Borderline personality disorder
Explains Borderline personality disorder (BPD), including possible causes and how you can access treatment and support. Includes tips for helping yourself, and guidance for friends and family.
What is borderline personality disorder?
What is borderline personality disorder?
BPD is one of many personality disorders listed in the manuals used by doctors when they are giving someone a psychiatric diagnosis.
Below are the symptoms of borderline personality disorder according to government guidelines (National Institute for Health and Clinical Excellence [NICE] 2009). A doctor may diagnose you with borderline personality disorder if you have five or more of these symptoms and if the symptoms have a significant impact on your everyday life.
- you have emotions that are up and down (for example, feeling confident one day and feeling despair another), with feelings of emptiness and often anger
- you find it difficult to make and maintain relationships
- you have an unstable sense of identity, such as thinking differently about yourself depending on who you are with
- you take risks or do things without thinking about the consequences
- you harm yourself or think about harming yourself (for example, cutting yourself or overdosing)
- you fear being abandoned or rejected or being alone
- you sometimes believe in things that are not real or true (called delusions) or see or hear things that are not really there (called hallucinations).
If you have been diagnosed with borderline personality disorder you may be more likely to experience other mental health related problems, such as depression, anxiety, eating disorders or substance misuse (misusing drugs or alcohol).
The question of 'personality disorders' is controversial. What some experts term as 'personality' others regard as 'the self'; so any suggestion that a person's self is disordered, damaged or flawed can be distressing. What matters is that you get the help you feel you need. If after reading this booklet you feel you may have BPD, you may want to talk to someone who is medically qualified – be very wary of making a self-diagnosis.
How common is BPD?
BPD is thought to affect less than one per cent of the general population. It's been estimated that three-quarters of those given this diagnosis are women. It's a condition that is usually diagnosed in adults only.
What if I disagree with the diagnosis?
Some people feel they are only given this diagnosis because they do not fit easily into any other category. If you feel your GP or psychiatrist has misunderstood you, you are entitled to ask for a second opinion, although this doesn't necessarily mean that your request will be granted. If you are having problems getting the help you need, you may find an advocate (someone who can speak up for you and support you) useful. (For more information about advocates, contact the Mind Infoline or see The Mind guide to advocacy.)
What are the common feelings and experiences of people with BPD?
If you have BPD you may have had a series of unstable and intense relationships, or felt the need to cling too long to damaging relationships. This may be because you feel insecure, alone or lack self-worth.
You may have a poor self image, feel that you don't fit or belong, and find that your moods and feelings change rapidly. Therefore you may find social relationships difficult.
I have BPD and for me it feels like [I'm] a child being forced to live in an adult world. I feel too fragile and vulnerable for the world I live in.
Many people with BPD experience a deep sense of emptiness.
Feeling bereft and lifeless – with a void I can't fill no matter how much food I put down or activity, exercise, self harm and constant thinking I've gone through. I try to keep busy to combat the emptiness but it only masks it. The best antidote is to try to experience life and relationships more fully, then store the better memories.
You may feel tempted to harm yourself if your emotions become intensely painful and hard to cope with or express.
When it was really bad, I would be in so much emotional pain that suicide seemed like the only way I could find any release. My attempts at overdosing kept failing: I was secretly screaming for someone to just listen to me and show me a way out. But in the end, if they wouldn't or couldn't be bothered to help me I would rather have been dead than carry on as I was – I just didn't care about anything, apart from getting rid of the pain.
Research shows that people with BPD are more likely to have suicidal thoughts and make suicide attempts compared to people with other psychiatric diagnoses. If this applies to you, or someone close to you, you can find information about where to get help in the tab 'Getting help in an emergency'.
What causes BPD?
The causes of BPD are unclear. Most researchers think that BPD develops through a combination of factors, including temperament, childhood and adolescent experiences. Difficult life events such as the early loss of a parent, childhood neglect, sexual or physical abuse are common in people diagnosed with BPD, though this is not always the case.
Stressful experiences, such as the break-up of a relationship or the loss of a job, can lead to already present symptoms of BPD getting worse.
What can help?
What helps with BPD?
If you are diagnosed with BPD you may find it especially important to feel accepted, heard and understood. You will also want to find ways of coping with the sometimes very extreme emotions you may be feeling, in a safe environment, where you can be with people you feel you trust and who you can develop meaningful relationships with while you work through any difficulties. You may find helpful:
- Talking treatments – when you feel ready and able, a talking therapy may help you explore your difficulties and find new ways of coping. There are a growing number of talking therapies that may help with BPD.
