Borderline personality disorder, sometimes called simply BPD, is a mental illness marked by mood swings and self-image issues that, if left untreated, can lead to impulsive behaviors and relationship troubles, among other serious health problems. (1) According to the National Alliance on Mental Illness, BPD is most commonly diagnosed among women. It is also more common in people who have a history of childhood trauma or abuse. (2)
According to the National Institute of Mental Health, diagnosing BPD generally involves a mental health professional interviewing the patient to talk through the symptoms he or she is experiencing, as well as reviewing family medical histories. (1) Marra Ackerman, MD, a clinical associate professor of psychiatry at NYU Langone Health in New York City, says symptoms of BPD can include interpersonal difficulties, intense and inappropriate anger, suicidal ideation, and fear of abandonment.
Difficulties Diagnosing Borderline Personality Disorder
Despite this list of specific symptoms, BPD can be tough to diagnose, just like other personality disorders, says David Ryan Hooper, PhD, a clinical psychologist in private practice and an assistant clinical professor of psychology at the University of Illinois at Chicago. He says that’s partly due to a lack of understanding. Personality disorders just aren’t talked about often, and they can be confusing to some people, which leaves many people suffering from BPD without ever realizing they have it.
Other times, a patient exhibiting the symptoms tied to BPD might be embarrassed to admit there’s something going on. “This is an illness that’s really been stigmatized because it’s a personality disorder,” Dr. Ackerman says. One problem is in the name. “When you call it a personality disorder, it makes people assume it’s not biologically driven,” Ackerman continues. On the contrary: Ackerman says there are biological underpinnings. Genetics, brain structure, and a history of traumatic events all play a role in putting someone at risk of BPD. (1)
Finally, BPD is often misdiagnosed, usually as bipolar disorder since there’s some overlap of symptoms — primarily unstable moods, according to a 2010 study. (3) Dr. Hooper says it can take as many as five interactions with the mental health system before BPD is identified as the root of the problem.
How to Treat Borderline Personality Disorder
The good news, though, is receiving a BPD diagnosis can be a step toward healing. “BPD can absolutely be treated,” Hooper says. “People respond to treatment, both psychotherapy and medication.”
He estimates that about three-quarters of the BPD patients he’s worked with have taken medication. Normally, medication is used to treat a co-occurring disorder. For instance, an antidepressant might be prescribed to treat the depression that can go along with BPD. (4) Psychotherapy, which is the first-line treatment for BPD, can help address the other symptoms. Over the past 10 years, dialectical behavior therapy (DBT), a cognitive behavioral treatment developed by Marsha Linehan, PhD, has become the gold standard in treating BPD, Hooper says. (5)
The Best Treatment and Therapy Options for BPD
But it won’t necessarily be easy. DBT can involve up to a year or more of intense therapy, which usually includes 2.5 hours of group therapy each week plus one-on-one therapy sessions, as well as case management if needed. This type of therapy is primarily skills-based. Those in treatment will learn how to handle different situations that come up by practicing mindfulness, tolerating distress, regulating emotions, and engaging with others effectively. (5)
If DBT isn’t successful for you, know that you have other psychotherapy options available. Other people may do well with good psychiatric management, while some may see success in transference-focused psychotherapy or mentalization-based therapy. (6)
What Happens if Borderline Personality Disorder Is Left Untreated
Maybe someone exhibits the signs of BPD but is not aware of the symptoms or actively decides not to seek treatment. Over the course of this person’s life, he or she might experience the following:
People with BPD have a black-and-white view of the world: Things (and people) are either good or bad, and how someone with BPD is feeling can change almost instantly. (1) Relationships in particular can be problematic. Hooper says people with BPD commonly have a love-hate approach to others. One day, a person with BPD might view their partner, friend, or family member as the best person in the world. The next day, he or she might do a 180 and decide that that “best person in the world” is now the worst.
