Borderline personality disorder

Borderline personality disorder
Other names	Emotionally unstable personality disorder – impulsive or borderline type[1] Emotional intensity disorder[2] Hysteria[3] Hysteric personality – Hysteroid[4] Negative affectivity/neuroticism[5]
Despair by Edvard Munch (1894), who is presumed to have had borderline personality disorder[6][7]
Specialty	Psychiatry, clinical psychology
Symptoms	Unstable relationships, distorted sense of self, and intense emotions; impulsivity; recurrent suicidal and self-harming behavior; fear of abandonment; chronic feelings of emptiness; inappropriate anger; dissociation[8][9]
Complications	Suicide, self-harm[8]
Usual onset	Early adulthood[9]
Duration	Long term[8]
Causes	Genetic, neurobiologic, psychosocial[10]
Risk factors	Family history, childhood trauma[10]
Diagnostic method	Based on reported symptoms[8]
Differential diagnosis	See § Differential diagnosis
Treatment	Behaviour therapy[8]
Prognosis	Improves over time,[9] remission occurs in 45% of patients over a wide range of follow-up periods[11][12][13][14][15]
Frequency	5.9% (lifetime prevalence)[8]

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD),^[16] is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses.^[9][17][18] Individuals diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges in regulating emotional states to a healthy, stable baseline.^[19][20][21] Symptoms such as dissociation (a feeling of detachment from reality), a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.^[17]

The onset of BPD symptoms can be triggered by events that others might perceive as normal,^[17] with the disorder typically manifesting in early adulthood and persisting across diverse contexts.^[9] BPD is often comorbid with substance use disorders,^[22] depressive disorders, and eating disorders.^[17] BPD is associated with a substantial risk of suicide;^[9][17] an estimated 8 to 10 percent of individuals with BPD die by suicide, with males affected at twice the rate of females.^[23] Despite its severity, BPD faces significant stigmatization in both media portrayals and within the psychiatric field, potentially leading to its underdiagnosis.^[24]

The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development.^[8][25] A genetic predisposition is evident, with the disorder being significantly more common in individuals with a family history of BPD, particularly immediate relatives.^[8] Psychosocial factors, particularly adverse life events like adverse childhood experiences, also play a role.^[26] Neurologically, the underlying mechanism appears to involve the frontolimbic neuronal network of the limbic system.^[26] The American Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies BPD as a cluster B personality disorder, alongside antisocial, histrionic, and narcissistic personality disorders.^[9] There exists a small risk of misdiagnosis, with BPD most commonly confused with a mood disorder, substance use disorder, or other mental health disorders.^[9]

Therapeutic interventions for BPD predominantly involve psychotherapy, with cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) being the most effective modalities.^[8] This psychotherapy can occur one-on-one or in a group.^[8] Although pharmacotherapy cannot cure BPD, it may be employed to mitigate associated symptoms,^[8] with quetiapine and selective serotonin reuptake inhibitor (SSRI) antidepressants being commonly prescribed even though their efficacy is unclear. A 2002 study found fluvoxamine (an SSRI) significantly decreased rapid mood shifts in females with BPD,^[27] while a more recent meta-analysis found the use of medications was still unsupported by evidence.^[28] In severe cases, hospitalization may be necessitated, even if for only short periods.^[8]

BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population,^{[9][8][29][30]} with a higher incidence rate among women compared to men in the clinical setting of up to three times.^[9][29] Two epidemiological studies conducted on the general population in the United States have shown that the lifetime prevalence of BPD shows no significant difference between males and females.^[31][32] Despite the high utilization of healthcare resources by individuals with BPD,^[33] up to half may show significant improvement over a ten-year period with appropriate treatment.^[9] The naming of the disorder, particularly the suitability of the term borderline, is a subject of ongoing debate. Initially, the term reflected historical notions referring to borderline insanity and later described patients on the border between neurosis and psychosis. These interpretations are now regarded as outdated and clinically imprecise.^[8][34]