It's easy to joke around about personality disorders: "I'm really OCD about keeping my house clean." Or, "Ugh, her mood swings are so bad; is she bipolar?"
The truth is, personality disorders—long-term unhealthy and inflexible patterns of thinking—are an all-too-real struggle for roughly 9% of Americans, according to the National Institutes of Health. Of the 10 personality disorders (which include obsessive-compulsive disorder (OCD), paranoid personality disorder, and narcissistic personality disorder) borderline personality disorder (BPD) tends to be the most misunderstood.
The disorder's name alone is enough to spark confusion, since "borderline" seems to imply that BPD is not a full-blown problem. Experts originally felt BPD fell on the border between psychosis (severe mental disorder) and neurosis (mild mental illness), and didn't warrant being classified as a distinct disorder, says John Oldham, MD, interim chair of psychiatry and behavioral Sciences at Baylor School of Medicine in Houston. It wasn’t until the DSM-III was published in 1980 that BPD was listed as its own disorder. Nevertheless, "borderline" stuck.
Since then, experts have grown to better understand and define the complex illness. There's ample evidence that it's “partly inherited genetically and partly a function of stressful experiences during growth and development that leads to some pretty significant interference in successful functioning," though experts still aren't 100% sure of the underlying cause, says Dr. Oldham, who is the co-creator of the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder.
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Wendy Bahary, a New Jersey-based licensed clinical social worker and founding fellow of the Academy of Cognitive Therapy, confirms many of her BPD patients had some form of loss, trauma, or abandonment in their childhood, which they try to reconcile as adults. That said, having a tough upbringing or family history of BPD doesn’t mean you’re destined to have the disorder, explains Dr. Oldham. “It just means that you have that risk factor.”
Are there telltale signs?
BPD is a difficult illness that impacts nearly 1.6% of adults in the United States. That stat may seem small, but probably fails to represent the entire BPD population, says Behary. BPD can be difficult to diagnose because many of the symptoms overlap with other mental illnesses such as depression, bipolar, and narcissistic personality disorder. Plus, borderline happens along a spectrum. “At one end there’s a very low-functioning individual, who can barely manage day-to-day life, and at the other is someone who’s very high functioning,” Behary says. People may spend their entire lives unaware they have a mental illness, and never seek resources to ease some of their struggles.
But there are some major red flags. Based on the latest diagnostic model in the DSM-V, here are the signs you or someone you know might have BPD.
Symptom: Low self-esteem
We all have an internal critic, but people with BPD struggle constantly with overwhelming self-doubt. These individuals have an incredibly unstable self-esteem, so they rely heavily on external praise and approval to help define their identity, Dr. Oldham says. “Underneath that, there’s a sense of inferiority and incompleteness,” he says. People with BPD may even copy others’ actions and behaviors, because “their ability to be independent and autonomous is very impaired.”
Symptom: Avoiding thinking about the future
Don’t know where you see yourself in five years? While you certainly don’t need to have your entire life mapped out, most people have at least vague aspirations and plans. People who have BPD often lack any sort of self-direction “There’s very little sense of knowing what you want out of life or what you want to work toward,” Dr. Oldham says.
Symptom: Trouble empathizing
“Interpersonally, there’s a real impairment in being able to see yourself from the outside and see others from the inside,” says Dr. Oldham. In other words, people with BPD struggle with both self-awareness and empathy. “There’s a lack of understanding about how your own behavior impacts people, so when your emotions are out of control, it doesn’t register that this causes stress for others,” he says. This lack of awareness is one reason people with borderline tend to have trouble maintaining healthy long-term relationships.
Symptom: Chaotic relationships
BPD sufferers frequently find themselves in physically or emotionally abusive relationships, says Behary. In many cases, they’ll gravitate toward partners who they hope can fill the needs that weren’t met in their childhoods, which often leads to staying in toxic relationships.
With BPD, people tend to be excessively needy, intense, and mistrusting in relationships, Dr. Oldham says. “There’s such a heightened anxiety you’ll lose the person that’s close to you, that you actually drive the other person away—it becomes a self-fulfilling prophecy.”
Romantic relationships aren’t the only stormy ones; people with BPD tend to swing from extreme closeness to extreme dislike with friends and family as well. It's these interpersonal relationships where highly functioning people with BPD often realize they have a problem.