Some of this can be traced back to the fact that people with BPD tend to fear abandonment. For instance, they might cut off communication with a loved one if they feel they’re at risk of being left behind. (1)
This, of course, can lead to lots of interpersonal conflict and chronic difficulties with relationships, Ackerman says. Hence relationship turmoil, divorce, and trouble maintaining positive relationships with family and friends can be common among people suffering from BPD. (2)
These interpersonal conflicts can also affect someone’s ability to maintain a steady job, especially if they take that love-hate approach with their boss or coworkers. (2) “Their life is in disarray,” Hooper says. The symptoms of BPD can be severe and debilitating, to the point where being unable to regulate emotions can “almost certainly wreck their life,” Hooper says. “What you begin to see is a life described as instability.”
But that doesn’t mean everyone with BPD will fall into this camp. “There are some people with BPD who function quite well,” Ackerman says. “I wouldn’t say the diagnosis alone means someone might not be able to hold a job or get married if they wanted to.” (For example, Dr. Linehan, mentioned above for her pioneering work in treatment of BPD, has acknowledged having BPD herself.) But should the relationship problems be severe, job loss could be the ultimate result.
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Hospitalizations Due to Self-Harm
Many people with BPD harm themselves, such as by cutting, to try to deal with their overwhelming feelings. (1) Some may even attempt to take their own lives.
Suicide attempts are so common among people with BPD that they are considered a symptom of the disorder. Up to 10 percent of the people who qualify for having BPD die by suicide, which is 50 times the rate of the population as a whole. (7)
Generally, this self-destructive behavior starts up when a person’s mood is down. “That’s where the self-mutilation comes in, the really impulsive behavior comes in,” Hooper says. Suicidal thoughts that become overwhelming may lead a person with BPD to seek help through hospitalization or by entering an inpatient treatment center, according to a study. (8)
Often, this kind of behavior serves as a wake-up call for the person suffering. “For a lot of clients, the suicide attempt scares them, and it wakes them up to how threatening this is to their life,” Hooper says.
A Desire to Engage in Reckless Behavior
Engaging in dangerous and reckless behavior is another complication of BPD. If left untreated, the person suffering from BPD may find themselves involved with extravagant spending, substance abuse, binge eating, reckless driving, and indiscriminate sex, Hooper says. The reckless behavior is usually linked to the poor self-image many BPD patients struggle with.
As a result of engaging in these dangerous activities, the person with BPD will have to face the health and physical repercussions, Ackerman says. For instance, binge eating can lead to serious health issues, such as heart disease and blood sugar spikes, while sexually transmitted diseases or unplanned pregnancies can result from engaging in unsafe sex. (1)
A General Feeling of Unsteadiness
Hooper says living with BPD without treatment is like trying to walk on ice. “That’s how a person with BPD feels almost at all times, like they can just never get their footing,” he says. For instance, people with BPD can be preoccupied with the fear of abandonment (whether real or imagined) mentioned earlier. They may also have a skewed view of reality and feel like they’re cut off from themselves and viewing their body from the outside. (1)
According to the National Institute of Mental Health, people with BPD who decline treatment are at risk of other medical issues and psychiatric diagnoses. (1) About 10 percent of people with BPD, for example, also have bipolar 1 disorder, and another 10 percent have bipolar 2 disorder, according to a 2013 study. (9)
It may seem strange that having one condition means you’ll likely have another, but this is common across personality disorders. People with personality disorders are at an increased risk of having other anxiety, mood, and impulse control disorders, as well as issues with substance abuse. Still, Ackerman says it’s entirely possible for a person to have BPD as their primary diagnosis.
Finding Hope: Borderline Personality Disorder Symptoms May Improve Over Time
Not all people with BPD will identify with these situations. And if they do, experiencing these chaotic, unstable life events may push them to seek treatment. “Because it’s so scary, it can really drive the people to change,” Hooper says.
There’s also a chance that BPD symptoms will improve with time. “Research shows that almost all mental health gets better,” Hooper says. In fact, according to a 2011 study, 85 percent of the study’s 175 BPD patients were able to enter remission by the 10-year mark. Only about 11 percent of the study participants relapsed, though some of the social functioning issues remained. (10)
Why might this happen? “Emotional dysregulation just changes with time,” Hooper says. “As you get older — into your thirties, forties, fifties — hormones change, and some of that dysregulation sort of subsides.”