- Alternative therapies – for other ways of expressing your feelings e.g. through a therapeutic community, arts therapies.
- Medication – this can you to cope with difficult thoughts and feelings.
- Access to help if you feel in crisis – this could be from a trusted friend or carer, or from your local council’s support services, see the 'Getting help in an emergency' tab.
- Self-help techniques – some everyday practices could help you to cope better.
What helps me to feel better is having several friends who have stuck by me, not judged me and tried to gain an understanding of my situation. This is invaluable in itself and involved a leap of faith from me to trust and be open and honest with them.
Access to help
If your GP thinks you have BPD, you should be offered an appointment with your local Community Mental Health Team. Their role is to assess your needs and develop a care plan with you, which could include some of the therapies or treatments described in the following sections of this booklet. They will also look at what support you may need to cope.
When I received my diagnosis it seemed like there would be no hope for me. It took a few tries, with the help of my doctor, to work out what would be the best kind of treatments for me, but we eventually found something right. Now I'm back in a full-time job, have better relationships with my friends and family and am thinking about buying my own place to live.
Brief talking treatments
Brief talking treatments are usually given for less than six months and usually no more frequently than once a week. NICE guidelines do not recommend very brief interventions (less than three months) if you have BPD.
Cognitive behavioural therapy (CBT)
CBT aims to help you tackle everyday difficulties through problem-solving techniques. You will learn how to replace negative thinking patterns with positive ones.
CBT is usually focused on the present but, when used for BPD, it also takes into account previous experiences which have influenced your current fundamental beliefs and ways of thinking. (See Making sense of cognitive behaviour therapy.)
Problem-solving therapy (PST)
PST is based on cognitive-behavioural techniques. It can help you if you are depressed and if you are in a crisis after an episode of self harm or attempted suicide. PST focuses on the present and has five stages:
- adopting a problem-solving strategy
- defining the problem and selecting goals
- thinking of possible solutions
- predicting possible results and choosing the best solution
- trying it out and looking at the effects.
Manual-assisted cognitive therapy (MACT)
MACT can help if you self harm. You will have a manual that will help to structure your treatment sessions and can act as a reminder inbetween them. The manual covers:
- your self-harm attempt(s)
- crisis skills
- problem solving
- how to manage self-harming episodes.
You are likely to be offered up to five sessions within three months of an episode of self harm, with the option of a further two booster sessions within six months.
Interpersonal psychotherapy (IPT)
IPT was developed to treat outpatients with major depression. The therapist will help you look at four main areas:
- sensitivity in relationships with others
- managing different social roles
- disputes with other people
You will look at how your role may change after, for example, a divorce or leaving a job. It has been further developed to treat people with BPD.
Cognitive analytic therapy (CAT)
CAT combines CBT's practical methods with more attention to the relationship between you and your therapist – the relationship you have with your therapist is likely to reflect how you relate to people generally. You will explore how your relationship patterns might have developed in unhelpful ways, including how you relate to yourself. It is particularly designed to deal with damage if you have had long-term experiences of trauma and deprivation.
Psychodynamic psychotherapy adapted for BPD
Psychodynamic psychotherapists can help you become aware of how early experiences, often from childhood, can create unconscious conflicts in your mind. These can make you confused and anxious. This therapy helps you become aware of what is behind any conflicting feelings you may have. And, as the relationship between you and the therapist often provides examples of relationship problems you experience elsewhere in your life, the therapist will discuss these problems with you during your sessions. If you are diagnosed with BPD, the therapist will provide more structure and be more active than usual. There is no set limit to the length of time this type of therapy can take.
Psychological therapy programmes
Psychological therapy programmes combine more than one treatment; for example, individual therapy plus group therapy.
Dialectical behaviour therapy (DBT)
DBT is a mixed method of treatment, initially developed for women who self harm. It has now been developed to help people with BPD. It aims to help you gain more control over your actions and behaviour. Programmes last up to a year, aiming to reduce suicidal behaviours, self harm, substance misuse and binge-eating. It also encourages you to define your life goals and work towards these. The programme can be offered as both individual and group therapy; however, the level of services varies around the country. In some areas, for example, you may only be offered group therapy. (See Making sense of dialectical behaviour therapy.)
