Exploring the condition of Borderline Personality Disorder (BPD)

History of BPD

Borderline Personality Disorder has its origins in ancient Greece where philosophers and scholars such as Homer and Hippocrates noticed the vacillating presence of impulsive anger, melancholy and mania amongst certain members of the population. Swiss physician Théophile Bonet revised the concept in 1684 when he coined the term “folie maniaco melancolique” to describe a demographic of the population the behaviour of whom aligned with the ancient Greek’s description (Millon, 1996).

In 1890 the term borderline insanity became prevalent amongst American psychiatrists, but it was not until the 1930s that the association between the disorder and childhood trauma was established. At this point the focus was on the neurotic and psychotic elements of the disorder. However, there was a shift in the 1960s where greater importance was assigned to the affective nature of the condition, links to bipolar and dysthymia were discovered, and the term borderline affective disorder became ubiquitous. About 20 years later the term borderline personality disorder was coined and there was a distinction made between it and sub-syndromal schizophrenia.

What is Borderline Personality Disorder?

BPD is a personality disorder characterised by intense emotional instability and fear of abandonment resulting in maladaptive behaviours including suicidality, substance abuse and interpersonal conflict. Below can be found two quotes from BPD patients which give an idea of just how difficult it can be to live with this condition.

“It doesn’t matter how many times a person tells me they like me, I always think they can change their mind instantly. Always with the fear of rejection. I don’t know how many times I have to fight off the thoughts that everyone hates me. I know it may not be a reality, but it feels very real.”

“My skin is so thin that the innocent words of others burn holes right through me”

Overview of Personality Disorders

There are 10 personality disorders according to the DSM-5 which can be grouped into three clusters:

Cluster A: paranoid, schizoid and schizotypical personality disorders

Cluster B: antisocial, borderline, histrionic, and narcissistic personality disorders

Cluster C: avoidant, dependent, and obsessive-compulsive personality disorder

Personality disorders tend to be difficult to treat and often require an intensive multidisciplinary approach where the focus is to develop better coping skills to deal with vulnerabilities and boost adaptive functioning while simultaneously aiming to reduce suffering in patients.

Characteristics of Borderline Personality Disorder

According to Patel et al. (2019), the primary characteristics of BPD are instability in:

  • Affective states
  • Relationships
  • Self-image

This often results in:

  • Impulsive or self-destructive behaviour
  • Fear of abandonment
  • Numerous intense but short-lived relationships

DSM-5 Diagnostic Criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following:

  1. Frantic efforts to avoid real or imagined abandonment
  2. A pattern of unstable and intense interpersonal relationships characterised by alternating
    between extremes of idealisation and devaluation
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self
  4. Impulsivity in at least two areas that are potentially self-damaging
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
  6. Affective instability due to a marked reactivity of mood
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger or difficulty controlling anger
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Prevalence of Borderline Personality Disorder

BPD is estimated to occur in approximately 1.7% of the general population, however this figure varies considerably depending on the source used. BPD patients are estimated to make up between 15-28% of the populations in psychiatric clinics or hospitals which speaks to an overrepresentation of individuals with this disorder in these settings. This suggests that BPD is a difficult condition to handle autonomously and often requires outside assistance to manage.

75% of recorded BPD cases are female, however there is a contention that males may be underrepresented in this figure due to frequent misdiagnoses. The theory is that often when young males present with the same behaviours that would earn a female a diagnosis of BPD, they are instead diagnosed with a substance use disorder or anti-social personality disorder. There is a well-established high suicide rate and prevalence of risk-taking behaviour among young males, both of these behaviours are congruent with BPD which may suggest that more males suffer from the disorder than previously thought.

Borderline Personality Disorder and Other Disorders

There is a substantial comorbidity between BPD and other disorders including both bipolar disorder and ADHD. Both bipolar disorder and BPD involve mood instability which considered in tandem with their high rate of comorbidity (Zimmerman et al., 2013), it is no wonder that BPD is often falsely diagnosed as bipolar disorder (Gunderson et al. 2018). Both disorders also carry substantial impairments in personal and professional functioning which further hampers one’s ability to differentiate the two.

