Misdiagnoses are common when looking at potential personality disorders because

Contents

A prospective, longitudinal, study of men with borderline personality disorder with and without comorbid antisocial personality disorder

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Comorbidity of personality disorder with intermittent explosive disorder

There is ambiguity in how recurrent anger and aggression are accounted for by psychiatric nosology. One area of uncertainty is the extent to which Intermittent Explosive Disorder (IED) overlaps with and is distinct from Personality Disorder (PD). Accordingly, we conducted a study of individuals with IED and PD in order to understand the nature of comorbidity relationships seen across these two areas of psychopathology. One-thousand-five-hundred-twenty-one adults were studied (441 Healthy Controls (HC), 430 Psychiatric Controls (PC), and 650 IED subjects) and assessed for DSM-5 psychiatric disorders, life history of aggressive behavior, trait aggression, state and trait anger reactivity, and impulsivity. While nearly half of IED study participants had a comorbid PD diagnosis, nearly half with a Cluster B PD, almost as many had other personality disorders. IED predicted anger symptoms and history of aggressive behavior above and beyond a PD diagnosis. Comorbidity between IED and either Antisocial (AsPD) or Borderline (BPD) PD was associated with the highest levels of aggressive behavior. However, having IED comorbid with either AsPD and/or BPD PD was not associated with higher levels of impulsivity. Underlying personality traits related to anger, affect, and social behavior, but not identity disturbance, contribute to the shared symptom profile of IED and PD. IED is usually comorbid with PD, but does not have a unique relationship with any single PD. When comorbid with PD, a diagnosis of IED predicts more severe anger and aggression, but not necessarily increased impulsivity. These results suggest that IED and PD diagnoses retain clinical utility when made in cases meeting criteria for both.

Borderline Personality Disorder (BPD)

If you have BPD, everything feels unstable: your relationships, moods, thinking, behavior—even your identity. But there is hope and this guide to symptoms, treatment, and recovery can help.

If you have borderline personality disorder (BPD), you probably feel like you’re on a rollercoaster—and not just because of your unstable emotions or relationships, but also the wavering sense of who you are. Your self-image, goals, and even your likes and dislikes may change frequently in ways that feel confusing and unclear.

People with BPD tend to be extremely sensitive. Some describe it as like having an exposed nerve ending. Small things can trigger intense reactions. And once upset, you have trouble calming down. It’s easy to understand how this emotional volatility and inability to self-soothe leads to relationship turmoil and impulsive—even reckless—behavior. When you’re in the throes of overwhelming emotions, you’re unable to think straight or stay grounded. You may say hurtful things or act out in dangerous or inappropriate ways that make you feel guilty or ashamed afterwards. It’s a painful cycle that can feel impossible to escape. But it’s not. There are effective BPD treatments and coping skills that can help you feel better and back in control of your thoughts, feelings, and actions.

BPD is treatable

In the past, many mental health professionals found it difficult to treat borderline personality disorder (BPD), so they came to the conclusion that there was little to be done. But we now know that BPD is treatable. In fact, the long-term prognosis for BPD is better than those for depression and bipolar disorder. However, it requires a specialized approach. The bottom line is that most people with BPD can and do get better—and they do so fairly rapidly with the right treatments and support.

Healing is a matter of breaking the dysfunctional patterns of thinking, feeling, and behaving that are causing you distress. It’s not easy to change lifelong habits. Choosing to pause, reflect, and then act in new ways will feel unnatural and uncomfortable at first. But with time you’ll form new habits that help you maintain your emotional balance and stay in control.

Recognizing borderline personality disorder

Do you identify with the following statements?

  • I often feel “empty.”
  • My emotions shift very quickly, and I often experience extreme sadness, anger, and anxiety.
  • I’m constantly afraid that the people I care about will abandon me or leave me.
  • I would describe most of my romantic relationships as intense, but unstable.
  • The way I feel about the people in my life can dramatically change from one moment to the next—and I don’t always understand why.
  • I often do things that I know are dangerous or unhealthy, such as driving recklessly, having unsafe sex, binge drinking, using drugs, or going on spending sprees.
  • I’ve attempted to hurt myself, engaged in self-harm behaviors such as cutting, or threatened suicide.
  • When I’m feeling insecure in a relationship, I tend to lash out or make impulsive gestures to keep the other person close.

If you identify with several of the statements, you may suffer from borderline personality disorder. Of course, you need a mental health professional to make an official diagnosis, as BPD can be easily confused with other issues. But even without a diagnosis, you may find the self-help tips in this article helpful for calming your inner emotional storm and learning to control self-damaging impulses.

Signs and symptoms

Borderline personality disorder (BPD) manifests in many different ways, but for the purposes of diagnosis, mental health professionals group the symptoms into nine major categories. In order to be diagnosed with BPD, you must show signs of at least five of these symptoms. Furthermore, the symptoms must be long-standing (usually beginning in adolescence) and impact many areas of your life.

