Borderline personality disorder (BPD)

Causes of BPD

There isn’t a single known cause for BPD. Research suggests that a combination of factors, including genetic predisposition, developmental or psychological problems, neglect, abuse, or trauma during childhood, make some people more susceptible to developing BPD. Not everyone who develops BPD has experienced trauma as a child, nor does everyone who experiences trauma develop BPD.

Symptoms of BPD

To receive a diagnosis of BPD, a person needs to experience five of the following nine symptoms. 

Fear of abandonment

People with BPD can sometimes feel intense anxiety, fear or anger at the idea of being left alone or abandoned, even when this is unlikely to happen. They might make efforts to try and prevent the perceived abandonment, such as begging, fighting, arguing or threatening. 

All-or-nothing approach to relationships

People with BPD often views relationships in a black-or-white, all-or-nothing way, where they see the other person as either ‘perfect’ or ‘bad’, with no in between. They might struggle to resolve conflicts with others.

Uncertain identity

People with BPD might have sudden changes of mind about their careers,  values and types of friends they have. They might feel unsure about who they are as a person, or what they want to do in the future.   

Impulsiveness

People with BPD might behave impulsively as a way of easing their distress, despite the possible consequences. Some examples of impulsive behaviour are reckless driving, gambling, reckless spending, binge eating, unsafe sex and unsafe drug and alcohol use. 

Suicidal or self-harming behaviour

People with BPD might deliberately physically harm themselves as a way to distract or get relief from emotional distress. Thoughts of suicide, and suicide attempts, are also common in people living with BPD, due to the intense emotional states they experience.  

Emotional surges

People living with BPD are often emotionally sensitive. This means they can have sudden, intense emotional responses, even to minor events. Sometimes these emotions are positive and pleasant, but often they can be negative and overwhelming.  It can take a long time for the person to return to a more stable mood. Managing these rapid, unpredictable surges in emotion can be overwhelming and leave the person feeling out of control. 

Feelings of emptiness

People with BPD often describe feeling empty. Some describe it as a physical sensation in their chest or abdomen, like a hole that needs to be filled. These feelings can occur for a number of reasons, including being let down throughout life, expecting others to let them down, a lack of close relationships and shutting out feelings to stop the emotional surges. 

Inappropriate anger

Anger is a normal human emotion, but it is often felt unusually strongly by people with BPD, especially in relationships. They can struggle to cope with their anger, which can be expressed as aggressive or destructive behaviour or turned inwards, often leading to self-harm. Not everyone with BPD is aggressive or self-harms, but the behaviour associated with unchecked anger can cause problems for the person with BPD, their family, friends and others. 

Paranoia & dissociation

During times of stress, people with BPD may perceive threats or dangers that don’t exist. They may worry that others are judging them and respond by withdrawing from social groups or lashing out at people they perceive as a threat. People with a history of trauma may be hypersensitive to their environment in order to protect themselves from perceived dangers. 

Dissociation is the feeling of being ‘checked out’, as though you’re not inside your body. It’s a bit like driving on a route that you take every day and getting to your destination with no memory of how you got there or what happened during the drive. Dissociation is a way of coping with distress, and while in certain situations it may be helpful, people can do things while they are dissociated that are dangerous. 

How common is BPD?

Around 1% of the population is estimated to have BPD (Ellison, 2018). Around 10% of psychiatric outpatients are thought to have BPD, and the rate is around 20% for people who are inpatients on mental health wards (Ellison, 2018). Symptoms generally first appear in teenage years or early adulthood. 

Recovery

BPD is a serious and distressing experience, but the right treatments are generally effective and a high proportion of people with the condition recover to the point where they no longer meet the diagnosis, or can live a meaningful life even with symptoms. Most people with BPD who receive good treatment and support get significantly better over time, though some effects can linger. 

Many people with BPD still don’t get the diagnosis, treatment and support they need. Understanding of BPD is insufficient (among health professionals as well as the general public) and access to appropriate services is limited. But the situation is improving, and with the right treatment and support, people with BPD can and do live full, meaningful lives.

Getting a diagnosis

As with any health issue, the best place to start is your local general practitioner (GP). 

• Book a longer appointment so there is time to talk through your situation 

• Make notes beforehand on what’s happening with your physical and mental health, relationships, work or study, and take them along 

Your GP can refer you to a psychologist, psychiatrist or other mental health professional, who can then develop a treatment plan and work with you in the role of therapist. Some people with BPD also benefit from accessing a case manager. 

The therapist may work in private practice (which can involve out of pocket expenses, though rebates are often available) or in the public mental health system, in your local mental health service or a specialist BPD service (which may be free or low cost, but can involve a longer waiting list). Your GP, a case manager or a helpline can help you determine what services are available in your area and the best options for you. 

