Borderline Personality Disorder (BPD) has been a stigmatized disorder for years. It has even been labeled by some as untreatable (this is not true). When BPD was first being diagnosed in the late 1970s it was thought to be a “borderline condition” between neurosis (anxiety) and psychosis (paranoia/delusion), which is how the name came to be. Mental health experts later realized that wasn’t accurate, but the name stayed.
BPD was officially added to the Diagnostic & Statistical Manual of Mental Disorders (DSM) in 1980. The DSM is the reference book that medical and mental health professionals use to identify a common label and definition for whatever symptoms they are seeing in each patient.
The first manual was published in 1952 and has been reviewed and revised periodically since then (7 total edits). The more we learn about humans and our brains, the more the diagnoses need to be tweaked and added. Around 2007, it was time to start working on the new update, the DSM 5.
For about 5 years, a large team of mental health professionals convened to review and make decisions about what needed to be changed and updated. This included taking a look at Borderline Personality Disorder. During this time, many experts (including the founder of DBT Marsha Linehan) proposed a new name, new diagnosing criteria, and new category for BPD.
Some of the experts argued that BPD should no longer be classified as a personality disorder, but instead be listed as a mood disorder because of the huge role that emotion regulation played.
Some of the experts argued that BPD should no longer be classified as a personality disorder, but instead be listed as a mood disorder or an identity disorder. Various new names for the disorder were proposed: Emotion Regulation Disorder, Emotional Dysregulation Disorder, Emotional Intensity Disorder, Impulsive-Emotional Dysregulation Disorder, Emotionally Unstable Personality Disorder, Impulsive Personality Disorder. The work groups were unable to come to a consensus and the name and classification for BPD stayed the same for the DSM 5.
But here’s the important takeaway: there is agreement that the core issue for those living with BPD is a difficultly with managing intensely felt emotions. It’s not brokenness or something that is unfixable. People with Borderline Personality have extremely perceptive and sensitive emotional systems. They are incredibly tuned in to the subtle emotional shifts in others. And they typically experience their own emotions much more intensively and for a much longer duration of time than others do.
This is a lot to manage every hour of every day, unless you are specifically taught how. Most of us are not really taught how to manage our emotions or even why we have emotions. So folks with Borderline Personality who experience these very intense emotions end up finding ways to cope with them that can end up being counter-productive and can seem very confusing from the outside.
Below is the official DSM-5 diagnostic criteria for BPD, located on p663 in the manual. Further underneath, these criteria are explained in categories that might help you better assess if this is something that applies to you or someone you care about.
The Borderline Personality Disorder definition in the DSM 5
A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following:
1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
*Taken from the Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association (2013).
Four ways Borderline Personality Disorder shows up in real life
It can be easier to understand the BPD diagnosis when it's broken into four basic categories. All of the elements described below do not apply to everyone with BPD, but those with Borderline Personality will have many of them. The elements will be regularly present for several years.
1. Emotions - intense, long lasting and overwhelming emotional responses that are difficult to manage. The most commonly affected emotions are anger, anxiety and depression.
This emotional dysregulation can look like:
Episodes of intense emotional anguish, irritability, anxiety, shame, jealousy and panic. Ex: someone doesn't message you back right away and you assume they are upset or with someone else, which leads to a severe spike in worry and jealousy that lasts until you hear from them or prompts you to reach out to them many many times in a row.
Anger or persistent irritability that seems out of proportion to the situation. Ex: your spouse doesn't take out the trash like they promised and you feel irate about it and may even refuse to talk to them for the rest of the day.
Emotional over-reactivity (very strong emotions that seem to come on suddenly) Ex: your doctor keeps you waiting 10 minutes past the start time and you can't stand the disrespect so you curse at the reception staff and storm out.
Emotional responses that are occasionally under-reactive (numb, muted, shut-down) Ex: your boss is telling you that your performance needs to improve and you shut down inside, feeling unable to say a thing or engage in the conversation. Later you might not remember what was said.
Moods fluctuate a lot throughout the day and easily change for no reason
Chronic boredom or emotional numbness (not caring much about anything, feeling "meh" most of the time)
Chronic feelings of emptiness Ex: every day you feel a dull ache inside and think there should be more to life but you don't really trust that there is or that you will achieve it.
2. Impulsive actions – pattern of impulsive behaviors that are harmful to you or to others.
This impulsivity can look like:
Self-damaging actions to your body such as: physical harm to your skin (cut, burn, hit, pick at, etc.), unsafe sexual encounters, excessive substance abuse, and disordered eating (over/under-eating)
Risky actions that cause harm to your stability such as: excessive spending, spending or giving away money you do not have, jeopardizing your employment, reckless driving, breaking laws
Recurrent thoughts of killing yourself or regularly craving to escape from the pain of daily life.
