Treating patients with borderline personality disorder

Borderline personality disorder (BPD) is a common but often misunderstood condition, even by seasoned mental health professionals. Fortunately, enhanced diagnostic criteria and training are helping to equip clinicians with the necessary tools to effectively assist patients. And with an accurate diagnosis, BPD is treatable through psychotherapy, according to experts.

First and foremost, BPD impacts how someone views themselves and others. For example, they may see themselves as bad or worthless, and their evaluations of others may change rapidly depending on circumstances—from idealizing to devaluing. The condition is marked by extreme emotions, thinking, and behavior, unstable relationships, and insecurity.

While doctors and scientists do not know what exactly causes BPD, they think that both environmental and biological factors play a role. Research suggests that a history of child abuse or neglect, genetics, and changes in some regions of the brain can trigger the condition.

For example, one study examined how childhood trauma and attachment styles influenced stress responses in women with varying levels of BPD symptoms (Ehrenthal, J. C., et al., Journal of Personality Disorders, Vol. 32, No. 6 [Suppl.], 2018opens in new window). Researchers measured stress responses through biomarkers like cortisol and salivary alpha-amylase (sAA) during a stressful task and found that adverse childhood experiences were linked to altered stress responses, especially when combined with insecure attachment styles. Women who scored higher on an avoidant attachment style—those who suppress their need for connection and struggle to rely on others, especially during stressful times—showed consistently higher levels of sAA, a marker of stress. When combined with childhood trauma, anxious attachment—defined by a doubt in the ability to handle emotions independently and constantly seek reassurance—was associated with less reactive and more blunted cortisol responses, indicating a dampened stress response. In other words, the combination of high childhood trauma and attachment insecurities led to distinct patterns in stress regulation, suggesting that early experiences shape how people cope with stress later in life.

Over the past 25 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has refined the diagnostic criteria for BPD and other personality disorders to ensure more reliable and valid diagnoses, eventually dividing personality disorders into three clusters. Each cluster includes a unique set of personality disorders with similarities in symptoms, behaviors, and underlying psychological patterns. Cluster A groups personality disorders with “odd or eccentric” characteristics, such as paranoid personality disorder. Cluster B includes BPD and other personality disorders with dramatic, emotional, or erratic behaviors. Cluster C covers personality disorders with anxious or fearful characteristics, such as avoidant personality disorder.

The current version of the DSM, the fifth edition (DSM-5), introduced an alternative model for diagnosing these conditions, “a sea change in how we conceptualize personality disorders,” explained Kenneth Levy, PhD, a clinical psychologist and professor of psychology at The Pennsylvania State University. The model recognizes that people often show traits from multiple personality disorders rather than fitting neatly into just one.

The alternative model was introduced to address problems with the older system, such as overlapping diagnoses and unclear distinctions between disorders. Since then, it has generated a large body of research. While some clinicians prefer the alternative approach, it has not been fully adopted into mainstream mental health treatment.

Two main criteria must be met to diagnose BPD under the alternative dimensional model. First, the person must have significant problems in at least two areas of personality functioning: identity, self-direction, empathy, or intimacy. Second, they must display at least four of these traits: emotional instability, anxiety, fear of separation, persistent sadness, impulsiveness, risky behavior, or hostility, and at least one of the traits must be impulsiveness, risky behavior, or hostility.

A third framework, the International Classification of Diseases (ICD) model for personality disorders, also takes a dimensional approach. It includes five broad trait domains: negative affectivity, detachment, dissociality, disinhibition, and anankastia (obsessive-compulsive tendencies). The ICD-11 model is even more fully dimensional than the alternative model, requiring clinicians to assess severity first before specifying personality traits. But it still maintains a “borderline pattern” specifier, acknowledging the extensive research and clinical focus on BPD. This helps bridge the gap between the new dimensional model and older diagnostic traditions.

BPD is the most commonly diagnosed personality disorder in clinical populations. Studies estimate that it affects about 0.7% to 2.7% of the general population. The prevalence is higher in health care settings—about 6% in primary care, 11% to 12% in outpatient psychiatric clinics, and 22% among psychiatric inpatients. Severe symptoms, including suicidal thoughts and self-harm, often lead people to seek out or require professional help in an emergency room or inpatient unit, which raises the likelihood that they will be diagnosed with BPD. Clinicians in these settings may be more familiar with BPD and better equipped to recognize its symptoms than those in general medical practice.

