Borderline Personality Disorder

21 Sep 2007
BOR DERLINE PERS ONA LI TY DISOR DER
Borderline Personality Disorder Treatment
by John M. Grohol, Psy.D. - June 22, 2007
Table of Contents
Introduction
•
Psychotherapy
•
Hospitalization
•
Medications
•
Self-Help
•
Introduction
Borderline personality disorder is a disturbance of certain brain functions that causes four
types of behavioral disturbances:
1. poorly regulated and excessive emotional responses;
2. harmful impulsive actions;
3. distorted perceptions and impaired reasoning; and
4. markedly disturbed relationships.
The symptoms of borderline personaliy disorder
were first described in the medical literature over
3000 years ago. The disorder has gained
increasing visibility over the past three decades.
The full spectrum of symptoms of bordelrine
personality disorder typically first appears in the
teenage years and early twenties. Although some
children with significant behavioral disturbances
may develop readily diagnosable borderline
disorder as they get older, it is very difficult to
make the diagnosis in children.
After its onset, the disorder becomes chronic.
Remissions, relapses, and overall significant
improvement with treatment is the most common
course of the illness. Borderline disorder appears to
be caused by the interaction of biological, usually
genetic, and environmental risk factors, such as
poor parental nurturing, and early and sustained
emotional, physical or sexual abuse.
Physical disorders, such as migraine headaches, and other mental disorders, such as
depression, anxiety, panic and substance abuse disorders, occur much more often in
people with borderline disorder than they do in the general population.

Borderline Personality Disorder is experienced in individuals in many different ways.
Often, people with this disorder will find it more difficult to distinguish between reality
from their own misperceptions of the world and their surrounding environment. While
this may seem like a type of delusion disorder to some, it is actually related to
their emotions overwhelming regular cognitive functioning.
People with this disorder often see others in “black-and-white” terms. Depending
upon the circumstances and situation, for instance, a therapist can be seen as being very
helpful and caring toward the client. But if some sort of difficulty arises in the therapy, or
in the patient’s life, the person might then begin characterizing the therapist as “bad”
and not caring about the client at all. Clinicians should always be aware of this “all-or-
nothing” lability most often found in individuals with this disorder and be careful not to
validate it.
Therapists and doctors should learn to be like a rock when dealing with a person who
has this disorder. That is, the doctor should offer his or her stability to contrast the
client’s lability of emotion and thinking. Many professionals are turned-off by working
with people with this disorder, because it draws on many negative feelings from the
clinician. These occur because of the client’s constant demands on a clinician, the
constant suicidal gestures, thoughts, and behaviors, and the possibility of self-mutiliating
behavior. These are sometimes very difficult items for a therapist to understand and
work with.
Psychotherapy is nearly always the treatment of choice for this disorder;
medications may be used to help stabilize mood swings. Controversy surrounds
overmedicating people with this disorder.
Psychotherapy
Like with all personality disorders,
psychotherapy is the treatment of
choice in helping people overcome this
problem. While medications can usually
help some symptoms of the disorder,
they cannot help the patient learn new
coping skills, emotion regulation, or any
of the other important changes in a
person’s life.
An initially important aspect of
psychotherapy is usually contracting
with the person to ensure that they do
not commit suicide. Suicidality should
be carefully assessed and
monitored throughout the entire course of treatment. If suicidal feelings are
severe, medication and hospitalization should be seriously considered.
The most successful and effective psychotherapeutic approach to date has been Marsha
Linehan’s Dialectical Behavior Therapy. Research conducted on this treatment have
shown it to be more effective than most other psychotherapeutic and medical approaches
to helping a person to better cope with this disorder. It seeks to teach the client how to
learn to better take control of their lives, their emotions, and themselves through self-
knowledge, emotion regulation, and cognitive restructuring. It is a comprehensive
approach that is most often conducted within a group setting. Because the skill set

learned is new and complex, it is not an appropriate therapy for those who may have
difficulty learning new concepts.
Like all personality disorders, borderline personality disorder is intrinsically difficult to
treat. Personality disorders, by definition, are long-standing ways of coping with the
world, social and personal relationships, handling stress and emotions, etc. that often do
not work, especially when a person is under increased stress or performance demands in
their lives. Treatment, therefore, is also likely to be somewhat lengthy in duration,
typically lasting at least a year for most.
Other psychological treatments which have been
used, to lesser effectiveness, to treat this disorder
include those which focus on social learning theory
and conflict resolution. These types of solution-
focused therapies, though, often neglect the core
problem of people who suffer from this disorder —
difficulty in expressing appropriate emotions (and
emotional attachments) to significant people in their
lives due to faulty cognitions.
Providing a structured therapeutic setting is
important no matter which therapy type is
undertaken. Because people with this disorder often
try and “test the limits” of the therapist or
professional when in treatment, proper and well-
defined boundaries of your relationship with the
client need to be carefully explained at the onset of therapy. Clinicians need to be
especially aware of their own feelings toward the patient, when the client may display
behavior which is deemed “inappropriate.” Individuals with borderline personality
disorder are often unfairly discriminated against within the
broad range of mental health professionals because they
are seen as “trouble-makers.” While they may indeed need
more care than many other patients, their behavior is
caused by their disorder. Phillip W. Long, M.D. also notes
that:
“The therapeutic alliance should form within the patient’s
real experiences with the therapist and with the treatment.
The therapist must be able to tolerate repeated episodes of
primitive rage, distrust, and fear. Uncovering is to be
avoided in favor of bolstering of ego defenses, in order to eventually allow the patient to
be less anxious about potential fragmentation and loss. The goals of therapy should be in
terms of life gains toward independent functioning, and not complete restructuring of the
personality.”

Hospitalization
Hospitalization is often a concern with people who
suffer from borderline personality disorder because
they so often visit hospital emergency rooms and
are sometimes seen on inpatient units because of
severe depression.
People with this disorder often present in crisis at
their local community mental health center, to their
therapist, or at the hospital emergency room. While
an emergency room is an immediate source of crisis
intervention for the patient, it is a costly treatment
and regular visits to the E.R. should be discouraged.
Instead, patients should be encouraged to find
additional social support within their community
(including self-help support groups), contact a crisis
hotline, or contact their therapist or treating
physician directly.
Emergency room personnel should be careful not to treat the person with borderline
personality disorder in blind conjunction with another set of therapists or doctors who are
treating the patient for the same problem at another facility. Every attempt should be
made to contact the client’s attending physician or primary therapist as soon as possible,
even before the administration of medication which may be contraindicated by the
primary treatment provider. Crisis management of the immediate problem is usually the
key component to effective treatment of this disorder when it presents in a hospital
emergency room, with discharge to the patient’s usual care provider.
Inpatient treatment often takes the form of medication in conjunction with psychotherapy
sessions in groups or individually. This is an appropriate treatment option if the person is
experiencing extreme difficulties in living and daily functioning. It is, however, relatively
rare to be hospitalized in the U.S. for this disorder. Long-term care of the person
suffering from borderline personality disorder within a hospital setting is nearly never
appropriate. The typical inpatient stay for someone with borderline personality disorder in
the U.S. is about 3 to 4 weeks, depending upon the person’s insurance. Since this
treatment is so expensive, it is getting more difficult to obtain. Results of such treatment
are also mixed. While it is an excellent way of helping stabilize the client, it is usually too
short a time to attain significant changes within the individual’s personality makeup.
Good inpatient care facilities for this disorder should be highly structured environments
which seek to expand the individual’s independence. Phillip W. Long, M.D., adds that the
goals of such a treatment modality, “include decreasing acting out, clearly identifying and
working with inappropriate behaviors and feelings, accepting with the patient the
magnitude of the therapeutic task, fostering more effective interpersonal relationships,
and working with both real and transference relationships within the hospital.”
Partial hospitalization or a day treatment program is often all that’s needed for people
who suffer from borderline personality disorder. This allows the individual to gain support
and structure from a safe environment for a short time, or during the day, and returning
home in the evening. In times of increased stress or difficulty coping with specific
situations, this type of treatment is more appropriate and more healthy for most people
than full inpatient hospitalization.

