What type of disorder is borderline personality disorder

This section has information on borderline personality disorder (BPD), including symptoms, causes and treatments. This information is for people affected by BPD in England who are 18 or over. It’s also for their carers, friends and relatives and anyone interested in this subject.

Borderline personality disorder is also called emotionally unstable personality disorder (EUPD) and emotional intensity disorder (EID). In this factsheet, we call it BPD as this is still the most common term for the condition. But we appreciate that all 3 terms can be controversial.

If you would like more advice or information you can contact our Advice and Information Service by clicking here.

• Overview
• About
• Symptoms
• Causes and treatment
• Problems and self-care
• Information for carers
• Further reading
• Useful contacts

About

What is borderline personality disorder (BPD)?

Everyone has different ways of thinking, feeling, and behaving. It is these thoughts, feelings, and behaviours that make up our ‘personality’. These are often called our traits. They shape the way we view the world and the way we relate to others. By the time we are adults these will make us part of who we are.

You can think of your traits as sitting along a scale. For example, everyone may feel emotional, get jealous, or want to be liked at times. But it is when these traits start to cause problems that you may be diagnosed as having a personality disorder.

BPD is a type of ‘personality disorder’.

BPD can affect how you cope with life, manage relationships, and feel emotionally. You may find that your beliefs and ways of dealing with day-to-day life are different from others. You can find it difficult to change them.

You may find your emotions confusing, tiring, and hard to control. This can be distressing for you and others. Because it is distressing, you may find that you develop other mental health problems like depression or anxiety. You may also do other things such as drink heavily, use drugs, or selfharm to cope.

Research shows that around 1 in 100 people live with BPD. It seems to affect men and women equally, but women are more likely to have this diagnosis. This may be because men are less likely to ask for help. BPD is sometimes called emotionally unstable personality disorder (EUPD). Some people feel that this describes the illness better.

Some people who live with BPD think that the name is insulting or makes them feel labelled. Doctors don’t use this term to make you feel judged or suggest that the illness is your fault. It is meant to describe the way the illness develops. It’s important to remember this is a health condition. And not a judgement of your character or you as a person.

Causes & treatment

What causes BPD?

There’s no single reason why some people develop borderline personality disorder (BPD). Professionals can’t use things like blood tests or brain scans to help diagnose people.

It is thought that BPD may be caused by a combination of factors:

• Genetics – you may be more vulnerable to BPD if a close family member also lives with BPD. There is no evidence though of a particular gene being responsible for BPD.
• Brain chemicals – problems with levels of your brain chemicals, particularly serotonin.
• Brain development – many people who live with BPD have smaller, or more active, parts of their brain. These parts of the brain are affected by your early upbringing. And can affect the regulation of your emotions, behaviour and self-control. They can also affect you planning and decision making.
• Environmental factors – a number of environmental factors seem to be common with people who live with BPD. These can include:
  • experiencing abuse,
  • experiencing long-term fear or distress as a child,
  • being neglected by 1, or both, of your care-givers as a child, and
  • growing up with a family member who had a serious mental health condition. Such as bipolar disorder or a problem with alcohol or drugs.

How can I get help if I think I have BPD?

The first step to get help is to speak to your GP.

Your GP will look at different things when deciding how best to help you. So, it can help to keep a record of your symptoms. This can help you and your GP to understand what difficulties you are facing. It may help if you keep a record of:

• how distressed you feel,
• any risks to yourself or other people, and
• details of anything you have done to try and reduce your levels of anxiety and distress.

Your GP can’t diagnose BPD. Only a psychiatrist should make a formal diagnosis. A psychiatrist is part of the community mental health team (CMHT). If your GP feels that you need more support they will refer you to the CMHT.

What happens if my GP refers me to the community mental health team (CMHT)?

There may be a waiting list to see your CMHT. You can ask your GP, or contact the CMHT, about how long the waiting list is.

When you have your first appointment with the CMHT they will ask you questions to understand how your mental health is affecting you. They will talk to you about:

• how you manage your day to day life, relationships and work,
• coping strategies that you use,
• your strengths,
• areas in your life that you find difficult.
• any other mental health problems you may have,
• any other social problems that you may have,
• any social care and support needs you may have,
• any support you may need in staying in your job, or finding a job,
• any psychological treatment you may need. This is also known as ‘talking therapy’, and
• the needs of any dependent children that you have.

How will the CMHT decide if I have BPD?
Psychiatrists use the following guidelines to decide if you have a mental disorder.

