View source for Medicine:Borderline personality disorder

{{Short description|Personality disorder with strong emotions}}
{{Infobox medical condition (new)
| name          = Borderline personality disorder
| image         = Edvard Munch - Despair (1894).jpg
| image_size    = 
| alt           = 
| caption       = ''Despair'' by Edvard Munch (1894), presumed to have lived with borderline personality disorder.<ref>{{cite book|title=Edvard Munch: The Life of a Person with Borderline Personality as Seen Through His Art|trans-title=Edvard Munch, et livsløb af en grænsepersonlighed forstået gennem hans billeder|isbn=978-8798352419|first=Tove|last=Aarkrog|year=1990|publisher=Lundbeck Pharma A/S|location=Danmark}}</ref><ref>{{cite journal|url=https://www.jstor.org/stable/26303797|accessdate=10 August 2021|title=Edvard Munch|pages=413–443|volume=37|issue=4|year=1980|journal=American Imago|publisher=Johns Hopkins University Press|jstor=26303797|issn=0065-860X|last1=Wylie|first1=Harold W.|pmid=7008567}}</ref>
| field         = [[Biology:Psychiatry|Psychiatry]]
| synonyms      = {{plainlist|
*Emotionally unstable personality disorder – impulsive or borderline type<ref name=Maj2005>{{cite book | vauthors = Cloninger RC | veditors = Maj M, Akiskal HS, Mezzich JE |chapter=Antisocial Personality Disorder: A Review |title=Personality disorders |date=2005 |publisher={{wipe|John Wiley & Sons}} |location=New York City |isbn=978-0-470-09036-7 |page=126 |chapter-url=https://books.google.com/books?id=9fgwbCW7OQMC&pg=PA126 |access-date=5 June 2020 |archive-date=4 December 2020 |archive-url=https://web.archive.org/web/20201204232038/https://books.google.com/books?id=9fgwbCW7OQMC&pg=PA126 |url-status=live }}</ref>
*Emotional intensity disorder<ref>{{cite book| vauthors = Blom JD |title=A Dictionary of Hallucinations |date=2010|publisher=Springer|location=New York|isbn=978-1-4419-1223-7|page=74|edition=1st|url=https://books.google.com/books?id=KJtQptBcZloC&pg=PA74|access-date=5 June 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232039/https://books.google.com/books?id=KJtQptBcZloC&pg=PA74|url-status=live}}</ref>}}
| symptoms      = Unstable relationships, [[Philosophy:Self-image|sense of self]], and [[Philosophy:Affect (psychology)|emotions]]; [[Social:Impulsivity|impulsivity]]; recurrent suicidal behavior and [[Medicine:Self-harm|self-harm]]; fear of [[Social:Abandonment (emotional)|abandonment]]; chronic feelings of [[Philosophy:Emptiness|emptiness]]; inappropriate [[Social:Anger|anger]]; [[Medicine:Dissociation (psychology)|feeling detached from reality]]<ref name=NIH2016/><ref name=DSM5/>
| complications = [[Medicine:Suicide|Suicide]]<ref name=NIH2016/>
| onset         = Early adulthood<ref name=DSM5/>
| duration      = Long term<ref name=NIH2016/>
| causes        = Unclear<ref name=CP2013/>
| risks         = [[Medicine:Family history|Family history]], [[Medicine:Psychological trauma|trauma]], abuse<ref name=NIH2016/><ref name=Lei2011/>
| diagnosis     = Based on reported symptoms<ref name=NIH2016/>
| differential  = [[Social:Identity disorder|Identity disorder]], [[Medicine:Mood disorder|mood disorder]]s, post traumatic stress disorder, C-PTSD, [[Medicine:Substance use disorder|substance use disorder]]s, [[Medicine:Cluster B personality disorders|histrionic, narcissistic, or antisocial personality disorder]]<ref name=DSM5/><ref>{{cite web |title=Borderline Personality Disorder Differential Diagnoses |url=https://emedicine.medscape.com/article/913575-differential |publisher=[[Medicine:Medscape|Medscape]] |date=5 November 2018 |author=Roy H. Lubit |access-date=10 March 2020 |archive-date=29 April 2011 |archive-url=https://web.archive.org/web/20110429130848/https://emedicine.medscape.com/article/913575-differential |url-status=live }}</ref>
| prevention    = 
| treatment     = Behavioral therapy<ref name=NIH2016/>
| medication    = 
| prognosis     = Improves over time<ref name=DSM5/>
| frequency     = Estimations at ca. 1.6% of people in a given year<ref name=NIH2016/>
| deaths        = 
}}
{{Personality disorders sidebar}}

<!-- Definition and symptoms -->
'''Borderline personality disorder''' ('''BPD'''), also known as '''emotionally unstable personality disorder''' ('''EUPD''')<ref name="NICEGuidelines2009">{{cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK55415/|title=Borderline personality disorder NICE Clinical Guidelines, No. 78|date=2009|publisher=British Psychological Society|access-date=11 September 2017|archive-date=12 November 2020|archive-url=https://web.archive.org/web/20201112031402/https://www.ncbi.nlm.nih.gov/books/NBK55415/|url-status=live}}</ref> or '''borderline pattern personality disorder''' is a [[Medicine:Personality disorder|personality disorder]] characterized by a long-term pattern of unstable [[Social:Interpersonal relationship|interpersonal relationships]], distorted sense of self, and strong [[Philosophy:Affect (psychology)|emotional]] reactions.<ref name=NIH2016/><ref name=DSM5/><ref>{{cite journal| vauthors = Chapman AL |date=August 2019|title=Borderline personality disorder and emotion dysregulation|url=https://www.cambridge.org/core/product/identifier/S0954579419000658/type/journal_article|journal=Development and Psychopathology|publisher={{wipe|Cambridge University Press}}|location=Cambridge, England|language=en|volume=31|issue=3|pages=1143–1156|doi=10.1017/S0954579419000658|pmid=31169118|s2cid=174813414|issn=0954-5794|access-date=5 April 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232023/https://www.cambridge.org/core/journals/development-and-psychopathology/article/abs/borderline-personality-disorder-and-emotion-dysregulation/EA2CB1C041307A34392F49279C107987|url-status=live}}</ref> Those affected often engage in [[Medicine:Self-harm|self-harm]] and other dangerous behavior.<ref>
{{cite web
 |url= https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
 |title= Borderline Personality Disorder
 |date= December 2017
 |publisher= The National Institute of Mental Health
 |access-date= 25 February 2021
 |quote= Other signs or symptoms may include: [...] Impulsive and often dangerous behaviors [...] Self-harming behavior [...]. Borderline personality disorder is also associated with a significantly higher rate of self-harm and suicidal behavior than the general public.
}}
</ref> They may also struggle with a feeling of [[Philosophy:Emptiness|emptiness]], fear of [[Social:Abandonment (emotional)|abandonment]], and [[Medicine:Dissociation (psychology)|detachment from reality]].<ref name=NIH2016/> Symptoms of BPD may be triggered by events considered normal to others.<ref name=NIH2016/> BPD typically begins by early adulthood and occurs across a variety of situations.<ref name=DSM5>{{harvnb|American Psychiatric Association|2013|pages=[https://archive.org/details/diagnosticstatis0005unse/page/645 645, 663–6]}}</ref> [[Medicine:Substance use disorder|Substance use disorder]]s, [[Medicine:Depression (mood)|depression]], and [[Medicine:Eating disorder|eating disorder]]s are commonly associated with BPD.<ref name=NIH2016/> Approximately 10% of people affected with the disorder die by [[Medicine:Suicide|suicide]].<ref name=NIH2016/><ref name=DSM5/> The disorder is stigmatized in both the media and the psychiatric field and as a result is often underdiagnosed.<ref>{{cite journal|vauthors=Aviram RB, Brodsky BS, Stanley B|date=2006|title=Borderline personality disorder, stigma, and treatment implications|journal=Harvard Review of Psychiatry|volume=14|issue=5|pages=249–56|doi=10.1080/10673220600975121|pmid=16990170|s2cid=23923078}}</ref>

<!-- Cause, mechanism, diagnosis -->
The causes of BPD are unclear but seem to involve genetic, neurological, environmental, and social factors.<ref name=NIH2016/><ref name=CP2013>{{cite book|title=Clinical Practice Guideline for the Management of Borderline Personality Disorder | publisher=National Health and Medical Research Council|year=2013|isbn=978-1-86496-564-3|location=Melbourne|pages=40–41|quote=In addition to the evidence identified by the systematic review, the Committee also considered a recent narrative review of studies that have evaluated biological and environmental factors as potential risk factors for BPD (including prospective studies of children and adolescents, and studies of young people with BPD)}}</ref> It occurs about five times more often in a person who has an affected close relative.<ref name=NIH2016>{{cite web|url=http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|title=Borderline Personality Disorder|website=NIMH|access-date=16 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160322130612/http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml|archive-date=22 March 2016}}</ref> Adverse life events appear to also play a role.<ref name=Lei2011/> The underlying mechanism appears to involve the [[Philosophy:Limbic system|frontolimbic]] network of [[Biology:Neuron|neuron]]s.<ref name=Lei2011>{{cite journal | vauthors = Leichsenring F, Leibing E, Kruse J, New AS, Leweke F | title = Borderline personality disorder | journal = Lancet | volume = 377 | issue = 9759 | pages = 74–84 | date = January 2011 | pmid = 21195251 | doi = 10.1016/s0140-6736(10)61422-5 | s2cid = 17051114 }}</ref> BPD is recognized by the ''[[Medicine:Diagnostic and Statistical Manual of Mental Disorders|Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM) as a [[Medicine:Personality disorder|personality disorder]], along with nine other such disorders.<ref name=DSM5/> The condition must be differentiated from an [[Social:Identity disorder|identity problem]] or substance use disorders, among other possibilities.<ref name=DSM5/>

<!-- Treatment -->
BPD is typically treated with [[Medicine:Psychotherapy|psychotherapy]], such as [[Medicine:Cognitive behavioral therapy|cognitive behavioral therapy]] (CBT) or [[Social:Dialectical behavior therapy|dialectical behavior therapy]] (DBT).<ref name=NIH2016/> DBT may reduce the risk of suicide in the disorder.<ref name=NIH2016/> Therapy for BPD can occur one-on-one or in a group.<ref name=NIH2016/> While medications cannot cure BPD, they may be used to help with the associated symptoms.<ref name=NIH2016/> Despite no evidence of their effectiveness, SSRI antidepressants and [[Chemistry:Quetiapine|quetiapine]] remain widely prescribed for the condition.<ref name=stofferswinterling20/> Severe cases of the disorder may require hospital care.<ref name=NIH2016/>

<!-- Epidemiology, prognosis, and culture -->
About 1.6% of people have BPD in a given year, with some estimates as high as 6%.<ref name=NIH2016/><!-- Quote (in archived version): 'According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year.' --><ref name=DSM5/><!-- Quote: 'The median population prevalence of borderline personality disorder is estimated to be 1.6% but may be as high as 5.9%' --><ref>{{Cite web|title=NIMH » Personality Disorders|url=https://www.nimh.nih.gov/health/statistics/personality-disorders|access-date=2021-05-20|website=www.nimh.nih.gov}}</ref> Women are diagnosed about three times as often as men.<ref name="DSM5" /> The disorder appears to become less common among older people.<ref name="DSM5" /> Up to half of those with BPD improve over a ten-year period.<ref name="DSM5" /> Those affected typically use a high amount of healthcare resources.<ref name="DSM5" /> There is an ongoing debate about the naming of the disorder, especially the suitability of the word ''borderline''.<ref name="NIH2016" />

==Signs and symptoms==
[[File:BPD_1.png|thumb|One of the symptoms of BPD is an intense fear of abandonment.]]
BPD is characterized by nine signs and symptoms. To be diagnosed, a person must meet at least five of the following:<ref name=":12">{{harvnb|American Psychiatric Association|2013|p={{page number needed|date=April 2021}}}}</ref>
* Frantic efforts to avoid real or imagined [[Social:Abandonment (emotional)|abandonment]]
* Unstable and chaotic interpersonal relationships, often characterized by alternating between extremes of idealization and devaluation, also known as "[[Philosophy:Splitting (psychology)|splitting]]"
* Markedly disturbed sense of identity and distorted [[Philosophy:Self-image|self-image]]<ref name="NIH2016" />
* [[Social:Impulsivity|Impulsive]] or reckless behaviors (e.g., impulsive or uncontrollable spending, unsafe sex, substance use disorders, reckless driving, binge eating)<ref>{{cite web|title=Diagnostic criteria for 301.83 Borderline Personality Disorder – Behavenet|url=https://behavenet.com/diagnostic-criteria-30183-borderline-personality-disorder|url-status=live|archive-url=https://web.archive.org/web/20190328215426/https://behavenet.com/diagnostic-criteria-30183-borderline-personality-disorder|archive-date=28 March 2019|access-date=23 March 2019|website=behavenet.com}}</ref>
* Recurrent suicidal gestures or self harm
* Intense or uncontrollable emotional reactions and rapidly shifting between different emotional states
* Chronic feelings of emptiness
* Inappropriate, intense anger or difficulty controlling anger
* Transient, stress-related [[Medicine:Paranoia|paranoid]] ideation or severe [[Medicine:Dissociation (psychology)|dissociative]] symptoms

Overall, the most distinguishing symptoms of BPD are pervasive patterns of instability in interpersonal relationships and self-image, alternating between extremes of [[Idealization and devaluation|idealization and devaluation]] of others, along with varying moods and difficulty regulating strong emotional reactions. Dangerous or impulsive behavior is also correlated with the disorder.

Other symptoms may include feeling unsure of one's [[Social:Identity (social science)|identity]], morals, and values; having [[Medicine:Paranoia|paranoid]] thoughts when feeling stressed; [[Philosophy:Depersonalization|depersonalization]]; and, in moderate to severe cases, stress-induced breaks with reality or [[Medicine:Psychosis|psychotic episodes]]. Individuals with BPD often have [[Medicine:Comorbidity|comorbid conditions]], such as depressive and bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder, and attention-deficit/hyperactivity disorder.<ref name=":12" />

===Emotions===
People with BPD may feel emotions with greater ease and depth and for a longer time than others do.<ref>{{harvnb|Linehan|1993|page=43}}</ref><ref name = Manning_36>{{harvnb|Manning|2011|page=36}}</ref> A core characteristic of BPD is affective instability, which generally manifests as unusually intense emotional responses to environmental triggers, with a slower return to a baseline emotional state.<ref>{{cite book | vauthors = Hooley J, Butcher J, Nock M, Mineka S |title=Abnormal Psychology |date=2017 |publisher=Pearson Education, Inc. |isbn=978-0-13-385205-9 |page=359 |edition=17th }}</ref><ref name = Linehan_45>{{harvnb|Linehan|1993|page=45}}</ref> According to Marsha Linehan, the sensitivity, intensity, and duration with which people with BPD feel emotions have both positive and negative effects.<ref name = Linehan_45 /> People with BPD are often exceptionally enthusiastic, idealistic, joyful, and loving,<ref name = Linehan_44>{{harvnb|Linehan|1993|page=44}}</ref> but may feel overwhelmed by negative emotions (anxiety, depression, guilt/shame, worry, anger, etc.), experiencing intense grief instead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness.<ref name = Linehan_44 /> BPD is believed to be the one psychiatric disorder that produces the most intense [[Medicine:Psychological pain|psychological pain]] and distress in those who suffer with this condition. Studies have shown that borderline patients experience chronic and significant emotional [[Social:Suffering|suffering]] and mental agony.<ref name=":12" /><ref>{{cite journal | vauthors = Fertuck EA, Jekal A, Song I, Wyman B, Morris MC, Wilson ST, Brodsky BS, Stanley B | display-authors = 6 | title = Enhanced 'Reading the Mind in the Eyes' in borderline personality disorder compared to healthy controls | journal = Psychological Medicine | volume = 39 | issue = 12 | pages = 1979–88 | date = December 2009 | pmid = 19460187 | pmc = 3427787 | doi = 10.1017/S003329170900600X }}</ref>

People with BPD are also especially sensitive to feelings of rejection, criticism, isolation, and perceived failure.<ref>{{cite journal | vauthors = Stiglmayr CE, Grathwol T, Linehan MM, Ihorst G, Fahrenberg J, Bohus M | title = Aversive tension in patients with borderline personality disorder: a computer-based controlled field study | journal = Acta Psychiatrica Scandinavica | volume = 111 | issue = 5 | pages = 372–9 | date = May 2005 | pmid = 15819731 | doi = 10.1111/j.1600-0447.2004.00466.x | s2cid = 30951552 }}</ref> Before learning other [[Social:Coping|coping mechanisms]], their efforts to manage or escape from their very negative emotions may lead to emotional isolation, self-injury or suicidal behavior.<ref name = reasons_NSSI /> They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, shut them down entirely since awareness would only cause further distress.<ref name=Linehan_45 /> This can be harmful since negative emotions alert people to the presence of a problematic situation and move them to address it.<ref name=Linehan_45 />

While people with BPD feel [[Chemistry:Euphoria|euphoria]] (ephemeral or occasional intense joy), they are especially prone to [[Medicine:Dysphoria|dysphoria]] (a profound state of unease or dissatisfaction), depression, and/or feelings of mental and emotional distress. Zanarini et al. recognized four categories of dysphoria typical of this condition: extreme emotions, destructiveness or self-destructiveness, feeling fragmented or lacking identity, and feelings of victimization.<ref name="dysphoria">{{cite journal | vauthors = Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG | title = The pain of being borderline: dysphoric states specific to borderline personality disorder | journal = Harvard Review of Psychiatry | volume = 6 | issue = 4 | pages = 201–7 | year = 1998 | pmid = 10370445 | doi = 10.3109/10673229809000330 | s2cid = 10093822 }}</ref> Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: feeling betrayed, feeling out of control, and "feeling like hurting myself".<ref name=dysphoria /> Since there is great variety in the types of dysphoria people with BPD experience, the amplitude of the distress is a helpful indicator.<ref name=dysphoria />

In addition to intense emotions, people with BPD experience emotional "lability" (changeability, or fluctuation). Although that term suggests rapid changes between depression and elation, mood swings in people with BPD more frequently involve anxiety, with fluctuations between anger and anxiety and between depression and anxiety.<ref>{{cite journal | vauthors = Koenigsberg HW, Harvey PD, Mitropoulou V, Schmeidler J, New AS, Goodman M, Silverman JM, Serby M, Schopick F, Siever LJ | title = Characterizing affective instability in borderline personality disorder | journal = The American Journal of Psychiatry | volume = 159 | issue = 5 | pages = 784–8 | date = May 2002 | pmid = 11986132 | doi = 10.1176/appi.ajp.159.5.784 }}</ref>

===Interpersonal relationships===
People with BPD can be very sensitive to the way others treat them, by feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.<ref name="cogemo">{{cite journal | vauthors = Arntz A | title = Introduction to special issue: cognition and emotion in borderline personality disorder | journal = Journal of Behavior Therapy and Experimental Psychiatry | volume = 36 | issue = 3 | pages = 167–72 | date = September 2005 | pmid = 16018875 | doi = 10.1016/j.jbtep.2005.06.001 }}</ref> People with BPD often engage in [[Idealization and devaluation|idealization and devaluation]] of others, alternating between high positive regard for people and great disappointment in them.<ref>{{harvnb|Linehan|1993|page=146}}</ref> Their feelings about others often shift from admiration or love to anger or dislike after a disappointment, a threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon is sometimes called [[Philosophy:Splitting (psychology)|splitting]].<ref>{{cite web |title=What Is BPD: Symptoms |url=http://www.borderlinepersonalitydisorder.com/understading-bpd/ |access-date=31 January 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130210110927/http://www.borderlinepersonalitydisorder.com/understading-bpd/ |archive-date=10 February 2013 }}</ref> Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers.<ref name="Robinson">{{cite book | vauthors = Robinson DJ | title = Disordered Personalities| publisher = Rapid Psychler Press| year = 2005| pages =255–310| isbn = 978-1-894328-09-8}}</ref>

