Borderline Personality Disorder (BPD) – Signs, DSM-5 Criteria and Treatments

Dr. Alexander Sidawi

Dr. Sidawi is an Orlando based, UF trained physician who is happy to be serving the community he grew up in by offering a combination of psychiatric medication management and psychodynamic psychotherapy.

Intro To Borderline Personality Disorder (BPD):

BPD is a complex personality disorder characterized by intense emotional experiences, unstable relationships, and challenges with self-identity. This blog post aims to explore the signs and symptoms of BPD, including as defined by the DSM-5 criteria, as well as treatment options.

Characteristics of BPD

Emotional Instability and Mood Swings:

A defining characteristic of BPD is the intense and rapid fluctuation of emotions. Individuals with BPD can experience extreme emotional highs and lows in quick succession. These mood swings often include feelings of anger, anxiety, sadness, and elation, all within a short timeframe. This emotional volatility can leave individuals feeling overwhelmed, exhausted, and struggling to maintain emotional equilibrium.

Unstable Relationships:

People with BPD often find it challenging to maintain stable, consistent relationships. Their interpersonal dynamics are marked by a pattern of idealization and devaluation. They may intensely admire someone one moment and then suddenly feel profound disappointment or anger towards them. This turbulent approach to relationships can cause significant stress and instability in both romantic and platonic connections.

Fear of Abandonment:

A pervasive fear of abandonment is common in individuals with BPD. This fear may manifest as clingy or needy behavior, extreme reactions to perceived rejections, and frantic efforts to avoid real or imagined abandonment. It can also lead to preemptive actions like ending relationships abruptly to avoid potential hurt or rejection.

Impulsive Behavior:

Impulsivity is another key aspect of BPD. Individuals may engage in risky or reckless behaviors, such as substance misuse, binge eating, unsafe driving, promiscuity, or excessive spending. These actions are often attempts to manage or escape from intense emotional pain, and they can have significant consequences for the individual’s health and well-being.

Self-Harm and Suicidal Behavior:

There is a strong association between BPD and self-harming behaviors, including cutting, which may be used as a coping mechanism for emotional distress or to exert control over one’s feelings. Additionally, the risk of suicide attempts is notably higher in individuals with BPD, particularly during periods of intense emotional turmoil.

Distorted Self-Image:

Individuals with BPD often struggle with a distorted sense of self. They may find it difficult to define their own goals, values, and beliefs, leading to a persistent sense of confusion and identity disturbance. This can contribute to feelings of emptiness and a chronic sense of uncertainty about their place in the world.

Intense Anger and Hostility:

Intense, inappropriate anger and hostility are common in individuals with BPD. These emotional responses are often triggered by perceived slights, rejections, or abandonment. The anger experienced can be overwhelming and may result in outbursts that are disproportionate to the situation at hand.

DSM-5 Criteria for Borderline Personality Disorder:

Borderline Personality Disorder is defined by the DSM-5 as:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects (emotions), and marked impulsivity, beginning by early adulthood and present in various contexts, as indicated by five (or more) of the following:

Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: Markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
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).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.

Treatment for BPD:

Effective treatment of BPD requires a multifaceted approach, often incorporating both medication and specialized psychotherapies to address the unique challenges and symptoms of the disorder.

Accurate Diagnosis:First and foremost, it is important to make sure this diagnosis is correct. For example, the rapid ups and downs in mood associated with BPD are often misdiagnosed as Bipolar Disorder. The sometimes intense but brief feelings of sadness associated with BPD could be misdiagnosed as Major Depressive Disorder (MDD). Significantly low self esteem and poor self identity can overlap with symptoms of Avoidant Personality Disorder (AvPD). Overwhelming feelings of tension and irritability can be misdiagnosed as Generalized Anxiety Disorder (GAD). Intense feelings of anger could be misdiagnosed as Intermittent Explosive Disorder. Additionally, these diagnoses may exist simultaneously with BPD, which may potentially complicate accurate diagnosis.
Medication: While there are no medications specifically approved for BPD, certain drugs can be helpful in managing co-occurring conditions and specific symptoms. Antidepressants, mood stabilizers, and anti-anxiety medications are commonly prescribed to alleviate symptoms like depression, mood swings, and anxiety. It’s important to note that medication can be more effective when used in conjunction with psychotherapy.
Dialectical Behavior Therapy (DBT): DBT is a cornerstone in the treatment of BPD. Developed specifically for BPD, it combines standard cognitive-behavioral techniques with concepts of distress tolerance, acceptance, and mindful awareness. DBT is particularly effective in teaching individuals skills to regulate emotions, tolerate distress, and improve interpersonal relationships. It often includes both individual therapy and group skills training.
Schema Therapy: This therapy focuses on identifying and changing deeply rooted patterns or schemas. Schema Therapy helps individuals with BPD to understand and alter their long-standing life patterns, particularly those related to self-image, relationships, and emotional regulation. This approach can be particularly beneficial in addressing the chronic feelings of emptiness and identity disturbance common in BPD.
Other Therapies: Other therapeutic approaches, such as Cognitive Behavioral Therapy (CBT) and Mentalization-Based Treatment (MBT), can also be effective. CBT helps in identifying and changing negative thought patterns and behaviors, while MBT focuses on improving the ability to understand and interpret one’s own and others’ mental states.

A tailored treatment plan, often incorporating a combination of these therapies, is crucial. The plan should be adjusted based on the individual’s specific symptoms, life circumstances, and co-occurring disorders.

Living With BPD:

Seeking professional support is essential for effective treatment and recovery. With the right therapeutic approach and support, individuals with BPD can achieve better emotional regulation, improved relationships, and a more stable and fulfilling life. It’s also vital to foster understanding and empathy towards individuals with BPD, as societal support can significantly impact their journey towards recovery. Mental health awareness plays a crucial role in creating a compassionate and inclusive society for everyone, including those living with the challenges of BPD.