Editing Borderline personality disorder

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{{Infobox medical condition (new)
| name = Borderline personality disorder
| image = File:Edvard Munch - The Brooch. Eva Mudocci - Google Art Project.jpg
| image_size = 280px
| caption = ''Idealization'' by [[Edvard Munch]] (1903), who is presumed to have had borderline personality disorder<ref>{{cite book|title=Edvard Munch: The Life of a Person with Borderline Personality as Seen Through His Art|trans-title=Edvard Munch, et livsløb af en grænsepersonlighed forstået gennem hans billeder|isbn=978-87-983524-1-9|vauthors=Aarkrog T|year=1990|publisher=Lundbeck Pharma A/S|location=Danmark}}</ref>
| field = [[Psychiatry]], [[clinical psychology]]
| synonyms = {{collapsible list|title={{pad}}|{{plainlist|
* Emotionally unstable personality disorder – impulsive or borderline type<ref name=Maj2005>{{cite book|vauthors=Cloninger RC|veditors=Maj M, Akiskal HS, Mezzich JE|chapter=Antisocial Personality Disorder: A Review|title=Personality disorders|date=2005|publisher=[[John Wiley & Sons]]|location=New York City|isbn=978-0-470-09036-7|page=126|chapter-url=https://books.google.com/books?id=9fgwbCW7OQMC&pg=PA126|access-date=5 June 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232038/https://books.google.com/books?id=9fgwbCW7OQMC&pg=PA126|url-status=live}}</ref>
* Emotional intensity disorder<ref>{{cite book|vauthors=Blom JD|title=A Dictionary of Hallucinations|date=2010|publisher=Springer|location=New York|isbn=978-1-4419-1223-7|page=74|edition=1st|url=https://books.google.com/books?id=KJtQptBcZloC&pg=PA74|access-date=5 June 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232039/https://books.google.com/books?id=KJtQptBcZloC&pg=PA74|url-status=live}}</ref>
* [[Hysteria]]<ref>{{cite book|url=https://psycnet.apa.org/record/2000-07204-000|vauthors=Bollas C|title=Hysteria|publisher=Taylor & Francis|collaboration=American Psychological Association|edition=1st|date=2000|access-date=December 14, 2022|archive-date=15 December 2022|archive-url=https://web.archive.org/web/20221215023801/https://psycnet.apa.org/record/2000-07204-000|url-status=live}}</ref>
* Hysteric personality – Hysteroid<ref name=NLM>{{cite journal|vauthors=Novais F, Araújo A, Godinho P|title=Historical roots of histrionic personality disorder|journal=Frontiers in Psychology|volume=6|issue=1463|pages=1463|date=25 September 2015|pmid=26441812|pmc=4585318|doi=10.3389/fpsyg.2015.01463|doi-access=free}}</ref>
* [[Negative affectivity]]/[[neuroticism]]<ref name=ICD11>{{cite web|title=ICD-11 – ICD-11 for Mortality and Morbidity Statistics|url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f953246526|access-date=6 October 2021|publisher=World Health Organization|archive-date=1 August 2018|archive-url=https://archive.today/20180801205234/https://icd.who.int/browse11/l-m/en%23/http://id.who.int/icd/entity/294762853#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f953246526|url-status=live}}</ref>
}} }}
| symptoms = Unstable [[interpersonal relationships|relationships]], distorted [[self-image|sense of self]], and intense [[affect (psychology)|emotions]]; [[impulsivity]]; recurrent suicidal and [[self-harm]]ing behavior; fear of [[abandonment (emotional)|abandonment]]; chronic feelings of [[emptiness]]; inappropriate [[anger]]; [[Dissociation (psychology)|dissociation]]<ref name=NIH2016/><ref name="DSM53"/>
| complications = Suicide, self-harm<ref name=NIH2016/>
| onset = Early adulthood<ref name="DSM53"/>
| duration = Long term<ref name=NIH2016/>
| causes = Genetic, neurobiologic, and psychosocial theories proposed
| risks = 
| diagnosis = Based on reported symptoms<ref name=NIH2016/>
| differential = See [[#Differential diagnosis and comorbidity|§ Differential diagnosis]]<!--[[Bipolar disorder]], [[attachment disorder]], [[dissociative identity disorder]], [[identity disorder]], [[mood disorder]]s, [[post-traumatic stress disorder]], [[complex post-traumatic stress disorder|CPTSD]], [[substance use disorder]]s, [[attention deficit hyperactivity disorder|ADHD]], [[Personality disorder#Cluster B (emotional or erratic disorders)|histrionic, narcissistic, or antisocial personality disorder]]<ref name="DSM53"/><ref>{{cite web|title=Borderline Personality Disorder Differential Diagnoses|url=https://emedicine.medscape.com/article/913575-differential|publisher=[[Medscape]]|date=5 November 2018|vauthors=Lubit RH|access-date=10 March 2020|archive-date=29 April 2011|archive-url=https://web.archive.org/web/20110429130848/https://emedicine.medscape.com/article/913575-differential|url-status=live}}</ref>-->
| prevention = 
| treatment = [[Behaviour therapy]]<ref name=NIH2016/>
| medication = 
| prognosis = Improves over time,<ref name="DSM53"/> remission occurs in 45% of patients over a wide range of follow-up periods<ref name="Skodol Siever Livesley Gunderson 2002 pp. 951–963">{{cite journal|last1=Skodol|first1=Andrew E|last2=Siever|first2=Larry J|last3=Livesley|first3=W.John|last4=Gunderson|first4=John G|last5=Pfohl|first5=Bruce|last6=Widiger|first6=Thomas A|title=The borderline diagnosis II: biology, genetics, and clinical course|journal=Biological Psychiatry|volume=51|issue=12|year=2002|doi=10.1016/S0006-3223(02)01325-2|pages=951–963|pmid=12062878}}</ref><ref name="Skodol Bender Pagano Shea 2007 pp. 1102–1108">{{cite journal|last1=Skodol|first1=Andrew E.|last2=Bender|first2=Donna S.|last3=Pagano|first3=Maria E.|last4=Shea|first4=M. Tracie|last5=Yen|first5=Shirley|last6=Sanislow|first6=Charles A.|last7=Grilo|first7=Carlos M.|last8=Daversa|first8=Maria T.|last9=Stout|first9=Robert L. | last10=Zanarini | first10=Mary C.|last11=McGlashan|first11=Thomas H.|last12=Gunderson|first12=John G.|title=Positive Childhood Experiences: Resilience and Recovery From Personality Disorder in Early Adulthood|journal=The Journal of Clinical Psychiatry|volume=68|issue=7|date=2007-07-15|issn=0160-6689|pmid=17685749|pmc=2705622|doi=10.4088/JCP.v68n0719|pages=1102–1108}}</ref><ref name="Zanarini Frankenburg Hennen Reich 2006 pp. 827–832">{{cite journal|last1=Zanarini|first1=Mary C.|last2=Frankenburg|first2=Frances R.|last3=Hennen|first3=John|last4=Reich|first4=D. Bradford|last5=Silk|first5=Kenneth R.|title=Prediction of the 10-Year Course of Borderline Personality Disorder|journal=American Journal of Psychiatry|volume=163|issue=5|year=2006|issn=0002-953X|doi=10.1176/ajp.2006.163.5.827|pages=827–832|pmid=16648323}}</ref><ref name="Zanarini Frankenburg Reich Fitzmaurice 2010 pp. 663–667">{{cite journal|last1=Zanarini|first1=Mary C.|last2=Frankenburg|first2=Frances R.|last3=Reich|first3=D. Bradford|last4=Fitzmaurice|first4=Garrett|title=Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-year Prospective Follow-Up Study|journal=American Journal of Psychiatry|volume=167|issue=6|year=2010|issn=0002-953X|pmid=20395399|pmc=3203735|doi=10.1176/appi.ajp.2009.09081130|pages=663–667}}</ref><ref name="Zanarini Frankenburg Reich Fitzmaurice 2012 pp. 476–483">{{cite journal|last1=Zanarini|first1=Mary C.|last2=Frankenburg|first2=Frances R.|last3=Reich|first3=D. Bradford|last4=Fitzmaurice|first4=Garrett|title=Attainment and Stability of Sustained Symptomatic Remission and Recovery Among Patients With Borderline Personality Disorder and Axis II Comparison Subjects: A 16-Year Prospective Follow-Up Study|journal=American Journal of Psychiatry|volume=169|issue=5|year=2012|issn=0002-953X|pmid=22737693|pmc=3509999|doi=10.1176/appi.ajp.2011.11101550|pages=476–483}}</ref>
| frequency = 5.9% ([[lifetime prevalence]])<ref name=NIH2016/>
| deaths = 
}}
{{Personality disorders sidebar}}
<!-- Definition and symptoms -->
'''Borderline personality disorder''' ('''BPD''') is a [[personality disorder]] characterized by a pervasive, long-term pattern of significant [[interpersonal relationship]] instability, an acute fear of [[Abandonment (emotional)|abandonment]], and intense [[emotional response|emotional outbursts]].<ref name="DSM53">{{harvnb|American Psychiatric Association|2013|pages=[https://archive.org/details/diagnosticstatis0005unse/page/645 645, 663–6]}}</ref><ref name="NIH20163">{{cite web|title=Borderline Personality Disorder|url=http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|url-status=live|archive-url=https://web.archive.org/web/20160322130612/http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|archive-date=22 March 2016|access-date=16 March 2016|website=NIMH}}</ref><ref>{{cite journal|vauthors=Chapman AL|title=Borderline personality disorder and emotion dysregulation|journal=Development and Psychopathology|volume=31|issue=3|pages=1143–1156|date=August 2019|pmid=31169118|doi=10.1017/S0954579419000658|url=https://www.cambridge.org/core/product/identifier/S0954579419000658/type/journal_article|url-status=live|publisher=[[Cambridge University Press]]|s2cid=174813414|access-date=5 April 2020|archive-url=https://web.archive.org/web/20201204232023/https://www.cambridge.org/core/journals/development-and-psychopathology/article/abs/borderline-personality-disorder-and-emotion-dysregulation/EA2CB1C041307A34392F49279C107987|archive-date=4 December 2020|url-access=subscription}}</ref> People diagnosed with BPD frequently exhibit [[self-harm]]ing behaviours and engage in risky activities, primarily due to [[Emotional dysregulation|challenges regulating emotional states]] to a healthy, stable baseline.<ref>{{cite journal|vauthors=Bozzatello P, Rocca P, Baldassarri L, Bosia M, Bellino S|title=The Role of Trauma in Early Onset Borderline Personality Disorder: A Biopsychosocial Perspective|journal=Frontiers in Psychiatry|volume=12|pages=721361|date=23 September 2021|pmid=34630181|pmc=8495240|doi=10.3389/fpsyt.2021.721361|doi-access=free}}</ref><ref>{{cite journal|vauthors=Cattane N, Rossi R, Lanfredi M, Cattaneo A|title=Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms|journal=BMC Psychiatry|volume=17|issue=1|pages=221|date=June 2017|pmid=28619017|pmc=5472954|doi=10.1186/s12888-017-1383-2|doi-access=free}}</ref><ref>{{cite web|date=December 2017|title=Borderline Personality Disorder|url=https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|access-date=25 February 2021|publisher=The National Institute of Mental Health|quote=Other signs or symptoms may include: [...] Impulsive and often dangerous behaviors [...] Self-harming behavior [...]. Borderline personality disorder is also associated with a significantly higher rate of self-harm and suicidal behavior than the general public.|archive-date=29 March 2023|archive-url=https://web.archive.org/web/20230329213453/http://nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|url-status=live}}</ref> Symptoms such as [[Dissociation (psychology)|dissociation]] (a feeling of [[Emotional detachment|detachment]] from reality), a pervasive sense of [[emptiness]], and distorted [[sense of self]] are prevalent among those affected.<ref name="NIH20163" />

The onset of BPD symptoms can be triggered by events that others might perceive as normal,<ref name="NIH20163" /> with the disorder typically manifesting in early adulthood and persisting across diverse contexts.<ref name="DSM53" /> BPD is often [[Comorbidity|comorbid]] with [[substance use disorder]]s,<ref>{{cite journal|vauthors=Helle AC, Watts AL, Trull TJ, Sher KJ|title=Alcohol Use Disorder and Antisocial and Borderline Personality Disorders|journal=Alcohol Research: Current Reviews|volume=40|issue=1|pages=arcr.v40.1.05|year=2019|pmid=31886107|pmc=6927749|doi=10.35946/arcr.v40.1.05}}</ref><ref>{{Cite journal|last1=Trull|first1=Timothy J.|last2=Freeman|first2=Lindsey K.|last3=Vebares|first3=Tayler J.|last4=Choate|first4=Alexandria M.|last5=Helle|first5=Ashley C.|last6=Wycoff|first6=Andrea M.|date=19 September 2018|title=Borderline personality disorder and substance use disorders: an updated review|journal=[[Borderline Personality Disorder and Emotion Dysregulation]]|language=en|volume=5|issue=1|page=15|doi=10.1186/s40479-018-0093-9|doi-access=free|pmid=30250740|pmc=6145127|issn=2051-6673}}</ref> [[depressive disorders]], and [[eating disorder]]s.<ref name="NIH20163" /> BPD is associated with a substantial risk of [[suicide]];<ref name="DSM53" /><ref name="NIH20163" /> studies estimated that up to 10 percent of people with BPD die by suicide.<ref name="Kreisman J, Strauss H 2004">{{cite book|url=https://archive.org/details/sometimesiactcra00jero|title=Sometimes I Act Crazy. Living With Borderline Personality Disorder|vauthors=Kreisman J, Strauss H|publisher=Wiley & Sons|year=2004|isbn=978-0-471-22286-6|url-access=registration|page=206}}</ref><ref>{{Cite journal|last1=Kaurin|first1=Aleksandra|last2=Dombrovski|first2=Alexandre|last3=Hallquist|first3=Michael|last4=Wright|first4=Aidan|date=2020-12-10|title=Momentary Interpersonal Processes of Suicidal Surges in Borderline Personality Disorder|journal=[[Psychological Medicine]]|volume=52|issue=13|pages=2702–2712|doi=10.1017/S0033291720004791|pmid=33298227|quote=People diagnosed with borderline personality disorder (BPD) are at high risk of dying by suicide: almost all report chronic suicidal ideation, 84% of patients with BPD engage in suicidal behavior, 70% attempt suicide, with a mean of 3.4 lifetime attempts per individual, and 5–10% die by suicide (Black et al., 2004; McGirr et al., 2007; Soloff et al., 1994).|pmc=8190164}}</ref> Despite its severity, BPD faces significant stigmatization in both media portrayals and the psychiatric field, potentially leading to underdiagnosis and insufficient treatment.<ref name="Borderline personality disorder, st">{{cite journal|vauthors=Aviram RB, Brodsky BS, Stanley B|year=2006|title=Borderline personality disorder, stigma, and treatment implications|url=https://static1.squarespace.com/static/5e7bbc0adb05de74ea06f6a0/t/5ea1c293f38c3a5c41f7ed9e/1587659411794/Aviram+BPD+and+Stigma+Har+Rev+Psychiatry.pdf|journal=[[Harvard Review of Psychiatry]]|volume=14|issue=5|pages=249–256|doi=10.1080/10673220600975121|pmid=16990170|s2cid=23923078|access-date=2024-12-24|quote=The stigmatization of BPD is likely to be a result of several characteristics of the BPD syndrome. [... Pejorative] terms such as "difficult," "treatment resistant," "manipulative," "demanding," and "attention seeking" [are used to describe such individuals. This] can have an impact upon the treater's a priori expectations. [... Such] stigmatization is likely to be a result of several characteristics of the BPD syndrome [... and the fact that] psychotherapy with [them] may involve disturbing and frightening behavior, including intense anger, chronic suicidal ideation, self-injury, and suicide attempts. [...Clinicians, under the stigma, may] see lower levels of [their patient's] functioning as deliberate and within [ones] control, or as manipulation, or as a rejection of help, [...and may therefore respond] in unintentially damaging ways, [...possibly by withdrawing] physically and emotionally. [...] It has been found that when one person has negative expectations of another, the former changes his or her behavior toward the latter. These interpersonal situations have been described as self-fulfilling prophecies.}}</ref><ref name="EP">{{Cite journal|vauthors=Dixon-Gordon KL, Peters JR, Fertuck EA, Yen S|year=2017|title=Emotional Processes in Borderline Personality Disorder: An Update for Clinical Practice|journal=[[Journal of Psychotherapy Integration]]|volume=27|issue=4|pages=425–438|doi=10.1037/int0000044|pmc=5842953|pmid=29527105|quote=[Clinicians] may hesitate to [provide treatment to BPD patients] due to discomfort working with the high-risk behaviours and intense interpersonal and emotional dysregulation typical of [the disorder... Treatments supported by empirical evidences include [[Dialectical behavior therapy]], [[Mentalization-based treatment]], [[Transference-focused psychotherapy]], [[Schema therapy|Schema-focused therapy]], and General Psychiatric Magement... On the psychopathology side, it's possible that] emotional reactivity may be [more] pronounced [...] in response to social stressors and in interpersonal and self-conscious emotions (e.g., anger, shame) [...] Emotional vulnerability in BPD may also vary across specific emotions, [particularly for] sadness, hostility, and fear.}}</ref><!--Cause, mechanism, diagnosis-->

