Borderline personality disorder

Signs to look for, how your doctor determines if you have BPD, treatment options and supporting recovery.
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Found in: Mental Health Conditions
Date: September 2022

About borderline personality disorder (BPD)

People with borderline personality disorder experience intense and overwhelming emotions, and it often takes them longer to get back to feeling okay. 

They find it challenging to maintain relationships and worry about being rejected or abandoned. They may have developed ways of thinking that don’t support their wellbeing. Some of their behaviour seems reckless or impulsive to others, even though it makes sense to the person at the time.

BPD is one of the 10 types of personality disorder that have been identified. You will find out more about personality disorders in this article: [link]. You may want to read it first and then come back here for borderline personality disorder in particular. The article explains that a personality disorder does not mean there is something wrong with your personality. It just means that some of the patterns you have learned to use in your life are causing you difficulties with others.

Everyone, of course, has strong emotions and difficulties in relationships at times. These patterns would only be diagnosed as a personality disorder where they resulted in significant difficulty in your day-to-day activities and relationships and caused significant distress. A diagnosis can help you access the support and treatment you need to learn new ways to manage these experiences and live a full and happy life.

' I thought that there was something wrong with my personality. That I was inherently flawed. I believed it would be like that forever. But I found that I could learn new things. My brain was not broken. Brains can create new pathways, and I could learn new ways of doing things. But that takes time. '

– Individual with lived experience of borderline personality disorder

Who experiences BPD?

Borderline personality disorder is diagnosed in around 2% of adults and in up to 20% of people using mental health services. It is more commonly diagnosed in women than men.

It is often assumed that borderline means “a marginal but not full-blown disorder”. This is not accurate. People with BPD are frequently in significant emotional pain.

It was originally thought to be on the “border” between psychosis and neurosis – that’s how it got its name. We now understand people with BPD experience difficulty managing their intense emotions and this impacts their relationships and behaviour.

A personality disorder such as BPD will be noticed by late adolescence or early adulthood, though many people with BPD and their families/whānau can notice early symptoms in childhood. Stress can make symptoms more intense.

Left untreated, this condition remains relatively stable throughout adult life, and may gradually improve in older age. This is in contrast to other mental health conditions, which sometimes come and go over time, with periods of illness interspersed with periods of wellness. For people with BPD, learning new strategies will be key to recovery – see the “treatment” section below.

The risks of self-harm and suicide in people who experience a personality disorder are real and significant. It is important that people with BPD can access support and treatment. If you are having any suicidal thoughts, seek help immediately

If you are in crisis

If you are in crisis, you may feel your world has fallen apart, that everything is black, that nothing makes sense or that you are in danger.

If you are extremely distressed and need immediate help, you or your family can call the mental health crisis team or call 111 for an ambulance.

Either way, you will be assessed by a mental health clinician. Options for care and treatment following a crisis situation are:

  • support in your own home (i.e. medication management)
  • respite care in a house staffed by mental health or peer workers
  • admission to an inpatient psychiatric ward for assessment and management of your symptoms and distress.

Symptoms

Signs to look for (symptoms)

People who live with BPD can find it difficult to recognise the following symptoms in themselves. They will often think the characterisation is quite wrong. It’s important to understand that these are not value judgements – as a person living with BPD, you are not a bad person or failing morally in some way. Instead, you experience a set of challenges you need some extra help with, to make sure you can thrive and live a fulfilled life.

People with BPD may experience what feels like a roller coaster of mood swings. They can display uncertainty about how they see themselves and their role in the world. As a result, their interests and values can change quickly. 

People with BPD also tend to view things in extremes, such as all good or all bad. Their opinions of other people can change quickly. A person who is seen as a friend one day may be considered an enemy or traitor the next. People with BPD are very sensitive. They worry about being rejected and are often on the lookout for signs this may be happening. Their shifting feelings can lead to intense and unstable relationships.

