Borderline personality disorder is characterized by instability of emotions, periodic impulsive and self-destructive behavior, and troubled relationships with other people. This pattern of feelings, behaviors, and relationships usually begins in early adulthood. People with the disorder experience a great deal of anxiety and psychological distress, and they have difficulties at school or work. They can learn to manage the disorder, but the disorder itself is lifelong.
People who have borderline personality disorder can be very sensitive to the way others treat them, reacting strongly to criticism or misinterpreting others' actions as hurtful. Their feelings about others often shift from positive to negative, generally after a disappointment or when they perceive a threat of losing someone. Similarly, their self-image can change rapidly from extremely positive to extremely negative.
Impulsive behaviors are typical among persons with borderline personality disorder, including alcohol or drug abuse, unsafe sex, gambling, and reckless disregard for personal safety. Self-destructive acts such as cutting and burning themselves as well as repeated suicidal threats and behaviors are common. Self-destructive acts often occur after a real or threatened separation from someone on whom they are emotionally dependent.
Unstable moods are also common, with intense reactions to stress and disappointment and fear of losing someone or something. These reactions are often out of proportion to the objective situation. Persons with borderline personality disorder may show powerful expressions of anger, panic, and despair followed by terrible feelings of self-recrimination and guilt. Such emotions are often superimposed on ongoing feelings of emptiness and loneliness. Persons with the disorder can experience brief states of suspicion, paranoia, and depersonalization—a feeling of being profoundly cut off from oneself. Some may lose their grasp on reality (psychosis).
Good treatment begins with a careful and comprehensive evaluation. The clinician must take time to understand the person, distinguish the disorder from others that may mimic it, assess whether the person is a danger to self or others, and begin building a working alliance that is essential if treatment is to be sustained over time.
Early in treatment, the patient and the psychiatrist or other mental health professional should establish treatment goals. Clear and realistic goals are essential. Because of the nature of borderline personality disorder, patients must understand the value as well as the limits of treatment and appreciate their responsibility and role in the treatment process. They also must understand the importance of recognizing when they do not feel safe and must learn new ways to respond to crises. Committing to ongoing therapy is important, despite its frustrations and demands. Successful treatment involves a collaborative process between the patient and the therapist.
Psychotherapy is often effective and is the primary treatment for borderline personality disorder. Several elements of therapy are known to be important. A working alliance between the patient and the therapist must be built and sustained. Validating the patient's suffering and experience is vital, but providing such validation is not a license for the person to forgo responsibility for his or her actions. Patients must learn to manage difficult feelings and to think rather than act. They must learn to recognize and report self-destructive behaviors, to understand the precipitants of such behaviors and their motivations, and to develop more effective ways of coping.
The two best-studied psychotherapies for treating borderline personality disorder are psychodynamic therapy and dialectical behavior therapy, a type of cognitive-behavioral therapy. At the center of psychodynamic therapy is the therapeutic relationship between the patient and the therapist. A variety of techniques are used: providing support and advice, encouraging patients to think about and explore feelings and behaviors, confronting issues the patient wishes to avoid or to deny responsibility for, and providing interpretations, by which the therapist helps the patient understand the meaning and purpose of disturbed feelings and actions. Research and clinical experience attest to the importance of longer-term therapy; benefits are unlikely to result from therapies that last less than one year.
Cognitive-behavioral therapy is a well-researched form of psychotherapy, especially for the treatment of depression and anxiety disorders. This approach is based on the theory that how we think determines how we feel. Specifically, distorted and maladaptive ideas and thought patterns are believed to underlie symptoms and disturbed behaviors. Cognitive-behavioral therapy involves recognizing the distorted thought patterns and creating new and more adaptive thinking and behavior. Dialectical behavior therapy is a form of cognitive-behavioral therapy developed by Dr. Marsha Linehan. Therapists must have special training in this therapy, which involves a combination of individual and group treatment guided by many of the principles of cognitive theory.
Psychodynamic or cognitive-behavioral therapy is apt to be more effective if the therapist has had special training and previous experience and has a particular interest in working with patients with borderline personality disorder.
The prescription of medications by a psychiatrist can be a useful addition to psychotherapy for patients with borderline personality disorder. Medications are chosen to target symptoms in three general areas: instability of mood, impulsive and uncontrolled behaviors, and disturbances in thinking and perceiving. Mood instability often takes the form of intense anger, severe and precipitous depressed moods, rapid changes in mood, and overreactions to events, especially in relationships. Studies have shown that selective serotonin reuptake inhibitors (SSRIs) and related antidepressant medications, such as venlafaxine, are effective for the mood problems that these patients experience. Older antidepressant medications—that is, tricyclic antidepressants—have not shown consistent effectiveness, and overdoses of these medications entail greater health risks.
Impulsive and poorly controlled behaviors include aggression, self-mutilation, promiscuous sex, and reckless actions. SSRIs are often the first choice to help control these symptoms; a low dosage of an antipsychotic (also called a neuroleptic) medication may sometimes be used. Lithium and mood stabilizers have also been used. Although studied less than the SSRIs, they appear to be effective; a less than adequate response to an SSRI may be improved by the addition of lithium or a mood stabilizer. Disturbances in thought and perception include suspicion, paranoia, delusions, depersonalization, and hallucinations. Low dosages of antipsychotic medications are the treatment of choice for these symptoms and may also improve mood and impulsivity.
Studies indicate that about 10 percent of individuals who are seen in outpatient mental health clinics and almost 20 percent of psychiatric inpatients have a diagnosis of borderline personality disorder. The disorder is seen worldwide, and it is diagnosed three times more often among women than among men. Borderline personality disorder is five times more common among first-degree relatives—siblings, parents, and children—of persons with the disorder than in the general population.
Long-term studies of patients with borderline personality disorder who have been treated show that the course of the disorder varies over time. Early adulthood is often characterized by considerable instability in symptoms and behaviors and frequent use of mental health and emergency services. The lifetime suicide rate among persons with the disorder is about 9 percent, and patients aged 30 and younger are at the greatest risk. Most patients with the disorder become more stable with age, and their social and occupational functioning improves. Some achieve mature relationships, modulated patterns of feeling and behaving, and success at work.