The 9 symptoms of BPD

  1. Fear of abandonment. People with BPD are often terrified of being abandoned or left alone. Even something as innocuous as a loved one arriving home late from work or going away for the weekend may trigger intense fear. This can prompt frantic efforts to keep the other person close. You may beg, cling, start fights, track your loved one’s movements, or even physically block the person from leaving. Unfortunately, this behavior tends to have the opposite effect—driving others away.
  2. Unstable relationships. People with BPD tend to have relationships that are intense and short-lived. You may fall in love quickly, believing that each new person is the one who will make you feel whole, only to be quickly disappointed. Your relationships either seem perfect or horrible, without any middle ground. Your lovers, friends, or family members may feel like they have emotional whiplash as a result of your rapid swings from idealization to devaluation, anger, and hate.
  3. Unclear or shifting self-image. When you have BPD, your sense of self is typically unstable. Sometimes you may feel good about yourself, but other times you hate yourself, or even view yourself as evil. You probably don’t have a clear idea of who you are or what you want in life. As a result, you may frequently change jobs, friends, lovers, religion, values, goals, or even sexual identity.
  4. Impulsive, self-destructive behaviors. If you have BPD, you may engage in harmful, sensation-seeking behaviors, especially when you’re upset. You may impulsively spend money you can’t afford, binge eat, drive recklessly, shoplift, engage in risky sex, or overdo it with drugs or alcohol. These risky behaviors may help you feel better in the moment, but they hurt you and those around you over the long-term.
  5. Self-harm. Suicidal behavior and deliberate self-harm is common in people with BPD. Suicidal behavior includes thinking about suicide, making suicidal gestures or threats, or actually carrying out a suicide attempt. Self-harm encompasses all other attempts to hurt yourself without suicidal intent. Common forms of self-harm include cutting and burning.
  6. Extreme emotional swings. Unstable emotions and moods are common with BPD. One moment, you may feel happy, and the next, despondent. Little things that other people brush off can send you into an emotional tailspin. These mood swings are intense, but they tend to pass fairly quickly (unlike the emotional swings of depression or bipolar disorder), usually lasting just a few minutes or hours.
  7. Chronic feelings of emptiness. People with BPD often talk about feeling empty, as if there’s a hole or a void inside them. At the extreme, you may feel as if you’re “nothing” or “nobody.” This feeling is uncomfortable, so you may try to fill the void with things like drugs, food, or sex. But nothing feels truly satisfying.
  8. Explosive anger. If you have BPD, you may struggle with intense anger and a short temper. You may also have trouble controlling yourself once the fuse is lit—yelling, throwing things, or becoming completely consumed by rage. It’s important to note that this anger isn’t always directed outwards. You may spend a lot of time feeling angry at yourself.
  9. Feeling suspicious or out of touch with reality. People with BPD often struggle with paranoia or suspicious thoughts about others’ motives. When under stress, you may even lose touch with reality—an experience known as dissociation. You may feel foggy, spaced out, or as if you’re outside your own body.

Common co-occurring disorders

Borderline personality disorder is rarely diagnosed on its own. Common co-occurring disorders include:

  • depression or bipolar disorder
  • substance abuse
  • eating disorders
  • anxiety disorders

When BPD is successfully treated, the other disorders often get improve, too. But the reverse isn’t always true. For example, you may successfully treat symptoms of depression and still struggle with BPD.

Causes—and hope

Most mental health professionals believe that borderline personality disorder (BPD) is caused by a combination of inherited or internal biological factors and external environmental factors, such as traumatic experiences in childhood.

Brain differences

There are many complex things happening in the BPD brain, and researchers are still untangling what it all means. But in essence, if you have BPD, your brain is on high alert. Things feel more scary and stressful to you than they do to other people. Your fight-or-flight switch is easily tripped, and once it’s on, it hijacks your rational brain, triggering primitive survival instincts that aren’t always appropriate to the situation at hand.

This may make it sound as if there’s nothing you can do. After all, what can you do if your brain is different? But the truth is that you can change your brain. Every time you practice a new coping response or self-soothing technique you are creating new neural pathways. Some treatments, such as mindfulness meditation, can even grow your brain matter. And the more you practice, the stronger and more automatic these pathways will become. So don’t give up! With time and dedication, you can change the way you think, feel, and act.

Personality disorders and stigma

When psychologists talk about “personality,” they’re referring to the patterns of thinking, feeling, and behaving that make each of us unique. No one acts exactly the same all the time, but we do tend to interact and engage with the world in fairly consistent ways. This is why people are often described as “shy,” “outgoing,” “meticulous,” “fun-loving,” and so on. These are elements of personality.

Because personality is so intrinsically connected to identity, the term “personality disorder” might leave you feeling like there’s something fundamentally wrong with who you are. But a personality disorder is not a character judgment. In clinical terms, “personality disorder” means that your pattern of relating to the world is significantly different from the norm. (In other words, you don’t act in ways that most people expect). This causes consistent problems for you in many areas of your life, such as your relationships, career, and your feelings about yourself and others. But most importantly, these patterns can be changed!

Self-help tips: 3 keys to coping with BPD

  1. Calm the emotional storm
  2. Learn to control impulsivity and tolerate distress
  3. Improve your interpersonal skills

Self-help tip 1: Calm the emotional storm

As someone with BPD, you’ve probably spent a lot of time fighting your impulses and emotions, so acceptance can be a tough thing to wrap your mind around. But accepting your emotions doesn’t mean approving of them or resigning yourself to suffering. All it means is that you stop trying to fight, avoid, suppress, or deny what you’re feeling. Giving yourself permission to have these feelings can take away a lot of their power.

Try to simply experience your feelings without judgment or criticism. Let go of the past and the future and focus exclusively on the present moment. Mindfulness techniques can be very effective in this regard.

  • Start by observing your emotions, as if from the outside.
  • Watch as they come and go (it may help to think of them as waves).
  • Focus in on the physical sensations that accompany your emotions.
  • Tell yourself that you accept what you’re feeling right now.
  • Remind yourself that just because you’re feeling something doesn’t mean it’s reality.

