Imagine a message that goes unanswered for three hours. For most people, it is a minor irritation, perhaps forgotten by the time the reply arrives. For a person with borderline personality disorder, the same silence can set off a chain of events that feels like an emergency. The stomach tightens, the thoughts begin to race, and a single idea takes over: something has gone wrong, the other person is angry or has lost interest, and the relationship is ending. Within minutes the fear may turn into anger, then into shame at the anger, then into a hollow numbness. When the reply finally arrives, with an ordinary explanation, the relief is enormous, but it is followed by exhaustion and embarrassment, and by the knowledge that the same storm will probably return the next time.
People who live with this condition often describe it as feeling emotions without a volume knob. Where other people seem to have a dial that turns feelings up or down, their own emotions arrive at full volume, switch on quickly, and fade slowly. A small disappointment can feel like a catastrophe, and a mild criticism can feel like proof of being worthless. The intensity is not exaggeration or theater. It is a genuine difference in the way the nervous system responds to emotional events, combined with a set of learned habits that make the intensity harder to bear.
Borderline personality disorder, often abbreviated as BPD, is among the most misunderstood conditions in mental health. It affects an estimated one to two percent of adults in the general population by commonly cited figures, and a far larger share of people who attend psychiatric clinics and hospitals. It is associated with considerable suffering, with a high risk of self-harm and suicidal behavior, and with difficulties in relationships, work, and daily life. At the same time, it is one of the personality disorders with the best evidence for effective treatment, and long-term studies show that most people improve substantially, and many recover. Yet it has long carried a heavy stigma. Patients have been described as manipulative, attention-seeking, or untreatable, and some clinicians have avoided the diagnosis or avoided the patients. This stigma has delayed help for many people and has obscured the plain fact that the disorder is understandable, and that it responds to treatment.
This article offers a detailed, evidence-based account of borderline personality disorder. It explains what the diagnosis means, how it came to be named, and what the diagnostic criteria describe in everyday terms. It examines the central problem of emotion dysregulation and the biosocial theory that explains it, reviews the biological and environmental factors that contribute to the disorder, and distinguishes it from conditions with which it is often confused. It sets out the treatments with the strongest evidence, including dialectical behavior therapy and mentalization-based treatment, describes practical strategies that people can use, and offers guidance for families and partners. The central message is that the intensity of emotion in this disorder is real, that it has identifiable causes, and that people can learn, with the right help, to turn the volume down.
What Borderline Personality Disorder Is
Borderline personality disorder is a mental health condition characterized by a long-standing pattern of instability in emotions, relationships, self-image, and behavior. It belongs to the group of conditions called personality disorders, which are defined as enduring patterns of inner experience and behavior that deviate markedly from cultural expectations, are pervasive and inflexible, begin in adolescence or early adulthood, are stable over time, and lead to distress or impairment. The word personality in this context does not mean that the person is flawed in character. It refers to the habitual ways of feeling, thinking, and relating that make up a person’s style of dealing with the world, which in this disorder have become a source of considerable pain.
The History of the Name
The term borderline has a curious history. In 1938, the American psychoanalyst Adolph Stern used it to describe a group of patients who did not fit neatly into the categories of the time. They seemed too troubled to be called neurotic, since their anxiety was intense and their relationships were chaotic, but they were not clearly psychotic, since they were not typically out of touch with reality. They appeared to stand on the border between the two. The label stuck long after the idea that the condition lies on a border between neurosis and psychosis had been abandoned. In the 1960s and 1970s, the psychoanalyst Otto Kernberg developed the concept of borderline personality organization, and the psychiatrist John Gunderson set out systematic criteria for diagnosis. The condition entered the official diagnostic manual of the American Psychiatric Association in 1980, in its third edition.
Many clinicians and patients consider the name misleading and unfortunate, since it suggests an unclear boundary and says nothing about the actual features. Alternative names have been proposed, including emotional regulation disorder and complex emotional needs. The tenth edition of the International Classification of Diseases used the term emotionally unstable personality disorder, borderline type, and some services in the United Kingdom prefer to speak of emotionally unstable personality disorder. The term borderline personality disorder remains the most widely recognized, and it is used in this article for that reason, with the understanding that the name tells little about the experience.
The Diagnostic Criteria
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the diagnosis requires a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, with marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of nine features. Each of the features describes a different side of the same underlying difficulty.
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense relationships, characterized by alternation between extremes of idealization and devaluation.
- Identity disturbance, with a markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging, such as spending, sex, substance use, reckless driving, or binge eating.
- Recurrent suicidal behavior, gestures, or threats, or self-harming behavior.
- Emotional instability due to a marked reactivity of mood, such as intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
Because only five of nine are required, two people with the same diagnosis may share only one criterion. This variation is one reason why the disorder looks so different from one individual to another, and why researchers have long discussed whether it is better understood as a single entity or as a collection of overlapping patterns. The criteria are also a description of behavior as seen from outside, and they do not capture the inner experience, which is the subject of much of this article.
Newer Ways of Describing Personality Disorders
Diagnostic thinking is changing. The eleventh edition of the International Classification of Diseases, adopted by the World Health Organization, has abandoned the separate personality disorder categories and instead asks the clinician to rate the severity of personality dysfunction as mild, moderate, or severe, and then to add trait domain specifiers, such as negative affectivity, disinhibition, detachment, dissociality, and anankastia. A borderline pattern specifier is available for those who show the characteristic mixture. The fifth edition of the American manual also contains an alternative model in its appendix, in which personality disorder is defined by impairments in the sense of self and in relationships, together with pathological personality traits. For borderline personality disorder, the relevant traits include emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk taking, and hostility. These dimensional approaches reflect the evidence that personality problems exist on a continuum and that severity matters more than category in predicting how well a person functions.
How Common It Is
Estimates of prevalence vary with the method of study. Surveys of the general population have generally produced figures of about one to two percent, while some large national surveys in the United States have reported higher lifetime rates, of around six percent. Among people receiving outpatient mental health care, roughly ten percent have the diagnosis, and among psychiatric inpatients the figure is around twenty percent. These rates make it one of the most common personality disorders seen in clinical practice, and the reason for its high profile in services.
The disorder usually first becomes evident in adolescence or early adulthood, and many people can trace the beginnings of their difficulties to the teenage years. A diagnosis in people under eighteen is now considered appropriate when the features are persistent and severe, and early recognition is encouraged, since early treatment can improve outcomes. In clinical settings, about three quarters of those diagnosed are women, which led for many years to the view that this is mainly a female disorder. Community surveys, however, suggest that the rates in men and women are much closer to equal. A likely explanation is that men with similar difficulties are more often diagnosed with other conditions, such as antisocial personality disorder or substance use disorders, or are found in the prison system, and that women are more likely to seek help from mental health services. This is a matter of continuing research, and it is a reason for caution in assuming that the disorder is rare in men.
Emotions Without a Volume Knob: The Heart of the Disorder
If one idea sits at the center of borderline personality disorder, it is emotion dysregulation. This term refers to difficulty in modulating emotional responses so that they fit the situation. It does not mean that the person feels too much in a general sense, or that emotions are bad. It means that the systems that normally adjust the intensity and duration of feelings do not do their work as efficiently, so that emotions rise higher, arrive faster, and last longer than the circumstances warrant, and the person has fewer tools to bring them back down.
The most influential account of this process was developed by the American psychologist Marsha Linehan, who created dialectical behavior therapy, and it will be discussed in detail. For the moment, it is helpful to look at the three components she identified, because they describe the experience of living without a volume knob quite precisely.
High Sensitivity, High Reactivity, Slow Return
The first component is emotional sensitivity. People with this vulnerability have a low threshold for emotional reaction: things that others would not notice, such as a change in tone of voice, a facial expression, or a delayed reply, set off an emotional response. They tend to notice emotional cues quickly and to be acutely aware of them. The second component is emotional reactivity. Once the reaction begins, it is intense, and it takes over thinking and behavior, so that the person finds it hard to reason or to act in line with their long-term goals. The third component is a slow return to baseline. After the emotion has been triggered, it takes longer than usual to subside, and in the meantime, further events can trigger new reactions, leaving the person in a prolonged state of arousal.
