Borderline Personality Disorder: Symptoms, Treatments, Causes

[David Baxter PhD]

What is Borderline Personality Disorder? BPD Symptoms, Treatments, Causes​

by Tori Morales, ADDitudemag.com
July 28, 2022

Borderline personality disorder (BPD) is a Cluster B personality disorder that causes unstable relationships, emotions, and self-concept. Understand BPD’s symptoms, causes, link to ADHD, treatments, and more.

What is Borderline Personality Disorder?​

Borderline personality disorder (BPD) is characterized by instability in self-image, relationships, and emotions. People with BPD are likely to self-harm and, in certain circumstances, may experience psychotic-like delusions and hallucinations.

BPD is estimated to be the third most prevalent personality disorder, affecting about 1.6% of the global population¹. Up to 20% of inpatient psychiatric patients have BPD, suggesting that people with BPD are more likely to require intensive mental health care².

BPD is one of 10 personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Along with histrionic, antisocial, and narcissistic personality disorders, BPD is a Cluster B disorder, which causes affected individuals to appear erratic, emotional, or dramatic.

BPD Symptoms​

Though symptoms may manifest in different ways, people with BPD experience at least five of the following:

• Efforts to avoid abandonment. People with BPD fear losing relationships, and they may make seemingly excessive attempts to keep people close.
• Unstable and intense relationships. People with BPD may become quickly infatuated with someone only to devalue them after a (real or perceived) slight.
• Unstable self-image. People with BPD struggle to sustain a sense of self.
• Impulsivity. In at least two areas, such as driving or substance use, people with BPD act in ways that are potentially self-damaging.
• Suicidality or self-harm. People with BPD may display suicidal behavior, gestures, or threats. They may also self-harm. The risk for suicide among people with BPD is 40 times higher than it is among the general population.
• Reactive mood. BPD causes unstable emotions, leading sufferers to intense, usually brief, emotional episodes in responses incongruent with their situations.
• Chronic feelings of emptiness.
• Inappropriate anger. People with BPD may experience disproportionate anger, leading to difficulty controlling their temper.
• Stress-related symptoms. Stress can cause people with BPD to experience paranoid ideation or severe dissociative symptoms³.

Other Signs of BPD​

Though symptoms are used to diagnose BPD, the following associated features may help clinicians support a diagnosis. These can include:

• Self-sabotage, especially just before the completion of a goal.
• Psychotic symptoms, such as hallucinations, in times of stress.
• A history of abuse, especially childhood abuse.
• Reliance on pets and inanimate objects due to unstable relationships with people.
• Increased risk for depression⁴.

Causes of BPD​

While research is still ongoing into causes of BPD, there are factors that have been correlated with an increased risk, including:

• Genetics. BPD runs in families, indicating that there is a likely genetic link. However, no specific genes have been identified as playing a role in BPD.
• Abuse. Especially in childhood, abuse may increase an individual’s chance of developing BPD. Potential triggers include sexual abuse, physical abuse, and emotional abuse or neglect.
• Brain differences. People with BPD experience a disconnect between the brain centers that control emotion and behavior, causing some of their symptoms.

BPD and ADHD​

ADHD commonly co-occurs with BPD, with 10% to 27% of people with ADHD meeting criteria for a BPD diagnosis⁵. Studies suggest that BPD is less common in people with inattentive ADHD. At the same time, people with ADHD, especially women, are sometimes misdiagnosed with BPD.

ADHD and BPD have similar symptoms, such as emotional dysregulation and impulsivity, making it difficult to differentiate the two conditions. However, stress-related psychotic symptoms and feelings of emptiness are unique to BPD, while hyperfocus and attention difficulties point primarily to ADHD.

New research suggests there may be a link between childhood ADHD and the development of BPD later in life. Severity of pediatric ADHD symptoms is correlated with severity of BPD symptoms in adulthood, according to a 2022 study from Scandinavia that found childhood impulsivity to be the strongest predictor of BPD⁶. The underlying reason for the link is unknown, though research is ongoing.

Treating BPD​

Though once considered untreatable, BPD now has a range of effective treatments. Dialectical behavior therapy (DBT), a type of cognitive behavioral therapy (CBT), was initially developed in the 1980s by Seattle psychologist Marsha Linehan, Ph.D., specifically to treat BPD. A study published in Borderline Personality Disorder and Emotional Dysregulation found that three-quarters of patients no longer met the symptom criteria for BPD after undergoing DBT treatment⁷.

