Borderline Personality Disorder (BPD): Causes, Types & Treatment

Personality Disorders

Personality disorders represent enduring patterns of behavior and inner experiences, such as emotions that are relatively inflexible (meaning that they are prone to be expressed in situations where an individual would normally temper certain aspects of their behavior), pervasive (meaning they occur in many different situations), are significant departures from expectations of a person’s social environment or culture, and appeared early in the development of the individual and continue to be expressed over time as the person matures. These enduring patterns of behavior are often dysfunctional and result in significant distress to the individual and/or to others with whom the individual interacts.

Thus, personality disorders:

• Are stable tendencies toward feeling and behaving that have endured since early childhood or adolescence
• Are in conflict with the normal expectations of the individual’s social environment or culture
• Lead to significant issues regarding the individual’s ability to function in society and negatively affect the person’s relationships, occupation, goals, and overall level of functioning

The 9 personality disorders in the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are further grouped into 3 major clusters of disorders, such that each cluster is based on the major feature that defines the behavior observed in those personality disorders. 

What is Borderline Personality Disorder (BPD)? 

BPD is a chronic but treatable mental illness that makes it very difficult for someone to control their emotions. This can make them overly impulsive and affect their self esteem and relationships with others. 

Borderline personality disorder is one of 4 personality disorders belonging to a group of personality disorders where dramatic and/or very eccentric emotional responses are the major personality features/characteristics that drive the person’s overall behavior.

Symptoms & Diagnosis of Borderline Personality Disorder

According to the American Psychiatric Association (APA), there are 9 potential symptoms that can occur in individuals who are diagnosed with borderline personality disorder (BPD). In order to receive a formal diagnosis of BPD, an individual would have to satisfy or meet at least 5 of the 9 diagnostic criteria (diagnostic criteria are synonymous to signs or symptoms). The general symptoms of borderline personality disorder include:

• A significant and persistently unstable sense of self
• Desperate efforts to avoid being abandoned (These can be efforts to avoid real situations where the individual feels that they will be abandoned or situations that they imagine can occur that will result in them being abandoned.)
• Long-term feelings of loneliness or emotional emptiness
• A long-term pattern of alternating between totally idealizing other people to totally devaluating them (In clinical terms, this is often referred to as splitting: The individual totally idolizes a person; then, when the person does something that offends them, they totally demonize the same person. Individuals engaging in splitting seem to have no middle ground.)
• The demonstration of a severe impulsivity that occurs in at least two areas of behavior and is potentially self-injurious or self-damaging (e.g., substance abuse, binge eating, multiple sexual contacts, etc.)
• Repeated gestures at suicide, threats of committing suicide, or even repeated actual attempts at suicide
• Engaging in various forms of self-mutilating behavior, such as cutting or burning oneself with a lighter
• Demonstrating multiple significant unstable emotional outbursts
• Paranoid thoughts or severe dissociative experiences, such as being removed or detached from reality, having severe amnestic events, or feeling as if one is detached from one’s body

Because the diagnostic criteria indicate that one must satisfy 5 of the 9 total criteria, there are literally many different ways that BPD can present itself in individuals. For example, there are over 100 different 5-symptom combinations possible. Of course, individuals can also have more than 5 symptoms, so there are many other combinations of six, seven, or eight criteria, as well as individuals with severe presentations who may fit all 9 diagnostic criteria. This means that BPD can present in a number of different ways.

BPD Subtypes

Millon classified BPD subtypes by the general pattern of their overall pathology. This resulted in 4 related, but relatively distinct, subtypes of BPD:

• Impulsive BPD: The major feature in this subtype is difficulty with impulse control. These individuals are at a high risk for self-harm, including attempts at suicide, and they often become engaged in thrill-seeking activities.
• Discouraged BPD: This subtype is very dependent on others and thus very needy and clingy. These individuals often present as being very passive until they perceive themselves as being abandoned. Once they feel abandoned, issues with anger control and emotional stability surface. Although they are dependent and clingy, any amount of attention will not satisfy them.
• Self-destructive BPD: This subtype harbors intense feelings of bitterness and self-hatred. They attempt to find comfort in getting attention from others, and if this need is not satisfied (and it never is for long), they may turn to self-destructive behaviors, including suicidal threats or attempts, substance use, and potentially destructive thrill-seeking.
• Petulant BPD: This subtype fluctuates between outbursts of explosive anger and feelings of being unworthy or unloved. They have a strong need to manipulate or control others, and they become very possessive, which results in extreme dissatisfaction in their relationships. This leads to issues with substance abuse and other potential damaging issues.

Many of the other classifications of the subtypes of BPD are similar to Millon’s but may combine one or two of the different subtypes. In addition, the observation made by Kernberg above – that the driving force behind BPD was one of loneliness and needing to belong – appears to be an important feature in all of the subtypes mentioned by Millon.

Causes of BPD

The vast majority of recognized forms of mental illness or psychiatric/psychological disorders have no known formal cause. Instead, there are a number of different associations noted with these disorders that may contribute to their development; however, no formal causal relationship has ever been established between any specific factor, including genetic associations, a history of abuse, certain other personality characteristics, or other environmental factors and any personality disorder.

