Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity. Originally thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women.¹ There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.^2,3 Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.⁴ Yet, with help, many improve over time and are eventually able to lead productive lives.

Symptoms

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.⁵ These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Treatment

Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.⁶ Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.⁷

Recent Research Findings

Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.⁸ Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.⁹ Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.

NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion.¹⁰ The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.¹¹

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.⁷

The DSM-IV gives these nine criteria; a diagnosis requires that the subject present with at least five of these. In I Hate You -- Don't Leave Me! Jerold Kriesman and Hal Straus refer to BPD as "emotional hemophilia; [a borderline] lacks the clotting mechanism needed to moderate his spurts of feeling. Stimulate a passion, and the borderline emotionally bleeds to death."

Traits involving emotions:

Quite frequently people with BPD have a very hard time controlling their emotions. They may feel ruled by them. One researcher (Marsha Linehan) said, "People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement."

1. Shifts in mood lasting only a few hours.

2. Anger that is inappropriate, intense or uncontrollable.

Traits involving behavior:

3. Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once

4. Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.

Traits involving identity

5. Marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, "I have a hard time figuring out my personality. I tend to be whomever I'm with."

6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn't know how to fill. My therapist told me that was from almost a "lack of a life". The more things you get into your life, the more relationships you get involved in, all of that fills that hole. As a borderline, I had no life. There were times when I couldn't stay in the same room with other people. It almost felt like what I think a panic attack would feel like."

Traits involving relationships

7. Unstable, chaotic intense relationships characterized by splitting (see below).

8. Frantic efforts to avoid real or imagined abandonment

• Splitting: the self and others are viewed as "all good" or "all bad." Someone with BPD said, "One day I would think my doctor was the best and I loved her, but if she challenged me in any way I hated her. There was no middle ground as in like. In my world, people were either the best or the worst. I couldn't understand the concept of middle ground."

• Alternating clinging and distancing behaviors (I Hate You, Don't Leave Me). Sometimes you want to be close to someone. But when you get close it feels TOO close and you feel like you have to get some space. This happens often.

• Great difficulty trusting people and themselves. Early trust may have been shattered by people who were close to you.

• Sensitivity to criticism or rejection.

• Feeling of "needing" someone else to survive

• Heavy need for affection and reassurance

• Some people with BPD may have an unusually high degree of interpersonal sensitivity, insight and empathy

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

This means feeling "out of it," or not being able to remember what you said or did. This mostly happens in times of severe stress.

Miscellaneous attributes of people with BPD:

• People with BPD are often bright, witty, funny, life of the party.

• They may have problems with object constancy. When a person leaves (even temporarily), they may have a problem recreating or remembering feelings of love that were present between themselves and the other. Often, BPD patients want to keep something belonging to the loved one around during separations.

• They frequently have difficulty tolerating aloneness, even for short periods of time.

• Their lives may be a chaotic landscape of job losses, interrupted educational pursuits, broken engagements, hospitalizations.

• Many have a background of childhood physical, sexual, or emotional abuse or physical/emotional neglect.

You know, I resent you writing things like this:

“Isn't it crazy how much we click on so many things but when it comes to "relationship rules" we differ so greatly? I realize now that it is not because anyone is lacking, it is just that we are two different souls... I guess we both know that the key now is for you to discover someone for you that you not only bond with the way we do, but also fullfills your relationship expectations and happily opporates on the same relationship rules! (I'm working on this myself)”

Don't over romanticize our break up. We broke up because, while I was out of the country on a mission for work, you were in a hotel room with some guy. Thank God I did not get sent to Iraq for six-months. So if you mean I need someone to operate on the relationship rules of loyalty and honesty, then yes you're right.

You claimed you didn't actually have sex, but since you lied about being there in the first place no other claims have credence.

Look, having a relationship means you have to be loyal to that other person. No sex with other women, no inviting ex-boyfriends to meet you in bars for flirting dates where they just hold you and smell your hair, and no shared weekend hotel accommodations. That's not hard.

You wanted to have your next relationship in the works before you left me, just like I was the next relationship already setup before you left Andrew. Bad on me for going into a relationship with you thinking you would change.

We were great together and clicked amazingly, but you are not loyal, and you are not honest. I hung on through the violence, the tantrums and the craziness, because I thought you were worth it underneath all that. But you are a cheater. And that's a deal breaker.

Be the perfect girlfriend…

1. By accepting this Lady-partisan date, The Man will be guaranteed one (1) date on which both parties participate in an activity of his choice—including, but not limited to: Attending an athletic event, watching a martial-arts movie, or going out for a large BBQ dinner.

1. Rule 2-A above may be broken if The Lady mentions a deep and abiding flaw in the ex-boyfriend, while also discussing ways in which The Man betters said ex.

1. Furthermore, The Lady may not devise any nickname that includes a diminutive or that is spoken in baby-voice (e.g., “Little John” or “Snuggle Bear”).

1. She will not ask The Man to attend any event on the day of a televised athletic match, any event that involves the phrase “pot luck,” or any event that celebrates the birth of a child, impending or otherwise.
2. She will not expect The Man to attend a gathering solely because the boyfriend/husband of The Lady’s Friend will also be in attendance. Misery does not make good company.
3. No. Ex-Boyfriends. Ever.

1. The Lady will be the first party to speak the phrase. She will do so clearly and while making eye contact so that The Man knows it is he who is being spoken to. The Lady will allow the man at least five (5) minutes to respond in kind. This reprieve does not mean he doesn’t feel the same way, only that he is apt to be flustered, frightened, and suddenly stricken with cotton-mouth.
2. After the first time the Man arranges the words “I,” “you,” and “love” into a sentence, he will not be required to do so in response every time The Lady speaks the phrase. The Lady will also accept “Me, too,” “Ditto,” or a high-five in return.
3. The Lady will never speak the three-worded phrase when The Man is in the presence of either friends or co-workers. This is done out of respect for the mockery that is sure to result should he be forced to reciprocate while with said company.