Borderline personality disorder (BPD) is a mental health condition that often causes emotional instability and difficulties within interpersonal relationships. Many with this diagnosis have experienced childhood abuse or trauma, which has led to an inability to tolerate distressing situations and emotions [1][2]. There are nine symptoms of BPD outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [3]. For an accurate diagnosis of borderline personality disorder, 5 out of the following 9 symptoms must be present.

1. Fear of abandonment

Often, people with borderline personality disorder experience an intense fear of abandonment and will make frantic or desperate efforts to avoid being abandoned. This fear may be present with seemingly no explanation, or when the likelihood of abandonment is not high.

For example, they may be having an argument with a partner, friend, or loved one, who then chooses to walk away from the discussion, to cool off. The person with BPD may then follow them, demanding or begging that they stay and continue their conversation, out of fear that they will not return or will cut off communication indefinitely, believing they do not care.

This fear can prevent people with BPD from feeling that they can be honest about their feelings, as they are afraid that if they express any concern about a relationship, the other person may react negatively, rather than attempting to resolve the issue [4].

This can create feelings of anxiety within friendships and relationships, and often results in intense and extreme reactions to otherwise manageable concerns [5].

2. Unstable relationships

People with BPD often have rapidly changing relationships and friendships. As previously mentioned, a fear of abandonment can contribute to this significantly, along with other causes.

The term ‘push and pull’ is often attributed to relationships with someone with BPD, as they commonly will experience rapidly changing views on their partner; they may idealize and adore them one day, followed by despising or resenting them the next [2]. This can cause relationships that are intense and short-lived [6].

In the phase of idealizing their friend or partner, people with BPD can become very attached to this person, becoming dependent on them. This can be overwhelming for the friend or partner, who may pull away because of this intensity, which often results in an increase in intense behavior, due to fear of abandonment.

Difficulties with interpersonal relationships can be one of the most distressing symptoms of BPD, often causing people with the diagnosis to retreat from social situations to prevent new attachments from forming, or to repeatedly experience fluctuating and intense emotions with relationships that feel difficult to manage.

3. Unstable identity

People with BPD often have an imbalanced sense of self, causing them to feel unsure of who they are, what they believe in, and whether they are ‘good or bad’.

This can result in them mirroring other people’s views, behaviors, or opinions, taking on parts of someone else’s identity as their own.

They may regularly change their appearance or the things they enjoy, as their unstable sense of identity is preventing them from being certain of their own ideals and views [5].

If they make a mistake or unintentionally upset someone, their reaction may be an intense feeling that they are a terrible person, while on the other hand, if they do something good or help someone, they may feel that they are a very good person. This view can regularly change back and forth to each extreme, rarely finding a middle ground.

4. Impulsive behavior

People with BPD are often very impulsive, regularly engaging in reckless behaviors that could be harmful, such as regular unsafe sex, substance abuse, reckless driving or driving under the influence of alcohol, and excessive spending [7].

They may feel very guilty or upset following these behaviors but are unable to regulate their impulsivity and so repeatedly engage in the same activities [1].

These behaviors can be very dangerous and may result in harmful consequences. The person may be aware of these risks and feel unconcerned or somewhat welcoming of them, because of their distorted self-image and feelings of low self-worth.

5. Self-harm

Self-harming behaviors are extremely common amongst people with a diagnosis of BPD, including cutting, burning, and poisoning or overdose. While attempted suicide is a high risk amongst this group, it is often not the intention of the self-harming behavior, but rather to inflict injury. Various studies suggest that 3-10% of people with a BPD diagnosis die by suicide, while up to 95% engage in self-harm [8][9].

Many report that these self-harming behaviors are used as a coping strategy, to help regulate emotions, reduce feelings of dissociation, or as a self-punishment [10].

6. Extreme mood swings

People with BPD can experience rapid changes in their mood, which may be triggered by external or internal experiences.

Mood changes occur in other mental health conditions, such as bipolar disorder, but in the context of BPD, these moods last a significantly shorter time, sometimes changing drastically within minutes or hours, and rarely lasting longer than a few days [2].

Each mood can be experienced very intensely, such as extreme anxiety, sadness, euphoria, and anger [6]. BPD is also referred to as emotionally unstable personality disorder (EUPD), due to these intense and changeable moods.

7. Chronic emptiness

Chronic emptiness is a common symptom of BPD, although has often been challenging to quantify or measure. It is believed to be associated with an unstable identity, causing the person to feel that have no purpose and are unfulfilled [11].

People with BPD have reported this feeling of emptiness to be related to feeling disconnected or detached from others and themselves, again prompting views that it is related to a lack of a sense of self.

Chronic emptiness is not necessarily synonymous with depression or low mood, but can result in these feelings, or alternatively, feeling numb or feeling nothing at all. This can lead to harmful behaviors as a way of reconnecting with one’s emotions or feelings.

