What is BPD and should it exist?

A deep dive into borderline personality disorder: what is it, how is it treated, can it be "cured," and should it be retired and merged into a pre-existing trauma disorder?

Jun 06, 2024

woman lying on bed — Photo by Yuris Alhumaydy on Unsplash

What is borderline personality disorder?

In a nutshell, borderline personality disorder (BPD) is described as a severe mental illness that affects an individual’s ability to manage their own emotions and impacts how they interact with others.1 It has the following symptoms, which will be explored in depth further down:

fear of abandonment
intense and quickly changing emotions
feeling insecure about who you are
finding it difficult to make and keep stable relationships
chronic feelings of emptiness
impulsivity that could be self-destructive
self-harm or suicidal feelings
intense anger
paranoia or dissociation during extreme stress2

You only need five of these nine symptoms to meet criteria for a diagnosis.3

What causes BPD?

BPD is believed to be caused by a combination of genetic and environmental factors. In his book, Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD, psychiatrist Robert O. Friedel said that people with BPD are “born with these disturbances, and they are usually amplified by events that occurred after birth.” It’s thought that certain people are “biologically predisposed” to BPD and their life experiences “increase the risk of developing specific symptoms and their severity.”4 Friedel’s website explains that the biological and environmental factors must reach a “critical level of brain dysfunction” in order for the symptoms of BPD to present, but it “can be achieved by a large amount of biological risk which then requires only a low exposure to environmental risk factors, or low levels of biological risk factors coupled with high environmental risk, or intermediate levels of both.”5

In terms of biological factors, psychiatrist Jerold J. Kreisman and health writer Hal Straus talk about change in the brain metabolism and structure in their book, I Hate You—Don’t Leave Me: Understanding the Borderline Personality.

“Borderline patients express hyperactivity in the part of the brain associated with emotionality and impulsivity (limbic areas), and decreased activity in the section that controls rational thoughts and regulation of emotions (the prefrontal cortex).”6

The neurological differences could be the result of many things, including pregnancy complications, brain trauma, encephalitis (brain inflammation), learning difficulties, ADHD, and more. ⁶ Current research also strongly suggests that BPD is inherited. Kreisman and Straus said:

“Though no evidence supports a specific BPD gene, humans may inherit chromosomal vulnerabilities that are later expressed as a particular illness, depending on a variety of contributing factors. […] So there may exist a genetic predisposition for BPD, involving a biological weakness in stabilising mood and impulses.” ⁶ (Some people consider this a naturally sensitive temperament7—though not all people with BPD are considered a “highly sensitive person.”)8

A 2023 study about the genetic influences of BPD suggests that “BPD arises from a complex interplay of genetic factors accounting for 40-60% of the variation, and environmental influences, notably childhood trauma.”9 It also referred to a 2009 study that confirmed that relatives of BPD patients “were more likely to have BPD than those without a family history of the disorder.”10

Environmental factors can be put down to challenging and adverse life experiences or bad parenting. These can include attachment disruption in early years and interpersonal trauma, such as emotional neglect, emotional abuse, physical neglect, physical abuse, and sexual abuse. Kreisman and Straus briefly ponder the chicken-egg debate:

“Is one afflicted with BPD because of a biological destiny inherited from parents—or because of the way parents handled—or mishandled—upbringing? Do the biochemical and neurological signs of the disorder cause the illness—or are they caused by the illness? ⁶

Nobody really knows.

Kreisman and Straus also ask why some people with a healthy upbringing develop BPD, and why some who have grown up surrounded by trauma and abuse don’t. They theorise that the most impactful factor across the board is the mother and child’s interactions in early years, and the mitigating effects of other factors, such as a “supportive father, accepting family and friends, superior education, and physical and mental abilities.” These help to “determine the ultimate emotional health of the individual.” The formation of BPD is indeed a “complex tapestry, richly embroidered with innumerable, intersecting threads.” ⁶

Attachment theory

As attachment theory appears to be crucial in the development of personality disorder, let’s take a deeper look into how these disruptions can cause BPD symptoms.

Austrian psychiatrist and psychoanalyst Margret Mahler and colleagues theorised that during the first months of a child’s life, they are oblivious to everything but themselves. In the months following, the child begins to recognise a world outside mother. He will recognise others, but as an extension of himself, rather than as separate beings. When the child is two-to-three years old, they begin to detach from their primary caregiver so they can begin to establish a sense of self. During this phase, the child will experience a conflicting desire for autonomy and closeness/dependence. This is complicated further by the child’s ability to view mother as “all-good” when she’s comforting and sensitive, but “all-bad” when she is unavailable. Like the peek-a-boo game, the child believes that mother no longer exists and is gone forever when she leaves his sight and so he cries for her to reappear and relieve his panic and despair. As the child continues to develop, this normal “splitting” is replaced by a healthy integration of mother’s good and bad traits, and separation anxiety is reduced by the development of object constancy—the knowledge that mother exists even when not physically present, and the understanding that she will eventually return. ⁶

As the child’s world keeps expanding, they try to create their own separate identity away from mother and begin to see others as separate beings. During the phase, the mother will “encourage the child’s experiments with individualisation while providing constant, supportive and refuelling reservoir.” This allows the child to develop a strong bond with parents but also learn to “separate and return enough times to build an enduring sense of self, love, and trust for parents, and a healthy ambivalence towards others.” However, a mother’s own problems may cause them to push the child away or become overly clingy, which burdens the child with intense fears of abandonment and/or engulfment (relying on another person to meet your needs). This means the child never grows into an emotionally separate being with a healthy sense of self. This is why difficulty to maintain object constancy results in “later problems with sustaining consistent, trusting relationships, establishing a core sense of identity, and tolerating anxiety and frustration.” In adolescence, the child may emulate their peers and intentionally seek to adopt behaviours different from their parents. This leads to their behaviour being “based less on independently determined internal needs” and more based on “reacting to the significant people in the immediate environment. Behaviour then becomes a quest to discover identity rather than to reinforce an established one.” ⁶

