma or abuse in childhood

While many people with BPD have histories of physical or sexual abuse in childhood or adolescence, not all do. Some people develop the disorder in response to experiences of parental abandonment or pervasive emotional invalidation and neglect.

The risks and outcomes associated with untreated BPD are severe. Borderline personality disorder is associated with a suicide risk 50 times greater than that of the general population. Almost 80 percent of people with the disorder attempt suicide at least once in their lifetimes.

Treatment for Borderline Personality Disorder

Psychotherapy is the primary form of treatment for borderline personality disorder. Medication is rarely used specifically to treat the symptoms of BPD, though in rare cases selective serotonin reuptake inhibitors (SSRIs), antipsychotic medications, or mood stabilizers are used to help with problems related to aggression or impulse control.

Medication is more commonly used when a person with BPD has a co-occurring disorder that responds well to it. A significant percentage of people with BPD have another mental health condition. Over half of people with BPD have an anxiety disorder, and the rates of comorbidity are similar for mood and substance use disorders.

Cognitive behavioral therapy (CBT) is a popular and effective choice for the treatment of both anxiety and depression and can also address specific symptoms of BPD. However, the most effective intervention for borderline personality disorder is dialectical behavior therapy (DBT). Developed in the 1980s by Marsha Linehan, DBT combines CBT interventions with techniques from mindfulness and meditation to improve emotional awareness and help people ground themselves more deeply in present moment experience in the body.

Both CBT and DBT focus on identifying distorted thought patterns that drive negative emotions and behavior. However, where CBT encourages people to counter and try to change thoughts, DBT helps clients learn how to become aware of thoughts without having to act on them or change them. In DBT, people learn how to develop and act from "wise mind," an intuitive knowing that comes from having access to both emotion and reason at the same time.

In dialectical behavior therapy, people usually spend some time developing "DBT skills" in the following four areas before moving on to deeper work in therapy:

• Emotional regulation
• Distress tolerance
• Impulse control
• Interpersonal effectiveness

Research shows that DBT significantly reduces rates of hospitalization and suicide attempts and significantly improves social and general functioning. An alternative to DBT that yields similar results is mentalization-based therapy (MBT), which helps people improve their capacity for understanding shared mental states.

After functional gains have been made in therapy, including improved self-regulation of impulse and emotion, people with BPD typically move on to therapies that help them process and heal from trauma. Some interventions that have been proven effective in treating trauma-related conditions are eye movement desensitization and reprocessing therapy (EMDR), cognitive processing therapy (CPT), and exposure therapy.

Borderline Personality Disorder and Addiction

Over half of people with borderline personality disorder have a substance use disorder at the time their BPD symptoms are active, and nearly 75 percent have a substance use disorder at some point in their lifetimes.

Most substances can provide relief from the overwhelming emotional pain, dysphoria, and anger people with BPD experience. The intensity of their distress and the confusion that follows from it often drives people with BPD to use substances in large amounts and to quickly progress from substance abuse to dependence.

People with BPD commonly use alcohol in excessive amounts and have episodes of binge drinking. Of the 24 percent of people with BPD who have an active alcohol use disorder, 18 percent meet clinical criteria for alcohol dependence. Alcohol is the substance most frequently used by people with BPD but a wide range of substance use disorders are associated with BPD.

Comorbid BPD and addiction significantly increase the risks associated with each disorder:

• Increased anxiety, especially in periods between use
• More frequent and intense episodes of dysphoria or depression
• Higher risk of accidental injury to self or others through impulsive behavior
• Increased risk of intentional self-harm, including self-mutilation and suicide attempts

Substance use generally increases affective instability while further reducing impulse control, making the full range of BPD symptoms worse. It also intensifies the shame many people with borderline personality disorder experience in conjunction with an unstable sense of self. The significant changes in self-concept and self-presentation that come with the disorder make it harder for people with BPD to separate behavior linked with substance use from their core sense of self.

Fortunately, there are many ways to effectively treat co-occurring BPD and substance use disorders. One is an integrated treatment approach in which treatment groups for substance use disorders are coordinated with individual and group work for BPD. There are also therapies specifically designed to address these co-occurring disorders, including dialectical behavioral therapy for substance use disorders (DBT-SUD). Research shows DBT-SUD improves treatment outcomes for BPD and substance use disorders in people with both conditions.

Conclusion

Borderline personality disorder affects a person’s emotional and interpersonal functioning and sense of self. It is linked with increased risks of suicide, intentional and accidental self-harm, and substance abuse. Fortunately, it is much more responsive to treatment than psychologists originally thought. With the right treatment, someone with borderline personality disorder can overcome addiction, experience more emotional harmony, improve the quality of their relationships, and even experience a full remission of symptoms.