The combination explains much. A person who is sensitive, reactive, and slow to recover is exposed to a great deal more emotional pain than the average person, and has to cope with it more often and for longer. Linehan once offered a vivid metaphor, comparing the situation of people with this disorder to that of someone with third-degree burns over most of the body: even the lightest touch, or a slight change in the air, causes severe pain. The image makes clear that the problem is not oversensitivity in the sense of fragility or a lack of toughness, but a lack of emotional skin, and that what is needed is not criticism but protection and healing.
Evidence From Research on Emotional Reactivity
Laboratory studies have supported this picture, although the findings are complex. Experiments that measure emotional responses to standardized images, sounds, or social situations have often found that people with borderline personality disorder report more intense negative emotions, show larger physiological responses, and recover more slowly in some conditions. Studies of ambulatory monitoring, in which participants record their feelings many times a day on a smartphone, have shown that people with the disorder experience greater swings in mood, particularly in anger, fear, and sadness, and that these swings are often triggered by interpersonal events. Research on social exclusion is especially striking. In a well-known computer game in which a participant is gradually left out of a ball-tossing game with other players, people with borderline personality disorder report stronger feelings of exclusion and distress than others, and some studies find that they perceive exclusion even in situations in which they are included.
Other studies have found that people with the disorder are particularly alert to emotional signals in faces, and that they may be more likely to read neutral expressions as threatening or hostile. This does not make them poor judges of emotion in general, and in some tasks they are as accurate as others, or even more so. The problem is that the speed and certainty with which they perceive threat may lead to reactions that others find disproportionate, which in turn produces conflict that confirms the original fear.
Emotional Instability Is Not the Same as Mood Disorder
The emotional shifts in borderline personality disorder differ in important ways from those of mood disorders such as bipolar disorder. In bipolar disorder, episodes of elevated or depressed mood typically last days to weeks, with changes in sleep, energy, and activity that persist regardless of events. In borderline personality disorder, the shifts happen within hours, are usually tied to events, especially interpersonal ones, and often involve rapid changes between anger, anxiety, and despair, rather than a sustained high or low. Understanding this difference matters, because the conditions require different treatments, and because the misdiagnosis of one as the other is common, as discussed later.
Shame, Anger, and Emptiness
Three emotional experiences deserve special attention because they are so characteristic. The first is shame. Many people with the disorder carry a deep sense of being defective, unlovable, or bad, and shame is often the emotion that follows an outburst or a mistake, compounding the original distress. Shame also drives behavior: it can lead to withdrawal, to self-criticism, and sometimes to self-harm, and it makes it hard to ask for help. The second is anger. Intense and sometimes explosive anger is a common feature, and it is often directed at those closest to the person. It is typically followed by guilt and fear of having damaged the relationship. For some people, anger is turned inward, and expressed as self-hatred. The third is emptiness, a chronic, hollow feeling that is described as a void or numbness, which is different from sadness. People often say that they do not know who they are or what they feel, and they may seek intense experiences to escape from the emptiness. This sense of inner void is one of the most distressing and least understood features of the disorder.
Secondary Emotions and the Struggle Against Feeling
A striking feature of the emotional life of people with this disorder is the way in which feelings about feelings add to the burden. A person who feels sadness may then feel shame about being sad, anger at being weak, and fear that the sadness will never end. These secondary emotions can be more painful than the primary one, and they make it harder to recover. Many people have also learned, often in childhood, that their feelings were not acceptable, and they try to suppress or avoid them. Suppression and avoidance have a cost: research on emotion regulation shows that suppressing emotion tends to increase physiological arousal and does not reduce the experience of the emotion, and that avoidance prevents the person from learning that the feeling will pass. The cycle of intense emotion, attempts to escape it, and the shame that follows is what treatments aim to interrupt.
The Nine Features in Everyday Life
The diagnostic criteria are written in the language of clinical description. To understand what they mean, it helps to consider how each feature appears in daily life and what lies behind it. Not every person will have all of them, and many people experience some features in a mild form. The aim here is to clarify, not to provide a means of self-diagnosis, which should be left to a qualified professional.
Fear of Abandonment
The fear of being left is often described as the core of the disorder. It may be triggered by real events, such as a partner going on a trip, or by ambiguous signals, such as a cancelled plan or a delayed message. The person may react with panic, clinging, accusations, or sudden withdrawal, and may read a minor change as evidence that the relationship is ending. Efforts to avoid abandonment can include repeated calls, demands for reassurance, pleading, or, in some cases, a preemptive break-up, in which the person leaves first to avoid the pain of being left. The fear is often rooted in early experiences of loss, neglect, or unreliable care, and it is felt as a threat to survival, not just a social worry. Because the reactions can be hard for others to understand, they may produce the very rejection that the person fears.
Unstable Relationships and Splitting
Relationships tend to be intense and to swing between closeness and conflict. A new friend or partner may be idealized, seen as perfect and as the one who finally understands, and the person may quickly share intimate details and demand a high level of involvement. When the other person disappoints, as every person eventually does, the view may flip abruptly, and the same person is seen as cruel, uncaring, or worthless. This pattern is called splitting, a term borrowed from psychoanalytic theory, and it reflects a difficulty in holding together positive and negative aspects of a person at the same time. In cognitive terms, it is a form of black-and-white thinking that is magnified under emotional stress. The shifts are usually not deliberate, and the person experiences the new view as the truth until emotions settle and the more balanced perspective returns, often accompanied by regret.
Identity Disturbance
Many people with the disorder describe an unclear or shifting sense of who they are. Goals, values, career plans, friends, and even appearance may change repeatedly, and they may feel like different people in different company. Some say that they take on the traits of whoever they are with, and that when alone they feel like nobody at all. This instability makes it hard to commit to long-term plans and contributes to chronic emptiness. In adolescence, a degree of identity exploration is normal, and it can be difficult to separate it from the disorder. The difference lies in the intensity, the distress, and the lack of a stable core over time.
Impulsivity
Impulsive behavior is common, and often occurs in response to emotional distress. It may take the form of reckless spending, unsafe sex, substance misuse, binge eating, dangerous driving, or sudden decisions to quit a job or end a relationship. The acts may bring brief relief from distress or excitement, but they often have serious consequences. Research suggests that the impulsivity in this disorder is closely tied to emotion: it tends to rise when emotions are intense, an effect sometimes called urgency, in which strong negative feelings produce a rush to act. This is different from the planned risk-taking seen in some other conditions.
Self-Harm and Suicidal Behavior
Self-harming behavior and suicidal thoughts and acts are among the most serious features of the disorder, and they bring many people to the attention of services. A large proportion of people with borderline personality disorder, perhaps seventy percent or more in clinical samples, have engaged in non-suicidal self-injury, in which the person deliberately harms their body without intending to die. Suicidal thoughts are common, and a substantial proportion make suicide attempts at some point. Clinicians understand self-injury as a way of coping with overwhelming emotion, and a sign of unbearable distress, not as an attempt to manipulate others, which is a harmful misconception. It does not, however, resolve the underlying pain, and it carries risks of injury, infection, shame, and escalation. A central aim of treatment is to help people find safer ways of managing intense emotion, and to build a life that feels worth living. This subject is discussed more fully in a later section, including information about seeking help.
Rapid Mood Shifts
Mood changes are rapid and reactive. A person may feel contented in the morning, anxious by noon, furious in the afternoon, and despairing in the evening, with each change linked to events or interpretations. The episodes are usually short, lasting hours, though the aftermath may linger. The speed of change can be bewildering to the person and to those around them, and it contributes to the sense of lacking control over inner life.
Chronic Emptiness
As mentioned, emptiness is a persistent feeling of inner void, boredom, or numbness. It is often described as worse than sadness, since sadness is at least a feeling. It may lead people to seek stimulation, intense relationships, or risky activities, and it can be a precursor to self-harm or substance use. Emptiness is also one of the features that is most responsive to treatments that help a person build a stable identity and a sense of purpose.