Do something that stimulates one or more of your senses

Engaging your sense is one of the quickest and easiest ways to quickly self-soothe. You will need to experiment to find out which sensory-based stimulation works best for you. You’ll also need different strategies for different moods. What may help when you’re angry or agitated is very different from what may help when you’re numb or depressed. Here are some ideas to get started:

Touch. If you’re not feeling enough, try running cold or hot (but not scalding hot) water over your hands; hold a piece of ice; or grip an object or the edge of a piece of furniture as tightly as you can. If you’re feeling too much, and need to calm down, try taking a hot bath or shower; snuggling under the bed covers, or cuddling with a pet.

Taste. If you’re feeling empty and numb, try sucking on strong-flavored mints or candies, or slowly eat something with an intense flavor, such as salt-and-vinegar chips. If you want to calm down, try something soothing such as hot tea or soup.

Smell. Light a candle, smell the flowers, try aromatherapy, spritz your favorite perfume, or whip up something in the kitchen that smells good. You may find that you respond best to strong smells, such as citrus, spices, and incense.

Sight. Focus on an image that captures your attention. This can be something in your immediate environment (a great view, a beautiful flower arrangement, a favorite painting or photo) or something in your imagination that you visualize.

Sound. Try listening to loud music, ringing a buzzer, or blowing a whistle when you need a jolt. To calm down, turn on soothing music or listen to the soothing sounds of nature, such as wind, birds, or the ocean. A sound machine works well if you can’t hear the real thing.

Reduce your emotional vulnerability

You’re more likely to experience negative emotions when you’re run down and under stress. That’s why it’s very important to take care of your physical and mental well-being.

Take care of yourself by:

  • Avoid mood-altering drugs
  • Eating a balanced, nutritious diet
  • Getting plenty of quality sleep
  • Exercising regularly
  • Minimizing stress
  • Practicing relaxation techniques

Tip 2: Learn to control impulsivity and tolerate distress

The calming techniques discussed above can help you relax when you’re starting to become derailed by stress. But what do you do when you’re feeling overwhelmed by difficult feelings? This is where the impulsivity of borderline personality disorder (BPD) comes in. In the heat of the moment, you’re so desperate for relief that you’ll do anything, including things you know you shouldn’t—such as cutting, reckless sex, dangerous driving, and binge drinking. It may even feel like you don’t have a choice.

Moving from being out of control of your behavior to being in control

It’s important to recognize that these impulsive behaviors serve a purpose. They’re coping mechanisms for dealing with distress. They make you feel better, even if just for a brief moment. But the long-term costs are extremely high.

Regaining control of your behavior starts with learning to tolerate distress. It’s the key to changing the destructive patterns of BPD. The ability to tolerate distress will help you press pause when you have the urge to act out. Instead of reacting to difficult emotions with self-destructive behaviors, you will learn to ride them out while remaining in control of the experience.

For a step-by-step, self-guided program that will teach you how to ride the “wild horse” of overwhelming feelings, check out our free Emotional Intelligence Toolkit. The toolkit teaches you how to:

  • get in touch with your emotions
  • live with emotional intensity
  • manage unpleasant or threatening feelings
  • stay calm and focused even in upsetting situations

The toolkit will teach you how to tolerate distress, but it doesn’t stop there. It will also teach you how to move from being emotionally shut down to experiencing your emotions fully. This allows you to experience the full range of positive emotions such as joy, peace, and fulfillment that are also cut off when you attempt to avoid negative feelings.

A grounding exercise to help you pause and regain control

Once the fight-or-flight response is triggered, there is no way to “think yourself” calm. Instead of focusing on your thoughts, focus on what you’re feeling in your body. The following grounding exercise is a simple, quick way to put the brakes on impulsivity, calm down, and regain control. It can make a big difference in just a few short minutes.

Find a quiet spot and sit in a comfortable position.

Focus on what you’re experiencing in your body. Feel the surface you’re sitting on. Feel your feet on the floor. Feel your hands in your lap.

Concentrate on your breathing, taking slow, deep breaths. Breathe in slowly. Pause for a count of three. Then slowly breathe out, once more pausing for a count of three. Continue to do this for several minutes.

In case of emergency, distract yourself

If your attempts to calm down aren’t working and you’re starting to feel overwhelmed by destructive urges, distracting yourself may help. All you need is something to capture your focus long enough for the negative impulse to go away. Anything that draws your attention can work, but distraction is most effective when the activity is also soothing. In addition to the sensory-based strategies mentioned previously, here are some things you might try:

Watch TV. Choose something that’s the opposite of what you’re feeling: a comedy, if you’re feeling sad, or something relaxing if you’re angry or agitated.

Do something you enjoy that keeps you busy. This could be anything: gardening, painting, playing an instrument, knitting, reading a book, playing a computer game, or doing a Sudoku or word puzzle.

Throw yourself into work. You can also distract yourself with chores and errands: cleaning your house, doing yard work, going grocery shopping, grooming your pet, or doing the laundry.

Get active. Vigorous exercise is a healthy way to get your adrenaline pumping and let off steam. If you’re feeling stressed, you may want try more relaxing activities such as yoga or a walk around your neighborhood.

Call a friend. Talking to someone you trust can be a quick and highly effective way to distract yourself, feel better, and gain some perspective.

Tip 3: Improve your interpersonal skills

If you have borderline personality disorder, you’ve probably struggled with maintaining stable, satisfying relationships with lovers, co-workers, and friends. This is because you have trouble stepping back and seeing things from other people’s perspective. You tend to misread the thoughts and feelings of others, misunderstand how others see you, and overlook how they’re affected by your behavior. It’s not that you don’t care, but when it comes to other people, you have a big blind spot. Recognizing your interpersonal blind spot is the first step. When you stop blaming others, you can start taking steps to improve your relationships and your social skills.

