What are the Signs and Symptoms of Borderline Personality Disorder?

Borderline personality disorder (BPD) was once considered a relatively rare condition. Rates of lifetime prevalence were estimated at less than 2 percent of the adult population, and young people were excluded from the list of sufferers. It was also believed that BPD was far more pervasive among women than men.

But recent research has refuted these assumptions. The Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which collected medical information on more than 34,000 adults in 2004, proved that past estimates of BPD incidence were much too low—and furthermore, that ongoing diagnostic differences between men and women were not a true reflection of the disorder’s pattern of distribution.

In the NESARC data, 5.6 percent of men and 6.2 percent of women met the diagnostic criteria for borderline personality disorder. These numbers refer to lifetime incidence, and they reflect the fact that mental health professionals understand more about BPD than they did in the past and are better prepared to identify BPD traits when they are apparent.

And old assumptions about borderline personality in youth have also come into question. A 2008 Scandinavian study found that 1.4 percent of 16-year-olds were experiencing symptoms consistent with a BPD diagnosis, and this number climbed to 3.2 percent by the age of 22. Definitive studies into borderline personality disorder in children do not exist, but mental health experts now know that a certain percentage of children do suffer from at least some BPD symptoms.

As a severe mental health condition that alters thought, behavior, communication, and self-image, borderline personality disorder is associated with a diverse range of signs and symptoms, all of which can be grouped under one of four categories or dimensions:

1. Excessive and poorly regulated emotional responses
2. Impulsive behaviors that are harmful to self or others
3. Distorted perceptions (or self, others, and the world) and impaired reasoning
4. Behaviors and attitudes that create disturbed and unstable relationships

These are the defining facets of borderline personality disorder. In some individuals, one or more of these dimensions may be dominant, but other BDP sufferers experience symptoms that cover all of them.

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For diagnostic purposes, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists nine primary symptoms for borderline personality disorder. Five out of the nine must be detected before a mental health professional can make a diagnosis of BPD, although it is common for sufferers to demonstrate more than five.

The nine symptoms are:

1. Strong, largely irrational fears of abandonment accompanied by frantic, desperate efforts to avoid it
2. In the context of relationships, alternating periods of idealization (intense love and admiration) and devaluation (feelings of revulsion and disillusionment)
3. Persistently unstable self-image and sense of identity
4. Impulsivity in at least two areas that can cause damage to self or others (reckless spending, substance abuse, binge eating, compulsive gambling, unsafe driving, etc.)
5. Episodes of acute emotional disquiet (irritability, anxiety, or anguish) that last for hours or days
6. Chronic feelings of emptiness, meaninglessness, and low motivation
7. Explosive, intense bursts of uncontrollable anger
8. Outbreaks of dissociative symptoms marked by extreme paranoia, suspicion, and a disconnection from reality
9. Suicidal threats and actions and self-harming behavior (cutting, burning, pulling out hair, scratching the skin until it bleeds, etc.)

These symptoms can cause enormous emotional pain and discomfort, and they can have significant real-world consequences (suicide rates among BPD sufferers are an astonishing 10 percent).

If their condition remains undiagnosed or is left untreated, borderline personality disorder sufferers may live in a state of perpetual chaos or flux. They may be extremely sensitive to criticism, to the point where even casual remarks may precipitate an emotional crisis. They can become highly frustrated over the slightest disappointment and may act out their feelings by lashing out at others. Their stress responses are often exaggerated, and they may lapse into deeply pessimistic moods in the blink of an eye.

As a result of their emotional instability, BPD sufferers may struggle to find or hold jobs, constantly change their life plans or belief systems, frequently jump in and out of friendships or romantic relationships, get mixed up with cults or become obsessed with self-help gurus. They may be drawn to people who actually do misuse and abuse them, adding new layers of trauma onto an already difficult situation. They may find happiness elusive, and their ability to succeed can be severely compromised.

Despite the latest findings that suggest men and women suffer from borderline personality disorder equally, women are still being diagnosed far more frequently. When men with BPD symptoms ask for help (which doesn’t always happen), they tend to be misdiagnosed with other conditions, such as bipolar disorder, ADHD, post-traumatic stress disorder (PTSD), intermittent explosive disorder, or depression.