Medications
Phillip W. Long, M.D. has noted:
Medications play three very important roles in the
treatment of most patients with borderline disorder. They
are effective in reducing the four major groups of
symptoms of the disorder. They thereby enhance the rate
and quality of improvement derived from psychotherapy.
Finally, medications are effective in treating other
emotional disorders that frequently are associated with
borderline disorder, for example, depression,
anxiety/panic attacks, and ADHD, and physical disorders
such as migraine headaches.
“During brief reactive psychoses, low doses of
antipsychotic drugs may be useful, but they are usually
not essential adjuncts to the treatment regimen, since
such episodes are most often self-limiting and of short
duration.
It is, however, clear that low doses of high potency neuroleptics (e.g., haloperidol) may
be helpful for disorganized thinking and some psychotic symptoms. Depression in some
cases is amenable to neuroleptics. Neuroleptics are particularly recommended for the
psychotic symptoms mentioned above, and for patients who show anger which must be
controlled. Dosages should generally be low and the medication should never be given
without adequate psychosocial intervention.”
Antidepressant and anti-anxiety agents may be appropriate during particular times in the
patient’s treatment, as appropriate. For example, if a client presents with severe suicidal
ideation and intent, the clinician may want to seriously consider the prescription of an
appropriate antidepressant medication to help combat the ideation. Medication of this
type should be avoided for long-term use, though, since most anxiety and depression is
directly related to short-term, situational factors that will quickly come and go in the
individual’s life.
Treatment for Depression Co-occurring
with Borderline Disorder
If you think you have the symptoms of either type of
depression, immediately alert your psychiatrist. If
appropriate, the treatment for depression frequently
involves the addition of an antidepressant, an increase
in dosage if one is already being used, and/or the use of
behavioral techniques.
There are no controlled studies on the relative
effectiveness of different antidepressants for the
treatment for depression in people with borderline
disorder. However, studies of these disorders in people
without borderline disorder, and experience, suggest
that the following initial treatment strategies may have
merit:

Treatment for Depression in Bipolar Disorder-Depressed
• Bupropion (Wellbutrin®)
• Lamotrigine (Lamictal®)
• SSRIs such as fluoxetine (Prozac®) or sertraline (Zoloft®) if bupropion and
lamotrigine are ineffective
Treatment for Depression in Major Depressive Disorder
• SSRIs such as fluoxetine or sertraline
• Bupropion and lamotrigine if SSRIs are ineffective
Note: It is important in the treatment for depression to recognize that some
antidepressants may cause an episode of mania or hypomania in patients with
depression who have never experienced such episodes in the past.
Cognitive Behavioral Therapy focused on treatment for depression may also prove
useful to help identify thought patterns and behaviors that operate as risk factors for
mood disorders, and to encourage new, more successful behaviors.
* Bipolar I and II, and major depressive disorders occur more commonly in patients with
borderline disorder than they do in the general population. Bipolar II disorder is the most
common type of bipolar disorder that occurs with borderline disorder. People with bipolar
II disorder do not experience manic episodes as do those with bipolar I disorder, but do
experience brief hypomanic periods and recurring episodes of depression. Depressions
associated with bipolar disorder appear to be related to depressions referred to as
atypical depression and seasonal affective disorder (SAD).
Self-Help
Self-help methods for the treatment of this disorder are often
overlooked by the medical profession because very few
professionals are involved in them. Encouraging the individual
with borderline personality disorder to gain additional social
support, however, is an important aspect of treatment. Many
support groups exist within communities throughout the
world which are devoted to helping individuals with this
disorder share their commons experiences and feelings.
Patients can be encouraged to try out new coping skills and
emotion regulation with people they meet within support
groups. They can be an important part of expanding the
individual’s skill set and develop new, healthier social
relationships.
Education and Support
During the past decade, an increasing number of educational and support groups have
been formed for patients with borderline disorder, and for their families. Many of these
have been the result of the efforts of lay advocacy groups dedicated to increasing
knowledge about, and reducing the stigma associated with borderline disorder.

Patient and Family Educational Programs
A growing number of educational programs are being conducted for people with
borderline disorder and their families. These are often co-sponsored by community
organizations working with the assistance of consumer and family organizations such as
the National Education Alliance for Borderline Personality Disorder (NEA-BPD), the
Treatment and Research Advancements National Association for Personality Disorder
(TARA), and the National Alliance on Mental Illness (NAMI).
A recent addition to the therapeutic opportunities for family members of people with
borderline disorder has been the introduction of family educational and training
programs.
Family Connections
The family education program, Family Connections (FC), is available in multiple locations
throughout the US, and at several locations in Canada, Europe and the UK. It operates
under the auspices of NEA-BPD with research funding from the National Institute of
Mental Health. Experienced family members co-lead the 12-week manualized series of
sessions for other families. These sessions provide
participants with the most current information and
research about borderline disorder, teach DBT and
family coping skills, and provide an opportunity to
develop a support network.
Research documents a reduction in family member
depression, burden, and grief and an increase in
coping skills. No registration fee is required, but in
some locations a donation to cover costs of the
course materials is suggested.
Family-to-Family
The National Alliance on Mental Illness (NAMI) has
recently designated borderline disorder as a “priority
population.” In doing so, NAMI has now extended its
popular 12 week Family Education Program to
include this disorder. The course is taught by trained
NAMI volunteers in every state in the country. It
provides a broad range of information essential to
those caring for loved ones with borderline and
other serious mental disorders.
Family Training Workshop
TARA sponsors an eight session DBT family training workshop in New York City and other
cities across the country. The main goals of the program are similar to that provided by
NEA-BPD. Each training cycle is limited to sixteen members, and a registration fee is
required.
Support Groups
In some communities, groups of people with borderline disorder and family members
meet on a regular basis, without a therapist or trained and skilled group leader, to help
one another. Such support groups typically do not charge members a fee and can be
very beneficial for the reasons cited above for therapist-assisted group therapy.