People with BPD experience some or all of the following:

  • frantic efforts to avoid real or imagined abandonment
  • intense fear of being alone
  • a pattern of unstable and intense interpersonal relationships
  • impulsiveness (potentially self-damaging)
  • intense anger, that does not fit with the situation, or difficulty controlling anger
  • recurrent suicidal behaviour
  • recurrent self-harm (up to 75% of people with BPD self-injure one or more times)
  • ongoing feelings of emptiness
  • experiencing minor problems as major crises
  • “black and white” thinking which often means switching between love and hate in personal relationships
  • the use of coping mechanisms to express, anger, frustration, desperation and unhappiness, with negative consequences for themselves
  • difficulty trusting, which is sometimes accompanied by a fear of others’ intentions
  • during times of stress, a belief that others are trying to hurt them, even when this belief doesn’t match the reality
  • a sense of being disconnected (dissociated) from themselves during times of stress.

The severity and frequency of these patterns of relating and moving through life will vary depending on the individual and their history of distress.

People who have a diagnosis of BPD

People with BPD may also develop other mental health conditions (called co-morbidities), particularly if stressed. These include eating disorders, social anxiety, post-traumatic stress disorder, depression and drug and alcohol abuse. 

It is vitally important for people with personality disorders to learn ways of coping with stress and to seek help early should any of these other conditions arise. It is important to get diagnosis and treatment as early as possible. With the best possible treatment, there is evidence to show people with BPD can recover and live well.

If you think you have a personality disorder, or you are worried about a loved one, it’s important to talk to your GP or counsellor or someone else you can trust as a first step to getting the important help you or they need.

' When I was diagnosed, I needed to know that the diagnosis was not an illness; it was a way that professionals could categorise my experience so they could think about what might be useful for me to learn to navigate life into the future. '

– Older person with borderline personality disorder

What causes BPD?

Unfortunately, the causes of BPD are not certain. There is good evidence that development of personality is a combination of our genes and our environment.

People with a personality disorder have often experienced trauma, or very difficult times. 

There are also some people with personality disorders who cannot identify anything that has gone wrong in their lives. They may feel their disorder is genetic and part of their nature (temperament). Many believe it is a combination of these things.

It’s important to remember it is not your fault you experience a mental health condition and that you can learn new ways of navigating life.

Factors that may be important include:

Family history:  People who have a close family member (such as a parent or sibling) with the disorder may be at a higher risk of developing BPD or BPD traits. This can also include intergenerational trauma, where the effects of distressing experiences are passed down through generations.

Sensitivity: People who are emotionally sensitive and reactive may be more likely to experience BPD. Being sensitive is not a bad thing, but people with BPD find it difficult to learn to manage their feelings. People with BPD can have very sensitive and reactive nervous systems, meaning their physical stress responses are easily triggered. 

Brain factors: Studies show that people with BPD can have structural and functional changes in the brain, especially in the areas that control impulses and emotional regulation. It isn’t clear whether these changes are risk factors for the disorder or caused by the disorder or by environmental factors such as trauma.

Environmental, cultural, and social factors: Many people with BPD report experiencing traumatic life events, such as abuse (sexual, physical and/or emotional), abandonment, or adversity during childhood. Others may have been exposed to unstable, invalidating relationships and hostile conflicts. Alienation from culture or faith can be a factor; so can emotional neglect or attachment difficulties in childhood, separation and loss. Similarly, an “invalidating environment” where the person’s feelings are denied, ridiculed, ignored or judged as “wrong” can be factors.

How the clinician determines if you have BPD (diagnosis)

People with personality disorders such as BPD often do not seek out treatment until the disorder starts to significantly impact their life. Many people with BPD say they were diagnosed after a suicide attempt, for example.

Because people with BPD often experience other mental health conditions which may be very similar to symptoms of BPD, it can be difficult to diagnose. Some people report being misdiagnosed prior to being diagnosed with BPD.

There is no single test for BPD. Once you have spent some time talking to your GP, they will refer you to a mental health professional qualified to diagnose and treat people with this condition.

A diagnosis for BPD is made after talking with you about what you have been experiencing, especially around your level of personal functioning and personality traits that may suggest a particular personality disorder. The clinician will ask you some questions – this may be a semi-structured interview and may involve some psychometric measures, where the clinician uses a specially designed set of questions to assess the likelihood that you have BPD. It is important that the mental health professional gets a full picture of the difficulties you have had, both from you and from your family/whānau or others who know you well, if appropriate.