<!-- Cause, mechanism, diagnosis -->The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development.<ref name=NIH2016/><ref name=CP2013>{{cite book|title=Clinical Practice Guideline for the Management of Borderline Personality Disorder|publisher=National Health and Medical Research Council|year=2013|isbn=978-1-86496-564-3|location=Melbourne|pages=40–41|quote=In addition to the evidence identified by the systematic review, the Committee also considered a recent narrative review of studies that have evaluated biological and environmental factors as potential risk factors for BPD (including prospective studies of children and adolescents, and studies of young people with BPD)}}</ref> A [[genetic predisposition]] is evident, with the disorder significantly more common in people with a family history of BPD, particularly immediate relatives.<ref name=NIH2016>{{cite web|url=http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|title=Borderline Personality Disorder|website=NIMH|access-date=16 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160322130612/http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|archive-date=22 March 2016}}</ref> Psychosocial factors, particularly [[adverse childhood experiences]], have been proposed.<ref name=Lei2011>{{cite journal|vauthors=Leichsenring F, Leibing E, Kruse J, New AS, Leweke F|title=Borderline personality disorder|journal=[[Lancet (journal)|Lancet]]|volume=377|issue=9759|pages=74–84|date=January 2011|pmid=21195251|doi=10.1016/s0140-6736(10)61422-5|s2cid=17051114}}</ref> The American ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM) classifies BPD in [[cluster B]] ("dramatic, emotional, or erratic" PDs) among [[personality disorders]].<ref name="DSM53"/> There is a risk of [[misdiagnosis]], with BPD most commonly confused with a [[mood disorder]], [[substance use disorders|substance use disorder]], or other mental health disorders.<ref name="DSM53"/><!-- Treatment -->

Therapeutic interventions for BPD predominantly involve [[psychotherapy]], with [[dialectical behavior therapy]] (DBT) and [[schema therapy]] the most effective modalities.<ref name="NIH2016" /><ref name="EP" /> Although [[pharmacotherapy]] cannot cure BPD, it may be employed to mitigate associated symptoms,<ref name="NIH2016" /> with [[Atypical antipsychotic|atypical antipsychotics]] (e.g., [[Quetiapine]]) and [[selective serotonin reuptake inhibitor]] (SSRI) antidepressants commonly being prescribed, though their efficacy is unclear. A 2020 meta-analysis found the use of medications was still unsupported by evidence.<ref name="stofferswinterling20" />

BPD has a [[point prevalence]] of 1.6% and a [[lifetime prevalence]] of 5.9% of the global population,<ref name="DSM53" /><ref name="NIH2016" /><ref name="Wolters Kluwer">{{Cite book|url=https://uptodate.com/|title=UpToDate|publisher=[[Wolters Kluwer]]|chapter=Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis|access-date=13 March 2024|chapter-url=https://www.uptodate.com/contents/borderline-personality-disorder-epidemiology-pathogenesis-clinical-features-course-assessment-and-diagnosis|url-access=subscription|archive-date=6 January 2009|archive-url=https://web.archive.org/web/20090106134307/http://uptodate.com/|url-status=live}}</ref><!-- Quote (in archived version): 'According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year.' --><ref name="nimh.nih.gov">{{cite web|title=NIMH " Personality Disorders|url=https://www.nimh.nih.gov/health/statistics/personality-disorders|access-date=20 May 2021|website=nimh.nih.gov|archive-date=18 June 2022|archive-url=https://web.archive.org/web/20220618193929/https://www.nimh.nih.gov/health/statistics/personality-disorders|url-status=live}}</ref> with a higher [[incidence rate]] among women compared to men in the clinical setting of up to three times.<ref name="DSM53" /><ref name="Wolters Kluwer" /> Despite the high utilization of healthcare resources by people with BPD,<ref name="Bourke_2018">{{cite journal|vauthors=Bourke J, Murphy A, Flynn D, Kells M, Joyce M, Hurley J|title=Borderline personality disorder: resource utilisation costs in Ireland|journal=Irish Journal of Psychological Medicine|volume=38|issue=3|pages=169–176|date=September 2021|pmid=34465404|doi=10.1017/ipm.2018.30|hdl-access=free|hdl=10468/7005}}</ref> up to half may show significant improvement over a ten-year period with appropriate treatment.<ref name="DSM53" /> The name of the disorder, particularly the suitability of the term ''borderline'', is a subject of ongoing debate. Initially, the term reflected historical ideas of ''borderline insanity'' and later described patients on the border between [[neurosis]] and [[psychosis]]. These interpretations are now regarded as outdated and clinically imprecise.<ref name="NIH2016" /><ref>{{cite journal|vauthors=Gunderson JG|title=Borderline personality disorder: ontogeny of a diagnosis|journal=The American Journal of Psychiatry|volume=166|issue=5|pages=530–539|date=May 2009|pmid=19411380|pmc=3145201|doi=10.1176/appi.ajp.2009.08121825}}</ref>
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== 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" />

==Causes==<!-- This section needs its sub-headers redone and re-imagined. -->

The [[etiology]], or causes, of BPD is multifaceted, with no consensus on a singular cause.<ref name="mayo">{{cite web|url=http://www.mayoclinic.com/health/borderline-personality-disorder/DS00442/DSECTION=3|title=Borderline personality disorder|publisher=Mayo Clinic|access-date=15 May 2008|url-status=live|archive-url=https://web.archive.org/web/20080430112844/http://www.mayoclinic.com/health/borderline-personality-disorder/DS00442/DSECTION%3D3|archive-date=30 April 2008}}</ref> BPD may share a connection with [[post-traumatic stress disorder]] (PTSD), having both a traumatic substrate.<ref name="BPD & PTSD">{{cite journal|vauthors=Gunderson JG, Sabo AN|title=The phenomenological and conceptual interface between borderline personality disorder and PTSD|journal=The American Journal of Psychiatry|volume=150|issue=1|pages=19–27|date=January 1993|pmid=8417576|doi=10.1176/ajp.150.1.19}}</ref> While childhood trauma is a recognized contributing factor, the roles of congenital brain abnormalities, genetics, [[neurobiology]], and non-traumatic environmental factors remain subjects of ongoing investigation.<ref name="mayo" /><ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR|year=1997|title=Pathways to the development of borderline personality disorder|journal=Journal of Personality Disorders|volume=11|issue=1|pages=93–104|doi=10.1521/pedi.1997.11.1.93|pmid=9113824|s2cid=20669909}}</ref>

===Genetics and heritability===
Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel.<ref name="pmid29032046">{{cite journal|vauthors=Bassir Nia A, Eveleth MC, Gabbay JM, Hassan YJ, Zhang B, Perez-Rodriguez MM|title=Past, present, and future of genetic research in borderline personality disorder|journal=Current Opinion in Psychology|volume=21|pages=60–68|date=June 2018|pmid=29032046|pmc=5847441|doi=10.1016/j.copsyc.2017.09.002}}</ref> Estimates suggest the [[heritability]] of BPD ranges from 37% to 69%,<ref name="Her2014">{{cite journal|vauthors=Gunderson JG, Zanarini MC, Choi-Kain LW, Mitchell KS, Jang KL, Hudson JI|date=August 2011|title=Family Study of Borderline Personality Disorder and Its Sectors of Psychopathology|journal=JAMA: The Journal of the American Medical Association|volume=68|issue=7|pages=753–762|doi=10.1001/archgenpsychiatry.2011.65|pmid=3150490|pmc=3150490}}</ref> indicating that [[human genetic variation]]s account for a substantial portion of the risk for BPD within the population. [[Twin study|Twin studies]], which often form the basis of these estimates, may overestimate the perceived influence of genetics due to the shared environment of twins, potentially skewing results.<ref>{{cite journal|vauthors=Torgersen S|title=Genetics of patients with borderline personality disorder|journal=The Psychiatric Clinics of North America|volume=23|issue=1|pages=1–9|date=March 2000|pmid=10729927|doi=10.1016/S0193-953X(05)70139-8}}</ref>

Certain studies propose that personality disorders are significantly shaped by genetics, more so than many [[Axis I disorders]], such as depression and eating disorders, and even surpassing the genetic impact on broad [[personality traits]].<ref name="TS" >{{cite journal|vauthors=Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E|title=A twin study of personality disorders|journal=Comprehensive Psychiatry|volume=41|issue=6|pages=416–425|year=2000|pmid=11086146|doi=10.1053/comp.2000.16560}}</ref> A twin study found that BPD ranks as the third most heritable among ten surveyed personality disorders.<ref name="TS"  />

Research involving twin and sibling studies has shown a genetic component to traits associated with BPD, such as impulsive aggression; with the genetic contribution to behavior from [[serotonin]]-related genes appearing to be modest.<ref name="neurotrauma">{{cite journal|vauthors=Goodman M, New A, Siever L|title=Trauma, genes, and the neurobiology of personality disorders|journal=Annals of the New York Academy of Sciences|volume=1032|issue=1|pages=104–116|date=December 2004|pmid=15677398|doi=10.1196/annals.1314.008|bibcode=2004NYASA1032..104G|s2cid=26270818}}</ref>

A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify [[genetic marker]]s associated with BPD.<ref name="Possible Genetic Causes">{{cite web|url=https://www.sciencedaily.com/releases/2008/12/081216114100.htm|title=Possible Genetic Causes of Borderline Personality Disorder Identified|publisher=sciencedaily.com|date=20 December 2008|url-status=live|archive-url=https://web.archive.org/web/20140501161311/https://www.sciencedaily.com/releases/2008/12/081216114100.htm|archive-date=1 May 2014}}</ref> This research identified a linkage to genetic markers on [[chromosome 9]] as relevant to BPD characteristics,<ref name="Possible Genetic Causes" /> underscoring a significant genetic contribution to the [[Variability (statistics)|variability]] observed in BPD features.<ref name="Possible Genetic Causes" /> Prior findings from this group indicated that 42% of BPD feature variability could be attributed to genetics, with the remaining 58% owing to environmental factors.<ref name="Possible Genetic Causes" />

Among specific genetic variants under scrutiny {{as of|2012|lc=y}}, the [[DRD4 7-repeat polymorphism]] (of the [[Dopamine receptor D4|dopamine receptor D<sub>4</sub>]]) located on [[chromosome 11]] has been linked to disorganized attachment, and in conjunction with the 10/10-repeat genotype of the [[dopamine transporter]] (DAT), it has been associated with issues with [[inhibitory control]], both of which are characteristic of BPD.<ref name="Brain Structure and Function">{{cite journal|vauthors=O'Neill A, Frodl T|title=Brain structure and function in borderline personality disorder|journal=Brain Structure & Function|volume=217|issue=4|pages=767–782|date=October 2012|pmid=22252376|doi=10.1007/s00429-012-0379-4|s2cid=17970001}}</ref> Additionally, potential links to [[chromosome 5]] are being explored, further emphasizing the complex genetic landscape influencing BPD development and manifestation.<ref>{{cite journal|vauthors=Lubke GH, Laurin C, Amin N, Hottenga JJ, Willemsen G, van Grootheest G, Abdellaoui A, Karssen LC, Oostra BA, van Duijn CM, Penninx BW, Boomsma DI|title=Genome-wide analyses of borderline personality features|journal=Molecular Psychiatry|volume=19|issue=8|pages=923–929|date=August 2014|pmid=23979607|pmc=3872258|doi=10.1038/mp.2013.109}}</ref><ref>{{Cite journal|last1=Bassir Nia|first1=Anahita|last2=Eveleth|first2=Matthew C.|last3=Gabbay|first3=Jonathan M.|last4=Hassan|first4=Yonis J.|last5=Zhang|first5=Bosi|last6=Perez-Rodriguez|first6=M. Mercedes|year=2018|title=Past, present, and future of genetic research in borderline personality disorder|journal=Current Opinion in Psychology|volume=21|pages=60–68|doi=10.1016/j.copsyc.2017.09.002|issn=2352-2518|pmc=5847441|pmid=29032046}}</ref>

===Psychosocial factors===
[[Empirical studies]] have established a strong [[correlation]] between [[adverse childhood experiences]] such as [[child abuse]], particularly [[child sexual abuse]], and the onset of BPD later in life.<ref>{{cite journal|vauthors=Cohen P|date=September 2008|title=Child Development and Personality Disorder|url=http://ereserve.library.utah.edu/Annual/PSY/6330/Crowell/child.pdf|journal=[[The Psychiatric Clinics of North America]]|volume=31|issue=3|pages=477–493, vii|doi=10.1016/j.psc.2008.03.005|pmid=18638647|archive-url=https://web.archive.org/web/20240531104923/http://ereserve.library.utah.edu/Annual/PSY/6330/Crowell/child.pdf|archive-date=2024-05-31|access-date=2025-01-08}}</ref><ref name="Herman91">{{cite book|url=https://archive.org/details/traumarecovery00herm_0|title=Trauma and recovery|vauthors=Herman JL|publisher=Basic Books|year=1992|isbn=978-0-465-08730-3|location=New York}}</ref><ref name="AxisOne/AxisTwo" /> Reports from individuals diagnosed with BPD frequently include narratives of extensive abuse and neglect during early childhood, though [[causality]] remains a subject of ongoing investigation.<ref>{{cite journal|vauthors=Ball JS, Links PS|date=February 2009|title=Borderline personality disorder and childhood trauma: evidence for a causal relationship|url=https://link.springer.com/article/10.1007/s11920-009-0010-4|journal=[[Current Psychiatry Reports]]|volume=11|issue=1|pages=63–68|doi=10.1007/s11920-009-0010-4|pmid=19187711|s2cid=20566309|url-access=subscription}}</ref> These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers,<ref>{{cite news|url=http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/risk-factors/con-20023204|title=Borderline personality disorder: Understanding this challenging mental illness|work=Mayo Clinic|access-date=5 September 2017|url-status=live|archive-url=https://web.archive.org/web/20170830054834/http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/risk-factors/con-20023204|archive-date=30 August 2017}}</ref> alongside a notable frequency of [[incest]] and loss of caregivers in early childhood.<ref name="failchild">{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Reich DB, Marino MF, Lewis RE, Williams AA, Khera GS|year=2000|title=Biparental failure in the childhood experiences of borderline patients|url=https://guilfordjournals.com/doi/abs/10.1521/pedi.2000.14.3.264|journal=[[Journal of Personality Disorders]]|volume=14|issue=3|pages=264–273|doi=10.1521/pedi.2000.14.3.264|pmid=11019749|url-access=subscription}}</ref>

Moreover, there have been consistent accounts of caregivers [[Emotional validation|invalidating]] the individuals' emotions and thoughts, neglecting physical care, failing to provide the necessary protection, and exhibiting emotional withdrawal and inconsistency.<ref name="failchild" /> Specifically, female individuals with BPD reporting past neglect or abuse by caregivers have a heightened likelihood of encountering sexual abuse from individuals outside their immediate family circle.<ref name="failchild" /> Research also indicates that neurodevelopment variations such as [[autism]] spectrum traits, [[ADHD]], or [[highly sensitive people]] (HSP) may increase vulnerability to trauma and subsequent borderline personality organization.<ref>{{Cite journal|last1=Matthies|first1=Swantje D|last2=Philipsen|first2=Alexandra|year=2014|title=Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)–review of recent findings|journal=Borderline Personality Disorder and Emotion Dysregulation|language=en|volume=1|issue=1|pages=3|doi=10.1186/2051-6673-1-3|issn=2051-6673|pmc=4739390|doi-access=free|pmid=26843958 }}</ref>

The enduring impact of chronic maltreatment and difficulties in forming [[secure attachment]]s during childhood has been hypothesized to potentially contribute to the development of BPD.<ref name="Dozier-1999">{{cite book|title=Handbook of attachment|vauthors=Dozier M, Stovall-McClough KC, Albus KE|publisher=[[Guilford Press]]|year=1999|veditors=Cassidy J, Shaver PR|location=New York|pages=497–519|chapter=Attachment and psychopathology in adulthood}}</ref> [[Marsha Linehan]]'s biosocial developmental theory posits that BPD arises from the interaction between a child's inherent emotional vulnerability and an invalidating environment – an environment characterized by the neglect, ridicule, dismissal, or discouragement of a child's emotions and needs.<ref>{{Cite journal|vauthors=Crowell SE, Beauchaine TP, Linehan MM|date=May 2009|title=A Biosocial Developmental Model of Borderline Personality: Elaborating and Extending Linehan's Theory|journal=[[Psychological Bulletin]]|volume=135|issue=3|pages=495–510|doi=10.1037/a0015616|pmc=2696274|pmid=19379027}}</ref>

===Brain and neurobiologic factors===<!-- Structural brain changes
 -->

Research employing [[structural neuroimaging]] techniques, such as [[voxel-based morphometry]], has reported variations in individuals diagnosed with BPD in specific [[brain regions]] that have been associated with the [[psychopathology]] of BPD. Reductions in volume enclosed have been observed in the [[hippocampus]], [[orbitofrontal cortex]], [[anterior cingulate cortex]], and [[amygdala]], among others, which are crucial for [[emotional self-regulation]] and [[stress management]].<ref name="Brain Structure and Function" /><!-- Biochemical alterations
 --><!-- Alterations in glucose metabolism and brain oxygenation
 --><!-- Neurometabolites
 -->

In addition to structural imaging, a subset of studies utilizing [[magnetic resonance spectroscopy]] has investigated the neurometabolic profile within these affected regions. These investigations have focused on the concentrations of various neurometabolites, including [[N-acetylaspartate|''N''-acetylaspartate]], [[creatine]], compounds related to [[glutamate]], and compounds containing [[choline]]. These studies aim to show the biochemical alterations that may underlie the symptomatology observed in BPD.<ref name="Brain Structure and Function" />

