BORDERLINE PERSONALITY DISORDER
Literature Review on Borderline Personality Disorder
Mary Winston Dozier
Wake Forest University
April 14, 2021
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Abstract
Borderline Personality Disorder (BPD) is a common and severe mental disorder characterized by
a persistent pattern of instability in affect regulation, impulse control, interpersonal relationships,
and self-image. Clinical signs of this Axis II, cluster-b personality disorder include impulsive
aggression, emotional dysregulation, repeated self-injury, and suicidal tendencies. BPD affects
between 2% and 6 % of the population (Torgersen, 2009; Grant et al. 2008). BPD is often
associated with high stress on families and careers as well as high internal levels of anxiety and
stress. Neurobiological research suggests that there is less connectivity between the prefrontal
cortex to the amygdala in people with BPD, leading to many of the symptoms associated with
BPD. The causation of Borderline Personality Disorder is unclear, however genetic factors and
adverse life events, such as physical and sexual abuse, seem to interact leading to BPD. As a
result, there is little understood about the neurobiology, heritable traits, and effects of
psychotherapeutic treatments. BPD symptoms can present themselves in individuals in over 256
combinations (Biskin & Paris, 2012). This, in conjunction with the high frequency of comorbid
psychiatric and personality disorders can lead to misdiagnosis as major depressive disorder or
bipolar disorder. This review aims to provide an overview of present research on the diagnosis,
related controversy and assessment tools in diagnosing, comorbidity in relation to BPD, and
treatment types. Finally, this manuscript will identify gaps in the literature and areas for growth
in research related to borderline personality disorder.
BORDERLINE PERSONALITY DISORDER
Introduction
Background
First appearing in 1980 in DSM-III, Borderline Personality Disorder is characterized in
the DSM-V as “a pervasive pattern of instability in interpersonal relationships, self-image, and
affects, and marked impulsivity” (American Psychiatric Association, 2013, Borderline
Personality Disorder Section, para 1). The DSM-V defines a personality disorder as the
following:
An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time, and leads to distress or impairment
(American Psychiatric Association, 2013, Personality Disorders section, para 1).
BPD is among the most common personality disorders in the Cluster B category, along with
antisocial, histrionic, and narcissistic personality disorders (American Psychiatric Association,
2013, Personality Disorder section, para 3). The DSM-V diagnostic criteria for Borderline
Personality Disorder states the following:
A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include
suicidal or self-mutilating behavior covered in Criterion 5.)
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2. A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of
self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely
more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
(American Psychiatric Association, 2013, Borderline Personality Disorder
Section, para 1.)
Significance
Borderline Personality Disorder (BPD) is a common and severe mental disorder that is
difficult on individuals and their family members. BPD negatively impacts the quality of life of
those who have the disorder and their loved ones. The typical age of onset for BPD is early
adulthood (age 18-25) at 50%, however it is normal for loved ones to have noticed symptoms
much earlier than that (Gunderson, 2008). These symptoms often result in impulsive actions and
BORDERLINE PERSONALITY DISORDER
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problems in relationships. BPD greatly impacts daily life, there may be frequent disruptions in
the routines of family members (Griffin et al, 2018). It's estimated that 1.4% of the adult
U.S. population have BPD. In clinical populations, individuals with BPD make up for 10% of
mental health outpatients, 20% of psychiatric inpatients, and 30-60% of patients being treated for
personality disorders (American Psychiatric Association, 2013, Borderline Personality Disorder
section, para 8). Nearly 75% of people diagnosed with BPD are women. However, recent
research suggests that men may be equally affected by BPD, but are commonly misdiagnosed
with PTSD or depression (Frías, Á et al, 2016).
Many loved ones have spent several years watching their relatives exhibit maladaptive
behaviors, like gambling, substance abuse, reckless driving, perilous sexual behavior, deliberate
self-harm, and suicide attempts. It is estimated that 10% of people with BPD die by suicide
(Black, 2004; Oldham 2006). Up to 75% of individuals with BPD have, cut, burned, hit, or
otherwise injured themselves (Gunderson, 2008). People with BPD may experience intense
episodes of anger, depression, and anxiety that can last from a few hours to days, causing
interpersonal and professional difficulties. BPD rarely stands alone; it is often comorbid with
other Axis I and Axis II disorders. According to the DSM-V, “Common co-occurring disorders
include depressive and bipolar disorders, substance use disorders, eating disorders (frequently
bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity
disorder. Borderline personality disorder also frequently co-occurs with the other personality
disorders” (American Psychiatric Association, 2013, Borderline Personality Disorder section,
para 7).
Methods
Preliminary research on BPD was conducted using Google search to get a basic
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understanding of Borderline Personality Disorder. The National Institute of Mental Health
website (NIMH, 2017) provides an overview of BPD including signs and symptoms, risk factors,
and treatment and therapy options. The National Education Alliance Borderline Personality
Disorder (NEA.BPD, 2012) is a non-profit organization that aims to raise public awareness,
provide resources and treatment options, as well as support those living with borderline
personality disorder and their loved ones. The organization’s website provides webinars, family
workshops, and information on treatment options. Additionally, preliminary research was
conducting using the DSM-V which provides information on the diagnostic criteria, comorbid
disorders, causation, genetic pattern, and treatment of BDP (American Psychiatric Association,
2013).
After acquiring the preliminary information, keyword searches were conducted using two
databases, PubMed and PsychInfo through the Wake Forest University Z. Smith Reynolds
Library website. Key words and phrases such as “borderline personality disorder”, with the
Boolean operator “and” combined with terms such as “treatments”, “emotion dysregulation”, and
“techniques” were used to find a vast array of sources on BPD. Articles were manually sorted
based on significance and limited to sources from 2007 to present. The database search yielded
positive and valuable results for this literature review.
Results
Diagnostic Criteria and Development
The diagnostic criteria for BPD in the DSM-V is the presence of five or more of these
nine criteria: frantic efforts to avoid real or imagined abandonment, unstable self-image,
impulsivity (potentially self-damaging), recurrent suicidal behavior or threats, affective
instability, feelings of emptiness, intense anger, stress-related paranoid ideation, and a pattern of
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unstable and intense interpersonal relationships that alternate between idealization and
devaluation (American Psychiatric Association, 2013, Borderline Personality Disorder Section,
para 1.). Additionally, Borderline Personality Disorder is associated with severe functional
impairments, high rates of comorbid mental disorders and suicide, and intensive use of treatment
(Leichsenring et al., 2011).
Individuals with BPD tend to have have a pattern of undermining themselves at the
moment of possible achievement (e.g., dropping out of school just before graduation).
Individuals with BPD report loss of identity, not knowing who they are (Al-Alem L, Omar H.,
2008). Loss of identity can lead an individual with BPD to abrupt changes in goals and values
such as career, sexual identity, friend group, and activities (American Psychiatric Association,
2012, Borderline Personality Disorder section, para 7). Some individuals report using self-harm
as a way to alleviate emotional stress (Al-Alem L, Omar H., 2008). Early death by suicide may
occur in individuals with this disorder, especially in those with comorbid depressive
disorders or substance use disorders. It is estimated that 10% of individuals with BPD commit
suicide before age 30 (Biskin & Paris, 2012; Soler et al., 2009). More than half of people with
BPD abuse alcohol or drugs, influencing rate of completed suicide (Biskin & Paris, 2012).
Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in
the childhood histories of those with borderline personality disorder (American Psychiatric
Association, 2012, Borderline Personality Disorder section, para 7).
To diagnose Borderline Personality Disorder, clinicians can use a number of interview
tools. To begin, many clinicians use a general personality disorder diagnostic tool to accurately
diagnosis a personality disorder. Comorbidity is common with BPD and other mental disorders.
Up to 13 measurements are used to diagnose BPD in commonly used screening tools such as the
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McLean Screening Instrument for BPD (MSI-BPD), the Borderline Personality Questionnaire
(BPQ), the International Personality Disorder Examination (IPDE), the PDQ-4 BPD, and the
Structured Clinical Interview for DSM-IV Axis II Personality Disorders-Patient Questionnaire –
BPD Scale (SCID-II-PQ BPD). These measurements use either self-reported data or clinician
ratings (Lohanan, T. et al, 2020; Meaney, R. et al, 2016).