BPD symptoms

As the previous sections indicate, biological vulnerabilities and problems during early infancy between how both mother (or other primary caregiver) and child interact may “perpetuate interpersonal patterns, which may endure over many years and extend to other relationships,” ⁶ therefore causing the wide array of symptoms seen in BPD. This is, of course, in combination with potential interpersonal trauma. Remember you only need a minimum of five of these symptoms to quality for a diagnosis, meaning there are 256 possible symptom combinations.11

1. Intense and quickly changing emotions

People with BPD experience a range of intense negative emotions which are overwhelming. These emotions often include: rage, sorrow, shame, panic, terror, irritability, and long-term feelings of emptiness and loneliness. It’s common for someone with BPD to feel despairingly suicidal and then fine a few hours later, as severe mood swings frequently occur over a short space of time, but typically not lasting more than a few days. In a new Substack post, published in May, freelance writer Sarah Myles said that “BPD can feel like we are the ball in a pinball machine—propelled at random, bouncing off a labyrinth of solid walls with no control over anything.”12

The psychological term for emotional instability is affective dysregulation, which is defined as “the impaired ability to regulate and/or tolerate negative emotional states.” This has been associated with experiencing interpersonal trauma and post-traumatic stress, in addition to biological differences and disruption in early attachment. Affect regulation difficulties in general are present in other psychiatric conditions, such as anxiety disorders, major depression, and bipolar disorder, to name a few.13 In Hate You—Don’t Leave Me, Kreisman and Straus wrote:

“A borderline suffers a kind of emotional haemophilia; she lacks the clotting mechanism needed to moderate her spurts of feelings. Stimulate a passion, and the borderline emotionally bleeds to death.” ⁶

Marsha Linehan, American psychologist and creator of dialectical behavioural therapy (DBT), once explained that those 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.”14 This is simply another way of explaining the difficulty people with BPD have in regulating their own emotions, behaviours, and thoughts. Such intensely experienced emotions urge people into internally felt and/or externally expressed chaos. It’s important to note that Linehan developed DBT as a way to help “highly suicidal people,” aka people with BPD, which includes herself.15

People often get BPD confused with bipolar disorder as they have similar symptoms, but they can be differentiated. People with bipolar disorder tend to experience distinct periods of severe depression and mania, which last longer, while people with BPD experience intense and ever-changing emotional pain. The mood shifts in BPD rarely involve elation and usually shift from feeling okay to feeling distressed, and vice versa, in a matter of minutes, hours, or days. A shift from feeling down to feeling euphoric to typical of bipolar disorder. While both are triggered by stress, mood changes in BPD are triggered by environmental stimuli—such as interactions with others—whereas they tend to occur more out of the blue in bipolar disorder. Mood changes in BPD can also be triggered by internal thoughts and sensations. It’s possible to have both conditions.16

2. Fear of abandonment

People with BPD tend to fear abandonment due to difficulties in early developmental and/or related interpersonal trauma. They can alternate between clingy and withdrawn because of a conflicting desire for intimacy versus fear of losing themselves in a relationship to co-dependency. It’s common for people with BPD to have experienced actual abandonment before, even multiple times, and they may subsequently have developed a pattern of leaving before they are left, to try and lessen the pain associated with rejection and abandonment.

People with BPD also struggle to tolerate being alone because it feels like “perpetual isolation” can trigger dissociation. Kreisman and Straus said:

“For many borderlines, ‘out of sight, out of mind’ is an excruciatingly real truism. Panic sets in when the borderline is separated from a loved one because the separation feels permanent.”
“Particularly when they are alone, borderlines may lose the sensation of existing, of feeling real. Rather than embracing Descartes’ ‘I think, therefore I am’ principle of existence, they live by a philosophy closer to ‘Others act upon me, there I am.’” ⁶

Because loneliness and real or perceived abandonment can trigger intense emotional responses, it can incite severe depression and impulsive behaviours as ways to cope. These behaviours may include being argumentative, constantly texting or calling someone, physically clinging to them, or making threats to harm or kill themself. On the other hand, they may become withdrawn or use verbal abuse to push someone away. Trying to leave before they are left creates a sense of control and the behaviours displayed here can make the borderline appear emotionless and uncaring, but the pain is usually so intense that they automatically dissociate or emotionally explode. Splitting (more about this below) is common when faced with the threat of abandonment.

3. Unstable and intense interpersonal relationships

It’s easy to see how early developmental difficulties and trauma cause the conflicting inability to tolerate both separation and intimacy in BPD. This drives a lot of the instability and intensity in interpersonal relationships, especially as people with BPD struggle with idealising and devaluing people (aka splitting). Kreisman and Straus explained:

“The borderline is typically dependent, clingy, and idealising until the lover, spouse, or friend repels or frustrates these needs with some sort of rejection or indifference, then the borderline carons to the other extreme—devaluation, resistance to intimacy, and outright avoidance.” ⁶

Just as with object constancy, people with BPD also struggle with emotional permanence. Dr. Patrice Le Goy, a licensed marriage and family therapist in California,17 describes this as the ability to “maintain certainty that your partner or other loved ones cares about you, even when you are not in their presence or when they are not actively telling you that they care about you.”18 In short, it’s the knowledge that feelings not being currently experienced are still true. This is one of the reasons people with BPD tend to frequently seek reassurance—they are checking that your feelings, and their feelings, are both real and true. They may also struggle to feel connected to someone they haven’t seen in a long time, but when they are reunited, they are reminded that things are okay as the feelings flood back in.

