What Is Borderline Personality Disorder?

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Borderline personality disorder (BPD), also known as emotionally unstable personality disorder – impulsive or borderline type or emotional intensity disorder, is a cluster-B personality disorder. The essential feature include a pattern of impulsivity and instability of behaviors, interpersonal relationships, and self-image. The pattern is present by early adulthood and occurs across a variety of situations and contexts.[1]
Other symptoms usually include intense fears of abandonment, intense anger, and irritability, the reason for which others have difficulty understanding.[1][2] People with BPD often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. [3] Self-harm, suicidal behavior, and substance abuse are common.[4]
The disorder is recognized in the Diagnostic and Statistical Manual of Mental Disorders. Because a personality disorder is a pervasive, enduring, and inflexible pattern of maladaptive inner experiences and pathological behavior, there is a general reluctance to diagnose personality disorders before adolescence or early adulthood.[5] However, some emphasize that without early treatment the symptoms may worsen.[6]

Symptoms include:


Splitting

Chaos in relationships

Markedly disturbed sense of identity

Intense or uncontrollable emotional triggers

Unstable interpersonal relationships and self-esteem

Concerns about abandonment

Self-damaging behavior

Impulsivity

Frequently accompanied by depression, anxiety, anger, substance abuse or rage

The most distinguishing symptoms of BPD are marked sensitivity to rejection, negative criticism, and thoughts and fears of possible abandonment.[9] Overall, the features of BPD include unusually intense sensitivity in relationships with others, difficulty regulating emotions, and impulsivity. Other symptoms may include feeling unsure of one’s personal identity and values, having paranoid thoughts when feeling stressed, and severe dissociation.[9]


Emotions

People with BPD feel emotions more easily, more deeply, and longer than others do.[10][11] Emotions may repeatedly resurge and persist a long time.[11] Consequently, it may take longer than normal for people with BPD to return to a stable emotional baseline following an intense emotional experience.[12]


In Marsha Linehan’s view, the sensitivity, intensity, and duration with which people with BPD feel emotions have both positive and negative effects.[12] People with BPD are often exceptionally enthusiastic, idealistic, joyful, and loving.[13] However, they may feel overwhelmed by negative emotions, experiencing intense grief instead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness.[13] People with BPD are especially sensitive to feelings of rejection, criticism, isolation, and perceived failure.[14] Before learning other coping mechanisms, their efforts to manage or escape from their intense negative emotions may lead to self-injury or suicidal behavior.[15] They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, they shut them down entirely.[12] This can be harmful to people with BPD, since negative emotions alert people to the presence of a problematic situation and move them to address it.[12]


While people with BPD feel joy intensely, they are especially prone to dysphoria, or feelings of mental and emotional distress. Zanarini et al. recognized four categories of dysphoria that are typical of this condition: extreme emotions, destructiveness or self-destructiveness, feeling fragmented or lacking identity, and feelings of victimization.[16] Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: feeling betrayed, “feeling like hurting myself”, and feeling out of control.[16] Since there is great variety in the types of dysphoria experienced by people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.[16]


In addition to intense emotions, people with BPD experience emotional lability, or changeability. Although the term suggests rapid changes between depression and elation, the mood swings in people with this condition actually occur more frequently between anger and anxiety and between depression and anxiety.[17]


Behavior

Impulsive behavior is common, including substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending, and reckless driving.[18] Impulsive behavior may also include leaving jobs or relationships, running away, and self-injury.[19]


People with BPD act impulsively because it gives them immediate relief from their emotional pain.[19] However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.[19] A cycle often begins in which people with BPD feel emotional pain, engage in impulsive behavior to relieve that pain, feel shame and guilt over their actions, feel emotional pain from the shame and guilt, and then experience stronger urges to engage in impulsive behavior to relieve the new pain.[19] As time goes on, impulsive behavior may become an automatic response to emotional pain.[19]


Self-harm and suicide

Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM IV-TR. Management of and recovery from this behavior can be complex and challenging.[20] The lifetime risk of suicide among people with BPD is between 3% and 10%.[9][21] There is evidence that men diagnosed with BPD are approximately twice as likely to commit suicide as women diagnosed with BPD.[22] There is also evidence that a considerable percentage of men who commit suicide may have undiagnosed BPD.[23]


Self-injury is common and may take place with or without suicidal intent.[24][25] The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts.[15] Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.[15] In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide.[15] Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.[15]


Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.[26][quantify]


Interpersonal relationships

People with BPD can be very sensitive to the way others treat them, feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.[27] Their feelings about others often shift from positive to negative after a disappointment, a perceived threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called splitting or black-and-white thinking, includes a shift from idealizing others (feeling admiration and love) to devaluing them (feeling anger or dislike).[28] Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers.[29] Self-image can also change rapidly from positive to negative.


While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships,[30] and they often view the world as dangerous and malevolent.[27] BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these factors appear to be linked to personality disorders in general.[31]


Manipulation to obtain nurturance is considered to be a common feature of BPD by many who treat the disorder, as well as by the DSM-IV.[32][33] However, some mental health professionals caution that an overemphasis on, and an overly broad definition of, manipulation can lead to misunderstanding and prejudicial treatment of people with BPD within the health care system.[34] (See Manipulative behavior and Stigma under Controversies.)


Sense of self

People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.[35] They are often unsure about their long-term goals for relationships and jobs. This difficulty with knowing who they are and what they value can cause people with BPD to experience feeling “empty” and “lost”.[35]
The often intense emotions experienced by people with BPD can make it difficult for them to control the focus of their attention—to concentrate.[35] In addition, people with BPD may tend to dissociate, which can be thought of as an intense form of “zoning out”.[36] Dissociation often occurs in response to experiencing a painful event (or experiencing something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event, presumably to protect against experiencing intense emotion and unwanted behavioral impulses that such emotion might otherwise trigger.[36] Although the mind’s habit of blocking out intense painful emotions may provide temporary relief, it can also have the unwanted side effect of blocking or blunting the experience of ordinary emotions, reducing the access of people with BPD to the information contained in those emotions, which helps guide effective decision-making in daily life.[36] Sometimes, it is possible for another person to tell when someone with BPD is dissociating, because their facial or vocal expressions may become flat or expressionless, or they may appear to be distracted; at other times, dissociation may be barely noticeable.[36]

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