Editing Borderline personality disorder (section)

== Signs and symptoms ==
[[File:BPD 1.png|thumb|alt=On the right a girl reaches out her arm for a male who is looking the other way, they are both black silhouettes. The girl has short hair and white squiggly lines in her body that condense near her heart and resemble lines seen on a black marble floor, and the male has a crew cut|One of the symptoms of BPD is an intense fear of emotional abandonment.]]

Borderline personality disorder, as outlined in the [[DSM-5]], manifests through nine distinct [[symptoms]], with a [[diagnosis]] requiring at least five of the following criteria to be met:<ref>{{cite web|title=Diagnostic criteria for 301.83 Borderline Personality Disorder – Behavenet|url=https://behavenet.com/diagnostic-criteria-30183-borderline-personality-disorder|url-status=live|archive-url=https://web.archive.org/web/20190328215426/https://behavenet.com/diagnostic-criteria-30183-borderline-personality-disorder|archive-date=28 March 2019|access-date=23 March 2019|website=behavenet.com|quote=A pervasive pattern of instability of interpersonal relationships, self-image, and affects [...] indicated by five (or more) of the following: [...]}}</ref>

# Frantic efforts to avoid real or imagined [[Abandonment (emotional)|emotional abandonment]].
# Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of [[idealization and devaluation]], also known as '[[Splitting (psychology)|splitting]]'.<ref>{{cite journal|vauthors=Fertuck EA, Fischer S, Beeney J|date=December 2018|title=Social Cognition and Borderline Personality Disorder: Splitting and Trust Impairment Findings|url=https://www.sciencedirect.com/science/article/abs/pii/S0193953X18311328|journal=The Psychiatric Clinics of North America|volume=41|issue=4|pages=613–632|doi=10.1016/j.psc.2018.07.003|pmid=30447728|s2cid=53948600|url-access=subscription|quote=BPO [Borderline Personality Organization] is rooted in psychoanalytic object relations theory (ORT) which conceptualizes BPD and BPO to exhibit a propensity to view significant others as either idealized or persecutory (splitting) and a trait-like paranoid view of interpersonal relations. From the ORT model, those with BPD think that they will ultimately be betrayed, abandoned, or neglected by significant others, despite periodic idealizations.|via=Elsevier Science Direct}}</ref>
# A markedly [[Identity disturbance|disturbed sense of identity]] and distorted [[self-image]].<ref name="NIH2016" />
# [[Impulsive (behavior)|Impulsive]] or reckless behaviors, including uncontrollable spending, unsafe sexual practices, substance use disorder, reckless driving, and [[binge eating]].
# Recurrent [[suicidal ideation]] or behaviors involving self-harm.
# Rapidly shifting intense [[emotional dysregulation]].
# Chronic feelings of [[emptiness]].
# Inappropriate, intense anger that can be difficult to control.
# Transient, stress-related [[paranoid ideation]] or severe [[Dissociation (psychology)|dissociative]] symptoms.

The distinguishing characteristics of BPD include a pervasive pattern of instability in one's interpersonal relationships and in one's self-image, with frequent oscillation between extremes of idealization and devaluation of others, alongside fluctuating moods and difficulty regulating intense emotional reactions. Dangerous or impulsive behaviors are commonly associated with BPD.

Additional symptoms may encompass uncertainty about one's [[Identity (social science)|identity]], [[values]], [[morals]], and [[belief]]s; experiencing paranoid thoughts under stress; episodes of [[depersonalization]]; and, in moderate to severe cases, stress-induced breaks with reality or episodes of [[psychosis]]. It is also common for individuals with BPD to have [[Comorbidity|comorbid conditions]] such as [[Depressive disorder|depressive]] or [[bipolar disorders]], [[substance use disorders]], [[eating disorders]], [[post-traumatic stress disorder]] (PTSD), and [[attention-deficit hyperactivity disorder|attention deficit hyperactivity disorder]] (ADHD).<ref name="DSM-5 Task Force_2013">{{cite book|author=((DSM-5 Task Force))|url=http://worldcat.org/oclc/863153409|title=Diagnostic and Statistical Manual of Mental Disorders : DSM-5|publisher=American Psychiatric Association|year=2013|isbn=978-0-89042-554-1|oclc=863153409|access-date=23 September 2020|archive-url=https://web.archive.org/web/20201204232019/https://www.worldcat.org/title/diagnostic-and-statistical-manual-of-mental-disorders-dsm-5/oclc/863153409|archive-date=4 December 2020|url-status=live}}</ref>