Check your assumptions

When you’re derailed by stress and negativity, as people with BPD often are, it’s easy to misread the intentions of others. If you’re aware of this tendency, check your assumptions. Remember, you’re not a mind reader! Instead of jumping to (usually negative) conclusions, consider alternative motivations. As an example, let’s say that your partner was abrupt with you on the phone and now you’re feeling insecure and afraid they’ve lost interest in you. Before you act on those feelings:

Stop to consider the different possibilities. Maybe your partner is under pressure at work. Maybe he’s having a stressful day. Maybe he hasn’t had his coffee yet. There are many alternative explanations for his behavior.

Ask the person to clarify their intentions. One of the simplest ways to check your assumptions is to ask the other person what they’re thinking or feeling. Double check what they meant by their words or actions. Instead of asking in an accusatory manner, try a softer approach: “I could be wrong, but it feels like…” or “Maybe I’m being overly sensitive, but I get the sense that…“

Put a stop to projection

Do you have a tendency to take your negative feelings and project them on to other people? Do you lash out at others when you’re feeling bad about yourself? Does feedback or constructive criticism feel like a personal attack? If so, you may have a problem with projection.

To fight projection, you’ll need to learn to apply the brakes—just like you did to curb your impulsive behaviors. Tune in to your emotions and the physical sensations in your body. Take note of signs of stress, such as rapid heart rate, muscle tension, sweating, nausea, or light-headedness. When you’re feeling this way, you’re likely to go on the attack and say something you’ll regret later. Pause and take a few slow deep breaths. Then ask yourself the following three questions:

  1. Am I upset with myself?
  2. Am I feeling ashamed or afraid?
  3. Am I worried about being abandoned?

If the answer is yes, take a conversation break. Tell the other person that you’re feeling emotional and would like some time to think before discussing things further.

Take responsibility for your role

Finally, it’s important to take responsibility for the role you play in your relationships. Ask yourself how your actions might contribute to problems. How do your words and behaviors make your loved ones feel? Are you falling into the trap of seeing the other person as either all good or all bad? As you make an effort to put yourself in other people’s shoes, give them the benefit of the doubt, and reduce your defensiveness, you’ll start to notice a difference in the quality of your relationships.

Diagnosis and treatment

It’s important to remember that you can’t diagnose borderline personality disorder on your own. So if you think that you or a loved one may be suffering from BPD, it’s best to seek professional help. BPD is often confused or overlaps with other conditions, so you need a mental health professional to evaluate you and make an accurate diagnosis. Try to find someone with experience diagnosing and treating BPD.

The importance of finding the right therapist

The support and guidance of a qualified therapist can make a huge difference in BPD treatment and recovery. Therapy may serve as a safe space where you can start working through your relationship and trust issues and “try on” new coping techniques.

An experienced professional will be familiar with BPD therapies such as dialectical behavior therapy (DBT) and schema-focused therapy. But while these therapies have proven to be helpful, it’s not always necessary to follow a specific treatment approach. Many experts believe that weekly therapy involving education about the disorder, family support, and social and emotional skills training can treat most BPD cases.

It’s important to take the time to find a therapist you feel safe with—someone who seems to get you and makes you feel accepted and understood. Take your time finding the right person. But once you do, make a commitment to therapy. You may start out thinking that your therapist is going to be your savior, only to become disillusioned and feel like they have nothing to offer. Remember that these swings from idealization to demonization are a symptom of BPD. Try to stick it out with your therapist and allow the relationship to grow. And keep in mind that change, by its very nature, is uncomfortable. If you don’t ever feel uncomfortable in therapy, you’re probably not progressing.

Don’t count on a medication cure

Although many people with BPD take medication, the fact is that there is very little research showing that it is helpful. What’s more, in the U.S., the Food and Drug Administration (FDA) has not approved any medications for the treatment of BPD. This doesn’t mean that medication is never helpful—especially if you suffer from co-occurring problems such as depression or anxiety—but it is not a cure for BPD itself. When it comes to BPD, therapy is much more effective. You just have to give it time. However, your doctor may consider medication if:

  • you have been diagnosed with both BPD and depression or bipolar disorder
  • you suffer from panic attacks or severe anxiety
  • you begin hallucinating or having bizarre, paranoid thoughts
  • you are feeling suicidal or at risk of hurting yourself or others

Borderline Personality Disorder

Borderline personality disorder has historically been viewed as difficult to treat. But, with newer, evidence-based treatment, many people with the disorder experience fewer or less severe symptoms, and an improved quality of life. It is important that people with borderline personality disorder receive evidence-based, specialized treatment from an appropriately trained provider. Other types of treatment, or treatment provided by a doctor or therapist who is not appropriately trained, may not benefit the person.

Many factors affect the length of time it takes for symptoms to improve once treatment begins, so it is important for people with borderline personality disorder and their loved ones to be patient and to receive appropriate support during treatment.

Tests and Diagnosis

A licensed mental health professional—such as a psychiatrist, psychologist, or clinical social worker—experienced in diagnosing and treating mental disorders can diagnose borderline personality disorder by:

  • Completing a thorough interview, including a discussion about symptoms
  • Performing a careful and thorough medical exam, which can help rule out other possible causes of symptoms
  • Asking about family medical histories, including any history of mental illness

Borderline personality disorder often occurs with other mental illnesses. Co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder. For example, a person with borderline personality disorder may be more likely to also experience symptoms of depression, bipolar disorder, anxiety disorders, substance use disorders, or eating disorders.