The development of BPD typically begins with severe levels of chronic instability that
take place in early adulthood. According to the DSM-V “tendency toward intense emotions,
impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic
intervention often show improvement beginning sometime during the first year” (American
Psychiatric Association, 2013, Borderline Personality Disorder section, para 9). When
individuals with BPD reach their 30s and 40s, a majority attain greater stability in their
relationships and career. Follow-up studies of individuals with BPD in outpatient mental health
clinics showed that after 10 years, about 50% of the individuals had fallen out of criteria for BPD
(American Psychiatric Association, 2013, Borderline Personality Disorder section, para 9).
Diagnostic difficulties and Comorbidity
According to the diagnostic criteria of Borderline Personality Disorder in the DSM-V,
symptoms can present themselves in individuals in over 256 combinations (Biskin & Paris,
2012). Due to the high number of symptom combinations, individuals with BPD are often
misdiagnosed with a mood disorder or bipolar disorder. A study by Belli et al, (2012) suggests
that that the BPD and bipolar disorder are closely linked in phenomenology and treatment
response. According to Zimmerman et al (2013) “about 20% of bipolar II patients and 10% of
bipolar I patients have comorbid BPD, and there is a robust relationship between BPD and
bipolar disorder II” (p. 158). Additionally, Borderline personality disorder is regularly associated
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with comorbid axis I and axis II disorders. According to Leichsenring et al (2011), “84·5% of
patients with borderline personality disorder met criteria for having one or more 12-month axis I
disorders, and 73·9% met criteria for another lifetime axis II disorder” (p. 76). Borderline
personality disorder is most frequently associated with mood disorders, anxiety disorders, and
disorders associated with substance misuse (Leichsenring et al., 2011; Grant et al, 2008).
According to the literature there are differing views as to whether BPD belongs to the
Bipolar (BP) spectrum. However, according Paris and Black (2015) certain BPD features (e.g.
micropsychotic symptoms and interpersonal difficulties) are not clearly associated with mood
fluctuations which challenges the view that it is a Bipolar condition (Paris & Black, 2015; Bayes
et al., 2019). Additionally, an analysis of BPD and BP symptoms in 34,653 individuals generated
a three-factor solution (i.e. BPD, depression and mania)—with correlations between factor pairs
indicative of two separate syndromes (BPD and BP disorder) (del la Rossa et al., 2017; Bayes et
al., 2019). Key differentiating factors of BPD and BP include genetics, relationship factors,
developmental background, illness progression, phenomenological differences in mood states,
and personality style. Less differentiating factors include impulsivity, neuropsychological
profiles, gender distribution, comorbidity and response to treatment (Bayes et al., 2019).
Genetics, Neurobiology, and the Environment
Emotional instability is a hallmark feature of BPD, yet its biology is poorly understood.
Research has found there is a genetic component to BPD. Prevailing view is that a certain trait or
cluster of traits (e.g. impulsivity and mood lability) is inherited rather than the disorder itself
(Gunderson, 2008). By contrast neurobiological research is in its infancy. In a study conducted
on BPD and emotional processing, Koenigsberg et al (2009) found that individuals with BPD
have a hyperactive amygdala. This increased activation of the amygdala leads to oversensitive
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reactions to facial expressions, perceiving neutral facial expressions as negative. Krause et al
(2014) found that “individuals with BPD showed structural and functional abnormalities in a
fronto-limbic network including regions involved in emotion processing (e.g., amygdala, insula)
and frontal brain regions implicated in regulatory control processes (e.g., anterior cingulate
cortex, medial frontal cortex, orbitofrontal cortex, and dorsolateral prefrontal cortex)” (p. 438).
According to one study, individuals with BPD have “hyper active amygdala leading to
predisposal to highly intense interpersonal relationships and frantic to avoid abandonment”
(Fonagy et al., 2011, p. 55), suggesting that children with insecure attachment may have poor
self –regulation and mentalization consequently developing BPD. As defined by the literature,
mentalization is the ability to understand the mental state of oneself and others. It is proposed
that children that experience childhood trauma use avoidance of self-regulation and learning to
mentalize as a coping mechanism. This is supported by the DSM- V which states “physical and
sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood
histories of those with borderline personality disorder” (American Psychiatric Association, 2013,
Borderline Personality Disorder section, para 9).