It can also be difficult when an interaction ends negatively, such as in an argument. As Kreisman and Straus explain, “the borderline experiences another on the basis of his most recent encounter, rather than on a broader-based consistent series of interactions.” ⁶ It’s easy for someone with BPD to be consumed by their emotions. Due to this and their lack of emotional memory, they often struggle to integrate their experiences into a bigger picture. Some borderlines are unable to see the grey areas, which can lead to repeated mistakes—but even when they can, emotional intensity can remain high despite a reduction in impulsive behaviour.

The inability to believe things that aren’t currently happening or currently felt is common for people with BPD and can be applied quite broadly. Kreisman and Straus sum this up well: “Just because the sun has risen in the East for thousands of years does not mean it will happen today. He must see it for himself each and every day.” ⁶ It’s difficult for people with BPD to emotionally believe things they surely know to be true. The doubt is so strong because of the problems in developing object constancy and emotional permanence in the early years of life.

4. Identity disturbances

People with BPD are not safe from splitting on themselves. They can see themselves as the best person in the world one minute, the worst person the next. Ultimately, there is a prevalent struggle to accept one’s own strengths. Kreisman and Straus explained that “the borderline does not accept her own intelligence, attractiveness, or sensitivity as constant traits, but rather as comparative qualities to be continually re-earned and judged against others.” For example, someone may receive great exam results at university and see themselves as intelligent, but the same day, they may make a simple mistake and see themselves as stupid. ⁶ Self-acceptance is difficult and people with BPD feel as though they have to convince themselves and others of their good traits, as though to gain evidence to prove that they are still real and true. It becomes harder to remember any past achievement or consider it valid in the present.

“The borderline allows herself no laurels on which to rest. Like Sisyphus, she is doomed to roll the boulder repeatedly up the hill, needing to prove herself over and over again. Self-esteem is only attained through impressing others, so pleasing others becomes critical to loving oneself.” ⁶

Someone with BPD will often exist in a constant state of faking it until they make it, but they seldom reach true, lasting self-confidence. Even when a new achievement is made, it’s common for people with BPD to feel undeserving as they are never truly convinced of their own skills or strengths. “If he fails in the role, he fears he will be punished; if he succeeds, he is surely he will soon be uncovered as a fraud and be humiliated,” explained Kreisman and Straus. ⁶ This all happens when, for whatever reason, a child doesn’t develop a separate sense of self from their parents and form their own identity. Instead, they spend their lives trying on the identities of those around them as a way to fit in or perhaps discover their “true” self.

Due to an unstable sense of self, people with BPD are constantly striving for some sort of “satisfaction or contentment,” which can show up in holding themselves to unrealistic standards of perfection and an inability to tolerate small things, or, on the other hand, they may chase fulfilment through constant change in jobs, careers, goals, friends, appearance, hobbies, and so forth. ⁶ It’s common for people with BPD to experience both of these in different areas of their lives. There can be a push and pull between control and impulsivity.

When you don’t know who you are, life can feel like an uncomfortable performance of trying on identities that don’t quite fit. This reflects Helene Deutsch’s 1930s theory about the ‘as if’ personality; a person who gives an impression of normalcy but has no identity of their own and borrows it from others,19 performing as if they were a normal person. Myles wrote on her blog in 2013 about the mirroring behaviours of BPD:

“People with [BPD] instinctively ‘mirror’ others to fit in, because without that behaviour, we have no idea what will happen. We have little or no sense of our own identity, so we can’t know if that will be acceptable to others. Without acceptance by others, we risk abandonment. […] Why do we have this intense abandonment? Because if we are abandoned, we have nobody to ‘mirror.’ The fear of abandonment is a fear of being alone. It is terrifying to be left alone with yourself when you don’t know who yourself is. […] So you’ll go to great lengths to avoid that situation, because, as an emotionally dysregulated person who experiences feelings in extremes, that situation will put you headfirst into a tailspin.”20

This is certainly an interesting—and relatable—theory as people with BPD often use others to tell them who they are. Other people inform actions, behaviour, and even mood. Intense negative emotions—such as fear, anxiety, and loneliness—do not appear to have the opportunity to become more neutral or positive emotions without the presence of another person whose energy and normalcy can be mirrored.

5. Impulsivity

People with BPD are typically impulsive in numerous ways as an attempt to help them cope with and regulate their intense, ever-changing emotions, including chronic emptiness. The diagnostic criteria states there must be impulsive behaviour in at least two areas that are potentially damaging and self-destructive, which aren’t self-harm or suicidal behaviour as they make up their own, separate symptom. Kreisman and Straus said:

“The immediacy of the present exists in isolation, without the benefits of the experiences of the past, or the hopefulness of the future. Because historical patterns, consistency, and predictability are unavailable to the borderline, similar mistakes are repeated again and again.” ⁶

Impulsivity can also happen because the borderline has adapted into passivity, into apathy, through chronic dysregulation. They are willing to try anything to chase away the chronic emptiness and other intense and all-consuming negative emotions.