While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied [[Philosophy:Attachment theory#Attachment patterns|attachment patterns]] in relationships,<ref>{{cite journal | vauthors = Levy KN, Meehan KB, Weber M, Reynoso J, Clarkin JF | title = Attachment and borderline personality disorder: implications for psychotherapy | journal = Psychopathology | volume = 38 | issue = 2 | pages = 64–74 | year = 2005 | pmid = 15802944 | doi = 10.1159/000084813 | s2cid = 10203453 }}</ref> and often view the world as dangerous and malevolent.<ref name="cogemo"/>

Like other personality disorders, BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, [[Medicine:Domestic violence|abuse]], and unwanted [[Medicine:Pregnancy|pregnancy]].<ref name="Daley SE, Burge D, Hammen C 2000 451–60">{{cite journal | vauthors = Daley SE, Burge D, Hammen C | title = Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity | journal = Journal of Abnormal Psychology | volume = 109 | issue = 3 | pages = 451–460 | date = August 2000 | pmid = 11016115 | doi = 10.1037/0021-843X.109.3.451 | citeseerx = 10.1.1.588.6902 }}</ref>

===Behavior===
Impulsive behavior is common, including [[Medicine:Substance use disorder|substance use disorder]]s (e.g., alcohol use disorder), eating in excess, unprotected sex or [[Social:Promiscuity|indiscriminate sex with multiple partners]], [[Finance:Spendthrift|reckless spending]], and reckless driving.<ref>{{cite web|last=National Education Alliance for Borderline Personality Disorder|title=A BPD Brief|url=http://new.borderlinepersonalitydisorder.com/wp-content/uploads/2011/07/A_BPD_Brief_REV2011.pdf|access-date=30 June 2013|page=4|archive-url=https://web.archive.org/web/20120912024603/http://new.borderlinepersonalitydisorder.com/wp-content/uploads/2011/07/A_BPD_Brief_REV2011.pdf|archive-date=12 September 2012|url-status=dead}}</ref> Impulsive behavior may also include leaving jobs or relationships, running away, and self-injury.<ref name=Manning_18/> People with BPD might do this because it gives them the feeling of immediate relief from their emotional pain,<ref name=Manning_18/> but in the long term may feel shame and guilt over consequences of this behavior.<ref name=Manning_18>{{harvnb|Manning|2011|page=18}}</ref> A cycle often begins in which people with BPD feel emotional pain, engage in impulsive behavior to relieve that pain, feel shame and guilt over their actions, feel emotional pain from the shame and guilt, and then experience stronger urges to engage in impulsive behavior to relieve the new pain.<ref name=Manning_18/> As time goes on, impulsive behavior may become an automatic response to emotional pain.<ref name=Manning_18/>

===Self-harm and suicide===
<!-- Do not remove this image without clear consensus -->
[[File:SelfHarm2017.jpg|thumb|Scarring as a result of self-harm, which is a common sign in borderline personality disorder.<ref name=NIH2016/>]]
<!-- Self harm -->
[[Medicine:Self-harm|Self-harm]]ing or suicidal behavior is one of the core diagnostic criteria in the DSM-5.<ref name=DSM5/> Self-harm occurs in 50 to 80% of people with BPD.<!-- <ref name=Ou2008/> --> The most frequent method of self-harm is cutting.<ref name="Ou2008">{{cite journal | vauthors = Oumaya M, Friedman S, Pham A, Abou Abdallah T, Guelfi JD, Rouillon F | title = [Borderline personality disorder, self-mutilation and suicide: literature review] | language = fr | journal = L'Encéphale | volume = 34 | issue = 5 | pages = 452–8 | date = October 2008 | pmid = 19068333 | doi = 10.1016/j.encep.2007.10.007 }}</ref> Bruising, burning, head banging or biting are not uncommon with BPD.<ref name=Ou2008/> People with BPD may feel emotional relief after cutting themselves.<ref name="DucasseCourtet2014">{{cite journal | vauthors = Ducasse D, Courtet P, Olié E | title = Physical and social pains in borderline disorder and neuroanatomical correlates: a systematic review | journal = Current Psychiatry Reports | volume = 16 | issue = 5 | pages = 443 | date = May 2014 | pmid = 24633938 | doi = 10.1007/s11920-014-0443-2 | s2cid = 25918270 }}</ref>

<!-- Suicide -->
The estimation of lifetime risk of suicide among people with BPD varied - depending on method of investigation - between 3% and 10%.<ref name="pmid31142033">{{cite journal| author=Paris J| title=Suicidality in Borderline Personality Disorder. | journal=Medicina (Kaunas) | year= 2019 | volume= 55 | issue= 6 | page=223 | pmid=31142033 | doi=10.3390/medicina55060223 | pmc=6632023 | doi-access=free }}</ref><ref name=Gund2011/><ref>{{cite book| vauthors = Gunderson JG, Links PS |year=2008|title=Borderline Personality Disorder: A Clinical Guide|edition=2nd|publisher=American Psychiatric Publishing, Inc|page=9|isbn=978-1-58562-335-8}}</ref> There is evidence that men diagnosed with BPD are approximately twice as likely to die by suicide as women diagnosed with BPD.<ref name="Kreisman J, Strauss H 2004 206">{{cite book |vauthors=Kreisman J, Strauss H |title=Sometimes I Act Crazy. Living With Borderline Personality Disorder |url=https://archive.org/details/sometimesiactcra00jero |url-access=registration | year=2004 | publisher=Wiley & Sons | page=[https://archive.org/details/sometimesiactcra00jero/page/206 206]|isbn=9780471222866 }}</ref> There is also evidence that a considerable percentage of men who die by suicide may have undiagnosed BPD.<ref name="Paris J 2008 21–22">{{cite book | vauthors = Paris J |title=Treatment of Borderline Personality Disorder. A Guide to Evidence-Based Practice | year=2008 | publisher=The Guilford Press | pages=21–22}}</ref>

<!-- Reasons -->
The reported reasons for self-harm differ from the reasons for suicide attempts.<ref name="reasons_NSSI">{{cite journal | vauthors = Brown MZ, Comtois KA, Linehan MM | s2cid = 4649933 | title = Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder | journal = Journal of Abnormal Psychology | volume = 111 | issue = 1 | pages = 198–202 | date = February 2002 | pmid = 11866174 | doi = 10.1037/0021-843X.111.1.198 }}</ref> Nearly 70% of people with BPD self-harm without trying to end their lives.<ref>{{cite journal | vauthors = Urnes O | title = [Self-harm and personality disorders] | journal = Tidsskrift for den Norske Laegeforening | volume = 129 | issue = 9 | pages = 872–6 | date = April 2009 | pmid = 19415088 | doi = 10.4045/tidsskr.08.0140 | doi-access = free }}</ref> Reasons for self-harm include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.<ref name=reasons_NSSI /> In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide.<ref name=reasons_NSSI /> Suicide and self-harm are responses to feeling negative emotions.<ref name=reasons_NSSI /> Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.<ref>{{cite journal | vauthors = Horesh N, Sever J, Apter A | title = A comparison of life events between suicidal adolescents with major depression and borderline personality disorder | journal = Comprehensive Psychiatry | volume = 44 | issue = 4 | pages = 277–83 | date = July–August 2003 | pmid = 12923705 | doi = 10.1016/S0010-440X(03)00091-9 }}</ref>

===Sense of self===
People with BPD tend to have trouble seeing their identity clearly. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.<ref name=Manning_23/> They are often unsure about their long-term goals for relationships and jobs. This can cause people with BPD to feel "empty" and "lost".<ref name=Manning_23/> Self-image can also change rapidly from healthy to unhealthy. People with BPD may base their identity on others, leading to chameleon-like changes in identity.

===Cognitions===
The often intense emotions people with BPD experience may make it difficult for them to concentrate.<ref name=Manning_23>{{harvnb|Manning|2011|page=23}}</ref> They may also tend to [[Medicine:Dissociation (psychology)|dissociate]], which can be thought of as an intense form of "zoning out".<ref name=Manning_24>{{harvnb|Manning|2011|page=24}}</ref> Others can sometimes tell when someone with BPD is dissociating because their facial or vocal expressions may become flat or expressionless, or they may appear distracted.<ref name=Manning_24/>

Dissociation often occurs in response to a painful event (or something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event—presumably to protect against intense emotion and unwanted behavioral impulses that such emotion might trigger.<ref name=Manning_24/> The mind's habit of blocking out intense painful emotions may provide temporary relief, but it can also have the side effect of blocking or blunting ordinary emotions, reducing the access of people with BPD to the information those emotions provide, information that helps guide effective decision-making in daily life.<ref name=Manning_24/>

=== Psychotic symptoms ===
Though BPD is primarily seen as a disorder of emotional regulation, psychotic symptoms are fairly common, with an estimated 21–54% prevalence in clinical BPD populations.<ref name=":8">{{cite journal | vauthors = Schroeder K, Fisher HL, Schäfer I | title = Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management | journal = Current Opinion in Psychiatry | volume = 26 | issue = 1 | pages = 113–9 | date = January 2013 | pmid = 23168909 | doi = 10.1097/YCO.0b013e32835a2ae7 | s2cid = 25546693 }}</ref> These symptoms are sometimes referred to as “pseudo-psychotic” or “psychotic-like,” terms that suggest a distinction from those seen in primary psychotic disorders. Recent research, however, has indicated that there is more similarity between pseudo-psychotic symptoms in BPD and “true” psychosis than originally thought.<ref name=":8" /><ref name=":9">{{cite journal | vauthors = Niemantsverdriet MB, Slotema CW, Blom JD, Franken IH, Hoek HW, Sommer IE, van der Gaag M | title = Hallucinations in borderline personality disorder: Prevalence, characteristics and associations with comorbid symptoms and disorders | journal = Scientific Reports | volume = 7 | issue = 1 | pages = 13920 | date = October 2017 | pmid = 29066713 | pmc = 5654997 | doi = 10.1038/s41598-017-13108-6 | bibcode = 2017NatSR...713920N }}</ref> Some researchers critique the concept of pseudo-psychosis for, on top of weak construct validity, the implication that it is “not true” or “less severe,” which could trivialize distress and serve as a barrier to diagnosis and treatment. Some researchers have suggested classifying these BPD symptoms as “true” psychosis, or even eliminating the distinction between pseudo-psychosis and true psychosis altogether.<ref name=":8" /><ref name=":10">{{cite journal | vauthors = Slotema CW, Blom JD, Niemantsverdriet MB, Sommer IE | title = Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review | journal = Frontiers in Psychiatry | volume = 9 | pages = 347 | date = 2018-07-31 | pmid = 30108529 | pmc = 6079212 | doi = 10.3389/fpsyt.2018.00347 | doi-access = free }}</ref>

The DSM-5 recognizes transient paranoia that worsens in response to stress as a symptom of BPD.<ref name="DSM5" /> Studies have documented both [[Unsolved:Hallucination|hallucination]]s and [[Medicine:Delusion|delusion]]s in BPD patients who lack another diagnosis that would [[Medicine:Differential diagnosis|better account]] for those symptoms.<ref name=":9" /> Phenomenologically, research suggests that [[Unsolved:Auditory hallucination|auditory verbal hallucinations]] found in patients with BPD cannot be reliably distinguished from those seen in [[Medicine:Schizophrenia|schizophrenia]].<ref name=":9" /><ref name=":10" /> Some researchers suggest there may be a common [[Philosophy:Etiology|etiology]] underlying hallucinations in BPD and those in other conditions like psychotic and [[Medicine:Mood disorder|affective disorders]].<ref name=":9" />

===Disability===
Many people with BPD are able to work if they find appropriate jobs and their condition is not too severe. People with BPD may be found to have a disability in the workplace if the condition is severe enough that the behaviors of sabotaging relationships, engaging in risky behaviors or intense anger prevent the person from functioning in their job role.<ref>{{cite journal | vauthors = Arvig TJ | title = Borderline personality disorder and disability | journal = AAOHN Journal | volume = 59 | issue = 4 | pages = 158–60 | date = April 2011 | pmid = 21462898 | doi = 10.1177/216507991105900401| doi-access = free }}</ref>

==Causes==
As is the case with other mental disorders, the causes of BPD are complex and not fully agreed upon.<ref name="mayo">{{cite web| url = http://www.mayoclinic.com/health/borderline-personality-disorder/DS00442/DSECTION=3| title = Borderline personality disorder| publisher = Mayo Clinic| access-date = 15 May 2008| url-status=live| archive-url = https://web.archive.org/web/20080430112844/http://www.mayoclinic.com/health/borderline-personality-disorder/DS00442/DSECTION%3D3| archive-date = 30 April 2008| df = dmy-all}}</ref> Evidence suggests that BPD and [[Medicine:Post-traumatic stress disorder|post-traumatic stress disorder]] (PTSD) may be related in some way.<ref name="BPD & PTSD">{{cite journal | vauthors = Gunderson JG, Sabo AN | title = The phenomenological and conceptual interface between borderline personality disorder and PTSD | journal = The American Journal of Psychiatry | volume = 150 | issue = 1 | pages = 19–27 | date = January 1993 | pmid = 8417576 | doi = 10.1176/ajp.150.1.19 }}</ref> Most researchers agree that a history of [[Medicine:Childhood trauma|childhood trauma]] can be a contributing factor,<ref name="kluft">{{cite book|title=Incest-Related Syndromes of Adult Psychopathology | vauthors = Kluft RP |year=1990 |publisher=American Psychiatric Pub, Inc.|pages=83, 89 |isbn=978-0-88048-160-1}}</ref> but less attention has historically been paid to investigating the causal roles played by congenital brain abnormalities, [[Biology:Genetics|genetics]], neurobiological factors, and environmental factors other than trauma.<ref name="mayo" /><ref>{{cite journal | vauthors = Zanarini MC, Frankenburg FR | s2cid = 20669909 | title = Pathways to the development of borderline personality disorder | journal = Journal of Personality Disorders | volume = 11 | issue = 1 | pages = 93–104 | year = 1997 | pmid = 9113824 | doi = 10.1521/pedi.1997.11.1.93 }}</ref>

Social factors include how people interact in their early development with their family, friends, and other children.<ref name="Psych Central">{{cite web|url=http://psychcentral.com/lib/symptoms-of-borderline-personality-disorder/0001063|title=Borderline Personality Disorder|publisher=psychcentral.com| vauthors = Grohol JM |date=30 January 2013|url-status=live|archive-url=https://web.archive.org/web/20140527125005/http://psychcentral.com/lib/symptoms-of-borderline-personality-disorder/0001063|archive-date=27 May 2014}}</ref>{{ums|date=November 2017}} Psychological factors include the individual's personality and temperament, shaped by their environment and learned coping skills that deal with stress.<ref name="Psych Central" />{{ums|date=November 2017}} These different factors together suggest that there are multiple factors that may contribute to the disorder.<ref>{{cite news|url=http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/causes/con-20023204|title=Borderline personality disorder: Understanding this challenging mental illness|work=Mayo Clinic|access-date=2017-09-05|url-status=live|archive-url=https://web.archive.org/web/20170830073811/http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/causes/con-20023204|archive-date=30 August 2017}}</ref>

===Genetics===
The [[Philosophy:Heritability|heritability]] of BPD is estimated to be between 37% to 69%.<ref name="Her2014">{{cite journal |vauthors=Gunderson JG, Zanarini MC, Choi-Kain LW, Mitchell KS, Jang KL, Hudson JI|date=August 2011|title=Family Study of Borderline Personality Disorder and Its Sectors of Psychopathology|journal=JAMA: The Journal of the American Medical Association|volume=68|issue=7|pages=753–762|doi=10.1001/archgenpsychiatry.2011.65|pmid=3150490|pmc=3150490}}</ref> That is, 37% to 69% of the variability in liability underlying BPD in the population can be explained by [[Biology:Human genetic variation|genetic differences]]. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment.<ref>{{cite journal | vauthors = Torgersen S | title = Genetics of patients with borderline personality disorder | journal = The Psychiatric Clinics of North America | volume = 23 | issue = 1 | pages = 1–9 | date = March 2000 | pmid = 10729927 | doi = 10.1016/S0193-953X(05)70139-8 }}</ref> Even so, the researchers of one study concluded that personality disorders "seem to be more strongly influenced by genetic effects than almost any [[Medicine:Diagnostic and Statistical Manual of Mental Disorders#DSM-IV-TR Multi-axial system|Axis I]] disorder [e.g., depression, [[Medicine:Eating disorder|eating disorder]]s], and more than most broad personality dimensions".<ref name="ReferenceA">{{cite journal | vauthors = Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E | title = A twin study of personality disorders | journal = Comprehensive Psychiatry | volume = 41 | issue = 6 | pages = 416–425 | year = 2000 | pmid = 11086146 | doi = 10.1053/comp.2000.16560 }}</ref> Moreover, the study found that BPD was estimated to be the third most-heritable personality disorder out of the 10 personality disorders reviewed.<ref name="ReferenceA"/> Twin, sibling, and other family studies indicate partial heritability for impulsive aggression, but studies of [[Chemistry:Serotonin|serotonin]]-related genes have suggested only modest contributions to behavior.<ref name="neurotrauma">{{cite journal | vauthors = Goodman M, New A, Siever L | title = Trauma, genes, and the neurobiology of personality disorders | journal = Annals of the New York Academy of Sciences | volume = 1032 | issue = 1 | pages = 104–116 | date = December 2004 | pmid = 15677398 | doi = 10.1196/annals.1314.008 | bibcode = 2004NYASA1032..104G | s2cid = 26270818 }}</ref>

Families with twins in the Netherlands were participants of an ongoing study by Trull and colleagues, in which 711 pairs of siblings and 561 parents were examined to identify the location of genetic traits that influenced the development of BPD.<ref name="Possible Genetic Causes">{{cite web|url=https://www.sciencedaily.com/releases/2008/12/081216114100.htm|title=Possible Genetic Causes Of Borderline Personality Disorder Identified|publisher=sciencedaily.com|date=20 December 2008|url-status=live|archive-url=https://web.archive.org/web/20140501161311/https://www.sciencedaily.com/releases/2008/12/081216114100.htm|archive-date=1 May 2014}}</ref> Research collaborators found that genetic material on chromosome 9 was linked to BPD features.<ref name="Possible Genetic Causes" /> The researchers concluded that "genetic factors play a major role in individual differences of borderline personality disorder features".<ref name="Possible Genetic Causes" /> These same researchers had earlier concluded in a previous study that 42% of variation in BPD features was attributable to genetic influences and 58% was attributable to environmental influences.<ref name="Possible Genetic Causes" /> Genes under investigation {{as of|2012|lc=y}} include the 7-repeat [[Biology:Polymorphism|polymorphism]] of the [[Biology:Dopamine receptor D4|dopamine D4 receptor (DRD4)]] on chromosome 11, which has been linked to disorganized attachment, whilst the combined effect of the 7-repeat polymorphism and the 10/10 [[Biology:Dopamine transporter|dopamine transporter]] (DAT) genotype has been linked to abnormalities in inhibitory control, both noted features of BPD.<ref name="Brain Structure and Function">{{cite journal | vauthors = O'Neill A, Frodl T | title = Brain structure and function in borderline personality disorder | journal = Brain Structure & Function | volume = 217 | issue = 4 | pages = 767–782 | date = October 2012 | pmid = 22252376 | doi = 10.1007/s00429-012-0379-4 | s2cid = 17970001 }}</ref> There is a possible connection to chromosome 5.<ref>{{cite journal | vauthors = Lubke GH, Laurin C, Amin N, Hottenga JJ, Willemsen G, van Grootheest G, Abdellaoui A, Karssen LC, Oostra BA, van Duijn CM, Penninx BW, Boomsma DI | title = Genome-wide analyses of borderline personality features | journal = Molecular Psychiatry | volume = 19 | issue = 8 | pages = 923–929 | date = August 2014 | pmid = 23979607 | pmc = 3872258 | doi = 10.1038/mp.2013.109 }}</ref>

