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Borderline personality disorder

Borderline personality disorder (BPD), also known as


emotionally unstable personality disorder, is a longterm pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of
self, and unstable emotions.[3][4] There is often an extreme fear of abandonment, frequent dangerous behavior,
a feeling of emptiness, and self-harm. Symptoms may be
brought on by seemingly normal events.[3] The behavior
typically begins by early adulthood, and occurs across a
variety of situations.[4] Substance abuse, depression, and
eating disorders are commonly associated with BPD.[3]
About 10% of those with BPD die by suicide.[3][4]

Frantic eorts to avoid real or imagined


abandonment and extreme reactions to such

BPDs causes are unclear, but seem to involve genetic,


brain, environment, and social factors. It occurs about
ve times more often in a person who has an aected
close relative.[3] Adverse life events also appear to play
a role. The underlying mechanism appears to involve
the frontolimbic network of neurons.[5] BPD is recognized by the Diagnostic and Statistical Manual of Mental
Disorders (DSM) as personality disorder along with nine
other such disorders.[4] Diagnosis is based on the symptoms while a medical exam may be done to rule out other
problems.[3] The condition must be dierentiated from
an identity problem or substance use disorders, among
other possibilities.[4]

Dissociation

Splitting (black-and-white thinking)


Severe impulsivity
Intense or uncontrollable emotional reactions that
often seem disproportionate to the event or situation
Unstable and chaotic interpersonal relationships
Self-damaging behavior
Distorted self-image[3]
Frequently accompanied by depression, anxiety,
anger, substance abuse, or rage

The most distinguishing symptoms of BPD are marked


sensitivity to rejection or criticism, and intense fear of
possible abandonment.[6] Overall, the features of BPD include unusually intense sensitivity in relationships with
others, diculty regulating emotions, and impulsivity.
Other symptoms may include feeling unsure of ones
personal identity, morals, and values; having paranoid
thoughts when feeling stressed; dissociation and depersonalization; and, in moderate to severe cases, stressBorderline personality disorder is typically treated with
induced breaks with reality or psychotic episodes.
therapy, such as cognitive behavioral therapy (CBT). Another type, dialectical behavior therapy (DBT) has been
found to reduce the risk of suicide. Therapy may occur 1.1 Emotions
one-on-one, or in a group. While medications do not cure
BPD, they may be used to help with the associated symp- People with BPD feel emotions more easily, more deeply,
toms. Some people require care in hospital.[3]
and longer than others do.[7][8] In addition, emotions
may repeatedly resurge and persist a long time.[8] Consequently, it may take more time for people with BPD
than others to return to a stable emotional baseline following an intense emotional experience.[9] People with
BPD often engage in idealization and devaluation of others, alternating between high positive regard and great
disappointment.[10]

About 1.6% of people have BPD in a given year.[3] Females are diagnosed about three times as often as males.
It appears to become less common among older people.
Up to half of people improve over a ten-year period. People aected typically use a high amount of healthcare
resources.[4] There is an ongoing debate about the naming of the disorder, especially the suitability of the word
borderline.[3]

In Marsha Linehan's view, the sensitivity, intensity, and


duration with which people with BPD feel emotions have
both positive and negative eects.[9] People with BPD
are often exceptionally enthusiastic, idealistic, joyful, and
1 Signs and symptoms
loving.[11] However, they may feel overwhelmed by negative emotions (anxiety, depression, guilt/shame, worry,
Borderline personality disorder may be characterized by
anger, etc.), experiencing intense grief instead of sadthe following signs and symptoms:
ness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of
Markedly disturbed sense of identity
nervousness.[11]
1

SIGNS AND SYMPTOMS

People with BPD are also especially sensitive to feelings


of rejection, criticism, isolation, and perceived failure.[12]
Before learning other coping mechanisms, their eorts to
manage or escape from their very negative emotions may
lead to emotional isolation, self-injury or suicidal behavior.[13] They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate
them, they shut them down entirely.[9] This can be harmful to people with BPD, since negative emotions alert people to the presence of a problematic situation and move
them to address it which the person with BPD would normally be aware of only to cause further distress.[9]
While people with BPD feel joy intensely, they are especially prone to dysphoria, depression, and/or feelings
of mental and emotional distress. Zanarini et al. recognized four categories of dysphoria that are typical of
this condition: extreme emotions, destructiveness or selfdestructiveness, feeling fragmented or lacking identity,
and feelings of victimization.[14] Within these categories,
a BPD diagnosis is strongly associated with a combination of three specic states: feeling betrayed, feeling like
hurting myself, and feeling out of control.[14] Since there
is great variety in the types of dysphoria experienced by
people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.[14]
In addition to intense emotions, people with BPD experience emotional lability; or in other words, changeability. Although the term emotional lability suggests
rapid changes between depression and elation, the mood
swings in people with this condition actually uctuate
more frequently between anger and anxiety and between
depression and anxiety.[15]

1.2

Behavior

Self-harm such as cutting oneself is a common sign in borderline


personality disorder.[3] Here in dierent states of wound healing.

1.3 Self-harm and suicide


Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM-5.[4] The lifetime risk of
suicide among people with BPD is between 3% and
10%.[6][18] There is evidence that men diagnosed with
BPD are approximately twice as likely to complete suicide as women diagnosed with BPD.[19] There is also evidence that a considerable percentage of men who complete suicide may have undiagnosed BPD.[20]
Self-harm, such as cutting, is common and takes place
with or without suicidal intent.[3][21][22] The reported
reasons for non-suicidal self-injury (NSSI) dier from
the reasons for suicide attempts.[13] Nearly 70% of people with BPD self-harm without trying to end their
life.[23] Reasons for NSSI include expressing anger, selfpunishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or dicult circumstances.[13] In contrast, suicide attempts typically reect a belief that others will
be better o following the suicide.[13] Both suicidal and
non-suicidal self-injury are a response to feeling negative
emotions.[13]
Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.[24]

Impulsive behavior is common, including substance or


alcohol abuse, eating disorders, unprotected sex or
indiscriminate sex with multiple partners, reckless spend1.4 Interpersonal relationships
ing, and reckless driving.[16] Impulsive behavior may also
include leaving jobs or relationships, running away, and People with BPD can be very sensitive to the way others
self-injury.[17]
treat them, by feeling intense joy and gratitude at perPeople with BPD act impulsively because it gives them ceived expressions of kindness, and intense sadness or
immediate relief from their emotional pain.[17] However, anger at perceived criticism or hurtfulness.[25] Their feelin the long term, people with BPD suer increased pain ings about others often shift from admiration or love to
from the shame and guilt that follow such actions.[17] A anger or dislike after a disappointment, a threat of loscycle often begins in which people with BPD feel emo- ing someone, or a perceived loss of esteem in the eyes
tional pain, engage in impulsive behavior to relieve that of someone they value. This phenomenon, sometimes
pain, feel shame and guilt over their actions, feel emo- called splitting, includes a shift from idealizing others to
tional pain from the shame and guilt, and then experience devaluing them.[26] Combined with mood disturbances,
stronger urges to engage in impulsive behavior to relieve idealization and devaluation can undermine relationships
the new pain.[17] As time goes on, impulsive behavior may with family, friends, and co-workers.[27] Self-image can
become an automatic response to emotional pain.[17]
also change rapidly from healthy to unhealthy.