Your treatment team will need as much information as possible about you and the impact of BPD on your life, in order to make a good diagnosis and ensure effective therapy. You can help by being open and honest about the thoughts, feelings, and behaviour which concern you. The better the therapist understands, the better they’re able to help you. 

Related: What use is a diagnosis? • Being at the centre of the conversation about your mental health

“It was a relief for me and my family to be able to put a name to what I was experiencing and to learn my triggers”

— Stephanie

The term ‘borderline personality disorder’

When it was first identified in the 1930s, psychologists thought the symptoms of BPD were on the border between two other kinds of diagnosis, hence ‘borderline’. BPD is better understood now, but the title has stuck. The term ‘borderline’ doesn’t describe the symptoms of BPD or the people living with it, just the history of the diagnosis.

Some people dislike the term or believe other terms would describe the condition better. For example, some people believe that BPD should be relabelled as ‘Complex Post-Traumatic Stress Disorder’ (Complex PTSD). 

Psychological therapy and medication

Psychological therapy is the most effective treatment for BPD (NMHRC, 2012). In therapy you’ll work with your therapist to reduce your symptoms and help you manage feelings, behaviour, and relationships better, so you feel more in control. With effective therapy, you’ll feel calmer, happier in yourself, and better able to cope with the ups and down of life.

Effective psychological therapies for BPD include:

• Dialectical Behavioural Therapy (DBT)
• Cognitive Analytic Therapy (CAT)
• Mentalisation-Based Therapy (MBT)
• Schema Therapy (ST)

Your GP or therapist can explain these and discuss which is the most helpful for you and what might be accessible to you. Therapy can take from several months to a year or more, depending on your needs and the services in your area. 

Despite their differences in approach, therapies for BPD share common features (NHMRC, 2012): 

• The therapist and you have a shared understanding of the therapy, and a commitment to work together
• The therapist is suitably trained, supported, and supervised
• The therapist pays attention to your emotions, thoughts, and current challenges
• Therapy is focused on achieving change in your current life
• You work in equal partnership with your therapist
• You agree to play an active role in therapy by working with the therapist, and working to make choices that will help you recover
• Therapy helps you learn skills to manage suicidal feelings and self-harm
• There is a focus on the relationship between you and the therapist
• Therapy sessions happen regularly (generally at least once a week, where possible)

Medication is not a primary treatment for BPD, though it may be helpful during periods of emotional crisis, and can be prescribed for other conditions (NHMRC, 2012). Taking multiple medications for long periods of time is not generally required. Discuss with your doctor the benefits and side-effects of any medication before making an informed decision.

Admission to hospital is only recommended in the short-term, to deal with a crisis where someone is at risk of serious self-harm or suicide. It is best if a hospital stay is brief, with a specific aim agreed between the person with BPD and their doctor or therapist.

Related: Psychotherapy • Treatments for mental illness • dialectial behavioural therapy • Changing thinking styles for better mental health

Learning about BPD

Education is important. Find out as much as you can about BPD: the symptoms, effective treatments, and ways to keep yourself well. Learning about BPD empowers you to manage your symptoms, making them more predictable and less scary.

There is a lot of inaccurate and misleading information on the internet about BPD, so be sure to access reliable sources, like those listed at the end of this guide.

After months or even years of distress caused by the effects of BPD, many people say that receiving a diagnosis can actually be a relief. Not only is there a medical explanation at last of why you have been feeling and behaving this way, there is also the good news that effective treatments are available.

Looking after yourself

What's true for people with BPD is true for all of us: make sure you eat healthily, get regular sleep, exercise and fresh air every day, don't drink alcohol excessively, and do things that make you feel calm — listen to music, do yoga, mindfulness exercises, or anything else that helps. It's the calming effect that matters, not the method, so choose whatever works for you.

Of course, we’ve all heard this advice many times, and it's often easier said than done. However, when you have BPD it's doubly important to look after yourself. This is because looking after your body, and developing healthy habits, can help people feel more in control and better able to manage their emotions and stress. 

Set yourself small, easy-to-achieve goals and reward yourself when you reach them. Whatever the activity, you can strengthen your sense of self-worth, stability and control over your life just by regularly doing things that make you feel better.

Some people with BPD find it helpful to use mindfulness techniques when they feel distressed or overwhelmed by emotion. Mindfulness is a way of giving your mind a break from worries by focussing your attention on your breathing, body and surroundings.

Related: Healthy living • What mindfulness app is right for you? • Ten tips for sleep hygiene

Self-harm

Some people with BPD physically harm themselves. This is something that other people understandably find confronting and hard to understand. While self-harm can bring momentary relief and distraction from emotional distress, the effect is very short-term. It’s also damaging to your body and can lead to serious, even fatal, consequences.