===Brain abnormalities===
A number of [[Biology:Neuroimaging|neuroimaging]] studies in BPD have reported findings of reductions in regions of the brain involved in the regulation of stress responses and emotion, affecting the [[Biology:Hippocampus|hippocampus]], the [[Biology:Orbitofrontal cortex|orbitofrontal cortex]], and the [[Medicine:Amygdala|amygdala]], amongst other areas.<ref name="Brain Structure and Function" /> A smaller number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of neurometabolites in certain brain regions of BPD patients, looking specifically at neurometabolites such as N-acetylaspartate, creatine, glutamate-related compounds, and choline-containing compounds.<ref name="Brain Structure and Function" />

Some studies have identified increased gray matter in areas such as the bilateral [[Biology:Supplementary motor area|supplementary motor area]], [[Biology:Dentate gyrus|dentate gyrus]], and bilateral [[Biology:Precuneus|precuneus]], which extends to the bilateral [[Biology:Posterior cingulate cortex|posterior cingulate cortex]] (PCC).<ref>{{cite journal | vauthors = Yang X, Hu L, Zeng J, Tan Y, Cheng B | title = Default mode network and frontolimbic gray matter abnormalities in patients with borderline personality disorder: A voxel-based meta-analysis | journal = Scientific Reports | volume = 6 | number = 34247 | date = October 2016 | page = 34247 | pmid = 27694955 | pmc = 5046132 | doi = 10.1038/srep34247 | bibcode = 2016NatSR...634247Y }}</ref> The hippocampus tends to be smaller in people with BPD, as it is in people with post-traumatic stress disorder (PTSD). However, in BPD, unlike PTSD, the amygdala also tends to be smaller.<ref name = "Chapman p47">{{harvnb|Chapman|Gratz|2007|page=47}}</ref> This unusually strong activity may explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.<ref name = "Chapman p47" /> Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties people with BPD experience in regulating their emotions and responses to stress.<ref>{{harvnb|Chapman|Gratz|2007|page=48}}</ref>

==== Neurobiology ====
Borderline personality disorder has previously been strongly associated with the occurrence of childhood trauma. While many psychiatric diagnoses are believed to be associated with traumatic experiences occurring during critical periods of childhood, specific neurobiological factors have been identified within patients diagnosed with BPD. Dysregulations of the [[Medicine:Hypothalamic–pituitary–adrenal axis|hypothalamic-pituitary-adrenal (HPA) axis]] and [[Chemistry:Cortisol|cortisol]] levels have been intensively studied in individuals who have experienced childhood traumas and have been formally diagnosed with BPD. The HPA axis functions to maintain [[Homeostasis|homeostasis]] when the body is exposed to stressors but has been found to be dysregulated among individuals with a history of childhood abuse. When the body is exposed to stress, the [[Biology:Hypothalamus|hypothalamus]], specifically the [[Biology:Paraventricular nucleus of hypothalamus|paraventricular nucleus]] (PVN) releases peptides [[Biology:Vasopressin|arginine vasopressin]] (AVP) and [[Biology:Corticotropin-releasing factor family|corticotropin-releasing factor]] (CRF). When these peptides travel through the body, they stimulate corticotrophic cells, resulting in the release of [[Biology:Adrenocorticotropic hormone|adrenocorticotropic hormone]] (ACTH). ACTH binds to receptors in the adrenal cortex, which stimulates the release of cortisol. Intracellular [[Chemistry:Glucocorticoid|glucocorticoid]] receptor subtypes of [[Biology:Mineralocorticoid receptor|mineralocorticoid receptor]] (MR) and [[Biology:Low-affinity nerve growth factor receptor|low-affinity]] type receptor (GR) have been found to mediate the effects of cortisol on different areas of the body. While MRs have high affinity for cortisol and are highly saturated in response to stress, GRs have low affinity for cortisol and bind cortisol at high concentrations when an individual is exposed to a stressor.<ref name="Cattane 221">{{cite journal | vauthors = Cattane N, Rossi R, Lanfredi M, Cattaneo A | title = Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms | journal = BMC Psychiatry | volume = 17 | issue = 1 | pages = 221 | date = June 2017 | pmid = 28619017 | pmc = 5472954 | doi = 10.1186/s12888-017-1383-2 }}</ref> There have also been associations identified with [[Biology:FKBP5|FKBP5]] polymorphisms, rs4713902 and rs9470079 in individuals with BPD. For those with BPD who have experienced childhood trauma, rs3798347-T and rs10947563-A have been associated, specifically in individuals with both BPD diagnosis and a history of childhood [[Medicine:Physical abuse|physical abuse]] and emotional neglect.<ref name="Cattane 221"/>

====Hypothalamic-pituitary-adrenal axis====
The hypothalamic-pituitary-adrenal axis (HPA axis) regulates [[Chemistry:Cortisol|cortisol]] production, which is released in response to stress. Cortisol production tends to be elevated in people with BPD, indicating a hyperactive HPA axis in these individuals.<ref name="Grossman">{{cite journal | vauthors = Grossman R, Yehuda R, Siever L | title = The dexamethasone suppression test and glucocorticoid receptors in borderline personality disorder | journal = Annals of the New York Academy of Sciences | volume = 821 | issue = 1 | pages = 459–464 | date = June 1997 | pmid = 9238229 | doi = 10.1111/j.1749-6632.1997.tb48305.x | bibcode = 1997NYASA.821..459G | s2cid = 33529212 }}</ref> This causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability.<ref name="Chapman p49">{{harvnb|Chapman|Gratz|2007|page=49}}</ref> Since traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average activity in the HPA axis of people with BPD may simply be a reflection of the higher than average prevalence of traumatic childhood and maturational events among people with BPD.<ref name="Chapman p49"/>

====Estrogen====
Individual differences in women's [[Biology:Estrogen|estrogen]] cycles may be related to the expression of BPD symptoms in female patients.<ref name="DeSoto_book">{{cite book | vauthors = DeSoto MC |chapter=Borderline Personality Disorder, Gender and Serotonin: Does Estrogen Play a Role? |chapter-url=https://books.google.com/books?id=T9MlHPqTyy8C&pg=PA149 |pages=149–160 | veditors = Czerbska MT |title=Psychoneuroendocrinology Research Trends |series=Nova Biomedical |year=2007 |publisher=Nova Science Publishers |isbn=978-1-60021-665-7 |access-date=5 June 2020 |archive-date=7 May 2016 |archive-url=https://web.archive.org/web/20160507061124/https://books.google.com/books?id=T9MlHPqTyy8C&pg=PA149 |url-status=live }}</ref> A 2003 study found that women's BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative [[Philosophy:Affect (psychology)|affect]].<ref name="DeSoto_article">{{cite journal | vauthors = DeSoto MC, Geary DC, Hoard MK, Sheldon MS, Cooper L | title = Estrogen fluctuations, oral contraceptives and borderline personality | journal = Psychoneuroendocrinology | volume = 28 | issue = 6 | pages = 751–766 | date = August 2003 | pmid = 12812862 | doi = 10.1016/S0306-4530(02)00068-9 | s2cid = 13570846 }}</ref>

===Developmental factors===

====Childhood trauma====
There is a strong correlation between child abuse, especially [[Medicine:Child sexual abuse|child sexual abuse]], and development of BPD.<ref>{{cite journal | vauthors = Cohen P | title = Child development and personality disorder | journal = The Psychiatric Clinics of North America | volume = 31 | issue = 3 | pages = 477–493, vii | date = September 2008 | pmid = 18638647 | doi = 10.1016/j.psc.2008.03.005 }}</ref><ref name="Herman91">{{cite book | vauthors = Herman JL |title=Trauma and recovery |publisher=Basic Books |location=New York |year=1992 |isbn=978-0-465-08730-3 |url=https://archive.org/details/traumarecovery00herm_0 }}</ref><ref name="AxisOne/AxisTwo"/> Many individuals with BPD report a history of abuse and neglect as young children, but causation is still debated.<ref>{{cite journal | vauthors = Ball JS, Links PS | title = Borderline personality disorder and childhood trauma: evidence for a causal relationship | journal = Current Psychiatry Reports | volume = 11 | issue = 1 | pages = 63–68 | date = February 2009 | pmid = 19187711 | doi = 10.1007/s11920-009-0010-4 | s2cid = 20566309 }}</ref> Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, or sexually abused by caregivers of either sex.<ref>{{cite news|url=http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/risk-factors/con-20023204|title=Borderline personality disorder: Understanding this challenging mental illness|work=Mayo Clinic|access-date=2017-09-05|url-status=live|archive-url=https://web.archive.org/web/20170830054834/http://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/basics/risk-factors/con-20023204|archive-date=30 August 2017}}</ref> They also report a high incidence of [[Social:Incest|incest]] and loss of caregivers in early childhood.<ref name="failchild">{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Reich DB, Marino MF, Lewis RE, Williams AA, Khera GS | title = Biparental failure in the childhood experiences of borderline patients | journal = Journal of Personality Disorders | volume = 14 | issue = 3 | pages = 264–273 | year = 2000 | pmid = 11019749 | doi = 10.1521/pedi.2000.14.3.264 }}</ref> Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have neglected their child's physical care. Parents of both sexes were typically reported to have withdrawn from the child emotionally and to have treated the child inconsistently.<ref name="failchild"/> Additionally, women with BPD who reported a previous history of neglect by a female caregiver or abuse by a male caregiver were significantly more likely to have experienced sexual abuse by a non-caregiver.<ref name="failchild"/>

It has been suggested that children who experience chronic early maltreatment and [[Philosophy:Attachment theory|attachment]] difficulties may go on to develop borderline personality disorder.<ref name="Dozier-1999">{{cite book | vauthors = Dozier M, Stovall-McClough KC, Albus KE |year=1999 |chapter=Attachment and psychopathology in adulthood | veditors = Cassidy J, Shaver PR |title=Handbook of attachment |pages=497–519 |location=New York |publisher=Guilford Press}}</ref> Writing in the psychoanalytic tradition, Otto Kernberg argues that a child's failure to achieve the developmental task of psychic clarification of self and other and failure to overcome [[Philosophy:Splitting (psychology)|splitting]] might increase the risk of developing a borderline personality.<ref>{{cite book | vauthors = Kernberg OF |title=Borderline conditions and pathological narcissism |publisher=J. Aronson |location=Northvale, New Jersey |isbn=978-0-87668-762-8 |year=1985 }}{{Page needed|date=July 2013}}</ref>

===Neurological patterns===
The intensity and reactivity of a person's negative affectivity, or tendency to feel negative emotions, predicts BPD symptoms more strongly than does childhood sexual abuse.<ref name="Rosenthal"/> This finding, differences in brain structure (see Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history<ref name="Gratz2007">{{harvnb|Chapman|Gratz|2007|page=52}}</ref> suggest that BPD is distinct from the post-traumatic stress disorder which frequently accompanies it. Thus, researchers examine developmental causes in addition to childhood trauma.

Research published in January 2013 by Anthony Ruocco at the University of Toronto has highlighted two patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder: (1) increased activity in the brain circuits responsible for the experience of heightened emotional pain, coupled with (2) reduced activation of the brain circuits that normally regulate or suppress these generated painful emotions. These two neural networks are seen to be dysfunctionally operative in the limbic system, but the specific regions vary widely in individuals, which calls for the analysis of more neuroimaging studies.<ref name="Ruocco, Anthony C.; Amirthavasagam, Sathya, Choi-Kain, Lois W.; McMain, Shelley F. 2013 153–160">{{cite journal | vauthors = Ruocco AC, Amirthavasagam S, Choi-Kain LW, McMain SF | title = Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis | journal = Biological Psychiatry | volume = 73 | issue = 2 | pages = 153–160 | date = January 2013 | pmid = 22906520 | doi = 10.1016/j.biopsych.2012.07.014 | s2cid = 8381799 }}</ref>

Also (contrary to the results of earlier studies) sufferers of BPD showed less activation in the amygdala in situations of increased negative emotionality than the control group. John Krystal, editor of the journal ''Biological Psychiatry'', wrote that these results "[added] to the impression that people with borderline personality disorder are 'set-up' by their brains to have stormy emotional lives, although not necessarily unhappy or unproductive lives".<ref name="Ruocco, Anthony C.; Amirthavasagam, Sathya, Choi-Kain, Lois W.; McMain, Shelley F. 2013 153–160" /> Their emotional instability has been found to correlate with differences in several brain regions.<ref name="Koenigsberg">{{cite journal | vauthors = Koenigsberg HW, Siever LJ, Lee H, Pizzarello S, New AS, Goodman M, Cheng H, Flory J, Prohovnik I | title = Neural correlates of emotion processing in borderline personality disorder | journal = Psychiatry Research | volume = 172 | issue = 3 | pages = 192–199 | date = June 2009 | pmid = 19394205 | pmc = 4153735 | doi = 10.1016/j.pscychresns.2008.07.010 | quote = BPD patients demonstrated greater differences in activation than controls, when viewing negative pictures compared with rest, in the amygdala, fusiform gyrus, primary visual areas, superior temporal gyrus (STG), and premotor areas, while healthy controls showed greater differences than BPD patients in the insula, middle temporal gyrus and dorsolateral prefrontal cortex. }}</ref>

===Mediating and moderating factors===

====Executive function====
While high rejection sensitivity is associated with stronger symptoms of borderline personality disorder, executive function appears to [[Mediation (statistics)|mediate]] the relationship between rejection sensitivity and BPD symptoms.<ref name="Executive_function">{{cite journal | vauthors = Ayduk O, Zayas V, Downey G, Cole AB, Shoda Y, Mischel W| title = Rejection Sensitivity and Executive Control: Joint predictors of Borderline Personality features | journal = Journal of Research in Personality | volume = 42 | issue = 1 | pages = 151–168 | date = February 2008 | pmid = 18496604 | pmc = 2390893 | doi = 10.1016/j.jrp.2007.04.002 }}</ref> That is, a group of cognitive processes that include planning, [[Working memory|working memory]], attention, and problem-solving might be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the relationship between a person's rejection sensitivity and BPD symptoms was stronger when executive function was lower and that the relationship was weaker when executive function was higher.<ref name="Executive_function"/> This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.<ref name="Executive_function"/> A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.<ref>{{cite journal | vauthors = Lazzaretti M, Morandotti N, Sala M, Isola M, Frangou S, De Vidovich G, Marraffini E, Gambini F, Barale F, Zappoli F, Caverzasi E, Brambilla P | title = Impaired working memory and normal sustained attention in borderline personality disorder | journal = Acta Neuropsychiatrica | volume = 24 | issue = 6 | pages = 349–355 | date = December 2012 | pmid = 25287177 | doi = 10.1111/j.1601-5215.2011.00630.x | s2cid = 34486508 }}</ref>

====Family environment====
Family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment predicts a lower risk. One possible explanation is that a stable environment buffers against its development.<ref name="Bradley">{{cite journal | vauthors = Bradley R, Jenei J, Westen D | title = Etiology of borderline personality disorder: disentangling the contributions of intercorrelated antecedents | journal = The Journal of Nervous and Mental Disease | volume = 193 | issue = 1 | pages = 24–31 | date = January 2005 | pmid = 15674131 | doi = 10.1097/01.nmd.0000149215.88020.7c | s2cid = 21168862 }}</ref>

====Self-complexity====
[[Philosophy:Self-complexity|Self-complexity]], or considering one's self to have many different characteristics, may lessen the apparent discrepancy between an actual self and a desired self-image. Higher self-complexity may lead a person to desire more characteristics instead of better characteristics; if there is any belief that characteristics should have been acquired, these may be more likely to have been experienced as examples rather than considered as abstract qualities. The concept of a norm does not necessarily involve the description of the attributes that represent the norm: cognition of the norm may only involve the understanding of "being like", a concrete relation and not an attribute.<ref name="Parker">{{cite journal | vauthors = Parker AG, Boldero JM, Bell RC | title = Borderline personality disorder features: the role of self-discrepancies and self-complexity | journal = Psychology and Psychotherapy | volume = 79 | issue = Pt 3 | pages = 309–321 | date = September 2006 | pmid = 16945194 | doi = 10.1348/147608305X70072 }}</ref>

====Thought suppression====
A 2005 study found that [[Philosophy:Thought suppression|thought suppression]], or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerability and BPD symptoms.<ref name="Rosenthal">{{cite journal | vauthors = Rosenthal MZ, Cheavens JS, Lejuez CW, Lynch TR | title = Thought suppression mediates the relationship between negative affect and borderline personality disorder symptoms | journal = Behaviour Research and Therapy | volume = 43 | issue = 9 | pages = 1173–1185 | date = September 2005 | pmid = 16005704 | doi = 10.1016/j.brat.2004.08.006 }}</ref> A later study found that the relationship between emotional vulnerability and BPD symptoms is not necessarily mediated by thought suppression. However, this study did find that thought suppression mediates the relationship between an invalidating environment and BPD symptoms.<ref>{{cite journal | vauthors = Sauer SE, Baer RA | title = Relationships between thought suppression and symptoms of borderline personality disorder | journal = Journal of Personality Disorders | volume = 23 | issue = 1 | pages = 48–61 | date = February 2009 | pmid = 19267661 | doi = 10.1521/pedi.2009.23.1.48 }}</ref>

=== Developmental theories ===
Marsha Linehan's biosocial developmental theory of borderline personality disorder suggests that BPD emerges from the combination of an emotionally vulnerable child, and an invalidating environment. Emotional vulnerability may consist of biological, inherited factors that affect a child's temperament. Invalidating environments may include contexts where a child's emotions and needs are neglected, ridiculed, dismissed, or discouraged, or may include contexts of trauma and abuse.

Linehan's theory was modified by Sheila Crowell, who proposed that impulsivity also plays an important role in the development of BPD. Crowell found that children who are emotionally vulnerable and are exposed to invalidating environments are much more likely to develop BPD if they are also highly impulsive.<ref>{{cite journal | vauthors = Crowell SE, Beauchaine TP, Linehan MM | title = A biosocial developmental model of borderline personality: Elaborating and extending Linehan's theory | journal = Psychological Bulletin | volume = 135 | issue = 3 | pages = 495–510 | date = May 2009 | pmid = 19379027 | pmc = 2696274 | doi = 10.1037/a0015616 }}</ref> Both theories describe an interplay between a child's inherited personality traits and their environment. For example, an emotionally sensitive or impulsive child may be difficult to parent, exacerbating the invalidating environment; conversely, invalidation can make an emotionally sensitive child more reactive and distressed.