“Sustained periods of contentment are foreign to the borderline. Chronic emptiness depletes him until he is forced to do anything to escape. In the grip of these lows, the borderline is prone to a myriad of impulsive, self-destructive acts—drugs and alcohol binges, eating marathons, anorexic fasts, bulimic purges, gambling forays, shopping sprees, sexuality promiscuity, and self-mutilation. He may attempt suicide, often not with intent to die but to feel something, to confirm he is alive.” ⁶

It’s common for people with BPD to be thrill seekers, to have little regard for their safety and wellbeing, and to numb themselves with drugs and alcohol. They may feel guilt or even regret following certain behaviour, such as sexual escapades or food or alcohol binges, which may paradoxically drive them to do it again. “Self-destructive behaviour [becomes] both a means of avoiding pain and a mechanism for inflicting it as expiation for her sins.” ⁶ Limited patience and the need for immediate gratification may be connected to other BPD traits.

“Impulsive conflict and rage may emerge from the frustration of a stormy relationship; precipitous mood changes may result in impulsive outbursts; self-destructive or self-mutilating behaviours may result from the borderline’s frustrations.” ⁶

6. Self-harm and suicidal feelings

Suicidal threats and gestures tend to be a result of the borderline’s “propensity for overwhelming depression and hopelessness,” but are also attributed to their “knack for manipulating others.” ⁶ It’s a common misconception that people with BPD are skilled manipulators with ulterior motives, though it’s not unheard of. Most “manipulative” behaviours tend to be an attempt to “communicate pain and plea for others to intervene.” ⁶ This isn’t limited to suicidal threats and can brand out into physical complaints, as vague, often unexplainable chronic physical symptoms and conditions are common in BPD. They are typically caused by stress and the rollercoaster of intense emotionality causing chronic nervous system dysregulation.21

However, as previously mentioned, people with BPD are frequently overwhelmed by severe depression, chronic depression, and hopelessness, which can be a deadly combination. These, alongside other intense and ever-changing painful emotions, can be extremely difficult to deal with and many people naturally want to escape it. Even if they don’t want to die, they want their suffering to end—but some do have a sincere wish to die therefore genuine attempts can be made. Research has shown that around 70% of people with BPD will attempt suicide at least once in their lifetime, while around 10% will be successful.22 Even if someone with BPD makes a half-hearted attempt, this should be taken seriously and not be dismissed as a “cry for help” as cries for help are a way of asking to acknowledge pain and solicit help.

It’s understandable that someone with BPD would want to receive comfort for their near-constant emotional pain, but it can feel to others (and to themselves) like a well that can never be filled. It can get tiresome for others for be constantly subjects to calls for attention—but even more so when they are threats of suicide, particularly if used in a seemingly controlling and manipulative manner (“Don’t leave me or I will kill myself”). People with BPD are often sensitive to this and know that their complex emotional needs are seen as “too much.” This can intensify feelings that they are a burden and reinforce the emptiness, leading to more thoughts of suicide. While most BPD traits can improve with age, “the risk of suicide persists throughout the lifecycle.” ⁶

Self-harm is “more closely connected to BPD than other psychiatric malady,” making it a hallmark symptom. It often begins as impulsive or self-punishing behaviour, a way to regulate overwhelming emotions, but may develop into ritualistic behaviour. ⁶ As people with BPD are very sensitive to the normal stressors of life, they may self-harm as a form of distraction and to calm the mind. Alternatively, they may self-isolate as a way to regulate their own emotions, but then the emptiness or numbness becomes the highlighted problem instead. Kreisman and Straus said:

“Borderlines form a kind of insulating bubble that not only protects them from emotional hurt but also serves as a barrier from the sensations of reality. The experience of pain, then, becomes an important link to existence.” ⁶

There is difficulty in both feeling nothing and feeling everything, especially because feeling nothing is not actually the absence of feeling.

7. Chronic emptiness

People with BPD lack a core sense of identity which comes with a painful loneliness and emptiness which drives pleasure-seeking behaviours to try and fill the void within. This feeling is often physically painful and can come with a boredom and deep disinterest in being alive, a type of ennui, which often drives suicidal ideation. Kreisman and Straus said:

“Tolstoy defined boredom as ‘the desire for desires’; in this context it can be seen that the borderline’s search for a way to relieve this boredom often results in impulsive ventures into destructive acts and disappointing relationships. In many ways the borderline seeks out a new relationship or experience not for its positive aspects but to escape the feelings of emptiness, acting out the existential destinies of characters described by Sartre, Camus, and other philosophers.” ⁶

People with BPD frequently experience a kind of “existential angst, which can be a major obstacle for treatment for it saps the motivational energy to get well.” The feeling of existential emptiness is one of the reasons for the other symptoms of BPD, including suicidal ideation, as suicide may feel like “the only rational response to a perpetual state of emptiness. The need to fill the void or relieve the boredom can lead to outbursts of anger and self-damaging impulsiveness—especially drug abuse.” Kreisman and Straus also argue that a “stable sense of self cannot be established in an empty shell. And mood instability may result from the feelings of loneliness. Indeed, depression and feeling of emptiness often reinforce each other.” ⁶

In a 2021 article by freelance journalist Kevin Redmayne, titled “The Chameleon: The Spirit Animal of Borderline Personality Disorder,” he explained how behaviourists believe “emptiness is the result of trying to suppress the pain.” He also talked about how, in times of distress, people usually picture a loved one or calming place for comfort, but when people with BPD close their eyes, they are often met with nothing. “Just imagine though, how impoverished life must be, that when we cry, there’s just an empty space.”23 It’s one of the explanations of “intolerance aloneness,” a term coined by American psychiatrist John G. Gunderson in 1996, which relates to insecure attachment development.24