BPD and ADHD have also been identified as highly comorbid disorders (O’Malley et al., 2016) with various neurological similarities such as shared abnormal patterns in temporoparietal profile (Pan et al., 2023). They also both display overlapping features in terms of their diagnostic criteria, the most obvious of which being impulse control deficits which is a prominent feature in both diagnoses.

Cortical Abnormalities Associated with Borderline Personality Disorder

Frontolimbic network dysfunction, particularly in the dorsolateral prefrontal cortex (DLPFC), has been shown to have a decisive role in the top-down regulation of impulsivity and emotional control (Perez et al 2023). BPD patients characteristically struggle to regulate their impulsivity and emotional states. This may be accounted for by the observation of substantial frontolimbic differences between BPD patients and healthy controls. Minzenberg et al. (2008), discovered significantly higher gray matter concentration in the amygdala and significantly lower gray matter concentration in the left rostral/subgenual anterior cingulate cortex than normal controls.

Furthermore, in a study carried out by Messina & Grecucci (2023), machine learning models were used to predict the presence of BPD. BPD patients were distinguished from healthy controls using a circuit including the basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex with an 80% accuracy. This circuit positively correlates with the severity of BPD symptomatology. Additionally, two gray matter/white matter co-varying circuits, including basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex, correctly classified BPD against healthy controls. These circuits are affected by specific child traumatic experiences and predict symptoms severity in the interpersonal and impulsivity domains.

Human Cost of Borderline Personality Disorder

One of the diagnostic criteria of BPD is chronic feelings of emptiness, while intense emotional instability is characteristic of those who suffer with the disorder. Living with these symptoms takes an undeniable toll and causes much suffering among BPD patients.

A diagnosis of BPD carries with it a considerably greater risk of suicide. In a study by Black et al. (2004), it was found that 75% of those with BPD will attempt suicide and 10% will complete suicide.

BPD also confers higher rates of substance use disorders. The comorbidity of BPD and SUD is massive with the vast majority of BPD sufferers turning to substances in an attempt to self-medicate. Trull et al. (2018), found that up to 72.7% of BPD patients will at some point in their life meet the diagnostic criteria for an SUD, while the current rate of SUDs among the sample of BPD patients which participated in the study was found to be 45.5%.

In addition to the increased rate of suicide and substance abuse among BPD patients, they have also been found to be significantly less likely to become college graduates with only 16% of BPD patients achieving a college degree, which less than half the rate achieved by bipolar patients (35%), and also substantially lower than the American national average (37.7%).

Stigma Associated with Borderline Personality Disorder

Unfortunately, there is a substantial stigma associated with BPD. This is a difficult issue to deal with as there are several factors which contribute to the negative prejudices towards BPD that are ubiquitous in our society.

Individuals with BPD tend to place a greater strain on the healthcare system for a variety of reasons. As discussed above, the frequent suicide attempts that are common in the BPD population adds to the workload of hospital staff. This coupled with the high prevalence of crises presentations of BPD patients and the complex needs they have can often colour the perceptions of hospital staff in a negative light.

Klein et al. (2022), found that 89% of psychiatric nurses consider BPD patients manipulative and 80% of hospital staff consider BPD patients to be more difficult to work with than patients with other mental health disorders.

Furthermore, there are several issues inherent in the way BPD is diagnosed and considered by healthcare professionals. Klein et al., (2022) also found that the legitimacy of a BPD diagnosis was contested in some health settings, and some healthcare practitioners were reluctant to disclose BPD diagnosis to patients possibly because BPD is often considered untreatable.

Pharmacological Treatment for Borderline Personality Disorder

In a study conducted by Dukes et al. (2023), to monitor the treatment trajectory of BPD patients using electronic health record data they found that the vast majority of patients were prescribed medication. This runs counter to the NICE guidelines which state that BPD patients “should not usually be offered medication specifically to treat borderline personality disorder or for any related symptoms or behaviour”.