There are two types of support groups:
• groups for the person with borderline disorder
• groups for their family members
Although it may be helpful, participation in such groups should be approached with
caution by the person with borderline disorder or family members. Considerable harm
can be done if one or more individuals in the group act in an angry, manipulative,
malicious, or otherwise inappropriate and destructive way toward another group member
or the group as a whole. Without a skilled leader or facilitator present to step in to handle
the situation promptly and properly, a member of the group, and even the group itself,
may be exposed to significant trauma.
Prior to joining a support group, it is wise to seek recommendations about groups in your
community from your nearest NAMI Chapter, or from mental health professionals
working with patients with borderline disorder. In addition, it may be helpful to request
information from members of such groups before joining.
Symptoms of Borderline Personality Disorder
by John M. Grohol, Psy.D. - June 22, 2007
The main feature of borderline personality disorder (BPD) is a pervasive pattern of
instability in interpersonal relationships, self-image and emotions. People with borderline
personality disorder are also usually very impulsive.
This disorder occurs in most by early adulthood. The instable pattern of interacting with
others has persisted for years and is usually closely related to the person’s self-image
and early social interactions. The pattern is present in a variety of settings (e.g., not just
at work or home) and often is accompanied by a similar lability (fluctuating back and
forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships
and the person’s emotion may often be characterized as being shallow.

A person with this disorder will also often exhibit impulsive
behaviors and have a majority of the following symptoms:
Frantic efforts to avoid real or imagined abandonment
•
A pattern of unstable and intense interpersonal relationships characterized by
•
alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or sense of
•
self
Impulsivity in at least two areas that are potentially self-damaging (e.g.,
•
spending, sex, substance abuse, reckless driving, binge eating)
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
•
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)
Chronic feelings of emptiness
•
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays
•
of temper, constant anger, recurrent physical fights)
Transient, stress-related paranoid ideation or severe dissociative symptoms
•
Details about Borderline Personality Disorder Symptoms
Frantic efforts to avoid real or imagined abandonment.
The perception of impending separation or rejection, or the loss of external structure, can
lead to profound changes in self-image, emotion, thinking and behavior. Someone with
borderline personality disorder will be very sensitive to things happening around them in
their environment. They experience intense abandonment fears and inappropriate anger,
even when faced with a realistic separation or when there are unavoidable changes in
plans. For instance, becoming very angry with someone for being a few minutes late or
having to cancel a lunch date. People with borderline personality disorder may believ that
this abandonment implies that they are “bad.” These abandonment fears are related to
an intolerance of being alone and a need to have other people with them. Their frantic
efforts to avoid abandonment may include impulsive actions such as self-mutilating or
suicidal behaviors.

Unstable and intense relationships.
People with borderline personality disorder may idealize potential caregivers or lovers at
the first or second meeting, demand to spend a lot of time together, and share the most
intimate details early in a relationship. However, they may switch quickly from idealizing
other people to devaluing them, feeling that the other person does not care enough, does
not give enough, is not “there” enough. These individuals can empathize with and
nurture other people, but only with the expectation that the other person will “be there”
in return to meet their own needs on demand. These individuals are prone to sudden and
dramatic shifts in their view of others, who may alternately be seen as beneficient
supports or as cruelly punitive. Such shifts other reflect disillusionment with a caregiver
whose nurturing qualities had been idealized or whose rejection or abandonment is
expected.
Identity disturbance.
There are sudden and dramatic shifts in self-image, characterized by shifting goals,
values and vocational aspirations. There may be suddent changes in opinions and plans
about career, sexual identity, values and types of friends. These individuals may
suddenly change from the role of a needy supplicant for help to a righteous avenger of
past mistreatment. Although they usually have a self-image that is based on being bad or
evil, individuals with borderline personality disorder may at times have feelings that they
do not exist at all. Such experiences usually occur in situations in which the individual
feels a lack of a meaningful relationship, nurturing and support. These individuals may
show worse performance in unstructured work or school situations.
Display self-damaging impulsivity
Individuals with Borderline Personality Disorder display impulsivity in at least two areas
that are potentially self-damaging. They may gamble, spend money irresponsibly, binge
eat, abuse substances, engage in unsafe sex, or drive recklessly.

Display recurrent suicidal behavior
Individuals with Borderline Personality Disorder
may also sometimes display recurrent suicidal
behavior, gestures, or threats, or self-mutilating
behavior. Completed suicide occurs in 8%-10% of
such individuals, and self-mutilative acts (e.g.,
cutting or burning) and suicide threats and
attempts are very common. Recurrent suicidality is
often the reason that these individuals present for
help. These self-destructive acts are usually
precipitated by threats of separation or
rejection or by expectations that they assume increased responsibility. Self-mutilation
may occur during dissociative experiences and often brings relief by reaffirming the
ability to feel or by expiating the individual’s sense of being evil.
Display affective instability
Individuals with Borderline Personality Disorder may display affective instability that is
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). The basic
dysphoric mood of those with Borderline Personality Disorder is often disrupted by
periods of anger, panic, or despair and is rarely relieved by periods of well-being or
satisfaction.
These episodes may reflect the individual’s extreme reactivity troubled by chronic
feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to
do. Individuals with Borderline Personality Disorder frequently express inappropriate,
intense anger or have difficulty controlling their anger (Criterion 8). They may display
extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited
when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning.
Such expressions of anger are often followed by shame and guilt and contribute to the
feeling they have of being evil. During periods of extreme stress, transient paranoid
ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but
these are generally of insufficient severity or duration to warrant an additional diagnosis.
These episodes occur most frequently in response to a real or imagined abandonment.
Symptoms tend to be transient, lasting minutes or hours.
The real or perceived return of the caregiver’s nurturance may result in a remission of
symptoms.
Associated Features and Disorders
Individuals with Borderline Personality Disorder may have a pattern of undermining
themselves at the moment a goal is about to be realized (e.g., dropping out of school
just before graduation; regressing severely after a discussion of how well therapy is
going; destroying a good relationship just when it is clear that the relationship could
last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-
image distortions, ideas of reference, and hypnagogic phenomena) during times of
stress. Individuals with this disorder may feel more secure
with transitional objects (i.e., a pet or inanimate possession) than in interpersonal
relationships. Premature death from suicide may occur in individuals with this disorder,
especially in those with co-occurring Mood Disorders or Substance-Related Disorders.
Physical handicaps may result from self-inflicted abuse behaviors or failed suicide
attempts. Recurrent job losses, interrupted education, and broken marriages are
common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or