8. Intense anger

People with BPD tend to have outbursts of rage that are typically disproportionate to their trigger. Alongside emotional instability, anger is considered to be the “most persistent symptom of BPD overtime.” ⁶ It’s possible for people with BPD to be violent, resulting most commonly in intimate partner violence. They have higher rates of violent acts than the general population—but not all people with BPD are violent, even if they are victims of violence themselves. Some may feel intense anger but are more likely to direct it inwards, at themselves, rather than at other people. Kreisman and Straus said:

“The rage, so intense and so near the surface, is often directed at the borderline’s closest relationship—spouse, children, parents. Borderline anger may represent a cry for help, a testing of devotion, or a fear of intimacy—whatever the underlying factors, it pushes away those whom the borderline needs most.” ⁶

While violence is associated with BPD, a natural tendency towards it doesn’t exist within the diagnosis. One study showed that 73% of people with BPD engaged in violent behaviour over a one-year period, but they “frequently exhibited comorbid antisocial personality disorder (ASPD).” The reported violence was often disputes with significant others or acquaintances.25 Another study, from 2016, backed up that violence in those diagnosed with BPD is “explained better by comorbidity,” such as ASPD, anxiety, and substance misuse, rather than a natural tendency to violence existing in BPD.26

The reason people with BPD tend to lash out in violent or aggressive behaviour is because they are often victims of violence themselves or have learnt to use aggression to deal with strong emotions, which may have been modelled for them as children. ²³ Anger is often connected to previous trauma and the present fear of disappointment and abandonment. In short, it’s the result of intense emotion and poor regulation and self-control. Sometimes aggressive behaviour can be externalised without being directed at someone—for example, breaking objects or punching walls, though this may cause concern or distress for anyone in the vicinity.27

It’s common for mental health professionals to drop patients for being “difficult to treat,” but people with BPD commonly react to the lack of compassion often shown by professionals who carry around stigma or simply do not know how to effectively respond to people with this diagnosis. Some patients may simply be unwilling to cooperate, not wanting treatment. These problems create problems in the developing relationships, making it intolerable for both parties. Many borderlines have experienced their fair share of abandonment—even from mental health services—and will subsequently fear new relationships, especially ones where someone is supposed to help and understand them. People with BPD are particularly sensitive to real or perceived criticism and feeling dismissed and misunderstood, which can result in them behaving unfavourably. They are gearing up for the seemingly inevitable abandonment.

Some mental health professionals do genuinely have bad experiences with people with BPD, which will naturally make them reluctant to treat them again, but it would be beneficial for everyone if more training was widely available to increase the amount of professionals who are not only willing to treat borderline patients, but know how to. According to Psychology Today, inexperienced and undertrained therapists sometimes react defensively to patients lashing out, which makes things worse and therapeutically ineffective.28 If a mental health professional does not—or cannot—put in the work to repair misunderstandings, then the borderline will never learn to trust others. Relational problems are a massive part of BPD so it’s important that a therapist can effectively demonstrate the rupture and repair process, suggesting to the borderline that abandonment is not inevitable or necessary.

9. Stress-related paranoia and dissociation

The symptoms of BPD pertaining to psychosis are stress-induced paranoia and feelings of unreality (such as depersonalisation and derealisation), which have classically been associated with the initial phase of psychosis. Psychosis is typically when people lose some contact with reality, which can include seeing or hearing things that aren’t there (hallucinations), strong but strange beliefs (paranoid thinking of delusions), and distorted thought and speech. People in full-blown psychotic episodes generally aren’t aware they are experiencing psychosis, and while people with BPD can experience this, they usually develop “psychosis-like” symptoms. Drugs.com explains:

“[People with BPD] experience a distortion of their perceptions or beliefs rather than a distinct break with reality. Especially in close relationships, they tend to misinterpret or amplify what other people feel about them. For example, they may assume a friend or family member is having extremely hateful feelings towards them, when they person may be only mildly annoyed or angry.”29

It’s nigh impossible to convince someone experiencing false beliefs through stress-related psychosis that they aren’t true, even if evidence suggests otherwise.

Dissociation is typically described as “a disconnection between your thoughts, emotions, behaviours, perceptions, memories, and identity.” around 75-80% of people with BPD report experiencing stress-related dissociation. It can range from mild to severe, and most people experience mild dissociation from time-to-time, perhaps a general “zoned-out” feeling. You don’t need to have experienced trauma to experience dissociation, but it often affects people “who have experienced repetitive, overwhelming trauma, such as severe child abuse or neglect.” This is because dissociation is thought to be the brain’s way of coping with trauma and making it more bearable to live with. It can therefore be a learned behaviour that develops from childhood into adulthood.30 People with BPD often experience dissociation as feeling “lost, scared, and detached from reality.”31

On the topic of stress-related paranoia and dissociation, Kreisman and Straus wrote:

“Borderline psychosis is usually of shorter duration and perceived as more acutely frightening to the patient and extremely different from his ordinary experience. And yet, to the outside world, the presentation of psychosis in BPD may be indistinguishable, in the acute form, from the psychosis experience of [schizophrenia mania, psychotic depression, or organ/drug illnesses]. […] The main difference is duration: within hours or days the breaks from reality may disappear, as the borderline recalibrates to usual functioning, unlike other forms of psychosis.” ⁶

While “borderline” is now considered an outdated term, it was named that way because people were thought to be on the borderline of neurosis and psychosis. Today, BPD is thought to be more of an emotional dysregulation disorder.32

Dialectical dilemmas

Linehan, the creator of DBT, has a theory called “apparent competence,” which describes the mirroring and pretending behaviour that occurs within BPD. Apparent competence is when you appear to be able to cope with situations and problems on the outside, but are experiencing extreme distress and emotional dysregulation on the inside. It fits into Linehan’s three dialectical dilemmas in DBT, which are emotional vulnerability versus self-invalidation, active passivity versus apparent competence, and unrelenting crisis versus inhibited grieving. These highlight the ways in which the life of someone with BPD can appear contradictory and chaotic. As Psych Central says:

“At one moment, they may be desperate for help and want to give up, while at others they are seemingly skilled and capable. Often, people with BPD experience constant stress with immediate and extreme emotional reactions, but they hold back the expression of grief and sadness.”33

It’s important to note that, in this context, “dialectical” means combining two conflicting truths.

