Borderline: A Disorder in Search of Itself

Borderline Personality Disorder (BPD) is very often misdiagnosed as something else. In fact, back in the 1980s, a group of psychiatrists conducted a clinical trial and decided it wasn’t a personality disorder (Aklskal et al., 1985). Instead, they pointed to the similarity of its symptoms to other disorders, like MDD, bipolar disorders, and psychotic disorders.

Today, the medical community remains divided about the scientific validity of BPD as a personality disorder (Mulder & Tyrer, 2023). At the same time, a single Google search will reveal considerable stigma toward the disease- to the point that some doctors refuse to give a BPD diagnosis (Fruzzetti, 2017). How can something that “doesn’t exist” have such a bad reputation?

Here are some facts about BPD from our podcast. You be the judge.

Definition
The DSM 5-TR defines BPD as “A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts” (American Psychiatric Association, 2022).

Diagnostic Criteria

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least 2 areas that are potentially self-damaging (such as spending, sex, substance abuse, reckless driving, binge eating)
  5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms. (American Psychiatric Association, 2022).

Prevalence Rates
In the general population, 2.7%-6% of Americans are estimated to have BPD, according to the National Institutes of Health (Have et al., 2016). Women have a slightly higher prevalence than men; however, they are disproportionately diagnosed with BPD. Those with a family income under 20,000 a year or without a high school diploma also have a higher prevalence, suggesting a relationship between BPD and socio-economic status. BPD is highest in people under 30 and people who are not married (American Psychiatric Association, 2022). It’s also more prevalent in the LGBTQ+ community, with queer adults likely to meet a high number of diagnostic criteria (Denning et al., 2022). There are also racial and ethnic differences. Native American (5%) and Black individuals (3.5%) are more likely to have BPD than white (2.7%) or Latinx (2.5%) populations. Asian Americans reported the lowest rates of the disorder at 1.2% (Have et al.)

Potential Impact to Social Functioning
BPD often leads to chaotic or dysfunctional relationships, making intimacy difficult to sustain. Career success may be impacted by a lack of self-directed goals, leading to a lower SES (American Psychiatric Association, 2022). Studies have linked BPD to deficits in trust and cooperation (Lazarus et al., 2014), along with decreased cognitive empathy, or “people-reading” skills. (Jeung & Herpertz, 2014). People with BPD tend to have more hospitalizations and place a greater burden on the healthcare system. The most significant risk for people with BPD is death from suicide (Jacobi et al., 2021). 

Etiology Theories
BPD may have a genetic correlation to other mental health conditions that are also genetic, meaning those with mental illness in the family are more likely to have BPD. There is also a link to trauma, such as child abuse or neglect. Finally, people with BPD show differences in the brain, specifically in the areas that affect emotions, aggression, and delayed gratification (Mayo Clinic, 2024).

Psychosocial and Psychopharmacological Interventions
BPD was considered untreatable until the 1990s. That’s when Dr. Marsha Linehan created Dialectical Behavioral Therapy. Linehan built on CBT with mindfulness, distress tolerance, emotional regulation, and interpersonal skills (Dialectical Behavioral Therapy, 2025). Today, DBT is still considered the most effective treatment for BPD (Cristea et al., 2017). It is also used for depression, anxiety, substance use, non-suicidal self-injury, eating disorders, ADHD, and PTSD (Dialectical Behavioral Therapy, 2025). 

Other evidence-based therapies for BPD are Schema Focused, which is CBT-based, as well as Mentalization Based and Transference Focused, which are psychodynamic (Levy et al., 2018). There is still no approved medication for the treatment of BPD, as many psychiatrists believe it isn’t a scientifically valid construct (Confue et al., 2025). Most people with BPD have prescriptions for co-occurring conditions. Sometimes anticonvulsants or antipsychotics are used off label to reduce volatility or regulate emotion (Gartlehner et al., 2021). Since these are off-label uses, there aren’t a lot of funded trials, and there is limited confidence in how well they work. While there may be some side effects with any medication, anticonvulsants and antipsychotics are relatively common and not high-risk.