==== Neurological patterns ====
Research has shown changes in two [[brain circuits]] implicated in the emotional dysregulation characteristic of BPD: firstly, an escalation in activity within brain circuits associated with experiencing severe emotional pain, and secondly, a decreased activation within circuits tasked with the regulation or suppression of these intense emotions. These dysfunctional activations predominantly occur within the [[limbic system]], though individual variances necessitate further neuroimaging research to explore these patterns in detail.<ref name="Ruocco, Anthony C.; Amirthavasagam, Sathya, Choi-Kain, Lois W.; McMain, Shelley F. 2013 153–160">{{cite journal|vauthors=Ruocco AC, Amirthavasagam S, Choi-Kain LW, McMain SF|title=Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis|journal=Biological Psychiatry|volume=73|issue=2|pages=153–160|date=January 2013|pmid=22906520|doi=10.1016/j.biopsych.2012.07.014|s2cid=8381799}}</ref><!-- Seems this was inserted by someone related to study possibly for self-gain? -->

Contrary to earlier findings, individuals with BPD exhibit decreased amygdala activation in response to heightened negative emotional stimuli compared to control groups. John Krystal, the editor of ''[[Biological Psychiatry (journal)|Biological Psychiatry]]'', commented on these findings, suggesting they contribute to understanding the innate neurological predisposition of individuals with BPD to lead emotionally turbulent lives, which are not inherently negative or unproductive.<ref name="Ruocco, Anthony C.; Amirthavasagam, Sathya, Choi-Kain, Lois W.; McMain, Shelley F. 2013 153–160" /> This emotional volatility is consistently linked to disparities in several brain regions, emphasizing the neurobiological underpinnings of BPD.<ref name="Koenigsberg">{{cite journal|vauthors=Koenigsberg HW, Siever LJ, Lee H, Pizzarello S, New AS, Goodman M, Cheng H, Flory J, Prohovnik I|title=Neural correlates of emotion processing in borderline personality disorder|journal=Psychiatry Research|volume=172|issue=3|pages=192–199|date=June 2009|pmid=19394205|pmc=4153735|doi=10.1016/j.pscychresns.2008.07.010|quote=BPD patients demonstrated greater differences in activation than controls, when viewing negative pictures compared with rest, in the amygdala, fusiform gyrus, primary visual areas, superior temporal gyrus (STG), and premotor areas, while healthy controls showed greater differences than BPD patients in the insula, middle temporal gyrus and dorsolateral prefrontal cortex.}}</ref>

===Mediating and moderating factors<!-- These 'factors' are all causes anyway? Why not be part of causes, why their own 'mediating and moderating factors'? -->===

====Executive function and social rejection sensitivity<!-- Should likely be under Brain function -->====
High sensitivity to [[social rejection]] is linked to more severe symptoms of BPD, with [[executive function]] playing a mediating role.<ref name="Executive_function">{{cite journal|vauthors=Ayduk O, Zayas V, Downey G, Cole AB, Shoda Y, Mischel W|author-link6=Walter Mischel|title=Rejection Sensitivity and Executive Control: Joint predictors of Borderline Personality features|journal=Journal of Research in Personality|volume=42|issue=1|pages=151–168|date=February 2008|pmid=18496604|pmc=2390893|doi=10.1016/j.jrp.2007.04.002}}</ref> Executive function—encompassing [[planning]], [[working memory]], [[attentional control]], and [[problem-solving]]—moderates how rejection sensitivity influences BPD symptoms. Studies demonstrate that individuals with lower executive function exhibit a stronger correlation between rejection sensitivity and BPD symptoms.<ref name="Executive_function"/> Conversely, higher executive function may mitigate the impact of rejection sensitivity, potentially offering protection against BPD symptoms.<ref name="Executive_function"/> 

==Diagnosis==
The clinical diagnosis of BPD can be made through a [[psychiatric assessment]] conducted by a [[mental health professional]], ideally a [[psychiatrist]] or [[psychologist]]. This comprehensive assessment integrates various sources of information to confirm the diagnosis, encompassing the patient's self-reported [[clinical history]], observations made by the clinician during interviews, and corroborative details obtained from family members, friends, and medical records. It is crucial to thoroughly assess patients for co-morbid mental health conditions, substance use disorders, suicidal ideation, and any self-harming behaviors.<ref>{{Cite book|url=https://www.uptodate.com/|title=UpToDate|publisher=[[Wolters Kluwer]]|veditors=Post TW|chapter=Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis|access-date=11 March 2023|chapter-url=https://www.uptodate.com/contents/borderline-personality-disorder-epidemiology-pathogenesis-clinical-features-course-assessment-and-diagnosis|url-access=subscription|archive-date=6 January 2009|archive-url=https://web.archive.org/web/20090106134307/http://uptodate.com/|url-status=live}}</ref>

An effective approach involves presenting the criteria of the disorder to the individual and inquiring if they perceive these criteria as reflective of their experiences. Involving individuals in the diagnostic process may enhance their acceptance of the diagnosis. Despite the stigma associated with BPD and previous notions of its untreatability, disclosing the diagnosis to individuals is generally beneficial. It provides them with validation and directs them to appropriate treatment options.<ref name="Gund2011" />

The [[psychological evaluation]] for BPD typically explores the onset and intensity of symptoms and their impact on the individual's [[quality of life]]. Critical areas of focus include suicidal thoughts, self-harm behaviors, and any thoughts of harming others.<ref name="Mayo_Clinic_Diagnosis">{{cite web|title=Personality Disorders: Tests and Diagnosis|url=http://www.mayoclinic.com/health/personality-disorders/DS00562/DSECTION=tests-and-diagnosis|publisher=Mayo Clinic|access-date=13 June 2013|url-status=live|archive-url=https://web.archive.org/web/20130606185940/http://www.mayoclinic.com/health/personality-disorders/DS00562/DSECTION%3Dtests-and-diagnosis|archive-date=6 June 2013}}</ref> The diagnosis relies on both the individual's self-reported symptoms and the clinician's observations.<ref name="Mayo_Clinic_Diagnosis" /> To exclude other potential causes of the symptoms, additional assessments may include a [[physical examination]] and [[blood test]]s, to exclude thyroid disorders or substance use disorders.<ref name="Mayo_Clinic_Diagnosis" /> The [[International Classification of Diseases]] (ICD-10) categorizes the condition as ''emotionally unstable personality disorder'', with diagnostic criteria similar to those in the ''[[Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition]]'' (DSM-5), where the disorder's name remains unchanged from previous editions.<ref name="DSM53" />

=== ''DSM-5'' diagnostic criteria ===
<!-- Please do not add diagnosis criteria as this constitutes a copyright violation. APA has forbidden us.-->
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5) has eliminated the multiaxial diagnostic system, integrating all disorders, including personality disorders, into Section II of the manual. For a diagnosis of BPD, an individual must meet five out of nine specified diagnostic criteria.<ref name="DSM-5-borderine personality disorders" /> The DSM-5 characterizes BPD as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and a significant propensity towards impulsive behavior.<ref name="DSM-5-borderine personality disorders">{{harvnb|American Psychiatric Association|2013|pages=663–8}}</ref> Moreover, the DSM-5 introduces alternative diagnostic criteria for BPD in Section III, titled [[Alternative DSM-5 Model for Personality Disorders|''Alternative DSM-5 Model for Personality Disorders'']] (AMPD). These criteria are rooted in trait research and necessitate the identification of at least four out of seven maladaptive traits.<ref name="DSM-5-borderline-alternative">{{harvnb|American Psychiatric Association|2013|pages=766–7}}</ref> Marsha Linehan highlights the diagnostic challenges faced by mental health professionals in using the DSM criteria due to the broad range of behaviors they encompass.<ref name="Manning_13">{{harvnb|Manning|2011|page=13}}</ref> To mitigate these challenges, Linehan categorizes BPD symptoms into five principal areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.<ref name="Manning_13" />

===International Classification of Disease (ICD) diagnostic criteria===
{{See also|ICD-11#Personality disorder|label 1=ICD-11 § Personality disorder}}
The [[World Health Organization]]'s [[ICD-11]] completely restructured its personality disorder section. It classifies BPD as ''Personality disorder'', ({{ICD11|6D10}}) ''Borderline pattern'', ({{ICD11|6D11.5}}).<ref name="ICD-11">{{Cite web|title=ICD-11 for Mortality and Morbidity Statistics|url=https://icd.who.int/browse/2024-01/mms/en#2006821354|url-status=live|archive-url=https://web.archive.org/web/20240314103223/https://icd.who.int/browse/2024-01/mms/en#2006821354|archive-date=14 March 2024|access-date=2024-03-11|publisher=World Health Organization}}</ref>{{Failed verification|date=April 2025|reason=The source does not claim that Borderline pattern is the successor to EUPD, let alone that it "classifies BPD as" it. BPD has again not even been an ICD diagnosis.}} Previously, the ICD-10 (version 2019) had identified a condition akin to BPD, termed ''Emotionally unstable personality disorder'' (EUPD) ({{ICD10|F|60|3|f|60}}).<ref name="ICD-10">{{Cite web|title=ICD-10 Version:2019|url=https://icd.who.int/browse10/2019/en#F60.3|access-date=2024-03-11|publisher=World Health Organization|archive-date=31 March 2020|archive-url=https://archive.today/20200331004754/https://icd.who.int/browse10/2019/en%23/U07.1#F60.3|url-status=live}}</ref> The borderline pattern specifier is defined as a personality disturbance marked by instability in interpersonal relationships, self-image, and emotions, as well as impulsivity.

{{blockquote
|text =  The Borderline pattern specifier may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by five (or more) of the following:
* Frantic efforts to avoid real or imagined abandonment.
* A pattern of unstable and intense interpersonal relationships, which may be characterized by vacillations between idealization and devaluation, typically associated with both a strong desire for and fear of closeness and intimacy.
* Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
* A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).
* Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).
* Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one's own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.
* Chronic feelings of emptiness.
* Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).
* Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.

Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:
* A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
* An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
* Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.
|source=[https://icd.who.int/browse/2024-01/mms/en#2006821354&#124; 6D11.5 Borderline pattern in ICD-11]}}

===Millon's subtypes===
Psychologist [[Theodore Millon]] proposed four subtypes of BPD, where individuals with BPD would exhibit none, one, or multiple subtypes.<ref name="Millon">{{cite book|title=Personality Disorders in Modern Life|vauthors=Millon T|publisher=John Wiley & Sons|year=2004|isbn=978-0-471-23734-1|location=Hoboken, New Jersey|pages=482–88}}</ref>
{| class="wikitable"
!Subtype
!Features
!Personality Traits
|-
|'''Discouraged borderline'''
|Including [[Avoidant personality disorder|avoidant]], [[Depressive personality disorder|depressive]], and [[Dependant personality disorder|dependant]] features
|Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
|-
|'''Impulsive borderline'''
|Including [[Histrionic personality disorder|histrionic]] or [[Antisocial personality disorder|antisocial]] features
|Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, becomes agitated, and gloomy and irritable; potentially suicidal.
|-
|'''Petulant borderline'''
|Including [[Passive-aggressive personality disorder|negativistic]] features
|Negativistic, impatient, restless, as well as stubborn defiant, sullen, pessimistic, and resentful; easily slighted and quickly disillusioned. 
|-
|'''Self-destructive borderline'''
|Including [[Depressive personality disorder|depressive]] or [[Self-defeating personality disorder|masochistic]] features
|Inward-turning, intropunitively angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide
|}

===Misdiagnosis===
{{Main|Misdiagnosis of borderline personality disorder}}
Individuals with BPD are subject to [[misdiagnosis]] due to various factors, such as the overlap (comorbidity) of BPD symptoms with those of other disorders such as depression, PTSD, and bipolar disorder.<ref name="Chanen">{{cite journal|vauthors=Chanen AM, Thompson KN|title=Prescribing and borderline personality disorder|journal=Australian Prescriber|volume=39|issue=2|pages=49–53|date=April 2016|pmid=27340322|pmc=4917638|doi=10.18773/austprescr.2016.019}}</ref><ref>{{cite journal|vauthors=Meaney R, Hasking P, Reupert A|title=Borderline Personality Disorder Symptoms in College Students: The Complex Interplay between Alexithymia, Emotional Dysregulation and Rumination|journal=PLOS ONE|volume=11|issue=6|pages=e0157294|year=2016|pmid=27348858|pmc=4922551|doi=10.1371/journal.pone.0157294|bibcode=2016PLoSO..1157294M|doi-access=free}}</ref> Misdiagnosis of BPD can lead to a range of adverse consequences. Diagnosis plays a crucial role in informing healthcare professionals about the patient's mental health status, guiding treatment strategies, and facilitating accurate reporting of successful interventions.<ref>{{Cite journal|last=Sartorius|first=Norman|year=2015|title=Why do we need a diagnosis? Maybe a syndrome is enough?|journal=Dialogues in Clinical Neuroscience|volume=17|issue=1|pages=6–7|doi=10.31887/DCNS.2015.17.1/nsartorius|pmc=4421902|pmid=25987858}}</ref> Consequently, misdiagnosis may deprive individuals of access to suitable psychiatric medications or evidence-based psychological interventions tailored to their specific disorders.<ref>{{Cite journal|last1=Paris|first1=Joel|last2=Black|first2=Donald W.|year=2015|title=Borderline Personality Disorder and Bipolar Disorder|url=http://dx.doi.org/10.1097/nmd.0000000000000225|journal=The Journal of Nervous and Mental Disease|volume=203|issue=1|pages=3–7|doi=10.1097/nmd.0000000000000225|issn=0022-3018|pmid=25536097|s2cid=2825326|url-access=subscription}}</ref>

Critics of the BPD diagnosis contend that it is indistinguishable from negative affectivity upon undergoing regression and factor analyses. They maintain that the diagnosis of BPD does not provide additional insight beyond what is captured by other diagnoses, positing that it may be redundant or potentially misleading.<ref name=FG>{{cite journal|vauthors=Gutiérrez F, Aluja A, Ruiz Rodríguez J, Peri JM, Gárriz M, Garcia LF, Sorrel MA, Sureda B, Vall G, Ferrer M, Calvo N|title=Borderline, where are you? A psychometric approach to the personality domains in the International Classification of Diseases, 11th Revision (ICD-11)|journal=Personality Disorders|date=June 2022|volume=14|issue=3|pages=355–359|pmid=35737563|doi=10.1037/per0000592|s2cid=249805748|hdl=2445/206520|hdl-access=free}}</ref>

===Adolescence and prodrome===
The onset of BPD symptoms typically occurs during adolescence or early adulthood, with possible early signs in childhood.<ref>{{harvnb|Linehan|1993|page=49}}</ref> Predictive symptoms in adolescents include [[body image]] issues, extreme sensitivity to rejection, behavioral challenges, [[non-suicidal self-injury]], seeking exclusive relationships, and profound shame.<ref name="Gund2011" /> Although many adolescents exhibit these symptoms without developing BPD, those who do are significantly more likely to develop the disorder and potentially face long-term social challenges.<ref name="Gund2011" />

BPD is recognized as a stable and valid diagnosis during adolescence, supported by the DSM-5 and ICD-11.<ref name="Miller_2008">{{cite journal|vauthors=Miller AL, Muehlenkamp JJ, Jacobson CM|date=July 2008|title=Fact or fiction: diagnosing borderline personality disorder in adolescents|url=http://dx.doi.org/10.1016/j.cpr.2008.02.004|url-status=live|journal=Clinical Psychology Review|volume=28|issue=6|pages=969–81|doi=10.1016/j.cpr.2008.02.004|pmid=18358579|archive-url=https://web.archive.org/web/20201204232033/https://www.sciencedirect.com/science/article/abs/pii/S0272735808000299?via%3Dihub|archive-date=4 December 2020|access-date=23 September 2020|url-access=subscription}}</ref><ref name="National Collaborating Centre for Mental Health (UK)_2009">{{cite book|author=National Collaborating Centre for Mental Health (UK)|url=https://www.ncbi.nlm.nih.gov/books/NBK55399/|title=Young People With Borderline Personality Disorder|date=2009|publisher=British Psychological Society|access-date=23 September 2020|archive-url=https://web.archive.org/web/20201204232017/https://www.ncbi.nlm.nih.gov/books/NBK55399/|archive-date=4 December 2020|url-status=live}}</ref><ref name="Kaess_2014">{{cite journal|vauthors=Kaess M, Brunner R, Chanen A|date=October 2014|title=Borderline personality disorder in adolescence|url=https://publications.aap.org/pediatrics/article-pdf/134/4/782/1098814/peds_2013-3677.pdf|journal=Pediatrics|volume=134|issue=4|pages=782–93|doi=10.1542/peds.2013-3677|pmid=25246626|s2cid=8274933|access-date=23 September 2020}}</ref><ref name="Biskin_2015">{{cite journal|vauthors=Biskin RS|date=July 2015|title=The Lifetime Course of Borderline Personality Disorder|journal=Canadian Journal of Psychiatry|volume=60|issue=7|pages=303–8|doi=10.1177/070674371506000702|pmc=4500179|pmid=26175388}}</ref> Early detection and treatment of BPD in young individuals are emphasized in national guidelines across various countries, including the US, Australia, the UK, Spain, and Switzerland, highlighting the importance of early intervention.<ref name="Kaess_2014" /><ref>{{cite book|last=National Health and Medical Research Council (Australia)|url=http://worldcat.org/oclc/948783298|title=Clinical practice guideline for the management of borderline personality disorder|date=2013|publisher=National Health and Medical Research Council|isbn=978-1-86496-564-3|oclc=948783298|access-date=23 September 2020|archive-url=https://web.archive.org/web/20201204232022/https://www.worldcat.org/title/clinical-practice-guideline-for-the-management-of-borderline-personality-disorder/oclc/948783298|archive-date=4 December 2020|url-status=live}}</ref><ref>{{cite web|date=28 January 2009|title=Overview {{!}} Borderline personality disorder: recognition and management {{!}} Guidance {{!}} NICE|url=https://www.nice.org.uk/guidance/cg78|url-status=live|archive-url=https://web.archive.org/web/20191011171334/https://www.nice.org.uk/guidance/CG78|archive-date=11 October 2019|access-date=23 September 2020|website=nice.org.uk}}</ref>