Dukes et al., (2023) found:

  • 80.4% of patients were first prescribed antidepressants (AD)
  • 83.1% were prescribed more than one medication at baseline (with or without comorbidity)
  • Younger patients were less likely to have multiple medication prescriptions compared with those aged 35 to 65 years
  • The number of patients prescribed 1 medication decreased over the 12-month follow-up period whereas those prescribed 2 or more medications increased.

During the 12-month period patients were commonly prescribed:

  • Antidepressants (AD): sertraline (5.5%), Fluoxetine (5.0%), Citalopram (5.0%)
  • Second Generation Antipsychotics (SGA): Quetiapine (22.1%), Aripiprazole (19.0%)
  • Anxiolytics
  • Mood stabilisers (MS): Lamotrigine (24.9%), Gabapentin (15.4%), Valproate (7.1%)

Talk Therapies Used to Treat BPD

  • Dialectical behaviour therapy (DBT) – uses individual and group therapy to help teach skills to cope with difficult emotions
  • Mentalisation-based therapy (MBT) – aims to help individuals to recognise and understand their and other people’s mental states, and to examine their thoughts about themselves and others
  • Cognitive behavioural therapy (CBT) – teaches individuals to understand how their thoughts and beliefs might affect their feelings and behaviour
  • Cognitive Analytic Therapy (CAT) – combines CBT’s practical methods with a focus on the relationship between patient and therapist

TMS and Borderline Personality Disorder

Several studies have been carried out with the aim of ascertaining if TMS treatment can confer any benefit to those suffering from BPD. While like most other treatments for BPD, TMS is unable to treat the personality disorder directly, a growing body of research has shown that TMS is effective at addressing the depressive symptoms often experienced by BPD patients.

In a study carried out by Smart TMS in 2022 with the aim of ascertaining if traits of borderline personality disorder affect the likelihood of response to TMS for depression, it was found that the severity of co-morbid BPD traits did not predict TMS treatment outcome. This led to the conclusion that TMS may be a relatively effective option for BPD patients suffering with comorbid depression.

Muir et al. (2022), found that major depressive disorder responds equally well to deep TMS treatment in the presence and absence of comorbid personality disorders. This conclusion was drawn from the results of paired t-tests which showed a statistically significant reduction in Beck Depression Inventory scores in major depressive disorder patients both with and without a comorbid personality disorder.

In a study by Nassan et al. (2020), psychiatric comorbidities were not found to influence remission and response rates in patients treated with transcranial magnetic stimulation for major depressive disorder. The study comprised a retrospective review of patients who completed TMS for MDD between 2009 and 2019 with treatment measured to be equally effective among patients with generalized anxiety disorder, persistent depressive disorder and borderline personality disorder comorbidities.

In a case report conducted by Perez et al. (2023), repetitive transcranial magnetic stimulation was found to be highly effective in treating the impulsiveness of a 30-year-old woman with a diagnosis of BPD. An 11% reduction was observed in Barratt Impulsiveness Scale (BIS-11) scores post treatment and up to a 20% reduction in the follow-up with greater impact on the motor and non-planning impulsivity sub-scales.

The results of these studies suggest that TMS is an effective treatment option for BPD patients suffering with comorbid depression.

