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Borderline personality disorder or ‘BPD’ as it is referred to in its abbreviated term, is a condition that affects a person’s thoughts, emotions and behaviour. The presence of BPD can at times become close to insufferable, proving to be a debilitating disorder that can cause an individual to exhibit behaviours that when in remission from the disorder may be less prevalent. One example of this might be outbursts of rage over seemingly minor issues when meeting the criteria for the diagnosis versus a recovered individual who may have expanded their skill set of coping strategies that no longer meet the criteria for BPD.
Every person has a personality: longstanding ways of perceiving, relating to, and thinking about the environment and oneself. However, when these traits are inflexible, maladaptive and cause significant functional impairment or subjective distress, they constitute a personality disorder.
There are 10 classified personality disorders and of those, Borderline Personality Disorder (BPD) is the most common, most complex, most studied, and certainly one of the most devastating, with up to 10% of those diagnosed committing suicide.
John Gunderson, MD
Lifestyle and the quality of life that is experienced will be significantly impaired in some areas when meeting the criteria for Borderline Personality Disorder, this will often affect multiple areas of an individual’s being, one example would be their ability to build and maintain relationships. Problems associated with BPD include anger outbursts, chaotic relationships, impulsivity, an unstable sense of self, suicide attempts, self-harm, shame, fears of abandonment, and chronic feelings of emptiness, most difficulties are of an interpersonal nature. This disorder may affect an individual’s ability to hold down employment, interact effectively with others. Their sense of self may be distorted and unhealthy impacting on their own advancement and the way in which they experience the world and the way in which others are viewed.
Individuals who meet the criteria for this diagnosis are often very sensitive and astute people and because of that can be highly skilled in the arts and creative writing, they can also be very swift at picking up social cues and have a low tolerance to a person showing a disingenuous or insincere input. There is a lot of work to do to make further headway in the understanding of Borderline Personality Disorder for many healthcare professionals, part of the reason for this may be that the individuals diagnosed can often appear to be extremely high functioning in some areas of their life leading to the assumption that the individual does not ‘need’ the input, that they in fact may desperately need.
When will a diagnosis be given?
A diagnosis of BPD will not normally be given before the age of 18 but symptoms can be recognised in younger people. The term ‘Borderline’ was originally used by psychiatrists to suggest that the condition was thought to be on the ‘border’ of other psychiatric problems. There is much controversy associated with the name assigned to this disorder, it is seen by many to be non explanatory and unhelpful.
How is BPD diagnosed?
Clinicians and healthcare professionals predominantly refer to the DSM (Diagnostic and Statistical Manual for Mental Disorders) to diagnose mental health illness, another source referred to is the ICD-10 (International Classification of Diseases), chapter 5 ‘Mental and behavioural disorders’.
Below is the criteria listed in DSM IV used to make a Borderline Personality Disorder diagnosis, the general guidance is that a person needs to have five or more of these traits or symptoms present for around a year or so. In blue is the DSM criteria listing, alongside is a more ‘person friendly’ explanation given from the National Institute of Mental Health, NIMH
The borderline traits are subdivided into four factors, each of which represents an underlying temperament, those are:
1. Interpersonal hypersensitivity (criteria 1, 2 and 7)
2. Affect (emotional) dysregulation (criteria 6, 8 and 7)
3. Behavioural lack of control (Impulsivity) (criteria 4 and 5)
4. Disturbed self (criteria 3 and 9)
Frantic efforts to avoid real or imagined abandonment (Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived)
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love ‘idealization’ to extreme dislike or anger ‘devaluation’)
Identity disturbance: markedly and persistently unstable self-image or sense of self (Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future, such as school or career choices)
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Recurring suicidal behaviours or threats or self-harming behavior, such as cutting
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). Intense and highly changeable moods, with each episode lasting from a few hours to a few days
Chronic feelings of emptiness. Chronic feelings of emptiness and/or boredom
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Inappropriate, intense anger or problems controlling anger
Transient, stress-related paranoid ideation or severe dissociative symptoms. Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality
DSM-5 Criteria – Revised June 2011
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behaviour.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behaviour under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
- having emotions that are up and down (for example, feeling confident one day and feeling despair another), with feelings of emptiness and often anger
- difficulty in making and maintaining relationships
- having an unstable sense of identity, such as thinking differently about yourself depending on who you are with
- taking risks or doing things without thinking about the consequences
- harming yourself or thinking about harming yourself (for example, cutting yourself or overdosing)
- fearing being abandoned or rejected or being alone
- sometimes believing in things that are not real or true (called delusions) or seeing or hearing things that are not really there (called hallucinations).
A person diagnosed with borderline personality disorder will have most of these symptoms and they will have a significant impact on their life.
Source: NICE guidelines [CG78] Published date:
Borderline Personality Disorder in the International Classification of Mental and Behavioural Disorders (ICD-10)
After initial hesitation, a brief description of borderline personality disorder (F60.31) was included as a subcategory of emotionally unstable personality disorder (F60.3) into the more recent publication of the ICD, the ICD-10
Emotionally unstable personality disorder
A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).
Marsha the founder of Dialectical Behavioural Therapy (DBT) speaks about her own recovery from mental illness. Marsha has pioneered the development of better treatment and clinical outcomes for those with a BPD diagnosis for what spans over four decades.