Mentalisation-based therapy (MBT)
MBT teaches you greater awareness of how your thoughts can impact on your actions. It also teaches you how to separate thoughts and actions. This can help give you more choice about how to act in any given situation. Mentalisation-based therapy is based on the belief that early problems stopped you from learning how to understand your own and others' thoughts and feelings. The treatment takes up to 18 months and usually happens in a day hospital. It includes individual and group therapy.
Access to talking treatments
If you are interested in pursuing a talking treatment, you could talk to your GP about seeing someone through the NHS. Some voluntary organisations also offer low cost and, sometimes, free treatment. Alternatively, if you can afford it, there are private treatments available. (See Useful contacts for organisations listing practitioners.)
A therapeutic community is a 'planned environment'. It will usually offer you social and group therapies, including: analytic groups, psychodrama, art therapy, cognitive therapy and problem solving. 'Members' of the community encourage each other to discuss their experiences and emotional issues and provide feedback to each other. Being a part of a community may help you develop awareness of how you interact with other people.
Therapeutic communities for personality disorder range from residential hospitals to units that operate for a few hours once a week. Therapeutic communities generally offer time-limited placements. In some areas the NHS runs inpatient therapeutic communities that specialise in treating clients with personality disorders. (See The Consortium for Therapeutic Communities (TCTC) for more information.)
Arts therapies are sometimes offered if you experience BPD. They include art, dance movement, drama and music therapies. These therapies can help you express your thoughts and feelings if you can’t immediately put them into words. Therapy is normally weekly, in small groups or individually. (See Making sense of arts therapies.)
Complementary and alternative therapies
You may find therapies such as massage, reflexology, aromatherapy and healing useful as part of your coping strategy. Although they are all available privately, some can be accessed through the voluntary sector, including some local Minds. Also see the Institute for Complementary Medicine.
There are no psychiatric drugs specifically for BPD, but some medications can help to treat particular symptoms you may experience, including anxiety, depression, anger and impulsive behaviour.
These may help if you are depressed (see Making sense of antidepressants).
Anticonvulsants and lithium
These may help if you have mood disturbances or are diagnosed with a mood disorder (see Making sense of lithium and other mood stabilisers).
Antipsychotics (also called major tranquillisers) may help if you experience delusions, hallucinations or rapid thoughts. These drugs can cause weight gain and other unwanted effects. NICE recommend that they are only given short term for people with BPD. (For more information, see Making sense of antipsychotics.)
If you have been diagnosed with BPD there are many things you can do to help yourself cope better. Here are a few things people have found helpful:
- Physical activity such as walking, cleaning, dancing – anything that can distract you from your present emotions.
- Playing music can create a very different feeling to the one you are struggling with e.g. happy music if you are feeling sad, relaxing music if you are anxious.
- Talking to someone you trust can be a big help when you are struggling with strong feelings e.g. calling a supportive friend, a family member or a helpline.
- Meditation or taking some quiet time in peaceful surroundings might help.
- Breathing exercises. Sit or lie somewhere quiet and bring your attention to your breathing. Breathe evenly, slowly, and deeply, letting your stomach rise and fall with each breath (also see How to manage stress).
- Getting enough sleep can help you cope better with stress.
- Reading something uplifting.
- Acknowledging your emotions. Notice the emotion you are having, and let yourself experience it as a wave, without trying to block it, suppress it, or hold on to it. Try to accept the emotion for what it is.
- Riding it out. Strong emotional reactions (and the urges to self harm, binge or drink) usually last for a few minutes and then begin to subside. Set a timer for 10 minutes and practice riding out the emotion.
- A warm bath or shower. Add some scented bath salts or candles and allow the warm water and pleasant fragrances take you into a different emotional space.
- Grounding exercises. Sounds, sights, smells and sensations can help you come back into the present, for instance: take a deep breath, and then start to mentally list the things you see around you; listen to the sounds you hear around you, how they rise and fall and change; take hold of an ice cube and hold it in your hand until it starts to cause mild discomfort; or snap a rubber band against your wrist.
- Helping someone else. This can be as small a thing such as smiling at the shop assistant at the supermarket checkout.
- Being prepared for a crisis: keeping handy a list of contact details of people or organisations you trust can be really useful in a crisis.
How can friends and family help?
How can friends and family help?
This section is for friends or family who wish to support someone they know who has borderline personality disorder.