==Diagnosis==
Diagnosis of borderline personality disorder is based on a clinical [[Medicine:Psychiatric assessment|assessment]] by a mental health professional. The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them.<ref name=Gund2011/> Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it.<ref name=Gund2011/> Some clinicians prefer not to tell people with BPD what their diagnosis is, either from concern about the stigma attached to this condition or because BPD used to be considered untreatable; it is usually helpful for the person with BPD to know their diagnosis.<ref name=Gund2011/> This helps them know that others have had similar experiences and can point them toward effective treatments.<ref name=Gund2011/>

In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others.<ref name="Mayo_Clinic_Diagnosis">{{cite web|title=Personality Disorders: Tests and Diagnosis|url=http://www.mayoclinic.com/health/personality-disorders/DS00562/DSECTION=tests-and-diagnosis|publisher=Mayo Clinic|access-date=13 June 2013|url-status=live|archive-url=https://web.archive.org/web/20130606185940/http://www.mayoclinic.com/health/personality-disorders/DS00562/DSECTION%3Dtests-and-diagnosis|archive-date=6 June 2013}}</ref> Diagnosis is based both on the person's report of their symptoms and on the clinician's own observations.<ref name=Mayo_Clinic_Diagnosis /> Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or a substance use disorder.<ref name = Mayo_Clinic_Diagnosis /> The [[Medicine:ICD-10|ICD-10]] manual refers to the disorder as ''emotionally unstable personality disorder'' and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in the previous editions.<ref name=DSM5/>

===''Diagnostic and Statistical Manual''===
<!-- Please do not add diagnosis criteria as this constitutes a copyright violation. APA has forbidden us.-->
The ''[[Medicine:Diagnostic and Statistical Manual of Mental Disorders|Diagnostic and Statistical Manual of Mental Disorders]]'' fifth edition (DSM-5) has removed the multiaxial system. Consequently, all disorders, including personality disorders, are listed in Section II of the manual. A person must meet five of nine criteria to receive a diagnosis of borderline personality disorder.<ref name="DSM-5-borderine personality disorders" /> The DSM-5 defines the main features of the condition as a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as markedly impulsive behavior.<ref name="DSM-5-borderine personality disorders">{{harvnb|American Psychiatric Association|2013|pages=663–8}}</ref> In addition, the DSM-5 proposes alternative diagnostic criteria for BPD in section III, "Alternative DSM-5 Model for Personality Disorders". These alternative criteria are based on trait research and include specifying at least four of seven maladaptive traits.<ref name="DSM-5-borderline-alternative">{{harvnb|American Psychiatric Association|2013|pages=766–7}}</ref> According to Marsha Linehan, many mental health professionals find it challenging to diagnose BPD using the DSM criteria, since these criteria describe such a wide variety of behaviors.<ref name=Manning_13>{{harvnb|Manning|2011|page=13}}</ref> To address this issue, Linehan has grouped the symptoms of BPD under five main areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.<ref name=Manning_13/>

===International Classification of Disease===
The [[Organization:World Health Organization|World Health Organization]]'s [[Medicine:ICD-10|ICD-10]] defines a disorder that is conceptually similar to BPD, called ''({{ICD10|F|60|3|f|60}}) Emotionally unstable personality disorder''. Its two subtypes are described below.<ref name="borderline">[http://bpdfamily.com/pdfs/ICD-10.pdf "Emotionally unstable personality disorder"]. ''International Statistical Classification of Diseases and Related Health Problems'', 10th Revision ([[Medicine:ICD-10|ICD-10]]). [[Organization:World Health Organization|World Health Organization]]. {{webarchive|url=https://web.archive.org/web/20141020191619/http://bpdfamily.com/pdfs/ICD-10.pdf |date=20 October 2014 }}</ref>

====F60.30 Impulsive type====
At least three of the following must be present, one of which must be (2):
# marked tendency to act unexpectedly and without consideration of the consequences;
# marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
# liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
# difficulty in maintaining any course of action that offers no immediate reward;
# unstable and capricious (impulsive, whimsical) mood.

====F60.31 Borderline type====
At least three of the symptoms mentioned in ''F60.30 Impulsive type'' must be present [see above], with at least two of the following in addition:
# disturbances in and uncertainty about self-image, aims, and internal preferences;
# liable to become involved in intense and unstable relationships, often leading to emotional crisis;
# excessive efforts to avoid abandonment;
# recurrent threats or acts of self-harm;
# chronic feelings of emptiness;
# demonstrates impulsive behavior, e.g., speeding in a car or substance use.<ref>{{cite book | vauthors = Carlson NR, Heth CD |title=Psychology: The Science of Behavior |publisher=Pearson Canada |year=2010 |page=570}}</ref>
The ICD-10 also describes some general criteria that define what is considered a personality disorder.

===Millon's subtypes===
American psychologist Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or multiple of the following:<ref name="Millon">{{cite book | vauthors = Millon T |year=2004 |title=Personality Disorders in Modern Life |page=4 |publisher=John Wiley & Sons |location=Hoboken, New Jersey |isbn=978-0-471-23734-1}}</ref>
{| class="wikitable"
|-
! Subtype
! Features
|-
| '''Discouraged borderline''' (including [[Medicine:Avoidant personality disorder|avoidant]] and [[Medicine:Dependent personality disorder|dependent]] features)
| Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
|-
| '''Petulant borderline''' (including negativistic features)
| Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels "slighted" and quickly disillusioned.
|-
| '''Impulsive borderline''' (including [[Medicine:Histrionic personality disorder|histrionic]] or [[Medicine:Antisocial personality disorder|antisocial]] features)
| Captivating, capricious, superficial, flighty, distractable, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal.
|-
| '''Self-destructive borderline''' (including [[Medicine:Depressive personality disorder|depressive]] or [[Medicine:Self-defeating personality disorder|masochistic]] features)
| Inward-turning, intropunitive (self-punishing), angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.
|}

===Misdiagnosis===
{{Main|Medicine:Misdiagnosis of borderline personality disorder}}
People with BPD may be misdiagnosed for a variety of reasons. One reason for misdiagnosis is BPD has symptoms that coexist ([[Medicine:Comorbidity|comorbidity]]) with other disorders such as depression, post-traumatic stress disorder (PTSD), and [[Medicine:Bipolar disorder|bipolar disorder]].<ref name="Chanen">{{cite journal | vauthors = Chanen AM, Thompson KN | title = Prescribing and borderline personality disorder | journal = Australian Prescriber | volume = 39 | issue = 2 | pages = 49–53 | date = April 2016 | pmid = 27340322 | pmc = 4917638 | doi = 10.18773/austprescr.2016.019 }}</ref><ref>{{cite journal | vauthors = Meaney R, Hasking P, Reupert A | title = Borderline Personality Disorder Symptoms in College Students: The Complex Interplay between Alexithymia, Emotional Dysregulation and Rumination | journal = PLOS ONE | volume = 11 | issue = 6 | pages = e0157294 | date = 2016 | pmid = 27348858 | pmc = 4922551 | doi = 10.1371/journal.pone.0157294 | bibcode = 2016PLoSO..1157294M | doi-access = free }}</ref>

===Family members===
People with BPD are prone to feeling angry at members of their family and alienated from them. On their part, family members often feel angry and helpless at how their BPD family members relate to them.<ref name="Gund2011">{{cite journal | vauthors = Gunderson JG | title = Clinical practice. Borderline personality disorder | journal = The New England Journal of Medicine | volume = 364 | issue = 21 | pages = 2037–2042 | date = May 2011 | pmid = 21612472 | doi = 10.1056/NEJMcp1007358 | hdl = 10150/631040 | hdl-access = free }}</ref> Parents of adults with BPD are often both over-involved and under-involved in family interactions.<ref name="parents">{{cite journal | vauthors = Allen DM, Farmer RG | title = Family relationships of adults with borderline personality disorder | journal = Comprehensive Psychiatry | volume = 37 | issue = 1 | pages = 43–51 | year = 1996 | pmid = 8770526 | doi = 10.1016/S0010-440X(96)90050-4 }}</ref> In romantic relationships, BPD is linked to increased levels of chronic stress and conflict, decreased satisfaction of romantic partners, [[Medicine:Domestic violence|domestic abuse]], and unwanted pregnancy. However, these links may apply to personality disorders in general.<ref name="Daley SE, Burge D, Hammen C 2000 451–60"/>

===Adolescence===
Onset of symptoms typically occurs during adolescence or young adulthood, although symptoms suggestive of this disorder can sometimes be observed in children.<ref>{{harvnb|Linehan|1993|page=49}}</ref> Symptoms among adolescents that predict the development of BPD in adulthood may include problems with body-image, extreme sensitivity to rejection, behavioral problems, non-suicidal self-injury, attempts to find exclusive relationships, and severe shame.<ref name=Gund2011/> Many adolescents experience these symptoms without going on to develop BPD, but those who experience them are 9 times as likely as their peers to develop BPD. They are also more likely to develop other forms of long-term social disabilities.<ref name=Gund2011/>

BPD is recognised as a valid and stable diagnosis during adolescence.<ref name=":2">{{cite journal | vauthors = Miller AL, Muehlenkamp JJ, Jacobson CM | title = Fact or fiction: diagnosing borderline personality disorder in adolescents | journal = Clinical Psychology Review | volume = 28 | issue = 6 | pages = 969–81 | date = July 2008 | pmid = 18358579 | doi = 10.1016/j.cpr.2008.02.004 | url = http://dx.doi.org/10.1016/j.cpr.2008.02.004 | access-date = 23 September 2020 | archive-date = 4 December 2020 | archive-url = https://web.archive.org/web/20201204232033/https://www.sciencedirect.com/science/article/abs/pii/S0272735808000299?via%3Dihub | url-status = live }}</ref><ref name=":3">{{cite book | author = National Collaborating Centre for Mental Health (UK)|url=https://www.ncbi.nlm.nih.gov/books/NBK55399/|title=Young People With Borderline Personality Disorder |date=2009 |publisher=British Psychological Society|language=en|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232017/https://www.ncbi.nlm.nih.gov/books/NBK55399/|url-status=live}}</ref><ref name=":4">{{cite journal | vauthors = Kaess M, Brunner R, Chanen A | title = Borderline personality disorder in adolescence | journal = Pediatrics | volume = 134 | issue = 4 | pages = 782–93 | date = October 2014 | pmid = 25246626 | doi = 10.1542/peds.2013-3677 | s2cid = 8274933 | url = https://pubmed.ncbi.nlm.nih.gov/25246626/ | access-date = 23 September 2020 | archive-date = 12 November 2020 | archive-url = https://web.archive.org/web/20201112012431/https://pubmed.ncbi.nlm.nih.gov/25246626/ | url-status = live }}</ref><ref name=":5">{{cite journal | vauthors = Biskin RS | title = The Lifetime Course of Borderline Personality Disorder | journal = Canadian Journal of Psychiatry | volume = 60 | issue = 7 | pages = 303–8 | date = July 2015 | pmid = 26175388 | pmc = 4500179 | doi = 10.1177/070674371506000702 }}</ref> The diagnosis of BPD (also described as "personality disorder: borderline pattern qualifier") in adolescents is supported in recent updates to the international diagnostic and psychiatric classification tools including the DSM-5 and [[Medicine:ICD-11|ICD-11]].<ref>{{cite book|last=American Psychiatric Association. American Psychiatric Association. DSM-5 Task Force.|url=http://worldcat.org/oclc/863153409|title=Diagnostic and Statistical Manual of Mental Disorders : DSM-5|year=2013|isbn=978-0-89042-554-1|oclc=863153409|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232019/https://www.worldcat.org/title/diagnostic-and-statistical-manual-of-mental-disorders-dsm-5/oclc/863153409|url-status=live}}</ref><ref>{{cite web|title=ICD-11|url=https://icd.who.int/dev11/f/en#/http://id.who.int/icd/entity/37291724|access-date=2020-09-23|website=icd.who.int|archive-date=19 November 2019|archive-url=https://web.archive.org/web/20191119021828/https://icd.who.int/dev11/f/en#/http://id.who.int/icd/entity/37291724|url-status=live}}</ref><ref>{{cite journal | vauthors = Bach B, First MB | title = Application of the ICD-11 classification of personality disorders | journal = BMC Psychiatry | volume = 18 | issue = 1 | pages = 351 | date = October 2018 | pmid = 30373564 | doi = 10.1186/s12888-018-1908-3 | pmc = 6206910 }}</ref> Early diagnosis of BPD has been recognised as instrumental to the early intervention and effective treatment for BPD in young people.<ref name=":4" /><ref>{{cite journal| vauthors = Chanen AM, McCutcheon LK, Jovev M, Jackson HJ, McGorry PD |date=2007-10-01|title=Prevention and early intervention for borderline personality disorder |journal=The Medical Journal of Australia |volume=187 |issue=7 |pages=S18-21 |doi=10.5694/j.1326-5377.2007.tb01330.x |pmid=17908019|s2cid=9389185}}</ref><ref>{{cite journal | vauthors = Guilé JM, Boissel L, Alaux-Cantin S, de La Rivière SG | title = Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies | journal = Adolescent Health, Medicine and Therapeutics | volume = 9 | pages = 199–210 | date = 2018-11-23 | pmid = 30538595 | pmc = 6257363 | doi = 10.2147/AHMT.S156565 }}</ref> Accordingly, national treatment guidelines recommend the diagnosis and treatment of BPD among adolescents in many countries including Australia, the United Kingdom, Spain, and Switzerland.<ref>{{cite book|last=National Health and Medical Research Council (Australia)|url=http://worldcat.org/oclc/948783298|title=Clinical practice guideline for the management of borderline personality disorder|date=2013|publisher=National Health and Medical Research Council|isbn=978-1-86496-564-3|oclc=948783298|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232022/https://www.worldcat.org/title/clinical-practice-guideline-for-the-management-of-borderline-personality-disorder/oclc/948783298|url-status=live}}</ref><ref>{{cite web|title=Overview {{!}} Borderline personality disorder: recognition and management {{!}} Guidance {{!}} NICE|url=https://www.nice.org.uk/guidance/cg78|access-date=2020-09-23|website=www.nice.org.uk|archive-date=11 October 2019|archive-url=https://web.archive.org/web/20191011171334/https://www.nice.org.uk/guidance/CG78|url-status=live}}</ref><ref>{{cite journal | author = Grupo de Trabajo de la Guía de Práctica Clínica sobre Trastorno Límite de la Personalidad |date=June 2011|title=Guía de práctica clínica sobre trastorno límite de la personalidad|url=https://scientiasalut.gencat.cat/handle/11351/810|journal=Scientia|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232022/https://scientiasalut.gencat.cat/handle/11351/810|url-status=live}}</ref><ref>{{cite journal| vauthors = Euler S, Dammann G, Endtner K, Leihener F, Perroud N, Reisch T, Schmeck K, Sollberger D, Walter M, Kramer U |title=Trouble de la personnalité borderline : recommandations de traitement pour la Société suisse de psychiatrie et psychothérapie (SSPP) [Borderline personality disorder: The treatment recommendations of the Swiss Society of Psychiatry and Psychotherapy (SSPP)]| doi = 10.1684/ipe.2020.2053 |journal=L'Information Psychiatrique|volume=96|pages=35–43|doi-broken-date=31 May 2021|via=https://www.cairn-int.info/}}</ref>

The diagnosis of BPD during adolescence has been controversial.<ref name=":4" /><ref>{{cite book|vauthors=de Vito E, Ladame F, Orlandini A|veditors=Derksen J, Maffei C, Groen H|chapter=Adolescence and Personality Disorders|date=1999|chapter-url=http://link.springer.com/10.1007/978-1-4757-6876-3_7|title=Treatment of Personality Disorders|pages=77–95|place=Boston, MA|publisher=Springer US|language=en|doi=10.1007/978-1-4757-6876-3_7|isbn=978-1-4419-3326-3|access-date=2020-09-23|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232040/https://link.springer.com/chapter/10.1007%2F978-1-4757-6876-3_7|url-status=live}}</ref><ref>{{cite journal | vauthors = Guilé JM, Boissel L, Alaux-Cantin S, de La Rivière SG | title = Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies | journal = Adolescent Health, Medicine and Therapeutics | volume = 9 | pages = 199–210 | date = 2018-11-23 | pmid = 30538595 | pmc = 6257363 | doi = 10.2147/ahmt.s156565}}</ref> Early clinical guidelines encouraged caution when diagnosing BPD during adolescence.<ref name="DSM-IV-TR">{{harvnb|American Psychiatric Association|2000}}{{Page needed|date=July 2013}}</ref><ref>{{cite book|last=American Psychiatric Association. Work Group on Borderline Personality Disorder.|url=http://worldcat.org/oclc/606593046|title=Practice guideline for the treatment of patients with borderline personality disorder|date=2001|publisher=American Psychiatric Association|oclc=606593046|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232020/https://www.worldcat.org/title/practice-guideline-for-the-treatment-of-patients-with-borderline-personality-disorder/oclc/606593046|url-status=live}}</ref><ref>{{cite book| author = World Health Organization |url=http://worldcat.org/oclc/476159430|title=The ICD-10 Classification of Mental and Behavioural Disorders : Clinical Descriptions and Diagnostic Guidelines.|date=1992|publisher=World Health Organization|isbn=978-92-4-068283-2|oclc=476159430|access-date=23 September 2020|archive-date=4 December 2020|archive-url=https://web.archive.org/web/20201204232022/https://www.worldcat.org/title/icd-10-classification-of-mental-and-behavioural-disorders-clinical-descriptions-and-diagnostic-guidelines/oclc/476159430|url-status=live}}</ref> Perceived barriers to the diagnosis of BPD during adolescence included concerns about the validity of a diagnosis in young people, the misdiagnosis normal adolescent behaviour as symptoms of BPD, the stigmatising effect of a diagnosis for adolescents, and whether personality during adolescence was sufficiently stable for a valid diagnosis of BPD.<ref name=":4" /> Psychiatric research has since shown BPD to be a valid, stable and clinically useful diagnosis in adolescent populations.<ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":5" /> However, ongoing misconceptions about the diagnosis of BPD in adolescence remain prevalent among mental health professionals.<ref name=":6">{{cite journal | vauthors = Baltzersen ÅL | title = Moving forward: closing the gap between research and practice for young people with BPD | journal = Current Opinion in Psychology | volume = 37 | pages = 77–81 | date = August 2020 | pmid = 32916475 | doi = 10.1016/j.copsyc.2020.08.008 }}</ref><ref>{{cite journal | vauthors = Boylan K | title = Diagnosing BPD in Adolescents: More good than harm | journal = Journal of the Canadian Academy of Child and Adolescent Psychiatry | volume = 27 | issue = 3 | pages = 155–156 | date = August 2018 | pmid = 30038651 | pmc = 6054283 }}</ref><ref>{{cite journal | vauthors = Laurenssen EM, Hutsebaut J, Feenstra DJ, Van Busschbach JJ, Luyten P | title = Diagnosis of personality disorders in adolescents: a study among psychologists | journal = Child and Adolescent Psychiatry and Mental Health | volume = 7 | issue = 1 | pages = 3 | date = February 2013 | pmid = 23398887 | pmc = 3583803 | doi = 10.1186/1753-2000-7-3 }}</ref> Clinical reluctance to diagnose BPD as a key barrier to the provision of effective treatment in adolescent populations.<ref name=":6" /><ref>{{cite journal | vauthors = Chanen AM | title = Borderline Personality Disorder in Young People: Are We There Yet? | journal = Journal of Clinical Psychology | volume = 71 | issue = 8 | pages = 778–91 | date = August 2015 | pmid = 26192914 | doi = 10.1002/jclp.22205 | url = http://doi.wiley.com/10.1002/jclp.22205 | access-date = 23 September 2020 | archive-date = 4 December 2020 | archive-url = https://web.archive.org/web/20201204232036/https://onlinelibrary.wiley.com/doi/abs/10.1002/jclp.22205 | url-status = live }}</ref><ref>{{cite journal | vauthors = Koehne K, Hamilton B, Sands N, Humphreys C | title = Working around a contested diagnosis: borderline personality disorder in adolescence | journal = Health | volume = 17 | issue = 1 | pages = 37–56 | date = January 2013 | pmid = 22674745 | doi = 10.1177/1363459312447253 | s2cid = 1674596 }}</ref>