===Mood and affect===
{{Further|Emotional dysregulation}}
Individuals with BPD exhibit emotional dysregulation.<!-- This is actually a Transclusion of the first paragraph of the lede of [[Emotional dysregulation]] --> Emotional dysregulation is characterized by an inability to flexibly respond to and manage [[emotional state]]s, resulting in intense and prolonged emotional reactions that deviate from [[social norms]], given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli.<ref>{{Cite book|last1=Austin|first1=Marie-Paule|title=Mental Health Care in the Perinatal Period|last2=Highet|first2=Nicole|last3=Expert Working Group|publisher=Centre of Perinatal Excellence|year=2017|location=Melbourne}}</ref><ref>{{harvnb|Linehan|1993|page=43}}</ref><ref name="Manning_364">{{harvnb|Manning|2011|page=36}}</ref><ref name="CE">{{Cite journal|last1=Carpenter|first1=Ryan W.|last2=Trull|first2=Timothy J.|date=January 2013|title=Components of Emotion Dysregulation in Borderline Personality Disorder: A Review|journal=Current Psychiatry Reports|volume=15|issue=1|page=335|doi=10.1007/s11920-012-0335-2|pmid=23250816|pmc=3973423|issn=1523-3812}}</ref>

A core characteristic of BPD is ''affective instability'', which manifests as rapid and frequent shifts in [[Mood (psychology)|mood]] of high [[Affect (psychology)|affect]] intensity and rapid onset of [[emotion]]s, triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to [[Social cue|psychosocial cues]], leading to significant challenges in managing emotions effectively.<ref>{{cite book|title=Abnormal Psychology|vauthors=Hooley J, Butcher JM, Nock MK|date=2017|publisher=[[Pearson Education]]|isbn=978-0-13-385205-9|edition=17th|location=London, England|page=359}}</ref><ref name="Linehan_45">{{harvnb|Linehan|1993|page=45}}</ref><ref>{{Cite journal|last1=Dick|first1=Alexandra M.|last2=Suvak|first2=Michael K.|date=July 2018|title=Borderline personality disorder affective instability: What you know impacts how you feel.|journal=Personality Disorders: Theory, Research, and Treatment|volume=9|issue=4|pages=369–378|doi=10.1037/per0000280|issn=1949-2723|pmc=6033624|pmid=29461071}}</ref>

As the first component of emotional dysregulation, individuals with BPD are shown to have increased [[emotional sensitivity]], especially towards negative mood states such as fear, anger, sadness, rejection, criticism, isolation, and perceived failure.<ref name="CE" /><ref>{{cite journal|vauthors=Stiglmayr CE, Grathwol T, Linehan MM, Ihorst G, Fahrenberg J, Bohus M|date=May 2005|title=Aversive tension in patients with borderline personality disorder: a computer-based controlled field study|journal=Acta Psychiatrica Scandinavica|volume=111|issue=5|pages=372–9|doi=10.1111/j.1600-0447.2004.00466.x|pmid=15819731|s2cid=30951552}}</ref> This increased sensitivity results in an intensified response to environmental cues, including the emotions of others.<ref name="CE" /> Studies have identified a [[negativity bias]] in those with BPD, showing a predisposition towards recognizing and reacting more strongly to negative emotions in others, along with an [[attentional bias]] towards processing negatively-[[Valence (psychology)|valenced]] stimuli.<ref name="CE" /> Without effective [[coping mechanisms]], individuals might resort to self-harm, or suicidal behaviors to manage or escape from these intense negative emotions.<ref name = reasons_NSSI /><ref name="CE" /> While conscious of the exaggerated nature of their emotional responses, individuals with BPD face challenges in regulating these emotions. To mitigate further distress, there may be an unconscious suppression of emotional awareness, which paradoxically hinders the recognition of situations requiring intervention.<ref name=Linehan_45 />