3
While strongly desiring intimacy, people with BPD
tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships,[28]
and they often view the world as dangerous and
malevolent.[25] BPD, like other personality disorders, is
linked to increased levels of chronic stress and conict in
romantic relationships, decreased satisfaction on the part
of romantic partners, abuse, and unwanted pregnancy.[29]

1.5

Sense of self

2 Causes
As is the case with other mental disorders, the causes
of BPD are complex and not fully agreed upon.[33] Evidence suggests that BPD and post-traumatic stress disorder (PTSD) may be related in some way.[34] Most researchers agree that a history of childhood trauma can be
a contributing factor,[35] but less attention has historically
been paid to investigating the causal roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.[33][36]

People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have
diculty knowing what they value, believe, prefer, and
enjoy.[30] They are often unsure about their long-term
goals for relationships and jobs. This diculty with
knowing who they are and what they value can cause
people with BPD to experience feeling empty and
lost.[30]

Social factors include how people interact in their


early development with their family, friends, and other
children.[37] Psychological factors include the individuals
personality and temperament, shaped by his or her environment and learned coping skills that deal with stress.[37]
These dierent factors together suggest that there are
multiple factors that may contribute to the disorder.

1.6

2.1 Genetics

Cognitions

The heritability of BPD has been estimated at 40%.[38]


That is, 40 percent of the variability in liability underlying BPD in the population can be explained by genetic
dierences. Twin studies may overestimate the eect of
genes on variability in personality disorders due to the
complicating factor of a shared family environment.[39]
Nonetheless, the researchers of this study concluded that
personality disorders seem to be more strongly inuenced by genetic eects than almost any axis I disorder
[e.g., bipolar disorder, depression, eating disorders], and
more than most broad personality dimensions.[40] Moreover, the study found that BPD was estimated to be the
third most-heritable personality disorder out of the 10
Although the minds habit of blocking out intense painful
personality disorders reviewed.[40]
emotions may provide temporary relief, it can also have
the unwanted side eect of blocking or blunting the ex- Twin, sibling, and other family studies indicate parperience of ordinary emotions, reducing the access of tial heritability for impulsive aggression, but studies of
people with BPD to the information contained in those serotonin-related genes have suggested only modest con[41]
emotions, which helps guide eective decision-making in tributions to behavior.
[31]
daily life. Sometimes, it is possible for another person Families with twins in the Netherlands were participants
to tell when someone with BPD is dissociating, because of an ongoing study by Trull and colleagues, in which 711
their facial or vocal expressions may become at or ex- pairs of siblings and 561 parents were examined to idenpressionless, or they may appear to be distracted; at other tify the location of genetic traits that inuenced the detimes, dissociation may be barely noticeable.[31]
velopment of BPD.[42] Research collaborators found that
The often intense emotions experienced by people with
BPD can make it dicult for them to control the focus
of their attentionto concentrate.[30] In addition, people
with BPD may tend to dissociate, which can be thought
of as an intense form of zoning out.[31] Dissociation
often occurs in response to experiencing a painful event
(or experiencing something that triggers the memory of
a painful event). It involves the mind automatically redirecting attention away from that event, presumably to protect against experiencing intense emotion and unwanted
behavioral impulses that such emotion might otherwise
trigger.[31]

1.7

Disability

genetic material on chromosome nine was linked to BPD


features.[42] The researchers concluded that genetic factors play a major role in individual dierences of borderline personality disorder features.[42] These same researchers had earlier concluded in a previous study that
42 percent of variation in BPD features was attributable
to genetic inuences and 58 percent was attributable to
environmental inuences.[42]

BPD is related to lower functioning and disability, even


when socioeconomic status, medical conditions, and all
psychiatric disorders were controlled.[32] Further, it is
more common for females with BPD to experience disabilities than males with BPD.[32] More research is necessary to determine if this is due to a genetic sex dierence Genes currently under investigation include the 7-repeat
or social reasons, but more females with BPD are diag- polymorphism of the dopamine D4 receptor (DRD4),
nosed than males.[32]
which has been linked to disorganized attachment, whilst

the combined eect of the 7-repeat polymorphism and


the 10/10 dopamine transporter (DAT) genotype has
been linked to abnormalities in inhibitory control, both
noted features of BPD.[43] There is a possible connection
to chromosome 5.[44]

2.2

Brain abnormalities

CAUSES

2.2.4 Hypothalamic-pituitary-adrenal axis


The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response
to stress. Cortisol production tends to be elevated in
people with BPD, indicating a hyperactive HPA axis in
these individuals.[50] This causes them to experience a
greater biological stress response, which might explain
their greater vulnerability to irritability.[51] Since traumatic events can increase cortisol production and HPA
axis activity, one possibility is that the prevalence of
higher than average activity in the HPA axis of people
with BPD may simply be a reection of the higher than
average prevalence of traumatic childhood and maturational events among people with BPD.[51] Another possibility is that, by heightening their sensitivity to stressful events, increased cortisol production may predispose
those with BPD to experience stressful childhood and
maturational events as traumatic.

A number of neuroimaging studies in BPD have reported ndings of reductions in regions of the brain involved in the regulation of stress responses and emotion, aecting the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas.[43] A smaller
number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of
neurometabolites in certain brain regions of BPD patients, looking specically at neurometabolites such as Nacetylaspartate, creatine, glutamate-related compounds, Increased cortisol production is also associated with an
and choline-containing compounds.[43]
increased risk of suicidal behavior.[52]

2.2.1

Hippocampus

2.3 Neurobiological factors

2.3.1 Estrogen
The hippocampus tends to be smaller in people with
BPD, as it is in people with post-traumatic stress disorder Individual dierences in womens estrogen cycles may
(PTSD). However, in BPD, unlike PTSD, the amygdala be related to the expression of BPD symptoms in fealso tends to be smaller.[45]
male patients.[53] A 2003 study found that womens BPD
symptoms were predicted by changes in estrogen levels
throughout their menstrual cycles, an eect that remained
signicant when the results were controlled for a general
2.2.2 Amygdala
increase in negative aect.[54]
The amygdalas are smaller and more active in people
with BPD.[45] Decreased amygdala volume has also been
found in people with obsessive-compulsive disorder.[46]
One study has found unusually strong activity in the left
amygdalas of people with BPD when they experience and
view displays of negative emotions.[47] Since the amygdala generates all emotions (including unpleasant ones),
this unusually strong activity may explain the unusual
strength and longevity of fear, sadness, anger, and shame
experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.[45]

2.2.3

Prefrontal cortex

The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of
abandonment.[48] This relative inactivity occurs in the
right anterior cingulate (areas 24 and 32).[48] Given its
role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the diculties
people with BPD experience in regulating their emotions
and responses to stress.[49]

2.4 Developmental factors


2.4.1 Childhood trauma
There is a strong correlation between child abuse,
especially child sexual abuse, and development of
BPD.[55][56][57] Many individuals with BPD report a history of abuse and neglect as young children, but causation
is still debated.[58] Patients with BPD have been found
to be signicantly more likely to report having been verbally, emotionally, physically, or sexually abused by caregivers of either gender. They also report a high incidence
of incest and loss of caregivers in early childhood.[59]
Individuals with BPD were also likely to report having
caregivers of both sexes deny the validity of their thoughts
and feelings. Caregivers were also reported to have failed
to provide needed protection and to have neglected their
childs physical care. Parents of both sexes were typically
reported to have withdrawn from the child emotionally
and to have treated the child inconsistently.[59] Additionally, women with BPD who reported a previous history of
neglect by a female caregiver and abuse by a male care-