In the general population, however, BPD is frequently underdiagnosed, and when it overlaps with symptoms of conditions like anxiety, depression, and bipolar disorder, it can lead to misdiagnosis. Symptoms can appear similar, but skilled clinicians can spot distinctions. For example, mood instability tends to be moment-to-moment in people with BPD, with their moods changing much quicker than those of people with bipolar disorder.

Research shows that clinicians miss many BPD cases simply because they do not evaluate for the condition, highlighting the importance of a thorough assessment, including a detailed patient interview and mental health evaluation, medical history, and symptom discussion.

The main treatment for BPD is psychotherapy; there is currently no medication approved specifically for treating BPD. Therapies designed specifically for BPD, including those listed below, have been shown to improve functioning, reduce symptoms, and may help lower self-harm and depression.

■ Mentalization-based treatment (MBT), helps people with BPD better understand and manage their emotions and involves both individual and group therapy to improve emotional awareness and empathy for others.

■ Dialectical behavior therapy (DBT) combines mindfulness with skills to manage emotions and relationships. It focuses on helping people tolerate distressing feelings through individual and group therapy and weekly team consultations with therapists.

■ Transference-focused psychotherapy (TFP) leverages the patient-therapist relationship to help patients recognize unhealthy interpersonal patterns, and the therapist offers clarification and feedback.

■ Schema therapy (ST) aims to help people build healthier adult behaviors by addressing four key emotional patterns in BPD: feeling abandoned or abused, anger and impulsivity, emotional detachment, and a critical inner voice. ST uses a mix of cognitive behavioral, psychodynamic, attachment, and emotion-focused techniques.

One study explored how different BPD therapies perform depending on a person’s ability to understand their own and others’ thoughts and feelings, a skill known as reflective functioning (Keefe, J. R., et al., Journal of Consulting and Clinical Psychology, Vol. 91, No. 1, 2023). Researchers looked at four types of treatment: TFP, DBT, supportive psychodynamic therapy (SPT), and community-based care.

They found that patients with low reflective functioning benefited more from TFP or SPT, showing improved symptoms and better reflective functioning. These therapies focus on understanding emotional states and relationships. Patients with high reflective functioning responded better to community-based care and DBT, which involve building specific skills for emotional regulation and interpersonal effectiveness. These findings suggest that matching the type of therapy to a patient’s reflective functioning level could enhance treatment outcomes for BPD.

Unfortunately, treatment, regardless of type, isn’t effective for everyone. “Patients with high trauma rates or antisocial traits often don’t do as well in treatment,” Levy said.

He added that research is increasingly focused on understanding how treatments for BPD work rather than just if they work. “What changes within the patient? What does the therapist do to enact that change?”

While there are no FDA-approved medications for personality disorders, medication can be used to manage mental health conditions that often accompany BPD, such as depression or anxiety. If a patient is at risk of harming themselves, hospitalization is recommended.

Building a trusting clinician-­patient relationship is also critical, said Julia Becker, PsyD, a clinical psychologist and coach who treats college students and adults with a range of mental health issues including borderline personality disorder. Since BPD is marked by unstable relationships characterized by extremes of idealization and devaluation, it can affect the bond between therapist and patient. So, for people with BPD, building a strong therapeutic alliance may require more than just trust and shared goals—it might involve managing this instability.

To explore this, researchers analyzed daily patient ratings of the therapeutic process for 51 patients with BPD and 66 with major depressive disorder who were receiving inpatient treatment and examined the stability of the therapeutic alliance and how it related to treatment outcomes. (Kratzer, L., et al., Journal of Contemporary Psychotherapy, Vol. 54, 2024opens in new window). The findings showed that the alliance was much more unstable for patients with BPD. Interestingly, this instability—when it included periods of breakdown and repair—was linked to better outcomes for BPD patients. This suggests that working through challenges in the therapeutic relationship may play a key role in effective treatment.

Many clinicians are reluctant to diagnose adolescents with BPD because of the common belief that personality is not sufficiently formed during adolescence, so a personality diagnosis would be premature.

However, both the current and older versions of the DSM allow providers to diagnose BPD in people younger than 18. And research indicates that many features of BPD are already present and stable in adolescents.

“We used to think that personality disorders couldn’t be diagnosed until adulthood, but the features of BPD are remarkably similar in adolescents and adults,” said Carla Sharp, PhD, a clinical psychologist and director of the Adolescent Diagnosis Assessment Prevention Treatment Center at the University of Houston.