Intense Anger
Anger may flare quickly and out of proportion to its cause, and may be expressed in shouting, sarcasm, rage, or, at times, physical aggression. More often than people realize, the anger is a reaction to a perceived slight, rejection, or injustice, and it is accompanied by fear and hurt underneath. Afterwards, people often feel remorse and shame, and may fear that they have driven others away. Some people with the disorder rarely express anger outwardly and instead direct it at themselves.
Paranoia and Dissociation Under Stress
Under severe stress, some people experience brief paranoid thoughts, such as the belief that others are against them or are plotting to abandon them, or dissociative states, in which they feel detached from themselves or from reality, as if watching from outside, or as if the world is unreal or foggy. These experiences are usually short-lived and linked to periods of acute emotional distress, and they typically resolve when the stress eases. They differ from the persistent delusions and hallucinations of psychotic disorders, and people usually retain some awareness that the experience is related to stress. Dissociation may serve as a way of escaping unbearable feelings, though it also interferes with functioning and with therapy, so it is an important target of treatment.
The Interpersonal Storm: Rejection Sensitivity and the Push-Pull Pattern
Relationships are the arena in which the disorder is most visible and most painful. Because emotional sensitivity is strongest in response to interpersonal cues, a person with the condition may be especially alert to signs of rejection, criticism, or withdrawal, and may react quickly to them. This heightened rejection sensitivity is one of the best-documented features of the disorder in research, and it helps to explain why relationships become so intense and so unstable.
The Push-Pull Dynamic
A common pattern in close relationships is a cycle of pulling close and pushing away. The person fears abandonment and seeks closeness and reassurance, but intimacy also brings the fear of being hurt, controlled, or engulfed, and the person may then withdraw or lash out. The partner or friend, confused by the alternation, may become exhausted or defensive, and may pull away in turn, which triggers the fear of abandonment again. Family members often describe the experience of walking on eggshells, trying to avoid saying anything that might set off a reaction. The pattern is painful for everyone involved and is usually driven by fear, not malice, which both the person and their loved ones can find helpful to understand.
The Favorite Person Phenomenon
Online communities have popularized the phrase favorite person to describe an intense attachment to one individual, often a partner, friend, or family member, on whom the person depends heavily for emotional stability. The feelings may include a strong need for constant contact, a sense that one’s mood depends on the person’s behavior, and a terror of losing them. The phrase is not a clinical term, and not everyone with the disorder experiences this pattern, but it describes a real feature of attachment in some people, and it is associated with the fear of abandonment and with splitting. Clinicians note that such dependence places a heavy burden on the other person and on the relationship, and that part of recovery involves building a wider network of support and a more stable inner sense of security.
Mentalizing and Misreading Others
Researchers such as Peter Fonagy and Anthony Bateman have suggested that a core problem is difficulty in mentalizing, the capacity to understand one’s own and others’ behavior in terms of underlying thoughts, feelings, and intentions. When emotions are intense, especially in the context of close relationships, this capacity may collapse, and the person may jump to certain conclusions about what others think and feel, such as that they are angry or contemptuous, without considering other possibilities. The collapse is temporary, and it is most likely when attachment feelings are aroused. This theory has produced an effective treatment, discussed below, and it offers a way to understand why certain misunderstandings occur in relationships and how they can be repaired.
Quiet BPD and the Many Faces of the Disorder
The picture of borderline personality disorder that most people hold, of dramatic outbursts and visible crises, captures only part of the reality. Some people with the condition, particularly those who direct their distress inward, appear calm, capable, and even highly successful on the surface, while suffering intensely in private. In popular discussions, this pattern has been called quiet borderline personality disorder, or high-functioning borderline personality disorder. These are not formal diagnostic terms, but they describe a recognizable presentation in which anger and despair are turned against the self, in the form of self-criticism, self-blame, withdrawal, perfectionism, and people-pleasing, rather than expressed outwardly. A person with this pattern may rarely argue with others, may take great care to avoid conflict for fear of abandonment, and may be regarded by colleagues as reliable and kind, while experiencing emotional storms, shame, and self-harm in secret.
Different Subtypes and Patterns
Researchers have attempted to identify subtypes of the disorder, with varying results. Some studies have distinguished an internalizing form, marked by depression, emptiness, anxiety, and avoidance, from an externalizing form, marked by anger, impulsivity, substance use, and antisocial behavior. Others have described discouraged, impulsive, petulant, and self-destructive patterns. None of these classifications has been adopted as a formal standard, but they underline the point that the disorder is heterogeneous, and that treatment needs to be adapted to the individual.
Differences Between Men and Women
Studies suggest that, on average, men and women with the disorder may differ in the way they express it, with men more likely to show impulsive and externalizing behaviors such as substance misuse and aggression, and women more likely to show internalizing features such as depression, eating disorders, and self-harm. These tendencies are averages, and many individuals do not fit them. They may contribute to the difference in diagnosis rates, since externalizing behaviors in men are more often attributed to other conditions. Clinicians increasingly stress that men with borderline personality disorder are underdiagnosed and that they respond to the same treatments.
Online Self-Diagnosis and Its Pitfalls
The growth of social media has increased awareness of the disorder, which can be valuable for people who have lived without a name for their experience. Videos and posts have helped many people to recognize patterns and to seek help. They have also encouraged self-diagnosis based on short descriptions, and have sometimes promoted a simplified view that every intense emotion or difficult relationship is a sign of the disorder. Intense emotions, fear of rejection, and relationship difficulties are common in many people and in many conditions, including depression, anxiety, post-traumatic stress, bipolar disorder, attention-deficit hyperactivity disorder, and autism. Only a thorough assessment by a trained clinician can establish a diagnosis, and anyone who recognizes themselves in these descriptions is encouraged to seek one, not to rely on online checklists.
Where Borderline Personality Disorder Comes From
The causes of the disorder are complex, and, as with most mental health conditions, no single factor is sufficient. The leading explanation is a biosocial one, in which a biological vulnerability to emotional sensitivity interacts with a social environment that fails to respond to it effectively. This model, developed by Linehan, fits with a large body of research and has guided treatment.
The Biosocial Theory
According to the biosocial theory, the disorder arises from a transaction between an emotionally vulnerable child and an invalidating environment. The vulnerable child is born with, or develops early, a high sensitivity to emotional stimuli, a strong reaction, and a slow return to baseline, which makes emotional experience especially intense. An invalidating environment is one in which the child’s inner experiences are consistently dismissed, punished, trivialized, or treated as wrong, and in which problems are attributed to character defects. Examples include being told that one is overreacting, being punished for crying, or being told that one does not really feel what one says. In extreme forms, the invalidating environment includes abuse and neglect, but it can also be subtle: a loving family in which emotional expression is discouraged, or in which the parents are overwhelmed and cannot respond to a very sensitive child, may be invalidating in this sense.
The key point is that the interaction is a two-way process. A highly reactive child is more difficult to soothe, and parents may find their usual strategies do not work, and may become frustrated, which further invalidates the child. The child does not learn how to label emotions, to regulate them, or to trust their own feelings, and may learn instead that emotions must be escalated to be noticed, or suppressed to be tolerated. Over time, this transaction produces the pattern of emotion dysregulation, impulsivity, and unstable relationships that is recognized as the disorder. The theory does not blame parents, since many are doing their best with a difficult situation, and many who are loving and well-meaning are unable to meet the needs of an extremely sensitive child.
Genetic Contributions
Twin and family studies show that genes contribute significantly. Estimates of heritability from twin studies generally fall between about forty and fifty percent, which is similar to that of many other psychiatric conditions. First-degree relatives of people with the disorder have a higher risk, and the traits most closely linked to the disorder, such as emotional instability and impulsivity, are themselves heritable. As with other disorders, no single gene is responsible. Many genes with small effects are probably involved, and they probably influence temperament and the functioning of brain systems involved in emotion, rather than coding for the disorder as such. Genes also interact with experience, and some research suggests that genetic vulnerability increases the effect of adverse childhood events.