A second component of emotional dysregulation in BPD is high levels of [[negative affectivity]], stemming directly from the individual's emotional sensitivity to negative emotions.<ref name="EP" /> This negative affectivity causes emotional reactions that diverge from [[Social norm|socially accepted norms]], in ways that are disproportionate to the environmental stimuli presented.<ref name="CE" /> Those with BPD find it difficult to tolerate the distress that is encountered in daily life, and they are prone to engage in maladaptive strategies to try to reduce the distress experienced. Maladaptive coping strategies include [[Rumination (psychology)|rumination]], [[thought suppression]], [[experiential avoidance]], [[emotional isolation]], as well as impulsive and self-injurious behaviours.<ref name="CE" />

American psychologist [[Marsha Linehan]] highlights that while the sensitivity, intensity, and duration of emotional experiences in individuals with BPD can have positive outcomes, such as exceptional enthusiasm, idealism, and capacity for joy and love, it also predisposes them to be overwhelmed by negative emotions.<ref name="Linehan_45" /><ref name="Linehan_44">{{harvnb|Linehan|1993|page=44}}</ref> This includes experiencing profound [[grief]] instead of mere sadness, intense shame instead of mild embarrassment, rage rather than annoyance, and panic over nervousness.<ref name="Linehan_44" /> Research indicates that individuals with BPD endure chronic and substantial emotional suffering.<ref name="DSM-5 Task Force_2013" />

Emotional dysregulation is a significant feature of BPD, yet Fitzpatrick et al. (2022) suggest that such dysregulation may also be observed in other disorders, like [[generalized anxiety disorder]] (GAD). Nonetheless, their findings imply that individuals with BPD particularly struggle with disengaging from negative emotions and achieving emotional equilibrium.<ref>{{cite journal|vauthors=Fitzpatrick S, Varma S, Kuo JR|date=September 2022|title=Is borderline personality disorder really an emotion dysregulation disorder and, if so, how? A comprehensive experimental paradigm|journal=Psychological Medicine|volume=52|issue=12|pages=2319–2331|doi=10.1017/S0033291720004225|pmid=33198829|s2cid=226988308}}</ref>

[[Euphoria]], or transient intense joy, can occur in those with BPD, but they are more commonly afflicted by [[dysphoria]] (a profound state of unease or dissatisfaction), depression, and pervasive distress. Zanarini et al. identified four types of dysphoria characteristic of BPD: intense emotional states, destructiveness or self-destructiveness, feelings of fragmentation or identity loss, and perceptions of [[victimization]].<ref name="dysphoria">{{cite journal|vauthors=Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG|year=1998|title=The pain of being borderline: dysphoric states specific to borderline personality disorder|journal=Harvard Review of Psychiatry|volume=6|issue=4|pages=201–7|doi=10.3109/10673229809000330|pmid=10370445|s2cid=10093822}}</ref> A diagnosis of BPD is closely linked with experiencing feelings of betrayal, lack of control, and self-harm.<ref name="dysphoria" />

Moreover, [[emotional lability]], indicating variability or fluctuations in emotional states, is frequent among those with BPD. Although emotional lability may imply rapid alternations between depression and elation, [[mood swing]]s in BPD are more commonly between anger and anxiety or depression and anxiety.<ref>{{cite journal|vauthors=Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, Goodman M, Silverman JM, Serby M, Schopick F, Siever LJ|date=May 2002|title=Characterizing affective instability in borderline personality disorder|journal=The American Journal of Psychiatry|volume=159|issue=5|pages=784–8|doi=10.1176/appi.ajp.159.5.784|pmid=11986132}}</ref>