Historically, diagnosing BPD during adolescence was met with caution,<ref name="Kaess_2014" /><ref>{{cite book|title=Treatment of Personality Disorders|vauthors=de Vito E, Ladame F, Orlandini A|date=1999|publisher=Springer US|isbn=978-1-4419-3326-3|veditors=Derksen J, Maffei C, Groen H|place=Boston, MA|pages=77–95|chapter=Adolescence and Personality Disorders|doi=10.1007/978-1-4757-6876-3_7|access-date=23 September 2020|chapter-url=http://link.springer.com/10.1007/978-1-4757-6876-3_7|archive-url=https://web.archive.org/web/20201204232040/https://link.springer.com/chapter/10.1007%2F978-1-4757-6876-3_7|archive-date=4 December 2020|url-status=live}}</ref><ref>{{cite journal|vauthors=Guilé JM, Boissel L, Alaux-Cantin S, de La Rivière SG|date=23 November 2018|title=Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies|journal=Adolescent Health, Medicine and Therapeutics|volume=9|pages=199–210|doi=10.2147/ahmt.s156565|pmc=6257363|pmid=30538595|doi-access=free}}</ref> due to concerns about the accuracy of diagnosing young individuals,<ref>{{cite book|last=American Psychiatric Association. Work Group on Borderline Personality Disorder.|url=http://worldcat.org/oclc/606593046|title=Practice guideline for the treatment of patients with borderline personality disorder|date=2001|publisher=American Psychiatric Association|oclc=606593046|access-date=23 September 2020|archive-url=https://web.archive.org/web/20201204232020/https://www.worldcat.org/title/practice-guideline-for-the-treatment-of-patients-with-borderline-personality-disorder/oclc/606593046|archive-date=4 December 2020|url-status=live}}</ref><ref>{{cite book|author=World Health Organization|url=http://worldcat.org/oclc/476159430|title=The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines.|date=1992|publisher=World Health Organization|isbn=978-92-4-068283-2|oclc=476159430|access-date=23 September 2020|archive-url=https://web.archive.org/web/20201204232022/https://www.worldcat.org/title/icd-10-classification-of-mental-and-behavioural-disorders-clinical-descriptions-and-diagnostic-guidelines/oclc/476159430|archive-date=4 December 2020|url-status=live}}</ref> the potential misinterpretation of normal adolescent behaviors, stigma, and the stability of personality during this developmental stage.<ref name="Kaess_2014" /> Despite these challenges, research has confirmed the validity and clinical utility of the BPD diagnosis in adolescents,<ref name="Miller_2008" /><ref name="National Collaborating Centre for Mental Health (UK)_2009" /><ref name="Kaess_2014" /><ref name="Biskin_2015" /> though misconceptions persist among mental health care professionals,<ref name="Baltzersen_2020">{{cite journal|vauthors=Baltzersen ÅL|date=August 2020|title=Moving forward: closing the gap between research and practice for young people with BPD|journal=Current Opinion in Psychology|volume=37|pages=77–81|doi=10.1016/j.copsyc.2020.08.008|pmid=32916475|s2cid=221636857|doi-access=free}}</ref><ref>{{cite journal|vauthors=Boylan K|date=August 2018|title=Diagnosing BPD in Adolescents: More good than harm|journal=Journal of the Canadian Academy of Child and Adolescent Psychiatry|volume=27|issue=3|pages=155–156|pmc=6054283|pmid=30038651}}</ref><ref>{{cite journal|vauthors=Laurenssen EM, Hutsebaut J, Feenstra DJ, Van Busschbach JJ, Luyten P|date=February 2013|title=Diagnosis of personality disorders in adolescents: a study among psychologists|journal=Child and Adolescent Psychiatry and Mental Health|volume=7|issue=1|pages=3|doi=10.1186/1753-2000-7-3|pmc=3583803|pmid=23398887|doi-access=free}}</ref> contributing to clinical reluctance in diagnosing and a key barrier to the provision of effective treatment BPD in this population.<ref name="Baltzersen_2020" /><ref>{{cite journal|vauthors=Chanen AM|date=August 2015|title=Borderline Personality Disorder in Young People: Are We There Yet?|url=http://doi.wiley.com/10.1002/jclp.22205|url-status=live|journal=Journal of Clinical Psychology|volume=71|issue=8|pages=778–91|doi=10.1002/jclp.22205|pmid=26192914|archive-url=https://web.archive.org/web/20201204232036/https://onlinelibrary.wiley.com/doi/abs/10.1002/jclp.22205|archive-date=4 December 2020|access-date=23 September 2020|url-access=subscription}}</ref><ref>{{cite journal|vauthors=Koehne K, Hamilton B, Sands N, Humphreys C|date=January 2013|title=Working around a contested diagnosis: borderline personality disorder in adolescence|journal=Health|volume=17|issue=1|pages=37–56|doi=10.1177/1363459312447253|pmid=22674745|s2cid=1674596}}</ref>

A diagnosis of BPD in adolescence can indicate the persistence of the disorder into adulthood,<ref name="DSM-IV-TR">{{harvnb|American Psychiatric Association|2000}}{{Page needed|date=July 2013}}</ref><ref name="Netherton">{{cite book|vauthors=Netherton SD, Holmes D, Walker CE|year=1999|title=Child and Adolescent Psychological Disorders: Comprehensive Textbook|location=New York|publisher=Oxford University Press}}{{Page needed|date=July 2013}}</ref> with outcomes varying among individuals. Some maintain a stable diagnosis over time, while others may not consistently meet the diagnostic criteria.<ref name="Fact_or_Fiction">{{cite journal|vauthors=Miller AL, Muehlenkamp JJ, Jacobson CM|title=Fact or fiction: diagnosing borderline personality disorder in adolescents|journal=Clinical Psychology Review|volume=28|issue=6|pages=969–981|date=July 2008|pmid=18358579|doi=10.1016/j.cpr.2008.02.004}}</ref> Early diagnosis facilitates the development of effective treatment plans,<ref name="DSM-IV-TR" /><ref name="Netherton" /> including family therapy, to support adolescents with BPD.<ref>{{harvnb|Linehan|1993|page=98}}</ref>

===Differential diagnosis and comorbidity===
Lifetime [[Comorbidity|co-occurring]] (comorbid) conditions are prevalent among individuals diagnosed with BPD. Individuals with BPD exhibit higher rates of comorbidity compared to those diagnosed with other personality disorders. These comorbidities include [[mood disorders]] (such as [[major depressive disorder]] and [[bipolar disorder]]), [[anxiety disorder]]s (including [[panic disorder]], [[social anxiety disorder]], and [[post-traumatic stress disorder]] (PTSD)), other personality disorders (notably [[Schizotypal personality disorder|schizotypal]], [[Antisocial personality disorder|antisocial]], and [[dependent personality disorder]]), substance use disorder, [[eating disorders]] ([[anorexia nervosa]] and [[bulimia nervosa]]), [[attention deficit hyperactivity disorder]] (ADHD),<ref name="PM">{{cite journal|vauthors=Ferrer M, Andión O, Matalí J, Valero S, Navarro JA, Ramos-Quiroga JA, Torrubia R, Casas M|title=Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder|journal=Journal of Personality Disorders|volume=24|issue=6|pages=812–822|date=December 2010|pmid=21158602|doi=10.1521/pedi.2010.24.6.812}}{{primary source inline|date=May 2013}}</ref> [[somatic symptom disorder]], and the [[dissociative disorders]].<ref name="comorbidity">{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V|title=Axis I comorbidity of borderline personality disorder|journal=The American Journal of Psychiatry|volume=155|issue=12|pages=1733–1739|date=December 1998|pmid=9842784|doi=10.1176/ajp.155.12.1733}}</ref> It is advised that a personality disorder diagnosis should be made cautiously during untreated mood episodes or disorders unless a comprehensive lifetime history supports the existence of a personality disorder.<ref>{{cite journal|vauthors=Vieta E|title=Bipolar II Disorder: Frequent, Valid, and Reliable|journal=Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie|volume=64|issue=8|pages=541–543|date=August 2019|pmid=31340672|pmc=6681515|doi=10.1177/0706743719855040}}</ref>

====Comorbid Axis I disorders====

{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
	
|-
	
|+Gender variations in lifetime prevalence of comorbid Axis I disorders among individuals diagnosed with BPD: A comparative study between 2008<ref name="Grant_2008" /> and 1998<ref name="comorbidity2">{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V|date=December 1998|title=Axis I comorbidity of borderline personality disorder|journal=The American Journal of Psychiatry|volume=155|issue=12|pages=1733–1739|doi=10.1176/ajp.155.12.1733|pmid=9842784}}</ref>
	
|-
	
! Axis I diagnosis !! Overall (%) !! Male (%) !! Female (%)
	
|-
	
! Mood disorders !! 75.0 !! 68.7 !! 80.2
	
|-
	
|[[Major depressive disorder]] || 32.1 || 27.2 || 36.1
	
|-
	
|[[Dysthymia]] || {{0}}9.7 || {{0}}7.1 || 11.9
	
|-
	
|[[Bipolar I disorder]] || 31.8 || 30.6 || 32.7
	
|-
	
|[[Bipolar II disorder]] || {{0}}7.7 || {{0}}6.7 || {{0}}8.5
	
|-
	
! Anxiety disorders !! 74.2 !! 66.1 !! 81.1
	
|-
	
|[[Panic disorder]] with [[agoraphobia]] || 11.5 || {{0}}7.7 || 14.6
	
|-
	
|Panic disorder without agoraphobia || 18.8 || 16.2 || 20.9
	
|-
	
|[[Social phobia]] || 29.3 || 25.2 || 32.7
	
|-
	
|[[Specific phobia]] || 37.5 || 26.6 || 46.6
	
|-
	
|[[post-traumatic stress disorder|PTSD]] || 39.2 || 29.5 || 47.2
	
|-
	
|[[Generalized anxiety disorder]] || 35.1 || 27.3 || 41.6
	
|-
	
|[[Obsessive–compulsive disorder]]** || 15.6 || – || –
	
|-
	
! Substance use disorders !! 72.9 !! 80.9 !! 66.2
	
|-
	
|Any [[alcohol use disorder]] || 57.3 || 71.2 || 45.6
	
|-
	
|Any non-alcohol [[substance use disorder]] || 36.2 || 44.0 || 29.8
	
|-
	
! Eating disorders** !! 53.0 !! 20.5 !! 62.2
	
|-
	
|[[Anorexia nervosa]]** || 20.8 || {{0}}7 * || 25 *
	
|-
	
|[[Bulimia nervosa]]** || 25.6 || 10 * || 30 *
	
|-
	
|[[Eating disorder not otherwise specified]]** || 26.1 || 10.8 || 30.4
	
|-
	
! Somatoform disorders** !! 10.3 !! 10 * !! 10 *
	
|-
	
|[[Somatization disorder]]** || {{0}}4.2 || – || –
	
|-
	
|[[Hypochondriasis]]** || {{0}}4.7 || – || –
	
|-
	
|[[psychogenic pain|Somatoform pain disorder]]** || {{0}}4.2 || – || –
	
|-
	
! [[Psychotic disorders]]** !! {{0}}1.3 !! {{0}}1 * !! {{0}}1 *
	
|-
	
| Colspan="4" | * Approximate values <br />** Values from 1998 study<ref name = comorbidity /><br>– Value not provided by from both studies
	
|}

A 2008 study stated that 75% of individuals with BPD at some point meet criteria for mood disorders, notably major depression and bipolar I, with a similar percentage for anxiety disorders.<ref name="Grant_2008">{{cite journal |vauthors=Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ |date=April 2008 |title=Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions |journal=The Journal of Clinical Psychiatry |volume=69 |issue=4 |pages=533–545 |doi=10.4088/JCP.v69n0404 |pmc=2676679 |pmid=18426259}}</ref>{{Secondary source needed|date=April 2025}} They found that 73% of individuals with BPD meet criteria for substance use disorders, and about 40% for PTSD.<ref name="Grant_2008"/> A higher proportion of males meet criteria for substance use disorders, whereas females are more likely to have PTSD and eating disorders.<ref name="Grant_2008" /> 38% of individuals with BPD were found to meet criteria for ADHD,<ref name="PM" /> and 15% for [[autism spectrum disorder]] (ASD) in separate studies.<ref name="Ryden2008">{{cite journal|volume=5|issue=1|pages=22–30|vauthors=Rydén G, Rydén E, Hetta J|title=Borderline personality disorder and autism spectrum disorder in females: A cross-sectional study|journal=Clinical Neuropsychiatry|access-date=7 February 2013|year=2008|url=http://www.clinicalneuropsychiatry.org/pdf/04_ryden_hetta.pdf|url-status=dead|archive-url=https://web.archive.org/web/20130921055225/http://www.clinicalneuropsychiatry.org/pdf/04_ryden_hetta.pdf|archive-date=21 September 2013}}</ref>{{Secondary source needed|date=April 2025}}

====Mood disorders====
Seventy-five percent (75%) of individuals with BPD concurrently experience mood disorders, notably major depressive disorder (MDD) or bipolar disorder (BD),<ref name="Robinson"/> complicating diagnostic clarity due to overlapping symptoms.<ref>{{cite journal|vauthors=Bolton S, Gunderson JG|date=September 1996|title=Distinguishing borderline personality disorder from bipolar disorder: differential diagnosis and implications|journal=The American Journal of Psychiatry|volume=153|issue=9|pages=1202–1207|doi=10.1176/ajp.153.9.1202|pmid=8780426}}</ref><ref name="APAguide">{{cite journal|author=American Psychiatric Association Practice Guidelines|date=October 2001|title=Practice guideline for the treatment of patients with borderline personality disorder. American Psychiatric Association|journal=The American Journal of Psychiatry|volume=158|issue=10 Suppl|pages=1–52|doi=10.1176/appi.ajp.158.1.1|pmid=11665545|s2cid=20392111}}</ref><ref>{{cite web|title=Differential Diagnosis of Borderline Personality Disorder|url=http://www.borderlinepersonalitytoday.com/main/diffdx.htm|url-status=dead|archive-url=https://web.archive.org/web/20040509181831/http://www.borderlinepersonalitytoday.com/main/diffdx.htm|archive-date=9 May 2004|work=BPD Today}}</ref> Distinguishing BPD from BD is particularly challenging, as behaviors part of diagnostic criteria for both BPD and BD may emerge during depressive or [[manic episodes]] in BD. However, these behaviours are likely to subside as mood normalises in BD to [[Euthymia (medicine)|euthymia]], but typically are pervasive in BPD.<ref name="Chapman_87">{{harvnb|Chapman|Gratz|2007|page=87}}</ref>

Differences between BPD and BD mood swings include their duration, with BD episodes typically lasting for at least two weeks at a time,{{efn| 	
An exception is rapid-cycling BD, which can be challenging to differentiate from the affective lability found in BPD.<ref>{{cite journal|vauthors=Mackinnon DF, Pies R|title=Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders|journal=Bipolar Disorders|volume=8|issue=1|pages=1–14|date=February 2006|pmid=16411976|doi=10.1111/j.1399-5618.2006.00283.x|doi-access=free}}</ref><ref name="Chapman_88">{{harvnb|Chapman|Gratz|2007|page=88}}</ref><ref name="Chapman_87" />}} in contrast to the rapid and transient mood shifts seen in BPD.<ref name="Chapman_87" /><ref name="BPD_vs_BD">{{cite book |url=https://archive.org/details/manicdepressivei00good/page/108 |title=Manic-depressive illness |vauthors=Jamison KR, Goodwin FJ |publisher=Oxford University Press |year=1990 |isbn=978-0-19-503934-4 |location=Oxford |page=[https://archive.org/details/manicdepressivei00good/page/108 108]}}</ref><ref name="Chapman_88">{{harvnb|Chapman|Gratz|2007|page=88}}</ref> Additionally, BD mood changes are generally unresponsive to environmental stimuli, whereas BPD moods are. For example, a positive event might alleviate a depressive mood in BPD, responsiveness not observed in BD.<ref name="BPD_vs_BD" /> Furthermore, the [[euphoria]] in BPD lacks the [[racing thoughts]] and reduced need for sleep characteristic of BD,<ref name="BPD_vs_BD" /> though sleep disturbances have been noted in BPD.<ref>{{cite journal|vauthors=Selby EA|title=Chronic sleep disturbances and borderline personality disorder symptoms|journal=Journal of Consulting and Clinical Psychology|volume=81|issue=5|pages=941–947|date=October 2013|pmid=23731205|pmc=4129646|doi=10.1037/a0033201}}</ref>