separation are more common in the childhood histories of those with Borderline
Personality Disorder. Common co-occurring Axis I disorders include Mood Disorders,
Substance-Related Disorders, Eating Disorders (notably Bulimia), Posttramatic Stress
Disorder, and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder
also frequently co-occurs with the other Personality Disorders.
Specific Culture, Age, and Gender Features
The pattern of behavior seen in Borderline Personality Disorder has been identified in
many settings around the world. Adolescents and young adults with identity problems
(especially when accompanied by substance abuse) may transiently display behaviors
that misleadingly give the impression of Borderline Personality Disorder. Such situations
are characterized by emotional instability, \"existential\" dilemmas, uncertainty, anxiety-
provoking choices, conflicts about sexual orientation, and competing social pressures to
decide on careers. Borderline Personality Disorder is diagnosed predominantly (about
75%) in females.
Prevalence
The prevalence of Borderline Personality Disorder is estimated to be about 2% of the
general population, about 10% among individuals seen in outpatient mental health
clinics, and about 20% among psychiatric inpatients. In ranges from 30% to 60% among
clinical populations with Personality Disorders.
Course
There is considerable variability in the course of Borderline Personality Disorder. The
most common pattern is one of chronic instability in early adulthood, with episodes of
serious affective and impulsive dyscontrol and high levels of use of health and mental
health resources. The impairment from the disorder and the risk of suicide are greatest in
the young-adult years and gradually wane with advancing age. During their 30s and 40s,
the majority of individuals with this disorder attain greater stability in their relationships
and vocational functioning.
Familial Pattern
Borderline Personality Disorder is about five times more common among first-degree
biological relatives of those with the disorder than in the general population. There is also
an increased familial risk for Substance-Related Disorders, Antisocial Personality
Disorder, and Mood Disorders.
Differential Diagnosis
Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria
for both are met, both may be diagnosed. Because the cross-sectional presentation of
Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the
clinician should avoid giving an additional diagnosis of Borderline Personality Disorder
based only on cross-sectional presentation without having documented that the pattern
of behavior has an early onset and a long-standing course.

Look-alikes
Other Personality Disorders may be confused with Borderline Personality Disorder
because they have certain features in common. It is, therefore, important to distinguish
among these disorders based on differences in their characteristic features. However, if
an individual has personality features that meet criteria for one or more Personality
Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Although
Histrionic Personality Disorder can also be characterized by attention seeking,
manipulative behavior, and rapidly shifting emotions, Borderline Personality Disorder is
distinguished by self-destructiveness, angry disruptions in close
relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or
illusions may be present in both Borderline Personality Disorder and Schizotypal
Personality Disorder, but these symptoms are more transient, interpersonally reactive,
and responsive to external structuring in Borderline Personality Disorder.
Although Paranoid Personality Disorder and Narcissistic Personality Disorder may also be
characterized by an angry reaction to minor stimuli, the relative stability of self-image as
well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns
distinguish these disorders from Borderline Personality Disorder. Although Antisocial
Personality Disorder and Borderline Personality Disorder are both characterized by
manipulative behavior, individuals with Antisocial Personality Disorder are manipulative
to gain profit, power, or some other material gratification, whereas the goal in Borderline
Personality Disorder is directed more toward gaining the concern of caretakers. Both
Dependent Personality Disorder and Borderline Personality Disorder are characterized by
fear of abandonment, however, the individual with Borderline Personality Disorder reacts
to abandonment with feelings of emotional emptiness, rage, and demands, whereas the
individual with Dependent Personality Disorder reacts with increasing appeasement and
submissiveness and urgently seeks a replacement relationship to provide caregiving and
support. Borderline Personality Disorder can further be distinguished from Dependent
Personality Disorder by the typical pattern of unstable and intense relationships.
Borderline Personality Disorder must be distinguished from Personality Change Due to a
General Medical Condition, in which the traits emerge due to the direct effects of a
general medical condition on the central nervous system. It must also be distinguished
from symptoms that may develop in association with chronic substance use (e.g.,
Cocaine-Related Disorder Not Otherwise Specified).
Borderline Personality Disorder should be distinguished from Identity Problem...which is
reserved for identity concerns related to a developmental phase (e.g., adolescence) and
does not qualify as a mental disorder.\"

Frequently Asked Questions about Borderline
by John M. Grohol, Psy.D. - June 22, 2007
What is Borderline Personality Disorder (BPD)?
The main feature of borderline personality disorder
(BPD) is a long pattern of instability in their
relationships with others, and in their own self-image
and emotions. People with borderline personality
disorder are also usually very impulsive. The instable
pattern of interacting with others has persisted for
years and is usually closely related to the person’s
self-image and early social interactions. The pattern is
present in a variety of settings (e.g., not just at work
or home) and often is accompanied by a similar lability
(fluctuating back and forth, sometimes in a quick
manner) in a person’s emotions and feelings.
Relationships and the person’s emotion may often be characterized as being shallow. The
disorder occurs in most by early adulthood.
How common is Borderline Personality Disorder?
It is not very common, and is estimated to be found in
1 to 2% of the general U.S. population at any give
time. It is more common amongst people seeking
treatment for another mental disorder.
How does Borderline Personality Disorder
cause problems?
Like any mental health issue, borderline personality
disorder causes problems in a person’s social and life
functioning by interfering with the person’s ability to reliably maintain these relationships
or their everyday living. People with this disorder often cause a great amount of stress or
conflict in relationships with others, especially significant others or those who are very
close to the person. This can often lead to divorce, physical, sexual or emotional abuse,
additional emotional problems (such as an eating disorder or depression), losing one’s
job, estrangement from one’s family, and more.
What is the course of Borderline Personality Disorder?
There is considerable variability in the course of Borderline
Personality Disorder. The most common pattern is one of
chronic instability in early adulthood, with episodes of serious
loss of emotion and impulsive control, as well as high levels of
use of health and mental health resources. The impairment
from the disorder and the risk of suicide are greatest in the
young-adult years and gradually wane with advancing age.
During their 30s and 40s, the majority of individuals with this
disorder attain greater stability in their relationships and job
functioning.

Is Borderline Personality Disorder inherited?
Borderline Personality Disorder is about five times more common among first-degree
biological relatives of those with the disorder than in the general population. There is also
an increased familial risk for Substance-Related Disorders (e.g., drug abuse), Antisocial
Personality Disorder, and Mood Disorders, like depression or bipolar disorder.
Where can I go to learn more about Borderline Personality Disorder?
Psych Central has a reviewed list of resources you can consult
for further information about Borderline Personality Disorder.
We also recommend the following two books to understand
more about this disorder:
Stop Walking on Eggshells: Taking Your Life Back
•
When Someone You Care about Has Borderline
Personality Disorder by Paul T. Mason and Randi
Kreger
•
The Stop Walking on Eggshells Workbook: Practical
Strategies for Living With Someone Who Has
Borderline Personality Disorder by Randi Kreger and
James Paul Shirley
FOR LOVED ONES
People with borderline disorder have marked difficulties with relationships, especially with
the people who are closest to them, such as families, partners and friends. Episodes of
anger outbursts, moodiness, and unreasonable, impulsive, and erratic behaviors, which
often appear unprovoked, can result in considerable harm to these important
relationships. Attempts to engage in a discussion to work out reasonable solutions to
problems frequently turn into highly emotional battles.
This usually results in responses from family,
partners and friends that include anxiety and
frustration, attempts to placate, and angry retorts
when the limits of normal patience have been
exceeded. Therefore, most loved ones of
individuals with borderline disorder are quite
relieved to learn that effective treatment is
available for the disorder, and that there are
ways they can help as well.
Two significant advances in the area of borderline disorder have been the recent research
on the effectiveness of different educational and therapeutic experiences for families, and
the development of consumer and family organizations focused on the disorder.

