Borderline personality disorder (BPD): testing, types, and traits

Your personality is the expression of your feelings, thoughts, and the way you behave—it’s what makes you “you.” For some people, though, their personality can create significant difficulties relating to others, along with problems controlling their thoughts or feelings. If that sounds familiar, you may have a personality disorder, specifically borderline personality disorder (BPD). Keep reading to learn about BPD and possible treatments. 

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A personality disorder is when your thoughts, feelings, and behaviors deviate significantly from your culture and sometimes don’t match reality. These reactions can interfere with any aspect of your life—at home, work, school, or with friends. These problems aren’t caused by any other underlying medical conditions, mental health disorders, or substance abuse (Fariba, 2020).

There are three categories of personality disorders (Fariba, 2020): 

• Cluster A with a paranoid or suspicious presentation

• Cluster B with emotional, impulsive, and dramatic actions

• Cluster C with anxiety and avoidance behaviors

Borderline personality disorder falls into cluster B—the emotional and impulsive category. 

Borderline personality disorder (BPD) is a complex mental health condition that causes hypersensitivity to rejection. This hypersensitivity can affect a person’s self-image, mood, and behavior. As a result, people with borderline personality disorder often tend to have unstable relationships, challenges regulating their emotions, and sometimes self-destructive behavior. People who live with a person with BPD may find the person’s mood swings to be extreme and their behaviors irrational (Chapman, 2021).

Borderline personality disorder can be very distressing for the person who has it and others in their life. People with BPD may have very intense emotions that change rapidly—such as feeling depressed in the morning and confident at night. They may struggle to control intense anger. They may act in impulsive and risky ways like driving dangerously, using recreational drugs recklessly, or binge eating.

A person with BPD will often have challenges with social relationships, such as difficulty making and keeping friends or having stable romantic relationships. Their sensitivity to rejection may lead to fears of abandonment. They often work very hard to keep people around or even push people away to avoid feeling abandoned first. A person with BPD may find it very hard to trust other people (Chapman, 2021).

Some people with BPD have extreme reactions when they are under extreme stress. They may have paranoid thoughts or hallucinations. They may also feel numb or forget that certain events happened (called dissociation). Some people with BPD self-harm or have suicidal thoughts or behavior (Chapman, 2021).

The National Institute of Mental Health (NIMH) says that 1.4% of adults in the U.S. have borderline personality disorder (NIMH, 2017).

Close to 75% of people diagnosed with BPD are women. Men may also be affected, but they are more likely to be misdiagnosed with depression or post-traumatic stress disorder (PTSD) than borderline personality disorder (NAMI, 2017).

If you or someone you love has had a pervasive fear of rejection leading to a consistent pattern of instability in relationships, along with impulsivity and extreme mood swings starting in adolescence, BPD may be the cause. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) says that a person must have five out of nine symptoms to be diagnosed with BPD (NAMI, 2017).

What are the nine symptoms of BPD?

• Frantic efforts to avoid real or imagined abandonment by friends or family

• Unstable and chaotic interpersonal relationships, with alternating extremes of intense love or extreme aversion

• Markedly disturbed sense of identity and a distorted, unstable self-image

• Impulsive, dangerous, or reckless behaviors (e.g., impulsive or uncontrollable spending, unsafe sex, substance use disorders, reckless driving, binge eating)

• Frequent suicidal gestures or self-harm

• Intense or uncontrollable emotional reactions and rapid changes between different emotional states

• Chronic feelings of emptiness

• Inappropriate, intense anger, or difficulty controlling anger

• Short-term, stress-related paranoia, or feeling disconnected from yourself or others

These symptoms can be divided into emotional, impulsive, and interpersonal categories. 

Emotional symptoms of BPD

If you have BPD, you may feel your feelings more intensely and for more extended periods than other people. Also, if you’re going through a stressful time, it can be harder to get back to your normal baseline.

People with BPD tend to get angrier faster and more often than people without BPD. This, in turn, may lead to guilty feelings after the anger fades away. Some people with BPD may harm themselves as a self-punishment. People with BPD are at higher risk of suicide than those with other personality disorders (Kulacaoglu, 2018).

Impulsive symptoms of BPD

Impulsive behaviors can be reckless or even dangerous. Common examples include overspending, gambling, taking drugs they wouldn’t usually take, drinking excessive alcohol, or risky sexual activity with different people (Kulacaoglu, 2018).

Interpersonal symptoms of BPD

Many people with BPD have challenges with interpersonal relationships with family, friends, romantic partners, or people they interact with at school or work. Their relationships can be unstable, with feelings alternating from an extreme form of love (idealization) to an intense dislike (devaluation) frequently (NIMH, 2017).

Some people with BPD have a deep fear of abandonment. The threat of being left alone may spur on certain feelings, thoughts, or behaviors that make it challenging to be in a relationship.

If you have BPD, you may feel upset with your family and friends or feel abandoned by them. Likewise, if you have a loved one with BPD, you may feel helpless or upset with them (Kulacaoglu, 2018). 

If you are a parent or a sibling to a person with BPD, you may find yourself overly involved in their lives. Other family members may choose not to engage at all and alienate themselves (Kulacaoglu, 2018). 