Historically, BPD was considered a milder form of BD,<ref>{{cite journal|vauthors=Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H|title=The nosologic status of borderline personality: clinical and polysomnographic study|journal=The American Journal of Psychiatry|volume=142|issue=2|pages=192–198|date=February 1985|pmid=3970243|doi=10.1176/ajp.142.2.192}}</ref><ref>{{cite journal|vauthors=Gunderson JG, Elliott GR|title=The interface between borderline personality disorder and affective disorder|journal=The American Journal of Psychiatry|volume=142|issue=3|pages=277–788|date=March 1985|pmid=2857532|doi=10.1176/ajp.142.3.277}}</ref> or part of the bipolar spectrum. However, distinctions in phenomenology, family history, disease progression, and treatment responses refute a singular underlying mechanism for both conditions.<ref>{{cite journal|vauthors=Paris J|title=Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders|journal=Harvard Review of Psychiatry|volume=12|issue=3|pages=140–145|year=2004|pmid=15371068|doi=10.1080/10673220490472373|s2cid=39354034}}</ref> Research indicates only a modest association between BPD and BD, challenging the notion of a close spectrum relationship.<ref>{{cite book|vauthors=Jamison KR, Goodwin FJ|title=Manic-depressive illness|publisher=Oxford University Press|location=Oxford|year=1990|page=[https://archive.org/details/manicdepressivei00good/page/336 336]|isbn=978-0-19-503934-4|url=https://archive.org/details/manicdepressivei00good/page/336}}</ref><ref>{{cite journal|vauthors=Benazzi F|title=Borderline personality-bipolar spectrum relationship|journal=Progress in Neuro-Psychopharmacology & Biological Psychiatry|volume=30|issue=1|pages=68–74|date=January 2006|pmid=16019119|doi=10.1016/j.pnpbp.2005.06.010|s2cid=1358610}}</ref>

====Premenstrual dysphoric disorder====
BPD is a psychiatric condition distinguishable from [[premenstrual dysphoric disorder]] (PMDD), despite some symptom overlap. BPD affects individuals persistently across all stages of the menstrual cycle, unlike PMDD, which is confined to the [[luteal phase]] and ends with [[menstruation]].<ref>{{cite journal|vauthors=Rapkin AJ, Berman SM, London ED|title=The Cerebellum and Premenstrual Dysphoric Disorder|journal=AIMS Neuroscience|volume=1|issue=2|pages=120–141|year=2014|pmid=28275721|pmc=5338637|doi=10.3934/Neuroscience.2014.2.120|bibcode=2014AIMES...1..120R}}</ref><ref name="Grady-Weliky">{{cite journal|vauthors=Grady-Weliky TA|date=January 2003|title=Clinical practice. Premenstrual dysphoric disorder|journal=The New England Journal of Medicine|volume=348|issue=5|pages=433–8|doi=10.1056/NEJMcp012067|pmid=12556546}}</ref> While PMDD, affecting 3–8% of women,<ref name="Rapkin">{{cite journal|vauthors=Rapkin AJ, Lewis EI|title=Treatment of premenstrual dysphoric disorder|journal=Women's Health|volume=9|issue=6|pages=537–56|date=November 2013|pmid=24161307|doi=10.2217/whe.13.62|doi-access=free}}</ref> includes mood swings, irritability, and anxiety tied to the [[menstrual cycle]], BPD presents a broader, constant emotional and behavioral challenge irrespective of hormonal changes.

====Comorbid Axis II disorders====
Approximately 74% of individuals with BPD also fulfill criteria for another [[Axis II (psychiatry)|Axis II]] personality disorder during their lifetime, according to research conducted in 2008.<ref name="Grant_2008" /> The most prevalent co-occurring disorders are from Cluster A (paranoid, schizoid, and schizotypal personality disorders), affecting about half of those with BPD, with schizotypal personality disorder alone impacting one-third of individuals. Being part of Cluster B, BPD patients also commonly share characteristics with other Cluster B disorders (antisocial, histrionic, and narcissistic personality disorders), with nearly half of individuals with BPD showing signs of these conditions, and narcissistic personality disorder affecting roughly one-third.<ref name="Grant_2008" /> Cluster C disorders (avoidant, dependent, and obsessive-compulsive personality disorders) have the least comorbidity with BPD, with just under a third of individuals with BPD meeting the criteria for a Cluster C disorder.<ref name="Grant_2008" />

==Management==
{{Main|Management of borderline personality disorder}}
The main approach to managing BPD is through [[psychotherapy]], tailored to the individual's specific needs rather than applying a one-size-fits-all model based on the diagnosis alone.<ref name =Lei2011/> While medications do not directly treat BPD, they are beneficial in managing comorbid conditions like depression and anxiety.<ref>{{cite web|url=http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English|title=CG78 Borderline personality disorder (BPD): NICE guideline|publisher=Nice.org.uk|date=28 January 2009|access-date=12 August 2009|url-status=live|archive-url=https://web.archive.org/web/20090411104754/http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English|archive-date=11 April 2009}}</ref> Evidence states short-term hospitalization does not offer advantages over community care in terms of enhancing outcomes or in the long-term prevention of suicidal behavior among individuals with BPD.<ref>{{cite journal|vauthors=Paris J|s2cid=28921269|title=Is hospitalization useful for suicidal patients with borderline personality disorder?|journal=Journal of Personality Disorders|volume=18|issue=3|pages=240–247|date=June 2004|pmid=15237044|doi=10.1521/pedi.18.3.240.35443}}</ref>

===Psychotherapy===
[[File:Dialectical Behavior Therapy Cycle EN.jpg|thumb|right|The stages used in [[dialectical behavior therapy]]]]Long-term, consistent psychotherapy stands as the preferred method for treating BPD and engagement in any therapeutic approach tends to surpass the absence of treatment, particularly in diminishing self-harm impulses.<ref name="BPD_therapies">{{cite journal|vauthors=Zanarini MC|title=Psychotherapy of borderline personality disorder|journal=Acta Psychiatrica Scandinavica|volume=120|issue=5|pages=373–377|date=November 2009|pmid=19807718|pmc=3876885|doi=10.1111/j.1600-0447.2009.01448.x}}</ref> Among the effective psychotherapeutic approaches, dialectical behavior therapy (DBT), [[schema therapy]], and [[psychodynamic]] therapies have shown efficacy, although improvements may require extensive time, often years of dedicated effort.<ref>{{cite journal|vauthors=Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P|title=Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis|journal=JAMA Psychiatry|volume=74|issue=4|pages=319–328|date=April 2017|pmid=28249086|doi=10.1001/jamapsychiatry.2016.4287|hdl=1871.1/845f5460-273e-4150-b79d-159f37aa36a0|s2cid=30118081|url=https://research.vu.nl/en/publications/845f5460-273e-4150-b79d-159f37aa36a0|access-date=12 December 2019|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232025/https://research.vu.nl/en/publications/efficacy-of-psychotherapy-for-borderline-personality-disorder-a-s|url-status=live|hdl-access=free}}</ref>

Available treatments for BPD include [[dynamic deconstructive psychotherapy]] (DDP),<ref>{{cite book|vauthors=Gabbard GO|date=2014|title=Psychodynamic psychiatry in clinical practice|edition=5th|publisher=American Psychiatric Publishing|location=Washington, D.C.|pages=445–448}}</ref> [[mentalization-based treatment]] (MBT), [[schema therapy]], transference-focused psychotherapy, dialectical behavior therapy (DBT), and general psychiatric management.<ref name="Gund2011" /><ref name="Choi-Kain_2017">{{cite journal|vauthors=Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT|title=What Works in the Treatment of Borderline Personality Disorder|journal=Current Behavioral Neuroscience Reports|volume=4|issue=1|pages=21–30|year=2017|pmid=28331780|pmc=5340835|doi=10.1007/s40473-017-0103-z}}</ref> The effectiveness of these therapies does not significantly vary between more intensive and less intensive approaches.<ref name="LinksShah2017">{{cite journal|vauthors=Links PS, Shah R, Eynan R|title=Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges|journal=Current Psychiatry Reports|volume=19|issue=3|page=16|date=March 2017|pmid=28271272|doi=10.1007/s11920-017-0766-x|s2cid=1076175}}</ref>

[[Transference focused psychotherapy|Transference-focused psychotherapy]] is designed to mitigate absolutist thinking by encouraging individuals to express their interpretations of social interactions and their emotions, thereby fostering more nuanced and flexible categorizations.<ref name="Bliss_2014">{{cite journal|vauthors=Bliss S, McCardle M|date=1 March 2014|title=An Exploration of Common Elements in Dialectical Behavior Therapy, Mentalization Based Treatment and Transference Focused Psychotherapy in the Treatment of Borderline Personality Disorder|journal=Clinical Social Work Journal|volume=42|issue=1|pages=61–69|doi=10.1007/s10615-013-0456-z|s2cid=145079695|issn=0091-1674}}</ref> [[Dialectical behavior therapy]] (DBT), on the other hand, focuses on developing skills in four main areas: interpersonal communication, distress tolerance, emotional regulation, and mindfulness, aiming to equip individuals with BPD with tools to manage intense emotions and improve interpersonal relationships.<ref name="Bliss_2014" /><ref>{{cite book|vauthors=Livesay WJ|chapter=Understanding Borderline Personality Disorder|title=Integrated Modular Treatment for Borderline Personality Disorder|year=2017|pages=29–38|place=Cambridge, England|publisher=[[Cambridge University Press]]|doi=10.1017/9781107298613.004|isbn=978-1-107-29861-3|url=https://zenodo.org/record/4384573|access-date=14 March 2024|archive-date=25 December 2020|archive-url=https://web.archive.org/web/20201225055919/https://zenodo.org/record/4384573|url-status=live}}</ref><ref name="Choi-Kain_2017" />

[[Cognitive behavioral therapy]] (CBT) targets the modification of behaviors and beliefs through problem identification related to BPD, showing efficacy in reducing anxiety, mood symptoms, suicidal ideation, and self-harming actions.<ref name="NIH2016" />

[[Mentalization-based treatment|Mentalization-based therapy]] and transference-focused psychotherapy draw from [[psychodynamic]] principles, while DBT is rooted in cognitive-behavioral principles and [[mindfulness]].<ref name="BPD_therapies" /> General psychiatric management integrates key aspects from these treatments and is seen as more accessible and less resource-intensive.<ref name="Gund2011" /> Studies suggest DBT and MBT may be particularly effective, with ongoing research into developing abbreviated forms of these therapies to enhance accessibility and reduce both financial and resource burdens on patients and providers.<ref name="DBT_vs_therapyByExperts">{{cite journal|vauthors=Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N|title=Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder|journal=Archives of General Psychiatry|volume=63|issue=7|pages=757–766|date=July 2006|pmid=16818865|doi=10.1001/archpsyc.63.7.757|doi-access=free}}</ref><ref name="DBT_and_Mentalization">{{cite journal|vauthors=Paris J|title=Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder|journal=Current Psychiatry Reports|volume=12|issue=1|pages=56–60|date=February 2010|pmid=20425311|doi=10.1007/s11920-009-0083-0|s2cid=19038884}}</ref><ref name="BPD_therapies" />

[[Schema therapy]] considers [[List of maladaptive schemas|early maladaptive schemas]], conceptualized as organized patterns that recur throughout life in response to memories, emotions, bodily sensations, and cognitions associated with unmet childhood needs.<ref>{{Cite book|last1=Young|first1=Jeffrey E|title=Schema Therapy: A Practitioner's Guide|last2=Klosko|first2=Janet S|last3=Weishaar|first3=Marjorie E|publisher=[[Guilford Press]]|year=2003|isbn=9781593853723|location=New York|pages=306–372|chapter=Schema Therapy for Borderline Personality Disorder}}</ref>

Additionally, [[mindfulness meditation]] has been associated with positive structural changes in the brain and improvements in BPD symptoms, with some participants in mindfulness-based interventions no longer meeting the diagnostic criteria for BPD after treatment.<ref name="Mindfulness_neuroscience">{{cite journal|vauthors=Tang YY, Posner MI|title=Special issue on mindfulness neuroscience|journal=Social Cognitive and Affective Neuroscience|volume=8|issue=1|pages=1–3|date=January 2013|pmid=22956677|pmc=3541496|doi=10.1093/scan/nss104}}</ref><ref name="Mindfulness_mechanisms">{{cite journal|vauthors=Posner MI, Tang YY, Lynch G|title=Mechanisms of white matter change induced by meditation training|journal=Frontiers in Psychology|volume=5|issue=1220|page=1220|year=2014|pmid=25386155|pmc=4209813|doi=10.3389/fpsyg.2014.01220|doi-access=free}}</ref><ref name="Mindfulness_therapies">{{cite journal|vauthors=Chafos VH, Economou P|date=October 2014|title=Beyond borderline personality disorder: the mindful brain|journal=Social Work|volume=59|issue=4|pages=297–302|doi=10.1093/sw/swu030|pmid=25365830|s2cid=14256504}}</ref><ref name="Mindfulness_BPD">{{cite journal|vauthors=Sachse S, Keville S, Feigenbaum J|date=June 2011|title=A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder|journal=Psychology and Psychotherapy|volume=84|issue=2|pages=184–200|doi=10.1348/147608310X516387|pmid=22903856}}</ref>

===Medications===
A 2010 [[Cochrane (organisation)|Cochrane]] review found that no medications were effective for the core symptoms of BPD, such as chronic feelings of emptiness, identity disturbances, and fears of abandonment. Some medications might impact isolated symptoms of BPD or those of comorbid conditions.<ref name="Stoffers">{{cite journal|vauthors=Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K|title=Pharmacological interventions for borderline personality disorder|journal=The Cochrane Database of Systematic Reviews|issue=6|page=CD005653|date=June 2010|pmid=20556762|pmc=4169794|doi=10.1002/14651858.CD005653.pub2}}</ref> A 2017 systematic review<ref name="Drugs2017rev"/> and a 2020 Cochrane review<ref name="pmid20044651">{{cite journal|vauthors=Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM|title=Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials|journal=Br J Psychiatry|volume=196|issue=1|pages=4–12|date=January 2010|pmid=20044651|doi=10.1192/bjp.bp.108.062984}}</ref> confirmed these findings.<ref name="Drugs2017rev">{{cite journal|vauthors=Hancock-Johnson E, Griffiths C, Picchioni M|title=A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder|journal=CNS Drugs|volume=31|issue=5|pages=345–356|date=May 2017|pmid=28353141|doi=10.1007/s40263-017-0425-0|s2cid=207486732}}</ref><ref name="pmid20044651"/> This 2020 Cochrane review found that while some medications, like mood stabilizers and second-generation antipsychotics, showed some benefits, [[SSRI]]s and [[SNRI]]s lacked high-level evidence of effectiveness.<ref name="pmid20044651"/> The review concluded that stabilizers and second-generation antipsychotics may effectively treat some symptoms and associated psychopathology of BPD, but these drugs are not effective for the overall severity of BPD; as such, pharmacotherapy should target specific symptoms.<ref name="pmid20044651"/>

Specific medications have shown varied effectiveness on BPD symptoms: [[haloperidol]] and [[flupenthixol]] for anger and suicidal behavior reduction; [[aripiprazole]] for decreased impulsivity and interpersonal problems;<ref name=Stoffers/> and [[olanzapine]] and quetiapine for reducing affective instability, anger, and anxiety, though olanzapine showed less benefit for suicidal ideation than a placebo.<ref name="Stoffers" /><ref name="Drugs2017rev" /> Mood stabilizers like [[valproate]] and [[topiramate]] showed some improvements in depression, impulsivity, and anger, but the effect of [[carbamazepine]] was not significant. Of the [[antidepressant]]s, [[amitriptyline]] may reduce depression, but [[mianserin]], [[fluoxetine]], [[fluvoxamine]], and [[phenelzine]] sulfate showed no effect. [[Omega-3 fatty acid]] may ameliorate suicidality and improve depression. {{as of|2017}}, trials with these medications had not been replicated and the effect of long-term use had not been assessed.<ref name="Stoffers" /><ref name="Drugs2017rev" /> [[Lamotrigine]]<ref name="stofferswinterling20" /> and other medications like IV ketamine<ref>{{cite journal|vauthors=Purohith AN, Chatorikar SA, Nagaraj AK, Soman S|date=December 2021|title=Ketamine for non-suicidal self-harm in borderline personality disorder with co-morbid recurrent depression: A case report|journal=Journal of Affective Disorders Reports|volume=6|pages=100280|doi=10.1016/j.jadr.2021.100280|issn=2666-9153|doi-access=free}}</ref><ref>{{cite journal|vauthors=Chen KS, Dwivedi Y, Shelton RC|date=October 2022|title=The effect of IV ketamine in patients with major depressive disorder and elevated features of borderline personality disorder|journal=Journal of Affective Disorders|volume=315|pages=13–16|doi=10.1016/j.jad.2022.07.054|pmid=35905793|s2cid=251117957|doi-access=free}}</ref> for unresponsive depression require further research for their effects on BPD.