Ten Guidelines for Families, Partners and Friends
If you are a family member, partner or friend of someone with borderline disorder, you
probably have developed feelings of anger and resentment towards them that conflict
with your feelings of empathy and desire to help. The following are ten specific actions
that you can take that will help the person with borderline disorder gain better control
over her or his life, and help you in the process.
1. Learn About the Disorder
It is essential to understand that the
person with borderline disorder is
suffering from an illness that is as
real as diabetes, heart disease, or
hypertension. For most people,
physical symptoms are easier to
accept as indications of a disease
than are behavioral symptoms.
However, there is no reason to
assume that a complex organ such as
the brain is less susceptible to
diseases that affect behavior than are
other bodily organs that result in
physical symptoms. Recently
developed medical research studies
demonstrate abnormal brain structure and function in patients with borderline disorder,
thus confirming this conclusion.
It is also helpful to realize that persons with borderline disorder did not acquire the
disorder through any actions of their own, nor do they enjoy having the disorder.
Imagine what it must be like to feel that you are frequently at the mercy of forces within
you, over which you seem to have little control, and that cause you extreme emotional
pain and significant life problems.
Therefore, a critical first step in the process of helping them and you is to learn as much
as you can about the symptoms and nature of borderline disorder, and the specific
situational causes of acute episodes in the member of your family with the disorder.
2. Seek Professional Help
Facilitate the process of obtaining optimal help. It may be necessary that you do the
initial work necessary to set up the first appointment. It may also be helpful if you agree
to go also. Some people with borderline disorder initially refuse to seek professional help.
Provide them with a copy of my book and suggest they read the first two chapters. This
may help them understand their potential problems well enough to
agree to an initial appointment with a psychiatrist.
Other people with borderline disorder are steadfast in their refusal
of help. This, of course, is a major problem. Dr. Perry Hoffman,
the founding president of the National Education Alliance for
Borderline Personality Disorder (NEA-BPD) offers this advice:
The best way of approaching this problem from my perspective is
for one to accept that you cannot get someone into treatment.
Timing is important as to when someone might be “open” to
hearing the idea. But the bottom line is to free families of feeling

guilty, and to understand that they are not so powerful to effect that goal. Along that
line, relatives need to get help and support for themselves as they watch their loved one
in the throes of the illness.
3. Support the Treatment Program
Once in treatment, encourage and support your loved one with
borderline disorder to regularly attend therapy sessions, to take
medicine as prescribed, to eat, exercise, and rest appropriately,
and to engage in wholesome recreational activities. If alcohol or
other drugs are a problem, strongly support their efforts to abstain
completely from these substances, and encourage regular
attendance in treatment programs or self-help groups, such as
Alcoholics Anonymous. Remember, there is little hope of
improvement of the symptoms of borderline disorder if alcohol and
drugs are abused. It is very important that you remain persistent in
your efforts to do everything possible to help reduce the risk of this
behavior, and not enable it.
4. Respond Consistently to Problematic Behaviors
Develop a clear understanding (it may even be written) of the realistic consequences of
recurring, problematic, destructive behaviors
such as episodes of alcohol and drug abuse,
physically self-damaging acts, and excessive
spending and gambling. Also, agree beforehand
on how best to respond to threats and acts of
self-harm.
These and other problematic behaviors are often
triggered by stressful events that need to be
identified, and a clear plan developed for
handling these events and situations more
appropriately and effectively in the future. Such a plan is best developed with the help of
the patient’s primary clinician.
Experience has shown that responding positively to appropriate behaviors is also very
important in encouraging change to new and more successful ways of handling stressful
situations. Doing so also reduces the incidence of inappropriate behaviors that then
cause additional problems. Issuing spontaneous ultimatums should be avoided.
5. Attempt to Remain Calm
Reacting desperately or angrily when there is a flare up of
symptoms will often add to the existing problem. Remain
calm. Acknowledge that it must be difficult to experience
the expressed feelings, even if they seem out of proportion
to the situation. This does not mean that you agree with
these feelings, or that you think that the actions resulting
from them are justified. However, it is reassuring if you
listen to their feelings, the pain they are experiencing, and
the difficulty they are having in dealing with this pain.
Remember that you do not have to defend yourself if
verbally attacked, or develop solutions to their problems. If

they express thoughts of self-harm, remind them of the plan for dealing with this
problem that has been worked out with their therapist.
Allow and encourage the person with borderline disorder to attempt to bring their
response levels in line with the situation at hand. This may require that you give them a
little time alone to collect themselves. Then it may be possible to more calmly and
reasonably discuss the relevant issues.
In addition, do not be hesitant to express your feelings freely and openly, but with
moderation. Recent research suggests that caring involvement with your loved one with
borderline disorder is associated with better outcomes than a cool, disinterested
approach. Stay involved.
6. Remain Positive and Optimistic
It is important to remain optimistic about the ultimate results of treatment, especially
when the patient has a setback. The usual course of borderline disorder with optimal
treatment is one of increasing periods of time when symptoms are absent or minimal,
interrupted by episodes when the symptoms flare up. Over time, the specific causes of
relapses can be identified, anticipated, then steps taken to develop alternative, more
adaptive and effective responses. Occasional family meetings with the therapist may help
clarify the causes of relapses and identify new ways of preventing them.

7. Participate in Educational Experiences About Borderline Disorder
It is very important that you learn as much as possible about borderline disorder and
your role in the treatment process. Your participation in educational opportunities may
benefit both you and your loved one with the disorder. When conducted by skilled and
experienced people, such structured and informative experiences may involve both
patients and family.
8. Join a Borderline Disorder Consumer and Family Support Organization
For information on such consumer organizations, contact the National Alliance on Mental
Illness (NAMI) or the National Education Alliance for Borderline Personality Disorder
(NEA-BPD). If such an organization exists in or near your community, seriously consider
joining it. You will then have available to you a large amount of new information about
borderline disorder, what you can do to help the member of your family with the disorder
and yourself, and compassionate and understanding support in your efforts. If there is
not a group in your area, consider starting one with other family members you have met.
Also consider joining one of these national consumer organizations for borderline
disorder.
9. Remember:
the Person with Borderline Disorder Must Take Charge
Remember that it is primarily the
responsibility of the person with
borderline disorder to take charge
of her or his behavior and life.
Although difficult at times, it is
important for you to provide the
opportunity for your family
member with borderline disorder
to take reasonable risks in order
to try new behaviors. It is also
important that you help her or
him to be accountable for the
consequences of old, destructive
behaviors.
Excessive dependency on family
and friends is not helpful in the
long run. Beware of the tendency
of people with borderline disorder to act at the extremes. For example, the proper
alternative to excessive dependency is not immediate, total independency. The more
appropriate responses are to remain engaged and to gradually help move to a more
balanced, mature relationship level of mutual interdependency.
10. Take Care of Yourself
If you take the time to meet your own needs, when your help is needed most, you will be
best able to provide it. Remember that you cannot save your loved one with borderline
disorder on your own.
If you are the parent, there is a natural tendency to focus much of your attention on the
person with borderline disorder. However, make certain that you are not neglecting your
other sons and daughters who may appear to be doing well. They have need of your time

and attention too, even as they grow into adulthood. You will learn from educational
experiences the extent of this potential problem and how best to deal with it.
THE WORLD
NEEDS PEOPLE...
who cannot be bought;
whose word is their bond;
who put character above wealth;
who possess opinions and a will;
who are larger than their vocations;
who do not hesitate to take chances;
who will not lose their individuality in a crowd;
who will be as honest in small things as in great things;
who will make no compromise with wrong;
whose ambitions are not confined to their own selfish desires;
who will not say they do it\" because everybody else does it\";
who are true to their friends through good report and evil
report,
in adversity as well as in prosperity;
who do not believe that shrewdness, cunning, and
hardheadedness are the best qualities for winning success;
who are not ashamed or afraid to stand for the truth when it is
unpopular;
who can say \"no\" with emphasis, although all the rest of the
world says \"yes.\" - Charles Swindoll.

