What is Borderline personality disorder?

Borderline personality disorder is one of the common personality disorders that is characterized by a pronounced instability in functioning, mood, expression and relationships with other people. It is often associated with other disorders such as depression, use of illicit substances and other psychotic disorders. Around 70-75% of people with borderline personality disorder have a history of at least one suicide attempt or self-harm, with a rate of 9% of completed suicides (resulting in death).

Every normal individual have personality traits which are patterns of perception about the environment or oneself. When these traits affect functioning or causes significant distress, it is considered as a personality disorder. Most of them are noticed during adolescence and they tend to persist throughout adult life. However, the diagnosis is not usually made during adolescence as they are undergoing developmental changes. The diagnosis of borderline personality disorder is made according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

In the United States, it is estimated that around 1-2% of the population has borderline personality disorder. It usually begins in late adolescence and begins rarely in people over 40 years. It is more common among women compared to men.

What are the causes and risk factors for borderline personality disorder?

The exact cause of borderline personality disorder is unknown. However, it is believed to be due to the interaction of several factors, including:

• Biologic predisposition
• Psychological factors
• Environmental factors

A history of abuse is common in people with borderline personality disorder.

What are the signs and symptoms of borderline personality disorder?

The following signs and symptoms are usually present in borderline personality disorder:

• Marked impairment and instability in functioning, mood, outwards expressions of feeling and emotions
• Marked instability in relationships with other people
• Episodes of overwhelming anger when faced to a critical situation
• Psychotic symptoms, for examples, hallucinations and delusions
• Marked feeling of dissatisfaction
• Distorted self-image
• Impaired judgement
• Frequent mood swings
• Difficulty tolerating being alone
• Intense fear of being abandoned
• Feeling depressed

How is the diagnosis of borderline personality disorder made?

To make the diagnosis of borderline personality disorder, your doctor will first ask you a series of questions to know more about how you feel and to know more about your symptoms. He/she will then proceed with a physical examination to look for signs of self-harm (for examples scars from self-cutting). Your doctor will also perform a mental status examination which includes the following:

• Looking at your general appearance and behaviour
• Your eye contact
• Your outward expression of your feelings, also known as affect
• Your general mood
• Your speech
• Assessing for the presence of hallucinations or delusions
• Assessing your level of attention and concentration
• Assessing how far are you aware of your situation and disorder

The diagnosis of borderline personality disorder is made according to a criteria known as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

The diagnosis is made if at least 5 of the following is present:

• Desperate efforts to avoid abandonment (whether real or imagined)
• Presence of unstable and intense relationships with other people
• Persistent and marked unstable self-image
• Impulsivity that can be self-damaging (overspending, sex, illicit drug abuse, irresponsible driving,  binge eating)
• Recurrent suicidal behaviour or gestures, as well as threats of self-harm
• Constantly feeling empty
• Uncontrolled anger (with frequent displays of anger or recurrent physical fights)

There are no specific laboratory tests for the diagnosis of borderline personality disorder. No imaging tests are available either.

How is borderline personality disorder managed?

The mainstay of treatment for borderline personality disorder is psychotherapeutic interventions. However, if an individual also has symptoms such as anxiety, depression, hallucinations or delusions, medications may have to be taken. However, these must be done cautiously and under supervision, as people with the condition tend to be impulsive and can take too much of the medication leading to overdoses.

If someone with the disorder has suicidal tendencies, or is even threatening about doing it, he/she will have to be hospitalized for his/her own safety. If you have the condition, your doctor will know best whether it is in your own interest to be admitted or not.

Treatment options include the following:

• Psychotherapy: This is the best treatment option for people with borderline personality disorder. Also known as talk therapy, it works by changing the way someone perceives what surrounds him/her as well as oneself. In psychotherapy, you will learn how to tolerate hateful and destructive feelings and replacing them with more constructive and positive reactions. You will learn how to regulate your emotions. Psychotherapy has been proved to reduce the rates of suicides and self-injuries. If a child is found to have borderline personality traits, a family-oriented psychotherapy is considered to be the best approach.
• Selective serotonin reuptake inhibitors (SSRIs): These medications are helpful in reducing impulsivity and aggression. They also have some effect against depression. Some examples include: fluoxetine, sertraline, paroxetine, escitalopram and fluvoxamine.
• Antipsychotic medications: These medications are helpful in people who have hallucinations, are impulsive and aggressive. Some examples include: risperidone, olanzapine and quetiapine.

The treatment of borderline personality disorder is a long term treatment. Around 50% of people recovery completely. However, recovery may seem difficult for many people, but once attained, it can be stable over time.

What is the prognosis for borderline personality disorder?

Borderline personality disorder, as many other personality disorders, is a chronic condition. However, many people have shown improvement over time. Several other disorders may coexist with borderline personality disorder such as depression or other psychotic disorders. The rate of premature deaths in people with borderline personality disorder is mostly due to their increased likelihood to commit suicide. These people also tend to have unstable relationships and impulsivity. They tend to achieve poorly in their social and work activities. People with this personality disorder also tend to dropout treatment often. If you have the condition, do not get discouraged as many people get better with treatment over time and can still live an almost normal life.

Lubit, R., 2018. Borderline Personality Disorder

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 663-6.

Skodol, A., 2021. Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis

Skodol, A., 2021. Approach to treating patients with borderline personality disorder

Skodol, A., 2021. Psychotherapy for borderline personality disorder