[[Quetiapine]] showed some benefits for BPD severity, psychosocial impairment, aggression, and manic symptoms at doses of 150{{nbsp}}mg/day to 300{{nbsp}}mg/day,<ref name="stofferswinterling20"/> but the evidence is mixed.<ref name="pmid20044651"/>

Despite the lack of solid evidence, [[SSRI]]s and [[SNRI]]s are prescribed off-label for BPD<ref name="stofferswinterling20">{{cite journal|vauthors=Stoffers-Winterling J, Storebø OJ, Lieb K|year=2020|title=Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies|url=https://link.springer.com/content/pdf/10.1007/s11920-020-01164-1.pdf|journal=Current Psychiatry Reports|volume=22|issue=37|page=37|doi=10.1007/s11920-020-01164-1|pmc=7275094|pmid=32504127|doi-access=free|access-date=30 May 2021|archive-date=4 May 2022|archive-url=https://web.archive.org/web/20220504162542/https://link.springer.com/content/pdf/10.1007/s11920-020-01164-1.pdf|url-status=live}}</ref><ref name="pmid37256484">{{cite journal|date=31 May 2023|doi=10.1016/S0140-6736(21)00476-1|title=Pharmacological Management of Borderline Personality Disorder and Common Comorbidities|pmid=37256484|journal=CNS Drugs|vauthors=Pascual JC, Arias L, Soler J|volume=37|issue=6|pages=489–497|pmc=10276775}}</ref> and are typically considered adjunctive to psychotherapy.<ref name="pmid37256484"/>

Given the weak evidence and potential for serious side effects, the UK [[National Institute for Health and Clinical Excellence]] (NICE) recommends against using drugs specifically for BPD or its associated behaviors and symptoms. Medications may be considered for treating comorbid conditions within a broader treatment plan.<ref>{{cite web|url=http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|publisher=UK National Institute for Health and Clinical Excellence (NICE)|title=2009 clinical guideline for the treatment and management of BPD|access-date=6 September 2011|url-status=dead|archive-url=https://web.archive.org/web/20120618094650/http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|archive-date=18 June 2012}}</ref> Reviews suggest minimizing the use of medications for BPD to very low doses and short durations, emphasizing the need for careful evaluation and management of drug treatment in BPD.<ref>{{cite journal|vauthors=Crawford MJ, Sanatinia R, Barrett B, Cunningham G, Dale O, Ganguli P, Lawrence-Smith G, Leeson V, Lemonsky F, Lykomitrou G, Montgomery AA, Morriss R, Munjiza J, Paton C, Skorodzien I, Singh V, Tan W, Tyrer P, Reilly JG|title=The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial|journal=The American Journal of Psychiatry|volume=175|issue=8|pages=756–764|date=August 2018|pmid=29621901|doi=10.1176/appi.ajp.2018.17091006|s2cid=4588378|doi-access=free|hdl=10044/1/57265|hdl-access=free}}</ref><ref>{{cite journal|vauthors=Cattarinussi G, Delvecchio G, Prunas C, Moltrasio C, Brambilla P|title=Effects of pharmacological treatments on emotional tasks in borderline personality disorder: A review of functional magnetic resonance imaging studies|journal=Journal of Affective Disorders|volume=288|pages=50–57|date=June 2021|pmid=33839558|doi=10.1016/j.jad.2021.03.088|s2cid=233211413}}</ref>

===Health care services===
The disparity between those benefiting from treatment and those receiving it, known as the "treatment gap," arises from several factors. These include reluctance to seek treatment, healthcare providers' underdiagnosis, and limited availability and accessibility to advanced treatments.<ref name="BPD Article">{{cite news|vauthors=Johnson RS|title=Treatment of Borderline Personality Disorder|url=http://bpdfamily.com/content/treatment-borderline-personality-disorder|publisher=[[BPDFamily.com]]|date=26 July 2014|access-date=5 August 2014|url-status=live|archive-url=https://web.archive.org/web/20140714183908/http://bpdfamily.com/content/treatment-borderline-personality-disorder|archive-date=14 July 2014}}</ref> Furthermore, establishing clear pathways to services and medical care remains a challenge, complicating access to treatment for individuals with BPD. Despite efforts, many healthcare providers lack the training or resources to address severe BPD effectively, an issue acknowledged by both affected individuals and medical professionals.<ref>{{cite journal|vauthors=Friesen L, Gaine G, Klaver E, Burback L, Agyapong V|title=Key stakeholders' experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care|journal=PLOS ONE|volume=17|issue=9|pages=e0274197|date=2022-09-22|pmid=36137103|pmc=9499299|doi=10.1371/journal.pone.0274197|bibcode=2022PLoSO..1774197F|doi-access=free}}</ref>

In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions.<ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J|title=Treatment histories of borderline inpatients|journal=Comprehensive Psychiatry|volume=42|issue=2|pages=144–150|year=2001|pmid=11244151|doi=10.1053/comp.2001.19749}}</ref> While many engage in outpatient treatment consistently over several years, reliance on more restrictive and expensive treatment options, such as inpatient admission, tends to decrease over time.<ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Hennen J, Silk KR|title=Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years|journal=The Journal of Clinical Psychiatry|volume=65|issue=1|pages=28–36|date=January 2004|pmid=14744165|doi=10.4088/JCP.v65n0105}}</ref>

Service experiences vary among individuals with BPD.<ref>{{cite journal|vauthors=Fallon P|title=Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services|journal=Journal of Psychiatric and Mental Health Nursing|volume=10|issue=4|pages=393–401|date=August 2003|pmid=12887630|doi=10.1046/j.1365-2850.2003.00617.x}}</ref> Assessing suicide risk poses a challenge for clinicians, with patients underestimating the lethality of self-harm behaviors. The suicide risk among people with BPD is significantly higher than that of the general population, characterized by a history of multiple suicide attempts during crises.<ref>{{cite journal|vauthors=Links PS, Bergmans Y, Warwar SH|date=1 July 2004|url=http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder|title=Assessing Suicide Risk in Patients With Borderline Personality Disorder|journal=Psychiatric Times|series=Psychiatric Times Vol 21 No 8|volume=21|issue=8|url-status=live|archive-url=https://web.archive.org/web/20130821210809/http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder|archive-date=21 August 2013}}</ref> About half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association.<ref>{{cite journal|vauthors=Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M|title=Borderline personality disorder|journal=Lancet|volume=364|issue=9432|pages=453–461|year=2004|pmid=15288745|doi=10.1016/S0140-6736(04)16770-6|s2cid=54280127}}</ref>

==Prognosis==
With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve [[Remission (medicine)|remission]], defined as a consistent relief from symptoms for at least two years.<ref name="longitudinal_remission">{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Hennen J, Silk KR|title=The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder|journal=The American Journal of Psychiatry|volume=160|issue=2|pages=274–283|date=February 2003|pmid=12562573|doi=10.1176/appi.ajp.160.2.274}}</ref><ref name=PToverview/>  Remission rates are about 50 to 70% over the course of five years.<ref name="Alvarez-Tomas 2019">{{cite journal |last1=Álvarez-Tomás |first1=Irene |last2=Ruiz |first2=José |last3=Guilera |first3=Georgina |last4=Bados |first4=Arturo |year=2019 |title=Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies |journal=European Psychiatry |volume=56 |issue=1 |pages=75–83 |doi=10.1016/j.eurpsy.2018.10.010 |pmid=30599336 |hdl-access=free |hdl=2445/175985}}</ref>  The remission rate is estimated to be around 50% at 10 years, with 93% of people being able to achieve a 2-year remission and 86% achieving at least a 4-year remission, with a 30% risk of relapse over 10 years.<ref name="Leichsenring 2023">{{cite journal|last1=Leichsenring|first1=Falk|last2=Heim|first2=Nikolas|last3=Leweke|first3=Frank|last4=Spitzer|first4=Carsten|last5=Steinert|first5=Christiane|last6=Kernberg|first6=Otto F.|title=Borderline Personality Disorder: A Review|journal=JAMA|date=28 February 2023|volume=329|issue=8|pages=670–679|doi=10.1001/jama.2023.0589|pmid=36853245}}</ref> 

Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing [[dialectical behavior therapy]] (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of [[agreeableness]] in the patient, compared to patients either low in agreeableness or not being treated with DBT. This association was mediated through the strength of a [[working alliance]] between patient and therapist; that is, more agreeable patients developed stronger working alliances with their therapists, which in turn, led to better clinical outcomes.<ref>{{cite journal|vauthors=Hirsh JB, Quilty LC, Bagby RM, McMain SF|s2cid=33621688|title=The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder|journal=Journal of Personality Disorders|volume=26|issue=4|pages=616–627|date=August 2012|pmid=22867511|doi=10.1521/pedi.2012.26.4.616}}</ref>

In addition to recovering from distressing symptoms, people with BPD can also achieve high levels of [[psychosocial]] functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall.<ref>{{cite journal|vauthors=Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR|title=Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years|journal=Journal of Personality Disorders|volume=19|issue=1|pages=19–29|date=February 2005|pmid=15899718|doi=10.1521/pedi.19.1.19.62178}}</ref>

==Epidemiology==
BPD has a [[point prevalence]] of 1.6%<ref name="PToverview" /> and a [[lifetime prevalence]] of 5.9% of the global population.<ref name="Grant_2008" /><ref name="DSM53" /><ref name="NIH2016" /><ref name="Wolters Kluwer" /><!-- Quote (in archived version): 'According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year.' --><ref name="nimh.nih.gov" /> Within clinical settings, the occurrence of BPD is 6.4% among urban primary care patients,<ref>{{cite journal|vauthors=Gross R, Olfson M, Gameroff M, Shea S, Feder A, Fuentes M, Lantigua R, Weissman MM|title=Borderline personality disorder in primary care|journal=Archives of Internal Medicine|volume=162|issue=1|pages=53–60|date=January 2002|pmid=11784220|doi=10.1001/archinte.162.1.53}}</ref> 9.3% among psychiatric [[outpatients]],<ref>{{cite journal|vauthors=Zimmerman M, Rothschild L, Chelminski I|title=The prevalence of DSM-IV personality disorders in psychiatric outpatients|journal=The American Journal of Psychiatry|volume=162|issue=10|pages=1911–1918|date=October 2005|pmid=16199838|doi=10.1176/appi.ajp.162.10.1911}}</ref> and approximately 20% among psychiatric [[inpatients]].<ref>{{Cite book|title=American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)}}</ref> Utilization of healthcare resources by individuals with BPD is high.<ref name="Bourke_2018" /> Up to half may show significant improvement in their condition, resulting in ineligibility for diagnosis of BPD, following a ten-year period with appropriate treatment.<ref name="DSM53" />

Regarding gender distribution, women are diagnosed with BPD three times more frequently than men in clinical environments.<ref name="DSM53" /><ref name="Wolters Kluwer" /> Nonetheless, [[epidemiological research]] in the United States indicates no significant gender difference in the lifetime prevalence of BPD within the general population.<ref name="Lenzenweger_2007">{{cite journal|vauthors=Lenzenweger MF, Lane MC, Loranger AW, Kessler RC|date=September 2007|title=DSM-IV personality disorders in the National Comorbidity Survey Replication|journal=Biological Psychiatry|volume=62|issue=6|pages=553–564|doi=10.1016/j.biopsych.2006.09.019|pmc=2044500|pmid=17217923}}</ref><ref name="Grant_2008" /> The relationship between BPD and ethnicity continues to be ambiguous, with divergent findings reported in the United States.<ref name="Wolters Kluwer" /> The overall prevalence of BPD in the U.S. prison population is thought to be 17%.<ref name="BPD_fact_sheet">{{cite web|year=2013|title=BPD Fact Sheet|url=http://www.borderlinepersonalitydisorder.com/understading-bpd/bpd-fact-sheet/|url-status=live|archive-url=https://web.archive.org/web/20130104231941/http://www.borderlinepersonalitydisorder.com/understading-bpd/bpd-fact-sheet/|archive-date=4 January 2013|publisher=National Educational Alliance for Borderline Personality Disorder}}</ref> 

==History==
[[File:Edvard Munch - Salomé.jpg|thumb|Devaluation in [[Edvard Munch]]'s ''Salome'' (1903). Idealization and devaluation of others in personal relations are common traits of BPD. The painter Edvard Munch depicted his new friend, the violinist [[Eva Mudocci]], in both ways within days. First as "a woman seen by a man in love", then as "a bloodthirsty and [[Human cannibalism|cannibalistic]] [[Salome]]".<ref name="Ed1990">{{cite book|title=Edvard Munch: the life of a person with borderline personality as seen through his art|date=1990|publisher=Lundbeck Pharma A/S|location=[Danmark]|isbn=978-87-983524-1-9|pages=34–35}}</ref> In modern times, Munch has been diagnosed as having had BPD.<ref>{{cite book|author-link=James F. Masterson|vauthors=Masterson JF|title=Search for the Real Self. Unmasking The Personality Disorders of Our Age|chapter=Chapter 12: The Creative Solution: Sartre, Munch, and Wolfe|pages=208–230, especially 212–213|publisher=Simon and Schuster|location=New York|date=1988|isbn=978-1-4516-6891-9}}</ref><ref>{{cite book|vauthors=Aarkrog T|title=Edvard Munch: the life of a person with borderline personality as seen through his art|publisher=Lundbeck Pharma A/S|location=Denmark|year=1990|isbn=978-87-983524-1-9}}</ref>]]
The coexistence of intense, divergent moods within an individual was recognized by [[Homer]], [[Hippocrates]], and [[Aretaeus of Cappadocia|Aretaeus]], the latter describing the vacillating presence of impulsive anger, [[melancholia]], and [[mania]] within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term ''folie maniaco-mélancolique'',<ref>{{Harvnb|Millon|Grossman|Meagher|2004|p=172}}</ref> described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity".<ref>{{cite journal|vauthors=Hughes CH|year=1884|title=Borderline psychiatric records – prodromal symptoms of psychical impairments|journal=Alienists & Neurology|volume=5|pages=85–90|oclc=773814725}}</ref> In 1921, [[Emil Kraepelin]] identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.<ref name="millon">{{Harvnb|Millon|1996|pp= 645–690}}</ref>

The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s.<ref name="David W Jones history of borderline">{{cite journal|vauthors=Jones DW|title=A history of borderline: disorder at the heart of psychiatry|journal=Journal of Psychosocial Studies|date=1 August 2023|volume=16|issue=2|pages=117–134|doi=10.1332/147867323X16871713092130|s2cid=259893398|url=https://oro.open.ac.uk/90946/1/90946.pdf|access-date=25 September 2023|doi-access=free|archive-date=16 March 2024|archive-url=https://web.archive.org/web/20240316010907/https://oro.open.ac.uk/90946/1/90946.pdf|url-status=live}}</ref> The first formal definition of borderline disorder is widely acknowledged to have been written by [[Adolph Stern]] in 1938.<ref name="stern">{{cite journal|vauthors=Stern A|year=1938|title=Psychoanalytic investigation of and therapy in the borderline group of neuroses|journal=Psychoanalytic Quarterly|volume=7|issue=4|pages=467–489|doi=10.1080/21674086.1938.11925367}}</ref><ref name="alberto">{{cite journal|vauthors=Stefana A|year=2015|title=Adolph Stern, father of term 'borderline personality'|journal=Minerva Psichiatrica|volume=56|issue=2|pages=95}}</ref> He described a group of patients who he felt to be on the ''borderline'' between [[neurosis]] and [[psychosis]], who very often came from family backgrounds marked by trauma. He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques.

The 1960s and 1970s saw a shift from thinking of the condition as [[Pseudoneurotic schizophrenia|borderline schizophrenia]] to thinking of it as a borderline affective disorder (mood disorder), on the fringes of bipolar disorder, [[cyclothymia]], and [[dysthymia]]. In the [[DSM-II]], stressing the intensity and variability of moods, it was called [[cyclothymic personality]] (affective personality).<ref name="DSM-IV-TR"/> While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as [[Otto Kernberg]] were using it to refer to a broad [[Spectrum disorder|spectrum]] of issues, describing an intermediate level of personality organization<ref name="millon"/> between neurosis and psychosis.<ref name="pmid3898174">{{cite journal|vauthors=Aronson TA|title=Historical perspectives on the borderline concept: a review and critique|journal=Psychiatry|volume=48|issue=3|pages=209–222|date=August 1985|pmid=3898174|doi=10.1080/00332747.1985.11024282}}</ref>

After standardized criteria were developed by [[John G. Gunderson|John Gunderson]]<ref>{{cite journal|vauthors=Gunderson JG, Kolb JE, Austin V|title=The diagnostic interview for borderline patients|journal=The American Journal of Psychiatry|volume=138|issue=7|pages=896–903|date=July 1981|pmid=7258348|doi=10.1176/ajp.138.7.896}}</ref> to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the [[Diagnostic and Statistical Manual of Mental Disorders|DSM-III]].<ref name="PToverview">{{cite web|vauthors=Oldham JM|date=July 2004|url=http://www.psychiatrictimes.com/articles/borderline-personality-disorder-overview-0|title=Borderline Personality Disorder: An Overview|work=Psychiatric Times|volume=XXI|issue=8|url-status=live|archive-url=https://web.archive.org/web/20131021180803/http://www.psychiatrictimes.com/articles/borderline-personality-disorder-overview-0|archive-date=21 October 2013}}</ref> The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder".<ref name=pmid3898174/> The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder", which is still in use by the DSM-5.<ref name="DSM53"/> However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.<ref>{{cite book|vauthors=Stone MH|year=2005|chapter=Borderline Personality Disorder: History of the Concept|veditors=Zanarini MC|title=Borderline personality disorder|pages=1–18|publisher=Taylor & Francis|location=Boca Raton, Florida|isbn=978-0-8247-2928-8}}</ref>