Seek and Stick with Treatment

NIMH-funded studies show that people with borderline personality disorder who don’t receive adequate treatment are:

  • More likely to develop other chronic medical or mental illnesses
  • Less likely to make healthy lifestyle choices

Borderline personality disorder is also associated with a significantly higher rate of self-harm and suicidal behavior than the general public.

People with borderline personality disorder who are thinking of harming themselves or attempting suicide need help right away.

If you or someone you know is in crisis, call the toll-free National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255), 24 hours a day, 7 days a week. The service is available to everyone. The deaf and hard of hearing can contact the Lifeline via TTY at 1-800-799-4889. All calls are free and confidential. Contact social media outlets directly if you are concerned about a friend’s social media updates or dial 911 in an emergency. Read more on NIMH’s Suicide Prevention health topic page.

The treatments described on this page are just some of the options that may be available to a person with borderline personality disorder.

Psychotherapy

Psychotherapy is the first-line treatment for people with borderline personality disorder. A therapist can provide one-on-one treatment between the therapist and patient, or treatment in a group setting. Therapist-led group sessions may help teach people with borderline personality disorder how to interact with others and how to effectively express themselves.

It is important that people in therapy get along with, and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with the disorder to maintain a comfortable and trusting bond with their therapist.

Two examples of psychotherapies used to treat borderline personality disorder include:

  • Dialectical Behavior Therapy (DBT): This type of therapy was developed for individuals with borderline personality disorder. DBT uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help:
    • Control intense emotions
    • Reduce self-destructive behaviors
    • Improve relationships
  • Cognitive Behavioral Therapy (CBT): This type of therapy can help people with borderline personality disorder identify and change core beliefs and behaviors that underlie inaccurate perceptions of themselves and others, and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.

Read more on NIMH’s Psychotherapies health topic page.

Medications

Because the benefits are unclear, medications are not typically used as the primary treatment for borderline personality disorder. However, in some cases, a psychiatrist may recommend medications to treat specific symptoms such as:

  • mood swings
  • depression
  • other co-occurring mental disorders

Treatment with medications may require care from more than one medical professional.

Certain medications can cause different side effects in different people. Talk to your doctor about what to expect from a particular medication. Read more in NIMH’s Mental Health Medications health topic.

Other Elements of Care

Some people with borderline personality disorder experience severe symptoms and need intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care.

Therapy for Caregivers and Family Members

Families and caregivers of people with borderline personality disorder may also benefit from therapy. Having a relative or loved one with the disorder can be stressful, and family members or caregivers may unintentionally act in ways that can worsen their loved one’s symptoms.

Some borderline personality disorder therapies include family members, caregivers, or loved ones in treatment sessions. This type of therapy helps by:

  • Allowing the relative or loved one develop skills to better understand and support a person with borderline personality disorder
  • Focusing on the needs of family members to help them understand the obstacles and strategies for caring for someone with borderline personality disorder. Although more research is needed to determine the effectiveness of family therapy in borderline personality disorder, studies on other mental disorders suggest that including family members can help in a person’s treatment.

Finding Help

More information about finding a health care provider or treatment for mental disorders in general is available on our Help for Mental Illness webpage. You may also find additional information through the NIMH Outreach Partners or the NIMH National Partners.

Tips for Family and Caregivers

To help a friend or relative with the disorder:

  • Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with borderline personality disorder, but it is possible for them to get better over time
  • Learn about mental disorders, including borderline personality disorder, so you can understand what the person with the disorder is experiencing
  • Encourage your loved one who is in treatment for borderline personality disorder to ask about family therapy
  • Seek counseling for yourself from a therapist. It should not be the same therapist that your loved one with borderline personality disorder is seeing

Jump to: Signs & Symptoms Suicide Treatment

A personality disorder is a pattern of feelings and behaviors that seem appropriate and justified to the person experiencing them, even though these feelings and behaviors cause a great deal of problems in that person’s life.

Borderline personality disorder (BPD) is a personality disorder that typically includes the following symptoms:

  • Inappropriate or extreme emotional reactions
  • Highly impulsive behaviors
  • A history of unstable relationships

Intense mood swings, impulsive behaviors, and extreme reactions can make it difficult for people with borderline personality disorder to complete schooling, maintain stable jobs and have long-lasting, healthy relationships.

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Symptoms of Borderline Personality Disorder

Borderline personality disorder symptoms vary from person to person and women are more likely to have this disorder than men. Common symptoms of the disorder include the following:

  • Having an unstable or dysfunctional self-image or a distorted sense of self (how one feels about one’s self)
  • Feelings of isolation, boredom and emptiness
  • Difficulty feeling empathy for others
  • A history of unstable relationships that can change drastically from intense love and idealization to intense hate
  • A persistent fear of abandonment and rejection, including extreme emotional reactions to real and even perceived abandonment
  • Intense, highly changeable moods that can last for several days or for just a few hours
  • Strong feelings of anxiety, worry and depression
  • Impulsive, risky, self-destructive and dangerous behaviors, including reckless driving, drug or alcohol abuse and having unsafe sex
  • Hostility
  • Unstable career plans, goals and aspirations

Many people experience one or more of the above symptoms regularly, but a person with borderline personality disorder will experience many of the symptoms listed above consistently throughout adulthood.

The term “borderline” refers to the fact that people with this condition tend to “border” on being diagnosed with additional mental health conditions in their lifetime, including psychosis.

One of the ironies of this disorder is that people with BPD may crave closeness, but their intense and unstable emotional responses tend to alienate others, causing long-term feelings of isolation.

Borderline Personality Disorder and Suicidality

Around 80 percent of people with borderline personality disorder display suicidal behaviors, including suicide attempts, cutting themselves, burning themselves, and other self-destructive acts. It is estimated that between 4 and 9 percent of people with BPD will die by suicide.