ONLINE TEST
The following \"test\" may help you to evaluate the possibility
that you or a loved one has borderline disorder. It is simply
a check list of the nine criteria of borderline disorder as
defined by the American Psychiatric Association in their
diagnostic manual, DSM-IV-TR. However, it is reworded so
that you may readily apply the criteria to your situation.
Please note that you should not use the results of the test
to arrive at any fixed conclusion, but rather to provide you
with an estimation of the possibility that this disorder, or its
traits, may exist.
How to Use the Borderline Disorder Test
First, read carefully about the symptoms of borderline
disorder provided on this website, or as they are described
in more detail in my book, Borderline Personality Disorder Demystified.
Next, print this page and place a check mark next to those symptoms or behaviors listed
below that you believe accurately describe your condition. If you are in doubt, leave the
item blank.
The Borderline Disorder Test
1) My emotions change very quickly, and I experience intense episodes of sadness,
___
irritability, and anxiety or panic attacks.
___ 2) My level of anger is often inappropriate, intense and difficult to control.
___ 3) I suffer from chronic feelings of emptiness and boredom.
4) I engage in two or more self-damaging acts such as excessive spending, unsafe
___ and inappropriate sexual conduct, substance abuse, reckless driving, and binge
eating.
5) Now, or in the past, when upset, I have engaged in recurrent suicidal behaviors,
___
gestures, threats, or self-injurious behavior such as cutting, burning or hitting myself.
6) I have a significant and persistently unstable image or sense of my self, or of who
___
I am or what I truly believe in.
7) I have very suspicious ideas, and am even paranoid (falsely believe that others are
___ plotting to cause me harm) at times; or I experience episodes under stress when I
feel that I, other people or the situation is somewhat unreal.
8) I engage in frantic efforts to avoid real or imagined abandonment by people who
___
are close to me.
9) My relationships are very intense, unstable, and alternate between the extremes of
___
over idealizing and undervaluing people who are important to me.

How to Score the Borderline Disorder Test
Score of five or greater:
If you have checked five or more items on the
above list, you may have borderline disorder. In
order to determine if this is the case, you will
require an evaluation by a psychiatrist or mental
health care clinician who is well trained and
experienced in borderline disorder.
Score of one to four:
If you have checked one to four items on the above
checklist, you may have borderline disorder traits.
Depending on the level of severity of your
symptoms or behaviors, and the amount of
disruption that they cause you, your family, friends
and others, you may require an evaluation by a
psychiatrist or mental health care clinician who is
well trained and experienced in borderline disorder.
It is important to realize that you do not have to
meet five or more criteria of borderline disorder for these symptoms to significantly
disrupt your life. You may still benefit greatly from appropriate treatment.
Guidelines for the Selection of a Psychiatrist and
Other Clinicians
Once you have located the names of one or more clinicians, you may wish to contact
them to determine if they provide the services you are looking for.
The following is a list of issues that you may wish to clarify in order to determine if you
have a reasonably suitable fit given your individual needs:
Primary Clinician: Ideally, in most cases, you are looking for a psychiatrist with
experience in borderline disorder who can serve as your primary clinician, that is,
perform your initial clinical evaluation and the other tasks of someone assuming this role
in your care. If such a person is not available in your community, you should ask other
potential providers of care about their level of experience in the area of borderline
disorder.
Types of Treatment: Determine what forms of treatment they typically use for their
patients with the disorder, especially medications and psychotherapies. Most psychiatrists
and other clinicians do not typically provide the full range of treatments that we now
know are useful for treating the disorder. In other words, you may need several people
working with you, for example, one to prescribe medications, another to provide therapy,
and possibly a third for group therapy work. Therefore, you will need to ask how your
special needs will be met by each clinician. If you will be seeing just one person, be
especially cautious if they recommend only one form of treatment for all patients with
borderline disorder, for example either medications or psychotherapy, or one specific
type of psychotherapy. As noted elsewhere on this site, borderline disorder affects people

in many different ways. Therefore, in most cases, effective treatment plans are more
complex than can be accomplished by a single type of treatment.
Immediate Help: You should establish how the provider handles those times when you
may need immediate help, for example who will respond to your telephone calls and
under what circumstances. Also, should
you require brief hospitalization, what
hospital will be utilized, and who will direct
your care when you are in the hospital.
Communication: If you will have more
than one clinician working with you, it is
important to establish the degree to which
they will work with you and with your
family or partner, and with each other. It is
important that the team communicate
openly. Under most circumstances, it is
essential that those people who are very
important in your life are included in your
treatment. The types and frequency of
involvement required are best discussed prior to the onset of treatment.
Finding the Right Fit: Ultimately, you are looking for clinicians who appear to be “good
fits” for you and your special needs. To some degree this is a subjective quality, and
cannot be easily defined further, but patients often sense when they have found the right
professionals with whom to work.
Credentials: It is very appropriate to ask about the potential provider’s specific
credentials: in what mental health specialty do they have their degree; are they certified
properly, for example., for psychiatrists, by the American Board of Psychiatry and
Neurology; are they licensed to practice in their specific clinical area; and what degree of
training and experience do they have with borderline disorder.
Payment Information: Finally, you should obtain their fee schedule and method of
payment for different services, for example medication checks, and individual and group
psychotherapy sessions. Many clinicians accept insurance with co-payments, while some
require self payment.
At the outset of care, remember that your doctor may not be able to determine precisely
the most effective treatments for you. Therefore, it seems to me most reasonable to find
a psychiatrist, and other clinicians when necessary, who know the relevant medical
literature, that have open minds regarding different diagnostic possibilities and treatment
approaches, and who communicate well with you and your family. Given our current level
of knowledge about borderline disorder, it is likely that such professionals will give you
the best help available, now and in the future.

