Borderline personality disorder

BPD is a type of ‘personality disorder’. It is an illness that makes you struggle with your emotions and this can affect your relationships with other people. Around 1 in 100 people have BPD.

Overview

  • BPD means that you feel strong emotions that you struggle to cope with. You may feel upset or angry a lot of the time.
  • Around 1 in 100 people have BPD.
  • There are different reasons why people get BPD. A lot of people with BPD have had traumatic problems in their childhood.

About

What is borderline personality disorder (BPD)?

BPD is a type of ‘personality disorder’. It is an illness that makes you struggle with your emotions and this can affect your relationships with other people. Around 1 in 100 people have BPD. It seems to affect men and women equally, but women are more likely to have this diagnosis. This may be because men are less likely to ask for help. Everyone will experience BPD differently. If you have BPD, you may have problems with:

  • feeling isolated or abandoned by others,
  • self-harming or suicidal thoughts,
  • coping with stress,
  • getting on with other people,
  • strong emotions that you find hard to cope with,
  • misusing alcohol and prescription drugs,
  • illegal drugs and substances,
  • understanding other people’s points of view,
  • staying in work,
  • having a long-term relationship, or
  • being able to maintain a home.

It is called ‘borderline’ because doctors used to think it was on the border between two different disorders: neurosis and psychosis. Doctors no longer like to use these terms to describe mental illness. It is sometimes called Emotionally Unstable Personality Disorder (EUPD). Some people feel that this describes the illness better.

Some people with a personality disorder think that the name is insulting or makes them feel labelled. But doctors do not use this term to make you feel judged or suggest that the illness is your fault. It is meant to describe the way the illness develops.

Symptoms & types

What are the symptoms of BPD and how is it diagnosed?

If your GP thinks that you may have borderline personality disorder (BPD), they should arrange for you to see a psychiatrist. They may send your details to your local community mental health team (CMHT). This is called a ‘referral’.

Your psychiatrist will decide if you have an illness based on the following guidelines.

  • International Classification of Diseases (ICD-10), produced by the World Health Organisation (WHO).
  • Diagnostic and Statistical Manual of Mental Disorders (DSM-5), produced by the American Psychiatric Association.

The guidelines tell your psychiatrist what to look for. They will diagnose you with BPD if you have at least five of the symptoms below.

  • Extreme reactions to feeling abandoned.
  • Unstable relationships with others.
  • Confused feelings about who you are.
  • Being impulsive in ways that could be damaging. For example, spending, sex, substance abuse, reckless driving, and binge eating
  • Regular self-harming, suicidal threats or behaviour.
  • Long lasting feelings of emptiness or being abandoned.
  • Difficulty controlling your anger. For example, losing your temper or getting into fights.
  • Intense, highly changeable moods.
  • Paranoid thoughts when you’re stressed.

Your psychiatrist will ask you about how you feel and about your life history. They may talk to other people close to you. They can diagnose you after one assessment if they have enough information to do this.

Previously, psychiatrists would not usually diagnose BPD in someone who is under 18. But more recently they are diagnosing young people with BPD.

What are the different types of BPD?

Borderline personality disorder (BPD) is also known as emotionally unstable personality disorder (EUPD). In England, doctors use both of these terms.

If your doctor says you have EUPD, they may say you have ‘borderline’ or ‘impulsive’ type EUPD. There are small differences but there is some overlap between these illnesses.

Borderline-type

If you have borderline-type EUPD you may have more difficulties with relationships, self-harming and feelings of emptiness.

Impulsive-type

If you have impulsive-type EUPD you may have more difficulties with impulsive behaviour and angry feelings.

Causes & treatment

What causes BPD?

It is not clear exactly what causes BPD. There are different factors that can lead to someone getting borderline personality disorder (BPD). The main causes seem to be the following.

  • Traumatic childhood. You might have experienced difficulties in your childhood. This could include neglect or being abandoned by a parent. Or physical, emotional or sexual abuse.
  • Brain problems. You might have slight differences in your brain.
  • Genetics. Some research shows that BPD may be passed on through genes. But there is no clear evidence that there is a gene that causes BPD.

What are the treatments for BPD?

You and your doctor will decide what treatment to try. The main treatment for borderline personality disorder (BPD) is psychological therapy, also called ‘talking therapy’. This may be one-to-one or in a group. There can be long waiting lists for therapy.

We have listed some types of psychological therapies below. Not all of these will be available on the NHS in your area.

Dialectical Behaviour Therapy (DBT)

DBT is helpful for people with BPD. DBT helps you to build skills to deal with distress. Therapists call this ‘emotional regulation’. DBT can help you learn how to control harmful ways of coping with distress, such as self-harming or using drugs or alcohol.

Mindfulness

The NHS may offer you a place on a mindfulness course. Mindfulness can help you to manage your emotions by focusing on the ‘here and now’. You may also do mindfulness in DBT (see above).

Cognitive Analytical Therapy (CAT)

CAT helps you to understand problems you have in relationships. You and your therapist will work together to understand these patterns and try change them. This may be useful if you ‘switch’ between liking and disliking people who are close to you.

Mentalisation-Based-Therapy (MBT)

This sort of therapy may help you if you make assumptions about what other people think or feel. You may base these assumptions on the worst-case scenario rather than more likely explanations. For example, if someone you care about wants to do something by themselves, you might think they don’t care about you, hate you or they will never want to come back. These feelings might make you panic and feel angry.

Mentalising is about understanding other people’s behaviour and your reaction to it. You do this by thinking about thoughts, intentions, needs and desires. It is about being aware of what’s going on in your own mind. This will help you to try to take a more balanced view about what might be going on in other people’s minds. This kind of therapy might help you if you worry about being abandoned.