===Interpersonal relationships===
Interpersonal relationships are significantly impacted in individuals with BPD, characterized by a heightened sensitivity to the behavior and actions of others. Individuals with BPD can be very conscious of and susceptible to their perceived or real treatment by others. Individuals may experience profound happiness and gratitude for perceived kindness, yet feel intense sadness or anger<ref>{{Cite journal|vauthors=Hepp J, Lane SP, Carpenter RW, Niedtfeld I, Brown WC, Trull TJ|year=2017|title=Interpersonal Problems and Negative Affect in Borderline Personality and Depressive Disorders in Daily Life|journal=[[Clinical Psychological Science]]|publisher=[[Sage Publishing]]|volume=5|issue=3|pages=470–484|doi=10.1177/2167702616677312|pmid=28529826|pmc=5436804|quote=[We] assessed the relations between momentary negative affect (hostility, sadness, fear) and interpersonal problems (rejection, disagreement) in a sample of 80 BPD and 51 depressed outpatients at 6 time-points over 28 days [...] Results revealed a mutually reinforcing relationship between disagreement and hostility, rejection and hostility, and between rejection and sadness in both groups, at the momentary and day level. The mutual reinforcement between hostility and rejection/disagreement was significantly stronger in the BPD group.}}</ref> towards perceived criticism or harm.<ref name="cogemo">{{cite journal|vauthors=Arntz A|date=September 2005|title=Introduction to special issue: cognition and emotion in borderline personality disorder|journal=[[Journal of Behavior Therapy and Experimental Psychiatry]]|volume=36|issue=3|pages=167–72|doi=10.1016/j.jbtep.2005.06.001|pmid=16018875}}</ref> A notable feature of BPD is the tendency to engage in [[idealization and devaluation]] of others – that is to idealize and subsequently devalue others – oscillating between extreme admiration and profound mistrust or dislike.<ref>{{harvnb|Linehan|1993|page=146}}</ref> This pattern, referred to as "[[Splitting (psychology)|splitting]]", can significantly influence the dynamics of interpersonal relationships.<ref>{{cite web|title=What Is BPD: Symptoms|url=http://www.borderlinepersonalitydisorder.com/understading-bpd/|url-status=dead|archive-url=https://web.archive.org/web/20130210110927/http://www.borderlinepersonalitydisorder.com/understading-bpd/|archive-date=10 February 2013|access-date=31 January 2013|website=National Education Alliance for Borderline Personality Disorder}}</ref><ref name="Robinson">{{cite book|vauthors=Robinson DJ|title=Disordered Personalities|publisher=Rapid Psychler Press|year=2005|pages=255–310|isbn=978-1-894328-09-8}}</ref> In addition to this external "splitting",  patients with BPD typically have internal splitting, i.e. vacillation between considering oneself a good person who has been mistreated (in which case anger predominates) and a bad person whose life has no value (in which case self-destructive or even suicidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking.<ref name="Gund2011" />

Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent, or fearfully preoccupied [[Attachment theory#Attachment patterns|attachment styles]] in relationships, complicating their interactions and connections with others.<ref>{{cite journal|vauthors=Levy KN, Meehan KB, Weber M, Reynoso J, Clarkin JF|title=Attachment and borderline personality disorder: implications for psychotherapy|journal=Psychopathology|volume=38|issue=2|pages=64–74|year=2005|pmid=15802944|doi=10.1159/000084813|s2cid=10203453}}</ref> Family members, including parents of adults with BPD, may find themselves in a cycle of being overly involved in the individual's life at times and, at other times, significantly detached,<ref name="parents">{{cite journal|vauthors=Allen DM, Farmer RG|title=Family relationships of adults with borderline personality disorder|journal=Comprehensive Psychiatry|volume=37|issue=1|pages=43–51|year=1996|pmid=8770526|doi=10.1016/S0010-440X(96)90050-4}}</ref> contributing to a sense of alienation within the family unit.<ref name="Gund2011">{{cite journal|vauthors=Gunderson JG|title=Clinical practice. Borderline personality disorder|journal=The New England Journal of Medicine|volume=364|issue=21|pages=2037–2042|date=May 2011|pmid=21612472|doi=10.1056/NEJMcp1007358|hdl=10150/631040|hdl-access=free}}</ref> Anthropologist Rebecca Lester argues that BPD is a disorder of relationships and communication, namely that a person with BPD lacks the communication skills and knowledge to interact effectively with others within their society and culture given their life experience.<ref name="Lester 70–77">{{Cite journal|last=Lester|first=Rebecca J|date=February 2013|title=Lessons from the borderline: Anthropology, psychiatry, and the risks of being human|url=http://journals.sagepub.com/doi/10.1177/0959353512467969|journal=Feminism & Psychology|volume=23|issue=1|pages=70–77|doi=10.1177/0959353512467969|issn=0959-3535}}</ref>