Childhood Adversity and Trauma
A history of adverse childhood experiences is common. Studies of people with the diagnosis find high rates of emotional, physical, or sexual abuse and of neglect, with estimates varying widely, from about thirty percent to well over half, depending on the sample and the definition. Separation from caregivers, parental mental illness, family conflict, and bullying are also frequently reported. Prospective studies, which follow children over time, have confirmed that childhood maltreatment and neglect increase the risk of later borderline personality disorder features. It is important to be clear, however, that not everyone with the disorder has a history of abuse, and that most people who experience abuse do not develop the disorder. Trauma is a risk factor, and not a necessary or sufficient cause. In some cases, the person’s difficulties come mainly from temperament and an environment that was unable to meet their needs, without any dramatic trauma.
Attachment and Early Relationships
Attachment research provides another perspective. Children who experience unreliable or frightening care may develop insecure or disorganized attachment, in which they simultaneously seek and fear closeness. Adults with borderline personality disorder show high rates of insecure attachment, particularly the preoccupied and the fearful-disorganized styles, characterized by a craving for closeness together with a fear of rejection and of engulfment. These patterns match the push-pull dynamic seen in relationships, and they suggest that the disorder can be seen in part as an adaptation to early relationship experiences that have been carried into adult life.
The Brain and Emotion Regulation
Neuroimaging studies have identified differences in brain regions involved in emotion processing and regulation. Several studies report heightened reactivity in the amygdala, a structure that detects threat and generates fear and anger, in response to negative emotional stimuli. Others find reduced activity or connectivity in regions of the prefrontal cortex, including the orbitofrontal cortex and the anterior cingulate cortex, which normally help to dampen the amygdala and to regulate emotion. Some studies have also found reduced volume in the hippocampus and the amygdala, although the findings are not consistent. In simple terms, the alarm system tends to be overactive, and the brakes may be less efficient, which is consistent with the experience of intense, fast, and long-lasting emotion. Differences in the stress hormone system, including the hypothalamic-pituitary-adrenal axis, and in neurotransmitters such as serotonin and the opioid and oxytocin systems, have also been reported, but the picture is still being clarified. It is important to note that these brain differences are not fixed, and that studies show changes in brain activity following successful psychotherapy, which supports the view that the system can be retrained.
Why Adolescence Is a Crucial Period
The disorder typically emerges in adolescence, a period of rapid change in the brain, in particular in the systems that regulate emotion, and of heightened emotional and social demands. The brain regions involved in reward and emotion develop earlier than those involved in control and planning, which makes adolescents more prone to emotional intensity and risk-taking. For a young person with a vulnerable temperament, these normal developmental pressures can reveal and amplify difficulties. This is why early recognition and support can be so valuable, and why families and schools have an important role.
Is It Borderline Personality Disorder, or Something Else?
Borderline personality disorder is often misdiagnosed, and it frequently occurs together with other conditions. Careful assessment is needed to distinguish it from the conditions with which it overlaps, since treatment depends on the correct identification of the problem or problems. The following are the most common sources of confusion.
Bipolar Disorder
Bipolar disorder and borderline personality disorder share mood instability, impulsivity, and a risk of suicide, and they have been confused with each other for decades. The differences, however, are clear. In bipolar disorder, episodes of mania or hypomania, with elevated or irritable mood, decreased need for sleep, increased energy, and grandiosity, last at least four days to a week, and episodes of depression last at least two weeks, and these episodes occur largely independent of events. In borderline personality disorder, mood shifts are brief, reactive to circumstances, usually interpersonal, and not accompanied by the sustained changes in sleep and energy characteristic of mania. The two conditions can co-occur, and people with bipolar disorder may also have personality difficulties, so careful longitudinal assessment is needed. Treatment differs in an important way, since mood stabilizing medication is the cornerstone for bipolar disorder, while psychotherapy is the primary treatment for borderline personality disorder.
Post-Traumatic Stress and Complex Post-Traumatic Stress Disorder
Post-traumatic stress disorder frequently co-occurs with borderline personality disorder, and the overlap is substantial. The eleventh edition of the International Classification of Diseases includes complex post-traumatic stress disorder, which involves, in addition to the core features of post-traumatic stress, disturbances in self-organization: problems with emotion regulation, negative self-concept, and difficulties in relationships. These resemble features of borderline personality disorder, and the two diagnoses are the subject of continuing debate. The distinction is generally made on the basis of the central features: complex post-traumatic stress disorder is defined by re-experiencing, avoidance, and sense of threat linked to trauma, whereas borderline personality disorder is characterized by frantic efforts to avoid abandonment, unstable relationships and identity, and impulsivity. Many people meet the criteria for both, and treatment must then address both trauma and emotion regulation.
Depression and Anxiety Disorders
Depression is very common in people with borderline personality disorder, and the two often occur together, with a history of depressive episodes in the great majority. The distinction lies in the pattern: in major depression, low mood and loss of interest are persistent, whereas in borderline personality disorder, the low mood fluctuates with events, and the person may feel better quickly when circumstances improve, and the emptiness and anger are often more prominent. Anxiety disorders, including panic disorder, social anxiety, and generalized anxiety, are also common, and need attention in their own right.
Attention-Deficit Hyperactivity Disorder
Attention-deficit hyperactivity disorder shares impulsivity and emotional reactivity with borderline personality disorder, and the two frequently co-occur, with some studies suggesting that people with attention-deficit hyperactivity disorder are at greater risk of developing the personality disorder. Distinguishing them involves looking at the history: attention-deficit hyperactivity disorder begins in childhood, with problems of attention and hyperactivity across settings, whereas the characteristic features of borderline personality disorder, such as fear of abandonment and unstable identity, emerge later. When both are present, treating the attention disorder may help with emotion regulation.
Autism Spectrum Conditions
Autistic people, particularly women and girls whose traits may have been overlooked or masked, are sometimes misdiagnosed with borderline personality disorder because of intense emotional reactions, difficulties in relationships, and sensory overload that may produce meltdowns. The underlying causes are different: in autism, emotional distress is often linked to sensory and social communication differences, and the person may not show the fear of abandonment or the rapid idealization and devaluation that are characteristic of borderline personality disorder. A careful developmental history is needed, and treatments need to be adapted to the person’s needs.
Other Personality Disorders
Borderline personality disorder overlaps with other personality disorders, especially histrionic, narcissistic, avoidant, dependent, and antisocial types. Histrionic personality disorder involves attention-seeking and emotionality, but without the same degree of self-harm, identity disturbance, and chronic emptiness. Narcissistic personality disorder involves grandiosity and a need for admiration, though the vulnerable form shares fragile self-esteem and shame with borderline personality disorder. Antisocial personality disorder involves a pattern of disregard for the rights of others, which may be mistaken for the anger and impulsivity of the borderline pattern. Because the dimensional approach recognizes that traits overlap, many clinicians focus on the individual’s specific pattern of difficulties.
Substance Use and Eating Disorders
Substance use disorders occur in a large proportion of people with the diagnosis, and they complicate both diagnosis and treatment, since intoxication and withdrawal can produce mood instability and impulsive behavior. Eating disorders, particularly bulimia nervosa and binge eating disorder, are also common. Where these conditions are present, an integrated approach that addresses both is generally recommended, and a period of abstinence or stability may be needed to clarify the diagnosis.
Self-Harm and Suicidal Thoughts: A Serious Part of the Picture
It would be dishonest to discuss borderline personality disorder without addressing self-harm and suicide, which are among the most serious consequences. Estimates suggest that the risk of death by suicide is substantially higher in people with the disorder than in the general population, with commonly cited lifetime figures of several percent to around ten percent in clinical samples, although the figure is lower in more recent and community-based studies. The great majority of people with the disorder do not die by suicide, and most improve over time. But the elevated risk means that suicidal thoughts and behavior must always be taken seriously, and that safety is a priority in treatment.
Understanding Self-Injury
Non-suicidal self-injury is different from a suicide attempt in intent, although the two can coexist and a person who self-injures is at higher risk of attempting suicide. Clinicians understand self-injury as a response to intolerable emotional states, which is why it is often triggered by interpersonal stress, shame, or numbness. It carries physical risk, can lead to infection, scarring, and accidental serious injury, and is often accompanied by shame and secrecy. It does not resolve the underlying pain, and the pattern tends to become entrenched with repetition. Treatment aims to build other ways of tolerating and changing emotion, and to address the underlying causes, so that self-injury is no longer needed. The urge to self-injure can be intense, and relapses are common, and are not a reason for despair or for self-criticism.