2.6

Mediating and moderating factors

giver were signicantly more likely to experience sexual executive function appears to mediate the relationship beabuse by a non-caregiver.[59]
tween rejection sensitivity and BPD symptoms.[62] That
It has been suggested that children who experience is, a group of cognitive processes that include planning,
chronic early maltreatment and attachment diculties working memory, attention, and problem-solving might
may go on to develop borderline personality disorder.[60] be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the reWriting in the psychoanalytic tradition, Otto Kernberg ar- lationship between a persons rejection sensitivity and
gues that a childs failure to achieve the developmental BPD symptoms was stronger when executive function
task of psychic clarication of self and other and failure was lower and that the relationship was weaker when exto overcome splitting might increase the risk of develop- ecutive function was higher.[62] This suggests that high
ing a borderline personality.[61]
executive function might help protect people with high
[62]
A childs inability to tolerate delayed gratication at age rejection sensitivity against symptoms of BPD.
4 does not predict later development of BPD.[62]
A 2012 study found that problems in working memory
might contribute to greater impulsivity in people with
BPD.[67]

2.5

Neurological patterns

The intensity and reactivity of a persons negative affectivity, or tendency to feel negative emotions, predicts
BPD symptoms more strongly than does childhood sexual abuse.[63] This nding, dierences in brain structure
(see Brain abnormalities), and the fact that some patients
with BPD do not report a traumatic history,[64] suggest
that BPD is distinct from the post-traumatic stress disorder which frequently accompanies it. Thus, researchers
examine developmental causes in addition to childhood
trauma.
Research published in January 2013 by Dr. Anthony
Ruocco at the University of Toronto has highlighted two
patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder: (1) increased
activity in the brain circuits responsible for the experience of heightened emotional pain, coupled with (2) reduced activation of the brain circuits that normally regulate or suppress these generated painful emotions. These
two neural networks are seen to be dysfunctionally operative in the frontolimbic regions, but the specic regions
vary widely in individuals, which calls for the analysis of
more neuroimaging studies.[65]
Also (contrary to the results of earlier studies) suerers
of BPD showed less activation in the amygdala in situations of increased negative emotionality than the control
group. Dr. John Krystal, editor of the journal Biological Psychiatry, wrote that these results "[added] to the
impression that people with borderline personality disorder are 'set-up' by their brains to have stormy emotional
lives, although not necessarily unhappy or unproductive
lives.[65] Their emotional instability has been found to
correlate with dierences in several brain regions.[66]

2.6

Mediating and moderating factors

2.6.2 Family environment


Family environment mediates the eect of child sexual
abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment predicts a lower
risk. One possible explanation is that a stable environment buers against its development.[68]
2.6.3 Self-complexity
Self-complexity, or considering ones self to have many
dierent characteristics, appears to moderate the relationship between Actual-Ideal self-discrepancy and the
development of BPD symptoms. That is, for individuals
who believe that their actual characteristics do not match
the characteristics that they hope to acquire, high selfcomplexity reduces the impact of their conicted selfimage on BPD symptoms.[69]
However, self-complexity does not moderate the relationship between Actual-Ought self-discrepancy and the
development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not
match the characteristics that they should already have,
high self-complexity does not reduce the impact of their
conicted self-image on BPD symptoms. The protective
role of self-complexity in Actual-Ideal self-discrepancy,
but not in Actual-Ought self-discrepancy, suggests that
the impact of conicted or unstable self-image in BPD
depends on whether the individual views self in terms of
characteristics that they hope to acquire, or in terms of
characteristics that they should already have acquired.[69]
2.6.4 Thought suppression

A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerability and
While high rejection sensitivity is associated with BPD symptoms.[63] A later study found that the relationstronger symptoms of borderline personality disorder, ship between emotional vulnerability and BPD symptoms
2.6.1

Executive function

3 DIAGNOSIS

is not necessarily mediated by thought suppression. However, this study did nd that thought suppression mediates
the relationship between an invalidating environment and
BPD symptoms.[70]

Diagnosis

Diagnosis of borderline personality disorder is based on a


clinical assessment by a mental health professional. The
best method is to present the criteria of the disorder to
a person and to ask them if they feel that these characteristics accurately describe them.[6] Actively involving
people with BPD in determining their diagnosis can help
them become more willing to accept it.[6] Although some
clinicians prefer not to tell people with BPD what their diagnosis is, either from concern about the stigma attached
to this condition or because BPD used to be considered
untreatable, it is usually helpful for the person with BPD
to know their diagnosis.[6] This helps them know that others have had similar experiences and can point them toward eective treatments.[6]
In general, the psychological evaluation includes asking
the patient about the beginning and severity of symptoms, as well as other questions about how symptoms
impact the patients quality of life. Issues of particular
note are suicidal ideations, experiences with self-harm,
and thoughts about harming others.[71] Diagnosis is based
both on the persons report of their symptoms and on the
clinicians own observations.[71] Additional tests for BPD
can include a physical exam and laboratory tests to rule
out other possible triggers for symptoms, such as thyroid
conditions or substance abuse.[71]

According to Marsha Linehan, many mental health professionals nd it challenging to diagnose BPD using the
DSM criteria, since these criteria describe such a wide
variety of behaviors.[74] To address this issue, Linehan
has grouped the symptoms of BPD under ve main areas
of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.[74]

3.2 International Classication of Disease


The World Health Organization's ICD-10 denes a disorder that is conceptually similar to borderline personality
disorder, called (F60.3) Emotionally unstable personality
disorder. Its two subtypes are described below.[75]
F60.30 Impulsive type
At least three of the following must be present, one of
which must be (2):
1. marked tendency to act unexpectedly and without
consideration of the consequences;
2. marked tendency to engage in quarrelsome behavior
and to have conicts with others, especially when
impulsive acts are thwarted or criticized;
3. liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
4. diculty in maintaining any course of action that offers no immediate reward;
5. unstable and capricious (impulsive, whimsical)
mood.

The ICD-10 manual refers to the disorder as emotionally


unstable personality disorder and has similar diagnostic
criteria. In the DSM-5, the name of the disorder remains F60.31 Borderline type
the same as in the previous editions.[4]
At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two
of the following in addition:
3.1 Diagnostic and Statistical Manual
The Diagnostic and Statistical Manual of Mental Disorders fth edition (DSM-5) has removed the multiaxial
system. Consequently, all disorders, including personality disorders, are listed in Section II of the manual. A person must meet 5 of 9 criteria to receive a diagnosis of borderline personality disorder.[72] The DSM-5 denes the
main features of BPD as a pervasive pattern of instability
in interpersonal relationships, self image, and aect, as
well as markedly impulsive behavior.[72]

1. disturbances in and uncertainty about self-image,


aims, and internal preferences;
2. liability to become involved in intense and unstable
relationships, often leading to emotional crisis;
3. excessive eorts to avoid abandonment;
4. recurrent threats or acts of self-harm;

5. chronic feelings of emptiness.