The Diagnosis and Treatment for Depression Co-
Occurring with Borderline Disorder
by Robert O. Friedel, MD
More than 80 percent of people with borderline disorder suffer from episodes of major
depression. Treatment for depression is vital in these individuals. There are two
categories of major depressive episodes, those associated with bipolar I and II disorder-
depressed*, and those referred to as major depressive disorder.
Therefore, if you have borderline disorder, it is important that you know and recognize
the symptoms of these disorders. If they occur, you should alert your physician so that
you may receive prompt treatment for depression.
Symptoms of a Major Depressive Episode:
persistently depressed or irritable mood
•
diminished interest or pleasure in activities
•
significant decrease or increase in appetite, or weight loss or
•
weight gain
increased or decreased sleep
•
decreased mental and physical activity, or increase in such activity as
•
demonstrated by excessive worrying and agitated behavior
fatigue, or loss of energy
•
feelings of worthlessness or excessive or inappropriate guilt
•
diminished ability to think or concentrate, or indecisiveness
•
recurrent thoughts of death and dying, recurrent suicidal thoughts with a specific
•
plan, or a suicide attempt
Understand the differences in symptoms of Borderline
Disorder, Bipolar Disorder-Depressed and Major Depressive
Disorder, and learn about the various plans for treatment
for depression.
In order to initiate the proper treatment for depression, it is
necessary to determine if you are experiencing a decrease in
mood associated with borderline disorder, or if you have
developed a bipolar II disorder- depressed or major depressive
disorder.
Depressed Mood in Borderline Disorder
In borderline disorder alone, depressed mood often occurs as follows:
• sad, depressed, and lonely feelings are frequently triggered by some life event
and are often associated with strong feelings of emptiness, loneliness and fears of
abandonment.
• symptoms readily improve if the situation causing them improves
• sleep, appetite and energy disturbances (if present) are usually related to an
identifiable life stress and stop when the stress is managed successfully.
• acute suicidal thoughts and self-injurious behavior are usually the direct result of
a personal problem (for example, an argument with a parent, boyfriend, spouse,
or boss)

Bipolar II Disorder-Depressed*
In bipolar disorder-depressed, the symptoms of a
major depressive episode listed above are often
characterized by:
• increased appetite or weight gain
• increased sleep and napping
• marked decrease in mental and physical
activity
• marked fatigue and loss of energy
Major Depressive Disorder
In major depressive disorder, the symptoms of a
major depressive episode listed above are often
characterized by:
• decreased appetite or weight loss
• decreased sleep with early morning
awakening
• increased mental and physical activity as
demonstrated by excessive worrying
and agitated behavior
Substance Abuse Treatment in Patients with
Borderline Disorder
by Robert O. Friedel, MD
Two-thirds of people with borderline disorder seriously abuse alcohol, street drugs,
and/or prescribed drugs. This is a major factor resulting in poor outcome of people with
borderline disorder. Alcohol and drugs are abused by people with borderline disorder to
temporarily relieve the severe emotional pain that they experience, especially when
under stress. Predictably, this relief is short lived. Even worse, the use of these
substances markedly increases many of the symptoms of borderline disorder making
substance abuse treatment all the more important.
It is possible that some of the genetic alterations that are risk factors in borderline
disorder may also be among the group of genes that predispose people to alcoholism and
drug abuse.
DSM-IV-TR Criteria for Substance Use Disorders:
There are two types of substance use disorders, substance dependence and substance
abuse. Substance abuse treatment is important in both types of substance use disorders.
Substance Dependence
A pattern of substance use that leads to significant impairment or distress in three (or
more) of the following ways:

• tolerance, as defined by either
o a need for markedly increased amounts of the substance to achieve the
desired effect, or
o a markedly diminished effect with continued used of the same amount
of the substance
• withdrawal symptoms characteristic for the substance, or increased use to relieve
or avoid withdrawal symptoms
• the substance is taken in larger amounts or over a longer period than intended
• a persistent desire or unsuccessful efforts to cut down or control substance use
• much time is spent in activities to obtain the substance, use the substance, or
recover from its effects
• important social, occupational, or recreational activities are given up or reduced
• the substance use is continued despite it causing a persistent or recurrent physical
or psychological problem (e.g., current cocaine use despite recognition of
cocaine-induced depression)

Self-Injurious Behaviors and Suicidality in
Borderline Disorder
by Robert O. Friedel, MD
In a recent study, approximately 75 percent of women with borderline disorder engaged
in self-injurious behaviors such as cutting, burning and small drug overdoses. Cutting is
by far the most common act of this type. About 9 percent of people with the disorder
commit suicide. The most frequent means is by drug overdose. Both types of behavior
may occur in the same individual. Cutting behaviors double the risk of suicide in people
with borderline disorder.
Self-Injurious Behaviors
In addition to cutting and burning themselves, and taking small drug overdoses, people
with borderline disorder hit themselves, pull out their hair, scratch their skin to the point
they open wounds, and injure themselves in other ways. Most people with the disorder
who injure themselves report that they do so mainly to decrease the intense emotional
pain they experience. Remarkably, they also often report that the first time they engaged
in cutting and other self injurious behaviors, the idea just came to them. Finally, they
report that these acts usually do result in brief emotional relief.
It is important that family and other loved ones understand that this is the main motive
of self injurious behaviors, not primarily to manipulate the situation or the people around
them, though this is often a secondary motive.

Risk Factors for Suicidality
There are a number of factors that increase the risk that a person with borderline
disorder will commit suicide. Although nothing can be done to reverse some of these
factors, others are highly treatable, and deserve
immediate attention.
co-occurring disorders
•
antisocial personality disorder (higher in males)
•
major depression
•
substance abuse*
•
personality characteristics
•
impulsive aggression
•
poor emotional control
•
hopelessness
•
history and severity of childhood sexual abuse
•
age over 30 years
•
number of prior self-injurious behaviors and suicide attempts
•
no prior treatment, or extensive and unsuccessful treatment history
•
Prevalence Across the Life Cycle:
Self-injurious behaviors do not appear to decrease
or “burn out” with increasing age in people with
borderline disorder, as do other aggressive and
impulsive behaviors
Management of Self-Injurious
Behaviors and Suicidality
General Treatment Interventions for Self-Injurious
Behaviors and Suicidality:
careful evaluation
•
determine the level of intent and risk of
•
self-injurious behaviors and suicide - overt
and unstated
directly involve the patient and family in the
•
process
treat at the least restrictive level of care for
•
the shortest period of time indicated
aggressively treat all co-occurring disorders
•
modify the treatment to accommodate the
•
significant increase in severity of borderline
disorder symptoms
highly structure the environment
•
identify and promptly address precipitating events
•
assure involvement and coordination of the entire treatment team, including the
•
family
continue to balance risk vs. reward
•

Specific Treatment Interventions: Medications
Purposes
• reduce or eliminate co-occurring disorders, such as major depressive episodes,
substance abuse, ADHD and anxiety disorders
• reduce core symptoms of borderline disorder: e.g., emotional dysregulation;
aggressive-impulsivity; and cognitive-perceptual impairment
Specific Treatment Interventions: Psychotherapy
(dialectical behavior therapy-DBT; supportive
therapy)
Purposes
reduce self-injurious behaviors and suicidality
decrease the frequency of hospitalizations
* Note: If you have borderline disorder and
have a tendency to abuse alcohol or drugs,
it is essential that you obtain help to abstain
completely from doing so.
Substance Abuse
A pattern of substance use that leads to
significant impairment or distress in one (or
more) of the following ways:
• a failure to fulfill major role obligations
at work, school, or home
• recurrent substance use in situations in
which it is physically hazardous
• recurrent substance-related legal problems
• continued substance use despite having persistent or recurrent social or
interpersonal problems caused or worsened by the effects of the substance

Consequences of Abuse of Alcohol and
Street Drugs in Borderline Disorder
dramatic worsening of the symptoms of borderline disorder
• marked decrease in the effectiveness of medications and psychotherapy.
• addiction to and sustained craving for these substances.
Substance Abuse Treatment Interventions
For all of these reasons, for substance abuse
treatment purposes, I strongly advise my
patients with borderline disorder to not use
alcohol, to not take any street drugs, and to
take prescribed medications only as ordered
by their physicians.
In addition, I encourage those patients who
have a substance-use disorder to engage fully
in a substance abuse treatment program and
attend support groups (Alcoholics Anonymous
or Narcotics Anonymous). I also suggest to
some of them that they may benefit from a
trial on a medication appropriate for their
specific drug dependency, as this may help
reduce craving and use.
Conclusions
Substance use disorders are major predictors
of poor short- and long-term outcome of
borderline disorder.
There is little or no hope of gaining control
over the symptoms of borderline disorder
while alcohol and other drugs are being used,
no matter how appropriate the substance abuse treatment program is otherwise.
Substance abuse treatment is essential if this problem co-occurs with borderline disorder.