Help for Borderline Personality Disorder

Living with borderline personality disorder, or being in a relationship with someone who has BPD, can be stressful. It can be very difficult to acknowledge and accept the reality of BPD, but treatment may help.

If you are concerned that you, or that someone you care about, may have borderline personality disorder, contact a licensed mental health professional. Many supportive healthcare professionals are available to help you get started on the path to healing. Since BPD can be a complex condition, and treatment usually requires long-term talk therapy, it will be important to find a mental health professional who has expertise in treating this condition.

It is possible to learn how to manage feelings better and find ways to have healthier and more rewarding relationships. With the help of talk therapy, one can learn how to reduce impulsive and self-destructive behaviors and understand more about the condition. With a commitment to long-term treatment, positive and healthy change is within reach.

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Last Updated: May 13, 2019

Single-diagnosis treatments

  • Single-diagnosis treatments are those that focus primarily or only on treating PTSD. These treatments may include individuals with various comorbid problems such as BPD, but comorbid problems are not targeted directly. Thus, any improvements in comorbid problems that occur during these treatments are a secondary result of treating PTSD.

Prolonged exposure (PE)

Standard procedure:

PE is a brief outpatient treatment that was originally developed for women with sexual assault-related PTSD and has since been shown to be efficacious in a variety of trauma populations . The primary components of PE include imaginal exposure to trauma memories and in vivo exposure to feared but safe situations. PE is typically delivered in 9–15 weekly or biweekly individual therapy sessions.

Two randomized controlled trials (RCTs) have evaluated the efficacy of PE among individuals with full or partial BPD or BPD characteristics. One RCT examined the impact of full or partial BPD on treatment outcome following PE, stress inoculation training (SIT, focused on anxiety management skills), and a combined PE/SIT treatment. Participants were female sexual and non-sexual assault survivors with a primary diagnosis of PTSD related to an assault occurring after age 16. Exclusion criteria were: acute suicidality, suicide attempt or serious self-injurious behavior in the past 3 months, ongoing abuse, substance dependence, bipolar disorder, and psychotic disorders. In the treatment completer sample (n = 58), 9 (15.5 %) met full or partial criteria for BPD. Given the small sample of BPD patients, analyses were not conducted separately by treatment. When the three treatments were combined, BPD was not significantly related to outcome. However, women with full or partial BPD were significantly less likely than those without BPD to achieve good end-state functioning (11 % vs 51 %), which was defined as being below clinical cut-offs on PTSD, depression, and general anxiety.

A second RCT evaluated the effect of borderline personality characteristics (BPC) on outcomes following PE or Cognitive Processing Therapy (CPT). Participants included 131 adult female rape victims with PTSD, of whom 39 (25.2 %) were identified as having a clinical level of BPC according to self-report. Women with PTSD related to an index rape occurring in adulthood or childhood that was not perpetrated by a family member were included. Women with serious suicidal intent, recent suicidal or self-injurious behavior, ongoing abuse, current substance dependence, or bipolar or psychotic disorders were excluded. Results indicated that BPC scores were unrelated to treatment dropout and there was no evidence that BPC were related to worse outcomes in PTSD or other trauma-related symptoms. PE and CPT were comparably effective for individuals with BPC.

Contraindications:

Individuals with acute suicidality (i.e., ideation with intent and a plan) and recent suicidal or serious self-injurious behavior are excluded from PE. Many studies of PE, including the two RCTs reviewed above, have also excluded individuals with ongoing abuse, substance dependence, bipolar disorder, and psychotic disorders. Of note, emerging research suggests that PE can be safely and effectively applied in several populations previously thought to be inappropriate for this treatment, such as those with substance dependence and psychotic disorders. See for a recent review of contraindications for PE.

Complications:

None identified.

Special points:

The existing research on PE for this population has either included individuals meeting partial criteria for BPD or has not assessed the full BPD diagnosis . Further, these studies have excluded women with either an index assault occurring in childhood or an index assault involving incest . Both studies excluded individuals with many behaviors common in severe BPD (e.g., acute suicidality, recent suicidal and self-injurious behavior, substance dependence). Thus, additional research is needed to evaluate the efficacy of PE for individuals meeting full criteria for BPD, exhibiting more severe levels of BPD, and with childhood assault or incest-related PTSD. Finally, additional treatment may be necessary for BPD patients who do not achieve good end-state functioning after a standard course of PE.

Cognitive processing therapy (CPT)

Standard procedure:

CPT is a brief outpatient treatment for PTSD that was originally developed to treat sexual assault-related PTSD and has since been found to be efficacious for a variety of trauma types . CPT consists of 12 weekly or biweekly sessions that can be delivered in individual, group, or a combined format. The treatment is primarily cognitive and focuses largely on identifying and challenging trauma-related beliefs. It can also include an exposure component in the form of writing a detailed account of the traumatic event.

To date, one RCT has evaluated the effect of BPC on outcomes in CPT among adult female rape victims. This study found no effect of borderline characteristics on treatment dropout or PTSD and other trauma-related outcomes, suggesting that CPT is comparably efficacious for individuals with and without BPC.

Contraindications:

Individuals with acute suicidality (i.e., ideation with intent and a plan) and recent suicidal or serious self-injurious behavior are excluded from CPT. Other common exclusion criteria include ongoing abuse, substance dependence, bipolar disorder, and current psychosis.

Complications:

None identified.