[[Personality disorders]], including BPD, are associated with an increased incidence of [[chronic stress]] and conflict, reduced satisfaction in romantic partnerships, [[domestic abuse]], and [[unintended pregnancies]].<ref name="Daley SE, Burge D, Hammen C 2000 451–60">{{cite journal|vauthors=Daley SE, Burge D, Hammen C|title=Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity|journal=Journal of Abnormal Psychology|volume=109|issue=3|pages=451–460|date=August 2000|pmid=11016115|doi=10.1037/0021-843X.109.3.451|citeseerx=10.1.1.588.6902}}</ref> Research indicates variability in relationship patterns among individuals with BPD. A portion of these individuals may transition rapidly between relationships, a pattern metaphorically described as "butterfly-like," characterized by fleeting and transient interactions and "fluttering" in and out of relationships.<ref name="Ryan_2007">{{Cite journal|vauthors=Ryan K, Shean G|date=2007-01-01|title=Patterns of interpersonal behaviors and borderline personality characteristics|journal=Personality and Individual Differences|volume=42|issue=2|pages=193–200|doi=10.1016/j.paid.2006.06.010|issn=0191-8869}}</ref> Conversely, a subgroup, referred to as "attached," tends to establish fewer but more intense and dependent relationships. These connections often form rapidly, evolving into deeply intertwined and tumultuous bonds.<ref name="Ryan_2007" /> In certain cases, BPD may be recognized as a [[disability]] within the workplace, particularly if the condition's severity results in behaviors that undermine relationships, involve engagement in risky activities, or manifest as intense anger, thereby inhibiting the individual's ability to perform their job role effectively.<ref>{{cite journal|vauthors=Arvig TJ|title=Borderline personality disorder and disability|journal=AAOHN Journal|volume=59|issue=4|pages=158–60|date=April 2011|pmid=21462898|doi=10.1177/216507991105900401|doi-access=free}}</ref>

Individuals with BPD express higher levels of jealousy towards their partners in romantic relations.<ref>{{cite journal|doi=10.1016/j.avb.2016.03.005|title=Battering typologies, attachment insecurity, and personality disorders: A comprehensive literature review|year=2016|last1=Cameranesi|first1=Margherita|journal=Aggression and Violent Behavior|volume=28|pages=29–46}}</ref><ref name="pmid16757985">{{cite journal|vauthors=Stone MH|title=Management of borderline personality disorder: a review of psychotherapeutic approaches|journal=World Psychiatry|volume=5|issue=1|pages=15–20|date=February 2006|pmid=16757985|pmc=1472266}}</ref>

===Behavior===
Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, and self-injury among other self-harming practices.<ref name=Manning_18/> These behaviors are a response to the intense emotional distress experienced by individuals with BPD, serving as an immediate but temporary alleviation of their [[emotional pain]].<ref name=Manning_18/> However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle.<ref name=Manning_18>{{harvnb|Manning|2011|page=18}}</ref> This cycle typically begins with emotional discomfort, followed by impulsive behavior aimed at mitigating this discomfort, only to lead to shame and guilt, which in turn exacerbates the emotional pain.<ref name=Manning_18/> This escalation of emotional pain then intensifies the [[Compulsive behavior|compulsion]] towards impulsive behavior as a form of relief, creating a vicious cycle. Over time, these impulsive responses can become an automatic mechanism for coping with emotional pain.<ref name=Manning_18/>

===Self-harm and suicide===<!-- Self harm -->

Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5.<ref name="DSM53" /> Between 50% and 80% of individuals diagnosed with BPD<!--<ref name=Ou2008/> --> engage in self-harm, with [[cutting]] being the most common method.<ref name="Ou2008">{{cite journal|vauthors=Oumaya M, Friedman S, Pham A, Abou Abdallah T, Guelfi JD, Rouillon F|title=[Borderline personality disorder, self-mutilation and suicide: literature review]|language=fr|journal=L'Encéphale|volume=34|issue=5|pages=452–8|date=October 2008|pmid=19068333|doi=10.1016/j.encep.2007.10.007}}</ref> Other methods, such as bruising, burning, head banging, or biting, are also prevalent.<ref name="Ou2008" /> It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.<ref name="DucasseCourtet2014">{{cite journal|vauthors=Ducasse D, Courtet P, Olié E|title=Physical and social pains in borderline disorder and neuroanatomical correlates: a systematic review|journal=Current Psychiatry Reports|volume=16|issue=5|pages=443|date=May 2014|pmid=24633938|doi=10.1007/s11920-014-0443-2|s2cid=25918270}}</ref><!-- Suicide -->

Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation.<ref name="pmid31142033">{{cite journal|vauthors=Paris J|year=2019|title=Suicidality in Borderline Personality Disorder.|journal=Medicina (Kaunas)|volume=55|issue=6|page=223|doi=10.3390/medicina55060223|pmc=6632023|pmid=31142033|doi-access=free}}</ref><ref name="Gund2011" /><ref>{{cite book|title=Borderline Personality Disorder: A Clinical Guide|vauthors=Gunderson JG, Links PS|publisher=American Psychiatric Publishing, Inc|year=2008|isbn=978-1-58562-335-8|edition=2nd|page=9}}</ref> There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD.<ref name="Paris J 2008 21–22">{{cite book|vauthors=Paris J|title=Treatment of Borderline Personality Disorder. A Guide to Evidence-Based Practice|year=2008|publisher=The Guilford Press|pages=21–22}}</ref><!-- Reasons -->

The motivations behind self-harm and [[suicide attempts]] among individuals with BPD are reported to differ.<ref name="reasons_NSSI">{{cite journal|vauthors=Brown MZ, Comtois KA, Linehan MM|s2cid=4649933|title=Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder|journal=Journal of Abnormal Psychology|volume=111|issue=1|pages=198–202|date=February 2002|pmid=11866174|doi=10.1037/0021-843X.111.1.198}}</ref> Nearly 70% of individuals with BPD engage in self-harm without the intention of ending their lives. Motivations for self-harm include expressing anger, self-punishment, inducing normal feelings or feelings of normality in response to dissociative episodes, and distraction from emotional distress or challenging situations.<ref name="reasons_NSSI" />{{Secondary source needed|date=April 2025}} Conversely, true suicide attempts by individuals with BPD frequently are motivated by the notion that others will be better off in their absence.<ref name="reasons_NSSI" />{{Secondary source needed|date=April 2025}}

===Sense of self and self-concept===
Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable [[self-concept]].<ref>{{Cite journal|last1=Vater|first1=Aline|last2=Schröder|first2=Michela|last3=Weißgerber|first3=Susan|last4=Roepke|first4=Stefan|last5=Schütz|first5=Astrid|date=March 2015|title=Self-concept structure and borderline personality disorder: Evidence for negative compartmentalization|url=https://www.sciencedirect.com/science/article/abs/pii/S0005791614000731|journal=[[Journal of Behavior Therapy and Experimental Psychiatry]]|publisher=[[Elsevier]]|volume=46|pages=50–58|doi=10.1016/j.jbtep.2014.08.003|pmid=25222626|quote=Borderline personality disorder (BPD) is characterized by an unstable and incongruent self-concept. [...] The results of our study show that patients with BPD exhibit more compartmentalized self-concepts than non-clinical and depressed individuals, i.e., they have difficulties incorporating both positive and negative traits within separate self-aspects.}}</ref> This instability manifests as uncertainty in personal [[values]], [[belief]]s, [[preference]]s, and interests.<ref name="Manning_23" /> They may also express confusion regarding their aspirations and objectives in terms of relationships and career paths. Such indeterminacy leads to feelings of emptiness and a profound sense of disorientation regarding their own [[Identity (social science)|identity]].<ref name=Manning_23/> Moreover, their [[Self-perception theory|self-perception]] can fluctuate dramatically over short periods, oscillating between positive and negative evaluations. Consequently, individuals with BPD might adopt their sense of self based on their surroundings or the people they interact with, resulting in a chameleon-like adaptation of identity.<ref>{{cite journal|vauthors=Biskin RS, Paris J|title=Diagnosing borderline personality disorder|journal=CMAJ|volume=184|issue=16|pages=1789–1794|date=November 2012|pmid=22988153|pmc=3494330|doi=10.1503/cmaj.090618}}</ref>

