Borderline - DEAN AMORY

Borderline
Personality Disorder

BORDERLINE PERSONALITY DISORDER
Borderline Personality Disorder Treatment
by John M. Grohol, Psy.D. - June 22, 2007
Introduction
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
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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 solutionfocused
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 welldefined
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:
“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.
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.

Symptoms of Borderline Personality Disorder
by John M. Grohol, Psy.D. - June 22, 2007
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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.

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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.
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Characteristics of Borderline Personality Disorder
by John M. Grohol, Psy.D. - June 22, 2007
Individuals with Borderline Personality Disorder make 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, affect,
cognition, and behavior. These
individuals are very sensitive to
environmental circumstances. They
experience intense abandonment fears
and inappropriate anger even when
faced with a realistic time-limited
separation or when there are
unavoidable changes in plans (e.g.,
sudden despair in reaction to a

clinician’s announcing the end of the hour; panic or fury when someone important to them is
just a few minutes late or must cancel an appointment). They may believe that this
“abandonment” implies 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.
Individuals with Borderline Personality Disorder
have a pattern of unstable and intense
relationships. They 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 beneficent supports or as cruelly punitive. Such shifts often reflect
disillusionment with a caregiver whose nurturing qualities had been idealized or whose
rejection or abandonment is expected.
There may be an identity disturbance characterized by markedly and persistently unstable
self-image or sense of self. There are sudden and dramatic shifts in self-image, characterized
by shifting goals, values, and vocational aspirations. There may be sudden changes in
opinions and plans about career, sexual identity, va lues, 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
this 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.
Individuals with Borderline Personality Disorder display
impulsivity in at least two areas that are potentially selfdamaging.
They may gamble, spend money irresponsibly, binge eat, abuse substances, engage
in unsafe sex, or drive recklessly.
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.

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 to interpersonal
stresses.
Individuals with Borderline
Personality Disorder may be
troubled by chronic feelings
of emptiness. 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. 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, 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.

Frequently Asked Questions about Borderline
by John M. Grohol, Psy.D. - June 22, 2007
Below are some of the most frequently asked questions, and their answers, about Borderline
Personality Disorder.
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 disorderdepressed
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
Treatment for Depression Cooccurring
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).
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.
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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
a need for markedly increased amounts of the substance to achieve the desired effect,
or 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 cocaineinduced
depression)
Self-Injurious Behaviors and Suicidality in
Borderline Disorder
by Robert O. Friedel, MD
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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
Panic Attacks
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.
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.
not already prescribed.
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
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.

RECAP : WHAT IS BPD?
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.
TREATMENTS
There are six key elements of care that directly bear on the effectiveness of the treatment you
receive for borderline disorder. These include your level of commitment to treatment, locating
a skilled primary clinician, determining the most appropriate level of care for you, evaluating
your need for medication, and selecting the type of psychotherapy and support group that will
be most effective for you.
Taking Responsibility
If you have borderline disorder, it is essential that you understand clearly and believe deeply
that you, more than anyone or anything else, have the ability and responsibility for gaining
increasing control over your life.
Primary Clinician
You will need help. The number and complexity of decisions involved in the proper treatment
of a patient with borderline disorder requires that a highly skilled clinician assumes a central
role in helping you. This person is referred to as your primary clinician, and ideally will be a
psychiatrist experienced in treating borderline disorder.

Level of Care
Most patients with borderline disorder are most appropriately treated as outpatients. However,
there are times when acute inpatient or residential care is necessary. Under most
circumstances, this decision is best made by you, your primary clinician, and your family or
spouse.
Medications
{ HYPERLINK "http://www.bpddemystified.com/index.asp?id=21" } 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.
Psychotherapy
Psychotherapy is also an important component of your treatment program. A number of
different psychotherapeutic approaches appear to be effective in the treatment of borderline
disorder. These include supportive, psychodynamic and modified psychoanalytic therapy,
interpersonal therapy, dialectical behavior therapy (DBT), cognitive behavior therapy (CBT),
and a variety of group and family therapies.
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.
Conclusion
In summary, there are a number of different levels of care, medications, and individual and {
HYPERLINK "http://www.bpddemystified.com/index.asp?id=22" \l "6" } approaches that can
be utilized to help you gain increasing control over your life. The treatment plan that works
best for another patient may not be appropriate or work well for you. Therefore, it is very
important that you work closely with your psychiatrist and other mental health professionals
to formulate that treatment plan that will produce the best results under your specific
circumstances.