Special points:

The only RCT that has evaluated the efficacy of CPT for this population did not assess for the full BPD diagnosis and excluded women with serious suicidal intent, recent suicidal or self-injurious behavior, ongoing abuse, current substance dependence, bipolar and psychotic disorders, or an index rape involving incest. Thus, the generalizability of these findings to individuals meeting full diagnostic criteria for BPD, exhibiting more severe levels of BPD, and incest-related PTSD is unknown.

Phase-Based Treatments

  • Phase-based treatments typically include an initial phase focused on stabilization and behavioral skills training followed by a second phase of trauma-focused treatment. Some treatments also include a third phase in which impairments in psychosocial functioning are typically addressed.

Dialectical behavior therapy for PTSD (DBT-PTSD)

Standard procedure:

DBT-PTSD is an adaptation of standard DBT that is designed to address PTSD related to childhood sexual abuse. DBT-PTSD is delivered as a 12-week residential treatment that includes three treatment phases. The first phase (weeks 1–4) focuses on psychoeducation, identification of typical cognitive, emotional, and behavioral strategies to escape emotions, and teaching of DBT skills to control these behaviors. The second phase (weeks 5–10) consists of trauma-focused cognitive and exposure-based interventions. The final phase (weeks 11–12) addresses radical acceptance of trauma-related facts and psychosocial functioning. Patients receive biweekly individual sessions (23 total), group DBT skills training (11 total), group focused on self-esteem (8 total), and group mindfulness practice (3 total). In addition, patients attend three non-specific groups each week (e.g., music and art therapy).

The efficacy of DBT-PTSD for adult women with and without BPD has been evaluated in an RCT comparing DBT-PTSD with a treatment as usual–waitlist control (TAU-WL) . Participants were women with childhood sexual abuse-related PTSD and at least one of the following current conditions: eating disorder, major depressive disorder, substance abuse, and/or at least four criteria for BPD. Of the 74 women in the sample, 33 (44.6 %) met full criteria for BPD. Women actively engaging in NSSI were included, and those with a life-threatening behavior in the prior 4 months, current substance dependence, a lifetime diagnosis of schizophrenia, or a body mass index less than 16.5 were excluded. Results indicate that DBT-PTSD was superior to TAU-WL in improving PTSD, depression, and global functioning, but not global symptom severity, dissociation, or BPD symptoms. These results were comparable for the subgroup of women with BPD in each condition, and BPD severity was generally unrelated to treatment outcome. Among women with BPD who received DBT-PTSD, the rate of diagnostic remission of PTSD was 41.2 %.

Contraindications:

DBT-PTSD is not used with individuals with recent life-threatening behavior (e.g., serious suicide attempts) and some severe comorbidities (substance dependence, schizophrenia, and severe anorexia nervosa).

Complications:

None identified. There was no evidence of worsening of PTSD, NSSI or suicidality in DBT-PTSD.

Special points:

Although women who were actively engaging in NSSI were included, treatment occurred in a residential setting that allowed for close monitoring of patient safety. The generalizability of these findings to outpatient samples of BPD patients as well as those with recent life-threatening behavior and the specified exclusionary diagnoses (e.g., substance dependence) is unknown. In addition, DBT-PTSD is primarily intended to target PTSD and associated trauma-related problems, and its effects on BPD symptoms did not differ from those obtained in a non-active treatment control.

Integrated Treatments

  • Integrated treatments are intended to comprehensively address the full range of problems with which individuals with PTSD and BPD present. This includes directly targeting both PTSD- and BPD-related problems, as well as factors that may explain the relationships between these two disorders. In addition, other problems (e.g., additional comorbid disorders, psychosocial functioning) are addressed as needed.

Dialectical behavior therapy (DBT)

Standard procedure:

DBT is a comprehensive cognitive behavioral therapy that is the most well researched treatment available for BPD. DBT combines change-based interventions from behavior therapy (e.g., skills training, exposure, cognitive modification, contingency management) with acceptance-based interventions derived from Western contemplative and eastern Zen practices (e.g., validation, radical acceptance). DBT was developed for chronically suicidal individuals with BPD and is idiographically applied to address a hierarchy of treatment targets: (i) life-threatening behaviors (e. g., suicide attempts, NSSI), (ii) therapy-interfering behaviors (e.g., noncompliance, nonattendance), and (iii) quality-of-life-interfering behaviors (e.g., severe Axis I disorders, significant relationship problems, financial instability). The first stage of treatment focuses on reducing behavioral dyscontrol and increasing behavioral skills in the areas of emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. PTSD is targeted as needed in the second stage of treatment. Standard DBT is typically delivered as a 1-year outpatient treatment consisting of four modes: (i) individual therapy (1 hour/week), (ii) group skills training (2.5 hours/week), (iii) therapist consultation team (1 hour/week), and (iv) between-session telephone consultation (as needed).

Two RCTs have evaluated the efficacy of standard DBT in treating PTSD among individuals with BPD. One RCT included adult women with BPD and recent and recurrent suicide attempts and/or NSSI. Among the subgroup with PTSD assigned to DBT (n = 23; 50 %), 34.8 % achieved diagnostic remission from PTSD across 1 year of treatment and 1 year of follow-up. A second RCT included adult women with BPD, PTSD, and recent and recurrent suicide attempts and/or NSSI. Among patients who received DBT (n = 9), there was a large and significant reduction in PTSD severity across 1 year of treatment and 3 months of follow-up (g = 0.9). At post-treatment, 66.7 % of patients in DBT exhibited reliable improvement in PTSD and 33.3 % achieved diagnostic remission from PTSD.

Contraindications:

DBT requires patients to achieve control over life-threatening behaviors and serious therapy-interfering behaviors prior to addressing PTSD.