If you are a parent of a teenager with diagnosed or undiagnosed BPD, you may find their adolescence particularly challenging. Teenagers with BPD often have behavioral and self-image problems and extreme sensitivity to rejection. They may also be more likely to engage in impulsive, risky behavior than the average teenager (Videler, 2019).

If you are in a romantic relationship with someone with BPD, you may receive alternating periods of extreme affection and rejection from your partner, have high levels of conflict and stress, and potentially suffer from domestic abuse (Kulacaoglu, 2018).

A person with BPD may experience feelings of self-harm or suicidal thoughts. If you are concerned about yourself or someone you love, you can call the Suicide Helpline 24 hours a day, every day, at 800-273-8255 to speak to someone who can help you.

There isn’t one single cause of BPD. Instead, scientists and researchers in mental health have identified several factors that may contribute to borderline personality disorder.

Family history and genetic factors 

There is some evidence that if someone in your immediate family has a personality disorder or other mental illness, you or a loved one may have one as well. In addition, studies on twins show that over 50 percent of identical twins share a borderline personality diagnosis (Chapman, 2021).

Environmental factors

Many people with symptoms of borderline personality disorder had traumatic experiences when they were young. There are estimates that close to 70%of people with BPD experienced physical, emotional, or sexual abuse in childhood. Others may have suffered physical or emotional neglect (Chapman, 2021).

Neurological or brain factors

Some studies found that people with diagnosed BPD had smaller functional areas in the brain responsible for regulating emotions and stress. Some people’s brains may also register negative feelings and emotional pain stronger than others. Others may have an altered stress hormone response affecting their mood and behavior (Chapman, 2021).

If you think you or a loved one may have BPD, you will need to have a clinical assessment by a healthcare provider or mental health professional. This evaluation will include questions about when the symptoms began, how severe they are, and how they impact daily life and interpersonal relationships. In addition, you may be asked if you’ve experienced any self-harm behaviors (such as cutting, binge eating, or other dangerous behaviors) or suicidal thoughts (Chapman, 2021). 

Some healthcare providers will complete physical exams and lab tests to rule out underlying health conditions like thyroid disorders or substance abuse, which can occasionally present some of the same symptoms or behaviors as BPD. 

It is difficult to diagnose borderline personality disorder as many of the BPD symptoms are also symptoms of other mental health disorders. In addition, some people may have coexisting mental health disorders like bipolar disorder, depression, post-traumatic stress disorder (PTSD), or anxiety, making it hard to tease out and identify BPD (Chapman, 2021).

These challenges in diagnosing borderline personality disorder cause many people to be misdiagnosed, and they may not receive the exact treatment they need (Chapman, 2021).

The primary treatment for borderline personality disorder is psychotherapy. It may take a long time for you or your loved one to feel better, but it’s important to stay the course. There is evidence that actively participating in psychotherapy can help lessen the negative impact of BPD symptoms, allow you to function better, and improve your quality of life (Storebø, 2020).

Psychotherapy

There are several types of psychotherapy that help people with a diagnosis of BPD (Storebø, 2020):

• Cognitive-behavioral therapy (CBT) is where you learn what provokes specific negative thoughts, feelings, or behaviors and how to manage your response to these triggers.

• Dialectical behavior therapy (DBT) is similar to CBT, where you identify triggers and practice learned skills to help reduce your symptoms. DBT adds both physical and meditative exercises to help you regulate your emotions. 

• Mentalization-based therapy is where you learn to identify and separate your thoughts and feelings so you can regulate your emotions rationally rather than assume you know what other people are thinking about you.

• Schema-focused therapy is where you learn to reframe your self-image to feel more positively about yourself.

• Transference-focused therapy is where you learn how to manage rigid thoughts about yourself and others. Your therapist may help you reinterpret interpersonal relationship challenges.

Medications

There is no medication currently available to specifically treat BPD. However, there are medications to treat some of the mental health conditions that can occur alongside a borderline personality disorder (Bozzatello, 2020):

• If you have an anxiety or depressive disorder, you may be prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.

• If you have symptoms of bipolar disorder or other mood disorders, you may be prescribed a mood stabilizer or a second-generation antipsychotic medication. 

• Some healthcare professionals recommend increasing omega-3 fatty acids (found in fish oil and flax seeds) to help lessen symptoms of depression.

If you have tried to seriously harm yourself, you may need hospitalization to keep yourself safe. In this case, you would likely start therapy in the hospital and continue seeing your therapist outside of the hospital once you are released.

Living with borderline personality disorder can be difficult. However, treatments can help reduce symptoms. Dialectical behavior therapy, mentalization-based therapy, and cognitive behavioral therapy effectively treat borderline personality disorder. In fact, studies show that many people who go for treatment have ongoing relief from their symptoms for years (Storebø, 2020).

Growing older lessens the impact of BPD. Many people with BPD symptoms in their younger years become more stable in their 30s and older (Videler, 2019).

If you have a loved one with symptoms of borderline personality disorder, you may want to seek a support group or go to family therapy to help you manage your own feelings (NAMI, 2017).

A borderline personality disorder is a complex condition, but it does respond well to treatment. Getting the help you need and mobilizing social support can help you and your loved ones improve your quality of life.

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Current version

June 22, 2021

Written by

Tobi Ash, MBA, RN, BSN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.