Psychodynamic theorists have historically offered the most comprehensive theoretical models of BPD. Gunderson stressed the patient's fundamental interpersonal hypersensitivity, which he viewed as partially genetic.<ref>{{Cite journal|last1=Gunderson|first1=John G.|last2=Lyons-Ruth|first2=Karlen|date=February 2008|title=BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model|journal=Journal of Personality Disorders|volume=22|issue=1|pages=22–41|doi=10.1521/pedi.2008.22.1.22|issn=0885-579X|pmc=2596628|pmid=18312121}}</ref> Kernberg sees the disorder as one involving disturbed [[Object relations theory|object relations]], marked by an excess of aggression and use of primitive defenses, such as splitting, projection, and projective identification.<ref>{{Cite journal|last1=Kernberg|first1=Otto F.|last2=Michels|first2=Robert|date=May 2009|title=Borderline Personality Disorder|url=https://psychiatryonline.org/doi/10.1176/appi.ajp.2009.09020263|journal=American Journal of Psychiatry|volume=166|issue=5|pages=505–508|doi=10.1176/appi.ajp.2009.09020263|pmid=19411373|issn=0002-953X}}</ref> Gerald Adler, writing from a [[self psychology]] perspective, viewed the disorder as resulting from the failure of evocative memory and characterized by an intolerance of aloneness.<ref>{{Cite journal|last1=Adler|first1=G.|last2=Buie|first2=D. H.|year=1979|title=Aloneness and borderline psychopathology: the possible relevance of child development issues|url=https://pubmed.ncbi.nlm.nih.gov/457345/|journal=The International Journal of Psycho-Analysis|volume=60|issue=1|pages=83–96|issn=0020-7578|pmid=457345}}</ref> [[James F. Masterson|Masterson]] hypothesized that the disorder resulted from core developmental problems with [[Margaret Mahler|separation-individuation]].<ref>{{Cite journal|last=LENZENWEGER|first=MARK F.|date=October 2001|title=The Personality Disorders: A New Look at the Developmental Self and Object Relations Approach|url=https://psychiatryonline.org/doi/10.1176/appi.ajp.158.10.1755-a|journal=American Journal of Psychiatry|volume=158|issue=10|pages=1755–a|doi=10.1176/appi.ajp.158.10.1755-a|issn=0002-953X}}</ref> More recently, Mark L. Ruffalo has advanced the hypothesis that BPD is fundamentally a disorder of paradox or self-contradiction.<ref>{{Cite journal|last=Ruffalo|first=Mark L.|year=2025|title=Heads I win, tails you lose: Interpersonal aspects of borderline personality disorder|url=https://pubmed.ncbi.nlm.nih.gov/40063356/|journal=Bulletin of the Menninger Clinic|volume=89|issue=1|pages=52–69|doi=10.1521/bumc.2025.89.1.52|issn=1943-2828|pmid=40063356}}</ref>

===Etymology===
Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the [[Psychosis|psychotics]] and the [[Neurosis|neurotics]]. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis.<ref>{{cite book|vauthors=Moll T|title=Mental Health Primer|isbn=978-1-7205-1057-4|page=43|date=29 May 2018|publisher=CreateSpace Independent Publishing Platform}}</ref> The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s.<ref>{{cite book|title=Psychopharmacology Bulletin|date=1966|publisher=The Clearinghouse|page=555|url=https://books.google.com/books?id=_kOnSecueiYC&pg=PA555|access-date=5 June 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232024/https://books.google.com/books?id=_kOnSecueiYC&pg=PA555|url-status=live}}</ref><ref>{{cite journal|vauthors=Spitzer RL, Endicott J, Gibbon M|title=Crossing the border into borderline personality and borderline schizophrenia. The development of criteria|journal=Archives of General Psychiatry|volume=36|issue=1|pages=17–24|date=January 1979|pmid=760694|doi=10.1001/archpsyc.1979.01780010023001}}</ref> Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.<ref>Harold Merskey, ''Psychiatric Illness: Diagnosis, Management and Treatment for General Practitioners and Students'', Baillière Tindall (1980), p. 415. "Borderline personality disorder is a very controversial and confusing American term, best avoided.</ref>

==Controversies==

===Credibility and validity of testimony===
The credibility of individuals with personality disorders has been questioned at least since the 1960s.<ref name="Goodwin">{{cite book|vauthors=Goodwin J|veditors=Kluft RP|title=Childhood antecedents of multiple personality|date=1985|publisher=American Psychiatric Press|isbn=978-0-88048-082-6|chapter=Chapter 1: Credibility problems in multiple personality disorder patients and abused children|chapter-url=https://archive.org/details/childhoodanteced00kluf|url-access=registration|url=https://archive.org/details/childhoodanteced00kluf}}</ref>{{rp|2}} Two concerns are the incidence of [[dissociation (psychology)|dissociation episodes]] among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition.<ref>{{cite journal|vauthors=Dike CC, Baranoski M, Griffith EE|title=Pathological lying revisited|journal=The Journal of the American Academy of Psychiatry and the Law|volume=33|issue=3|pages=342–349|year=2005|pmid=16186198|url=https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=43902f103c5ab7f664c1fdfe6b2bcb7743f9bcdb|access-date=10 January 2023|archive-date=10 January 2023|archive-url=https://web.archive.org/web/20230110160409/https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=43902f103c5ab7f664c1fdfe6b2bcb7743f9bcdb|url-status=live}}</ref>

====Dissociation====
Researchers disagree about whether dissociation or a sense of [[emotional detachment]] and physical experiences, impact the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of [[autobiographical memory]] was decreased in BPD patients.<ref name="Startup">{{cite journal|vauthors=Jones B, Heard H, Startup M, Swales M, Williams JM, Jones RS|date=November 1999|title=Autobiographical memory and dissociation in borderline personality disorder|url=https://www.cambridge.org/core/journals/psychological-medicine/article/abs/autobiographical-memory-and-dissociation-in-borderline-personality-disorder/FE4B6F11C259022D29FB3F351FEB9147|journal=[[Psychological Medicine]]|volume=29|issue=6|pages=1397–1404|doi=10.1017/S0033291799001208|pmid=10616945|s2cid=19211244|url-access=subscription|via=[[Cambridge University Press|Cambridge Core]]}}</ref> The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid [[episodic memory|episodic]] information that would evoke acutely negative [[affect (psychology)|affect]]'.<ref name = "Startup" /><ref>{{Cite journal|vauthors=Al-Shamali HF, Winkler O, Talarico F, Greenshaw AJ, Forner C, Zhang Y, Vermetten E, Burback L|date=2022-02-13|title=A systematic scoping review of dissociation in borderline personality disorder and implications for research and clinical practice: Exploring the fog|journal=[[Australian and New Zealand Journal of Psychiatry]]|volume=56|issue=10|pages=1252–1264|doi=10.1177/00048674221077029|pmid=35152771|pmc=9511244}}</ref>

===Gender===
{{see also|Gender differences in suicide}}

In a clinic, up to 80% of patients are women, but this might not necessarily reflect the gender distribution in the entire population.<ref>{{cite book|title=Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice|vauthors=Paris J|publisher=The Guilford Press|year=2008|page=21}}</ref> According to Joel Paris, the primary reason for gender disparities in clinical settings is that women are more likely to develop symptoms that prompt them to seek help. Statistics indicate that twice as many women as men in the community experience depression. Conversely, men more frequently meet criteria for [[substance use disorder]] and [[psychopathy]], but tend not to seek treatment as often. Additionally, men and women with similar symptoms may manifest them differently. Men often exhibit behaviors such as increased alcohol consumption and criminal activity, while women may internalize anger, leading to conditions like depression and self-harm, such as cutting or overdosing. Hence, the gender gap observed in [[antisocial personality disorder]] and borderline personality disorder, which may share similar underlying pathologies but present different symptoms influenced by gender. In a study examining completed suicides among individuals aged 18 to 35, 30% of the suicides were attributed to people with BPD, with a majority being men and almost none receiving treatment. Similar findings were reported in another study.<ref name="Paris J 2008 21–22" />

Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide.<ref name="Kreisman J, Strauss H 2004 206">{{cite book|url=https://archive.org/details/sometimesiactcra00jero|title=Sometimes I Act Crazy. Living With Borderline Personality Disorder|vauthors=Kreisman J, Strauss H|publisher=Wiley & Sons|year=2004|isbn=978-0-471-22286-6|page=[https://archive.org/details/sometimesiactcra00jero/page/206 206]|url-access=registration}}</ref>

There are also sex differences in personality traits and Axis I and II comorbidity.<ref name="Sansone_2011">{{cite journal|vauthors=Sansone RA, Sansone LA|date=May 2011|title=Gender patterns in borderline personality disorder|journal=Innovations in Clinical Neuroscience|volume=8|issue=5|pages=16–20|pmc=3115767|pmid=21686143|quote=Men with borderline personality disorder are more likely to demonstrate an explosive temperament and higher levels of novelty seeking. [For Axis I comobidity, men are] more likely to evidence substance use disorders whereas [women with BPD] are more likely to evidence eating, mood, anxiety, and posttraumatic stress disorders. With regard to Axis II comobridity, [men] are more likely than women to evidence antisocial personality disorder. Finally, in terms of treatment utilization, [men] are more likely to have treatment histories relating to substance abuse whereas women are more likely to have treatment histories characterized by more pharmacotherapy and psychotherapy.}}</ref> Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of [[novelty seeking]] and have (especially) antisocial, [[Narcissism|narcissistic]], passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones<ref name="Sansone_2011" />). Women with BPD are more likely to have eating, mood, anxiety, and post-traumatic stress disorders.<ref name="Sansone_2011" />

===Manipulative behavior===
[[Manipulation (psychology)|Manipulative behavior]] to obtain nurturance is considered by the [[diagnostic and statistical manual of mental disorders#DSM-IV-TR (2000)|DSM-IV-TR]] and many mental health professionals to be a defining characteristic of borderline personality disorder.<ref>{{harvnb|American Psychiatric Association|2000|page=705}}</ref> In one research study, 88% of therapists reported that they have experienced manipulation attempts from patient(s).<ref>{{cite journal|vauthors=Mandal E, Kocur D|year=2013|title=Psychological masculinity, femininity, and tactics of manipulation in patients with borderline personality disorder|url=https://www.researchgate.net/publication/259344581|journal=Archives of Psychiatry and Psychotherapy|issue=1|pages=45–53|issn=2083-828X|access-date=14 March 2024|archive-date=14 March 2024|archive-url=https://web.archive.org/web/20240314152609/https://www.researchgate.net/publication/259344581_Psychological_masculinity_femininity_and_tactics_of_manipulation_in_patients_with_borderline_personality_disorder|url-status=live}}</ref> [[Marsha Linehan]] has argued that doing so relies upon the assumption that people with BPD who communicate intense pain, or who engage in self-harm and suicidal behavior, do so with the intention of influencing the behavior of others.<ref name = Linehanp14>{{harvnb|Linehan|1993|page=14}}</ref> The impact of such behavior on others—often an intense emotional reaction in concerned friends, family members, and therapists—is thus assumed to have been the person's intention.<ref name = Linehanp14/>

According to Linehan, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable, however, making their assumed manipulative behavior an involuntary and unintentional response.<ref>{{harvnb|Linehan|1993|page=15}}</ref>

===Stigma===
{{see also|Social stigma}}
The features of BPD include emotional instability, intense and unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "[[attention seeking]]", are often used and may become a [[self-fulfilling prophecy]], as the negative treatment of these individuals may trigger further self-destructive behavior.<ref name="Borderline personality disorder, st"/>

Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers.<ref>{{cite journal|vauthors=Nehls N|title=Borderline personality disorder: gender stereotypes, stigma, and limited system of care|journal=Issues in Mental Health Nursing|volume=19|issue=2|pages=97–112|year=1998|pmid=9601307|doi=10.1080/016128498249105}}{{subscription required}}</ref> One camp{{Who|date=June 2023}} argues that it would be better to diagnose these people with post-traumatic stress disorder (PTSD), as this would acknowledge the impact of abuse on their behavior.{{Citation needed|date=June 2023}} Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.<ref>{{cite journal|vauthors=Becker D|title=When she was bad: borderline personality disorder in a posttraumatic age|journal=The American Journal of Orthopsychiatry|volume=70|issue=4|pages=422–432|date=October 2000|pmid=11086521|doi=10.1037/h0087769}}</ref> Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see [[#Brain abnormalities|brain abnormalities]] and [[#Terminology|terminology]]).

====Physical violence====
The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others.<ref name=Chapman_31>{{harvnb|Chapman|Gratz|2007|page=31}}</ref> While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others.<ref name="Chapman_31"/> Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.<ref name=Chapman_32>{{harvnb|Chapman|Gratz|2007|page=32}}</ref>

One 2020 study found that BPD is individually associated with psychological, physical, and sexual forms of intimate partner violence (IPV), especially amongst men.<ref name=MunroMartin>{{cite journal|vauthors=Munro OE, Sellbom M|title=Elucidating the relationship between borderline personality disorder and intimate partner violence|journal=Personality and Mental Health|volume=14|issue=3|pages=284–303|date=August 2020|pmid=32162499|doi=10.1002/pmh.1480|s2cid=212677723|hdl=10523/10488}}</ref>{{Non-primary source needed|date=April 2025}} In terms of the [[Alternative DSM-5 model for personality disorders#Criterion B: Pathological personality traits|AMPD trait facets]], hostility (negative affectivity), suspiciousness (negative affectivity) and risk-taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.<ref name=MunroMartin/>

In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind.<ref name=Chapman_32/> Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs.<ref name=Chapman_32/> This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others.<ref name=Chapman_32/><ref name=reasons_NSSI /><ref name="Chapman_31"/>

====Mental health care providers====

People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment.<ref>{{cite journal|vauthors=Hinshelwood RD|author-link=R. D. Hinshelwood|title=The difficult patient. The role of 'scientific psychiatry' in understanding patients with chronic schizophrenia or severe personality disorder|journal=The British Journal of Psychiatry|volume=174|issue=3|pages=187–190|date=March 1999|pmid=10448440|doi=10.1192/bjp.174.3.187|doi-access=free}}</ref> A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups.<ref>{{cite journal|vauthors=Cleary M, Siegfried N, Walter G|title=Experience, knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder|journal=International Journal of Mental Health Nursing|volume=11|issue=3|pages=186–191|date=September 2002|pmid=12510596|doi=10.1046/j.1440-0979.2002.00246.x}}</ref>{{Non-primary source needed|date=April 2025}} This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed.<ref name="Campbell_2020">{{cite journal|vauthors=Campbell K, Clarke KA, Massey D, Lakeman R|date=19 May 2020|title=Borderline Personality Disorder: To diagnose or not to diagnose? That is the question|journal=International Journal of Mental Health Nursing|volume=29|issue=5|pages=972–981|doi=10.1111/inm.12737|pmid=32426937|s2cid=218690798|issn=1445-8330}}</ref> With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features.<ref name="Campbell_2020" /> Efforts are ongoing to improve public and staff attitudes toward people with BPD.<ref>{{cite journal|vauthors=Deans C, Meocevic E|title=Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder|journal=Contemporary Nurse|volume=21|issue=1|pages=43–49|year=2006|pmid=16594881|doi=10.5172/conu.2006.21.1.43|s2cid=20500743|hdl=1959.17/66356|url=https://researchonline.federation.edu.au/vital/access/services/Download/vital:236/DS1|access-date=16 March 2024|archive-date=4 August 2024|archive-url=https://web.archive.org/web/20240804193236/https://researchonline.federation.edu.au/vital/access/services/Download/vital:236/DS1|url-status=live}}</ref><ref>{{cite journal|vauthors=Krawitz R|title=Borderline personality disorder: attitudinal change following training|journal=The Australian and New Zealand Journal of Psychiatry|volume=38|issue=7|pages=554–559|date=July 2004|pmid=15255829|doi=10.1111/j.1440-1614.2004.01409.x}}</ref>

Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who have developed helpful coping mechanisms. However, others experience the term "borderline personality disorder" as a [[pejorative]] [[labeling theory|label]] rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative and that the stigma surrounding this disorder limits their access to health care.<ref>{{cite journal|vauthors=Nehls N|title=Borderline personality disorder: the voice of patients|journal=Research in Nursing & Health|volume=22|issue=4|pages=285–293|date=August 1999|pmid=10435546|doi=10.1002/(SICI)1098-240X(199908)22:4<285::AID-NUR3>3.0.CO;2-R}}</ref> Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.<ref name=Manning_ix>{{harvnb|Manning|2011|page=ix}}</ref>

===Terminology===
Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see [[#History|history]]), there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed,<ref name="borderlinepersonalitytoday.com">{{cite news|vauthors=Bogod E|title=Borderline Personality Disorder Label Creates Stigma|url=http://www.borderlinepersonalitytoday.com/main/label.htm|url-status=dead|archive-url=https://web.archive.org/web/20150502181810/http://www.borderlinepersonalitytoday.com/main/label.htm|archive-date=2 May 2015}}</ref> since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate.<ref name="borderlinepersonalitytoday.com"/><ref>{{cite web|url=http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=12|title=Understanding Borderline Personality Disorder|publisher=Treatment and Research Advancements Association for Personality Disorder|year=2004|url-status=dead|archive-url=https://web.archive.org/web/20130526035257/http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=12|archive-date=26 May 2013}}</ref>

Alternative suggestions for names include ''emotional regulation disorder'' or ''emotional dysregulation disorder''. ''Impulse disorder'' and ''interpersonal regulatory disorder'' are other valid alternatives, according to [[John G. Gunderson]] of [[McLean Hospital]] in the United States.<ref>{{cite book|vauthors=Gunderson JG, Hoffman PD|title=Understanding and Treating Borderline Personality Disorder A Guide for Professionals and Families|url=https://archive.org/details/understandingtre00john|url-access=registration|location=Arlington, Virginia|publisher=American Psychiatric Publishing|year=2005|isbn=978-1-58562-135-4}}{{Page needed|date=July 2013}}</ref> Another term suggested by psychiatrist [[Carolyn Quadrio]] is ''post-traumatic personality disorganization'' (PTPD), reflecting the condition's status as (often) both a form of chronic post-traumatic stress disorder (PTSD) as well as a personality disorder.<ref name="AxisOne/AxisTwo">{{cite journal|vauthors=Quadrio C|date=December 2005|title=Axis One/Axis Two: A disordered borderline|url=https://www.researchgate.net/publication/295309096|url-status=dead|journal=[[Australian and New Zealand Journal of Psychiatry]]|volume=39|pages=A97–A153|doi=10.1111/j.1440-1614.2005.01674_39_s1.x|archive-url=https://archive.org/details/quadrio-disordered-borderlline-2005|archive-date=2025-01-08|access-date=2025-01-08|via=[[ResearchGate]]}}</ref> However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.<ref name="Gratz2007">{{harvnb|Chapman|Gratz|2007|page=52}}</ref>