Complications:

No complications related to targeting PTSD during DBT have been identified. However, several studies have shown that BPD individuals with PTSD exhibit poorer outcomes during DBT in terms of NSSI and suicidality . Thus, untreated/active PTSD may complicate treatment of BPD-related problems during DBT.

Special points:

In the two studies reporting PTSD outcomes during DBT, PTSD was either not routinely targeted or direct targeting of PTSD via formal exposure procedures was prohibited . Thus, these results are best interpreted as demonstrating the indirect effects of DBT on PTSD when this comorbid disorder is not directly targeted. In addition, individuals with bipolar and psychotic disorders were excluded from both studies and the generalizability of these findings to individuals with those disorders is unknown.

Dialectical behavior therapy with the dbt prolonged exposure protocol (DBT + DBT PE)

Standard procedure:

The DBT PE protocol was developed to facilitate routine and direct targeting of PTSD during standard DBT . The combined DBT + DBT PE treatment includes 1 year of DBT (including all four treatment modes as described above) that begins with a focus on reducing behavioral dyscontrol and increasing behavioral skills. If/when patients meet specified readiness criteria (e.g., abstinence from suicidal and self-injurious behaviors for at least 2 months, no serious therapy-interfering behaviors), the DBT PE protocol is integrated into individual therapy sessions to directly target PTSD. This protocol is based on PE with adaptations made to address the specific needs and characteristics of BPD patients. The primary treatment components include imaginal exposure to trauma memories and in vivo exposure to avoided situations. Following completion of the DBT PE protocol, standard DBT is continued with a focus on addressing any remaining treatment targets (e.g., psychosocial functioning).

To date, DBT + DBT PE has been evaluated in case studies , an open trial , and an RCT . Each of these studies included adult women with BPD, PTSD, and recent and recurrent suicide attempts and/or NSSI. In the open trial and RCT, the DBT PE protocol was feasible to implement for 80–100 % of treatment completers who started the protocol after an average of 20 weeks of DBT; of these, 73 % completed the full protocol in an average of 13 sessions. Across both studies, patients in DBT + DBT PE showed large and significant improvements in PTSD severity (effect sizes >1.3). In addition, at post-treatment there were high rates of reliable improvement (70.0–83.3 %) and diagnostic remission of PTSD (58.3–60.0 ;%). Large and significant reductions in suicidal and self-injurious behaviors as well as a variety of secondary outcomes (i.e., dissociation, trauma-related guilt, shame, depression, anxiety, social and global adjustment) were also found. In the RCT, improvements in DBT + DBT PE were larger than those in DBT for PTSD and other outcomes.

Contraindications:

In DBT + DBT PE, patients are required to achieve control over life-threatening behaviors and serious therapy-interfering behaviors prior to beginning the DBT PE protocol.

Complications:

None identified. Of note, adding the DBT PE protocol to DBT is associated with improvement, not worsening, of PTSD and suicidal and self-injurious urges and behaviors in comparison with DBT alone .

Special points:

The RCT evaluating DBT + DBT PE used a relatively small sample and replication in a large-scale RCT is needed. Individuals with bipolar and psychotic disorders were excluded from the open trial and RCT and additional research is needed to evaluate the generalizability of these findings to BPD patients with these diagnoses.

Emerging therapies

  • The following psychotherapy has been evaluated in a preliminary open trial, and an RCT is complete but not yet published.

Narrative exposure therapy (NET)

Standard procedure:

NET is a brief treatment for PTSD that is designed for survivors of multiple and complex traumas such as victims of organized violence and conflict . NET is typically delivered in 5–10 weekly or biweekly individual sessions. The primary component of NET is the creation of a written, cohesive life narrative that includes significant traumatic and non-traumatic events.

NET has been evaluated in an open feasibility trial with ten adult women with BPD and PTSD . Women who were actively engaging in NSSI were included, but those with acute suicidality, a recent suicide attempt, and other severe comorbidities (e.g., substance dependence, psychosis, body mass index <18) were excluded. Treatment lasted an average of 14 sessions and was primarily delivered in an inpatient setting, although three women were treated solely on an outpatient basis. Results indicated large and significant improvements from pre-treatment to 6 months after therapy in PTSD, depression, and dissociation, but not BPD symptoms.

Contraindications:

In this study, NET was not provided to individuals with recent suicidal behavior, acute suicidality, and other severe comorbidities.

Complications:

None identified.

Special points:

Although NET was delivered to women who were actively engaging in NSSI, treatment occurred primarily in an inpatient setting where patient safety could be closely monitored. The generalizability of these findings to outpatient samples of BPD patients as well as those with significant suicidality and other severe comorbidities is unknown. In addition, NET is intended to treat PTSD and does not appear to improve BPD symptoms.

Pediatric considerations

  • To date, no psychotherapies have been evaluated as a treatment for PTSD among children or adolescents with BPD or BPD traits. However, several of the treatments reviewed above have been adapted for adolescents and/or children and evaluated in RCTs. Specifically, developmentally adapted PE has been shown to be superior to time-limited dynamic therapy and supportive counseling in improving PTSD and other outcomes among adolescents girls with sexual abuse-related PTSD . Similarly, an adapted version of narrative exposure therapy outperformed a waiting list in reducing PTSD among refugee children and adolescents living in exile . Finally, a shortened form of DBT for adolescents has been found to be more efficacious than enhanced usual care in reducing self-harm, suicidal ideation, and depression among adolescents with repeated suicidal and self-harming behavior . Future research is needed to evaluate the efficacy of these treatments specifically for children and adolescents with comorbid PTSD and BPD or BPD traits.

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