Borderline Personality Disorder
Borderline personality disorder is marked by extraordinary instability across several domains at once: behaviour, emotion, mood, and the person's very sense of who they are. Impulsivity often expresses itself as repeated self-harm, commonly cutting, used to express anger, to seek attention, or to numb emotional pain, and there is a striking intolerance of being alone that can drive a frantic search for company. Relationships tend to be intense and fraught, swinging between idealisation and rejection, and are shaped by a deep fear of abandonment and a tendency to see people as either all good or all bad.
This has traditionally been described as standing on the border between neurosis and psychosis, reflecting both the intensity of the person's inner experience and the fact that brief, short-lived psychotic-like episodes can occur, though at times these may be vague enough to raise genuine doubt about whether true psychotic symptoms are present at all.
Recognition features
- Extraordinary instability of behaviour, affect, mood, and self-image
- Impulsivity, frequently including repeated self-harm such as cutting, used to express anger, seek attention, or numb emotional pain
- Chronic feelings of boredom and emptiness, and a marked intolerance of being alone, sometimes driving a frantic search for company and promiscuous behaviour
- Disturbance of body image and, at times, uncertainty about gender identity
- Intense fear of abandonment together with 'splitting,' in which other people are seen as entirely good or entirely bad, producing fraught, unstable relationships that swing between intense idealisation and sudden rejection
- Rapid mood swings, moving between anger, low mood, and a feeling of having no emotions at all in quick succession
- A history of sexual or physical abuse is common and believed to be of aetiological significance
- Brief, self-limiting micropsychotic episodes may occur, sometimes vague enough that the presence of true psychotic symptoms is genuinely in doubt
- A tendency toward projective identification, in which intolerable aspects of the self are projected onto another person, who is then, often unwittingly, drawn into acting them out
Eliciting it at interview
- Ask directly and sensitively about self-harm, including its function for the person (expressing anger, seeking attention, or numbing pain), given how central this is to the presentation
- Explore the person's tolerance of being alone and their pattern of relationships, including how quickly closeness can turn to rejection or conflict
- Ask about fear of abandonment and about how the person tends to view others, watching for an 'all good or all bad' quality in their descriptions
- Take a careful, sensitive history of past abuse, given its recognised aetiological association, while remaining alert to the person's current distress and safety
- Where brief psychotic-like experiences are described, assess them carefully for how vivid, fixed, and sustained they are, since some can be genuinely difficult to characterise
- Be alert, especially in clinical team settings, to how the person's shifting view of different staff members can generate disagreement or disharmony within the team itself, a pattern worth naming and managing directly rather than being drawn into
Distinguishing features
- Differs from an ordinary episode of low mood in the sheer breadth of instability involved, spanning behaviour, affect, relationships, and self-image rather than mood alone
- Differs from dissocial personality disorder in that callousness and lack of remorse are not core features here; the intensity of borderline personality disorder is more often turned toward desperate attachment and fear of loss than toward exploitation of others, and this distinction is recognised as an especially important one to make in women
- Micropsychotic episodes are brief and self-limiting, distinguishing them from a sustained primary psychotic illness, though the distinction can be genuinely difficult when the symptoms described are vague
- The diagnosis itself remains contested by some, on the grounds that it may be overly broad and carries very high rates of overlap with other conditions
Common misconceptions
- That self-harm in borderline personality disorder is always a genuine suicide attempt; it is often, though not always, better understood as a way of expressing or managing overwhelming emotion, without this making it any less serious or deserving of a careful safety assessment
- That people with borderline personality disorder are simply manipulative; behaviours that can look manipulative are often better understood as desperate, poorly regulated attempts to manage an intense fear of abandonment
- That any brief unusual experience described by someone with this pattern is a personality trait rather than a genuine, if short-lived, psychotic-like episode requiring its own assessment
Related phenomena
Emotionally Unstable Personality Disorder · Impulsive Personality Disorder · Body Image Disturbance · Narcissistic Personality Disorder
Related defences
Projective Identification · Splitting
Practice this
A 26-year-old woman describes a new colleague as "the only person who has ever really understood her" within days of meeting them, then, after the colleague cancels a coffee catch-up due to a scheduling conflict, calls them "selfish and uncaring" and says she never wants to see them again. She describes a longstanding pattern like this across many relationships, alongside a persistent feeling of emptiness and an intense fear that people will eventually leave her. What is this presentation most consistent with? · On an inpatient ward, a patient praises one nurse extravagantly as "the only person who actually cares," while calling another "completely incompetent and uncaring" after a minor disagreement about visiting hours. By the following week, which nurse is 'good' and which is 'bad' has completely swapped. Before revealing the answer: what is this pattern called, and why does it matter for how the clinical team manages it? · Two patients each have a history of intense relationships, impulsivity, and difficulty with other people. Before revealing the answer, decide what would tell borderline personality disorder apart from dissocial personality disorder. · A patient has a long history of turbulent relationships and behaviour that has harmed others. Before revealing the answer, decide what distinguishes dissocial personality disorder from borderline personality disorder, especially since the two can be confused, particularly in women. · A clinician is describing a patient's personality pattern. Before revealing the answer, decide what distinguishes emotionally unstable personality disorder from borderline personality disorder specifically. · You are assessing a patient for features of borderline personality disorder. Before revealing the answer, decide what areas you would explore, and how you would approach the more sensitive parts of the history. · Explain why it would be a mistake to describe self-harm in borderline personality disorder as simply 'attention-seeking' or manipulative.
Illustration
A 24-year-old woman describes her new therapist as 'the only person who has ever truly understood her' after a single session, then, three weeks later, following a session she experienced as slightly less warm than usual, calls the same therapist 'useless and uncaring' and cuts her own forearm that evening, telling a friend afterward that the physical pain was the only thing that made the emptiness stop.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 10, 'Personality Disorders'.