The Role of Crisis Planning
An important part of treatment is a written crisis or safety plan, developed together with a clinician when the person is calm. It typically lists personal warning signs, steps the person can take to calm themselves, people and places that provide distraction and support, the names and numbers of trusted contacts and professionals, and the ways to make the environment safer. People who live with recurrent suicidal thoughts often find that a plan that has been practiced in advance is easier to follow during a crisis than one that has to be improvised.
Where to Turn in a Crisis
Anyone who is thinking of ending their life, or who feels at risk of seriously harming themselves, should contact local emergency services or a crisis line in their country immediately, or go to the nearest emergency department, and should tell a trusted person. Crisis lines are staffed by trained people and are available at all hours in many countries. Suicidal feelings are a sign of unbearable pain and not of a character flaw, they often pass, and help is effective. If you are reading this because you or someone close to you is struggling in this way, please reach out to a professional or an emergency service today, and consider sharing this article with a clinician who can help to find the right support.
Treatment: What the Evidence Supports
For many years, borderline personality disorder was considered very difficult or impossible to treat, and some services refused to accept patients with the diagnosis. This pessimism has been overturned by research. Several specialized psychotherapies have been tested in randomized controlled trials and shown to reduce self-harm, suicidal behavior, hospitalization, and the severity of symptoms, and clinical guidelines in many countries now recommend structured psychological therapy as the main treatment. Medication plays a secondary role.
Dialectical Behavior Therapy
Dialectical behavior therapy, developed by Marsha Linehan at the University of Washington in the late 1980s and early 1990s, is the most extensively studied treatment for the disorder. It began as an adaptation of cognitive behavioral therapy for chronically suicidal women, and Linehan found that standard approaches, which focus on change, were experienced as invalidating by people who were in great pain, while approaches that focused on acceptance alone did not lead to enough change. The solution was a balance of both, which is the meaning of the word dialectical: the synthesis of opposites, in this case acceptance and change.
The standard form of the therapy includes four components. Individual therapy, usually weekly, addresses the person’s motivation, their specific problems, and the application of skills to daily life, with a hierarchy of targets that places life-threatening behavior first, followed by behaviors that interfere with therapy, then behaviors that interfere with quality of life, and finally the acquisition of skills. A weekly skills training group, run in a classroom style, teaches four sets of skills. Telephone coaching provides brief support between sessions to help the person to use skills in real situations. And a consultation team for therapists supports the clinicians, who are working with difficult and emotionally demanding problems and who need support to remain effective and compassionate.
The Four Skills Modules of DBT
Mindfulness skills are the foundation. They teach the person to observe and describe experience, to participate fully, and to do so without judgment, one thing at a time, and effectively. A central concept is wise mind, the integration of emotional mind and reasonable mind, in which the person can acknowledge feelings and use reason to decide on actions. Mindfulness helps people to notice emotions as they arise, to put a pause between feeling and action, and to see that thoughts and feelings are events that come and go.
Distress tolerance skills help people to survive crises without making things worse. They include ways of distracting oneself, of soothing oneself through the senses, of improving the moment, of weighing the pros and cons of acting on an urge, and of accepting reality as it is, without approving of it, a skill called radical acceptance. The aim is to get through a period of intense emotion without engaging in behaviors that bring short-term relief and long-term harm.
Emotion regulation skills teach people to understand and name their emotions, to reduce vulnerability to intense emotion by caring for sleep, eating, exercise, and physical health, to increase positive experiences, and to act opposite to the emotion’s urge when the emotion does not fit the facts. For example, a person who feels shame and the urge to hide may, when the shame is not justified, practice approaching and engaging. Another skill is to check the facts, to examine whether the interpretation of a situation fits the evidence.
Interpersonal effectiveness skills teach people to ask for what they need, to say no, and to manage conflict while maintaining relationships and self-respect. They include structured steps for describing a situation, expressing feelings, asserting a request, reinforcing the other person, staying mindful of the goal, appearing confident, and negotiating. The skills address the common situation in which a person either does not ask for fear of rejection, or asks in a way that damages the relationship.
Validation: The Heart of DBT
Validation is a core principle of the therapy, and it is relevant to everyone who has a relationship with a person who has the disorder. To validate is to communicate that a person’s feelings, thoughts, and behavior make sense given their experience and the situation, even if one does not agree with the behavior or consider the response effective. It is not the same as approval or agreement. A therapist might say, “Given what happened and how you have been treated in the past, it makes sense that you were terrified when she did not call.” Validation reduces emotional arousal, builds trust, and makes change feel possible. It is balanced in the therapy with encouragement to change, since validation alone would leave the person stuck, and change alone would feel invalidating.
The Evidence for DBT
Randomized trials in several countries have found that dialectical behavior therapy reduces self-harm, suicide attempts, emergency visits, and hospital stays, and improves depression, anger, and social functioning, compared with treatment as usual and other control conditions. A trial in Seattle by Linehan and colleagues, which compared the therapy with expert community treatment, found that the people who had received it made fewer suicide attempts and less self-injury, and had fewer admissions. Reviews have generally concluded that the therapy is effective, particularly in reducing self-harm, although the quality of some trials is modest and the long-term benefits have been less thoroughly studied. Adapted forms have been tested in adolescents, with encouraging results, and shorter or skills-only versions have been developed and used in a range of settings.
Mentalization-Based Treatment
Mentalization-based treatment, developed by Anthony Bateman and Peter Fonagy, builds on the idea that the disorder involves a fragile capacity to mentalize under emotional stress. The therapy aims to strengthen this capacity by helping the person to pause and reflect on mental states, their own and those of others, and to recognize that their interpretation of events is one possible view among others. The therapist adopts a stance of curiosity and not-knowing, asks about thoughts and feelings in the moment, and helps the person to recover mentalizing when it has collapsed. It may be delivered in individual and group formats, over a period of about a year or eighteen months. Trials, including those in day hospital and outpatient settings, have shown reductions in self-harm, suicide attempts, and hospitalization, and the benefits have been maintained at follow-up.
Schema-Focused Therapy
Schema therapy, developed by Jeffrey Young and adapted for the disorder, proposes that unmet emotional needs in childhood lead to enduring maladaptive schemas, such as abandonment, mistrust, defectiveness, and emotional deprivation, and to modes, which are states of mind that dominate at particular times, such as the abandoned child, the angry child, the punitive parent, and the detached protector. Therapy involves identifying the schemas and modes, using cognitive, experiential, and behavioral techniques, and a concept called limited reparenting, in which the therapist provides, within professional boundaries, some of the care that was lacking. A Dutch trial found that schema therapy was more effective than transference-focused psychotherapy in producing recovery, and it has been shown to have good results, though it is a long treatment, typically lasting two to three years.
Transference-Focused Psychotherapy
Transference-focused psychotherapy, developed by Otto Kernberg and colleagues, is a psychodynamic treatment that focuses on the relationship between patient and therapist to understand the person’s internal representations of self and others, particularly split images of good and bad. Sessions are twice weekly, and the therapist helps the person to recognize and integrate these split views. Trials have shown benefits for borderline symptoms, suicidal behavior, and psychosocial functioning.
Good Psychiatric Management and Other Approaches
Good Psychiatric Management, developed by John Gunderson and colleagues, is a simpler approach designed for general mental health clinicians who lack specialist training. It combines education about the disorder, a focus on interpersonal hypersensitivity, case management, and judicious use of medication, and it has been found in a trial to be about as effective as dialectical behavior therapy. Other treatments with supporting evidence include systems training for emotional predictability and problem solving, known as STEPPS, a group program that includes family and friends, cognitive analytic therapy, and mentalization-based approaches adapted for adolescents. The choice among them depends on availability, the preferences of the person, and the clinical picture, and the evidence suggests that the common factors of structure, a coherent model, a focus on emotions and relationships, a collaborative stance, and consistent therapist support are essential.