In addition to DBT, mentalization-based treatment (MBT), schema-focused therapy (SFT), transference focused therapy (TFP), and systems training for emotional predictability and problem solving (STEPPS) have been established as evidence-based treatments for BPD⁸.

In addition to psychotherapy, medication may be prescribed to treat specific symptoms. Antipsychotic medications, mood stabilizers, and antidepressants are commonly used in people with BPD, though there is doubt about the effectiveness of antidepressants outside of major depressive episodes⁹.

Article Sources​

1. Sansone, R. A., & Sansone, L. A. (2011). Personality disorders: a nation-based perspective on prevalence. Innovations in clinical neuroscience, 8(4), 13–18.
2. Chapman J, Jamil RT, Fleisher C. Borderline Personality Disorder. StatPearls. Borderline Personality Disorder - StatPearls - NCBI Bookshelf
   American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 663 Psychiatry Online
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). , 665 Psychiatry Online
4. Matthies, S. D., & Philipsen, A. (2014). Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)-review of recent findings. Borderline personality disorder and emotion dysregulation, 1, 3. Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)–review of recent findings - Borderline Personality Disorder and Emotion Dysregulation
5. Tiger, A, Ohlis, A, Bjureberg, J, et al. Childhood symptoms of attention-deficit/hyperactivity disorder and borderline personality disorder. Acta Psychiatr Scand. 2022; 1- 11. https://doi.org/10.1111/acps.13476
6. Stiglmayr, C., Stecher-Mohr, J., Wagner, T. et al. Effectiveness of dialectic behavioral therapy in routine outpatient care: the Berlin Borderline Study. Borderline Personality Disorder and Emotional Dysregulation, 1, 20 (2014). Effectiveness of dialectic behavioral therapy in routine outpatient care: the Berlin Borderline Study - Borderline Personality Disorder and Emotion Dysregulation
7. Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What Works in the Treatment of Borderline Personality Disorder. Current behavioral neuroscience reports, 4(1), 21–30. https://doi.org/10.1007/s40473-017-0103-z
8. Olabi, B., & Hall, J. (2010). Borderline personality disorder: current drug treatments and future prospects. Therapeutic advances in chronic disease, 1(2), 59–66. https://doi.org/10.1177/2040622310368455

More information

• Self-Test: Borderline Personality Disorder
• Download: 9 Conditions Often Linked to ADHD

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[Daniel E.]

There are many paradoxes associated with BPD. A paradox is something that is self-contradictory. Those who have BPD have a tendency to experience something called the empathy paradox. The empathy paradox, for individuals with BPD, is that they are good at reading emotions in others due to paying extra attention to what’s going on in their environment and the people in it, but this information gets distorted along the way causing the individual with BPD to misinterpret those emotions as negative which leads to a greater likelihood of reacting negatively in situations. Also, the greater degree of the felt need for rapid response, the greater the impairment.

Research shows that those with BPD do possess enhanced empathic skills. Individuals with BPD have an increased sensitivity to negatively perceive emotional stimuli, and that this leads to a reduced ability to stop, think, determine best outcome, and then react that impairs self-control and performance, especially in tasks requiring quick responses. It also leads to a higher tendency to feel overwhelmed, a common feeling for those with BPD. Individuals with BPD have a tendency to perceive and respond to internal urges that are a mixture of learned distrust of others that disrupts the ability to develop lasting and stable mental pictures of how you see and evaluate people in your mind, which leads to chronic social dysfunction.

This history of learned inconsistency drives individuals with BPD to react as though they're going to be disrespected, hurt, abandoned or all 3. What can you do about it? When you recognize emotions in others, stop and remind yourself of that negative tendency, look for environmental evidence to support or disprove what you’re feeling and interpreting, then reassess, and determine best outcome. Slow and steady wins the race here, not rapid pace to this finish. The tortoise wins, not the hare.

Daniel J. Fox, Ph.D., is a licensed psychologist in Texas, international speaker, and award winning author. He has been specializing in the treatment and assessment of individuals with personality disorders for over 15 years in the state and federal prison system, universities, and in private practice. His specialty areas include personality disorders, ethics, burnout prevention, and emotional intelligence.

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