A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood.<ref name="DSM-IV-TR" /><ref name="Netherton">{{cite book | vauthors = Netherton SD, Holmes D, Walker CE |year=1999 |title=Child and Adolescent Psychological Disorders: Comprehensive Textbook |location=New York |publisher=Oxford University Press}}{{Page needed|date=July 2013}}</ref> Among individuals diagnosed with BPD during adolescence, there appears to be one group in which the disorder remains stable over time and another group in which the individuals move in and out of the diagnosis.<ref name="Fact_or_Fiction">{{cite journal | vauthors = Miller AL, Muehlenkamp JJ, Jacobson CM | title = Fact or fiction: diagnosing borderline personality disorder in adolescents | journal = Clinical Psychology Review | volume = 28 | issue = 6 | pages = 969–981 | date = July 2008 | pmid = 18358579 | doi = 10.1016/j.cpr.2008.02.004 }}</ref> Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent.<ref name="DSM-IV-TR" /><ref name="Netherton" /> Family therapy is considered a helpful component of treatment for adolescents with BPD.<ref>{{harvnb|Linehan|1993|page=98}}</ref>

===Differential diagnosis and comorbidity===
Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD showed a higher rate of also meeting criteria for<ref name="comorbidity">{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A, Reynolds V | title = Axis I comorbidity of borderline personality disorder | journal = The American Journal of Psychiatry | volume = 155 | issue = 12 | pages = 1733–1739 | date = December 1998 | pmid = 9842784 | doi = 10.1176/ajp.155.12.1733 }}</ref>
* [[Medicine:Mood disorder|mood disorder]]s, including major depression and bipolar disorder
* [[Medicine:Anxiety disorder|anxiety disorder]]s, including [[Medicine:Panic disorder|panic disorder]], [[Medicine:Social anxiety disorder|social anxiety disorder]], and post-traumatic stress disorder (PTSD)
* other personality disorders, including [[Medicine:Schizotypal personality disorder|schizotypal]], antisocial and dependent personality disorder
* substance use
* eating disorders, including [[Medicine:Anorexia nervosa|anorexia nervosa]] and bulimia
* [[Medicine:Attention deficit hyperactivity disorder|attention deficit hyperactivity disorder]]<ref name="PM">{{cite journal | vauthors = Ferrer M, Andión O, Matalí J, Valero S, Navarro JA, Ramos-Quiroga JA, Torrubia R, Casas M | title = Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder | journal = Journal of Personality Disorders | volume = 24 | issue = 6 | pages = 812–822 | date = December 2010 | pmid = 21158602 | doi = 10.1521/pedi.2010.24.6.812 }}{{primary source inline|date=May 2013}}</ref>
* [[Medicine:Somatic symptom disorder|somatic symptom disorder]]s (formerly known as somatoform disorders: a category of mental disorders included in a number of diagnostic schemes of mental illness)
* dissociative disorders

A diagnosis of a personality disorder should not be made during an untreated mood episode/disorder, unless the lifetime history supports the presence of a personality disorder.

====Comorbid Axis I disorders====
{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
|-
|+Sex differences in Axis I lifetime comorbid diagnosis, 2008<ref name="Grant et al 2008"/> and 1998<ref name=comorbidity />
|-
! Axis I diagnosis !! Overall (%) !! Male (%) !! Female (%)
|-
! Mood disorders !! 75.0 !! 68.7 !! 80.2
|-
|Major depressive disorder || 32.1 || 27.2 || 36.1
|-
|[[Medicine:Dysthymia|Dysthymia]] || {{0}}9.7 || {{0}}7.1 || 11.9
|-
|[[Medicine:Bipolar I disorder|Bipolar I disorder]] || 31.8 || 30.6 || 32.7
|-
|[[Medicine:Bipolar II disorder|Bipolar II disorder]] || {{0}}7.7 || {{0}}6.7 || {{0}}8.5
|-
! Anxiety disorders !! 74.2 !! 66.1 !! 81.1
|-
|[[Medicine:Panic disorder|Panic disorder]] with [[Medicine:Agoraphobia|agoraphobia]] || 11.5 || {{0}}7.7 || 14.6
|-
|Panic disorder without agoraphobia || 18.8 || 16.2 || 20.9
|-
|Social phobia  || 29.3 || 25.2 || 32.7
|-
|Specific phobia || 37.5 || 26.6 || 46.6
|-
|[[Medicine:Post-traumatic stress disorder|PTSD]] || 39.2 || 29.5 || 47.2
|-
|[[Medicine:Generalized anxiety disorder|Generalized anxiety disorder]] || 35.1 || 27.3 || 41.6
|-
|Obsessive-compulsive disorder** || 15.6 || --- || ---
|-
! Substance use disorders !! 72.9 !! 80.9 !! 66.2
|-
|Any alcohol use disorder || 57.3 || 71.2 || 45.6
|-
|Any [[Medicine:Substance use disorder|substance use disorder]] || 36.2 || 44.0 || 29.8
|-
!Eating disorders** !! 53.0 !! 20.5 !! 62.2
|-
|[[Medicine:Anorexia nervosa|Anorexia nervosa]]** || 20.8 || {{0}}7 * || 25 *
|-
|[[Medicine:Bulimia nervosa|Bulimia nervosa]]** || 25.6 || 10 * || 30 *
|-
|[[Medicine:Eating disorder not otherwise specified|Eating disorder not otherwise specified]]** || 26.1 || 10.8 || 30.4
|-
!Somatoform disorders** !! 10.3 !! 10 * !! 10 *
|-
|[[Medicine:Somatization disorder|Somatization disorder]]** || {{0}}4.2 || --- || ---
|-
|[[Medicine:Hypochondriasis|Hypochondriasis]]** || {{0}}4.7 || --- || ---
|-
|[[Medicine:Psychogenic pain|Somatoform pain disorder]]** || {{0}}4.2 || --- || ---
|-
!Psychotic disorders** !! {{0}}1.3 !! {{0}}1 * !! {{0}}1 *
|-
| Colspan="4" | * Approximate values <br />** Values from 1998 study<ref name = comorbidity /><br>--- Value not provided by study
|}
A 2008 study found that at some point in their lives, 75% of people with BPD meet criteria for mood disorders, especially major depression and [[Medicine:Bipolar I disorder|bipolar I]], and nearly 75% meet criteria for an anxiety disorder.<ref name="Grant et al 2008">{{cite journal | vauthors = Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ | title = Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions | journal = The Journal of Clinical Psychiatry | volume = 69 | issue = 4 | pages = 533–545 | date = April 2008 | pmid = 18426259 | pmc = 2676679 | doi = 10.4088/JCP.v69n0404 }}</ref> Nearly 73% meet the criteria for a substance use disorder, and about 40% for PTSD.<ref name="Grant et al 2008"/> It is noteworthy that less than half of the participants with BPD in this study presented with PTSD, a prevalence similar to that reported in an earlier study.<ref name=comorbidity /> The finding that less than half of patients with BPD experience PTSD during their lives challenges the theory that BPD and PTSD are the same disorder.<ref name=comorbidity />

There are marked sex differences in the types of comorbid conditions a person with BPD is likely to have<ref name=comorbidity /> – a higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.<ref name = comorbidity /><ref name="Grant et al 2008"/><ref>{{cite web | vauthors = Gregory RJ | date = November 2006 |url=http://www.psychiatrictimes.com/articles/clinical-challenges-co-occurring-borderline-personality-and-substance-use-disorders |title=Clinical Challenges in Co-occurring Borderline Personality and Substance Use Disorders |work=Psychiatric Times |url-status=live |archive-url=https://web.archive.org/web/20130921063228/http://www.psychiatrictimes.com/articles/clinical-challenges-co-occurring-borderline-personality-and-substance-use-disorders |archive-date=21 September 2013 }}</ref> In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD.<ref name="PM"/> In another study, 6 of 41 participants (15%) met the criteria for an [[Medicine:Autism spectrum|autism spectrum]] disorder (a subgroup that had significantly more frequent suicide attempts).<ref name="Ryden2008">{{cite journal| volume = 5| issue = 1| pages = 22–30| vauthors = Rydén G, Rydén E, Hetta J | title = Borderline personality disorder and autism spectrum disorder in females: A cross-sectional study| journal = Clinical Neuropsychiatry| access-date = 7 February 2013| year = 2008| url = http://www.clinicalneuropsychiatry.org/pdf/04_ryden_hetta.pdf| url-status = dead| archive-url = https://web.archive.org/web/20130921055225/http://www.clinicalneuropsychiatry.org/pdf/04_ryden_hetta.pdf| archive-date = 21 September 2013| df = dmy-all}}</ref>

Regardless that it is an infradiagnosed disorder, a few studies have shown that the "lower expressions" of it might lead to wrong diagnoses. The many and shifting Axis I disorders in people with BPD can sometimes cause clinicians to miss the presence of the underlying personality disorder. However, since a complex pattern of Axis I diagnoses has been found to strongly predict the presence of BPD, clinicians can use the feature of a complex pattern of comorbidity as a clue that BPD might be present.<ref name=comorbidity />

=====Mood disorders=====
Many people with borderline personality disorder also have mood disorders, such as major depressive disorder or a bipolar disorder.<ref name="Robinson"/> Some characteristics of BPD are similar to those of mood disorders, which can complicate the diagnosis.<ref>{{cite journal | vauthors = Bolton S, Gunderson JG | title = Distinguishing borderline personality disorder from bipolar disorder: differential diagnosis and implications | journal = The American Journal of Psychiatry | volume = 153 | issue = 9 | pages = 1202–1207 | date = September 1996 | pmid = 8780426 | doi = 10.1176/ajp.153.9.1202 }}</ref><ref name="APAguide">{{cite journal | author = American Psychiatric Association Practice Guidelines | s2cid = 20392111 | title = Practice guideline for the treatment of patients with borderline personality disorder. American Psychiatric Association | journal = The American Journal of Psychiatry | volume = 158 | issue = 10 Suppl | pages = 1–52 | date = October 2001 | pmid = 11665545 | doi = 10.1176/appi.ajp.158.1.1 }}</ref><ref>{{cite web |url= http://www.borderlinepersonalitytoday.com/main/diffdx.htm |archive-url= https://web.archive.org/web/20040509181831/http://www.borderlinepersonalitytoday.com/main/diffdx.htm |url-status=dead |archive-date=2004-05-09 |title=Differential Diagnosis of Borderline Personality Disorder |work=BPD Today }}</ref> It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa.<ref name=Chapman_87>{{harvnb|Chapman|Gratz|2007|page=87}}</ref> For someone with bipolar disorder, behavior suggestive of BPD might appear while experiencing an episode of major depression or [[Medicine:Mania|mania]], only to disappear once mood has stabilized.<ref name = BPD_vs_BD /> For this reason, it is ideal to wait until mood has stabilized before attempting to make a diagnosis.<ref name = BPD_vs_BD />

At face value, the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar.<ref>{{cite journal | vauthors = Mackinnon DF, Pies R | title = Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders | journal = Bipolar Disorders | volume = 8 | issue = 1 | pages = 1–14 | date = February 2006 | pmid = 16411976 | doi = 10.1111/j.1399-5618.2006.00283.x }}</ref> It can be difficult even for experienced clinicians, if they are unfamiliar with BPD, to differentiate between the mood swings of these two conditions.<ref name=Chapman_88>{{harvnb|Chapman|Gratz|2007|page=88}}</ref> However, there are some clear differences.<ref name=Chapman_87 />

First, the mood swings of BPD and bipolar disorder tend to have different durations. In some people with bipolar disorder, episodes of depression or mania last for at least two weeks at a time, which is much longer than moods last in people with BPD.<ref name=Chapman_87 /> Even among those who experience bipolar disorder with more rapid mood shifts, their moods usually last for days, while the moods of people with BPD can change in minutes or hours.<ref name=Chapman_88/> So while euphoria and impulsivity in someone with BPD might resemble a manic episode, the experience would be too brief to qualify as a manic episode.<ref name = BPD_vs_BD /><ref name=Chapman_88/>

Second, the moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD do respond to changes in the environment.<ref name="BPD_vs_BD">{{cite book | vauthors = Jamison KR, Goodwin FJ |title=Manic-depressive illness |publisher=Oxford University Press |location=Oxford |year=1990 |page=[https://archive.org/details/manicdepressivei00good/page/108 108] |isbn=978-0-19-503934-4 |url=https://archive.org/details/manicdepressivei00good/page/108 }}</ref> That is, a positive event would not lift the depressed mood caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD. Similarly, an undesirable event would not dampen the euphoria caused by bipolar disorder, but an undesirable event would dampen the euphoria of someone with borderline personality disorder.<ref name = BPD_vs_BD />

Third, when people with BPD experience euphoria, it is usually without the racing thoughts and decreased need for sleep that are typical of [[Medicine:Hypomania|hypomania]],<ref name = BPD_vs_BD /> though a later 2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were associated with chronic sleep disturbances, including difficulty initiating sleep, difficulty maintaining sleep, and waking earlier than desired, as well as with the consequences of poor sleep, and noted that "[f]ew studies have examined the experience of chronic sleep disturbances in those with borderline personality disorder".<ref>{{cite journal | vauthors = Selby EA | title = Chronic sleep disturbances and borderline personality disorder symptoms | journal = Journal of Consulting and Clinical Psychology | volume = 81 | issue = 5 | pages = 941–947 | date = October 2013 | pmid = 23731205 | pmc = 4129646 | doi = 10.1037/a0033201 }}</ref>

Because the two conditions have a number of similar symptoms, BPD was once considered to be a mild form of bipolar disorder<ref>{{cite journal | vauthors = Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H | title = The nosologic status of borderline personality: clinical and polysomnographic study | journal = The American Journal of Psychiatry | volume = 142 | issue = 2 | pages = 192–198 | date = February 1985 | pmid = 3970243 | doi = 10.1176/ajp.142.2.192 }}</ref><ref>{{cite journal | vauthors = Gunderson JG, Elliott GR | title = The interface between borderline personality disorder and affective disorder | journal = The American Journal of Psychiatry | volume = 142 | issue = 3 | pages = 277–788 | date = March 1985 | pmid = 2857532 | doi = 10.1176/ajp.142.3.277 }}</ref> or to exist on the bipolar spectrum. However, this would require that the underlying mechanism causing these symptoms be the same for both conditions. Differences in phenomenology, family history, longitudinal course, and responses to treatment suggest that this is not the case.<ref>{{cite journal | vauthors = Paris J | title = Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders | journal = Harvard Review of Psychiatry | volume = 12 | issue = 3 | pages = 140–145 | year = 2004 | pmid = 15371068 | doi = 10.1080/10673220490472373 | s2cid = 39354034 }}</ref> Researchers have found "only a modest association" between bipolar disorder and borderline personality disorder, with "a strong spectrum relationship with [BPD and] bipolar disorder extremely unlikely".<ref>{{cite book | vauthors = Jamison KR, Goodwin FJ  |title=Manic-depressive illness |publisher=Oxford University Press |location=Oxford |year=1990 |page=[https://archive.org/details/manicdepressivei00good/page/336 336] |isbn=978-0-19-503934-4 |url=https://archive.org/details/manicdepressivei00good/page/336 }}</ref> Benazzi et al. suggest that the DSM-IV BPD diagnosis combines two unrelated characteristics: an affective instability dimension related to bipolar II and an impulsivity dimension not related to bipolar II.<ref>{{cite journal | vauthors = Benazzi F | title = Borderline personality-bipolar spectrum relationship | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 30 | issue = 1 | pages = 68–74 | date = January 2006 | pmid = 16019119 | doi = 10.1016/j.pnpbp.2005.06.010 | s2cid = 1358610 }}</ref>

=====Premenstrual dysphoric disorder=====
Premenstrual dysphoric disorder (PMDD) occurs in 3–8% of women.<ref name="Rapkin">{{cite journal | vauthors = Rapkin AJ, Lewis EI | title = Treatment of premenstrual dysphoric disorder | journal = Women's Health | volume = 9 | issue = 6 | pages = 537–56 | date = November 2013 | pmid = 24161307 | doi = 10.2217/whe.13.62 | doi-access = free }}</ref> Symptoms begin during the luteal phase of the menstrual cycle, and end during menstruation.<ref>{{cite journal | vauthors = Rapkin AJ, Berman SM, London ED | title = The Cerebellum and Premenstrual Dysphoric Disorder | journal = AIMS Neuroscience | volume = 1 | issue = 2 | pages = 120–141 | date = 2014 | pmid = 28275721 | pmc = 5338637 | doi = 10.3934/Neuroscience.2014.2.120 }}</ref> Symptoms may include marked mood swings, irritability, depressed mood, feeling hopeless or suicidal, a subjective sense of being overwhelmed or out of control, anxiety, binge eating, difficulty concentrating, and substantial impairment of interpersonal relationships.<ref name="Grady-Weliky">{{cite journal | vauthors = Grady-Weliky TA | title = Clinical practice. Premenstrual dysphoric disorder | journal = The New England Journal of Medicine | volume = 348 | issue = 5 | pages = 433–8 | date = January 2003 | pmid = 12556546 | doi = 10.1056/NEJMcp012067 }}</ref><ref>{{cite web| vauthors = Steriti R |title=Premenstrual Dysphoric Disorder |url=http://www.integrativepractitioner.com/assets/0/19886/1ec99e2b-735b-425d-a56f-4eddc84e05cc.pdf |url-status=dead |archive-url=https://web.archive.org/web/20141020191624/http://www.integrativepractitioner.com/assets/0/19886/1ec99e2b-735b-425d-a56f-4eddc84e05cc.pdf |archive-date=20 October 2014 }}</ref> People with PMDD typically begin to experience symptoms in their early twenties, although many do not seek treatment until their early thirties.<ref name="Grady-Weliky" />

Although some of the symptoms of PMDD and BPD are similar, they are different disorders. They are distinguishable by the timing and duration of symptoms, which are markedly different: the symptoms of PMDD occur only during the luteal phase of the [[Medicine:Menstrual cycle|menstrual cycle]],<ref name = Grady-Weliky /> whereas BPD symptoms occur persistently at all stages of the menstrual cycle. In addition, the symptoms of PMDD do not include impulsivity.<ref name="Grady-Weliky" />