The Role of Medication
No medication is approved by regulatory agencies for the treatment of borderline personality disorder itself. Medications are often prescribed in practice, sometimes in large numbers, but reviews have found limited evidence of benefit for the core features. Some studies suggest that mood stabilizers and low doses of antipsychotics may modestly reduce anger, impulsivity, and affective instability, and antidepressants may help when depression is present, but the effects are small, and the evidence is inconsistent. For this reason, guidelines in several countries, including those of the National Institute for Health and Care Excellence in the United Kingdom, advise against the use of medication specifically for the disorder or its individual symptoms, and recommend it only to treat coexisting conditions, such as depression or severe anxiety, or briefly in a crisis. Benzodiazepines are generally avoided because of the risk of dependence and disinhibition, and because overdose is a risk in people with suicidal thoughts. Anyone who takes medication should not stop it abruptly, and should discuss any changes with their prescriber.
Hospital Care and Crisis Services
Hospital admission may be necessary when there is a high risk to life, but long admissions are generally not recommended, since they may produce regression and dependence and have not been shown to reduce long-term risk. Brief, planned admissions, crisis teams, and clear crisis plans are preferred. The most important element of long-term safety is access to a good outpatient therapy with a therapist who understands the condition.
What Therapy Is Like
Therapy for this disorder is demanding for both therapist and patient. Early sessions often focus on safety, building a collaborative relationship, and agreeing on goals. The person may find that therapy brings up strong emotions, and that the therapist’s holidays or changes in schedule trigger fear of abandonment, which can then be addressed. Good therapists are consistent, boundaried, and warm, they validate while encouraging change, and they discuss problems in the therapeutic relationship openly. Progress is rarely linear, and setbacks are expected. Many people notice early improvements in the frequency of crises and self-harm, followed by a slower process in which identity, relationships, and sense of purpose improve.
A Composite Example
The following account is a composite and does not describe a real person. It is offered to show how the ideas in this article fit together. A woman in her mid-twenties, whom we shall call Mira, comes to a clinic after a hospital visit related to self-harm. She describes herself as having always been too sensitive. As a child, she was easily upset, and her parents, who were loving but anxious, often told her to stop being dramatic. In adolescence, she began to feel that she did not know who she was, and she changed groups of friends several times. She tells her therapist that when her partner goes out with friends, she feels a surge of panic, sends repeated messages, then becomes furious when he does not answer, and later feels deep shame. She says that she feels empty most of the time when she is alone, and that harming herself is the only thing that makes the feelings stop for a while.
Her therapist explains the biosocial model, and Mira feels, for the first time, that her reactions are understandable and not simply evidence that she is bad. She begins a course of dialectical behavior therapy, learning to notice the early signs of rising emotion, to check the facts of a situation, to use distress tolerance skills when the urge to harm herself is strong, and to ask her partner for reassurance in a calm way. She writes a crisis plan with her therapist. The first months are difficult, and there are setbacks, including one episode of self-harm after an argument. Gradually, however, the intensity and frequency of crises decrease, and she starts to build a life that includes a course of study and friends who are not part of her partner’s circle. After a year, she says that her emotions are still strong, but that she can now feel them without being swept away. The volume knob has not been installed, she says, but she has learned to turn down the speakers.
Practical Strategies for Living With Intense Emotions
Professional treatment is the best route to lasting change, and the strategies below are not a substitute for it. They are drawn from evidence-based approaches, particularly dialectical behavior therapy, and may help people who are waiting for treatment, who are in therapy and want to practice, or who wish to understand the principles. People who are in crisis, or who have thoughts of suicide or self-harm, should contact emergency services or a crisis line without delay, as described above.
Learn to Name and Track Emotions
The first step in regulating emotion is to identify it accurately. Keeping a brief daily record of emotions, their triggers, their intensity on a scale of zero to one hundred, the thoughts and urges that accompanied them, and what the person did, helps to reveal patterns. Research on affect labeling shows that putting feelings into words reduces activity in the amygdala and may reduce the intensity of the feeling. A simple practice is to say to oneself, silently, “I am feeling shame, and I have the urge to hide.” Distinguishing primary from secondary emotions, such as the fear that lies beneath anger, can help the person to respond to what is really going on.
Reduce Vulnerability Through Basic Care
Emotional vulnerability is greater when the body is stressed. Linehan’s approach includes a set of guidelines for reducing vulnerability: treating physical illness, eating balanced meals, avoiding mood-altering substances, sleeping regularly, and exercising. Sleep deprivation in particular increases emotional reactivity, and alcohol and drugs disrupt emotion regulation and increase impulsivity. These steps are not glamorous, but they have a large effect, and they build a foundation on which other skills can work.
Pause Between Feeling and Action
Because impulsive behavior follows quickly after intense emotion, building a pause is a valuable skill. A simple method is to stop, take a step back, observe what is happening inside and outside, and proceed mindfully, a sequence sometimes taught under the name of the stop skill. Slow, paced breathing with a long exhalation, practiced regularly, helps to calm the nervous system. It can also help to delay a decision, such as sending an angry message or ending a relationship, for twenty-four hours, and to ask a trusted person for their view. These pauses do not remove the emotion, but they prevent it from dictating action.
Check the Facts and Act Opposite
When emotions are intense, interpretations tend to be extreme. Asking, “What exactly happened? What am I assuming? What are other explanations? Does the intensity of my emotion fit the facts?” can reduce the conviction that the worst is true. The skill of opposite action involves acting against the urge of an emotion when the emotion does not fit the facts or is not helpful: approaching when afraid of something safe, being kind and gentle when feeling an unjustified urge to attack, and engaging with others when the urge is to hide in shame. Acting opposite changes the emotion over time.
Build a Self-Soothing Repertoire
People benefit from having a list of things that soothe them through the senses: a favorite piece of music, a warm shower, the smell of a particular scent, a soft blanket, a walk outdoors, or time with an animal. Other helpful activities include vigorous exercise, creative work, and a call to a supportive friend. These skills are best practiced when the person is calm, so that they are familiar when needed. It is important that these activities are safe and genuinely soothing, and that they do not involve causing pain or harm to the body.
Practice Validation, for Yourself and Others
Self-validation means acknowledging that one’s feelings make sense given one’s history and circumstances, and replacing harsh self-criticism with a more compassionate stance. A person might tell themselves, “Of course I feel this way, given what happened, and I can handle it.” Research on self-compassion shows that it reduces shame and promotes motivation to change, and it is not the same as self-indulgence. In relationships, validating the other person’s perspective, even in a conflict, reduces defensiveness and helps repair.
Build a Wider Web of Support
Because intense dependence on one person is a source of vulnerability, it helps to build a broader network of friends, family, groups, and activities, so that no one person is expected to meet all needs. Peer support groups, which exist in many communities and online, can provide understanding and a sense of belonging, and many people find it a relief to meet others who share their experience. It is advisable to choose communities that encourage recovery and skills, and to be cautious of those that reinforce hopelessness or the idea that the disorder is untreatable.
Make and Use a Crisis Plan
As discussed above, writing a crisis plan when calm is one of the most useful steps. It can include warning signs, skills that have helped, people to contact, professional and emergency numbers, and steps to make the environment safer. Keeping it on a phone or a card makes it available at the moment it is needed.
Be Patient With Setbacks
Recovery is rarely a straight line. Periods of improvement are often followed by relapse, particularly at times of stress, and this is not a failure but an expected part of the process. Each time a person uses a skill, even imperfectly, they strengthen it. Self-criticism for slips tends to increase shame and the risk of further problems, while a compassionate stance and a return to practice support recovery.
Supporting Someone With Borderline Personality Disorder
Living with, or loving, a person with this disorder can be exhausting and bewildering. Family members often describe cycles of closeness and conflict, fear of triggering an outburst, worry about self-harm, and guilt, anger, and grief. They may also be blamed, accused, or idealized in turns. It is important to say that they are not to blame for the disorder, that their own wellbeing matters, and that they can play a crucial role in recovery.
Understand the Disorder
Learning about the condition is the first step. Understanding that intense reactions come from emotional dysregulation, and not from a wish to hurt or manipulate, changes how behavior is interpreted. It helps to remember that behind anger often lie fear and hurt, and that behavior which seems manipulative is usually an attempt, often a clumsy one, to cope with overwhelming emotion or to get a need met. Programs for families, such as the Family Connections program, developed by Alan Fruzzetti and Perry Hoffman, and similar courses offered in many countries, provide education, skills, and support, and have been shown to reduce burden and distress in relatives.