Psychotherapeutic Treatment
Working with individuals with BPD is challenging for clinicians and requires specific
skills. Many psychotherapeutic approaches are used in the management of BPD including
cognitive behavioral therapy, mentalization-based therapy, transference-focused therapy, and
dialectical behavior therapy (DBT) (O’Connell & Dowling, 2014). A full discussion of the
various treatments is outside the reach of this literature review. Of all the mentioned approaches,
DBT is the most studied and is considered to be the most effective treatment of BPD. According
to O’Connell & Dowling (2014), dialectical behavior therapy is a “multi-pronged approach
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comprising of skills-based group training, individual psychotherapy, telephone calls, and
consultation team meetings” (p. 518). DBT is a complex treatment, that typically takes place in
outpatient settings over 12 months. Evidence supports the use of DBT to mitigate symptoms of
BPD among inpatients (Bloom et al. 2012). The treatment goals of DBT reduce maladaptive,
life-threatening behaviors and behaviors that interfere with therapy (Bloom et al. 2012). When
working with BPD individuals, DBT is associated with having a positive effect on health care
professionals, shifting therapeutic cynicism to that of optimism (O’Connell & Dowling 2014). In
a study comparing the effectiveness of DBT verses standard group therapy (SGT), a greater
decrease in BPD symptoms was found among the DBT group (O’Connell & Dowling 2014;
Soler et al. 2009). DBT has been endorsed by the American Psychiatric Association (2013) as
the treatment of choice for Borderline Personality Disorder.
Discussion
Borderline Personality Disorder is a common and complex mental disorder that has a
significant negative impact on the quality of life of the individuals and their loved ones.
Individuals with BPD experiences chronic feelings of emptiness and may take extreme efforts to
avoid abandonment, leading to trouble in their personal and professional life. There is a need for
greater services, resources, and research for BPD clients and their families. According to the
National Institute of Mental Health (2017), funding for BPD which affects 6% of the population
is at $6 million, compared to Bipolar Disorder affecting 1.6% of the population at $100 million
and Schizophrenia only affecting 0.4% with funding of $300 million.
Age of onset is typically in early adulthood; however, family members usually notice
symptoms much earlier than that. BPD effects 6% of the population and makes up 30-60% of the
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clinical population being treated for personality disorders (American Psychiatric Association,
2013, Borderline Personality Disorder section, para 8). It is estimated that 10% of people with
BPD die by suicide (Black, 2004; Oldham 2006) and up to 75% of individuals with BPD have,
cut, burned, hit, or otherwise self-harmed (Gunderson, 2008). It is reported that self-harm is used
to alleviate the intense emotional stress experienced by individuals with BPD. About half of
individuals with BPD abuse substances.
The literature suggests a connection to childhood trauma and the correlating absence of
self-regulation and mentalization are common factors in the development of BPD (Fongay et al.
2011). Although there are several psychotherapy treatments for BPD, dialectic behavioral
therapy is the most researched showing the highest success rate and thus preferred by many
clinicians as well as the American Psychiatric Association. Research suggest that recovery is
possible, with 50% of clinically treated individuals falling out of criteria for BPD after 10 years’
post treatment, often occurring when individuals reach their 30s and 40s.
Future research should focus on the etiology of BPD. With more knowledge about the
hereditary, neurobiological, and environmental influences on the development of BPD, more
successful treatment plans can be created and clinicians can be trained to treat this complex
disorder. Additionally, research should be conducted on the cognitive symptoms of BPD, given
that symptoms can present themselves in individuals in over 256 combinations (Biskin & Paris,
2012) which can often lead to misdiagnosis. Research on the symptoms of BPD may provide
clinicians with a better understanding of the causes and development of the disorder as well as
aid in creating effective treatment plans.
Another area for future research is the gender disparity in individuals diagnosed with
BPD. Nearly 75% of people diagnosed with BPD are women, however research suggests it may
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be closer to a 50% women to men ratio (Frías, Á et al, 2016). This disparity may be due in part to
the likelihood that more women will seek treatment than men. It is also suggested that men are
often misdiagnosed with Antisocial Personality Disorder. Research on the gender disparity may
provide fruitful results in the diagnostic criteria between genders and lead to more effective
treatment tactics.
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