Symptom: Overwhelming anxiety
We all get anxious from time to time, but for those with BPD, anxiety is all consuming, characterized by intense feelings of nervousness, tenseness, or panic. These emotions often arise as a hypersensitive response to other people’s actions, says Dr. Oldham. People with BPD have an extreme desire to be needed and liked, and it can be debilitating. As a result of this heightened anxiety, people with borderline may express their emotions in explosive, inappropriate ways.
Symptom: Constant fear of abandonment
The fear of being alone, rejected, or abandoned is a telling sign of BPD. These insecurities breed irrational reactions and jealous, paranoid behaviors, such as checking a partner's email for clues he or she might bail, says David Mattila, a New York City-based licensed clinical social worker and cognitive and schema therapist. “This insecurity can even lead to more extreme and manipulative behaviors,” says Mattila, such as telling a partner, “If you don’t call me when you say you will, I’m going to kill myself.” For the person with BPD, it all folds into their desperate desire to avoid abandonment.
BPD is frequently misdiagnosed as chronic depression. Though depression is common in people who have BPD, their symptoms tend to manifest a little differently. “It’s a very heavy, profound depression,” says Behary. “It’s loaded with this chronic feeling they have no value and a pervasive sense that nothing matters.”
Symptom: Frequent mood swings
Erratic moods are a symptom of BPD, making it easy to mistake for bipolar disorder. “It’s not the same persistent mood state you’d see in someone with bipolar, characterized by hypomanic or hyperactive behavior,” says Dr. Oldham. Instead, BPD moods change rapidly, and are often triggered by overreactions to external events. For example, if a colleague was too preoccupied to say hello in the hallway, someone with BPD might suddenly become extremely agitated, says Dr. Oldham. “Small things that wouldn’t even occur to other people to take personally are completely overreacted to and internalized.”
Symptom: Uncontrollable anger
It’s common for people with BPD to react in a way that seems exaggerated or disproportional to an event. For example, explains Mattila, if your partner was supposed to pick you up at 7 and didn’t arrive until 7:30, the appropriate response would be irritation. Someone with BPD will react by saying something like, “'I’m breaking up with you, you don’t love me, I hate you, you’re never there for me,' and so on,” says Mattila.
People with BPD also frequently project their problems and emotions onto others, says Dr. Oldham. “They can’t tolerate to acknowledge that they’re the ones with the problem, so they blame others instead,” he says. “It’s virtually toxic for them to own that their rage and anger is not justified by another person, but actually coming from inside.”
Symptom: Inability to control actions
People with borderline are impulsive: they'll drop thousands of dollars on a new television without considering how it will impact their finances, have unprotected sex with multiple partners, or engage in other risky behavior. Dr. Oldham says they can’t help it—their minds work like hyperactive motors in cars with broken breaks. They just can’t stop.
At times, risk taking tendencies can even lead to cutting or other extreme self-harm, says Dr. Oldham. “It helps them turn off their emotions and produce release.” This generally happens when people with BPD feel extremely dissociated, detached, or numb for too long.
Symptom: Suicidal thoughts
While not an official symptom of borderline, Dr. Oldham points out there’s a high rate of suicidal ideation and suicide attempts in the BPD population. In fact, a whopping 8 to 10% of BPD patients commit suicide, a rate that's 400 times the national average. “The risk is higher in these patients because they can be impulsive,” Dr. Oldham says. “So instead of being so depressed they can’t get out of bed, they might really see suicide as the only logical solution to stop the pain.”
So, do I have BPD?
To be diagnosed with BPD, you need to identify with two of these characteristics:
- Low self esteem
- Avoiding thinking about the future
- Trouble empathizing
- Chaotic relationships
And four of these symptoms, with at least one being uncontrollable anger, impulsivity, or risk-taking:
- Overwhelming anxiety
- Fear of abandonment
- Frequent mood swings
- Uncontrollable anger
- Risk taking
If you’re still not sure, talk to your doctor or make an appointment with a psychologist.
Where to get help
Unlike some mental illnesses, the primary treatment for BPD is psychotherapy, not medication. Dr. Oldham suggests dialectical behavioral therapy (DPT), a specific kind of cognitive behavioral therapy (CBT) developed in the 1980s to better treat BPD. He also recommends looking into schema therapy, mentalization-based therapy, or any other kind that appeals to you. Just be sure to find a specialist who has experience with treating BPD, says Mattila.
If you don’t feel ready to speak to a professional, Behary recommends books like Love Me Don't Leave Me by Michelle Skeen ($12; amazon.com) and Reinventing Your Life by Jeffrey Young and Janet Klosko ($13; amazon.com). She also advises contacting the Personality Disorder Awareness Network (PDAN) for additional support and resources.