Like adults, adolescents with BPD experience emotional dysregulation and unstable relationships. But the social environments influencing their symptoms differ. For younger people, parental and peer relationships as well as social media play prominent roles in shaping how symptoms manifest. For example, social media heightens social comparison and identity pressures, which can intensify emotional and interpersonal difficulties. While adults are also susceptible to external influences, the nature of those influences varies, reflecting differences in their social contexts.

It is also important to distinguish the ways that BPD manifests in children and adolescents, according to Sharp. Personality disorders are characterized by an unstable sense of self and impairments in interpersonal functioning; however, children and adolescents are still forming their sense of self and interpersonal skills. In these age groups, clinicians may instead evaluate specific traits or behaviors, such as emotional sensitivity or impulsivity, which could indicate a risk of developing a personality disorder later in life.

Sharp, whose work focuses on personality disorders and other severe psychopathology in adolescents, believes that adolescence is an optimal time to treat BPD “because the brain is still plastic, and social relationships are in flux.”

Treatment should consider an adolescent’s ongoing development, particularly in identity formation, emotional regulation, and interpersonal relationships, Sharp added. Their impulsivity and emotional sensitivity require tailored interventions that address the challenges of this stage of their lives. For instance, DBT for adolescents often includes parents or other caregivers to enhance communication and reduce family conflict, while MBT also focuses on helping them make sense of themselves and others. While research shows that DBT and MBT improve symptoms in youth with BPD, more research is needed, given that the quality of studies has generally been low, said Sharp.

Cultural norms can also influence how clinicians interpret symptoms of BPD, leading to potential misdiagnosis. For example, people from more expressive cultures may display intense emotional swings that could be misinterpreted as pathological in less expressive cultures. Conversely, it may be difficult to identify BPD in people who live in cultures where expressive displays are not the norm, not even intense emotions like anger or sadness. “Clinicians might mistakenly diagnose a personality disorder when environmental factors actually explain the behavior, or they may underdiagnose because they’re using their own biases as the benchmark,” explained Vibh Forsythe Cox, PhD, a clinical psychologist, and director of the Marsha M. Linehan DBT Clinic at the University of Washington.

Misinterpreting cultural norms and the patient’s relationship to them can affect treatment outcomes, turning patients away from therapy or leading to inappropriate treatment plans, Cox added. It is essential that clinicians receive training on cultural humility and ask meaningful, contextual questions, she said. They should aim to understand the patient as an individual rather than making assumptions based on cultural stereotypes.

Cox, who is on the board of the International Society for the Improvement and Teaching of DBT (ISITDBT) and a founding member of the ISITDBT Anti-Racism Committee, encourages clinicians to ask questions like, “What’s the best way for me to understand how your emotions show up?” or “How do your emotions differ from those of other people around you or who share your culture?”

Although BPD was once thought to be more common in women, research now shows it affects men and women equally (Bozzatello, P., et al., Frontiers in Psychiatry, Vol. 15, 2024opens in new window). Historically, this misconception arose partly because women are more likely to seek mental health care, leading to their overrepresentation in psychiatric studies. Gender biases in the interpretation of mental health symptoms can also play a role. “Men’s anger may be socially acceptable, while women’s anger is more likely to be diagnosed as BPD,” explained Becker.

Gender bias can also extend to diagnosis. While BPD is equally prevalent in men and women, it is frequently underdiagnosed in men, whose symptoms may instead be labeled antisocial behavior or substance use disorder, for example. As a result, many men with BPD are left untreated or misdiagnosed. Experts say that the solution lies not in reducing care for women but in providing more support for men struggling with BPD.

Unfortunately, there remains considerable stigma surrounding BPD and its effect on people living with the condition, according to experts. BPD is often misunderstood as being untreatable or inherently linked to chronic dysfunction. This stigma can lead to misdiagnosis or avoidance of a diagnosis altogether, denying patients the chance for effective treatment and augmenting their challenges.

Slowly, the negative perception of BPD is beginning to change, led by younger generations and the voices of those with lived experience who view the condition as treatable. “Younger generations have come to a different understanding of personality disorders. Many have embraced them, understanding that the diagnosis does not mean they are defective or unworthy,” Becker said.

Still, misunderstandings persist within the health care system, underscoring the need for more education and training among clinicians. Clinicians must address their own biases about BPD and view it as a treatable disorder rather than a lifelong label. Sharp says there is also a push for frontline clinicians, such as general practitioners, to recognize and treat the condition.

“We need to move past the stigma and train all clinicians to identify and work with BPD symptoms earlier,” she said.