• International Classification of Diseases (ICD-10), produced by the World Health Organisation (WHO).
• Diagnostic and Statistical Manual of Mental Disorders (DSM-5), produced by the American Psychiatric Association.

The guidelines tell your psychiatrist what to look for. They will diagnose you with BPD if you have at least five of the symptoms below.

• Extreme reactions to feeling abandoned.
• Unstable and intense relationships with others
• Confused feelings about your self-image or your sense of identity.
• Being impulsive in ways that could be damaging. For example, spending, sex, substance abuse, reckless driving, and binge eating
• Regular self-harming, suicidal threats or behaviour.
• Long lasting feelings of emptiness or being abandoned.
• Inappropriate or intense anger. And difficulty controlling your anger. For example, losing your temper or getting into fights.
• Intense, highly changeable moods.
• Paranoid thoughts, or severe dissociation, when you’re stressed. Dissociation is a feeling of being disconnected from your own body. Or feeling disconnected from the world around you

You can find more information about:

• NHS Mental Health Teams (MHTs) by clicking here.
• Dissociation and dissociative disorders by clicking here.

What treatment should the NHS offer me?

You can check what treatment and care is recommended for BPD on the National Institute for Health and Care Excellence (NICE) website. NICE produce guidelines for how health professionals should treat certain conditions. You can download these from their website at:
www.nice.org.uk.

The NHS does not have to follow these recommendations. But they should have a good reason for not following them.

People who live with BPD have sometimes been excluded from NHS services because of their diagnosis. But the NHS should not refuse to give you specialist help because of your diagnosis. They should have services to support people with BPD.

If your local NHS doesn’t offer you appropriate treatment then there are things that you can do. For information about your options please see further down this page.

Should I be offered medication?

There is no medication to treat BPD. But your doctor may offer you medication if you also have symptoms of another mental illness like anxiety or depression.

What psychological treatment should I be offered?

Psychological therapy is also known as ‘talking therapy’. There are lots of different types of talking therapies and your doctor should talk to you about what is available, how it may help you and what type of therapy you would like.

We have included details below of some of the therapies that your doctor may use. But these are not available everywhere. And your doctor may recommend other types of talking therapy.

Your doctor will also think about:

• how much BPD is affecting you,
• how much you are willing to engage with therapy,
• if you want to change how react to your thoughts and feelings,
• if you will be able to work effectively with a counsellor, and
• the personal and professional support that is available.

The therapy you are offered should last at least 3 months. If your doctor decides that talking therapies are not suitable, they should explain why.

Dialectical behavioural therapy (DBT)
The guidance says that the NHS should offer DBT to women with BPD if they self-harm regularly.

DBT is a type pf therapy specifically designed to treat people with BPD. The goal of BPD is to help you accept that your emotions are real and acceptable. And to challenge how you respond to those emotions by being open to ideas and opinions which are different to your own.

DBT usually involves weekly individual and group sessions. And you should be given an out-of-hours contact number to call if your symptoms get worse.

DBT is based on teamwork. You'll be expected to work with your therapist and the other people in your group sessions. In turn, the therapists work together as a team.

Mentalisation-based therapy (MBT)
Mentalisation means the ability to think about thinking. This means looking at your own thoughts and beliefs. And working out if they are helpful and realistic.

This type of therapy also helps you to recognise that other people have their own thoughts, emotions and beliefs. And that you may not always understand these. The therapy also helps you to think about how your actions might affect what other people think or feel.

A course of MBT usually lasts around 18 months. You may first be offered MBT in a hospital as an inpatient. The treatment usually consists of daily individual sessions with a therapist and group sessions with other people with BPD.

Some hospitals and specialist centres like you to remain in hospital whilst you are having MBT. But others recommend that you leave the hospital after a certain period of time but remain being treated as an outpatient. This means that you will visit the hospital regularly.

Arts therapies
There are different types of arts of creative therapies. These include:

• art therapy,
• drama therapy,
• music therapy, and
• dance movement therapy.

These therapies can be offered individually but they are often done in groups. Sessions are usually weekly. These therapies can be helpful to people who find it hard to talk about their thoughts and feelings.

Therapeutic communities
Therapeutic communities are not a treatment themselves. They are places you can go to have treatment. Most therapeutic communities are residential. They help people with long-term emotional problems, and a history of self-harming, by teaching them skills to help them have better relationships.

These communities often set strict rules on behaviour. For example, no drinking alcohol, no violence and no attempts at self-harming.

You may stay for a few weeks or months, or you may visit for just a few hours a week. You may have group therapy and self-help sessions. You would be expected to take part in other activities to improve your self-confidence and social skills. These activities may include household chores, games and preparing meals.