A careful and thorough medical exam can also help to rule out other possible causes of symptoms.

BPD is usually not diagnosed in children. 

Accessing help

People with BPD and other personality disorders are faced with stigma in life. This, unfortunately, also happens when accessing health care. It can be challenging to access support, especially when in crisis. You may find that some people don’t believe what you are experiencing – this can be frustrating. 

Many people find it useful to prepare an information sheet that they can show the health care professional to explain their diagnosis and what they need to get better. Whānau and friends who understand your experience can also help you access support. 

Aims of therapy

For many people with BPD, important goals are: 

  • to manage emotions and reduce overwhelm
  • to reduce immediate self-harm and/or suicide risk
  • to find more purpose in life 
  • to develop healthy relationships
  • to learn to trust other people 
  • to learn how to understand, be kind to, and live with yourself 
  • to reconnect with your culture and/or faith
  • to improve physical health.

Therapy options

It is important to access specialist treatment with a clinician who is able to diagnose BPD and offer treatment that has been proven to help people with the disorder. Treatment of BPD can involve several things, each of which will be tailored to meet your individual needs. Psychological therapies are generally seen as the best treatment for personality disorders, with medication added only if required.

This may include individual, group, couple, or family/whānau therapy.

Successful therapy should:

  • be evidence-based
  • focus on strengths
  • focus on cultural and faith issues if applicable
  • have a clear focus, whether the targets are behavioural or interpersonal 
  • provide a framework for coping with risk and suicidality 
  • be well integrated with other services 
  • reduce blame or criticism of clients.

These therapies involve a trained professional who uses clinically researched techniques to assess and help people to make positive changes in their lives. Therapists may come from many disciplines: for example, psychologists, nurses, occupational therapists, psychiatrists and social workers.

They may involve the use of specific therapies such as the following: 

  • Dialectical Behaviour Therapy (DBT) is seen to be the gold-standard therapy for treating some personality disorders and co-morbidities. DBT is based on the idea that two seemingly opposite things can both be true: for example, you can accept your feelings and behaviour while also wanting to change some aspects of them. DBT involves four main components: learning distress tolerance, emotional regulation, interpersonal effectiveness and mindfulness strategies. DBT therapy often includes group skills training and individual sessions.

  • Cognitive Behaviour Therapy (CBT) largely focuses on recognising and overcoming unhelpful beliefs and learning strategies to elicit more helpful beliefs. CBT can help people with borderline personality disorder identify and change core beliefs and behaviours that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviours.

  • Acceptance and Commitment Therapy (ACT) has the goal of increasing psychological flexibility, to help people to be more in the present moment, lessen their unhelpful thoughts and connect with and live by their values.

Some other therapies that may be beneficial include attachment therapy, trauma-focused CBT, mentalisation therapy, schema therapy and narrative therapy, to name a few. Counselling may include some techniques referred to above but is mainly based on supportive listening, practical problem-solving and information-giving.

DBT and CBT approaches are the most effective and are usually continued over a significant period of time, often for a year or more. Personality disorders develop over a long period of time, so it is helpful to emotionally invest in a long-term treatment plan. 

All types of therapy/counselling should be provided to you and your family/whānau in a manner that is respectful of you, and that helps you feel comfortable and free to ask questions. It should be consistent with and incorporate your cultural beliefs and practices.

' Often people find that the greatest treatment is through relationship – with the therapist and with your loved ones. This is profoundly challenging for people who have a way of doing relationships that makes relationships hard. Understand that this takes time, and that is why therapy can often take so long. It is not because we are so broken but because this is the things that is often the hardest – the people part! '

– Individual with borderline personality disorder

Other strategies to help BPD

General coping strategies that can help you:

  • talk to your therapist/doctor about treatment options and stick with treatment
  • try to maintain a stable schedule of meals and sleep times
  • engage in mild activity or exercise to help reduce stress
  • set realistic goals for yourself
  • break up large tasks into small ones, set some priorities, and do what you can, as you can
  • try to spend time with other people and confide in a trusted friend or family member
  • tell others about events or situations that may be difficult for you
  • expect your experiences to improve gradually, not immediately
  • identify and seek out comforting situations, places, and people
  • continue to educate yourself about BPD, realising that everyone is different.