Anxiety and Panic Attack Symptoms Co-
Occurring with Borderline Disorder
by Robert O. Friedel, MD
Have you or a loved one been diagnosed with borderline disorder and are
suffering from anxiety and panic attack symptoms? Read the following article
and learn more about these symptoms and how they are treated.
Anxiety and panic attack symptoms are common in people with borderline disorder.
Anxiety disorders occur in almost 90% of people with the disorder. If you have borderline
disorder, you may experience heightened levels of anxiety and panic attack symptoms,
especially at times of stress. For example, this may occur when you feel you are
personally criticized and rejected, or during periods of separation from people who are
very important to you. Moderate to severe anxiety may also lead to physical symptoms,
such as migraine headaches, abdominal pain and irritable bowel syndrome.
Panic Attacks
A panic attack is an acute and severe form of anxiety that occurs in about 50% of people
with borderline disorder. Panic attacks are characterized by a discrete period of intense
fear in which four or more of the following symptoms develop abruptly and reach a peak
within 10 minutes:
• palpitations, pounding heart, or increased
heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or
smothering
feeling of choking
•
chest pain or discomfort
•
nausea or abdominal distress
•
feeling dizzy, unsteady, lightheaded, or
•
faint
• feelings of unreality or being detached
from oneself
fear of losing control or going crazy
•
fear of dying
•
numbness or tingling sensations
•
chills or hot flushes
•
Symptoms can appear unexpectedly and
suddenly, for no apparent reason, and
disappear either rapidly or slowly. People
who suffer from anxiety and panic attack
symptoms may also be fearful of placing
themselves in circumstances from which
escape may be difficult or embarrassing such as elevators, shopping malls and movie
theaters. This is referred to as agoraphobia.

Treatment of Anxiety and Panic Attack Symptoms in Borderline
Disorder
Effective treatment of disabling anxiety and panic attack symptoms in people with
borderline disorder should be initiated promptly when these disorders occur. Such
treatment usually consists of the use of medications and behavioral techniques.
The use of medications to treat anxiety and panic attack symptoms in patients with
borderline disorder must proceed with care. This is so because these disorders are
commonly treated with benzodiazepines (Xanax, Klonopin, Valium, etc.), that have been
found to be harmful in most patients with borderline disorder because they increase
impulsivity and have addictive potential. Therefore, in borderline disorder, other classes
of medications are often required, such as a temporary increase in the neuroleptic,
atypical antipsychotic or antidepressant medication being used to treat the disorder.
Initiating the use of an antipsychotic agent or an antidepressant may prove effective for
moderate to severe anxiety and panic attack symptoms if one is not already prescribed.
In addition, a course of cognitive behavioral therapy, or of biofeedback, specifically
tailored to target anxiety and panic attack symptoms are often considered as part of the
long-term treatment of these problems.
The Symptoms and Treatment of Attention
Deficit Hyperactivity Disorder in Patients
with Borderline Disorder
by Robert O. Friedel, MD
Background
Attention deficit hyperactivity disorder (ADHD) occurs in about 25% of people with
borderline disorder; 5 times more often than it does in the general population. The
symptoms of ADHD include decreased attention and concentration, easy distractibility,
difficulty in the completion of tasks, and poor management of time and the space area
that you use. These symptoms of ADHD result in significantly impaired school, work and
social performance, and are described in detail below.
ADHD is estimated to occur in about 5% of school age children. It is more common in
boys than in girls. There are subtypes associated with hyperactivity and normal activity
levels. The hyperactive subtype is much more common in boys, while the inattentive
subtype (the subtype with normal activity levels) is somewhat more evenly distributed
among boys and girls. The symptoms of ADHD are now known to persist into adulthood
in many people, and to require continued treatment. There is often a strong family
history of ADHD.

Identifying the symptoms of ADHD in patients with
Borderline Disorder is critical for their treatment plan.
Symptoms of ADHD*
Inattention
• fails to give close attention to details or
makes careless mistakes in school
work, work, or other activities
• has difficulty sustaining attention in
tasks or play activities
• does not follow through on instructions
and fails to finish school work, chores,
or duties in the workplace (not due to
oppositional behavior or failure to
understand instructions)
• has difficulty organizing tasks and
activities
• avoids, dislikes, or is reluctant to
engage in tasks that require sustained
mental effort (such as schoolwork or
homework)
• loses things necessary for tasks or
activities (e.g., toys, school
assignment, pencils, books, or tools)
• is easily distracted by extraneous
stimuli
• is often forgetful in daily activities
Hyperactivity
• fidgets with hands or feet or squirms in seat
• leaves seat in classroom or in other situations in which remaining seated is
expected
• runs about or climbs excessively in situations in which it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
• has difficulty playing or engaging in leisure activities quietly
• is often “on the go” or often acts as if “driven by a motor”
• talks excessively
Impulsivity
• blurts out answers before questions have been completed
• has difficulty awaiting turn
• interrupts or intrudes on others (e.g., butts into conversations or games)

Treatment of ADHD in Patients with Borderline Disorder
It is not uncommon for children,
teenagers and adults with borderline
disorder who have some symptoms of
ADHD to be misdiagnosed with ADHD,
and then receive customary
treatment with stimulants such as
methylphenidate or an amphetamine
derivative. People with borderline
disorder treated with these
medications typically do not do well,
and may even do worse than without
these medications.
If borderline disorder and ADHD co-
occur, patients often do worse when
treated for ADHD if they first receive
a medication for the symptoms of
ADHD. Under these circumstances,
they may then demonstrate an
increase in emotionality and
aggressive impulsivity. Fortunately,
clinical experience and anecdotal
reports in the scientific literature
suggest that this problem can be
effectively managed in one of two
ways.
When the symptoms of ADHD are
mild, behavioral treatments alone may be effective, thereby avoiding the risk of
increasing the symptoms of borderline disorder with a stimulant.
However, if medications are required to bring the symptoms of ADHD under optimal
control, it appears to be helpful to initiate treatment with a low dose of a neuroleptic or
antipsychotic agent for the symptoms of borderline disorder. Doing so then appears to
permit the use of a stimulant to produce a beneficial effect on the symptoms of ADHD
with a minimal risk of worsening the core symptoms of borderline disorder.
*Adapted from DSM-IV-TR. American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000.