What are the symptoms and treatment options for borderline personality disorder?

Symptoms of Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in self-image, interpersonal relationships, and affects, along with marked impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. 1

Core Diagnostic Features

BPD symptoms can be grouped into several key domains:

Emotional Dysregulation

• Affective instability with intense, rapidly shifting emotions
• Inappropriate or disproportionate anger and difficulty controlling it
• Chronic feelings of emptiness
• Emotional reactions that are highly reactive to interpersonal stressors 1

Disturbed Self-Image

• Unstable self-image or sense of self
• Identity disturbance and confusion
• Feelings of worthlessness alternating with grandiosity 2

Interpersonal Dysfunction

• Intense fear of abandonment and frantic efforts to avoid it
• Pattern of unstable relationships that alternate between idealization and devaluation
• Difficulty maintaining stable connections with others 1, 3

Impulsivity and Self-Destructive Behaviors

• Recurrent suicidal behavior, gestures, or threats
• Self-mutilating behaviors (cutting, burning)
• Impulsive behaviors in at least two potentially self-damaging areas (spending, sex, substance abuse, reckless driving, binge eating) 3

Cognitive Symptoms

• Transient stress-related paranoid ideation
• Severe dissociative symptoms (feeling detached from oneself or surroundings)
• Black-and-white thinking (splitting) 1, 2

Differential Diagnosis

BPD must be distinguished from several conditions with overlapping features:

• Bipolar Disorder: BPD mood changes are typically reactive to interpersonal stressors and brief (hours to days), whereas bipolar mood episodes last longer (days to weeks) 1
• Major Depression: Depression involves negative self-concept but appearance concerns are not the primary preoccupation and typically lack the repetitive behaviors characteristic of BPD 4
• Social Anxiety Disorder: Both involve fear of negative evaluation, but social anxiety focuses on embarrassing oneself rather than appearance-based rejection 4
• Psychotic Disorders: BPD may include transient paranoid ideation but lacks hallucinations, disorganized thought/speech, and other positive psychotic symptoms 1

Risk Assessment

Thorough risk assessment is crucial in BPD due to high rates of self-harm and suicidality:

• Approximately 70% of patients attempt suicide and 8-10% complete suicide 1
• About half of young people with BPD report self-harm 4
• Self-harm may be related to emotional dysregulation or serve as an attempt to change appearance 4
• Assess for current suicidal ideation, intent, history of attempts, access to lethal means, and impulsivity level 1

Treatment Approaches

Psychotherapy (First-Line Treatment)

Dialectical Behavior Therapy (DBT) is the only form of psychotherapy shown in randomized controlled trials to reduce suicidality in adults with borderline personality disorder. 4

DBT components include:

• Core Mindfulness Skills to diminish identity confusion and self-dysregulation
• Interpersonal Effectiveness Skills for problem-solving and assertiveness
• Distress Tolerance to reduce impulsivity through acceptance techniques
• Emotion Regulation Skills to identify emotions and reduce emotional vulnerability 4

Other effective psychotherapies include:

• Mentalization-Based Therapy
• Transference-Focused Therapy
• Schema Therapy 2, 3

Pharmacotherapy (Adjunctive Role)

No evidence consistently shows that any psychoactive medication is efficacious for the core features of BPD 2, 3. However, medications may help with specific symptoms:

• For comorbid depression or anxiety: SSRIs like escitalopram, sertraline, or fluoxetine may be prescribed 3
• For acute crisis management: Low-potency antipsychotics (e.g., quetiapine) or sedative antihistamines (e.g., promethazine) are preferred over benzodiazepines 3
• For mood instability: Mood stabilizers like valproate semisodium have shown promising results 5

Common Pitfalls in Diagnosis

• Overdiagnosing BPD based on a single crisis presentation
• Confusing acute stress reactions with personality disorder
• Missing comorbid conditions (83% have mood disorders, 85% have anxiety disorders, 78% have substance use disorders) 1, 3
• Gender bias in diagnosis
• Relying solely on self-report 1

Prognosis

Despite its reputation as a chronic condition, BPD symptoms often improve over time with appropriate treatment. However, functional impairment may persist, and ongoing support is typically needed to maintain improvements in interpersonal functioning and emotional regulation.