Emotional vulnerability versus self-invalidation

People with BPD have an extreme sensitivity to emotional stimuli, resulting in strong and persistent emotional reactions, even to small events. Emotionally vulnerable people have difficulty controlling their facial expressions, aggressive actions, and obsessive worries. On the other hand, people with BPD have a high tendency to invalidate their own emotional experiences. They frequently look to others for accurate reflections of reality and over-simplify problems and solutions. When these two things are combined, it can lead to shame and guilt following oversimplification of problems and an inability to achieve oversimplified goals. ³³

Active passivity versus apparent competence

As people with BPD live under extreme stress, it’s common for them to adopt a passive approach to life’s problems. They may act helpless and depend on the environment and the people in it to solve their problems for them. As previously stated, apparent competence is the ability to handle everyday life problems (including complicated things) with skill. “Often, people with BPD are appropriately assertive, able to control emotional responses and successful in coping with problems.” These competencies, however, are highly inconsistent and dependent on individual circumstances. When these two traits are combined, it leaves people with BPD feeling helpless and hopeless. Whether they will be able to cope or will need assistance is unpredictable and creates a fear of being left alone. ³³

Unrelenting crisis versus inhibited grieving

It’s common for people with BPD to experience states of unrelenting crisis caused by repetitive stressful events they are unable to fully recover from before another occurs. This pattern tends to result in urgent behaviours such as mental breakdowns, suicide attempts, self-harm, drinking, drug-taking, overspending, and other impulsive behaviour. Inhibited grieving is the tendency to avoid feeling painful emotions as much as possible, which can, again, cause the aforementioned impulsive behaviours as ways of avoidance and emotional suppression. This combination sees constant crisis which tends to cause trauma and painful emotions, and frantic attempts to avoid feeling these. ³³

Linehan’s identification of these conflicting dilemmas highlight the patterns that keep people with BPD stuck in unhelpful thoughts and behaviours. It also allows for them to be targeted and hopefully improved, giving people with BPD more helpful skills which can, in turn, give them back their lives. It’s possible that these or other dilemmas can also apply to people without BPD. As a wise person on Quora said last year: “It’s possible for two opposite traits to exist in the same person at the same time.”34 They can be polar opposites but are most commonly just different ends of the same spectrum, and the one that takes precedence depends on the situation at any given time.

Can personality disorders be “cured”?

BPD is considered to be an incurable, long-term condition that can be managed effectively. It’s a “personality” disorder because it’s more ingrained. A personality trait is simply a habitual pattern of thinking, feeling, and behaviour that will be consistent but not affect your life. A personality disorder, then, is a way of experiencing the world that not only deviates from the norm, but consistently has a negative impact on your life, since at least early childhood. It causes serious difficulty with work, relationships, social activities, and coping with everyday problems and stresses.35

“To be classified as a personality disorder, one’s way of thinking, feeling and behaving deviates from the expectations of the culture, causes distress or problems functioning, and lasts overtime.”36

Many people contest this, claiming that personality is not fixed in anyone. While it’s true that people’s personalities tend to evolve throughout their lives,37 they tend to be fairly consistent in their personality traits and changes occur as a natural response to ageing. An example is being introverted but becoming more extraverted as you get older. Personality changes can also be triggered by stress, medication, drugs and alcohol, menopause, brain injury, physical conditions, and other psychiatric conditions.38 The difference between normal personality disorders and a personality disorder is the latter has a negative impact on the individual’s ability to function. Dan Taylor, a Sunderland PhD student, told the University of Sunderland in 2019 that people with BPD are referred to as “consistently inconsistent. […] It’s rare that day-to-day feelings or experiences are much the same.”39 Someone without a personality disorder generally does not experience this much day-to-day variance in mood and functionality (unless they have another condition causing similar symptoms). It’s possible for people with personality disorders to have changing personality traits, both inside and outside of the disorder, as BPD is an ever-changing presentation of personality, and people can suddenly not meet diagnostic criteria anymore. The reason for this could be that therapy has helped improve a trait over time, or you could, quite simply, have “grown out of it.” It’s also possible for certain traits to gradually disappear due to improved environmental and lifestyle changes, but they may return with negative change.

Contrary to the above information, a lot of people believe that BPD can be cured. I am more inclined to believe the general consensus—that it can go into remission, and perhaps stay that way. A lot of online searches asking if BPD can be cured bring up articles talking about how BPD is often considered “untreatable” when it is, in fact, highly treatable, and there is an ever-growing body of evidence to support this. CPD Online College said that people often confuse “treatment” with “cure.”