====Comorbid Axis II disorders====
{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
|-
|+Percentage of people with BPD and a lifetime comorbid Axis II diagnosis, 2008<ref name="Grant et al 2008"/>
|-
! Axis II diagnosis !! Overall (%) !! Male (%) !! Female (%)
|-
! Any cluster A !! 50.4 !! 49.5 !! 51.1
|-
| Paranoid || 21.3  || 16.5 || 25.4
|-
| Schizoid || 12.4 || 11.1 || 13.5
|-
| Schizotypal || 36.7 || 38.9 || 34.9
|-
! Any other cluster B !! 49.2 !! 57.8 !! 42.1
|-
| Antisocial || 13.7  || 19.4 || 9.0
|-
| Histrionic || 10.3 || 10.3 || 10.3
|-
| Narcissistic || 38.9 || 47.0 || 32.2
|-
! Any cluster C !! 29.9 !! 27.0  !! 32.3
|-
| Avoidant || 13.4 || 10.8 || 15.6
|-
| Dependent || 3.1 || 2.6 || 3.5
|-
| Obsessive-compulsive || 22.7 || 21.7 || 23.6
|-
|}
About three-fourths of people diagnosed with BPD also meet the criteria for another Axis II personality disorder at some point in their lives. (In a major 2008 study – see adjacent table – the rate was 73.9%.)<ref name="Grant et al 2008"/> The Cluster A disorders, paranoid, schizoid, and schizotypal, are broadly the most common. The Cluster as a whole affects about half, with schizotypal alone affecting one third.<ref name="Grant et al 2008"/>

BPD is itself a Cluster B disorder. The other Cluster B disorders, antisocial, histrionic, and [[Medicine:Narcissistic personality disorder|narcissistic]], similarly affect about half of BPD patients (lifetime incidence), with again narcissistic affecting one third or more.<ref name="Grant et al 2008"/> Cluster C, avoidant, dependent, and obsessive-compulsive, showed the least overlap, slightly under one third.<ref name="Grant et al 2008"/>

==Management==
{{Main|Medicine:Management of borderline personality disorder}}
[[Medicine:Psychotherapy|Psychotherapy]] is the primary treatment for borderline personality disorder.<ref name =Lei2011/> Treatments should be based on the needs of the individual, rather than upon the general diagnosis of BPD. Medications are useful for treating comorbid disorders, such as depression and anxiety.<ref>{{cite web |url=http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English |title=CG78 Borderline personality disorder (BPD): NICE guideline |publisher=Nice.org.uk |date=28 January 2009 |access-date=12 August 2009 |url-status=live |archive-url=https://web.archive.org/web/20090411104754/http://www.nice.org.uk/Guidance/CG78/NiceGuidance/pdf/English |archive-date=11 April 2009 }}</ref> Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD.<ref>{{cite journal | vauthors = Paris J | s2cid = 28921269 | title = Is hospitalization useful for suicidal patients with borderline personality disorder? | journal = Journal of Personality Disorders | volume = 18 | issue = 3 | pages = 240–247 | date = June 2004 | pmid = 15237044 | doi = 10.1521/pedi.18.3.240.35443 }}</ref>

===Psychotherapy===
Long-term psychotherapy is currently the treatment of choice for BPD.<ref name="BPD_therapies">{{cite journal | vauthors = Zanarini MC | title = Psychotherapy of borderline personality disorder | journal = Acta Psychiatrica Scandinavica | volume = 120 | issue = 5 | pages = 373–377 | date = November 2009 | pmid = 19807718 | pmc = 3876885 | doi = 10.1111/j.1600-0447.2009.01448.x }}</ref> While psychotherapy, in particular dialectical behavior therapy and psychodynamic approaches, is effective, the effects are slow: many people have to put in years of work to be effective.<ref>{{cite journal | vauthors = Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P | title = Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis | journal = JAMA Psychiatry | volume = 74 | issue = 4 | pages = 319–328 | date = April 2017 | pmid = 28249086 | doi = 10.1001/jamapsychiatry.2016.4287 | hdl = 1871.1/845f5460-273e-4150-b79d-159f37aa36a0 | s2cid = 30118081 | url = https://research.vu.nl/en/publications/845f5460-273e-4150-b79d-159f37aa36a0 | access-date = 12 December 2019 | archive-date = 4 December 2020 | archive-url = https://web.archive.org/web/20201204232025/https://research.vu.nl/en/publications/efficacy-of-psychotherapy-for-borderline-personality-disorder-a-s | url-status = live }}</ref>

More rigorous treatments are not substantially better than less rigorous treatments.<ref name="LinksShah2017">{{cite journal | vauthors = Links PS, Shah R, Eynan R | title = Psychotherapy for Borderline Personality Disorder: Progress and Remaining Challenges | journal = Current Psychiatry Reports | volume = 19 | issue = 3 | page = 16 | date = March 2017 | pmid = 28271272 | doi = 10.1007/s11920-017-0766-x | s2cid = 1076175 }}</ref> There are six such treatments available: [[Medicine:Dynamic deconstructive psychotherapy|dynamic deconstructive psychotherapy (DDP)]],<ref>{{cite book | vauthors = Gabbard GO | date = 2014 | title = Psychodynamic psychiatry in clinical practice | edition = 5th | publisher = American Psychiatric Publishing | location = Washington, D.C. | pages = 445–448 }}</ref> [[Social:Mentalization-based treatment|mentalization-based treatment (MBT)]], [[Medicine:Transference focused psychotherapy|transference-focused psychotherapy]], dialectical behavior therapy (DBT), general psychiatric management, and [[Medicine:Schema therapy|schema-focused therapy]].<ref name="Gund2011" /><ref>{{cite journal | vauthors = Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT | title = What Works in the Treatment of Borderline Personality Disorder | journal = Current Behavioral Neuroscience Reports | volume = 4 | issue = 1 | pages = 21–30 | date = 2017 | pmid = 28331780 | pmc = 5340835 | doi = 10.1007/s40473-017-0103-z }}</ref> Long-term therapy of any kind is better than no treatment, especially in reducing urges to self-injure.<ref name="BPD_therapies" />

Transference-focused therapy aims to break away from absolute thinking. In this, it gets the people to articulate their social interpretations and their emotions in order to turn their views into less rigid categories. The therapist addresses the individual's feelings and goes over situations, real or realistic, that could happen as well as how to approach them.<ref name=":1">{{cite journal| vauthors = Bliss S, McCardle M |date=2014-03-01|title=An Exploration of Common Elements in Dialectical Behavior Therapy, Mentalization Based Treatment and Transference Focused Psychotherapy in the Treatment of Borderline Personality Disorder|journal=Clinical Social Work Journal|volume=42|issue=1|pages=61–69|doi=10.1007/s10615-013-0456-z|s2cid=145079695|issn=0091-1674}}</ref>

Dialectical behavior therapy (DBT) has similar components to CBT, adding in practices such as meditation. In doing this, it helps the individual with BPD gain skills to manage symptoms. These skills include emotion regulation, mindfulness, and stress hardiness.<ref name=":1" /> Since those diagnosed with BPD have such intense emotions, learning to regulate them is a huge step in the therapeutic process. Some components of DBT are working long-term with patients, building skills to understand and regulate emotions, homework assignments, and strong availability of therapist to their client.<ref>{{cite book | vauthors = Livesley WJ | chapter = Understanding Borderline Personality Disorder | title = Integrated Modular Treatment for Borderline Personality Disorder|year=2017|pages=29–38|place=Cambridge|publisher=Cambridge University Press|doi=10.1017/9781107298613.004|isbn=978-1-107-29861-3}}</ref> Patients with borderline personality disorder also must take time in DBT to work with their therapist to learn how to get through situations surrounded by intense emotions or stress as well as learning how to better their interpersonal relationships. 
[[File:Dialectical Behavior Therapy Cycle EN.jpg|thumb|right|The stages used in dialectical behavior therapy]]

[[Medicine:Cognitive behavioral therapy|Cognitive behavioral therapy]] (CBT) is also a type of psychotherapy used for treatment of BPD. This type of therapy relies on changing people's behaviors and beliefs by identifying problems from the disorder. CBT is known to reduce some anxiety and mood symptoms as well as reduce suicidal thoughts and self-harming behaviors.<ref name=NIH2016/>

Mentalization-based therapy and transference-focused psychotherapy are based on psychodynamic principles, and dialectical behavior therapy is based on cognitive-behavioral principles and mindfulness.<ref name=BPD_therapies/> General psychiatric management combines the core principles from each of these treatments, and it is considered easier to learn and less intensive.<ref name=Gund2011/> Randomized controlled trials have shown that DBT and MBT may be the most effective, and the two share many similarities.<ref name="DBT_vs_therapyByExperts">{{cite journal | vauthors = Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N | title = Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder | journal = Archives of General Psychiatry | volume = 63 | issue = 7 | pages = 757–766 | date = July 2006 | pmid = 16818865 | doi = 10.1001/archpsyc.63.7.757 | doi-access = free }}</ref><ref name="DBT_and_Mentalization">{{cite journal | vauthors = Paris J | title = Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder | journal = Current Psychiatry Reports | volume = 12 | issue = 1 | pages = 56–60 | date = February 2010 | pmid = 20425311 | doi = 10.1007/s11920-009-0083-0 | s2cid = 19038884 }}</ref> Researchers are interested in developing shorter versions of these therapies to increase accessibility, to relieve the financial burden on patients, and to relieve the resource burden on treatment providers.<ref name=BPD_therapies/><ref name=DBT_and_Mentalization/>

Some research indicates that mindfulness meditation may bring about favorable structural changes in the brain, including changes in brain structures that are associated with BPD.<ref name="Mindfulness_neuroscience">{{cite journal | vauthors = Tang YY, Posner MI | title = Special issue on mindfulness neuroscience | journal = Social Cognitive and Affective Neuroscience | volume = 8 | issue = 1 | pages = 1–3 | date = January 2013 | pmid = 22956677 | pmc = 3541496 | doi = 10.1093/scan/nss104 }}</ref><ref name="Mindfulness_mechanisms">{{cite journal | vauthors = Posner MI, Tang YY, Lynch G | title = Mechanisms of white matter change induced by meditation training | journal = Frontiers in Psychology | volume = 5 | issue = 1220 | page = 1220 | date = 2014 | pmid = 25386155 | pmc = 4209813 | doi = 10.3389/fpsyg.2014.01220 | doi-access = free }}</ref><ref name="Mindfulness_therapies">{{cite journal | vauthors = Chafos VH, Economou P | s2cid = 14256504 | title = Beyond borderline personality disorder: the mindful brain | journal = Social Work | volume = 59 | issue = 4 | pages = 297–302 | date = October 2014 | pmid = 25365830 | doi = 10.1093/sw/swu030 }}</ref> Mindfulness-based interventions also appear to bring about an improvement in symptoms characteristic of BPD, and some clients who underwent mindfulness-based treatment no longer met a minimum of five of the DSM-IV-TR diagnostic criteria for BPD.<ref name="Mindfulness_therapies" /><ref name="Mindfulness_BPD">{{cite journal | vauthors = Sachse S, Keville S, Feigenbaum J | title = A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder | journal = Psychology and Psychotherapy | volume = 84 | issue = 2 | pages = 184–200 | date = June 2011 | pmid = 22903856 | doi = 10.1348/147608310X516387 }}</ref>

===Medications===
A 2010 review by the Cochrane collaboration found that no medications show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance, and abandonment". However, the authors found that some medications may impact isolated symptoms associated with BPD or the symptoms of comorbid conditions.<ref name="Stoffers">{{cite journal | vauthors = Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K | title = Pharmacological interventions for borderline personality disorder | journal = The Cochrane Database of Systematic Reviews | issue = 6 | page = CD005653 | date = June 2010 | pmid = 20556762 | pmc = 4169794 | doi = 10.1002/14651858.CD005653.pub2 }}</ref> A 2017 review examined evidence published since the 2010 Cochrane review and found that "evidence of effectiveness of medication for BPD remains very mixed and is still highly compromised by suboptimal study design".<ref name="Drugs2017rev">{{cite journal | vauthors = Hancock-Johnson E, Griffiths C, Picchioni M | title = A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder | journal = CNS Drugs | volume = 31 | issue = 5 | pages = 345–356 | date = May 2017 | pmid = 28353141 | doi = 10.1007/s40263-017-0425-0 | s2cid = 207486732 }}</ref> A 2020 review found that research into pharmacological treatments had declined, with more results confirming no benefits. Despite lack of evidence of benefit, quetiapine and SSRI antidepressants continue to be widely prescribed to people with BPD.<ref name=stofferswinterling20>{{cite journal |vauthors=Stoffers-Winterling J, Storebø OJ, Lieb K |title=Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies |journal=Current Psychiatry Reports |date=2020 |volume=22 |issue=37 |page=37 |doi=10.1007/s11920-020-01164-1 |pmid=32504127 |pmc=7275094 |url=https://link.springer.com/content/pdf/10.1007/s11920-020-01164-1.pdf}}</ref>

Of the [[Chemistry:Typical antipsychotic|typical antipsychotic]]s studied in relation to BPD, [[Chemistry:Haloperidol|haloperidol]] may reduce anger and flupenthixol may reduce the likelihood of suicidal behavior. Among the [[Chemistry:Atypical antipsychotic|atypical antipsychotic]]s, one trial found that [[Chemistry:Aripiprazole|aripiprazole]] may reduce interpersonal problems and impulsivity.<ref name=Stoffers/> [[Chemistry:Olanzapine|Olanzapine]], as well as [[Chemistry:Quetiapine|quetiapine]], may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but a [[Medicine:Placebo|placebo]] had a greater benefit on suicidal ideation than olanzapine did. The effect of [[Chemistry:Ziprasidone|ziprasidone]] was not significant.<ref name=Stoffers/><ref name=Drugs2017rev/>

Of the mood stabilizers studied, valproate semisodium may ameliorate depression, impulsivity, interpersonal problems, and anger. [[Biology:Topiramate|Topiramate]] may ameliorate interpersonal problems, impulsivity, anxiety, anger, and general psychiatric pathology. The effect of [[Chemistry:Carbamazepine|carbamazepine]] was not significant. Of the [[Chemistry:Antidepressant|antidepressant]]s, [[Chemistry:Amitriptyline|amitriptyline]] may reduce depression, but [[Chemistry:Mianserin|mianserin]], [[Chemistry:Fluoxetine|fluoxetine]], [[Chemistry:Fluvoxamine|fluvoxamine]], and [[Biology:Phenelzine|phenelzine]] sulfate showed no effect. [[Chemistry:Omega-3 fatty acid|Omega-3 fatty acid]] may ameliorate suicidality and improve depression. {{as of|2017}}, trials with these medications had not been replicated and the effect of long-term use had not been assessed.<ref name=Stoffers/><ref name=Drugs2017rev/> [[Chemistry:Lamotrigine|Lamotrigine]] showed no benefit in a large randomized clinical trial.<ref name=stofferswinterling20/>

Because of weak evidence and the potential for serious side effects from some of these medications, the United Kingdom (UK) National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends, "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behavior associated with the disorder." However, "drug treatment may be considered in the overall treatment of comorbid conditions". They suggest a "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment".<ref>{{cite web|url=http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|publisher=UK National Institute for Health and Clinical Excellence (NICE) |title=2009 clinical guideline for the treatment and management of BPD|access-date=6 September 2011|url-status=dead|archive-url=https://web.archive.org/web/20120618094650/http://www.nice.org.uk/nicemedia/live/12125/42900/42900.pdf|archive-date=18 June 2012}}</ref>

===Services===
There is a significant difference between the number of those who would benefit from treatment and the number of those who are treated. The so-called "treatment gap" is a function of the disinclination of the afflicted to submit for treatment, an underdiagnosing of the disorder by healthcare providers, and the limited availability and access to state-of-the-art treatments.<ref name="BPD Article">{{cite news| vauthors = Johnson RS |title=Treatment of Borderline Personality Disorder|url=http://bpdfamily.com/content/treatment-borderline-personality-disorder|publisher=[[Organization:BPDFamily.com|BPDFamily.com]]|date=26 July 2014|access-date=5 August 2014|url-status=live|archive-url=https://web.archive.org/web/20140714183908/http://bpdfamily.com/content/treatment-borderline-personality-disorder|archive-date=14 July 2014}}</ref> Nonetheless, individuals with BPD accounted for about 20% of psychiatric hospitalizations in one survey.<ref>{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J | title = Treatment histories of borderline inpatients | journal = Comprehensive Psychiatry | volume = 42 | issue = 2 | pages = 144–150 | year = 2001 | pmid = 11244151 | doi = 10.1053/comp.2001.19749 }}</ref> The majority of individuals with BPD who are in treatment continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.<ref>{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Hennen J, Silk KR | title = Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years | journal = The Journal of Clinical Psychiatry | volume = 65 | issue = 1 | pages = 28–36 | date = January 2004 | pmid = 14744165 | doi = 10.4088/JCP.v65n0105 }}</ref>

Experience of services varies.<ref>{{cite journal | vauthors = Fallon P | title = Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services | journal = Journal of Psychiatric and Mental Health Nursing | volume = 10 | issue = 4 | pages = 393–401 | date = August 2003 | pmid = 12887630 | doi = 10.1046/j.1365-2850.2003.00617.x }}</ref> Assessing suicide risk can be a challenge for clinicians, and patients themselves tend to underestimate the lethality of self-injurious behaviors. People with BPD typically have a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.<ref>{{cite web | vauthors = Links PS, Bergmans Y, Warwar SH |date=1 July 2004 |url=http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder |title=Assessing Suicide Risk in Patients With Borderline Personality Disorder |work=Psychiatric Times |url-status=live |archive-url=https://web.archive.org/web/20130821210809/http://www.psychiatrictimes.com/articles/assessing-suicide-risk-patients-borderline-personality-disorder |archive-date=21 August 2013 }}</ref> Approximately half the individuals who commit suicide meet criteria for a personality disorder. Borderline personality disorder remains the most commonly associated personality disorder with suicide.<ref>{{cite journal | vauthors = Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M | title = Borderline personality disorder | journal = Lancet | volume = 364 | issue = 9432 | pages = 453–461 | year = 2004 | pmid = 15288745 | doi = 10.1016/S0140-6736(04)16770-6 | s2cid = 54280127 }}</ref>

After a patient suffering from BPD died, The National Health Service (NHS) in England was criticized by a coroner in 2014 for the lack of commissioned services to support those with BPD. Evidence was given that 45% of female patients had BPD and there was no provision or priority for therapeutic psychological services. At the time, there were only a total of 60 specialized inpatient beds in England, all of them located in London or the northeast region.<ref>{{cite news|title=National leaders warned over lack of services for personality disorders|url=https://www.hsj.co.uk/mersey-care-nhs-trust/national-leaders-warned-over-lack-of-services-for-personality-disorders/7020669.article|access-date=22 December 2017|publisher=Health Service Journal|date=29 September 2017|archive-date=23 December 2017|archive-url=https://web.archive.org/web/20171223102152/https://www.hsj.co.uk/mersey-care-nhs-trust/national-leaders-warned-over-lack-of-services-for-personality-disorders/7020669.article|url-status=live}}{{subscription required|s}}</ref>

==Prognosis==
With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years.<ref name="longitudinal_remission">{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Hennen J, Silk KR | title = The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder | journal = The American Journal of Psychiatry | volume = 160 | issue = 2 | pages = 274–283 | date = February 2003 | pmid = 12562573 | doi = 10.1176/appi.ajp.160.2.274 }}</ref><ref name=PToverview/> A [[Social:Longitudinal study|longitudinal study]] tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission.<ref name=longitudinal_remission /> Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained a stable recovery from symptoms.<ref name="Treatment">{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G | title = Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study | journal = The American Journal of Psychiatry | volume = 167 | issue = 6 | pages = 663–667 | date = June 2010 | pmid = 20395399 | pmc = 3203735 | doi = 10.1176/appi.ajp.2009.09081130 | url = http://www.mclean.harvard.edu/news/press/current.php?kw=long-term-study-borderline-personality-disorder-shows-importance-measuring&id=153 | lay-url = http://www.mclean.harvard.edu/news/press/current.php?kw=long-term-study-borderline-personality-disorder-shows-importance-measuring&id=153 | lay-date = 15 April 2010 | lay-source = McLean Hospital | access-date = 5 February 2013 | archive-date = 8 June 2013 | archive-url = https://web.archive.org/web/20130608092738/http://www.mclean.harvard.edu/news/press/current.php?kw=long-term-study-borderline-personality-disorder-shows-importance-measuring&id=153 | url-status = live }}</ref>

Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing dialectical behavior therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient, compared to patients either low in agreeableness or not being treated with DBT. This association was mediated through the strength of a working alliance between patient and therapist; that is, more agreeable patients developed stronger working alliances with their therapists, which in turn, led to better clinical outcomes.<ref>{{cite journal | vauthors = Hirsh JB, Quilty LC, Bagby RM, McMain SF | s2cid = 33621688 | title = The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder | journal = Journal of Personality Disorders | volume = 26 | issue = 4 | pages = 616–627 | date = August 2012 | pmid = 22867511 | doi = 10.1521/pedi.2012.26.4.616 }}</ref>

In addition to recovering from distressing symptoms, people with BPD also achieve high levels of [[Social:Psychosocial|psychosocial]] functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall.<ref>{{cite journal | vauthors = Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR | title = Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years | journal = Journal of Personality Disorders | volume = 19 | issue = 1 | pages = 19–29 | date = February 2005 | pmid = 15899718 | doi = 10.1521/pedi.19.1.19.62178 }}</ref>

==Epidemiology==
The [[Prevalence|prevalence]] of BPD was estimated in the mid-2000s to be 1–2% of the general population<ref name=PToverview/> and to occur three times more often in women than in men.<ref>{{cite journal | vauthors = Skodol AE, Bender DS | title = Why are women diagnosed borderline more than men? | journal = The Psychiatric Quarterly | volume = 74 | issue = 4 | pages = 349–360 | year = 2003 | pmid = 14686459 | doi = 10.1023/A:1026087410516 | s2cid = 207630240 }}</ref><ref>{{cite journal | vauthors = Korzekwa MI, Dell PF, Links PS, Thabane L, Webb SP | title = Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure | journal = Comprehensive Psychiatry | volume = 49 | issue = 4 | pages = 380–386 | year = 2008 | pmid = 18555059 | doi = 10.1016/j.comppsych.2008.01.007 }}</ref> However, the lifetime prevalence of BPD, as defined in the DSM-IV, in a 2008 study was found to be 5.9% of the American population, occurring in 5.6% of men and 6.2% of women.<ref name="Grant et al 2008"/> The difference in rates between men and women in this study was not found to be statistically significant.<ref name="Grant et al 2008"/>

Borderline personality disorder is estimated to contribute to 20% of psychiatric hospitalizations and to occur among 10% of outpatients.<ref name="BPD_fact_sheet">{{cite web |publisher=National Educational Alliance for Borderline Personality Disorder |title=BPD Fact Sheet |url=http://www.borderlinepersonalitydisorder.com/understading-bpd/bpd-fact-sheet/ |year=2013 |url-status=live |archive-url=https://web.archive.org/web/20130104231941/http://www.borderlinepersonalitydisorder.com/understading-bpd/bpd-fact-sheet/ |archive-date=4 January 2013 }}</ref>

29.5% of new inmates in the U.S. state of Iowa fit a diagnosis of borderline personality disorder in 2007,<ref>{{cite journal | vauthors = Black DW, Gunter T, Allen J, Blum N, Arndt S, Wenman G, Sieleni B | title = Borderline personality disorder in male and female offenders newly committed to prison | journal = Comprehensive Psychiatry | volume = 48 | issue = 5 | pages = 400–405 | year = 2007 | pmid = 17707246 | doi = 10.1016/j.comppsych.2007.04.006 }}</ref> and the overall prevalence of BPD in the U.S. prison population is thought to be 17%.<ref name=BPD_fact_sheet /> These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD, which is estimated at 38%.<ref name = BPD_fact_sheet/>

==History==
[[File:Edvard Munch - Salomé.jpg|thumb|Devaluation in Edvard Munch's ''Salome'' (1903). Idealization and devaluation of others in personal relations is a common trait in BPD. The painter Edvard Munch depicted his new friend, the violinist Eva Mudocci, in both ways within days. First as "a woman seen by a man in love", then as "a bloodthirsty and cannibalistic Salome".<ref name="Ed1990">{{cite book|title=Edvard Munch : the life of a person with borderline personality as seen through his art|date=1990|publisher=Lundbeck Pharma A/S|location=[Danmark]|isbn=978-8798352419|pages=34–35}}</ref> In modern times, Munch has been diagnosed as having had BPD.<ref>{{cite book |  vauthors = Masterson JF | title = Search For The Real Self. Unmasking The Personality Disorders Of Our Age | chapter = Chapter 12: The Creative Solution: Sartre, Munch, and Wolfe | pages = 208–230, especially 212–213 | publisher = Simon and Schuster | location = New York | date = 1988 | isbn = 978-1-4516-6891-9}}</ref><ref>{{cite book | vauthors = Aarkrog T | title = Edvard Munch: the life of a person with borderline personality as seen through his art | publisher = Lundbeck Pharma A/S | location = Denmark | year = 1990 | isbn = 978-8798352419 }}</ref>]]
The coexistence of intense, divergent moods within an individual was recognized by [[Biography:Homer|Homer]], [[Biography:Hippocrates|Hippocrates]], and Aretaeus, the latter describing the vacillating presence of impulsive anger, melancholia, and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term ''folie maniaco-mélancolique'',<ref>{{Harvnb|Millon|Grossman|Meagher|2004|p=172}}</ref> described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity".<ref>{{cite journal | vauthors = Hughes CH |year=1884 |title=Borderline psychiatric records – prodromal symptoms of psychical impairments |journal=Alienists & Neurology |volume=5 |pages=85–90 |oclc=773814725 }}</ref> In 1921, [[Biography:Emil Kraepelin|Kraepelin]] identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.<ref name="millon">{{Harvnb|Millon|1996|pp= 645–690}}</ref>

The first significant psychoanalytic work to use the term "borderline" was written by Adolf Stern in 1938.<ref name="stern">{{cite journal | vauthors = Stern A |year= 1938 |title= Psychoanalytic investigation of and therapy in the borderline group of neuroses |journal= Psychoanalytic Quarterly |volume= 7 |issue= 4 |pages= 467–489 |doi= 10.1080/21674086.1938.11925367 }}</ref><ref name="alberto">{{cite journal | vauthors = Stefana A |year= 2015 |title= Adolph Stern, father of term 'borderline personality' |journal= Minerva Psichiatrica |volume= 56 |issue=2 |pages= 95 }}</ref> It described a group of patients suffering from what he thought to be a mild form of schizophrenia, on the ''borderline'' between [[Medicine:Neurosis|neurosis]] and [[Medicine:Psychosis|psychosis]].

The 1960s and 1970s saw a shift from thinking of the condition as [[Medicine:Pseudoneurotic schizophrenia|borderline schizophrenia]] to thinking of it as a borderline affective disorder (mood disorder), on the fringes of bipolar disorder, [[Medicine:Cyclothymia|cyclothymia]], and [[Medicine:Dysthymia|dysthymia]]. In the DSM-II, stressing the intensity and variability of moods, it was called cyclothymic personality (affective personality).<ref name="DSM-IV-TR"/> While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization<ref name="millon"/> between neurosis and psychosis.<ref name="pmid3898174">{{cite journal | vauthors = Aronson TA | title = Historical perspectives on the borderline concept: a review and critique | journal = Psychiatry | volume = 48 | issue = 3 | pages = 209–222 | date = August 1985 | pmid = 3898174 | doi = 10.1080/00332747.1985.11024282 }}</ref>

After standardized criteria were developed<ref>{{cite journal | vauthors = Gunderson JG, Kolb JE, Austin V | title = The diagnostic interview for borderline patients | journal = The American Journal of Psychiatry | volume = 138 | issue = 7 | pages = 896–903 | date = July 1981 | pmid = 7258348 | doi = 10.1176/ajp.138.7.896 }}</ref> to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the [[Medicine:Diagnostic and Statistical Manual of Mental Disorders|DSM-III]].<ref name="PToverview">{{cite web | vauthors = Oldham JM | date = July 2004 |url=http://www.psychiatrictimes.com/articles/borderline-personality-disorder-overview-0 |title=Borderline Personality Disorder: An Overview |work=Psychiatric Times |volume=XXI |issue=8 |url-status=live |archive-url=https://web.archive.org/web/20131021180803/http://www.psychiatrictimes.com/articles/borderline-personality-disorder-overview-0 |archive-date=21 October 2013 }}</ref> The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder".<ref name=pmid3898174/> The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder", which is still in use by the DSM-5 today.<ref name=DSM5/> However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.<ref>{{cite book | vauthors = Stone MH |year=2005 |chapter=Borderline Personality Disorder: History of the Concept | veditors = Zanarini MC |title=Borderline personality disorder |pages=1–18 |publisher=Taylor & Francis |location=Boca Raton, Florida |isbn=978-0-8247-2928-8}}</ref>

===Etymology===
Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories, the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis.<ref>{{cite book | vauthors = Moll T |title=Mental Health Primer |isbn=978-1-72051-057-4 |page=43|date=2018-05-29 }}</ref> The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s.<ref>{{cite book |title=Psychopharmacology Bulletin |date=1966 |publisher=The Clearinghouse |page=555 |url=https://books.google.com/books?id=_kOnSecueiYC&pg=PA555 |access-date=5 June 2020 |archive-date=4 December 2020 |archive-url=https://web.archive.org/web/20201204232024/https://books.google.com/books?id=_kOnSecueiYC&pg=PA555 |url-status=live }}</ref><ref>{{cite journal | vauthors = Spitzer RL, Endicott J, Gibbon M | title = Crossing the border into borderline personality and borderline schizophrenia. The development of criteria | journal = Archives of General Psychiatry | volume = 36 | issue = 1 | pages = 17–24 | date = January 1979 | pmid = 760694 | doi = 10.1001/archpsyc.1979.01780010023001 }}</ref> Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.<ref>Harold Merskey, ''Psychiatric Illness: Diagnosis, Management and Treatment for General Practitioners and Students'', Baillière Tindall (1980), p. 415. "Borderline personality disorder is a very controversial and confusing American term, best avoided..</ref>

==Controversies==

===Credibility and validity of testimony===
The credibility of individuals with personality disorders has been questioned at least since the 1960s.<ref name="Goodwin">{{cite book| vauthors = Goodwin J | veditors = Kluft RP |title=Childhood antecedents of multiple personality|date=1985|publisher=American Psychiatric Press|isbn=978-0-88048-082-6|chapter=Chapter 1: Credibility problems in multiple personality disorder patients and abused children|chapter-url=https://archive.org/details/childhoodanteced00kluf|url-access=registration|url=https://archive.org/details/childhoodanteced00kluf}}</ref>{{rp|2}} Two concerns are the incidence of [[Medicine:Dissociation (psychology)|dissociation episodes]] among people with BPD and the belief that lying is a key component of this condition.

====Dissociation====
Researchers disagree about whether dissociation, or a sense of detachment from emotions and physical experiences, impacts the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of [[Biology:Autobiographical memory|autobiographical memory]] was decreased in BPD patients.<ref name="Startup">{{cite journal | vauthors = Jones B, Heard H, Startup M, Swales M, Williams JM, Jones RS | title = Autobiographical memory and dissociation in borderline personality disorder | journal = Psychological Medicine | volume = 29 | issue = 6 | pages = 1397–1404 | date = November 1999 | pmid = 10616945 | doi = 10.1017/S0033291799001208 | df = dmy-all }}</ref> The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation.<ref name = "Startup" />

====Lying as a feature====
Some theorists argue that patients with BPD often lie.<ref name="Linehan 1993, p.17">{{harvnb|Linehan|1993|page=17}}</ref> However, others write that they have rarely seen lying among patients with BPD in clinical practice.<ref name="Linehan 1993, p.17"/>

===Gender===
Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers.<ref>{{cite journal | vauthors = Nehls N | title = Borderline personality disorder: gender stereotypes, stigma, and limited system of care | journal = Issues in Mental Health Nursing | volume = 19 | issue = 2 | pages = 97–112 | year = 1998 | pmid = 9601307 | doi = 10.1080/016128498249105 }}{{subscription required}}</ref> One camp argues that it would be better to diagnose these men or women with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.<ref>{{cite journal | vauthors = Becker D | title = When she was bad: borderline personality disorder in a posttraumatic age | journal = The American Journal of Orthopsychiatry | volume = 70 | issue = 4 | pages = 422–432 | date = October 2000 | pmid = 11086521 | doi = 10.1037/h0087769 }}</ref> Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see brain abnormalities and terminology).

Joel Paris states that "In the clinic ... Up to 80% of patients are women. That may not be true in the community."<ref>{{cite book | vauthors = Paris J |title=Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice | year=2008 | publisher=The Guilford Press | page=21}}</ref> He offers the following explanations regarding these sex discrepancies:

{{quote|The most probable explanation for gender differences in clinical samples is that women are more likely to develop the kind of symptoms that bring patients in for treatment. Twice as many women as men in the community suffer from depression (Weissman & Klerman, 1985). In contrast, there is a preponderance of men meeting the criteria for substance use disorder and psychopathy (Robins & Regier, 1991), and males with these disorders do not necessarily present in the mental health system. Men and women with similar psychological problems may express distress differently. Men tend to drink more and carry out more crimes. Women tend to turn their anger on themselves, leading to depression as well as the cutting and overdosing that characterize BPD. Thus, anti-social personality disorder (ASPD) and borderline personality disorders might derive from similar underlying pathology but present with symptoms strongly influenced by gender (Paris, 1997a; Looper & Paris, 2000).

We have even more specific evidence that men with BPD may not seek help. In a study of completed suicides among people aged 18 to 35 years (Lesage et al., 1994), 30% of the suicides involved individuals with BPD (as confirmed by psychological autopsy, in which symptoms were assessed by interviews with family members). Most of the suicide completers were men, and very few were in treatment. Similar findings emerged from a later study conducted by our own research group (McGirr, Paris, Lesage, Renaud, & Turecki, 2007).<ref name="Paris J 2008 21–22"/>}}

In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology), possibly more likely to wind up in the correctional system due to criminal behavior, and possibly more likely to commit suicide prior to diagnosis.

Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide.<ref name="Kreisman J, Strauss H 2004 206"/>

There are also sex differences in borderline personality disorders.<ref name=":0">{{cite journal | vauthors = Sansone RA, Sansone LA | title = Gender patterns in borderline personality disorder | journal = Innovations in Clinical Neuroscience | volume = 8 | issue = 5 | pages = 16–20 | date = May 2011 | pmid = 21686143 | pmc = 3115767 }}</ref> Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have anti-social, narcissistic, passive-aggressive or sadistic personality traits.<ref name=":0" /> Women with BPD are more likely to have eating disorders, mood disorders, anxiety and post-traumatic stress.<ref name=":0" />

===Manipulative behavior===
[[Philosophy:Psychological manipulation|Manipulative behavior]] to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder.<ref>{{harvnb|American Psychiatric Association|2000|page=705}}</ref> However, Marsha Linehan notes that doing so relies upon the assumption that people with BPD who communicate intense pain, or who engage in self-harm and suicidal behavior, do so with the intention of influencing the behavior of others.<ref name = Linehanp14>{{harvnb|Linehan|1993|page=14}}</ref> The impact of such behavior on others—often an intense emotional reaction in concerned friends, family members, and therapists—is thus assumed to have been the person's intention.<ref name = Linehanp14/>

However, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable.<ref>{{harvnb|Linehan|1993|page=15}}</ref>

===Stigma===
The features of BPD include emotional instability; intense, unstable interpersonal relationships; a need for intimacy; and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "[[Medicine:Attention seeking|attention seeking]]", are often used and may become a self-fulfilling prophecy, as the negative treatment of these individuals triggers further self-destructive behavior.<ref>{{cite journal | vauthors = Aviram RB, Brodsky BS, Stanley B | title = Borderline personality disorder, stigma, and treatment implications | journal = Harvard Review of Psychiatry | volume = 14 | issue = 5 | pages = 249–256 | year = 2006 | pmid = 16990170 | doi = 10.1080/10673220600975121 | s2cid = 23923078 }}</ref>

====Physical violence====
The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others.<ref name=Chapman_31>{{harvnb|Chapman|Gratz|2007|page=31}}</ref> While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others.<ref name="Chapman_31"/> Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.<ref name=Chapman_32>{{harvnb|Chapman|Gratz|2007|page=32}}</ref> One of the key differences between BPD and antisocial personality disorder (ASPD) is that people with BPD tend to internalize anger by hurting themselves, while people with ASPD tend to externalize it by hurting others.<ref name=Chapman_32/>

One 2020 study found that BPD is individually associated with psychological, physical and sexual forms of intimate partner violence, especially amongst men.<ref name=MunroMartin>{{cite journal|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/pmh.1480|title=Elucidating the relationship between borderline personality disorder and intimate partner violence|journal=Personality and Mental Health|date=11 March 2020|last1=Munro|first1=Olivia E|last2=Sellbom|first2=Martin|doi=10.1002/pmh.1480|access-date=31 March 2021|volume=14|issue=3|pages=284–303|pmid=32162499|hdl=10523/10488}}</ref> In terms of the AMPD trait facets,  hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.<ref name=MunroMartin/>

In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind.<ref name=Chapman_32/> Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs.<ref name=Chapman_32/> This is one way in which people with BPD choose to harm themselves over potentially causing harm to others.<ref name=Chapman_32/> Another way in which people with BPD avoid expressing their anger through violence is by causing physical damage to themselves, such as engaging in non-suicidal self-injury.<ref name=reasons_NSSI /><ref name="Chapman_31"/>

====Mental health care providers====

People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment.<ref>{{cite journal | vauthors = Hinshelwood RD | title = The difficult patient. The role of 'scientific psychiatry' in understanding patients with chronic schizophrenia or severe personality disorder | journal = The British Journal of Psychiatry | volume = 174 | issue = 3 | pages = 187–190 | date = March 1999 | pmid = 10448440 | doi = 10.1192/bjp.174.3.187 | doi-access = free }}</ref> A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups.<ref>{{cite journal | vauthors = Cleary M, Siegfried N, Walter G | title = Experience, knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder | journal = International Journal of Mental Health Nursing | volume = 11 | issue = 3 | pages = 186–191 | date = September 2002 | pmid = 12510596 | doi = 10.1046/j.1440-0979.2002.00246.x }}</ref> This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed.<ref name=":7">{{cite journal| vauthors = Campbell K, Clarke KA, Massey D, Lakeman R |date=2020-05-19|title=Borderline Personality Disorder: To diagnose or not to diagnose? That is the question |journal=International Journal of Mental Health Nursing|volume=29|issue=5|pages=972–981|doi=10.1111/inm.12737|pmid=32426937|issn=1445-8330}}</ref> With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features.<ref name=":7" /> Efforts are ongoing to improve public and staff attitudes toward people with BPD.<ref>{{cite journal | vauthors = Deans C, Meocevic E | title = Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder | journal = Contemporary Nurse | volume = 21 | issue = 1 | pages = 43–49 | year = 2006 | pmid = 16594881 | doi = 10.5172/conu.2006.21.1.43 | s2cid = 20500743 | hdl = 1959.17/66356 }}</ref><ref>{{cite journal | vauthors = Krawitz R | title = Borderline personality disorder: attitudinal change following training | journal = The Australian and New Zealand Journal of Psychiatry | volume = 38 | issue = 7 | pages = 554–559 | date = July 2004 | pmid = 15255829 | doi = 10.1111/j.1440-1614.2004.01409.x }}</ref>

