An Introduction to BPD

Borderline personality disorder is a serious mental illness that has been estimated to affect as much as 5.9% of the population (1). BPD can hinder an individual's attempt to function at even the most basic levels, while also negatively impacting friends and family members of the person suffering from it. Despite its prevalence, BPD has historically been marginalized and misunderstood, used even among clinicians as a catch-all diagnosis for patients who are considered "difficult" and resistant to treatment.

One of the core features of BPD is an impaired ability to regulate emotions (2). Consequently, the emotional life of someone with BPD is frequently volatile, with even minor events leading to a disproportionate, usually very negative response. This could manifest as rage in response to a perceived insult from a close friend or as a bout of intense despair, marked by a global sense of hopelessness and profound sadness after a small setback. Though these emotional states rarely last more than several hours, the frequency of these changes can have a very destabilizing effect on the individual.

In addition to this emotional component, BPD is typified by disruptions in close interpersonal relationships. A person with BPD will tend to idealize their closest relationships only to lash out when they sense rejection (3). This hypersensitivity is largely derived from an intense fear of being deserted by friends and caregivers (2). Unfortunately, attempts to prevent this dreaded abandonment can often have the opposite effect, pushing those close to the borderline individual farther away, which then feeds into the self concept of "badness" that many people with BPD harbor. They often believe that there is something inherently negative or unworthy about them, though this perception is itself unstable and mood dependent (2,4).

In order to cope with these painful and turbulent emotions, those with BPD may resort to seemingly extreme measures. Self-injury—most commonly cutting, but also burning, hitting, and skin picking—is considered a hallmark of this disorder, as are many other impulsive, self-destructive acts such as eating disordered behaviors, promiscuity, and substance abuse (5). A history of suicide attempts is very common in those with BPD, and an estimated 8-10% of borderline patients will succeed in taking their own lives (6).

While the risks and dangers of this disorder are very real, the last several decades have seen an increased understanding of the factors underlying the disorder (7). Studies have shown that an invalidating environment contributes to the development of this disorder (8). A history of trauma or abuse is also common among patients with BPD (2). In addition to these environmental factors, research has demonstrated a significant genetic predisposition for borderline traits (2,7).

Along with these insights into the evolution of the disorder, there has been an emergence of more effective treatment methods specifically tailored to the needs of patients with BPD. One of the most well known and highly regarded of these is dialectical behavior therapy (DBT), developed by psychologist and researcher Marsha Linehan. (You can read more about her personal experience with BPD in this article by The New York Times.) DBT targets the borderline patient's interpersonal struggles, difficulty with emotion regulation, and impulsivity while teaching core "mindfulness" skills (8). Mentalization based therapy (MBT) is another emerging and promising treatment for BPD, developed by two researchers and clinicians, Peter Fonagy and Anthony Bateman (9). MBT has its basis in Fonagy's studies of attachment, which led to the creation of this therapy designed to help borderline patients improve their capacity to understand both their own as well as others' mental states and thereby create a more solid self-concept (2,9).

Even with these advances, much work still needs to be done to make these resources more accessible and widely available to those who need it. Further efforts also need to be made to combat the stigma that has been unfairly attached to this disorder. An increased awareness of BPD among both clinicians and the general public will allow for continued progress in understanding and treating this disorder. For too long, borderline personality disorder has been ignored and misrepresented, to the great detriment of the many people who still suffer from its effects.

  1. Grant, BF, Chou, SP, Goldstein RB, Huang B, Stinsin F, Saha T, Smith S, Damson D, Pulay A, Pickering R, Ruan J. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results form the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2008; 69(4); 533-545.
  2. Gunderson JG, with Links PS. Borderline personality disorder: A clinical guide, 2nd ed. Washington, DC: American Psychiatric Publishing, Inc., 2008.
  3. Gunderson JG. Borderline personality dismorder. N Engl J Med 2011; 364(21); 2037-2042
  4. Gunderson, JG. Revising the borderline diagnosis for DSM-V: An alternative proposal. J Pers Disord 2010; 24(6); 694-708.
  5. Gunderson JG, Hoffman PD (Eds.). Understanding and treating borderline personality disorder: A guide for professionals and families. Washington, DC: American Psychiatric Publishing, Inc., 2005.
  6. Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatry 2006; 163(1); 20-26.
  7. Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry 2009; 166: 530-539.
  8. Linehan, MM. Skills training manual for treating borderline personality disorder. New York: The Guilford Press, 1993.
  9. Bateman AW, Fonagy P. Psychotherapy for borderline personality disorder: Mentalization-based treatment. Oxford: Oxford University Press, 2004.