Some mental health professionals may have an unconscious bias that assumes BPD is much more common in women, and that may interfere with their ability to detect BPD in men even when it is present. Also, because women are treated more frequently, their symptoms have gained a default status as the “official” face of borderline personality disorder, making it difficult for psychiatrists and psychologists to recognize BPD symptoms in men that don’t quite fit their expectations.

The overall symptomatic profile for borderline personality disorder is largely the same for men and women. Nevertheless, there are some differences in the way the symptoms of BPD manifest in the two genders.

In general, men with BPD are:

• Highly sensitive to criticism, and aggressive in response to perceived insults or put-downs
• Overly controlling in relationships
• Intensely jealous and possessive
• Quick to become disillusioned with others, and openly expressive of their contempt
• Subject to mood changes that happen in an instant
• Excessively irritable and prone to episodes of explosive anger
• Likely to compensate for feelings of inadequacy through risky, dangerous behavior

As this list reveals, BPD in men often has an aggressive or assertive edge, which is not seen as frequently with BPD in women.

This can lead to unpleasant and unsympathetic behavior that alienates others and leads them to react in anger. Rather than offering assistance or encouragement, family members and friends may abandon or distance themselves from men with BPD, and without loved ones encouraging them to seek help they may never recognize the nature and depth of their problem.

Co-occurring disorders are common among BPD sufferers, but women with BPD are more likely to have multiple disorders than men. In virtually every category of co-occurring illness, women have higher rates of diagnosis. However, there are two notable exceptions to this pattern.

First, men with BPD are more likely to develop a substance use disorder than women with BPD (58 percent versus 44 percent past-year incidence in one study). Second, they are much more likely to be diagnosed with antisocial personality disorder, which is far from surprising given the hostility and aggressiveness that so often accompanies BPD in men.

Alcohol and drug abuse are a familiar coping mechanism for people with mental health disorders, and men with borderline personality disorder have a lifetime risk for substance abuse of above 80 percent. Because of their substance abuse issues, men with BPD often choose alcohol and drug rehab over other forms of treatment, incorrectly assuming all of their problems are caused by drugs and alcohol.

Adolescents tend to experience the same symptoms as adults suffering from borderline personality disorders.

However, they may not develop enough of those symptoms to qualify for a BPD diagnosis (five of the nine primary symptoms must be present in some form for a diagnosis to be made). What many adolescents (and children) experience is BPD in development, where a foundation is set for future encounters with a full-blown version of the disorder.

Children can also demonstrate the traits of borderline personality disorder. Kids exhibiting BPD signs tend to manifest what are normally categorized as childish behaviors, only in a more exaggerated form.

In comparison to other children, they are more:

• Demanding of time and attention
• Prone to tantrums and fits of rage
• Easily frustrated
• Restless and unfocused
• Sensitive to criticism
• Likely to suffer separation anxiety
• Subject to physical symptoms of anxiety (stomach cramps, headaches, eating or swallowing difficulties, etc.)

It is easy to see why such symptoms of BPD could be overlooked or dismissed as “kids being kids.” Diagnosing borderline personality disorder in children is a complicated process, and anyone with a child experiencing symptoms consistent with the disorder should consult with a child psychiatrist for evaluation and advice.

Regardless of gender, age, or background, individuals with borderline personality disorder can overcome their self-destructive and disabling symptoms, with the help of professionals trained to treat BPD.

Adult treatment regimens will likely include various types of therapy proven effective against the symptoms of BPD, medication (mood stabilizers and antipsychotics are preferred), holistic mind-body healing methods, education and life skills classes, and family-based interventions that can help everyone impacted by BPD.

For many individuals with BPD, a personalized inpatient program administered at a high-quality residential treatment center is an important first step on the road to lasting recovery. This is especially true for BPD sufferers with co-occurring disorders, who need comprehensive and multi-dimensional assistance to overcome their challenges.

Treatment services for adolescents and children are available as well, but they will not be as comprehensive, would only occur on an outpatient basis (with the occasional exception for an adolescent suffering severe BPD symptoms), and are less likely to involve the use of medication.

Research shows the vast majority of BPD sufferers can expect improvement in their symptoms over time, and treatment can help expedite this process and bring relief and recovery sooner rather than later.

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