Related: Self-harm • Self-care for self-harming behaviour

Managing suicidal thoughts

If you have suicidal thoughts sometimes, it’s a good idea to develop a safety plan so you can stay safe. When you're feeling calm, prepare a personal safety plan with your therapist or someone else you trust.

A safety plan includes strategies to delay, divert and distract yourself so when you feel the urge to self-harm, you can soothe yourself instead. Your plan will also include numbers of people and help services you can call in a crisis.

When you have a safety plan, make sure the people close to you know about it. Ask them to carry with them a simple summary of what to do and where to call for help if needed — in their phones, for example.

If you are at immediate risk, call 000 or visit your nearest hospital. For support with suicidal thoughts you can contact Lifeline on 13 11 14 or Suicide Call Back Service on 1300 659 467. 

Related: Finding help if you're feeling suicidal • Guide to staying alive

Relating to other people

Dealing with other people can be the most challenging part of having BPD. Relationships with family, friends, colleagues and others can be fraught with misunderstanding and confusion.

You might sometimes feel so distressed that you lose your temper, say things you later regret, or even say contradictory things about the same topic. On the other hand, feeling you don't have a safe way to express your anger can lead to your emotions turning inwards, sometimes leading to unhealthy coping mechanisms. 

The symptoms of BPD can affect your ability to communicate clearly and calmly. Practise strategies for better communication. For example:

• It can be helpful to prepare for difficult conversations, such as writing down what you want to communicate and how it makes you feel 
• It can be less stressful to discuss something when you’re out walking or doing another activity together, rather than staring at each other across a table 
• Recognise the warning signs that your emotions are becoming heightened when talking to other people. Say you need time out, give yourself permission to calm down and ask to meet again another time 

• Make an effort to imagine how things look and sound to the other person. Arguments are rarely black-and-white, and it helps to imagine the other perspective 
• When talking to someone about a distressing topic, consider having a third, independent person present 
• Remember that family and friends can find these situations upsetting too, and that they need understanding and support themselves 

Discuss with your therapist ways to manage your emotional responses and improve how you relate to other people. Doing this will reduce the distress caused by the surges of emotion you experience and the impact they have on your life.

Talk through one of these distressing episodes with your therapist or other suitable person. Treat it as a case study you can learn from. Discuss what was said and how it got out of control, and how next time you can manage it in a way that leads to a better outcome.

Related: Ten ways to get control of your anger

Finding support

Thousands of people in Australia have BPD, so you’re not alone. Sharing experiences, helpful information and tips can make a huge difference to how you feel and cope.

The BPD Foundation can help you find information and support. Talk to a treating health professional, your local GP or SANE's free counselling service about what support is available locally for people affected by mental health issues. 

Visit the SANE Forums to meet other people affected by mental health issues for peer support. 

Acknowledging BPD

People affected by BPD often feel great emotional insecurity and an unstable sense of self and their place in the world — including their own family. This can be challenging to manage in relationships. 

It's importantto recognise that the person with BPD is not choosing to behave like this. Their behaviour is an expression of, and a response to, the overwhelming and changeable emotions they’re experiencing. It’s a symptom of a complex mental health issue. 

Recognising and accepting this is the first step to improving family relationships, and to a less stressful, mentally healthier life for everyone involved. 

Find out about BPD and how other families manage it positively. Courses, support groups and online forums are all helpful ways to do this. Sometimes people use these to vent their very reasonable frustration, anger and despair. A good support group will acknowledge the turmoil BPD causes while focusing on positive strategies to help the family cope and thrive. 

Related: So you think your partner or friend has BPD

Listening with empathy

When someone is upset or angry, it's easy to be angry and emotional back at them. It’s a natural, understandable reaction, but not very helpful. A slower, calmer approach works better in general, but especially with people with BPD.

• Even when you don’t agree with everything that’s being said, give the person time to speak, and listen without expressing personal judgement or blame
• Empathise with the person, and imagine how distressed they must be feeling in order to be talking in that way
• Avoid sarcasm or other tones that can be misunderstood, and talk calmly, reflecting back their own words, to demonstrate that you have been listening

Related: Five tips for responding to someone who isn’t okay

Expressing yourself

Communicating calmly with someone doesn't mean you can't say how you feel. If you’re angry or frustrated by something, it doesn’t help to suppress it. Let the person know how you feel, but do so in a calm, matter-of-fact manner. Explain that this is how you are feeling and the reasons for it, so there is a better chance of resolving the issue.

Families affected by BPD explain how emotions can be contagious. While this often works in a negative way, you can turn it around to create an atmosphere of calm, setting the tone for everyone. 'Contagious calm' can be a surprisingly effective way of helping everyone feel they have had their turn and been heard, so you can move on to resolving disagreements.

