Borderline personality disorder: definition, causes, symptoms, diagnosis and treatment

By Cristiano Antonino Last updated Jun 20, 2023

Borderline personality disorder is a highly controversial diagnostic entity. Sometimes it is not even recognised as a specific disorder

It is used as a ‘container’ in which to place all those cases that cannot be diagnosed in any other way. In reality, borderline disorder has specific, well-known characteristics.

It is basically a relationship disorder, which prevents the subject from establishing stable friendship, affection or love relationships over time.

These are people who spend their lives in a state of extreme confusion and whose relationships are doomed to failure or are emotionally destructive to others.

People with borderline personality disorder drag others – relatives, friends and partners – into an emotional vortex from which it is often difficult to escape.

These individuals experience devastating emotions and manifest them in a dramatic way.

They dramatise and exaggerate many aspects of their lives or their feelings.

They project their failings onto others, appearing to be the victims of others when they are often the perpetrators.

They behave differently within a few minutes or hours.

Borderline personality disorder has often, and not wrongly, been associated with traumatic events suffered in childhood

E.g. sexual or physical abuse, but this is not always the case.

The most obvious and worrying aspect of borderline personality disorder is that it presents symptoms that are potentially harmful to the subject (binge eating, substance use and abuse, reckless driving, promiscuous sexuality, self-harm, antisocial behaviour, suicide attempts, etc.). It is also associated with sudden bursts of intense anger.

Symptoms of borderline personality disorder

According to the Diagnostic and Statistical Manual of Mental Disorders, borderline personality disorder is characterised by:

A pervasive pattern of instability in interpersonal relationships, self-image and mood, as well as marked impulsivity. These must have appeared in early adulthood and be present in various contexts, as indicated by five (or more) of the following:
desperate efforts to avoid real or imagined abandonment.
a framework of unstable and intense interpersonal relationships, characterised by alternating extremes of over-idealisation and devaluation.
altered identity: markedly and persistently unstable self-image and self-perception.
impulsivity in at least two areas that are potentially harmful to the subject, such as excessive spending, sexual promiscuity, substance abuse, reckless driving, binge drinking, etc.
recurrent threats, gestures, suicidal behaviour, or self-mutilating behaviour.
affective instability due to marked mood reactivity (e.g., episodic intense dysphoria, irritability or anxiety, usually lasting a few hours, and only rarely more than a few days)
chronic feelings of emptiness
unmotivated and intense anger or difficulty controlling anger (e.g., frequent fits of rage or constant anger, recurrent physical confrontations).
paranoid ideation, or severe, stress-related, transient dissociative symptoms.

Consequences of borderline personality disorder

Borderline personality disorder is a psychopathology that entails serious problems, given the impulse control it implies, the relational instability, and the tendency to idealise and devalue other people (who are ‘black or white’).

It is often associated with intense and explosive feelings of anger, desires for revenge, paranoia, even severe depression.

The area most affected is generally that of romantic relationships.

The partners of those with a borderline personality constantly live with the feeling of walking on a minefield.

They feel constantly under test, subjected to an inexhaustible demand for demonstrations of love, the object of obsessive jealousy that often verges on paranoia.

The mood instability of the borderline patient often leads to the (mis)diagnosis of bipolar mood disorder, but there are substantial differences between the two clinical pictures.

Treatment of borderline personality disorder

The treatment of borderline personality disorder necessarily involves structured psychotherapy, preferably with a cognitive-behavioural orientation.

In particular, there are certain approaches that have shown efficacy in numerous controlled studies.

First and foremost is dialectical behavioural therapy, devised by Marsha Linehan in the USA and now also widely used in Italy.

Schema Therapy and Interpersonal Metacognitive Therapy are also useful

Of primary importance is to interrupt aggressive or self-injurious behaviour, which often results in emergency hospitalisation.

Once the problematic risk behaviour has been reduced, the intervention shifts to the major difficulties of these persons in maintaining a stable and integrated representation of self and other.

The therapeutic relationship with the borderline patient is very problematic, however, because the patient’s relational dynamics are also activated in this context.

These can lead him/her to idealisation of the therapist (and even falling in love), but also to sudden devaluation of the therapist and consequent termination of therapy.

Maintaining therapeutic continuity is therefore very difficult, although it is necessary to obtain medium to long term results.

Drug therapy can hardly be decisive.

Nevertheless, the use of mood stabilisers may be indicated to reduce impulsivity, anxiety and emotional dysregulation.

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