“Although BPD cannot be ‘cured,’ treatment can help significantly to improve symptoms, help the person to function in everyday life and improve their quality of life. In reality, there are multiple effective treatment options available for BPD.”40

London-based psychiatrist Mark Silvert told Psych Central that “the quicker you deal with [BPD], the better,” though he acknowledges there’s no overnight fix and treatment does take time.41

As previously mentioned, BPD is considered to be in remission—or cured, depending on your view—if you no longer meet the diagnostic criteria. “A borderline patient who exhibits five symptoms of BPD theoretically ceases to be considered borderline if one symptom changes.” Kreisman and Straus explain that such a sudden “cure” is “inconsistent with the concept of personality.” They also discussed the idea that, as proposed by other researchers, BPD should perhaps exist on a spectrum of mild to severe which could measure functional impairment. “In a way, a higher or lower functioning borderline would be identified in her ability to manage her usual tasks of living.” This, and other suggestions I won’t go into, such as gauging particular traits, may “more accurately measure changes in degrees of improvement, rather than the presence or absence of the disorder.” ⁶ This is typically how we understand and measure autism, though functionality labels in autism are changing to “high and lower support needs,”42 and BPD changed to include mild to severe functionality measures in 2022 with the ICD-11.43

BPD has historically—and currently—been recognised as a “dustbin” diagnosis, associated with difficult patients who don’t get better and are given up on. In 2008 Dr. Robert J. Gregory, who developed deconstructive dynamic psychotherapy (DDP) for treatment-resistant BPD, said:

“There are a number of new treatments for [BPD]. It’s clear that some of those can be helpful. It used to be that once [BPD] was diagnosed, that patient was expected to never recover. Recent well-controlled studies are not bearing that out. We now see it as one of the better disorders to get. People actually do recover from it. It’s a sea change in our thinking, which is gradually permeating to the mental health community.”44

How is BPD treated?

DBT is the gold standard treatment for BPD. It is backed by “a large evidence base and is considered one of the best treatments for BPD in terms of documented success rates.”45 DBT is a form of cognitive behavioural therapy (CBT) that was developed by Linehan in the 1980s. The therapy embraces both acceptance and change, which is why it’s called “dialectical.” It’s a skills-based therapy based on the idea that BPD can be caused by emotional vulnerability and growing up in an environment where emotions were dismissed.46 DBT is split into four main areas: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. It empowers people with DBT to learn how to manage their emotions, handle and reduce distress, improve their relationships, and create a sense of purpose in their lives. The therapy is also structured with group therapy, where you learn skills, and then one-to-one and phone support where a trained DBT therapist can help you implement skills in real-time and support you during crisis.47 Recovery takes a lot of time and dedication to repetitively practise learned skills. One study showed that DBT is effective for improving BPD and specifically reducing “self-injurious behaviours, suicidal thoughts and attempts, and the frequently of emergency care and hospitalisations.”48 Another found that 77% of people no longer meet the criteria for BPD after a year of treatment with BPD.49

Other treatments, such as cognitive behavioural therapy, mentalisation-based therapy, eye movement desensitisation and reprocessing, schema-focused therapy, transference-focused psychotherapy, DDP, intensive short-term dynamic psychotherapy, and systems training for emotional predictability and problem solving, can also be effective for BPD. There is no approved medication to treat BPD and any prescribed medications are usually to reduce symptoms and treat comorbid mental health problems such as anxiety and depression. Antidepressants are common, but sometimes antipsychotics and mood stabilisers are used,50 though this doesn’t mean they are appropriate for everyone with BPD.

While all these different effective treatments for BPD exist, a huge problem is that they are not widely available. Even DBT, which is considered first-line treatment for, is not available across the UK. Because people with BPD are accessing ineffective treatment—or no treatment at all—they may mistakenly believe that they will never get better and there is no hope for them. This also makes it harder to treat comorbidities as, according to a 2017 Psychiatric Times article, BPD “may render comorbid disorders less responsive to therapy.”

“[Psychiatric] guidelines encourage clinicians to prioritise BPD over its most common comorbidities of depression, panic disorder, generalised anxiety, and other personality disorders, because these comorbidities are less likely to remit if BPD symptoms do not improve. […] Other comorbidities, such as substance dependence, anorexia, and mania, must be prioritised over BPD treatments, because these disorders interfere with the learning required in BPD treatment.”50

It’s absolutely imperative to the wellbeing and prognosis of people with BPD that treatments are available to them—even more so when we consider that it’s incredibly rare to have pure BPD. Comorbidity is extremely common and these other conditions need treating without the complication of BPD.

Is BPD actually just complex PTSD?

There is an ongoing debate regarding the name of BPD, as “borderline” is outdated and “personality disorder” is considered offensive. Many believe it should be renamed emotional dysregulation disorder, while others think it should be discarded entirely and recognised as a trauma disorder—more specifically, complex post-traumatic stress disorder. An article published in The Guardian in May discusses this very issue.

