BPD Awareness Month 2022 – What is Borderline Personality Disorder?

As part of our information series marking Borderline Personality Disorder Awareness Month 2022, Dr Paul Matthews, Consultant General Adult Psychiatrist and Chair of the CPsychI Personality Disorders Special Interest Group, provides an overview of what we mean when we discuss this often-misunderstood diagnosis.

While public awareness of mental illness keeps growing, and the stigma around mental health difficulties has drastically reduced, borderline personality disorder remains one of the most misunderstood diagnoses in psychiatry and mental health. This is despite occasional coverage in the media (such as the recent Amber Heard/Johnny Depp court case) and borderline personality being the most researched of all the personality disorders.

As a label, borderline personality disorder still carries a lot of stigma and negative connotations, amongst the general public but also among health professionals. Even the name itself is confusing, dating back to the 1930s when it was placed at the borderline between the psychoanalytic concepts of ‘psychosis’ and ‘neurosis’ – these labels don’t really map onto modern psychiatric practice but the name stuck. More recently the name ‘emotionally unstable personality disorder’ has been used but many people reject both as stigmatising and use terms like ‘complex emotional needs.’

What is borderline personality disorder?

Unlike mental illnesses such as clinical depression or psychosis, personality disorders are considered to be extreme manifestations of people’s underlying personality, the relatively stable ways of thinking, feeling, and behaving that become manifest in childhood or young adulthood. How we distinguish between something being at the extreme of the range of personalities and calling it a ‘disorder’ is when people start to develop distress and difficulties in their day-to-day living and functioning, but ultimately where we draw the line is somewhat arbitrary.

People with borderline personality can experience many of the following problems:

Emotional difficulties
o  Emotional sensitivity and mood swings
o  Feeling empty inside
o  Intense anger

Relationship problems
o  Fear of abandonment
o  Unstable and intense relationships

Self-destructive behaviours
o  Acting without thinking
o  Self-harming
o  Suicidal behaviours

Disturbed sense of self
o  Unsure of who they are or what they want
o  Feeling disconnected from the world or body
o  Periods of paranoia or other psychotic experiences (e.g. hearing voices)

These symptoms don’t necessarily mean someone has borderline personality but when they are severe and frequent enough to cause significant distress and problems in multiple situations then we say they have borderline personality disorder. People who meet the criteria for borderline personality will often meet the criteria for other personality disorders as well and there is a move to consider most personality disorders as more of an overlapping continuum than discrete diagnoses and the number of symptoms to be an indication of the severity of the personality disorder. The criteria for borderline personality also overlap with those of complex post-traumatic stress disorder and people with borderline personality commonly develop other mental disorders such as depression or substance misuse.

In the absence of specialist treatment, people who would meet the criteria for a diagnosis of borderline personality often present to health services in emotional crisis and tend to be treated at the margins, through emergency departments or unplanned hospital admissions. Clinicians in general health services, but also in mental health services, often feel unskilled to help people with borderline personality and there can be a reliance on inappropriate and ineffective treatments such as medication. Borderline personality disorder is not a trivial condition. In addition to the emotional suffering and social difficulties, people with a diagnosis of borderline personality have a significantly reduced life expectancy and lifetime suicide rates of around 10%, more than for people with clinical depression.

How common is borderline personality?

We don’t have good data available for the prevalence of borderline personality disorder in Ireland but estimates from other countries suggest that around 1-2% of people in the general population would meet the criteria for borderline personality disorder with 10-20% of people attending outpatient psychiatry clinics and 20% of psychiatric hospital inpatients. Although more women are diagnosed with borderline personality than men, this may be because they are more likely to seek help.

What causes it?

Like most psychiatric diagnoses, the causes of borderline personality are not entirely clear. We think that there is some contribution of family history and genetics because there is some evidence that borderline personality can run in families. But we also know that childhood traumatic experiences such as abuse and neglect are much more common in people with borderline personality.

What treatments are available?

In the past, psychiatrists avoided diagnosing borderline personality, either because they didn’t recognise it or because they didn’t think they could offer any help. This pessimism has left a lasting legacy and borderline personality is still probably under-diagnosed and poorly treated. However, we now have good, proven treatments available that can help people with borderline personality to tackle their difficulties. Although there have always been psychological treatments offered for borderline personality, such as democratic therapeutic communities or psychodynamic psychotherapy, it was in the 1990s that evidence based treatments such as dialectical behaviour therapy (DBT) started to be developed. Now there are a number of specialist therapies developed for treating borderline personality so there is not just DBT but mentalisation-based treatment (MBT) and a whole range of other therapies such as schema-focused therapy, cognitive analytic therapy, and many more. These seem to have some characteristics in common such as being longer-term than other therapies.

DBT is the most commonly available treatment for borderline personality available in Ireland but unfortunately we know that many areas are unable to offer any evidence-based therapies. Ireland lacks specialist psychiatrists trained in delivering psychotherapy or the specialist therapy services for borderline personality seen in other countries. The College of Psychiatrists of Ireland has recently published a position paper that highlights the level of unmet need in Ireland that remains for people with borderline personality: https://www.irishpsychiatry.ie/blog/new-position-paper-development-of-services-for-treatment-of-personality-disorder-in-adult-mental-health-services/

See below for further resources, information and discussion on Borderline Personality Disorder:

Development of Treatment for Personality Disorder in Adult Mental Health Services – Position Paper by the CPsychI Personality Disorders Special Interest Group

Symptoms, Causes, Treatment and Diagnosis – HSE Ireland,  Information on Personality Disorder

PersonalityDisorder.org.uk – Developed by the UK Department of Health.

About Borderline Personality Disorder – Mind, Uk-based mental health charity

Personality disorders: symptoms, treatments, self-care – resource by MindWise, mental health charity in Northern Ireland

Borderline Personality Disorder can be treated and achieve ‘good response – Article by Priscilla Lynch

The Wrong Kind of Mad podcast – Hollie Berrigan and Keir Harding talk about issues associated with “personality disorder”.