What can I do to help myself?

You are the expert in your own mental health and wellbeing. Taking charge of your mental health and doing things that make you feel better, stronger and more in control will help.

Make a list of things that feel good and keep it on your phone, in your diary or on the fridge. When you’re struggling, check your list and pick one thing you can do right now that might help.

These may include:

  • keeping a mood diary – this can help you learn your particular early warning signs, so you know when you need to take extra care of yourself
  • identifying and reducing stressful activities
  • ensuring you are eating healthy food
  • using relaxation exercises, mindfulness, yoga, meditation or massage
  • getting enough sleep (this can be difficult for new parents, but sleeping when you can is important)
  • spending time in nature – even just sitting in the sunshine listening to the birds singing for a few moments can be helpful
  • getting some exercise
  • peer support (e.g. support groups)
  • support from people with the same background as you (if you feel that is important to you); e.g. age, ethnic group, sexual orientation)
  • getting support from family/whānau, friends or therapists
  • humour: comedies on TV, funny movies
  • cutting back on non-prescribed drugs and alcohol
  • having fun – regularly do things that you enjoy and that give your life meaning
  • being kind to yourself and others
  • practices from your own culture (e.g. Māori or Pasifika therapies)
  • writing a “risk management and relapse plan” – see below.

Physical health

It’s really important to look after your physical wellbeing. Make sure you get an annual check-up with your doctor, and do what you can to reduce stress, get enough sleep, eat a balanced diet and exercise. Being in good physical health will also help your mental health.

' What has helped me? Self-acceptance, including acceptance and non-judgement of my big feelings and my fearfulness of people. Understanding my need for excitement and using activities in life that bring me that fun without them being ‘dangerous’. Understanding that nothing is ever all good or all bad … that everything is a varying degree of grey. And learning to live with that. '

– Individual with borderline personality disorder

Having a “wellbeing plan”

Many people find that having a written plan, developed together with their GP/psychiatrist, can help them to feel they’re in control if difficult feelings return. 

Make sure others (e.g. family/whānau, partners, and community mental health staff) are aware of your plan and what you’d like to happen if you become unwell again. 

Plans can detail (in your own words) symptoms, what can trigger these feelings and what things help you. They can also list the numbers of support people, helplines and more, and outline what you’d like to happen if you need professional support.

It’s a good idea for this plan to detail what your support people can tell family/whānau/friends about your health and what treatment you have found helpful in the past.

These can all help to ensure that you get the support and professional help that you need.

Important strategies to support someone else’s recovery

Family, whānau and friends of someone with a personality disorder such as BPD have found the following strategies important and useful.

  • Remember people with these conditions tend to easily take words and actions personally. It’s important to be very clear in what you say, and to be willing to clarify your meaning or intention if your intentions are misunderstood or lost in translation. It’s also important not to take these reactions personally but to see them as a result of the person’s misinterpreting you.
  • Learn what you can about the condition, its treatment, and what you can do to assist the person.
  • Take the opportunity, if possible, to contact a family or whānau support, advocacy group or faith-based or culturally appropriate organisation. For many, this is one of the best ways to learn about how to support the person, deal with difficulties, and access services when needed.
  • Encourage the person to continue treatment and to avoid alcohol and drug abuse.
  • Find ways of getting time out for yourself and feeling okay about this. It’s important to maintain your own wellbeing.
  • Get your own therapy for support if needed.

One of the biggest barriers to recovery is discrimination. Research shows that people with BPD experience a high rate of discrimination, and this stops many people from seeking professional help.

It is also why stopping discrimination and championing understanding, respect, rights, and equality for people with mental illness is just as important as providing the best treatments and therapies. 

Thanks to Jenni Beckett clinical psychologist, and members of the Thriving Madly peer support network in Christchurch for reviewing this content. Date last reviewed: September, 2022.