BPD Rarely Occurs in Isolation

The term comorbidity is used by clinicians to describe a situation where a person is diagnosed with more than one type of disorder at the same time. The terms dual diagnosis or co-occurring disorders are now often used to specify a situation where an individual has a mental health disorder that is comorbid with a substance use disorder. Because BPD is a severe disorder with extensive psychopathology, it is commonly comorbid with several other types of disorders. The most common disorders comorbid with BPD include the following:

• Major depressive disorder, often referred to as just clinical depression or depression, is the most common comorbid disorder diagnosed with BPD. As one might expect the severe feelings of emptiness, loneliness, fear of abandonment, and other behaviors associated with BPD often lead to severe feelings of depression.
• Anxiety disorders, such as panic disorders (the occurrence of multiple panic attacks) and phobias (unrealistic fears of situations or objects), are also frequently comorbid with BPD.
• BPD is often comorbid with bipolar disorder, which is a severe disorder where individuals vacillate between extreme presentations of depression and mania.
• Post-traumatic stress disorder is often comorbid with BPD due to a combination of the extreme emotional liability these individuals experience and of having a history of abuse as children, their tendency to get involved in relationships that are abusive and dysfunctional, or their vulnerability to be victims of aggressive types of crimes.
• Substance use disorders are very often comorbid with BPD as mentioned above. The tendency to engage in substance use is a result of a number of different factors for individuals with BPD, including their penchant for self-destructive behavior; impulsive acts; and chronic feelings of emptiness, loneliness, and fear of being abandoned. One-half to two-thirds of individuals who are diagnosed with BPD will also have some type of substance use disorder.
• Because personality disorders share a number of core features, it is not uncommon for individuals diagnosed with BPD to also be diagnosed with other personality disorders.

Treating Individuals with BPD

BPD is a notoriously difficult psychological/psychiatric disorder to treat. When an individual is diagnosed with BPD and some other comorbid condition, such as a co-occurring substance use disorder or comorbid personality disorder, this makes the treatment process even more complicated. BPD is specifically notoriously difficult to treat because individuals with the disorder will inevitably display:

• Noncompliance with treatment: People diagnosed with BPD become very reactive and often demonstrate an extreme resistance to change. This is because individuals with personality disorders often do not see themselves as a problem but instead view everyone else as being the cause of their difficulties. When these individuals have co-occurring substance use disorders, this increases the chances for noncompliance.
• Self-destructive tendencies: BPD patients are often self-destructive and have issues with self-injurious behaviors and suicidality. Because the treatment process attempts to correct dysfunctional behaviors, individuals with BPD must first see the need to change (which means they must accept deficiencies within themselves), which fosters even further issues with self-degradation, suicidality, etc. This often complicates the treatment process.
• Relationship issues: People with BPD have relationship issues with nearly everyone in their lives, and significant relationship issues will often develop with therapists as a result of the therapeutic process of change. The patient may first idolize the therapist and then later totally demonized them (splitting), or may attempt to manipulate different therapists against each other in order to manipulate the overall treatment. Professionals who treat people diagnosed with BPD must be aware of these potentialities and even expect them to occur. Unstable personal relationships within treatment itself as well as outside treatment contribute to the difficulty of helping these individuals adjust.

Despite these issues, there is a very good treatment protocol that is targeted at many of the difficulties these patients exhibit. A specific form of Cognitive Behavioral Therapy known as Dialectical Behavior Therapy (DBT) was originally developed to treat individuals who were suicidal, and the principles were found to be extremely well suited to the treatment of individuals with BPD. As a result, DBT has become the frontline treatment approach for BPD.

The process of DBT includes individual therapy sessions, group therapy sessions, the development of strict rules and regulations that are enforced based on contingencies for not abiding by them, and close supervision and involvement with these patients. The treatment attempts to get individuals to accept certain aspects of reality that are unchangeable and to focus on changing themselves in accordance with their broader needs and goals. As it turns out, DBT is also well suited to treating BPD patients with co-occurring diagnoses (BPD and substance abuse).

Medications can also be used in the treatment of BPD; however, there is no specific medication designed to treat the disorder. Most often, individuals with BPD are put on antidepressant medications, particularly selective serotonin reuptake inhibitors, and other medications that address specific symptoms displayed by the individual. This combination of therapy and medical management can be successful in the long-term management of individuals with BPD and in those who have comorbid disorders.

River Oaks Mental Health Services: A Center for Healing & Wellness

Coming this Fall, American Addiction Centers (AAC) is proud to offer primary mental health treatment for people without drug or alcohol addiction at River Oaks, our Tampa, FL facility. This residential treatment program is equipped to treat patients with BPD or other mental health conditions that may require:

• 24/7 monitoring.
• Medication administration.
• One-on-one and group therapy.
• Psychiatric rehabilitation.

The aim of this program is to help patients build the necessary skills to gain control of their lives, improve daily functioning, and avoid future crises.

Find Co-Occurring Disorder Treatment Near You

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