Schema therapy

Schema therapy looks at patterns of behaviour and emotional states. You may act in different ways in different situations, and your therapist might call these ‘modes’. The therapy tries to find the right ‘mode’ for you to move forward and deal with situations in the best way you can.

Psychodynamic psychotherapy

This therapy focuses on your unconscious. Your unconscious is the part of your mind that controls beliefs, emotions or behaviours without you thinking about them.

Therapists think that past experiences, especially those in your childhood, can affect your unconscious. The therapist will try to link your current problems to past events. This may help to explain why you feel the way you do.

Therapeutic Communities

Therapeutic communities are not a treatment themselves. They are places you can go to have treatment. They may be specific for certain groups of people. For example, some may be for young women who have problems with alcohol or drugs. They sometimes have a religious link.

You may stay for a few weeks or months, or you may visit for just a few hours a week. You may have group therapy and self-help sessions. There may also be other group activities such as gardening and help with daily living skills.

Therapeutic communities vary a lot because they are often run by the people who use them and they shape them based on what they want.

Medication

There is no medication to treat borderline personality disorder (BPD). But your doctor may give you medication if you have another mental illness like anxiety or depression as well as BPD.18 They may offer you medication in a crisis, but this isn’t helpful as a long-term treatment.

What treatment should the NHS offer me?

The National Institute for Health and Care Excellence (NICE) offers guidance on what the NHS should offer you. You can find this guidance at www.nice.org.uk. The NICE guidance sets out best practice for the NHS.

You cannot force the NHS to offer you a service that NICE recommends. But if your local NHS doesn’t offer you appropriate treatment then you can complain.

The NICE guidance says your doctor might offer you therapy if your borderline personality disorder (BPD) causes you significant problems. This therapy should not be less than three months.The guidance says that the NHS should offer dialectical behaviour therapy (DBT) to women with BPD if they self-harm regularly.

You may get support from a specialist service if your symptoms are getting worse. The NHS should not refuse to give you specialist help because of your diagnosis. They should have services to support people with BPD.

Problems & self-care

What if I am not happy with my treatment?

Patient Advice and Liaison Service (PALS)

If you are unhappy about your NHS care or treatment, you could call your local PALS. They can try to help answer your questions about the complaints procedure. You can find PALS’ details here.

Advocacy

An advocate is independent from mental health services. They can help you to voice your opinion and resolve problems. They may be able to help you to write letters or go to appointments or meetings with you.

Diagnosis

If you are unhappy with your diagnosis, you could ask for a second opinion. You do not have a legal right to a second opinion, but it is important to ask if it is important to you.

Complaints

If you cannot resolve the problem, you can make a complaint to have your concerns investigated in more detail.

What self-care and management skills can I try?

You might find some of the following things helpful.

  • Make sure you speak to a doctor if you think that your relationships with others are being affected.
  • Think about how you will benefit from making changes to your lifestyle.
  • Don’t pay too much attention to the name of the illness. BPD is a common condition and it is not meant to label you or to suggest that your situation won’t change.
  • If you’re offered group therapy or support, give it a chance. It may seem intimidating to start with but a lot of people find it helpful in the long-run.
  • If something annoys or upsets you, try to wait a while before responding.
  • Try to find ways of relaxing. Meditation, breathing techniques, listening to music and exercising may be helpful.
  • Look for patterns in the ways you respond to things that upset you. This may help you to work through problems in relationships.
  • If you self-harm to deal with distress, think of other ways to deal with this. Try punching a pillow or writing about how you feel.
  • Use an online mental health forum. Make sure that you check with a mental health professional how trustworthy the website is for helpful information on BPD.

Risks

What risks and complications can BPD cause?

Self-harm

It is common for people who have borderline personality disorder (BPD) to self-harm. Some people find self-harming can help them to deal with painful feelings. But it can cause serious injury, scars, infections, or accidental death. A big focus of BPD treatment is to find other ways to deal with painful emotions.

Drugs and alcohol

People with BPD may:

  • behave impulsively, 
  • drink too much alcohol,
  • misuse prescription medication, or
  • take illegal drugs.

You may be at an increased risk of becoming dependent on alcohol or drugs if you have BPD.

If you drink a lot of alcohol or use drugs, you may find it difficult to get BPD treatment. You may be less likely to want help, or your substance use may get in the way of your treatment.

When you have a mental illness and a problem with drink or drugs, professionals call this ‘dual diagnosis’.

Impulsive behaviours

When people make decisions quickly without thinking about the consequences, doctors call this ‘impulsive’. This can include driving erratically, having more sexual partners, and spending money without thinking.

If you have BPD you may have unprotected sex with people you don’t know very well. This can lead to sexually transmitted diseases or an unwanted pregnancy.

BPD may cause you to gamble without thinking about the possible outcomes. You might spend your rent money or get pay day loans. This can lead to debt.

Carers

What if I am a carer, friend or relative?

As a carer, As a carer, friend or family member of someone living with borderline personality disorder (BPD), you might find that you need support.

It can be useful to learn about the disorder as much as possible. This may help you to:

  • support the person who has BPD,
  • understand why they may act in certain ways, and perhaps take things less personally, and
  • become more aware of what situations make them more distressed.

There are books available that may help. These include:

  • ‘Stop Walking on Eggshells’ by Mason & Kreger, and
  • ‘I Hate You, Don’t Leave Me’ by Kreisman & Straus

It is important to get support if are struggling to cope. See if there is a local support group which you can join. You could ask social services for a carer’s assessment to see if they can help.

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