Repeatedly making gestures, plans, or threats of harm to yourself
Repeated physical aggression towards other people or property/material items
Other actions that are harmful and destructive to yourself, your stability, your freedom, to other people or to property.
3. Relationships – pattern of tumultuous and very stressful relationships (romantic, friendships, family, co-workers, self).
This relationship distress can look like:
Unsatisfying relationships with family and friends (you sometimes believe that they really value you and other times believe that they could care less about you).
Becoming extremely upset and panicked when you think that someone you really care about is going to leave you or pull away. Ex: your romantic partner says they need to take a walk alone because they are upset about the conversation and you try to block the door or follow them out because you want to get the situation resolved immediately and can't stand for them to leave upset at you.
Pushing people away before they can leave or judge you (starting an argument, being overly critical, intentionally doing things to upset them, refusing to accept apologies or efforts to repair arguments).
Intense relationships that feel unstable or that the connection varies greatly depending on the day/mood
Your sense of people alternates between the extremes of over-idealizing people (you love them, can’t get enough) and undervaluing people (despising, annoyed, want to be done with them)
You may have overly-dependent and/or clinging behavior in important relationships. Ex: you feel intensely jealous or anxious if your friend spends time with anyone else.
You may engage in frantic efforts to avoid real or imagined abandonment (doing whatever it takes to keep people from judging you, from being upset at you, or pulling away from you). Ex: your boyfriend seemed a little distant this morning so you rush out to buy 5 of his favorite things, ask him repeatedly during the day if he is upset with you, plan a weekend full of time together and frantically clean up the place so that everything will seem perfect when he arrives.
4. Perceptions – pattern of having an inaccurate view of yourself and others.
This can look like:
Expecting negative and harmful judgments, attitudes, and behaviors from most people. Ex: when meeting a new co-worker, you automatically assume they think you are unintelligent or boring or worthless or that they are out to get your job and throw you under the bus.
A high level of suspiciousness about the motives of others and concern they are acting against you despite having little evidence of it Ex: your friend tells you she had a fun time at the movies and you assume that she intentionally didn't invite you and that the friend she did go with is trying to wedge you out of the picture.
Paranoid thinking or misperceptions of situations (the reality of situations seems very different to you than it does to others) Ex: your sister hands her infant baby to you and the baby starts wailing. You instantly assume the baby knows you are an awful person and that there is something deeply wrong with you.
Persistent unstable self-image or sense of who you are (uncertain of your identity, significantly changing who you are depending on who you are with, changing careers or values often) Ex: your last boyfriend was into hockey, so you became a diehard hockey fan. Your new boyfriend is into guitar, so you buy a guitar to learn how to play and start following all the musicians your boyfriend follows. No more hockey.
Experiencing dramatic changes in how you think/feel about yourself (feeling fine about your worth on day and the next day questioning your worth, disliking who you are at the core)
Difficulty in making realistic assessments of social situations under stress
Impaired memory under stress (forgetting conversations or events even though you were there)
Severe dissociative episodes (often shutting down or feeling numb to events, perhaps even forgetting them). These episodes come & go and are stress related.
Do I have Borderline Personality?
If you are interested in a self-assessment quiz format, there are many versions online, some of them more accurate than others. The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is the one backed by research. It's a 10-item, self-report screening tool and a score of 7 or higher indicates possible BPD. You can learn more about its origin and Dr. Mary Zanarini's research that produced it.
Borderline Personality Disorder looks different in everyone, just like depression or anxiety can look different in everyone. If you or someone you care about exhibits some of the traits covered here, there are absolutely ways to improve things. For most people with BPD, professional help and support is needed and DBT has been well-documented as the ideal form of therapy. With proper treatment, most people with BPD can and do get better.
Resources for more information on Borderline Personality
There are some excellent books and resources for those with BPD and the people who care about them. A few are listed below.
For those who care about someone with BPD to learn more:
I Hate You--Don't Leave Me: Understanding the Borderline Personality by Jerold J. Kreisman and Hal Straus
Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship by Shari Manning
Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul Mason
For those with BPD to learn more:
The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating by Kiera Van Gelder
Beyond Borderline: True Stories of Recovery from Borderline Personality Disorder by Perry Hoffman
Sometimes I Act Crazy: Living with Borderline Personality Disorder by Jerold J. Kreisman and Hal Straus
Building a Life Worth Living: A Memoir by Marsha Linehan
The world-renowned developer of DBT tells her journey from suicidal teenager to successful recovery. An honest, detailed account of her painful struggles with mental illness and her hope for those suffering and for those who love them.
For learning skills and strategies to manage BPD:
DBT® Skills Training Handouts and Worksheets, Second Edition by Marsha M. Linehan (best book when in therapy with a trained DBT therapist)
The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance by Matthew McKay (best book when trying to learn on your own)
Note that these book links are affiliate links and if you make a purchase I may receive a small commission.