In addition, the DSM-5 proposes alternative diagnos6. demonstrates impulsive behavior, e.g., speeding,
tic criteria for Borderline personality disorder in secsubstance abuse[76]
tion III, Alternative DSM-5 Model for Personality Disorders. These alternative criteria are based on trait research and include specifying at least four of seven mal- The ICD-10 also describes some general criteria that dene what is considered a Personality disorder.
adaptive traits.[73]

3.7

Dierential diagnosis and comorbidity

3.3

Millons subtypes

3.4

Misdiagnosis

time and another group in which the individuals move


in and out of the diagnosis.[84] Earlier diagnoses may be
Theodore Millon has proposed four subtypes of BPD. He helpful in creating a more eective treatment plan for the
suggests that an individual diagnosed with BPD may ex- adolescent.[82][83] Family therapy is considered a helpful
hibit none, one, or more of the following:[77]
component of treatment for adolescents with BPD.[85]

People with BPD are may be misdiagnosed for a variety of reasons. One reason for misdiagnosis is BPD has
symptoms that coexist with other disorders such as depression, PTSD, and bipolar disorder. The tests to narrow down what disorder a person has are also similar in
questions that if the patient doesn't respond with the answers that have the word usually, then the disorder will
go untreated due to improper diagnosis.[78][79]

3.5

Family members

People with BPD are prone to feeling angry at members


of their family and alienated from them. On their part,
family members often feel angry and helpless at how their
BPD family members relate to them.[6]
Parents of adults with BPD are often both over-involved
and under-involved in family interactions.[80] In romantic relationships, BPD is linked to increased levels of
chronic stress and conict, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these links may apply to personality disorders in
general.[29]

3.7 Dierential diagnosis and comorbidity


Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other
personality disorders, people with BPD showed a higher
rate of also meeting criteria for[86]
mood disorders, including major depression and
bipolar disorder
anxiety disorders, including panic disorder, social
anxiety disorder, and post-traumatic stress disorder
(PTSD)
other personality disorders
substance abuse
eating disorders, including anorexia nervosa and
bulimia
attention decit hyperactivity disorder[87]
somatoform disorders
dissociative disorders

A diagnosis of a personality disorder should not be made


during an untreated mood episode/disorder, unless the
3.6 Adolescence
lifetime history supports the presence of a personality disOnset of symptoms typically occurs during adolescence order.
or young adulthood, although symptoms suggestive of
this disorder can sometimes be observed in children.[81]
3.7.1 Comorbid Axis I disorders
Symptoms among adolescents that predict the development of BPD in adulthood may include problems with A 2008 study found that at some point in their lives, 75
body-image, extreme sensitivity to rejection, behavioral
percent of people with BPD meet criteria for mood disproblems, non-suicidal self-injury, attempts to nd exclu- orders, especially major depression and Bipolar I, and
sive relationships, and severe shame.[6] Many adolescents
nearly 75 percent meet criteria for an anxiety disorder.[88]
experience these symptoms without going on to develop Nearly 73 percent meet criteria for substance abuse or deBPD, but those who experience them are 9 times as likely pendency, and about 40 percent for PTSD.[88] It is noteas their peers to develop BPD. They are also more likely worthy that less than half of the participants with BPD in
to develop other forms of long-term social disabilities.[6] this study presented with PTSD, a prevalence similar to
Clinicians are discouraged from diagnosing anyone with
BPD before the age of 18, due to the normal ups and
downs of adolescence and a still-developing personality.
However, BPD can sometimes be diagnosed before age
18, in which case the features must have been present and
consistent for at least 1 year.[82]
A BPD diagnosis in adolescence might predict that the
disorder will continue into adulthood.[82][83] Among adolescents who warrant a BPD diagnosis, there appears to
be one group in which the disorder remains stable over

that reported in an earlier study.[86] The nding that less


than half of patients with BPD experience PTSD during
their lives challenges the theory that BPD and PTSD are
the same disorder.[86]
There are marked gender dierences in the types of comorbid conditions a person with BPD is likely to have
[86]
a higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.[86][88][89] In one study, 38% of participants

8
with BPD met the criteria for a diagnosis of ADHD.[87]
In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had
signicantly more frequent suicide attempts).[90]

3 DIAGNOSIS
Third, when people with BPD experience euphoria, it is
usually without the racing thoughts and decreased need
for sleep that are typical of hypomania,[95] though a later
2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were
associated with chronic sleep disturbances, including difculty initiating sleep, diculty maintaining sleep, and
waking earlier than desired, as well as with the consequences of poor sleep, and noted that "[f]ew studies have
examined the experience of chronic sleep disturbances in
those with borderline personality disorder.[98]

Regardless that it is an infradiagnosed disorder, a few


studies have shown that the lower expressions of it
might lead to wrong diagnoses. The many and shifting
Axis I disorders in people with BPD can sometimes cause
clinicians to miss the presence of the underlying personality disorder. However, since a complex pattern of Axis
I diagnoses has been found to strongly predict the presence of BPD, clinicians can use the feature of a com- Because the two conditions have a number of similar
plex pattern of comorbidity as a clue that BPD might be symptoms, BPD was once considered to be a mild form
present.[86]
of bipolar disorder[99][100] or to exist on the bipolar spectrum. However, this would require that the underlying
mechanism causing these symptoms be the same for both
conditions. Dierences in phenomenology, family hisMood disorders Many people with borderline person- tory, longitudinal course, and responses to treatment indiality disorder also have mood disorders, such as major cate that this is not the case.[101] Researchers have found
depressive disorder or a bipolar disorder.[27] Some char- only a modest association between bipolar disorder and
acteristics of BPD are similar to those of mood disorders, borderline personality disorder, with a strong spectrum
which can complicate the diagnosis.[91][92][93] It is espe- relationship with [BPD and] bipolar disorder extremely
cially common for people to be misdiagnosed with bipo- unlikely.[102] Benazzi et al. suggest that the DSM-IV
lar disorder when they have borderline personality disor- BPD diagnosis combines two unrelated characteristics:
der or vice versa.[94] For someone with bipolar disorder, an aective instability dimension related to Bipolar II and
behavior suggestive of BPD might appear while the client an impulsivity dimension not related to Bipolar II.[103]
is experiencing an episode of major depression or mania,
only to disappear once the clients mood has stabilized.[95]
For this reason, it is ideal to wait until the clients mood Premenstrual dysphoric disorder Premenstrual dyshas stabilized before attempting to make a diagnosis.[95] phoric disorder (PMDD) occurs in 38 percent of
women.[104] Symptoms begin 511 days before menstruAt face value, the aective lability of BPD and the
ation and cease a few days after it begins. Symptoms
rapid mood cycling of bipolar disorders can seem very
may include marked mood swings, irritability, depressed
similar.[96] It can be dicult even for experienced clinimood, feeling hopeless or suicidal, a subjective sense
cians, if they are unfamiliar with BPD, to dierentiate beof being overwhelmed or out of control, anxiety, binge
tween the mood swings of these two conditions.[97] Howeating, diculty concentrating, and substantial impairever, there are some clear dierences.[94]
ment of interpersonal relationships.[105][106] People with
First, the mood swings of BPD and bipolar disorder tend PMDD typically begin to experience symptoms in their
to have dierent durations. In some people with bipo- early twenties, although many do not seek treatment until
lar disorder, episodes of depression or mania last for at their early thirties.[105]
least two weeks at a time, which is much longer than
Although some of the symptoms of PMDD and BPD
moods last in people with BPD.[94] Even among those
are similar, they are dierent disorders. They are distinwho experience bipolar disorder with more rapid mood
guishable by the timing and duration of symptoms, which
shifts, their moods usually last for days, while the moods
are markedly dierent: the symptoms of PMDD occur
[97]
of people with BPD can change in minutes or hours.
only during the luteal phase of the menstrual cycle,[105]
So while euphoria and impulsivity in someone with BPD
whereas BPD symptoms occur persistently at all stages of
might resemble a manic episode, the experience would
the menstrual cycle. In addition, the symptoms of PMDD
[95][97]
be too brief to qualify as a manic episode.
do not include impulsivity.[105]
Second, the moods of bipolar disorder do not respond
to changes in the environment, while the moods of BPD
do respond to changes in the environment.[95] That is, a 3.7.2 Comorbid Axis II disorders
positive event would not lift the depressed mood caused
by bipolar disorder, but a positive event would poten- More than two-thirds of people diagnosed with BPD also
tially lift the depressed mood of someone with BPD. meet the criteria for another Axis II personality disorder
Similarly, an undesirable event would not dampen the at some point in their lives. (In a 2008 study, the rate
euphoria caused by bipolar disorder, but an undesirable was 73.9 percent.)[88] Cluster A disorders, which include
event would dampen the euphoria of someone with bor- paranoid, schizoid, and schizotypal, are the most common, with a prevalence of 50.4 percent in people with
derline personality disorder.[95]