In psychoanalytic theory, the stigmatization among mental health care providers may be thought to reflect countertransference (when a therapist projects his or her own feelings on to a client). Thus, a diagnosis of BPD often says more about the clinician's negative reaction to the patient than it does about the patient and explains away the breakdown in [[Philosophy:Empathy|empathy]] between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon.<ref name="pmid3898174" /> This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation.<ref>{{cite journal | vauthors = Vaillant GE | title = The beginning of wisdom is never calling a patient a borderline; or, the clinical management of immature defenses in the treatment of individuals with personality disorders | journal = The Journal of Psychotherapy Practice and Research | volume = 1 | issue = 2 | pages = 117–134 | year = 1992 | pmid = 22700090 | pmc = 3330289 }}</ref>

Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who have developed helpful coping mechanisms. However, others experience the term "borderline personality disorder" as a pejorative [[Social:Labeling theory|label]] rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative and that the stigma surrounding this disorder limits their access to health care.<ref>{{cite journal | vauthors = Nehls N | title = Borderline personality disorder: the voice of patients | journal = Research in Nursing & Health | volume = 22 | issue = 4 | pages = 285–293 | date = August 1999 | pmid = 10435546 | doi = 10.1002/(SICI)1098-240X(199908)22:4<285::AID-NUR3>3.0.CO;2-R }}</ref>{{primary-inline|date=July 2015}} Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.<ref name=Manning_ix>{{harvnb|Manning|2011|page=ix}}</ref>

===Terminology===
Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed,<ref name="borderlinepersonalitytoday.com">{{cite news| vauthors = Bogod E |title=Borderline Personality Disorder Label Creates Stigma |url=http://www.borderlinepersonalitytoday.com/main/label.htm |url-status=dead |archive-url=https://web.archive.org/web/20150502181810/http://www.borderlinepersonalitytoday.com/main/label.htm |archive-date=2 May 2015 }}</ref> since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate.<ref name="borderlinepersonalitytoday.com"/><ref>{{cite web |url=http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=12 |title=Understanding Borderline Personality Disorder |publisher=Treatment and Research Advancements Association for Personality Disorder |year=2004 |url-status=dead |archive-url=https://web.archive.org/web/20130526035257/http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=12 |archive-date=26 May 2013 }}</ref> Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma".<ref>{{cite web|url=http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=32&Itemid=35 |title=How Advocacy is Bringing Borderline Personality Disorder Into the Light | vauthors = Porr V |year=2001 |url-status=dead |archive-url=https://web.archive.org/web/20141020191907/http://www.tara4bpd.org/dyn/index.php?option=content&task=view&id=32&Itemid=35 |archive-date=20 October 2014 }}</ref>

Alternative suggestions for names include ''emotional regulation disorder'' or ''[[Philosophy:Emotional dysregulation|emotional dysregulation]] disorder''. ''Impulse disorder'' and ''interpersonal regulatory disorder'' are other valid alternatives, according to John G. Gunderson of McLean Hospital in the United States.<ref>{{cite book | vauthors = Gunderson JG, Hoffman PD |title=Understanding and Treating Borderline Personality Disorder A Guide for Professionals and Families |url=https://archive.org/details/understandingtre00john |url-access=registration |location=Arlington, Virginia |publisher=American Psychiatric Publishing |year=2005|isbn=9781585621354 }}{{Page needed|date=July 2013}}</ref> Another term suggested by psychiatrist Carolyn Quadrio is ''post traumatic personality disorganization'' (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) as well as a personality disorder.<ref name="AxisOne/AxisTwo">{{cite journal | vauthors = Quadrio C | date=December 2005 |title=Axis One/Axis Two: A disordered borderline |journal=Australian and New Zealand Journal of Psychiatry |volume=39 |pages=A97–A153 |doi=10.1111/j.1440-1614.2005.01674_39_s1.x |url=http://med.unsw.edu.au/publication/axis-oneaxis-two-disordered-borderline |archive-url=https://archive.today/20130705153948/http://med.unsw.edu.au/publication/axis-oneaxis-two-disordered-borderline |url-status=dead |archive-date=2013-07-05 }}</ref> However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.<ref name="Gratz2007" />

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name "borderline personality disorder" remains unchanged and it is not considered a trauma- and stressor-related disorder.<ref name="DSM-5-borderline-663">{{harvnb|American Psychiatric Association|2013|pages=663–666}}</ref>

==Society and culture==

===Fiction===

==== Literature ====
In literature, characters with behavior consistent with borderline personality disorder include Catherine in ''Wuthering Heights'' (1847), Smerdyakov in ''The Brothers Karamazov'' (1880), and Harry Haller in ''Steppenwolf'' (1927).<ref>{{cite journal| vauthors = Morris P |date=2013-04-01|title=The Depiction of Trauma and its Effect on Character Development in the Brontë Fiction |journal=Brontë Studies|volume=38|issue=2|pages=157–168 |doi=10.1179/1474893213Z.00000000062 |s2cid=192230439 }}</ref><ref>{{cite journal| vauthors = Ohi SI |date=2019-10-26|title=Personality Disorder of Character Smerdyakov in Novel the Brother Karamazov Bu Fyodor Dostovesky (Translated by Constance Clara Garnett) |url= https://repository.ung.ac.id/skripsi/show/321412044/personality-disorder-of-character-smerdyakov-in-novel-the-brother-karamazov-bu-fyodor-dostovesky-translated-by-constance-clara-garnett.html|journal=Skripsi|language=en|volume=1|issue=321412044}}</ref><ref>{{cite book| vauthors = Wellings N, McCormick EW |url=https://books.google.com/books?id=RXa0uEkiNbQC&q=borderline+personality+disorder+%22steppenwolf%22&pg=PA74|title=Transpersonal Psychotherapy |date=2000-01-01|publisher=SAGE|isbn=978-1-4129-0802-3|language=en}}</ref>

==== Film ====
Films attempting to depict characters with the disorder include ''A Thin Line Between Love and Hate'' (1996), ''Filth'' (2013), ''Fatal Attraction'' (1987), ''The Crush'' (1993), ''Mad Love'' (1995), ''Malicious'' (1995), ''Interiors'' (1978), ''The Cable Guy'' (1996), ''Mr. Nobody'' (2009), ''Moksha'' (2001), ''Margot at the Wedding'' (2007), ''Cracks'' (2009),<ref name="RobinsonFG">{{cite book| vauthors = Robinson DJ |title=The Field Guide to Personality Disorders|publisher=Rapid Psychler Press|year=1999|isbn=978-0-9680324-6-6|page=113 }}</ref> and ''Welcome to Me'' (2014).<ref>{{cite news| vauthors = O'Sullivan M | date=7 May 2015|title=Kristen Wiig earns awkward laughs and silence in 'Welcome to Me'|newspaper=Washington Post|url=https://www.washingtonpost.com/goingoutguide/movies/kristen-wiig-earns-awkward-laughs-and-silence-in-welcome-to-me/2015/05/06/c26d9b78-ef6d-11e4-8abc-d6aa3bad79dd_story.html|url-status=live|access-date=3 June 2015|archive-url=https://web.archive.org/web/20150604082145/http://www.washingtonpost.com/goingoutguide/movies/kristen-wiig-earns-awkward-laughs-and-silence-in-welcome-to-me/2015/05/06/c26d9b78-ef6d-11e4-8abc-d6aa3bad79dd_story.html|archive-date=4 June 2015 |df=dmy-all}}</ref><ref>{{cite news|vauthors = Chang J |date=11 September 2014|title=Toronto Film Review: 'Welcome to Me': Kristen Wiig plays a woman with borderline personality disorder in this startlingly inspired comedy from Shira Piven|newspaper=Variety|url=https://variety.com/2014/film/festivals/toronto-film-review-welcome-to-me-1201304067/|url-status=live|access-date=3 June 2015|archive-url=https://web.archive.org/web/20150617215603/http://variety.com/2014/film/festivals/toronto-film-review-welcome-to-me-1201304067/|archive-date=17 June 2015 |df=dmy-all}}</ref>

Robert O. Friedel has suggested that the behavior of Theresa Dunn, the leading character of ''Looking for Mr. Goodbar'' (1975) is consistent with a diagnosis of borderline personality disorder.<ref>{{cite journal|title=Early Sea Changes in Borderline Personality Disorder |url=http://www.nami.org/Template.cfm?Section=By_Illness&template=%2FContentManagement%2FContentDisplay.cfm&ContentID=43145 |archive-url=https://web.archive.org/web/20090417050113/http://www.nami.org/Template.cfm?Section=By_Illness&template=%2FContentManagement%2FContentDisplay.cfm&ContentID=43145 |url-status=dead |archive-date=2009-04-17 |access-date=17 April 2009|journal=Current Psychiatry Reports|date= 2006|volume= 8|issue = 1|pages=1–4| vauthors = Friedel RO |doi = 10.1007/s11920-006-0071-6|pmid = 16513034|s2cid = 27719611}}</ref>

The films ''Play Misty for Me'' (1971)<ref name="Robinson_2003">{{cite book |title=Reel Psychiatry: Movie Portrayals of Psychiatric Conditions| vauthors = Robinson DJ | year= 2003|publisher=Rapid Psychler Press |location=Port Huron, Michigan |isbn=978-1-894328-07-4|page=234}}</ref> and ''Girl, Interrupted'' (1999, based on the memoir of the same name) both suggest the emotional instability of the disorder.<ref>{{cite book |title=Movies and Mental Illness: Using Films to Understand Psychopathology |vauthors=Wedding D, Boyd MA, Niemiec RM |year=2005 |publisher=Hogrefe |location=Cambridge, Massachusetts |isbn=978-0-88937-292-4 |page=59}}</ref>

The film ''Single White Female'' (1992), like the first example, also suggests characteristics, some of which are actually atypical of the disorder: the character Hedy had markedly disturbed sense of identity and reacts drastically to abandonment.<ref name="Robinson_2003" />{{rp|235}}

Multiple commenters have noted that Clementine in ''Eternal Sunshine of a Spotless Mind'' (2004) shows classic borderline personality disorder behavior.<ref>{{cite journal| vauthors = Alberini CM |date=2010-10-29|title=Long-term Memories: The Good, the Bad, and the Ugly|journal=Cerebrum: The Dana Forum on Brain Science|volume=2010|page=21|issn=1524-6205|pmc=3574792|pmid=23447766}}</ref><ref>{{cite book| vauthors = Young SD |date=2012-03-14|title=Psychology at the Movies |language=en|doi=10.1002/9781119941149|isbn=9781119941149}}</ref>

In a review of the film ''Shame'' (2011) for the British journal ''The Art of Psychiatry'', another psychiatrist, Abby Seltzer, praises Carey Mulligan's portrayal of a character with the disorder even though it is never mentioned onscreen.<ref name="Art of Psychiatry Shame review">{{cite news | vauthors = Seltzer A |title=''Shame'' and ''A Dangerous Method'' reviews |url= http://www.artofpsychiatry.co.uk/shame-and-a-dangerous-method-reviews/ |newspaper=The Art of Psychiatry |date=16 April 2012 |access-date=13 January 2017 |url-status=live |archive-url=https://web.archive.org/web/20170116164632/http://www.artofpsychiatry.co.uk/shame-and-a-dangerous-method-reviews/ |archive-date=16 January 2017 }}</ref>

Psychiatrists Eric Bui and Rachel Rodgers argue that the Anakin Skywalker/Darth Vader character in the ''Star Wars'' films meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity, and dissociative episodes.<ref name="BPD paper">{{cite news| vauthors = Hsu J |title=The Psychology of Darth Vader Revealed|url=http://www.livescience.com/culture/psychology-darth-vader-revealed-100604.html|publisher=TopTenReviews|work=LiveScience|date=8 June 2010|access-date=8 June 2010|url-status=live|archive-url=https://web.archive.org/web/20100826000507/http://www.livescience.com/culture/psychology-darth-vader-revealed-100604.html|archive-date=26 August 2010}}</ref>

==== Television ====
On television, [[Company:The CW|The CW]] show ''Crazy Ex-Girlfriend'' portrays the main character, played by Rachel Bloom, with borderline personality disorder,<ref>{{cite web |url=http://metro.co.uk/2017/11/21/crazy-ex-girlfriend-is-the-best-depiction-of-mental-health-on-television-today-7097094/ |title=Crazy Ex-Girlfriend is the best depiction of mental health on television today |date=21 November 2017 |access-date=30 January 2018 |archive-date=1 December 2017 |archive-url=https://web.archive.org/web/20171201033347/http://metro.co.uk/2017/11/21/crazy-ex-girlfriend-is-the-best-depiction-of-mental-health-on-television-today-7097094/ |url-status=live }}</ref> and Emma Stone's character in the [[Company:Netflix|Netflix]] miniseries ''Maniac'' is diagnosed with the disorder.<ref>{{cite news|url=https://www.bustle.com/p/how-netflixs-maniac-uses-mental-illness-to-interrogate-what-it-means-to-be-normal-12019062|title=Netflix's 'Maniac' Is A Trippy Ride With A Lot To Say About Mental Illness| vauthors = Patton R |website=Bustle|access-date=2019-03-01|archive-date=2 March 2019|archive-url=https://web.archive.org/web/20190302024650/https://www.bustle.com/p/how-netflixs-maniac-uses-mental-illness-to-interrogate-what-it-means-to-be-normal-12019062|url-status=live}}</ref> Additionally, incestuous twins Cersei and Jaime Lannister, in George R. R. Martin's ''A Song of Ice and Fire'' series and its television adaptation, ''Game of Thrones'', have traits of borderline and narcissistic personality disorders.<ref>{{cite news|work=MTV News|title=A Therapist Explains Why Everyone on 'Game of Thrones' Has Serious Issues: Westeros is Basically A Living, Breathing Manual for Mental Illness|date=30 April 2015|vauthors=Rosenfield K|url=http://www.mtv.com/news/2146368/game-of-thrones-mental-illness/|access-date=13 May 2019|archive-date=13 May 2019|archive-url=https://web.archive.org/web/20190513175836/http://www.mtv.com/news/2146368/game-of-thrones-mental-illness/|url-status=live}}</ref>

===Awareness===
In early 2008, the United States House of Representatives declared the month of May Borderline Personality Disorder Awareness Month.<ref>HR 1005, 4/1/08</ref><ref>{{cite news|url= http://www.borderlinepersonalitydisorder.com/awareness/awareness-files/background.shtml |title= BPD Awareness Month – Congressional History |work= BPD Today |publisher= Mental Health Today |access-date= 1 November 2010 |url-status=dead |archive-url= https://web.archive.org/web/20110708083602/http://www.borderlinepersonalitydisorder.com/awareness/awareness-files/background.shtml |archive-date= 8 July 2011 |df= dmy-all }}</ref>

In 2020, South Korean singer-songwriter Lee Sunmi spoke out about her struggle with borderline personality disorder on the show ''Running Mates'', having been diagnosed 5 years prior.<ref>{{cite news|url= https://entertain.naver.com/ranking/read?oid=082&aid=0001052070 |title= What is the'Borderline Personality Disorder' that Sunmi confessed?}}</ref>

{{Clear}}

== See also ==
* Hysteria
* [[Philosophy:Emotional dysregulation|Emotional dysregulation]]
*[[Philosophy:Pseudohallucination|Pseudohallucination]]

==References==
{{Reflist}}

== Bibliography ==
{{Refbegin}}
* {{cite book|title=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Association|year=2000|isbn=978-0-89042-025-6|edition=4th|author=American Psychiatric Association|title-link=Diagnostic and Statistical Manual of Mental Disorders}}
* {{cite book|title=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Publishing|year=2013|isbn=978-0-89042-555-8|edition=5th|author=American Psychiatric Association|title-link=Diagnostic and Statistical Manual of Mental Disorders}}
* {{cite book|title=The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD | vauthors = Chapman AL, Gratz KL |publisher=New Harbinger Publications|year= 2007|isbn=978-1-57224-507-5|location=Oakland, CA}}
* {{cite journal | vauthors = Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N | title = Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder | journal = Archives of General Psychiatry | volume = 63 | issue = 7 | pages = 757–66 | date = July 2006 | pmid = 16818865 | doi = 10.1001/archpsyc.63.7.757 |  doi-access = free }}
* {{cite book|title= Cognitive-behavioral treatment of borderline personality disorder| vauthors = Linehan M |publisher= Guilford Press|year= 1993|isbn= 978-0-89862-183-9|location= New York|}}
* {{cite book|title=Loving Someone with Borderline Personality Disorder| vauthors = Manning S |publisher=The Guilford Press|year=2011|isbn=978-1-59385-607-6}}
* {{cite book|title= Disorders of Personality: DSM-IV-TM and Beyond| vauthors = Millon T |publisher= {{wipe|John Wiley & Sons}}|year= 1996|isbn= 978-0-471-01186-6|location= New York|}}
* {{cite book|title= Personality Disorders in Modern Life| vauthors = Millon T |year= 2004|isbn= 978-0-471-32355-6|}}
* {{cite book|title=Masters of the mind: exploring the story of mental illness from ancient times to the new millennium | vauthors = Millon T, Grossman S, Meagher SE |publisher={{wipe|John Wiley & Sons}}|year=2004|isbn=978-0-471-46985-8}}
* {{cite web|url= http://millon.net/taxonomy/summary.htm|title= Personality Subtypes| vauthors = Millon T |year= 2006|publisher= Dicandrien, Inc.|work= Institute for Advanced Studies in Personology and Psychopathology|access-date= 1 November 2010|archive-date= 1 March 2018|archive-url= https://web.archive.org/web/20180301104112/http://www.millon.net/taxonomy/summary.htm|url-status= live}}
{{Refend}}

== External links ==
* {{curlie|Health/Mental_Health/Disorders/Personality/Borderline/}}
* {{cite web|url= http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml |publisher= [[Organization:National Institute of Mental Health|National Institute of Mental Health]] |title= Borderline personality disorder}}
* [http://bpdfamily.com/content/borderline-personality-disorder/ APA DSM 5 Definition of Borderline personality disorder]
* [http://www.div12.org/psychological-treatments/disorders/borderline-personality-disorder/ APA Division 12 treatment page for Borderline personality disorder]
* [http://apps.who.int/classifications/icd10/browse/2016/en#/F60.3 ICD-10 definition of EUPD by the World Health Organization]
* [https://www.nhs.uk/conditions/borderline-personality-disorder/ NHS]
{{Medical condition classification and resources
| ICD10           = {{ICD10|F|60|3|f|60}}
| ICD9            = {{ICD9|301.83}}
| MeshID          = D001883
| ICDO            = 
| OMIM            = 
| OMIM_mult       = 
| MedlinePlus     = 000935
| eMedicineSubj   = article
| eMedicineTopic  = 913575
| eMedicine_mult  = 
| SNOMED CT       = 20010003
|ICD11={{ICD11|6D11.5}}}}
{{Borderline personality disorder}}
{{DSM personality disorders}}

{{DEFAULTSORT:Borderline personality disorder}}
[[Category:Borderline personality disorder| ]]
[[Category:Abnormal psychology]]
[[Category:Personality disorders]]
[[Category:Psychiatric diagnosis]]
[[Category:Wikipedia medicine articles ready to translate]]

{{Sourceattribution|Borderline personality disorder}}