# Borderline personality disorder

Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. People diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation (a feeling of detachment from reality), a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.
The onset of BPD symptoms can be triggered by events that others might perceive as normal, with the disorder typically manifesting in early adulthood and persisting across diverse contexts. BPD is often comorbid with substance use disorders, depressive disorders, and eating disorders. BPD is associated with a substantial risk of suicide; studies estimated that up to 10 percent of people with BPD die by suicide. Despite its severity, BPD faces significant stigmatization in both media portrayals and the psychiatric field, potentially leading to underdiagnosis and insufficient treatment.
The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development. A genetic predisposition is evident, with the disorder significantly more common in people with a family history of BPD, particularly immediate relatives. Psychosocial factors, particularly adverse childhood experiences, have been proposed. The American Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies BPD in the dramatic cluster of personality disorders. There is a risk of misdiagnosis, with BPD most commonly confused with a mood disorder, substance use disorder, or other mental health disorders.
Therapeutic interventions for BPD predominantly involve psychotherapy, with dialectical behavior therapy (DBT) and schema therapy the most effective modalities. Although pharmacotherapy cannot cure BPD, it may be employed to mitigate associated symptoms, with 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.
BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population, with a higher incidence rate among women compared to men in the clinical setting of up to three times. Despite the high utilization of healthcare resources by people with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment. 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.

## Signs and symptoms

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:
* Frantic efforts to avoid real or imagined emotional abandonment.
* Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of idealization and devaluation, also known as 'splitting'.
* A markedly disturbed sense of identity and distorted self-image.
* 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 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, values, morals, and beliefs; 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 comorbid conditions such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD).

### Mood and affect

Individuals with BPD exhibit emotional dysregulation. Emotional dysregulation is characterized by an inability in flexibly responding to and managing emotional states, 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.
A core characteristic of BPD is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, 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 psychosocial cues, leading to significant challenges in managing emotions effectively.
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. This increased sensitivity results in an intensified response to environmental cues, including the emotions of others. 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-valenced stimuli. Without effective coping mechanisms, individuals might resort to self-harm, or suicidal behaviors to manage or escape from these intense negative emotions. 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.
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. This negative affectivity causes emotional reactions that diverge from socially accepted norms, in ways that are disproportionate to the environmental stimuli presented. Those with BPD are relatively unable 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, thought suppression, experiential avoidance, emotional isolation, as well as impulsive and self-injurious behaviours.
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. This includes experiencing profound grief instead of mere sadness, intense shame instead of mild embarrassment, rage rather than annoyance, and panic over nervousness. Research indicates that individuals with BPD endure chronic and substantial emotional suffering.
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.
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. A diagnosis of BPD is closely linked with experiencing feelings of betrayal, lack of control, and self-harm.
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 swings in BPD are more commonly between anger and anxiety or depression and anxiety.

### 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 towards perceived criticism or harm. 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. This pattern, referred to as "splitting," can significantly influence the dynamics of interpersonal relationships. 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.
Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent, or fearfully preoccupied attachment styles in relationships, complicating their interactions and connections with others. 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, contributing to a sense of alienation within the family unit.
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. 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. 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, indicating a more pronounced dependence on these interpersonal ties compared to those without BPD.
Individuals with BPD express higher levels of jealousy towards their partners in romantic relations.

### 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. 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. However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle. 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. This escalation of emotional pain then intensifies the 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.

### Self-harm and suicide

Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5. Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method. Other methods, such as bruising, burning, head banging, or biting, are also prevalent. It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.
Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation. There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD.
The motivations behind self-harm and suicide attempts among individuals with BPD are reported to differ. 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. Conversely, true suicide attempts by individuals with BPD frequently are motivated by the notion that others will be better off in their absence.

### Sense of self and self-concept

Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable self-concept. This instability manifests as uncertainty in personal values, beliefs, preferences, and interests. 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. Moreover, their 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.

### Dissociation and cognitive challenges

The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function. Additionally, individuals with BPD may frequently dissociate, which can be regarded as a mild to severe disconnection from physical and emotional experiences. 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.
Dissociation typically arises in response to distressing occurrences or reminders of past trauma, acting as a psychological defense mechanism by diverting attention from the current stressor or by blocking it out entirely. This process is believed to shield the individual from the anticipated overwhelming negative emotions and undesired impulses that the current emotional situation might provoke, and is rooted in the avoidance of intense emotional pain based on past experiences. While this mechanism may offer temporary emotional respite, it can foster unhealthy coping strategies and inadvertently dull positive emotions, thereby obstructing the individual's access to crucial emotional insights. These insights are essential for informed, healthy decision-making in everyday life.

### 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. 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. 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.
The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD. Research has identified the presence of both hallucinations and delusions in individuals with BPD who do not possess an alternate diagnosis that would better explain these symptoms. Further, phenomenological analysis indicates that auditory verbal hallucinations in BPD patients are indistinguishable from those observed in schizophrenia. This has led to suggestions of a potential shared etiological basis for hallucinations across BPD and other disorders, including psychotic and affective disorders.

### Disability and employment

Individuals diagnosed with BPD often possess the capability to engage in employment, provided they secure positions that align with their skill sets and the severity of their condition remains manageable. 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. The United States Social Security Administration officially recognizes BPD as a form of disability, enabling those significantly affected to apply for disability benefits.

## Causes

The etiology, or causes, of BPD is multifaceted, with no consensus on a singular cause. BPD may share a connection with post-traumatic stress disorder (PTSD). 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.

### Genetics and heritability

Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel. Estimates suggest the heritability of BPD ranges from 37% to 69%, indicating that human genetic variations account for a substantial portion of the risk for BPD within the population. 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.
Despite these methodological considerations, 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. Notably, BPD ranks as the third most heritable among ten surveyed personality disorders.
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.
A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify genetic markers associated with BPD. This research identified a linkage to genetic markers on chromosome 9 as relevant to BPD characteristics, underscoring a significant genetic contribution to the variability observed in BPD features. 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.
Among specific genetic variants under scrutiny as of 2012, the DRD4 7-repeat polymorphism (of the dopamine receptor D$_4$) 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. Additionally, potential links to chromosome 5 are being explored, further emphasizing the complex genetic landscape influencing BPD development and manifestation.

### Psychosocial factors
#### Adverse childhood experiences

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. 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. These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers, alongside a notable frequency of incest and loss of caregivers in early childhood.
Moreover, there have been consistent accounts of caregivers invalidating the individuals' emotions and thoughts, neglecting physical care, failing to provide the necessary protection, and exhibiting emotional withdrawal and inconsistency. 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.
The enduring impact of chronic maltreatment and difficulties in forming secure attachments during childhood has been hypothesized to potentially contribute to the development of BPD.

#### Invalidating environment

Marsha Linehan's biosocial developmental theory posits that BPD arises from the interaction between a child's inherent emotional vulnerability and an invalidating environment. Emotional vulnerability is thought to be influenced by biological and genetic factors that shape the child's temperament. Traditional biomedical constructions of BPD often focus solely on biological factors. Though these factors certainly play a role in the development of borderline personality disorder, they do not provide a complete picture. A biosocial approach considers the interplay between genetic predispositions and environmental stressors, such as childhood trauma, invalidating environments, and social relationships, in shaping the course of the disorder.
Invalidating environments are characterized by the neglect, ridicule, dismissal, or discouragement of a child's emotions and needs, and may also encompass experiences of trauma and abuse. Invalidation from caregivers, peers, or authority figures can lead individuals with borderline personality disorder to doubt the legitimacy of their feelings and experiences. This can exacerbate their emotional dysregulation and contribute to a cycle of invalidation, distress, and maladaptive coping strategies. When emotions are consistently dismissed or criticized, individuals with BPD may resort to destructive behaviors such as self-harm, substance abuse, or impulsive actions to cope with their distress, further perpetuating the negative stigma attached to those who suffer from borderline personality disorder.

#### Clinical and cultural perspectives

Anthropologist Rebecca Lester raises two perspectives that BPD can be viewed: a clinical perspective where BPD is a "dysfunction of personality", and an academic perspective that views BPD as a "mechanism of social regulation". Lester provides the perspective that BPD as a disorder of relationships and communication; 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. Lester provides the metaphor of the particle-wave duality in quantum physics when dealing with the distinction between cultural and clinical perspectives of BPD. Like the particle-wave-duality, when asking particle-like questions you will get particle-like answers; and if you ask wave-like questions you will get wave-like answers. Lester argues the same applies to BPD; if you ask culturally based questions about the presence of BPD you will get culturally based answers, if you ask clinical personality-based questions it will reinforce personality-based perspectives. Lester advised both perspectives are valid and should work in tandem to provide a greater understanding of BPD culturally and for the individual.
In this light, Lester argues the higher diagnosis of women than men with BPD goes towards arguing feminist claims. A higher diagnosis BPD in women would be expected in cultures where females are victimised. In this view, BPD is seen as a cultural phenomenon. This is understandable when BPD behaviours are viewed as learned behaviours as a consequence of their experience of surviving environments that reinforce worthlessness and their rejection. To Lester these survival techniques evidence humans' "resilience, adaptation, creativity". Behaviours associated with BPD are therefore an inherently human response.

### Brain and neurobiologic factors

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. Notably, 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.
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, 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, offering insights into BPD's neurobiological basis.

#### Neurological patterns

Research into BPD has identified that the propensity for experiencing intense negative emotions, a trait known as negative affectivity, serves as a more potent predictor of BPD symptoms than the history of childhood sexual abuse alone. This correlation, alongside observed variations in brain structure and the presence of BPD in individuals without traumatic histories, delineates BPD from disorders such as PTSD that are frequently co-morbid. Consequently, investigations into BPD encompass both developmental and traumatic origins.
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.
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, 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. This emotional volatility is consistently linked to disparities in several brain regions, emphasizing the neurobiological underpinnings of BPD.

### Mediating and moderating factors
#### Executive function and social rejection sensitivity

High sensitivity to social rejection is linked to more severe symptoms of BPD, with executive function playing a mediating role. 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. Conversely, higher executive function may mitigate the impact of rejection sensitivity, potentially offering protection against BPD symptoms. Additionally, deficiencies in working memory are associated with increased impulsivity in individuals with BPD.

## 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.
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.
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. The diagnosis relies on both the individual's self-reported symptoms and the clinician's observations. To exclude other potential causes of the symptoms, additional assessments may include a physical examination and blood tests, to exclude thyroid disorders or substance use disorders. 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.

### DSM-5 diagnostic criteria

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. The DSM-5 characterizes BPD as a pervasive pattern of instability in interpersonal relationships, self-image, affect, and a significant propensity towards impulsive behavior. Moreover, the DSM-5 introduces alternative diagnostic criteria for BPD in Section III, titled "Alternative DSM-5 Model for Personality Disorders". These criteria are rooted in trait research and necessitate the identification of at least four out of seven maladaptive traits. 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. To mitigate these challenges, Linehan categorizes BPD symptoms into five principal areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.

### International Classification of Disease (ICD) diagnostic criteria
#### ICD-11 diagnostic criteria

The World Health Organization's ICD-11 completely restructured its personality disorder section. It classifies BPD as Personality disorder, (6D10) Borderline pattern, (6D11.5). The borderline pattern specifier is defined as a personality disturbance marked by instability in interpersonal relationships, self-image, and emotions, as well as impulsivity.
   Diagnosis requires meeting five or more out of nine specific criteria:
   * 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.

#### ICD-10 diagnostic criteria

The ICD-10 (version 2019) identified a condition akin to BPD, termed Emotionally unstable personality disorder (EUPD) (F60.3). This classification described EUPD as a personality disorder with a marked propensity for impulsive behavior without considering potential consequences. Individuals with EUPD have noticeably erratic and fluctuating moods and are prone to sudden emotional outbursts, struggling to regulate these rapid shifts in emotion. Conflict and confrontational behavior are common, especially in situations where impulsive actions are criticized or hindered.
The ICD-10 recognizes two subtypes of this disorder: the impulsive type, characterized mainly by emotional dysregulation and impulsivity, and the borderline type, which additionally includes disturbances in self-perception, goals, and personal preferences. Those with the borderline subtype also experience a persistent feeling of emptiness, unstable and chaotic interpersonal relationships, and a predisposition towards self-harming behaviors, encompassing both suicidal ideations and suicide attempts.

### Millon's subtypes

Psychologist Theodore Millon proposed four subtypes of BPD, where individuals with BPD would exhibit none, one, or multiple subtypes.
| Subtype | Personality Traits |
| Discouraged borderline (Including avoidant, depressive, and dependant features) | Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless. |
| Impulsive borderline (including histrionic or antisocial features) | Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, becomes agitated, and gloomy and irritable; potentially suicidal. |
| Petulant borderline (Including negativistic features) | Negativistic, impatient, restless, as well as stubborn defiant, sullen, pessimistic, and resentful; easily slighted and quickly disillusioned. |
| Self-destructive borderline (Including depressive or masochistic features) | Inward-turning, intropunitively angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide |

### Misdiagnosis

Individuals with BPD are subject to misdiagnosis due to various factors, notably the overlap (comorbidity) of BPD symptoms with those of other disorders such as depression, PTSD, and bipolar disorder. 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. Consequently, misdiagnosis may deprive individuals of access to suitable psychiatric medications or evidence-based psychological interventions tailored to their specific disorders.
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.

### Adolescence and prodrome

The onset of BPD symptoms typically occurs during adolescence or early adulthood, with possible early signs in childhood. Predictive symptoms in adolescents include body image issues, extreme sensitivity to rejection, behavioral challenges, non-suicidal self-injury, seeking exclusive relationships, and profound shame. 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.
BPD is recognized as a stable and valid diagnosis during adolescence, supported by the DSM-5 and ICD-11. 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.
Historically, diagnosing BPD during adolescence was met with caution, due to concerns about the accuracy of diagnosing young individuals, the potential misinterpretation of normal adolescent behaviors, stigma, and the stability of personality during this developmental stage. Despite these challenges, research has confirmed the validity and clinical utility of the BPD diagnosis in adolescents, though misconceptions persist among mental health care professionals, contributing to clinical reluctance in diagnosing and a key barrier to the provision of effective treatment BPD in this population.
A diagnosis of BPD in adolescence can indicate the persistence of the disorder into adulthood, with outcomes varying among individuals. Some maintain a stable diagnosis over time, while others may not consistently meet the diagnostic criteria. Early diagnosis facilitates the development of effective treatment plans, including family therapy, to support adolescents with BPD.

### Differential diagnosis and comorbidity

Lifetime 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 disorders (including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)), other personality disorders (notably schizotypal, antisocial, and dependent personality disorder), substance use disorder, eating disorders (anorexia nervosa and bulimia nervosa), attention deficit hyperactivity disorder (ADHD), somatic symptom disorder, and the dissociative disorders. 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.

#### Comorbid Axis I disorders

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. The same study stated that 73% of individuals with BPD meet criteria for substance use disorders, and about 40% for PTSD. This challenges the notion that BPD and PTSD are identical, as less than half of those with BPD exhibit PTSD symptoms in their lifetime. The study also noted significant gender differences in comorbidity among individuals with BPD: a higher proportion of males meet criteria for substance use disorders, whereas females are more likely to have PTSD and eating disorders. Additionally, 38% of individuals with BPD were found to meet criteria for ADHD, and 15% for autism spectrum disorder (ASD) in separate studies, highlighting the risk of misdiagnosis due to "lower expressions" of BPD or a complex pattern of comorbidity that might obscure the underlying personality disorder.

#### Mood disorders

Seventy-five percent (75%) of individuals with BPD concurrently experience mood disorders, notably major depressive disorder (MDD) or bipolar disorder (BD), complicating diagnostic clarity due to overlapping symptoms. 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, but typically are pervasive in BPD. Thus, diagnosis should ideally be deferred until after the mood has stabilised.
Differences between BPD and BD mood swings include their duration, with BD episodes typically lasting for at least two weeks at a time, in contrast to the rapid and transient mood shifts seen in BPD. 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. Furthermore, the euphoria in BPD lacks the racing thoughts and reduced need for sleep characteristic of BD, though sleep disturbances have been noted in BPD.
An exception would be individuals with rapid-cycling BD, who can be a challenge to differentiate from the affective lability of individuals with BPD.
Historically, BPD was considered a milder form of BD, 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. Research indicates only a modest association between BPD and BD, challenging the notion of a close spectrum relationship.

#### 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. While PMDD, affecting 3–8% of women, 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 personality disorder during their lifetime, according to research conducted in 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. 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.

## Management

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. While medications do not directly treat BPD, they are beneficial in managing comorbid conditions like depression and anxiety. 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.

### Psychotherapy

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. 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.
Available treatments for BPD include dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), schema therapy, transference-focused psychotherapy, dialectical behavior therapy (DBT), and general psychiatric management. The effectiveness of these therapies does not significantly vary between more intensive and less intensive approaches.
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. 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.
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.
Mentalization-based therapy and transference-focused psychotherapy draw from psychodynamic principles, while DBT is rooted in cognitive-behavioral principles and mindfulness. General psychiatric management integrates key aspects from these treatments and is seen as more accessible and less resource-intensive. 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.
Schema therapy considers 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. When activated by events in the patient's life, they manifest as schema modes associated with responses such as feelings of abandonment, anger, impulsivity, self-punitiveness, or avoidance and emptiness. Schema therapy attempts to modify early maladaptive schemas and their modes with a variety of cognitive, experiential, and behavioral techniques such as cognitive restructuring, mental imagery, and behavioral experiments. It also seeks to remove some of the stigma associated with BPD by explaining to clients that most people have maladaptive schemas and modes, but that in BPD, the schemas tend to be more extreme, while the modes shift more frequently. In schema therapy, the therapeutic alliance is based on the concept of limited reparenting: it does not only facilitate treatment, but is an integral part of it as the therapist seeks to model a healthy relationship that counteracts some of the instability, rejection, and deprivation often experienced early in life by BPD patients while helping them develop similarly healthy relationships in their broader personal lives.
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.

### Medications

A 2010 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. A 2017 systematic review and a 2020 Cochrane review confirmed these findings. This 2020 Cochrane review found that while some medications, like mood stabilizers and second-generation antipsychotics, showed some benefits, SSRIs and SNRIs lacked high-level evidence of effectiveness. 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.
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; and olanzapine and quetiapine for reducing affective instability, anger, and anxiety, though olanzapine showed less benefit for suicidal ideation than a placebo. Mood stabilizers like valproate and topiramate showed some improvements in depression, impulsivity, and anger, but the effect of carbamazepine was not significant. Of the antidepressants, 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. Lamotrigine and other medications like IV ketamine 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 mg/day to 300 mg/day, but the evidence is mixed.
Despite the lack of solid evidence, SSRIs and SNRIs are prescribed off-label for BPD and are typically considered adjunctive to psychotherapy.
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. 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.

### 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. 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.
In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions. 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.
Service experiences vary among individuals with BPD. 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. Notably, about half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association.
In 2014, following the death by suicide of a patient with BPD, the National Health Service (NHS) in England faced criticism from a coroner for the lack of commissioned services to support individuals with BPD. It was stated that 45% of female patients were diagnosed with BPD, yet there was no provision or prioritization for therapeutic psychological services. At that time, England had only 60 specialized inpatient beds for BPD patients, all located in London or the northeast region.

## Prognosis

With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. A longitudinal study tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission. Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained a stable recovery from symptoms. Other estimates have indicated an overall remission rate of 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. And a 30% risk of relapse over 10 years (relapse indicating a recurrence of BPD symptoms meeting diagnostic criteria). A meta-analysis which followed people over 5 years reported remission rates of 50-70%.
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.
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.

## Epidemiology

BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population. Within clinical settings, the occurrence of BPD is 6.4% among urban primary care patients, 9.3% among psychiatric outpatients, and approximately 20% among psychiatric inpatients. Despite the high utilization of healthcare resources by individuals with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment.
Regarding gender distribution, women are diagnosed with BPD three times more frequently than men in clinical environments. Nonetheless, epidemiological research in the United States indicates no significant gender difference in the lifetime prevalence of BPD within the general population. This finding implies that women with BPD may be more inclined to seek treatment compared to men. Studies examining BPD patients have found no significant differences in the rates of childhood trauma and levels of current psychosocial functioning between genders. The relationship between BPD and ethnicity continues to be ambiguous, with divergent findings reported in the United States. The overall prevalence of BPD in the U.S. prison population is thought to be 17%. These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD, which is estimated at 38%.

## History

The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates, and 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, 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". In 1921, Emil Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.
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. The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938. 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 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). 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 of issues, describing an intermediate level of personality organization between neurosis and psychosis.
After standardized criteria were developed by John Gunderson to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III. The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder". 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. However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.
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. Kernberg sees the disorder as one involving disturbed object relations, marked by an excess of aggression and use of primitive defenses, such as splitting, projection, and projective identification. 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. Masterson hypothesized that the disorder resulted from core developmental problems with separation-individuation. More recently, Mark L. Ruffalo has advanced the hypothesis that BPD is fundamentally a disorder of paradox or self-contradiction.

### Etymology

Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis. 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. Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.

## Controversies
### Credibility and validity of testimony

The credibility of individuals with personality disorders has been questioned at least since the 1960s.$^{:2}$ Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition.

#### 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. The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid episodic information that would evoke acutely negative affect'.

### Gender

In a clinic, up to 80% of patients are women, but this might not necessarily reflect the gender distribution in the entire population. 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.
In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology); more likely to wind up in the correctional system due to criminal behavior; and, more likely to commit suicide prior to diagnosis.
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.
There are also sex differences in personality traits and Axis I and II comorbidity. Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have (especially) antisocial, narcissistic, passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones). Women with BPD are more likely to have eating, mood, anxiety, and post-traumatic stress disorders.

### Manipulative behavior

Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder. In one research study, 88% of therapists reported that they have experienced manipulation attempts from patient(s). 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. 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.
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.
One paper identified possible reasons for manipulation in BPD: identifying others' feelings and reactions, a regulatory function due to insecurity, communicating one's emotions and connecting to others, or to feel as if one is in control, or allowing them to be "liberated" from relationships or commitments.

### 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.
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. One camp argues that it would be better to diagnose these people with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society. Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see brain abnormalities and terminology).

#### Physical violence

The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others. 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. Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.
One 2020 study found that BPD is individually associated with psychological, physical, and sexual forms of intimate partner violence (IPV), especially amongst men. In terms of the AMPD trait facets, hostility (negative affectivity), suspiciousness (negative affectivity) and risk-taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.
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. Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs. This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others.

#### 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. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups. 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. With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features. Efforts are ongoing to improve public and staff attitudes toward people with BPD.
In psychoanalytic theory, the stigmatization among mental health care providers may be thought to reflect countertransference (when a therapist projects his or her feelings onto a client). This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation.
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 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. Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.

### Terminology

Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see 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, since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate. Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma".
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. 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. 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.
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.

## 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 (1927).

### Film

Films have also attempted to portray BPD, with characters in Margot at the Wedding (2007), Mr. Nobody (2009), Cracks (2009), Truth (2013), Wounded (2013), Welcome to Me (2014), and Tamasha (2015) all suggested to show traits of the disorder. The behavior of Theresa Dunn in Looking for Mr. Goodbar (1975) is consistent with BPD, as suggested by Robert O. Friedel. Films like Play Misty for Me (1971) and Girl, Interrupted (1999, based on the memoir of the same name) suggest emotional instability characteristic of BPD, while Single White Female (1992) highlights aspects such as identity disturbance and fear of abandonment.$^{:235}$ Clementine in Eternal Sunshine of the Spotless Mind (2004) is noted to show classic BPD behavior, and Carey Mulligan's portrayal in Shame (2011) is praised for its accuracy regarding BPD characteristics by psychiatrists.
Psychiatrists have even analyzed characters such as Kylo Ren and Anakin Skywalker/Darth Vader from the Star Wars films, noting that they meet several diagnostic criteria for BPD.

### Television

Television series like Crazy Ex-Girlfriend (2015) and the miniseries Maniac (2018) depict characters with BPD. Traits of BPD and narcissistic personality disorders are observed in characters like Cersei and Jaime Lannister from A Song of Ice and Fire (1996) and its TV adaptation Game of Thrones (2011). In The Sopranos (1999), Livia Soprano is diagnosed with BPD, and even the portrayal of Bruce Wayne/Batman in the show Titans (2018) is said to include aspects of the disorder. The animated series Bojack Horseman (2014) also features a main character with symptoms of BPD.

### Awareness

Awareness of BPD has been growing, with the U.S. House of Representatives declaring May as Borderline Personality Disorder Awareness Month in 2008. People with BPD will share their personal experiences of living with the disorder on social media to raise awareness of the condition.
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.