Therapeutic communities vary a lot because they are often run by the people who use them. And they shape them based on what they want to achieve.

What happens if the CMHT can’t successfully treat me?

You may get support from a specialist service if your symptoms are getting worse. These specialist services are also called ‘Tier 3’ or ‘Tier 4’ services.

These services are not available in all NHS Trusts. And they can be difficult to access. You can speak to your CMHT and if they can refer you to a specialist service.

You can find more information about Tier 3 and Tier 4 services in our factsheet ‘Second Opinions’ by clicking here.

What treatment should I get if I am in crisis?

A mental health crisis is when you need urgent help. You may be feeling suicidal or wanting to self-harm. And you don’t think that you can use your normal coping strategies to stop yourself from acting on your feelings.

If you have a diagnosis of BPD but are not under the care of your local community mental health team (CMHT), then you should speak to your GP. Your GP should:

• assess the level of risk to yourself or others,
• talk to you about previous mental health crises. And what skills you have used to cope with these,
• help you to use these skills and focus on your current problems,
• help you to identify changes which you can put in place to manage your current problems, and
• offer you a follow-up appointment.

If you are already under the CMHT, or a specialist service, then you should have a care plan. The care plan should include a crisis plan that you can follow. Your crisis plan is written by you and your mental health team. It should include:

• what triggers might lead to a mental health crisis,
• self-management skills which you have used before and find helpful,
• details of how to access help if the self-management skills aren’t helping. This should include a list of support numbers for out-of-hours teams and crisis teams.

Your doctor may think about offering you sedative medication. Sedatives can help you feel more relaxed. But your doctor should not give you sedatives for more than a week.

Some people find it helpful to contact emotional support lines during a mental health crisis. There is a list of contact numbers at the bottom of this page.

You can find more information about ‘Getting help in a crisis’ by clicking here.

Problems & self-care

What risks and complications can BPD cause?

Self-harm

It is common for people who live with BPD to self-harm. Some people find self-harming can help them to deal with painful feelings. But it can cause serious injury, scars, infections, or accidental death. A big focus of BPD treatment is to find other ways to deal with painful emotions.

You can find more information about ‘Self-harm’ by clicking here.

Suicide

People who live with BPD are more at risk of suicide or of attempting suicide. Most people who live with BPD who feel suicidal will feel more positive within a few hours. So it is important to use techniques to try and distract from the strong suicidal feelings.

You can find more information about ‘Suicidal thoughts’ by clicking here.

Drugs and alcohol

People who live with BPD may:

• behave impulsively,
• drink too much alcohol,
• misuse prescription medication, or
• take illegal drugs.

You are more likely to die by suicide if you are also using alcohol. So If you are feeling suicidal you can help keep yourself safer by making sure that you don’t use alcohol.

You may be at an increased risk of becoming dependent on alcohol or drugs if you have BPD.

If you drink a lot of alcohol or use drugs, you may find it difficult to get treatment for BPD. But NICE guidelines state that you should be referred to a service that can help with your substance use. And you should be able to continue with BPD treatment where appropriate.

You can find more about ‘Drugs, alcohol and mental health’ by clicking here.

Impulsive behaviours

When people make decisions quickly without thinking about the consequences, doctors call this ‘impulsive’. This can include driving erratically or having multiple sexual partners. Or spending money on things you can't afford or don't need.

If impulsive behaviour leads you to have debt problems you can find more support and information at: www.mentalhealthandmoneyadvice.org.

What if I am not happy with my treatment?

If you are not happy with your treatment you can:

• talk to your doctor about your treatment options,
• ask for a second opinion,
• get an advocate to help you speak to your doctor,
• contact Patient Advice and Liaison Service (PALS) and see whether they can help, or
• make a complaint.

There is more information about these options below.

Treatment options

You should first speak to your doctor about your treatment. Explain why you are not happy with it. You could ask what other treatments you could try.

Tell your doctor if there is a type of treatment that you would like to try. Doctors should listen to your preference. If you are not given this treatment, ask your doctor to explain why it is not suitable for you.

Second opinion

A second opinion means that you would like a different doctor to give their opinion about what treatment you should have. You can also ask for a second opinion if you disagree with your diagnosis.

You don’t have a right to a second opinion. But your doctor should listen to your reason for wanting a second opinion.

Advocacy

An advocate is independent from the NHS. They are free to use. They can be useful if you find it difficult to get your views heard. There are different types of advocates available.

Community advocates can support you to get a health professional to listen to your concerns. And help you to get the treatment that you would like. This type of service doesn’t exist in all areas.