4.2

Medications

BPD.[88]

9
each of these treatments, and it is considered easier to
learn and less intensive.[6] Randomized controlled trials
have shown that DBT and MBT may be the most eective, and the two share many similarities.[111][112] However, a naturalistic study indicated that DDP may be
more eective than DBT.[113] Researchers are interested
in developing shorter versions of these therapies to increase accessibility, to relieve the nancial burden on patients, and to relieve the resource burden on treatment
providers.[109][112]

The second most common is another Cluster B disorder, which includes antisocial, histrionic, and narcissistic.
These have an overall prevalence of 49.2 percent in people with BPD, with narcissistic being the most common, at 38.9 percent; antisocial the second most common, at 13.7 percent; and histrionic the least common, at
10.3 percent.[88] The least common are Cluster C disorders, which include avoidant, dependent, and obsessivecompulsive, and have a prevalence of 29.9 percent in people with BPD.[88] The percentages for specic comorbid From a psychodynamic perspective, a special probAxis II disorders can be found in the adjacent table.
lem of psychotherapy with people with BPD is intense
projection. It requires the psychotherapist to be exible
in considering negative attributions by the patient rather
than quickly interpreting the projection.[114]

Management

Main article: Management of borderline personality


disorder

Some research indicates that mindfulness meditation may


bring about favorable structural changes in the brain, including changes in brain structures that are associated
with BPD.[115][116][117] Mindfulness-based interventions
also appear to bring about an improvement in symptoms characteristic of BPD, and some clients who underwent mindfulness-based treatment no longer met a minimum of ve of the DSM-IV-TR diagnostic criteria for
BPD.[117][118]

Psychotherapy is the primary treatment for borderline


personality disorder.[5] Treatments should be based on the
needs of the individual, rather than upon the general diagnosis of BPD. Medications are useful for treating comorbid disorders, such as depression and anxiety.[107] Shortterm hospitalization has not been found to be more effective than community care for improving outcomes or 4.2 Medications
long-term prevention of suicidal behavior in those with
BPD.[108]
A 2010 review by the Cochrane collaboration found that
no medications show promise for the core BPD symptoms of chronic feelings of emptiness, identity distur4.1 Psychotherapy
bance and abandonment. However, the authors found
that some medications may impact isolated symptoms
Long-term psychotherapy is currently the treatment associated with BPD or the symptoms of comorbid
of choice for BPD.[109] There are six such treat- conditions.[119]
ments available: dynamic deconstructive psychother- Of the typical antipsychotics studied in relation to BPD,
apy (DDP),[110] mentalization-based treatment (MBT),
haloperidol may reduce anger and upenthixol may retransference-focused psychotherapy, dialectical behav- duce the likelihood of suicidal behavior. Among the
ior therapy (DBT), general psychiatric management, and
atypical antipsychotics, one trial found that aripiprazole
schema-focused therapy.[6] While DBT is the therapy may reduce interpersonal problems and impulsivity.[119]
that has been studied the most, empirical research and
Olanzapine may decrease aective instability, anger, psycase studies have shown that all of these treatments are chotic paranoid symptoms, and anxiety, but a placebo
eective for treating BPD, except for schema-focused
had a greater ameliorative impact on suicidal ideation
therapy.[6] Long-term therapy of any kind, including than olanzapine did. The eect of ziprasidone was not
schema-focused therapy, is better than no treatment, es- signicant.[119]
pecially in reducing urges to self-injure.[109]
Of the mood stabilizers studied, valproate semisodium
Cognitive behavioral therapy (CBT) is also a type of psy- may ameliorate depression, interpersonal problems, and
chotherapy used for treatment of BPD. This type of ther- anger. Lamotrigine may reduce impulsivity and anger;
apy relies on changing peoples behaviors and beliefs by topiramate may ameliorate interpersonal problems, imidentifying problems from the disorder. CBT is known pulsivity, anxiety, anger, and general psychiatric patholto reduce some anxiety and mood symptoms as well as ogy. The eect of carbamazepine was not signicant. Of
reduce suicidal thoughts and self-harming behaviors.[3]
the antidepressants, amitriptyline may reduce depression,
Mentalization-based therapy and transference-focused but mianserin, uoxetine, uvoxamine, and phenelzine
psychotherapy are based on psychodynamic principles, sulfate showed no eect. Omega-3 fatty acid may ameand dialectical behavior therapy is based on cognitive- liorate suicidality and improve depression. As of 2010,
behavioral principles and mindfulness.[109] General psy- trials with these medications had not been replicated and
chiatric management combines the core principles from the eect of long-term use had not been assessed.[119]

10

EPIDEMIOLOGY

Because of weak evidence and the potential for serious side eects from some of these medications, the
UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment
and management of BPD recommends, Drug treatment
should not be used specically for borderline personality disorder or for the individual symptoms or behavior
associated with the disorder. However, drug treatment
may be considered in the overall treatment of comorbid
conditions. They suggest a review of the treatment of
people with borderline personality disorder who do not
have a diagnosed comorbid mental or physical illness and
who are currently being prescribed drugs, with the aim of
reducing and stopping unnecessary drug treatment.[120]

rienced recurrences. A later study found that ten years


from baseline (during a hospitalization), 86% of patients
had sustained a stable recovery from symptoms.[129]

4.3

In addition to recovering from distressing symptoms,


people with BPD also achieve high levels of psychosocial
functioning. A longitudinal study tracking the social
and work abilities of participants with BPD found that
six years after diagnosis, 56% of participants had good
function in work and social environments, compared to
26% of participants when they were rst diagnosed. Vocational achievement was generally more limited, even
compared to those with other personality disorders.
However, those whose symptoms had remitted were signicantly more likely to have good relationships with a
romantic partner and at least one parent, good performance at work and school, a sustained work and school
history, and good psychosocial functioning overall.[131]

Services

There is a signicant dierence between the number of


those who would benet from treatment and the number
of those who are treated. The so-called treatment gap
is a function of the disinclination of the aicted to submit for treatment, an underdiagnosing of the disorder by
healthcare providers, and the limited availability and access to state-of-the-art treatments.[121] Nonetheless, individuals with BPD accounted for about 20 percent of psychiatric hospitalizations in one survey.[122] The majority
of individuals with BPD who are in treatment continue
to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and
costly forms of treatment, such as inpatient admission,
declines with time.[123]