It can be easier to talk about something while walking or doing something together outside, rather than staring at each other across a table. Suggest going for a walk together or doing something else outside that the person with BPD finds relaxing. Sometimes it can help to have a neutral third-party there too, as a kind of mediator.

As well as giving the person with BPD respect, you have a right to expect it too. If you need to set boundaries for what is acceptable behaviour, explain these clearly and calmly, giving your reasons.

Encouraging independence

It can be tempting to feel responsible for fixing the problems and difficulties of a loved one with BPD. This is a natural instinct, but it can be counter-productive, especially if they have BPD.

Offer support, but encourage self-care and independence. This will not only help them become more self-reliant, but also promote a better sense of self-respect and a stronger sense of existing as an independent being, less vulnerable to other people's attitudes and actions.

“Caring is constant and hard. It’s very important to look after yourself and stay connected. I know this from personal experience”

— Jo

Looking after yourself

Caring can be hard and carers often put their needs last, but it doesn’t have to be that way. Carers deserve care. Also, if your mental or physical health suffers as a result of being a carer, you are less able to help. 

You can't directly make someone with BPD get better. It's not your 'fault' they have the condition, and not your responsibility to 'cure' them. Recovery is something that people with BPD choose for themselves. Your contribution to this process is to be supportive while looking after your own health and wellbeing too. 

So whenever you can, take time to prioritise your own needs: eat healthily, get regular sleep, exercise and fresh air, keep your alcohol consumption down and do things that calm you — listen to music, do yoga, mindfulness exercises or anything else that helps. It's the calming effect that matters, not the method, so choose whatever works for you. 

This might seem like obvious advice, and it's easier said than done. But self-care has a powerful effect on people’s capacity to cope, and it's doubly important to look after yourself when you look after someone else too. 

When someone has experiences BPD, it's easy for the conditionto become the focus of the family's concern, with everyone else coming second or expected to look after themselves. So it’s important that everyone feels their needs are met. 

Related: Healthy living • Guide for families, friends & carers • Looking after yourself as a carer

Safety in a crisis

People with BPD have higher rates of self-harm and suicide than the general population. It can be really upsetting to know that someone is suicidal. If this is a concern in your family, it’s a good idea to develop a safety plan that includes strategies to delay, divert and distract from self-harm, and also the numbers of people and help services to call in times of high distress.

Discuss this with the person with BPD, who can develop a plan with support from their therapist.

When the person with BPD has their safety plan, ask for a simple summary of what to do that helps them to keep safe and where to call for help if needed — in your phone, for example.

If someone is suicidal, it is important to work with them on their safety where possible, and to encourage them to remove access to anything that could be used to harm them. 

If they are in immediate danger, contact 000 or visit your nearest hospital. You can also talk to Lifeline on 13 11 14 or Suicide Call Back Service on 1300 659 467 when someone is feeling suicidal, but not at immediate risk. 

Related: How to help when someone is suicidal • How to help in a crisis • Supporting someone having thoughts of suicide

Finding support

Thousands of families in Australia are affected by BPD, so you’re not alone. Sharing experiences, helpful information and tips can make a huge difference to how you feel and cope.

The BPD Foundation can help you find information and support. Talk to a treating health professional, your local GP or the SANE's free counselling service about what support is available locally for people affected by mental illness.

Visit the SANE Forums to meet other people in families affected by mental illness for peer support.

Related: What I wish I knew when I became a carer • Five tips to aid family recovery

On BPD

BPD Foundation

The BPD Foundation is a partnership of people with BPD, families, and clinicians working together to improve the lives of all those affected by the condition. The Foundation provides referrals to courses and support groups around Australia.

National Education Alliance of Borderline Personality Disorder Australia

Provides news, information and support for people living with BPD, families and health professionals.

Project Air Strategy for Personality Disorders

A NSW personality disorder initiative that works with health services, agencies, clinicians, families and carers, and people with personality disorders to provide information, treatment guidelines and resources, training, conferences and events, consultation, complex care reviews, and research. Project Air publishes a national Australian service directory.

Spectrum

A Victorian service that supports and works with local Area Mental Health Services to provide treatment for people with personality disorder.

Safety Planning

Beyondnow, Beyond Blue’s safety planning app & website

Clinical information in this resource is derived from the National Health and Medical Research Council, Clinical Practice Guideline for the Management of Borderline Personality Disorder.

Advice and review were provided by Spectrum, Project Air and the Australian BPD Foundation.

This SANE resource was created with support from The Vizard Foundation.

Ellison, W. D., Rosenstein, L. K., Morgan, T. A., & Zimmerman, M. (2018). Community and clinical epidemiology of borderline personality disorder. Psychiatric Clinics, 41(4), 561-573.

National Health and Medical Research Council. (2012). Clinical practice guideline for the management of borderline personality disorder.