An NHS Complaints Advocate can help you if you want to complain about the NHS. This service exists in all areas.

To search for services, you can try the following.

• Use an internet search engine – use search terms like ‘advocacy Leicestershire’ or ‘mental health advocacy Devon’.
• Ask a support worker or key worker, if you have one.
• Ask your local council whether they have a list.
• Ask your local NHS Patient Advice and Liaison Service (PALS) whether they have a list of local advocacy services.
• Look at local service directories. You can sometimes find useful directories of mental health services online.
• Get in touch with organisations that offer advocacy such as Rethink Mental Illness, Mind, The Advocacy People, Voiceability and POhWER.

The Patient Advice and Liaison Service (PALS)

PALS is part of the NHS. They give information and support to patients.

You can find your local PALS’ details through this website link:
www.nhs.uk/Service-Search/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363.

You can find out more about:

• Medication. Choice and managing problems by clicking here.
• Second opinions by clicking here.
• Advocacy by clicking here.
• Complaining about the NHS or social services by clicking here.

What can I do to manage my symptoms?

You can learn to manage your symptoms by looking after yourself. Selfcare is how you take care of your diet, sleep, exercise, daily routine, relationships and how you are feeling.

Lifestyle

Making small lifestyle changes can improve your wellbeing and can help your recovery.

Routine helps many people with their mental wellbeing. It will help to give a structure to your day and may give you a sense of purpose. This could be a simple routine such as eating at the same time each day, going to bed at the same time each day and buying food once per week.

Breathing exercises

Breathing exercises can help to calm you when you are feeling anxious. You will get the most benefit if you do them regularly, as part of your daily routine.

There is more information about breathing exercises in the further reading section at the bottom of this page.

Support groups

You could join a support group. A support group is where people come together to share information, experiences and give each other support.

You might be able to find a local group by searching online. Rethink Mental Illness have support groups in some areas. You can find out what is available in your area if you follow this link: www.rethink.org/about-us/our-support-groups. Or you can call the Rethink Mental Illness Advice Service on 0808 801 0525 for more information.

Recovery College

Recovery colleges are part of the NHS. They offer free courses about mental health to help you manage your symptoms. They can help you to take control of your life and become an expert in your own wellbeing and recovery. You can usually self-refer to a recovery college. But the college may inform your care team.

Unfortunately, recovery colleges are not available in all areas. To see if there is a recovery college in your area you can use a search engine such as Google. Or contact Rethink Mental Illness Advice Service on 0808 801 0525.

You might also find some of the following things helpful.

• Make sure you speak to a doctor if you think that your relationships with others are being affected.
• Think about how you will benefit from making changes to your lifestyle.
• Don’t pay too much attention to the name of the condition. BPD is a common condition and it is not meant to label you or to suggest that your situation won’t change.
• If you’re offered group therapy or support, give it a chance. It may seem intimidating to start with, but a lot of people find it helpful in the long-run.
• If something annoys or upsets you, try to wait a while before responding. Think carefully about what you’re going to say and how you’re going to say it.
• Try to find ways of relaxing. Meditation, breathing techniques, listening to music and exercising may be helpful.
• Look for patterns in the ways you respond to things that upset you. This may help you to work through problems in relationships.
• If you self-harm to deal with distress, think of other ways to deal with this. Try punching a pillow or writing about how you feel.
• Use an online mental health forum. Make sure that you check with a mental health professional how trustworthy the website is for helpful information on BPD.

You can find more information about:

• Recovery by clicking here.
• Self-harm by clicking here.
• Suicidal feelings – how to cope by clicking here.

Further reading

North West Boroughs Healthcare NHS Foundation Trust
This NHS website has information dedicated to different breathing techniques. These techniques can help you when you feel anxious.

Website: www.nwbh.nhs.uk/healthandwellbeing/Pages/Breathing-Techniques-.aspx

Centre for Clinical Interventions
This website is provided by the department of Health in Western Australia. They have some useful information sheets and a workbook for people who are experiencing problems with coping with their feelings. And for people experiencing distress.

Website: www.cci.health.wa.gov.au/Resources/For-Clinicians/Distress-Tolerance

You can find out more about:

• Getting help in a crisis by clicking here.
• Suicidal thoughts - How to cope by clicking here.
• Self-harm by clicking here.
• Drugs, alcohol and mental health by clicking here.
• Carers assessment - Under the Care Act 2014 by clicking here.
• Confidentiality and information sharing - For carers, friends and family by clicking here.
• Worried about someone’s mental health by clicking here.
• Stress - How to cope by clicking here.

More resources

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