Patient personality can play an important role during the


therapeutic process, leading to better clinical outcomes.
Recent research has shown that BPD patients undergoing
Dialectical Behavior Therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of
agreeableness in the patient, compared to patients either
low in agreeableness or not being treated with DBT. This
association was mediated through the strength of a working alliance between patient and therapist; that is, more
agreeable patients developed stronger working alliances
with their therapists, which in turn, led to better clinical
outcomes.[130]

Experience of services varies.[124] Assessing suicide risk


can be a challenge for clinicians, and patients themselves
tend to underestimate the lethality of self-injurious behaviors. People with BPD typically have a chronically
elevated risk of suicide much above that of the general 6 Epidemiology
population and a history of multiple attempts when in
crisis.[125] Approximately half the individuals who commit suicide meet criteria for a personality disorder. Bor- The prevalence of BPD was initially estimated to be 1 to
derline personality disorder remains the most commonly 2 percent of the general population[128][132] and to occur
associated personality disorder with suicide.[126]
three times more often in women than in men.[133][134]
However, the lifetime prevalence of BPD in a 2008 study
was found to be 5.9% of the general population, occurring
in 5.6% of men and 6.2% of women.[88] The dierence
5 Prognosis
in rates between men and women in this study was not
found to be statistically signicant.[88]
With treatment, the majority of people with BPD can
nd relief from distressing symptoms and achieve remis- Borderline personality disorder is estimated to contribute
and to occur
sion, dened as a consistent relief from symptoms for to 20 percent of psychiatric hospitalizations
[135]
among
10
percent
of
outpatients.
[127][128]
This longitudinal study trackat least two years.
ing the symptoms of people with BPD found that 34.5% 29.5 percent of new inmates in Iowa USA, t a diagnosis
achieved remission within two years from the beginning of borderline personality disorder in 2007,[136] and the
of the study. Within four years, 49.4% had achieved re- overall prevalence of BPD in the U.S.-prison population
mission, and within six years, 68.6% had achieved re- is thought to be 17 percent.[135] These high numbers may
mission. By the end of the study, 73.5% of participants be related to the high frequency of substance abuse and
were found to be in remission.[127] Moreover, of those substance use disorders among people with BPD, which
who achieved recovery from symptoms, only 5.9% expe- is estimated at 38 percent.[135]

11

Idealization in Edvard Munchs The Brooch. Eva Mudocci


(1903)

History

The coexistence of intense, divergent moods within


an individual was recognized by Homer, Hippocrates,
and Aretaeus, the latter describing the vacillating presence of impulsive anger, melancholia, and mania within
a single person. The concept was revived by Swiss
physician Thophile Bonet in 1684 who, using the
term folie maniaco-mlancolique,[140] described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist C. Hughes in 1884 and
J.C. Rosse in 1890, who called the disorder borderline
insanity.[141] In 1921, Kraepelin identied an excitable
personality that closely parallels the borderline features
outlined in the current concept of BPD.[142]
The rst signicant psychoanalytic work to use the term
borderline was written by Adolf Stern in 1938.[143] It
described a group of patients suering from what he
thought to be a mild form of schizophrenia, on the borderline between neurosis and psychosis.
The 1960s and 1970s saw a shift from thinking of the
condition as borderline schizophrenia to thinking of it as
a borderline aective disorder (mood disorder), on the
fringes of bipolar disorder, cyclothymia, and dysthymia.
In the DSM-II, stressing the intensity and variability of
moods, it was called cyclothymic personality (aective
personality).[82] While the term borderline was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer

Devaluation in Edvard Munchs Salome (1903). Idealization


and devaluation of others in personal relations is a highly specic trait in BPD (introduction and main text). The painter Edvard Munch depicted his new friend, the violinist Eva Mudocci,
in both ways within days. First as a woman seen by a man
in love, then as a bloodthirsty and cannibalistic Salome.[137]
In modern times, Munch has been diagnosed by psychiatrists as
having had BPD, including by an authority in the eld, James F.
Masterson.[138][139]

to a broad spectrum of issues, describing an intermediate level of personality organization[142] between neurosis
and psychosis.[144]
After standardized criteria were developed[145] to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in
1980 with the publication of the DSM-III.[128] The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "Schizotypal personality disorder".[144] The DSM-IV Axis II Work Group of the American Psychiatric Association nally decided on the name
borderline personality disorder, which is still in use by
the DSM-5 today.[4] However, the term borderline has
been described as uniquely inadequate for describing the
symptoms characteristic of this disorder.[146]

8 Controversies

12

8.1

8 CONTROVERSIES

Credibility and validity of testimony

Joel Paris states that In the clinic ... Up to 80%


of patients are women. That may not be true in the
The credibility of individuals with personality disor- community.[153] He oers the following explanations reders has been questioned at least since the 1960s.[147] garding these gender discrepancies:
Two concerns are the incidence of dissociation episodes
among people with BPD and the belief that lying is a key
The most probable explanation for gender
component of this condition.
dierences in clinical samples is that women
8.1.1

Dissociation

Researchers disagree about whether dissociation, or a


sense of detachment from emotions and physical experiences, impacts the ability of people with BPD to recall the
specics of past events. A 1999 study reported that the
specicity of autobiographical memory was decreased in
BPD patients.[148] The researchers found that decreased
ability to recall specics was correlated with patients levels of dissociation.[148]
8.1.2

Lying as a feature

Some theorists argue that patients with BPD often lie.[149]


However, others write that they have rarely seen lying
among patients with BPD in clinical practice.[149] Regardless, lying is not one of the diagnostic criteria for
BPD.

are more likely to develop the kind of symptoms that bring patients in for treatment. Twice
as many women as men in the community suffer from depression (Weissman & Klerman,
1985). In contrast, there is a preponderance
of men meeting criteria for substance abuse
and psychopathy (Robins & Regier, 1991), and
males with these disorders do not necessarily present in the mental health system. Men
and women with similar psychological problems may express distress dierently. Men
tend to drink more and carry out more crimes.
Women tend to turn their anger on themselves,
leading to depression as well as the cutting and
overdosing that characterize BPD. Thus, antisocial personality disorder (ASPD) and borderline personality disorders might derive from
similar underlying pathology but present with
symptoms strongly inuenced by gender (Paris,
1997a; Looper & Paris, 2000). We have even
more specic evidence that men with BPD may
not seek help. In a study of completed suicides
among people aged 18 to 35 years (Lesage et
al., 1994), 30% of the suicides involved individuals with BPD (as conrmed by psychological autopsy, in which symptoms were assessed
by interviews with family members). Most of
the suicide completers were men, and very few
were in treatment. Similar ndings emerged
from a later study conducted by our own research group (McGirr, Paris, Lesage, Renaud,
& Turecki, 2007).[20]