Dr. Karen Williams, who runs New South Wales’ Ramsay Clinic Thirroul (Australia’s first women-only trauma hospital), believes “there is no symptom that a borderline personality disordered person has that a PTSD patient doesn’t also have.” She also explains that BPD is a “gendered diagnosis that is given to women who have got histories of abuse, whereas we see a man come back from a traumatic event, we [say] he’s got PTSD.” Men get sympathy, whereas women are deemed “difficult.”51

Professor Jayashri Kulkarni, director of the Monash Alfred Psychiatry Research Centre, agrees with Williams. She believes that the BPD label implies behaviour is part of a personality disorder, with an implied “stern moralistic approach” that people “should just be able to control themselves.” Kulkarni says that the more she has researched BPD, “the more obvious it seems that the women and the men who have been labelled with this condition often have dreadful early life trauma. I really think this is an injustice, to say to somebody who’s gone through hell in their early life and onwards, that they’ve got a significant flaw of their inner core.” For these reasons, both Kulkarni and Williams prefer the term complex PTSD to BPD. ⁵¹

In a counter response to Kulkarni and Williams, Professor Andrew Chanen, chief of clinical practice and head of personality research at the National Centre of Excellence in Youth Mental Health at the University of Melbourne, says he finds the term “personality disorder” because it “captures the identity and relationship difficulties he says are at the heart of the issue.” He also referred to a 2023 study on childhood maltreatment,52 which showed that nearly two-thirds of the population have experienced some form of childhood adversity—yet BPD is rare in comparison, occurring in only 1-3% of the population. Chanen echoed Kreisman and Straus’ comments regarding how BPD doesn’t manifest in everyone with childhood trauma:

“There’s something important going on in each individual that interacts with the experience of adversity. While that interaction might give rise to [BPD], it might also give rise to another disorder, such as depression, or no mental disorder. That’s not to say that the adversity is unimportant, but it’s not inevitable that a person will develop a mental disorder, and certainly not inevitable that they will develop [BPD].” ⁵¹

Chanen goes on to say that the debate around renaming BPD to CPTSD is “not really supported by the science and weakens the moral argument for respect, dignity and equality of access to services.” He explained that changing the name might also invalidate the experiences of people with BPD who have not experienced trauma.

British author and psychologist Jessica Taylor, who specialises in sexual violence and victim blaming, wrote a book in 2022 titled Sexy But Psycho which explores how psychiatry and the patriarchy uses women’s trauma against them. She has been largely outspoken about the many women who were diagnosed with BPD following sexual violence such as rape—including herself.53 In this instance, BPD is used to dismiss and blame women for their trauma symptoms, as though their thoughts, feelings, and behaviours are character flaws they should just fix. People also wonder if BPD is just modern “hysteria.” Mollie Adler, host of the Back from the Borderline podcast, recently did an episode exploring the history of BPD, including its links to hysteria and the “persistent myth of female instability.”54 She also shared a photo on Instagram which said:

“Diagnosing victims of abuse/oppression with personality disorders implies that there is an ‘ordered’ way to react to abuse/oppression, which reinforces the ‘perfect victim’ myth.”55

I wonder if there’s so much historical stigma attached to BPD that people like Williams and Kulkarni are trying to find a better, more respectable diagnosis to replace it with, whereas Chanen agreed that BPD is the most stigmatised and discriminated against mental illness worldwide, but still saw it as its own unique disorder that deserves its own respect.

A 2022 study tried to distinguish whether BPD and complex PTSD can be differentiated. An example of a difference was that in complex PTSD, there is a persistent negative sense of self, while in BPD there is an unstable sense of self that alternates between positive and negative. Ultimately, the study concluded that it depends on the PTSD criteria.

“Overall, out findings support the distinct constructs of PTSD […] and BPD when using ICD-11 PTSD criteria but not when using DSM-5 PTSD criteria, demonstrating that how PTSD is defined matters significantly when considering the construct of CPTSD and its value as a distinct diagnosis.”56

A 2009 article, which summarises alternative ideas regarding BPD, references a 2001 study by Yen & Shea57 who have suggested it could be considered a form of delayed PTSD.

“Because of this considerable overlap with disorders, many have suggested that [BPD] should not be classified as a personality disorder; rather it should be classified with the mood disorders or with disorders of identity. Its association with past traumas and the manifest similarities with PTSD have led some to suggest that borderline personality disorder should be regarded as a form as delayed PTSD.”58

It’s hard to deny that, while there are similarities with complex PTSD and a long, yet still prevalent, history of unfair stigma, BPD is now a “more uniform category than other personality disorders and is the most widely researched of the personality disorders.” ⁵⁸ An aforementioned 2023 study also concluded that BPD has moved on (or tried to) from its “dustbin” diagnosis and has become its own valid condition.

“[BPD] has moved from being a psychoanalytic colloquialism for untreatable neurotics to becoming a valid diagnosis with significant heritability and with specific effective psychotherapeutic treatments. Nonetheless, patients with this disorder pose a major public health problem while they themselves remain highly stigmatised and largely neglected.” ¹⁰

On these divided opinions, Loyola McLean, a psychiatrist, psychotherapist, and associate professor at the University of Sydney, said: “It could well be that we’re talking about two halves of the same whole,” ⁵¹ and she’s right. The BPD label covers a broad range of people and is the most well-defined and backed-up personality disorder. While changing BPD to complex PTSD would honour victims of trauma, not everyone with BPD has experienced childhood trauma or even a particularly adverse childhood. It’s possible that those with a history of severe abuse should actually be diagnosed with complex PTSD instead (or as well as).

If any changes were to be made, it would make sense to keep BPD as a disorder in its own right, but to rename it emotional dysregulation disorder. This is because it’s hard to refute the BPD symptomatology explored here. While it would still be a huge change, it is considered a more accurate description by many. However, that doesn’t mean stigma would necessarily be reduced. BPD is called emotionally unstable personality disorder (EUPD) in the UK, which, again, is perhaps more accurate, but it doesn’t sound like a respectable diagnosis and is still fuel for a fire of stigma. Renaming the condition, even to complex PTSD, ultimately won’t reduce the stigma people have against “hysterical” and “difficult” women. The term “personality disorder” is considered offensive, but I no longer see it that way. There is always a greater discussion to be had about whether using diagnostic labels is useful at all… but that’s a whole other topic.