Validate Without Agreeing to Everything
Validation is among the most useful skills for family members. It involves acknowledging the feeling and its sense without necessarily agreeing with the interpretation or accepting harmful behavior. For example, one might say, “I can see how frightened you felt when I did not answer, and I am sorry that it was so painful,” and, later, calmly state one’s own limits. Invalidation, such as telling the person that they are overreacting or that they should calm down, tends to escalate the situation. At the same time, validation does not mean giving in to every demand or accepting abuse.
Set Clear and Kind Boundaries
Boundaries are essential for the health of the relationship and the family member. They involve being clear about what is acceptable, what one is willing and unwilling to do, and what the consequences will be, stated calmly and consistently, and not as threats or punishments during a crisis. Examples include stating that one will not continue a conversation when it involves shouting, but will return to it after a break, or that one cannot be available at all hours but will respond at agreed times. Boundaries that are consistent and delivered with warmth are more likely to be experienced as predictable and safe than as rejection, and they help to reduce the push-pull cycle.
Respond to Crises Calmly
During a crisis, a calm and steady response is more helpful than a reactive one. This means listening, avoiding arguments about the facts, validating the emotion, and focusing on safety. If the person expresses thoughts of suicide or has harmed themselves, take it seriously, stay with them if possible, remove access to means of harm where it is safe to do so, and contact emergency services or a crisis line if the risk is immediate. It is not necessary to solve the problem during the crisis, and discussing it afterwards, when emotions have settled, is more productive.
Avoid Common Traps
Common traps include walking on eggshells, in which family members avoid any topic that might cause a reaction, which in the long run reinforces the pattern and fosters resentment. Another is taking over responsibility for the person’s emotions, trying to prevent all distress, which can prevent the person from learning to cope. A third is to oscillate between over-involvement and withdrawal, which mirrors the person’s own instability. Seeking support from a therapist, a support group, or a family program helps relatives to find a sustainable balance.
Take Care of Yourself
Family members often neglect their own needs. Maintaining friendships, interests, sleep, and health is not selfish, and it enables them to continue to support their loved one. Professional help for the family member, including therapy for their own stress, is appropriate and often valuable, and families that look after themselves are better able to support recovery.
Parenting and Children
Parents who have the disorder face particular challenges. Intense emotions, impulsivity, and unstable relationships can make parenting difficult, and children may be affected by the instability. At the same time, many people with the disorder are loving, committed parents, and research shows that treatment improves parenting. Programs that combine treatment of the disorder with parenting support have shown promise, and early support for children of affected parents is valuable. Parents of adolescents who show signs of the disorder, such as extreme emotional reactivity and self-harm, should seek an assessment and consider family-based dialectical therapy.
Stigma, Language, and Respect
The stigma attached to this disorder is well documented. Studies have found that mental health professionals, including psychiatrists and nurses, often hold more negative attitudes toward patients with borderline personality disorder than toward patients with other conditions, describing them as manipulative, difficult, or attention-seeking, and sometimes withholding care. These attitudes are damaging. They can lead to poor treatment, to patients being turned away from emergency rooms, to a reluctance to disclose the diagnosis, and to a sense of hopelessness. Many people with the diagnosis report that being labeled felt like a verdict, and that they were treated as if their pain was less real.
Language matters. Terms such as manipulative, attention-seeking, and dramatic assign motives and imply blame, while person-first language, such as a person with borderline personality disorder, emphasizes the human being. Describing behavior in terms of the function it serves, such as an attempt to cope with unbearable emotion or to communicate distress when other ways have failed, is more accurate and more helpful. Some people with the condition prefer to speak of having a diagnosis or of living with emotional dysregulation, and respect for individual preferences is appropriate. Public understanding is growing, and increasing numbers of people with lived experience are speaking about recovery and contributing to research and service design, which helps to reduce stigma.
Common Myths About Borderline Personality Disorder
Several persistent myths contribute to misunderstanding. The first is that people with the disorder are manipulative. As noted, behavior that appears manipulative generally arises from distress and from a lack of effective skills for getting needs met, and not from a calculated plan. The second is that the disorder is untreatable. The evidence shows the opposite: it is one of the personality disorders for which there are well-tested treatments, and long-term follow-up shows high rates of remission. The third is that it occurs only in women. Men are affected too, though they are often misdiagnosed or overlooked.
A fourth myth is that self-harm is attention-seeking. In most cases, self-harm is a private act, hidden from others, driven by emotional pain and shame, and treating it as a bid for attention is both inaccurate and harmful. A fifth is that people with the disorder are dangerous or abusive. While anger and conflict can occur, most people with the disorder are more likely to harm themselves than others, and they are often victims of mistreatment. A sixth is that the disorder is the same as bipolar disorder. As described, the two differ in the duration and triggers of mood changes and in treatment. A seventh is that people with the disorder cannot sustain relationships or work. Many have long and loving relationships and successful careers, particularly after treatment, and some are among the most empathic and perceptive of people.
A Realistic and Hopeful Outlook
The long-term outlook for people with borderline personality disorder is considerably better than was once thought. The best known evidence comes from long-term follow-up studies, such as the McLean Study of Adult Development, led by Mary Zanarini and colleagues, which followed hospitalized patients with the diagnosis for more than a decade. It found that the large majority achieved remission of symptoms, meaning that they no longer met the criteria, within ten years, and that recurrence after remission was relatively uncommon. Other studies, including the Collaborative Longitudinal Personality Disorders Study, have reached similar conclusions. The impulsive and self-harming features tend to improve earliest, while the affective symptoms, such as chronic anger and emptiness, and difficulties in social and occupational functioning, take longer to resolve. In other words, many people recover in terms of symptoms before they recover in terms of life satisfaction, which suggests that treatment should continue to support the building of a meaningful life.
Recovery does not mean that emotions become muted or that sensitivity disappears. Many people with a history of the disorder remain emotionally sensitive and intense, but they have learned skills that allow them to manage the intensity, and to use their sensitivity as a strength, in empathy, creativity, and care for others. They have learned to recognize their emotions early, to pause, to communicate their needs, and to repair relationships after conflict. They have built a stable sense of who they are, and they have found sources of meaning and connection. Many describe recovery not as a return to a former self but as the discovery of a self that they had not been able to reach before.
When to Seek Help
It is time to seek professional help when emotions feel unmanageable, when relationships are repeatedly disrupted by intense reactions, when there is self-harm or thoughts of suicide, when impulsive behavior is causing damage, or when the person feels that their life is being controlled by their emotions. A good first step is to see a general practitioner or a mental health professional for an assessment. It is reasonable to ask whether the clinician has experience of treating borderline personality disorder and whether they offer dialectical behavior therapy, mentalization-based treatment, or another evidence-based therapy. Many countries now have specialist services, and online and telehealth options have expanded access. Early help produces better outcomes, and there is no need to wait until a crisis.
Conclusion
Borderline personality disorder is, at its core, a disorder of emotional intensity and of the struggle to live with it. People with the condition feel too much, too fast, and for too long, and they have often grown up in circumstances that did not teach them how to handle such feelings. The fear of abandonment, the unstable relationships, the shifting sense of self, the impulsive acts, the self-harm, the anger, and the emptiness that define the diagnosis are not signs of weakness or manipulation. They are the visible results of a nervous system that responds powerfully to emotional events, and of attempts, sometimes desperate and often costly, to cope with that response.
Understanding the disorder in this way changes what can be done about it. The biosocial theory explains how sensitivity and invalidation combine, neuroscience points to the circuits that can be retrained, and decades of clinical research show that therapies that teach emotion regulation, mindfulness, interpersonal skills, and the capacity to reflect on mental states can reduce suffering and save lives. Most people improve, and many recover. Family members and friends can contribute by learning about the condition, validating the person’s experience, setting kind and consistent boundaries, and looking after themselves. Anyone who recognizes themselves in this description, or who is struggling with intense emotions, self-harm, or thoughts of suicide, is encouraged to speak with a doctor or mental health professional, or to contact emergency services or a crisis line if in immediate danger. The volume of emotion may never become quiet, but it can be learned, with patience and the right help, to live with it, and to live well.