The belief that lying is a distinguishing characteristic of


BPD can impact the quality of care that people with
this diagnosis receive in the legal and healthcare systems. For instance, Jean Goodwin relates an anecdote of
a patient with multiple personality disorder, now called
dissociative identity disorder, who suered from pelvic
pain due to traumatic events in her childhood.[150] Due to
their disbelief in her accounts of these events, physicians
diagnosed her with borderline personality disorder, reecting a belief that lying is a key feature of BPD. Based
upon her BPD diagnosis, the physicians then disregarded
the patients assertion that she was allergic to adhesive
tape. The patient was in fact allergic to adhesive tape,
which later caused complications in the surgery to relieve In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of
her pelvic pain.[150]
BPD such as substance abuse rather than BPD itself (furthermore, the symptoms of BPD and ASPD may derive
8.2 Gender
from a similar underlying aetiology) and possibly men are
simply more likely to commit suicide prior to diagnosis.
Since BPD can be a stigmatizing diagnosis even within
the mental health community, some survivors of child- Among men diagnosed with BPD there is also evidence
hood abuse who are diagnosed with BPD are re- of a higher suicide rate: men are more than twice as
percent versus 8 percentto die
traumatized by the negative responses they receive from likely as women18
[19]
by
suicide.
[151]
One camp argues that it would
healthcare providers.
be better to diagnose these men or women with post- There are also sex dierences in borderline personality
traumatic stress disorder, as this would acknowledge the disorders.[154] Men with BPD are more likely to abuse
impact of abuse on their behavior. Critics of the PTSD substances, have explosive temper, high levels of novdiagnosis argue that it medicalizes abuse rather than ad- elty seeking and have anti-social, narcissistic, passivedressing the root causes in society.[152] Regardless, a di- aggressive or sadistic personality traits.[154] Women with
agnosis of PTSD does not encompass all aspects of the BPD are more likely to have eating disorders, mood disdisorder (see Brain abnormalities and Terminology).
orders, anxiety and post-traumatic stress.[154]

8.5

8.3

Terminology

Manipulative behavior

13
kind.[161] Their extreme aversion to violence can cause
many people with BPD to overcompensate and experience diculties being assertive and expressing their
needs.[161] This is one way in which people with BPD
choose to harm themselves over potentially causing harm
to others.[161] Another way in which people with BPD
avoid expressing their anger through violence is by causing physical damage to themselves, such as engaging in
non-suicidal self-injury.[13][160]

Manipulative behavior to obtain nurturance is considered


by the DSM-IV-TR and many mental health professionals to be a dening characteristic of borderline personality
disorder.[155] However, Marsha Linehan notes that doing
so relies upon the assumption that people with BPD who
communicate intense pain, or who engage in self-harm
and suicidal behavior, do so with the intention of inuencing the behavior of others.[156] The impact of such
behavior on othersoften an intense emotional reaction
in concerned friends, family members, and therapistsis 8.4.2 Mental healthcare providers
thus assumed to have been the persons intention.[156]
People with BPD are considered to be among the most
However, since people with BPD lack the ability to challenging groups of patients to work with in thersuccessfully manage painful emotions and interpersonal apy, requiring a high level of skill and training in the
challenges, their frequent expressions of intense pain, psychiatrists, therapists and nurses involved in their
self-harming, or suicidal behavior may instead represent treatment.[162] A majority of psychiatric sta report nda method of mood regulation or an escape mechanism ing individuals with BPD moderately to extremely diffrom situations that feel unbearable.[157] Linehan notes cult to work with and more dicult than other client
that if, for example, one were to withhold pain medica- groups.[163] Eorts are ongoing to improve public and
tion from burn victims and cancer patients, leaving them sta attitudes toward people with BPD.[164][165]
unable to regulate their severe pain, they would also exhibit attention-seeking and self-destructive behavior in In psychoanalytic theory, the stigmatization among
mental healthcare providers may be thought to reect
order to cope.[158]
countertransference (when a therapist projects his or her
own feelings on to a client). Thus, a diagnosis of BPD
often says more about the clinicians negative reaction
8.4 Stigma
to the patient than it does about the patient and exThe features of BPD include emotional instability; in- plains away the breakdown in empathy between the thertense, unstable interpersonal relationships; a need for apist and the patient and becomes an institutional epithet
[144]
This inadintimacy; and a fear of rejection. As a result, people in the guise of pseudoscientic jargon.
vertent
countertransference
can
give
rise
to
inappropriate
with BPD often evoke intense emotions in those around
them. Pejorative terms to describe people with BPD, clinical responses, including excessive use of medication,
such as dicult, treatment resistant, manipulative, inappropriate mothering, and punitive use of limit setting
[166]
demanding, and "attention seeking", are often used and interpretation.
and may become a self-fullling prophecy, as the neg- Some clients feel the diagnosis is helpful, allowing them
ative treatment of these individuals triggers further self- to understand that they are not alone and to connect
destructive behavior.[159]
with others with BPD who have developed helpful coping
mechanisms. However, others experience the term borderline personality disorder as a pejorative label rather
8.4.1 Physical violence
than an informative diagnosis. They report concerns that
their self-destructive behavior is incorrectly perceived as
The stigma surrounding borderline personality disorder
manipulative and that the stigma surrounding this disorincludes the belief that people with BPD are prone to vider limits their access to healthcare.[167] Indeed, mental
olence toward others.[160] While movies and visual media
health professionals frequently refuse to provide services
often sensationalize people with BPD by portraying them
to those who have received a BPD diagnosis.[168]
as violent, the majority of researchers agree that people
with BPD are unlikely to physically harm others.[160] Although people with BPD often struggle with experiences 8.5 Terminology
of intense anger, a dening characteristic of BPD is that
they direct it inward toward themselves.[161] One of the Because of the above concerns, and because of a move
key dierences between BPD and antisocial personality away from the original theoretical basis for the term (see
disorder (ASPD) is that people with BPD tend to internal- history), there is ongoing debate about renaming borderize anger by hurting themselves, while people with ASPD line personality disorder. While some clinicians agree
tend to externalize it by hurting others.[161]
with the current name, others argue that it should be
In addition, adults with BPD have often experienced changed,[169] since many who are labelled with borderabuse in childhood, so many people with BPD adopt a line personality disorder nd the name unhelpful, stigno-tolerance policy toward expressions of anger of any matizing, or inaccurate.[169][170] Valerie Porr, president

14

10 NOTES

of Treatment and Research Advancement Association for


Personality Disorders states that the name BPD is confusing, imparts no relevant or descriptive information,
and reinforces existing stigma.[171]

Vader in the Star Wars lms meets six of the nine diagnostic criteria; Bui also found Anakin a useful example
to explain BPD to medical students. In particular, Bui
points to the characters abandonment issues, uncertainty
[180]
Alternative suggestions for names include emotional reg- over his identity, and dissociative episodes.
ulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are
other valid alternatives, according to John Gunderson of 9.2 Awareness
McLean Hospital in the United States.[172] Another term
suggested by psychiatrist Carolyn Quadrio is post trau- In early 2008, the United States House of Representatives
as Borderline Personality Dismatic personality disorganization (PTPD), reecting the declared the month of May
[181][182]
order
Awareness
Month.
conditions status as (often) both a form of chronic post
traumatic stress disorder (PTSD) as well as a personality
disorder.[57] However, although many with BPD do have
traumatic histories, some do not report any kind of trau- 10 Notes
matic event, which suggests that BPD is not necessarily a
trauma spectrum disorder.[64]
[1] Blom, Jan Dirk (2010). A dictionary of hallucinations (1
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which
the name borderline personality disorder remains unchanged and it is not considered a trauma- and stressorrelated disorder.[173]

9
9.1

Society and culture


Film and television

There are several lms and television shows that portray


characters either explicitly diagnosed or with traits suggestive of BPD. These may be misleading if they are
thought to depict this disorder accurately. Unfortunately,
dramatic portrayals of people with BPD in movies and
other forms of visual media contribute to the stigma surrounding borderline personality disorder, especially the
myth that people with BPD are violent toward others.[160]
The majority of researchers agree that in reality, people
with BPD are very unlikely to harm others.[160]

ed.). New York: Springer. p. 74. ISBN 9781441912237.