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name "borderline personality disorder" remains unchanged and it is not considered a trauma- and stressor-related disorder.<ref name="DSM-5-borderline-663">{{harvnb|American Psychiatric Association|2013|pages=663–666}}</ref>

==Society and culture==

=== Literature ===
In literature, characters believed to exhibit signs of BPD include Catherine in ''[[Wuthering Heights]]'' (1847), Smerdyakov in ''[[The Brothers Karamazov]]'' (1880), and Harry Haller in ''[[Steppenwolf (novel)|Steppenwolf]]'' (1927).<ref>{{cite journal|vauthors=Morris P|date=1 April 2013|title=The Depiction of Trauma and its Effect on Character Development in the Brontë Fiction|journal=Brontë Studies|volume=38|issue=2|pages=157–168|doi=10.1179/1474893213Z.00000000062|s2cid=192230439}}</ref><ref>{{cite journal|vauthors=Ohi SI|date=26 October 2019|title=Personality Disorder of Character Smerdyakov in Novel the Brother Karamazov Bu [sic&#93; Fyodor Dostovesky (Translated by Constance Clara Garnett)|url=https://repository.ung.ac.id/skripsi/show/321412044/personality-disorder-of-character-smerdyakov-in-novel-the-brother-karamazov-bu-fyodor-dostovesky-translated-by-constance-clara-garnett.html|url-status=live|journal=Skripsi|volume=1|issue=321412044|archive-url=https://web.archive.org/web/20230213123501/https://repository.ung.ac.id/skripsi/show/321412044/personality-disorder-of-character-smerdyakov-in-novel-the-brother-karamazov-bu-fyodor-dostovesky-translated-by-constance-clara-garnett.html|archive-date=13 February 2023|access-date=22 May 2022}}</ref><ref>{{cite book|url=https://books.google.com/books?id=RXa0uEkiNbQC&q=borderline+personality+disorder+%22steppenwolf%22&pg=PA74|title=Transpersonal Psychotherapy|vauthors=Wellings N, McCormick EW|date=1 January 2000|publisher=SAGE|isbn=978-1-4129-0802-3|access-date=22 May 2022|archive-url=https://web.archive.org/web/20240314152701/https://books.google.com/books?id=RXa0uEkiNbQC&q=borderline+personality+disorder+%22steppenwolf%22&pg=PA74#v=onepage&q=borderline%20personality%20disorder%20%22steppenwolf%22&f=false|archive-date=14 March 2024|url-status=live}}</ref>

=== Film ===
Films have also attempted to portray BPD, with characters in ''[[Margot at the Wedding]]'' (2007), ''[[Mr. Nobody (film)|Mr. Nobody]]'' (2009), ''[[Cracks (film)|Cracks]]'' (2009),<ref name="RobinsonFG">{{cite book|title=The Field Guide to Personality Disorders|vauthors=Robinson DJ|publisher=Rapid Psychler Press|year=1999|isbn=978-0-9680324-6-6|page=113}}</ref> ''[[Truth (2013 film)|Truth]]'' (2013), ''[[Wounded (2013 film)|Wounded]] (2013)'', ''[[Welcome to Me]]'' (2014),<ref>{{cite news|date=7 May 2015|title=Kristen Wiig earns awkward laughs and silence in 'Welcome to Me'|url=https://www.washingtonpost.com/goingoutguide/movies/kristen-wiig-earns-awkward-laughs-and-silence-in-welcome-to-me/2015/05/06/c26d9b78-ef6d-11e4-8abc-d6aa3bad79dd_story.html|url-status=live|archive-url=https://web.archive.org/web/20150604082145/http://www.washingtonpost.com/goingoutguide/movies/kristen-wiig-earns-awkward-laughs-and-silence-in-welcome-to-me/2015/05/06/c26d9b78-ef6d-11e4-8abc-d6aa3bad79dd_story.html|archive-date=4 June 2015|access-date=3 June 2015|newspaper=The Washington Post|vauthors=O'Sullivan M}}</ref><ref>{{cite news|date=11 September 2014|title=Toronto Film Review: 'Welcome to Me': Kristen Wiig plays a woman with borderline personality disorder in this startlingly inspired comedy from Shira Piven|url=https://variety.com/2014/film/festivals/toronto-film-review-welcome-to-me-1201304067/|url-status=live|archive-url=https://web.archive.org/web/20150617215603/http://variety.com/2014/film/festivals/toronto-film-review-welcome-to-me-1201304067/|archive-date=17 June 2015|access-date=3 June 2015|newspaper=Variety|vauthors=Chang J}}</ref> and ''[[Tamasha (2015 film)|Tamasha]]'' (2015)<ref>{{cite web|date=9 November 2021|title=Use Your Movie Time To Get Help With Mental Health Issues|url=https://www.femina.in/wellness/mental-health/use-your-movie-time-to-get-help-with-mental-health-issues-211072.html|url-status=live|archive-url=https://web.archive.org/web/20220121130338/https://www.femina.in/wellness/mental-health/use-your-movie-time-to-get-help-with-mental-health-issues-211072.html|archive-date=21 January 2022|access-date=21 January 2022|website=[[Femina (India)]]|vauthors=Setia S}}</ref> all suggested to show traits of the disorder. The behavior of Theresa Dunn in ''[[Looking for Mr. Goodbar (novel)|Looking for Mr. Goodbar]]'' (1975) is consistent with BPD, as suggested by Robert O. Friedel.<ref>{{cite journal|title=Early Sea Changes in Borderline Personality Disorder|url=http://www.nami.org/Template.cfm?Section=By_Illness&template=%2FContentManagement%2FContentDisplay.cfm&ContentID=43145|archive-url=https://web.archive.org/web/20090417050113/http://www.nami.org/Template.cfm?Section=By_Illness&template=%2FContentManagement%2FContentDisplay.cfm&ContentID=43145|url-status=dead|archive-date=17 April 2009|access-date=17 April 2009|journal=Current Psychiatry Reports|year=2006|volume=8|issue=1|pages=1–4|vauthors=Friedel RO|doi=10.1007/s11920-006-0071-6|pmid=16513034|s2cid=27719611|url-access=subscription}}</ref> Films like ''[[Play Misty for Me]]'' (1971)<ref name="Robinson_2003">{{cite book|title=Reel Psychiatry: Movie Portrayals of Psychiatric Conditions|vauthors=Robinson DJ|publisher=Rapid Psychler Press|year=2003|isbn=978-1-894328-07-4|location=Port Huron, Michigan|page=234}}</ref> and ''[[Girl, Interrupted (film)|Girl, Interrupted]]'' (1999, based on the [[Girl, Interrupted|memoir of the same name]]) suggest emotional instability characteristic of BPD,<ref>{{cite book|title=Movies and Mental Illness: Using Films to Understand Psychopathology|vauthors=Wedding D, Boyd MA, Niemiec RM|year=2005|publisher=Hogrefe|location=Cambridge, Massachusetts|isbn=978-0-88937-292-4|page=59}}</ref> while ''[[Single White Female]]'' (1992) highlights aspects such as identity disturbance and fear of abandonment.<ref name="Robinson_2003" />{{rp|235}} Clementine in ''[[Eternal Sunshine of the Spotless Mind]]'' (2004) is noted to show classic BPD behavior,<ref>{{cite journal|vauthors=Alberini CM|date=29 October 2010|title=Long-term Memories: The Good, the Bad, and the Ugly|journal=Cerebrum: The Dana Forum on Brain Science|volume=2010|page=21|issn=1524-6205|pmc=3574792|pmid=23447766}}</ref><ref>{{cite book|vauthors=Young SD|date=14 March 2012|title=Psychology at the Movies|doi=10.1002/9781119941149|isbn=978-1-119-94114-9}}</ref> and [[Carey Mulligan]]'s portrayal in ''[[Shame (2011 film)|Shame]]'' (2011) is praised for its accuracy regarding BPD characteristics by psychiatrists.<ref name="Art of Psychiatry Shame review">{{cite news|vauthors=Seltzer A|title=''Shame'' and ''A Dangerous Method'' reviews|url=http://www.artofpsychiatry.co.uk/shame-and-a-dangerous-method-reviews/|newspaper=The Art of Psychiatry|date=16 April 2012|access-date=13 January 2017|url-status=live|archive-url=https://web.archive.org/web/20170116164632/http://www.artofpsychiatry.co.uk/shame-and-a-dangerous-method-reviews/|archive-date=16 January 2017}}</ref>

=== Television ===
Television series like ''[[Crazy Ex-Girlfriend (TV series)|Crazy Ex-Girlfriend]]'' (2015) and the miniseries ''[[Maniac (miniseries)|Maniac]]'' (2018) depict characters with BPD.<ref>{{cite news|date=26 September 2018|title=Netflix's 'Maniac' Is A Trippy Ride with a Lot To Say About Mental Illness|website=Bustle|url=https://www.bustle.com/p/how-netflixs-maniac-uses-mental-illness-to-interrogate-what-it-means-to-be-normal-12019062|url-status=live|access-date=1 March 2019|archive-url=https://web.archive.org/web/20190302024650/https://www.bustle.com/p/how-netflixs-maniac-uses-mental-illness-to-interrogate-what-it-means-to-be-normal-12019062|archive-date=2 March 2019|vauthors=Patton R}}</ref> Traits of BPD and narcissistic personality disorders are observed in characters like [[Cersei Lannister|Cersei]] and [[Jaime Lannister]] from ''[[A Song of Ice and Fire]]'' (1996) and its TV adaptation ''[[Game of Thrones]]'' (2011).<ref>{{cite news|publisher=MTV News|title=A Therapist Explains Why Everyone on 'Game of Thrones' Has Serious Issues: Westeros is Basically A Living, Breathing Manual for Mental Illness|date=30 April 2015|vauthors=Rosenfield K|url=http://www.mtv.com/news/2146368/game-of-thrones-mental-illness/|access-date=13 May 2019|archive-date=13 May 2019|archive-url=https://web.archive.org/web/20190513175836/http://www.mtv.com/news/2146368/game-of-thrones-mental-illness/|url-status=dead}}</ref> In ''[[The Sopranos]]'' (1999), [[Livia Soprano]] is diagnosed with BPD,<ref>{{cite book|vauthors=Lavery D|title=This Thing of Ours: Investigating the Sopranos|date=2002|publisher=Wallflower Press|page=118}}</ref> and even the portrayal of [[Bruce Wayne]]/Batman in the show ''[[Titans (2018 TV series)|Titans]]'' (2018) is said to include aspects of the disorder.<ref>{{cite web|title=Titans Gives Bruce Wayne a Psychological Diagnosis|date=26 August 2021|url=https://www.cbr.com/titans-bruce-wayne-borderline-personality-disorder/|access-date=9 August 2022|archive-date=9 August 2022|archive-url=https://web.archive.org/web/20220809095534/https://www.cbr.com/titans-bruce-wayne-borderline-personality-disorder/|url-status=live}}</ref> The animated series ''[[BoJack Horseman]]'' (2014) also features a main character with symptoms of BPD.<ref>{{cite web|last=Alvernaz|first=Adam|date=2019-01-29|title=The Depressing Themes Hiding in Bojack Horseman's Closet|url=https://www.highlandernews.org/34540/depressing-themes-hiding-bojack-horsemans-closet/|access-date=2024-01-04|website=Highlander|archive-date=4 January 2024|archive-url=https://web.archive.org/web/20240104230452/https://www.highlandernews.org/34540/depressing-themes-hiding-bojack-horsemans-closet/|url-status=live}}</ref>

=== Awareness ===
Awareness of BPD has been growing, with the [[U.S. House of Representatives]] declaring May as Borderline Personality Disorder Awareness Month in 2008.<ref>{{cite news|url=http://www.borderlinepersonalitydisorder.com/awareness/awareness-files/background.shtml|title=BPD Awareness Month – Congressional History|work=BPD Today|publisher=Mental Health Today|access-date=1 November 2010|url-status=dead|archive-url=https://web.archive.org/web/20110708083602/http://www.borderlinepersonalitydisorder.com/awareness/awareness-files/background.shtml|archive-date=8 July 2011}}</ref> People with BPD will share their personal experiences of living with the disorder on social media to raise awareness of the condition.<ref>{{cite news|url=https://bpd-aware.com/when-is-bpd-awareness-month/|title=When is BPD Awareness Month?|publisher=BPD-Aware|access-date=7 September 2024|archive-date=7 September 2024|archive-url=https://web.archive.org/web/20240907151908/https://bpd-aware.com/when-is-bpd-awareness-month/|url-status=live}}</ref>

Public figures like South Korean singer-songwriter [[Lee Sun-mi]] have opened up about their personal experiences with the disorder, bringing further attention to its impact on individuals' lives.<ref>{{cite web|vauthors=Kim E|date=16 December 2020|title=선미 고백한 '경계선 인격장애' 뭐길래?|trans-title=What is the 'borderline personality disorder' that Sunmi confessed to?|language=Korean|url=https://entertain.naver.com/ranking/read?oid=082&aid=0001052070|publisher=[[Naver TV]]|access-date=16 December 2020|archive-date=6 February 2021|archive-url=https://web.archive.org/web/20210206162916/https://entertain.naver.com/ranking/read?oid=082&aid=0001052070|url-status=live}}</ref>

{{clear}}

== See also ==
{{Portal|Psychology}}
* [[Affective empathy]]
* [[Obsessive love disorder]]
* [[Pseudohallucination]]

== Notes ==
{{notelist}}

== Citations ==
{{reflist}}

== General bibliography ==
{{Refbegin}}
* {{cite book|author=American Psychiatric Association|author-link=American Psychiatric Association|title=Diagnostic and Statistical Manual of Mental Disorders|title-link=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Association|year=2000|isbn=978-0-89042-025-6|edition=4th}}
* {{cite book|author=American Psychiatric Association|title=Diagnostic and Statistical Manual of Mental Disorders|title-link=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Publishing|year=2013|isbn=978-0-89042-555-8|edition=5th}}
* {{cite book|vauthors=Chapman AL, Gratz KL|year=2007|title=The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD|location=Oakland, CA|publisher=[[New Harbinger Publications]]|isbn=978-1-57224-507-5}}
* {{cite journal|vauthors=Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N|author-link1=Marsha M. Linehan|date=July 2006|title=Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder|journal=Archives of General Psychiatry|volume=63|issue=7|pages=757–66|pmid=16818865|doi=10.1001/archpsyc.63.7.757|doi-access=free}}
* {{cite book|vauthors=Linehan M|author-link=Marsha M. Linehan|year=1993|title=Cognitive-behavioral treatment of borderline personality disorder|location=New York|publisher=[[Guilford Press]]|isbn=978-0-89862-183-9}}
* {{cite book|vauthors=Manning S|year=2011|title=Loving Someone with Borderline Personality Disorder|publisher=The Guilford Press|isbn=978-1-59385-607-6}}
* {{cite book|vauthors=Millon T|author-link=Theodore Millon|year=1996|title=Disorders of Personality: DSM-IV-TM and Beyond|location=New York|publisher=[[John Wiley & Sons]]|isbn=978-0-471-01186-6}}
* {{cite book|vauthors=Millon T|author-link=Theodore Millon|year=2004|title=Personality Disorders in Modern Life|publisher=Wiley|isbn=978-0-471-32355-6}}
* {{cite book|vauthors=Millon T, Grossman S, Meagher SE|author-link1=Theodore Millon|year=2004|title=Masters of the mind: exploring the story of mental illness from ancient times to the new millennium|publisher=[[John Wiley & Sons]]|isbn=978-0-471-46985-8}}
* {{cite web|vauthors=Millon T|author-link=Theodore Millon|year=2006|title=Personality Subtypes|url=http://millon.net/taxonomy/summary.htm|access-date=1 November 2010|archive-date=4 November 2010|archive-url=https://web.archive.org/web/20101104162306/http://www.millon.net/taxonomy/summary.htm|url-status=dead|website=Institute for Advanced Studies in Personology and Psychopathology|publisher=Dicandrien, Inc.}}
{{refend}}

== External links ==
{{Commons category|Borderline personality disorder}}
* {{cite web|url=http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|publisher=[[National Institute of Mental Health]]|title=Borderline personality disorder}}
* [https://www.bpdfamily.com/content/borderline-personality-disorder APA DSM 5 Definition of Borderline personality disorder]
* [https://div12.org/psychological-treatments/disorders/borderline-personality-disorder/ APA Division 12 treatment page for Borderline personality disorder]
* [https://icd.who.int/browse/2024-01/mms/en#2006821354 ICD-11 definition of Personality disorder, Borderline pattern by the World Health Organization]
* [https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/overview/ NHS]
* {{cite web|url=https://borderlinesupport.org.uk|title=Borderline Support UK}}

{{Medical condition classification and resources
| ICD10           = {{ICD10|F|60|3|f|60}}
| ICD9            = {{ICD9|301.83}}
| MeshID          = D001883
| ICDO            =
| OMIM            =
| OMIM_mult       =
| MedlinePlus     = 000935
| eMedicineSubj   = article
| eMedicineTopic  = 913575
| eMedicine_mult  =
| SNOMED CT       = 20010003
|ICD11={{ICD11|6D11.5}}}}
{{Borderline personality disorder}}
{{ICD-10 personality disorders}}
{{Authority control}}

{{DEFAULTSORT:Borderline personality disorder}}
[[Category:Borderline personality disorder| ]]
[[Category:Cluster B personality disorders]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Wikipedia neurology articles ready to translate]]
[[Category:Women and psychology]]