FAQ About Borderline Personality Disorder
What are the main symptoms of borderline personality disorder?
The disorder is characterized by a pervasive pattern of instability in emotions, relationships, self-image, and behavior. The diagnostic criteria describe nine features: frantic efforts to avoid abandonment, intense and unstable relationships that swing between idealization and devaluation, an unstable sense of identity, impulsive behavior in areas such as spending, substance use, or sex, recurrent self-harm or suicidal behavior, rapid mood shifts that typically last hours, chronic feelings of emptiness, intense and difficult-to-control anger, and brief stress-related paranoid thoughts or dissociation. At least five of these must be present, beginning by early adulthood and across different situations, and they must cause distress or impairment. Because the combination varies from person to person, a diagnosis should be made by a qualified clinician after a careful assessment.
What causes borderline personality disorder?
No single cause has been identified. The leading explanation is the biosocial model, in which a biological vulnerability to intense and long-lasting emotional reactions interacts with an environment that repeatedly dismisses or punishes the child’s feelings. Genetic factors contribute, with heritability estimated at about forty to fifty percent, and many people report adverse childhood experiences such as abuse, neglect, or unstable caregiving, although not everyone does, and most people who experience such adversity do not develop the disorder. Differences in brain systems that regulate emotion, including heightened amygdala reactivity and reduced prefrontal regulation, have been found. The disorder is best understood as arising from the interaction of temperament, experience, and brain development, and not from a single event or from any person’s fault.
What is the difference between borderline personality disorder and bipolar disorder?
The two conditions share mood instability and impulsivity, but they differ in the pattern, duration, and triggers of mood changes. In bipolar disorder, episodes of mania or hypomania last at least several days, with sustained elevated or irritable mood, reduced need for sleep, and increased energy, and episodes of depression last at least two weeks, largely independent of events. In borderline personality disorder, mood shifts occur within hours and are usually triggered by interpersonal events, with rapid changes between anger, anxiety, and despair, and without the sustained changes in sleep and energy typical of mania. The conditions can occur together, and careful assessment over time is needed. Treatment differs, since mood-stabilizing medication is central in bipolar disorder, while psychotherapy is the main treatment for borderline personality disorder.
Can borderline personality disorder be treated, and can people recover?
Yes. Although the disorder was once considered untreatable, research has shown that specialized psychotherapies, notably dialectical behavior therapy and mentalization-based treatment, reduce self-harm, suicidal behavior, hospital admissions, and the severity of symptoms. Long-term follow-up studies show that the large majority of people achieve remission within about ten years, and that relapse after remission is relatively uncommon, although recovery of full social and occupational functioning may take longer. Recovery does not necessarily mean the disappearance of emotional sensitivity, but rather that the person learns skills to manage intense emotions and to build stable relationships and a meaningful life. Seeking treatment early and finding a therapist with relevant experience improves the likelihood of a good outcome.
What is dialectical behavior therapy, and does it work?
Dialectical behavior therapy is a structured form of cognitive behavioral therapy developed by Marsha Linehan, designed to balance acceptance of the person’s experience with the need for change. The standard program includes weekly individual therapy, a skills training group, telephone coaching between sessions, and a consultation team for therapists. The skills are taught in four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Randomized trials have found that it reduces self-harm, suicide attempts, and hospital stays, and improves depression, anger, and functioning, compared with usual treatment. It has been adapted for adolescents and for other conditions, and skills-only versions are widely used. Evidence for its long-term effects continues to accumulate, and it is the most widely recommended therapy for the disorder.
Is medication helpful for borderline personality disorder?
There is no medication approved specifically for the disorder, and the evidence that drugs improve its core features is limited. Some studies suggest that mood stabilizers or low doses of antipsychotic medication may modestly reduce anger, impulsivity, and mood instability, and antidepressants may help when depression is present, but the effects are small and inconsistent. For this reason, several clinical guidelines recommend that medication be used mainly to treat coexisting conditions such as depression, anxiety, or other disorders, or for short-term crisis management, and not as the main treatment. Benzodiazepines are generally avoided because of the risk of dependence and disinhibition. Anyone taking medication should discuss any changes with their prescriber and should not stop suddenly.
Is it true that people with borderline personality disorder are manipulative?
This is a common and harmful misconception. Behavior that appears manipulative, such as threats to leave, repeated demands for reassurance, or self-harm after a conflict, usually arises from intense emotional pain, fear of abandonment, and a lack of effective skills for communicating needs, not from a calculated attempt to control others. The person typically feels desperate, and often feels deep shame afterwards. Clinicians who work with the condition emphasize that understanding the function of such behavior, as an attempt to cope or to communicate when other means have failed, leads to better responses than judging it as manipulation. Treatment focuses on teaching more effective ways to express needs and to manage distress, and on providing validation.
How can I support a family member or partner with borderline personality disorder?
The most helpful approach combines understanding, validation, clear boundaries, and self-care. Learning about the disorder helps to see intense reactions as expressions of emotional dysregulation, and not as personal attacks. Validation, which means acknowledging that the person’s feelings make sense given their experience, without necessarily agreeing with every interpretation or accepting harmful behavior, reduces emotional arousal and builds trust. Boundaries stated calmly and consistently help to create safety and predictability. In a crisis, remain calm, focus on safety, and contact emergency services if there is immediate risk. Encouraging professional treatment, taking part in a family education program such as Family Connections, and looking after your own health and relationships are all valuable, since supporters who care for themselves can sustain their support.
Can men have borderline personality disorder?
Yes. Although about three-quarters of people diagnosed in clinical settings are women, community surveys suggest that the rates in men and women are much closer to equal. Men with the disorder are probably underdiagnosed, partly because their difficulties may be expressed through anger, impulsivity, substance misuse, or aggression, and may therefore be attributed to other conditions, such as antisocial personality disorder or substance use disorders. They may also be less likely to seek help from mental health services. Men with the disorder respond to the same treatments as women, and clinicians are increasingly aware of the need to consider the diagnosis in men who show a pattern of intense emotions, unstable relationships, and self-destructive behavior.
What does quiet borderline personality disorder mean?
Quiet borderline personality disorder is a popular term, not a formal diagnosis, used to describe a presentation in which a person directs their distress inward, and not outward. People with this pattern may appear calm, capable, and accommodating, while experiencing intense fear of abandonment, shame, self-criticism, and emptiness in private. They may avoid conflict, try hard to please others, withdraw when upset, and may engage in self-harm or other self-directed behavior without others knowing. Because the distress is hidden, the condition may be overlooked or misdiagnosed as depression or anxiety. The underlying difficulties are the same as in other presentations, and the same evidence-based treatments are appropriate. A clinical assessment is needed to establish whether the diagnosis applies.
Can borderline personality disorder be diagnosed in teenagers?
Yes, when the features are persistent, pervasive, and severe, and not simply part of normal adolescent turbulence. Current guidelines in several countries support the diagnosis in people under eighteen, recognizing that early identification allows early treatment, which can improve outcomes. Because adolescence involves normal changes in identity, mood, and relationships, clinicians take care to distinguish the disorder from typical development and from other conditions such as depression, anxiety, and trauma-related disorders. Adapted forms of dialectical behavior therapy and mentalization-based treatment for adolescents have shown benefits, and involving the family is an important part of treatment. Parents who are concerned about a teenager’s self-harm, extreme emotional reactions, or unstable relationships should seek an assessment from a child and adolescent mental health service.
Recommended Books on Borderline Personality Disorder
- Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan
- DBT Skills Training Manual by Marsha M. Linehan
- Building a Life Worth Living: A Memoir by Marsha M. Linehan
- Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. Mason and Randi Kreger
- I Hate You, Don’t Leave Me: Understanding the Borderline Personality by Jerold J. Kreisman and Hal Straus
- The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD by Alex L. Chapman and Kim L. Gratz
- The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating by Kiera Van Gelder
- Back from the Brink: A Parent’s Guide to Managing Borderline Personality Disorder by Blaise Aguirre and Gillian Galen
- Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship by Shari Y. Manning
- The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley
