Living with Borderline Personality Disorder (BPD)

Borderline personality disorder (BPD) is a mental health condition that affects approximately 1.4% of adults in the United States. It results in difficulty regulating emotions, and those living with BPD may suffer from severe symptoms that negatively impact their health and happiness.

However, with the right treatment and by learning coping strategies, you can develop strong relationships and have a fulfilling life.

This article explains what it's like to live with BPD and how to manage symptoms and possible complications.

What Is BPD?

There are four types of BPD, and with each, you may struggle with an ongoing pattern of mood instability, inconsistent behavior, self-image issues, and impulsive actions. With BPD, you may often experience intense emotions and find it hard to return to a stable baseline afterward. Relationship problems are common for people who have BPD.

The exact cause of BPD is not known, but current evidence suggests the development of BPD is influenced by:

• Genetics/inheritance
• Biology (such as certain "wired" personality or temperamental characteristics)
• Environmental (and possibly cultural) experiences

Symptoms

Symptoms of BPD vary between people and can fluctuate over time. Some people experience many symptoms, while others experience only a few.

Symptoms of BPD include:

• Intense mood swings
• Periods of intense depressed mood, irritability, or anxiety that last from a few hours to a few days
• Fear of and efforts to avoid abandonment (real or imagined)
• Feeling empty or bored
  
• Periods of uncontrollable anger which may be followed by feelings of shame or guilt
• Feelings of dissociation (disconnecting from oneself, living outside reality)
• Irrational fear of others' intentions
  
• Viewing things in extremes, such as all good or all bad
• Unstable sense of self or self-image
  

Triggers of BPD Symptoms

Symptoms of BPD can be triggered by objectively minor or ordinary events, such as a loved one leaving on a business trip. The nature of the symptoms, such as severity, frequency, and duration, depends on the individual.

Behaviors Associated With BPD

BPD symptoms affect many aspects of everyday life as people have trouble controlling their anger, caring for themselves, and building or maintaining healthy relationships.

The following are common behaviors displayed by people with BPD:

• Avoiding personal relationships or having a hard time building relationships
• Engaging in impulsive and/or dangerous behaviors, such as unprotected sex (also referred to as condomless sex), reckless driving, misuse of substances, "spree" spending, gambling, or binge eating
  
• Engaging in self-harm (such as cutting)
• Having recurring thoughts of suicide
• Quickly changing interests and values
• Showing distrust toward others

By some estimates, up to 75% of people with BPD engage in at least one instance of non-suicidal self-injury (such as cutting or burning with a cigarette) in an attempt to bring relief from intense emotional pain. This behavior usually begins in early adolescence. Up to 10% of people with BPD die by suicide.

Common Stigmas

People who have mental illnesses often face stigmas, meaning others make assumptions about things they can and cannot do.

BPD is one of the most misunderstood, misdiagnosed, and stigmatized mental health conditions. People with BPD face stigmas such as beliefs that they are:

• Dangerous to themselves and others
• Manipulative
• Attention-seeking
• Difficult to work with
• Resistant to treatment

These stigmas are not just hurtful, they are harmful to people with BPD, especially when they occur within the healthcare system.

People with BPD experience structural stigma and stigma from individual healthcare providers. One study found that over 80% of mental health providers viewed people with BPD as more difficult to treat than those with other illnesses.

These misleading and harmful beliefs affect the quality of care people with BPD receive and can lead to problems such as:

• Poor therapeutic conditions
• Prematurely ending treatment
• Rationalization of treatment failures
• Decreased likelihood of forming an effective treatment alliance between caregiver and person with BPD
• Emotional and social distancing
• Trouble empathizing
• Lack of belief in recovery
• Negative or inaccurate perceptions of people with BPD
• Worsening of the fear of abandonment for the person with BPD
  

To counter the stigma within society and medical environments, it's important to provide people with education about mental illness and introduce them to the experiences of those who have BPD.

Providing psychoeducation and training to healthcare providers, mental health professionals, and the families of people with BPD is also an effective way to stop stigmatizing those with the condition.

Tips for Living With BPD

BPD affects many areas of a person's life. Despite the difficulties this creates, there are measures that can be taken to make it easier to manage.

At Work

It can be difficult for people with BPD to gain and maintain employment, despite the desire to work.

A 2019 study suggests that further research into how reducing symptoms, addressing stigma, and increasing support for employment could improve success in the workplace for people with BPD.

A job preparedness pilot project involving a program called “The Connections Place” showed great promise. It was aimed at helping people with BPD overcome emotional barriers to employment and preparing them to enter/reenter the workplace.

While no job or career path is specifically "best" for all people with BPD, there are things to consider in regard to BPD when looking for employment:

• Flexibility: If you know you need to see a therapist or healthcare professional regularly, look for work that will make this easier.
• Scheduling: Maintaining a healthy sleep schedule is important when you have BPD, so look for a job that allows you to work daytime hours and get a good night's rest.
• Creativity: A career that allows you to use your creativity and try new things can help you avoid boredom and feeling like you're stuck.
• Self-knowledge: Be honest with yourself about what you are good at and how you work best. Do you like new challenges, or do you prefer to stick with a routine you are familiar with? Does a lot of group interaction stress you out, or do you thrive on big team projects? Knowing the environment that suits you will help you be successful.
  

Relationships

Relationship difficulties are a hallmark of BPD, but that doesn't mean people with BPD can't have fulfilling relationships.

Early diagnosis and treatment of BPD can help improve the person's ability to form stable relationships.

Therapy that includes partners, family members, and loved ones can help improve relationships for people with BPD. Therapy that helps people with BPD understand the perspectives of others can also be a way to strengthen relationships.

Self-Image

Internalized stigma can cause people with BPD to feel guilt and shame.

Learning to identify thoughts and emotions, use coping strategies, and understand themselves can help a person with BPD develop a stronger sense of self. This fosters a desire and willingness to engage in the recovery process and can improve treatment outcomes.

Physical Health 

Studies have shown that without adequate treatment, people with BPD are more likely to have other chronic medical or mental health conditions and less likely to make healthy lifestyle choices.

In addition to receiving quality treatment for BPD, people with BPD can help their physical health by:

• Getting enough good quality sleep
• Consuming nutritious foods and eating at regular meal times
• Being physically active
• Keeping track of BPD symptom triggers (people, places, situations, etc.)
  

How BPD Manifests at Different Ages

BPD presents across the lifespan and may be thought of in stages:

1. Premorbid stage (starts in childhood)
2. Subclinical stage (early adolescence)
3. First full BPD episode (middle or late adolescence)
4. Remission and relapse (from middle to late adulthood)

Not everyone with BPD follows this pattern. Other trajectories are possible.

Adolescence

BPD tends to first manifest in adolescence. A reliable BPD diagnosis can be made in adolescents as young as 11 years old.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association's handbook for diagnosing mental health conditions, BPD can be diagnosed in people under the age of 18 if symptoms are:

• Pervasive
• Persistent
• Not limited to particular developmental stage or a different mental disorder
• Present for at least one year
  

BPD symptoms can be distinguished from typical adolescent development. Some studies have shown that 30% of adults with BPD report having engaged in self-harm before the age of 13, while another 30% say they started this behavior between the ages of 13 and 17.

For adolescents without mental illness, impulsivity, identity issues, and affective instability typically diminish over the course of adolescence. For adolescents with BPD, these symptoms tend to increase over time.

Prevalence rates of BPD in adolescents vary widely. Regardless, education around BPD should be given to professionals who work with adolescents, such as youth and social workers, and school health staff.

Adolescents identified as having BPD should always be seen by a healthcare provider to explore their potential suicidal risk, as there are high rates of suicide attempts and completion in adolescents with BPD.

Adulthood

Adults with BPD may see a switch from the symptoms of impulsivity and suicidality predominantly seen in adolescence, to symptoms of maladaptive (negative) interpersonal functioning and enduring functional impairments.

Studies show diagnoses of full BPD generally decrease from young to middle adulthood, but relapse after remission is common.

Older Adults 

BPD is understudied in people over age 50, limiting the understanding of BPD in late life. Studies suggest a decline in BPD from middle adulthood to advanced age.

Symptoms such as impulsivity, rule-breaking, and emotional turmoil may decline, while fear of abandonment, selfishness, and lack of empathy may remain.

The loss of a spouse/partner or a transition to a nursing home/assisted living facility may contribute to a late-onset exacerbation of symptoms of a personality disorder. This may be related to the loss of social support, which had previously helped compensate for symptoms, and/or a renewed fear of abandonment.

While younger people may self-harm in ways such as cutting, older adults are more likely to self-harm by refusing food, necessary medication, or medical treatment.

More research is necessary to gain accurate information on the prevalence and presentation of BPD in older adults.

Treatment Options

While BPD has a reputation for being difficult to treat, newer, evidence-based treatments are offering people with BPD improved quality of life with fewer and less severe symptoms.

Psychotherapy

Psychotherapy (talk therapy) is the most-used treatment for BPD. It can be done individually or in a group setting.

Psychotherapies used to treat BPD include:

• Dialectical behavior therapy (DBT): DBT uses mindfulness and acceptance. It teaches skills that can help people with BPD control intense emotions, reduce self-destructive behaviors, and improve relationships.
• Cognitive behavioral therapy (CBT): CBT helps people with BPD identify and change problematic core beliefs and behaviors. It may help reduce some mood and anxiety symptoms and lower the number of suicidal or self-harming behaviors.
• Mentalization-based therapy (MBT): MBT helps a person with BPD develop more adaptive ways of thinking about and expressing emotions, stabilize their sense of self, and manage ups and downs.

Medication

Medication is not typically used as a treatment for BPD but may be prescribed if other mental health conditions are present, or to treat symptoms, such as:

• Mood swings
• Depression
• Anxiety
  

Summary

BPD is a mental health disorder that affects mood, behavior, and self-image. It typically begins in adolescence, followed by a decrease in symptoms after young adulthood, though relapses are common. People with BPD may face difficulties at work and in relationships.

BPD is often stigmatized, frequently in health care. Healthcare workers and mental health professionals should receive training to combat this stigma. BPD is typically treated with psychotherapy, but medication may be prescribed if necessary.