Borderline Personality Disorder


DSM-V Criteria and Information

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  2. A pattern of unstable and intense interpersonal relationships characterized by alternat­ing between extremes of idealization and devaluation
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Diagnostic Features

The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They ex­perience intense abandonment fears and inappropriate anger even when faced with a real­istic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician's announcing the end of the hour; panic or fury when some­one important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are re­lated to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or sui­cidal behaviors, which are described separately in Criterion 5.

Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not "there" enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will "be there" in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterized by markedly and persistently un­stable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to that of a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These in­dividuals may show worse performance in unstructured work or school situations.

Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irrespon­sibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat­ing behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that the individual assumes increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual's sense of being evil

Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anx­iety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satis­faction. These episodes may reflect the individual's extreme reactivity to interpersonal stresses. Individuals with borderline personality disorder may be troubled by chronic feel­ings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with this disorder frequently express inappropriate, intense anger or have dif­ficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., de­personalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in re­sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting min­utes or hours. The real or perceived return of the caregiver's nurturance may result in a remission of symptoms.

Associated Features Supporting Diagnosis

Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; de­stroying a good relationship just when it is clear that the relationship could last). Some in­dividuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individu­als with this disorder, especially in those with co-occurring depressive disorders or sub­stance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and separation or di­vorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories of those with borderline personality dis­order. Common co-occurring disorders include depressive and bipolar disorders, sub­stance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personality disorder also frequently co-occurs with the other personality disorders.

Prevalence

The median population prevalence of borderline personality disorder is estimated to be 1.6% but may be as high as 5.9%. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality disorder may decrease in older age groups.

Development and Course

There is considerable variability in the course of borderline personality disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health re­sources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. Although the tendency to­ward intense emotions, impulsivity, and intensity in relationships is often lifelong, indi­viduals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Fol­low-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of be­havior that meets full criteria for borderline personality disorder.

Risk and Prognostic Factors

Genetic and physiological. Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the gen­eral population. There is also an increased familial risk for substance use disorders, anti­social personality disorder, and depressive or bipolar disorders.

Culture-Related Diagnostic Issues

The pattern of behavior seen in borderline personality disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of borderline personality disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, con­flicts about sexual orientation, and competing social pressures to decide on careers.

Gender-Related Diagnostic issues

Borderline personality disorder is diagnosed predominantly (about 75%) in females.

Differential Diagnosis

Depressive and bipolar disorders. Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an addi­tional diagnosis of borderline personality disorder based only on cross-sectional presenta­tion without having documented that the pattern of behavior had an early onset and a long­standing course.

Other personality disorders. Other personality disorders may be confused with border­line personality disorder because they have certain features in common. It is therefore im­portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diag­nosed. Although histrionic personality disorder can also be characterized by attention seek­ing, manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be pres­ent in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structur­ing in borderline personality disorder. Although paranoid personality disorder and narcis­sistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns, distinguishes these disorders from borderline person­ality disorder. Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the con­cern of caretakers. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline person­ality disorder reacts to abandonment with feelings of emotional emptiness, rage, and de­mands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships.

Personality change due to another medical condition. Borderline personality disor­der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.

Substance use disorders. Borderline personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Identity problems. Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.


@YUUlCHlRO's Twitter thread

WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)?

it is a mental illness where a person’s relationships with people, emotions, self-image, and emotions are impaired. this usually causes the person to become incredibly insecure of whichever of those things they’re struggling with.

this causes INCREDIBLY impulsive behavior which may include some or all of the following:

self harm, binge eating/food restrictions, impulsive sex, attention seeking behavior, suicidal thoughts/actions, substance abuse, getting into near death situations just to feel something

one of the most prominent symptoms are relationship issues. people with borderline tend to want to cut off people at random. this is because of the “they hate me and want to leave me, so i have to leave first to avoid getting my feelings hurt” mentality. they require A LOT of reassurance if you’re going to be close to them. please try not to get frustrated, because they are struggling a lot just by being close to people. it can be really hard. if they ask if you hate them or something along the lines of that, please reassure them.

A LIST OF BORDERLINE SYMPTOMS THAT SOCIETY TRIES TO NORMALIZE

(if you do this, it doesn’t necessarily mean you have bpd, but they are symptoms)

the “are you mad at me?” or “do you hate me?” texts when the smallest things happen

freaking out over the smallest things and possibly feeling like they world is ending over them/feeling suicidal over them i.e someone leaving you on read, someone interacting with others more than you/seeming like they’re ignoring you, weight gain, acne, missing assignments, someone using a rough tone/yelling, etc

WHAT ARE SOME SYMPTOMS PEOPLE USUALLY IGNORE/DONT TALK ABOUT?

changing looks, opinions, etc to match the people around you to avoid being left behind
intense feelings of emptiness
experiencing you emotions Very strongly
imagining abandonment a lot
anger/irritability episodes

WHAT CAUSES BORDERLINE?

more often than not, people with borderline have experienced some sort of trauma, usually based upon abuse. after they are freed from their abuse, their brain is rewired to still believe that everyone is similar to their abuser in some cases

some research suggests that genetics may be a factor in developing bpd as well

people with bpd often experience HEAVY mood swings, depression, anxiety, PTSD, dissociation, and more. its pretty rare to see someone with only borderline.

ARE THERE WAYS TO HELP WITH BORDERLINE?

there aren’t very many medications for borderline in particular. usually people with bpd get put on mood stabilizers, antidepressants, anxiety medications, go to therapy, or get hospitalized in the worst cases.

despite it being treated as if its some rare mental illness by society, 1.6% of people in the U.S have it, which is roughly (if i did the math right) 525 thousand people.