- People with BPD can have very low self-esteem, and it may help if you remind them of good things about themselves.
- A person with BPD is likely to feel emotionally unstable, so it can help if you are able to keep calm and stable. You may need to find more support for yourself (see Carers UK for more).
- Your friend or relative may have more than average changes of mood and attitude, and feelings of being abandoned or let down by you. Try not to take this personally.
- Try to keep in mind that the person you care about wants very much to be loved and cared for but may not know how to ask for help.
- If the person you care about is not receiving any help or therapy then you could help them by offering to find information about therapies that might work for them.
- Learn about the disorder and find out whether there are any groups to support families and friends, as well as the person with BPD.
- You cannot give someone else a sense of self-worth. People with BPD have to find their own way to this, through therapy and hard work. But you can support and encourage them as they go through this process, which is likely to take time.
Getting help in an emergency
How can I get help in an emergency?
Finding help in a crisis or emergency
At times of great distress, you may feel you need to go to a place of safety. If you have previously used services, you may already have a care plan and a contact person to call. Otherwise you can:
- make an emergency appointment with your doctor or call your doctor's surgery out-of-hours service if the emergency is at night or the weekend
- call your mental health worker or care co-ordinator if you have one
- call your local mental health crisis team (see below)
- go to the accident and emergency department at your local hospital
- call 999.
What I needed was human contact and reassurance. Once I got to talk to someone on the crisis team and they put in place a follow-up meeting, I immediately felt that I would be able to cope better and not let my ever-changing emotions get out of control. I just wanted some understanding and to know someone cared.
Mental health crisis services
Most areas have a mental health crisis service; contact details are through your local council. They are available 24 hours a day, seven days a week and will:
- respond to a crisis within four hours wherever possible
- carry out assessments under the Mental Health Act 1983
- provide support and short-term help until another team is available or you no longer need help.
If you need help in a crisis and are assessed as a danger to yourself or to others you may be admitted compulsorily under the Mental Health Act. (See Mind’s guide to the Mental Health Act.)
In some areas there are crisis houses which may be run by social services or voluntary organisations and are free if you are offered a place. They usually take referrals from other services or allow you to refer yourself. Crisis houses do not admit people who are subject to the Mental Health Act.
A crisis house may have day services and beds for limited stays, plus various types of therapy and support, practical help with welfare benefits, housing issues, and training in life skills and problem solving. They link closely with other local services.
There may also be an out-of-hours telephone helpline. (See The Mind guide to crisis services).
Can I recover?
Can I recover from BPD?
There is evidence that BPD symptoms may get better over time, with or without treatment. Research suggests that the majority of people diagnosed with BPD improve in the long term (10 to 15 years), with 50 to 75 per cent no longer showing enough symptoms to meet the criteria for the diagnosis.
I no longer consider myself to have a diagnosis of borderline personality disorder. I have none of the symptoms and when I look around at other people I don't seem to be any different from anyone else.
NICE guidelines 2009
Remember that recovery may not be about getting rid of every symptom, and that people can learn to manage their condition better, gain control and aspire to a life worth living.
To regain control we can learn to live alongside our illnesses by re-thinking the way we think, to retrain the way we go about our daily lives and to learn to use our past experiences to guide us to where we want to be in life rather than carrying on the way we do.
Association for Cognitive Analytic Therapy (CAT)
Has a directory of accredited CAT practitioners.
Information and support to people with BPD, their families, friends and carers.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 705 4304
Lists CBT practitioners by specialism e.g. 'personality disorders'.
British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300
For practitioners in your area.
helpline: 0808 808 7777
Information and support for carers.
Support, advice and education for those affected by personality disorders.
tel. 0800 776 600
Free 24-hour national drugs helpline.
Institute for Complementary and Natural Medicine (ICNM)
tel. 020 7922 7980
Has a register of practitioners.
Information about mentalisation-based therapy (MBT).
Information about personality disorders, including BPD.
24-hour helpline: 08457 90 90 90
Freepost RSRB-KKBY-CYJK, Chris
PO Box 90 90
Emotional support for anyone feeling down, experiencing distress or struggling to cope
The Consortium for Therapeutic Communities (TCTC)
tel. 01242 620 077
Produces a directory of therapeutic communities.
UK Council for Psychotherapy (UKCP)
tel. 020 7014 9955
Has a directory of accredited psychotherapists.
To be reviewed 2014
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