What Do You Think?
Many people with BPD have experienced abuse, neglect, or another traumatic event in childhood. Recently, it’s been suggested that the disorder be renamed Complex PTSD. Would that make sense? What do you think of BPD? To see something super stigmatizing, check out this bestselling book first published in 1989. It was most people’s introduction to BPD, and it wasn’t a great first impression. To hear from those who think BPD is “spurious,” see this article by two New Zealanders here. They don’t hold back.

References *(see Word Document submission for APA7 formatted reference list)
Aklskal, H.S., Chen, S.E., Davis, G. C., Puzantian, V.R., Kashgarian, M., & Bolinger,
J.M. (1985). Borderline: An adjective in search of a noun. Journal of Clinical Psychiatry,46(2), 41-48.  PMID: 3968045.

American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).  https://doi.org/10.1176/appi.books.9780890425787

Confue, J., Maidment, I., Jones, S., & Jones, M. (2025). Factors that influence prescribing in borderline personality disorder: A systematic review. Personality and Mental Health, 19(2). https://doi.org/10.1002/pmh.70014

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuiipers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319-328. https://doi.10.1001/jamapsychiatry.2016.4287

Denning, D.M., Newlands, R. T., Gonzales, A., & Benuto, L.T. (2022). Borderline personality disorder symptoms in a community sample of sexually and gender diverse adults. Journal of Personality Disorders, 36(6), 701-716. http://doi.10.1521/pedi.2022.36.6.701

Dialectical Behavioral Therapy. (2025). DBT: Dialectical behavioral therapy. https://dialecticalbehaviortherapy.com

Duckworth, K. (2017, June 12). Borderline personality disorder and bipolar disorder: What’s the difference? National Alliance on Mental Illness. https://www.nami.org/advocate/borderline-personality-disorder-and-bipolar-disorder-whats-the-difference/

Fruzzetti, A.E. (2017, October 3). Why borderline personality disorder is misdiagnosed. National Alliance on Mental Illness. https://www.nami.org/advocate/why-borderline-personality-disorder-is-misdiagnosed/

Gartlehner, G., Crotty, K., Kennedy, S. Edlund, M.J., Ali, R., Siddiqui, M., Fortman, R., Wines, R., Persad, E., & Viswanathan, M. (2021). Pharmacological treatments for borderline personality disorder: A systematic review and meta-analysis. (2021). CNS Drugs, 35(10), 1053-1067. https://doi.10.1007/s40263-021-00855-4

Have, M.T., Verheul, R., Kaasenbrood, A., van Dorsselaer, S., Tuithof, M., Kleinian, & de Graaf, R.D. (2016). Prevalence rates of borderline personality disorder symptoms:  A study based on the Netherlands Mental Health Survey and Incidence Study-2. BMC Psychiatry, 16, 249.  https://doi.10.1186/s12888-016-0939-x

Jacobi, F., Grafiadeli, R., Volkmann, H., & Schneider, I. (2021).  Disease burden of borderline personality disorder: Cost of illness, somatic comorbidity and mortality. Nervenarzt, 92(7), 660-669. https://doi.10.1007/s00115-021-01139-4

Jeung, H., & Herpertz, S.C. (2014). Impairments of interpersonal functioning: Empathy and intimacy in borderline personality disorder. Psychopathology 47 (4), 220–234. https://doi.org/10.1159/000357191

Lazarus, S.A., Cheavens, J.S., Festa, F., & Rosenthal, M.Z. (2014). Interpersonal functioning in borderline personality disorder: A systematic review of behavioral and laboratory-based assessments. Clinical Psychology Review, 34(3), 193-205. https://doi.org/10.1016/j.cpr.2014.01.007

Levy, K.N., McMain, S., Bateman, A., & Clouthier, T. (2018). Treatment of borderline personality disorder. Psychiatric Clinics, 41(4), 711-728. https://doi.org.10.1016/j.psc.2018.011

Mayo Clinic. (2024, January 31). Borderline personality disorder. https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237

Mulder, R., & Tyrer, P. (2023). Borderline personality disorder: A spurious condition unsupported by science that should be abandoned. Journal of the Royal Society of Medicine, 116(4), 148-150.  https://doi.10.1177/01410768231164780

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