Written by Joe, Dublin Practitioner


  1. Black, D.W., Blum, N., Pfohl, B., Hale, N., (2004) Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J. Personal. Disord. 18 (3), 226–239
  2. Dukes, C., Rose, S., Dwyer, J., Palmer, E.O., Yeow, J., Oyesanya, M., Griffiths, K., Chee, B., Patel, R., (2023) Treatment Trajectory in People with Borderline Personality Disorder from Diagnosis to 12 Month Post Diagnosis. Neuroscience Applied 2 102442
  3. Gunderson, J.G., Herpertz, S.C., Skodol, A.E., Torgersen, S., Zanarini, M.C., (2018) Borderline personality disorder. Nat. Rev. Dis. Primers 4, 18029
  4. Klein, P., Fairweather, A.K., Lawn, S., (2022) Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review. International Journal of Mental Health Systems volume 16, Article number: 48
  5. Mayo Clinic (2023) Borderline Personality Disorder https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237
  6. Messina, I., & Grecucci, A., (2023) Toward the Identification of Neuroimaging Biomarkers of Borderline Personality Disorder from Brain Structures: Promising Applications of Machine Learning Approaches. Neuroscience Applied 2 (2023) 102442
  7. Millon T (1996). Disorders of Personality: DSM-IV-TM and Beyond. New York: John Wiley & Sons. ISBN 978-0-471-01186-6.
  8. Millon, T., Grossman, S. D., Meagher, S., Millon, C., & Ramnath, R. (2004). Personality Disorders in Modern Life. New York: Wiley.
  9. Mind (2023)What treatment or support is there for BPD? www.mind.org.uk/information-support/types-of-mental-health-problems/borderline-personality-disorder-bpd/treatment-and-support/
  10. Minzenberg, M.J., Fan, J., New, A.S., Tang, C.Y., and Siever, L.J., (2008) Frontolimbic structural changes in borderline personality disorder J Psychiatr Res. 2008 Jul; 42(9): 727–733.
  11. Muir, O., Abbot-Sinclair, R., Ruiz, D., Besvinick, R., MacMillan, C., (2020) MDD Responds Equally to DTMS with and without Comorbid Personality Disorders. Brain Stimulation 13 (2020) 1842e1862 / Abstracts
  12. Nassan, M., Hu, Y., Kung, S., Croarkin, P., (2020) Psychiatric Comorbidities Did Not Influence Remission and Response Rates in Patients Treated with Transcranial Magnetic Stimulation (TMS) for Major Depressive Disorder. Brain Stimulation 13 1842e1862 / Abstracts
  13. O’Malley, G.K., McHugh, L., Mac Giollabhui, N., Bramham, J., (2016) Characterizing adult attention-deficit/hyperactivity-disorder and comorbid borderline personality disorder: ADHD symptoms, psychopathology, cognitive functioning and psychosocial factors, European Psychiatry Volume 31, Pages 29-36
  14. Perez, P.D., Guillen, Y.G., Montalvo, J.P., (2023) Repetitive Transcranial Magnetic Stimulation as a Treatment for Impulsiveness in Borderline Personality Disorder: A Case Report. Brain Stimulation 16 (2023) 117e409
  15. Pan, N., Wang, S., Qin, K., Li, L., Chen, Y., Zhang, X., Lai, H., Suo, X., Long, Y., Yu, Y., Ji, S., Radua, J., Sweeney, J.A., Gong Q., (2023) Common and Distinct Neural Patterns of Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder: A Multimodal Functional and Structural Meta-analysis Biological Psychiatry: Cognitive Neuroscience and Neuroimaging Volume 8, Issue 6, Pages 640-650
  16. Patel, R.S., Manikkara, G., Chopra, A., (2019) Bipolar Disorder and Comorbid Borderline Personality Disorder: Patient Characteristics and Outcomes in US Hospitals. Medicina (Kaunas) 55(1): 13
  17. Smart TMS 2023 Does Having Traits of Borderline Personality Disorder Affect the Likelihood of Response to rTMS for Depression?Brain Stimulation 15 (2022) 1322e133
  18. Stefana A (2015). “Adolph Stern, father of term ‘borderline personality'”. Minerva Psichiatrica. 56 (2): 95
  19. Trull, T.J., Freeman, L.K., Vebares, T.J., Choate, A.M., Helle, A.C., Wycoff, A.M., (2018) Borderline personality disorder and substance use disorders: an updated review. Borderline Personality Disorder and Emotion Dysregulation volume 5, Article number: 15
  20. Zimmerman, M., Ellison, W., Morgan, T.A., Young, D., Chelminski, I., Dalrymple, K., 2015. Psychosocial morbidity associated with bipolar disorder and borderline personality disorder in psychiatric out-patients: comparative study. Br. J. Psychiatry 207 (4), 334–338.
  21. Zimmerman M., Morgan T.A. (2013) The relationship between borderline personality disorder and bipolar disorder. Dialogues Clin. Neurosci. 15:155–169.