8. Extreme anger

A feeling of extreme anger, also known as BPD rage, is common in people with this diagnosis. As people with BPD typically have difficulty in regulating their emotions, intense and extreme anger is one of the common reactions to challenging or distressing situations [12].

This anger can often present as a sudden bout of rage and may be shocking and upsetting to the people nearby or at whom it is directed. It can be because of something that may seem trivial to others but feels intensely distressing to the person with BPD and is often very difficult for them to stop or control.

This response can often be the cause of many challenges that people with BPD experience in interpersonal relationships, causing others to retreat from these relationships [12]. As such, following a bout of extreme anger, many experience feelings of guilt and shame [5].

9. Paranoia and psychosis

The occurrence of psychotic symptoms, such as hallucinations, delusions, and paranoia, within BPD is not currently well understood but is believed to be related to stress. It may be linked to an inability to tolerate distressing situations and regulate emotional responses, resulting in fears of emotional or physical harm, particularly when confronted with a stressful event or circumstance [13].

These psychotic symptoms may only last a short time or may persist for several days but do tend to be alleviated within this time. Severe or ongoing psychotic symptoms could be related to an undiagnosed mental health condition that is occurring alongside the BPD diagnosis.

Seeking help

If any of these symptoms apply to you and you are concerned you may have borderline personality disorder, contact your doctor, who can assist with a diagnosis and advise about appropriate treatment options.

Some of the most effective treatments for borderline personality disorder include a range of therapies, such as dialectical behavior therapy (DBT) or cognitive behavioral therapy (CBT). No medications have yet been approved by the FDA to treat BPD, but doctors may prescribe certain drugs to treat symptoms of the disorder, including antidepressants, antipsychotics, and mood stabilizers.

If you experience thoughts of wanting to end your own life, call a medical professional immediately to seek help.

Resources:

  1. Lieb, K., Zanarini, M.C., Schmahl, C., Linehan, M.M., & Bohus, M. (2004). Borderline Personality Disorder. The Lancet, 364(9432), 453-461. Retrieved from https://doi.org/10.1016/S0140-6736(04)16770-6
  2. American Psychiatric Association. (2013, text revision 2022). Personality Disorders. In The Diagnostic and Statistical Manual of Mental Disorders(5thed., text rev.). APA. Retrieved from https://doi.org/10.1176/appi.books.9780890425787.x18_Personality_Disorders
  3. Chapman, J., Jamil, R.T., & Fleisher, C. (2022). Borderline Personality Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430883/
  4. Hall, K. (2021). Fear of Abandonment. National Education Alliance for Borderline Personality Disorder. Retrieved from https://www.borderlinepersonalitydisorder.org/fear-of-abandonment/
  5. National Alliance on Mental Illness. (Reviewed 2017). Borderline Personality Disorder. NAMI. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Borderline-Personality-Disorder/Overview
  6. National Institute of Mental Health. (n.d). Borderline Personality Disorder. NIH. Retrieved from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder
  7. Mendez-Miller, M., Naccarato, J., & Radico, J. A. (2022). Borderline Personality Disorder. American Family Physician, 105(2), 156–161. Retrieved from https://pubmed.ncbi.nlm.nih.gov/35166488/
  8. Reichl, C., & Kaess, M. (2021). Self-Harm in the Context of Borderline Personality Disorder. Current Opinion in Psychology, 37, 139-144. Retrieved from https://doi.org/10.1016/j.copsyc.2020.12.007
  9. Paris J. (2019). Suicidality in Borderline Personality Disorder. Medicina (Kaunas, Lithuania), 55(6), 223. Retrieved from https://doi.org/10.3390/medicina55060223
  10. Colle, L., Hilviu, D., Rossi, R., Garbarini, F., & Fossataro, C. (2020). Self-Harming and Sense of Agency in Patients with Borderline Personality Disorder. Frontiers in Psychiatry, 11. Retrieved from https://doi.org/10.3389/fpsyt.2020.00449
  11. Miller, C.E., Townsend, M.L. & Grenyer, B.F.S. (2021). Understanding Chronic Feelings of Emptiness in Borderline Personality Disorder: A Qualitative Study. Borderline Personality Disorder and Emotion Dysregulation, 8(24).Retrieved from https://doi.org/10.1186/s40479-021-00164-8
  12. Berenson, K.R., Downey, G., Rafaeli, E., Coifman, K.G., & Paquin, N.L. (2011). The Rejection-Rage Contingency in Borderline Personality Disorder. Journal of Abnormal Psychology, 120(3), 681-690. Retrieved from https://doi.org/10.1037/a0023335
  13. Glaser, J.P., Van Os, J., Thewissen, V., & Myin-Germeys, I. (2010). Psychotic Reactivity in Borderline Personality Disorder. Acta Psychiatrica Scandinavica, 121(2), 125–134. Retrieved from https://doi.org/10.1111/j.1600-0447.2009.01427.x