===Dissociation and cognitive challenges===
The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function.<ref name=Manning_23>{{harvnb|Manning|2011|page=23}}</ref> Additionally, individuals with BPD may frequently [[Dissociation (psychology)|dissociate]], which can be regarded as a mild to severe disconnection from physical and emotional experiences.<ref name=Manning_24>{{harvnb|Manning|2011|page=24}}</ref> Observers may notice signs of dissociation in individuals with BPD through diminished expressiveness in their face or voice, or an apparent disconnection and insensitivity to emotional cues or stimuli.<ref name=Manning_24/>

=== Psychotic symptoms ===
BPD is predominantly characterized as a disorder involving emotional dysregulation, yet psychotic symptoms frequently occur in individuals with BPD, with about 20–50% of patients reporting psychotic symptoms.<ref name="Schroeder_2013">{{cite journal|vauthors=Schroeder K, Fisher HL, Schäfer I|date=January 2013|editor-last=Pull|editor-first=Charles B.|editor2-last=Janca|editor2-first=Aleksandar|title=Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management|journal=[[Current Opinion (Lippincott Williams & Wilkins) | Current Opinion in Psychiatry]]|volume=26|issue=1|pages=113–9|doi=10.1097/YCO.0b013e32835a2ae7|pmid=23168909|s2cid=25546693|quote=Of patients with BPD about 20–50% report psychotic symptoms. Hallucinations can be similar to those in patients with psychotic disorders in terms of phenomenology, emotional impact, and their persistence over time [...] terms like pseudo-psychotic or quasi-psychotic are misleading and should be avoided [...] and current diagnostic systems might require revision to emphasise psychotic symptoms.|doi-access=free}}</ref> These manifestations have historically been labeled as "pseudo-psychotic" or "psychotic-like", implying a differentiation from symptoms observed in primary [[psychotic disorders]]. Studies conducted in the 2010s suggest a closer similarity between psychotic symptoms in BPD and those in recognized psychotic disorders than previously understood.<ref name="Schroeder_2013" /><ref name="Niemantsverdriet_2017">{{cite journal|vauthors=Niemantsverdriet MB, Slotema CW, Blom JD, Franken IH, Hoek HW, Sommer IE, van der Gaag M|title=Hallucinations in borderline personality disorder: Prevalence, characteristics and associations with comorbid symptoms and disorders|journal=Scientific Reports|volume=7|issue=1|pages=13920|date=October 2017|pmid=29066713|pmc=5654997|doi=10.1038/s41598-017-13108-6|bibcode=2017NatSR...713920N}}</ref> The distinction of pseudo-psychosis has faced criticism for its weak [[construct validity]] and the potential to diminish the perceived severity of these symptoms, potentially hindering accurate diagnosis and effective treatment. Consequently, there are suggestions from some in the research community to categorize these symptoms as genuine psychosis, advocating for the abolishment of the distinction between pseudo-psychosis and true psychosis.<ref name="Schroeder_2013" /><ref name="Slotema_2018">{{cite journal|vauthors=Slotema CW, Blom JD, Niemantsverdriet MB, Sommer IE|title=Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review|journal=Frontiers in Psychiatry|volume=9|pages=347|date=31 July 2018|pmid=30108529|pmc=6079212|doi=10.3389/fpsyt.2018.00347|doi-access=free}}</ref>

The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD.<ref name="DSM53"/> Research has identified the presence of both [[hallucination]]s and [[delusions]] in individuals with BPD who do not possess an alternate diagnosis that would better explain these symptoms.<ref name="Niemantsverdriet_2017" /> Further, [[Interpretative phenomenological analysis|phenomenological analysis]] indicates that [[auditory verbal hallucinations]] in BPD patients are indistinguishable from those observed in [[schizophrenia]].<ref name="Niemantsverdriet_2017" /><ref name="Slotema_2018" /> This has led to suggestions of a potential shared [[etiological]] basis for hallucinations across BPD and other disorders, including psychotic and [[affective disorder]]s.<ref name="Niemantsverdriet_2017" />