[2] Maj, Mario (2005). Personality disorders. Chichester: J.
Wiley & Sons. p. 126. ISBN 9780470090367.
[3] Borderline Personality Disorder. NIMH. Retrieved 16
March 2016.
[4] Diagnostic and statistical manual of mental disorders :
DSM-5 (5th ed.). Washington [etc.]: American Psychiatric Publishing. 2013. pp. 645, 6636. ISBN
9780890425558.
[5] Leichsenring, F; Leibing, E; Kruse, J; New, AS; Leweke,
F (1 January 2011). Borderline personality disorder.. Lancet (London, England). 377 (9759): 7484.
doi:10.1016/s0140-6736(10)61422-5. PMID 21195251.
[6] Gunderson, John G. (26 May 2011). Borderline Personality Disorder. The New England Journal of Medicine.
364 (21): 20372042. doi:10.1056/NEJMcp1007358.
PMID 21612472.
[7] Linehan 1993, p. 43
[8] Manning 2011, p. 36

The lms Play Misty for Me[174] and Girl, Interrupted [9] Linehan 1993, p. 45
(based on the memoir of the same name) both suggest
the emotional instability of the disorder; however, the [10] Linehan 1993, p. 146
rst case shows a person more aggressive to others than
to herself, which is not characteristic of the disorder.[175] [11] Linehan 1993, p. 44
The 1992 lm Single White Female, like the rst exam- [12] Stiglmayr CE, Grathwol T, Linehan MM, Ihorst G,
ple, also suggests characteristics, some of which are acFahrenberg J, Bohus M (May 2005). Aversive tension in
tually atypical of the disorder: the character Hedy had
patients with borderline personality disorder: a computermarkedly disturbed sense of identity and reacts drastibased controlled eld study. Acta Psychiatr Scand.
cally to abandonment.[176]
111 (5): 3729. doi:10.1111/j.1600-0447.2004.00466.x.
PMID 15819731.

Films attempting to depict characters with the disorder


include A Thin Line Between Love and Hate, Filth, Fatal [13] Brown MZ, Comtois KA, Linehan MM (February 2002).
Attraction, The Crush, Mad Love, Malicious, Interiors,
Reasons for suicide attempts and nonsuicidal self-injury
The Cable Guy, Mr. Nobody, Cracks,[177] and Welcome
in women with borderline personality disorder. J Abto Me.[178][179] Psychiatrists Eric Bui and Rachel Rodgers
norm Psychol. 111 (1): 198202. doi:10.1037/0021argue that the character of Anakin Skywalker/Darth
843X.111.1.198. PMID 11866174.

15

[14] Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J,


Khera GS, Gunderson JG (1998). The pain of being
borderline: dysphoric states specic to borderline personality disorder. Harv Rev Psychiatry. 6 (4): 2017.
doi:10.3109/10673229809000330. PMID 10370445.
[15] Koenigsberg HW, Harvey PD, Mitropoulou V, et al. (May
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[151] Nehls N (1998).


Borderline personality disor- [167] Nehls N (August 1999). Borderline personality disorder:
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[168] Manning 2011, p. ix
[152] Becker D (October 2000). When she was bad: borderline personality disorder in a posttraumatic age. Am J Or[169] Bogod, Elizabeth. Borderline Personality Disorder Label
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Creates Stigma. Archived from the original on 2 May
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[153] Paris J (2008). Treatment of Borderline Personality Disorder. A Guide to Evidence-Based Practice. The Guilford [170] Understanding Borderline Personality Disorder. Treatment and Research Advancements Association for PerPress. p. 21.
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[154] Sansone, Randy A.; Sansone, Lori A. (1 May 2011).
Gender Patterns in Borderline Personality Disorder. In- [171] Porr, Valerie (2001). How Advocacy is Bringing Bordernovations in Clinical Neuroscience. 8 (5): 1620. ISSN
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[155] American Psychiatric Association 2000, p. 705
[156] Linehan 1993, p. 14
[157] Linehan 1993, p. 15
[158] Linehan 1993, p. 18

[172] Gunderson, John G.; Homan, Perry D. (2005). Understanding and Treating Borderline Personality Disorder A
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[173] American Psychiatric Association 2013, pp. 6636

[159] Aviram RB, Brodsky BS, Stanley B (2006). Bor- [174] Robinson, David J. (2003). Reel Psychiatry: Movie Portrayals of Psychiatric Conditions. Port Huron, Michigan:
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[175] Wedding D, Boyd MA, Niemiec RM (2005). Movies and
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[162] Hinshelwood RD (March 1999). The dicult patient. The role of 'scientic psychiatry' in understand- [176] Robinson (Reel Psychiatry: Movie Portrayals of Psychiatric Conditions), p. 235
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[177] Robinson, David J. (1999). The Field Guide to Persondoi:10.1192/bjp.174.3.187. PMID 10448440.
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[163] Cleary M, Siegfried N, Walter G (September 2002).
Experience, knowledge and attitudes of mental health
sta regarding clients with a borderline personality dis- [178] O'Sullivan, Michael (7 May 2015). Kristen Wiig earns
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[179] Chang, Justin (11 September 2014). Toronto Film Review: 'Welcome to Me': Kristen Wiig plays a woman with
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[165] Krawitz R (July 2004). Borderline personality disorder: attitudinal change following training. Aust N [180] Hsu, Jeremy (8 June 2010). The Psychology of Darth
Vader Revealed. LiveScience. TopTenReviews. ReZ J Psychiatry. 38 (7): 5549. doi:10.1111/j.1440trieved 8 June 2010.
1614.2004.01409.x. PMID 15255829.
[166] Vaillant GE (1992). The beginning of wisdom is never [181] HR 1005, 4/1/08
calling a patient a borderline; or, the clinical management
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2010.

21

11

References

Chapman, Alexander L.; Gratz, Kim L. (2007). The


Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD.
Oakland, CA: New Harbinger Publications. ISBN
978-1-57224-507-5.
Linehan, Marsha M.; Comtois, Katherine Anne;
Murray, Angela M.; Brown, Milton Z.; Gallop,
Robert J.; Heard, Heidi L.; Korslund, Kathryn E.;
Tutek, Darren A.; et al. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for
Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry. 63 (7):
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Linehan, Marsha (1993). Cognitive-behavioral
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Manning, Shari (2011). Loving Someone with Borderline Personality Disorder. The Guilford Press.
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Millon, Theodore (1996). Disorders of Personality:
DSM-IV-TM and Beyond. New York: John Wiley
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Millon, Theodore (2004). Personality Disorders in
Modern Life. ISBN 0-471-32355-1.
Millon, Theodore; Grossman, Seth; Meagher, Sarah
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American Psychiatric Association (2013).
Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.
ISBN 978-0-89042-555-8.

12

External links

Borderline personality disorder at DMOZ


Borderline personality disorder. National Institute
of Mental Health.

APA DSM 5 Denition of Borderline personality


disorder
APA Division 12 treatment page for Borderline personality disorder

22

13

13
13.1

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23

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A9.jpg License: Public domain Contributors: Christies: [1] Original artist: Edvard Munch
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