Borderline Personality Disorder

Borderline personality disorder is one of the most misunderstood diagnoses in mental health, and the words manipulative and attention-seeking are often used about the people who carry it. The clinical literature that therapists train on says why both are wrong.

What borderline personality disorder is

The diagnosis describes lasting instability in mood, sense of self, and relationships. Marked impulsivity goes with it. Two further features are common. One is fear of abandonment, the other a chronic sense of emptiness.¹

It is not rare. Studies put the prevalence in the general population at between 0.7% and 2.7%.¹

Symptoms usually appear in early adulthood. Rates run higher among people already seeking care. In primary care the figure is 6%, and 22% among psychiatric inpatients.¹

Several patterns recur.

• Fear of being left. A sense that someone is about to go, whether real or imagined.
• Relationships that swing. Closeness and conflict can alternate quickly.
• An unsteady sense of self. Values, goals and self-image shift.
• Fast-changing emotions. Feelings arrive strongly and are hard to settle.
• Impulsive behaviour. Acting quickly to relieve distress, sometimes in risky ways.
• Self-harm and thoughts of suicide. These are recognised features of the diagnosis,¹ and effective help exists for both.
• Feeling unreal or suspicious. Some people develop transient psychotic symptoms under stress.¹

Many people meet these first as accusations rather than as symptoms, and our page on self-harm goes into that in more detail.

What it is like from the inside

John Gunderson and Paul Links wrote one of the standard clinical texts on the diagnosis, and they place a single experience at its centre.

Being alone, in their account, is experienced as a terrifying loss of self.⁶

Much of the rest follows from that. They describe how the same person can present quite differently depending on where they stand with someone they need. When the person feels cared for and held, they can look depressed and weary, easy to sympathise with, and receptive to help.⁶

When that care seems about to be withdrawn, how they appear changes fast. Fear of abandonment arrives, and with it angry devaluation or self-harm, often with unexpected suddenness.⁶ Support at these moments makes a real difference.

When the person feels there is no caring other at all, something different again happens. There can be a loss of the sense of reality, or suspicion of other people. Suspicion invents a hostile other, and a hostile other is preferable to being alone.⁶

That is not disordered thinking for its own sake, but a mind doing whatever it can to avoid an emptiness it experiences as annihilating.

One anonymous account, published in a clinical guide edited by Gunderson and Perry Hoffman, describes an emptiness that could isolate the writer even inside a warm and noisy crowd.⁹

Feelings for someone would weaken, and the writer would always assume it was the other person who had changed.⁹ The writer also describes resisting it, holding out against a feeling that was moving them away from a friend they did not want to hurt.

Why the behaviour makes sense from the inside

Anthony Bateman and Peter Fonagy, who developed mentalization-based treatment, set out what is happening in detail.

Mentalizing is their word for something you do constantly without noticing. It is how you read actions, your own and other people's, as coming from feelings, beliefs, needs and reasons.⁷

They call it a folk psychology, the everyday capacity everyone uses to make sense of themselves and of others.⁷

When feeling runs high, mentalizing is what sits between the feeling and the next action. People with this diagnosis find mentalizing hard, and hardest of all in close relationships.⁷

High arousal throws a neurochemical switch which takes the prefrontal cortex offline, triggering fight, flight and freeze.⁷

What comes out is panic and impulsive behaviour rather than mentalizing.⁷ Nothing sits between the feeling and the action at the moment it is needed.

They add a second point. In that state, only visible, concrete goals of action are accepted as valid.⁷ Real physical contact becomes necessary to generate the experience of being loved. Inferring it from what others do or say is insufficient, empty, lacking in meaning.

In the same state, the other person's prior intention often goes unattributed, and the consequences of an action go unpredicted.⁷ Large interpersonal conflicts follow from that.

The word manipulative assumes something quite different. Manipulating someone requires holding their mind steadily in view and working on it deliberately. What Bateman and Fonagy describe is close to the opposite: the capacity to hold another mind in view drops away exactly when distress is highest.

Reaching for something visible and immediate, in that state, is not strategy; it is what is left when the capacity to read minds has dropped away.

What the stigma gets wrong

Three characterisations come up repeatedly: that people who carry it are manipulative, that they are attention-seeking, and that the condition cannot be treated.

The first is answered above, and the third by the long-term research below. The second is not only a public misunderstanding; it has a long history inside the professions.

Beginning in 1974, the psychiatrist George Vaillant gave a talk with a deliberately provocative title, "Wisdom Is Never Calling a Patient Borderline".⁶ His argument was that clinicians reach for the label for patients they do not like. Gunderson, reviewing this in his own text, says plainly that Vaillant is right.

Disliking a patient is not a reason to make this diagnosis, he writes. It is a reason for the clinician to understand their own reaction.⁶

Clinicians at the Stone Center made a related argument. The label misleadingly suggests that people are angry and manipulative, which interferes with a clinician's capacity for empathy towards people often better understood as having been traumatised.⁶

Guidance quoted by Bateman and Fonagy records service users calling it a very sticky label.⁷

One firsthand account shows how early this can start. When the family doctor was told of the diagnosis, the response was that the only hope was that it had been made in error.⁹

A second problem gets much less attention. The diagnosis is also missed.

Gunderson cites a study in which clinicians at one outpatient clinic recorded the diagnosis in 0.4% of patients. When a comparable group was assessed with structured interviews, the figure was 14.4%, some 36 times as many.⁶

Patricia Judd and Thomas McGlashan put the consequence bluntly. People with this diagnosis remain underserved, have treatment ended prematurely, or are made worse by treatment systems not designed to help them.⁸

The NICE guideline for England and Wales is explicit that people should not be excluded from a health or social care service.² That holds whether the reason is the diagnosis or the fact that they have self-harmed. The same guidance asks specialist teams to train staff on stigma and discrimination.

Some clinicians, and many people who carry the label, question the diagnosis itself. That debate is genuine and unresolved.

How it develops

Current models draw on several areas of research at once.¹ None of them makes this a matter of fault or weak character.

Judd and McGlashan set out one of the more careful developmental accounts. A person who develops the disorder is born with a range of neurobehavioural vulnerabilities, which environmental factors then amplify and exaggerate.⁸

Both the vulnerabilities and the environment work through the attachment system, which they describe as the central pathway.⁸ Their model is dynamic and nonlinear, laid out in order only because a book has to be.

Nothing in the model says that a particular childhood produces a particular adult.

Gunderson describes one specific mechanism, drawn from Fonagy's research. A caregiver who misreads a frightened child as angry, or who mistakes a child's ordinary attention-seeking for being demanding, responds in ways that impair the child's developing capacity to mentalize.⁶

That bears directly on the accusation. Ordinary attention-seeking, misread as something worse, is part of how the difficulty is thought to form. The word used against people as adults describes the very thing that was misread when they were small.

Specific genes may be involved, working through the body's stress-hormone system.¹

Brain-imaging studies have found differences in the amygdala, hippocampus and medial temporal lobes.¹ Those differences may also relate to self-reported childhood trauma.

Our page on trauma sets out how early experience shapes later distress.

None of this fixes what follows.

How it is diagnosed, and why that is changing

Diagnosis is made by a qualified clinician, through assessment over time, and an online quiz cannot settle it. The classification itself is being rebuilt, which matters when reading older material.

NICE notes that ICD-11 no longer separates the previous personality disorder types.³ It defines a single condition, classified by severity. NICE says it is still exploring how to bring its recommendations in line with ICD-11.

The World Health Organization team describing that change set out five trait domains. They are negative affectivity, detachment, dissociality, disinhibition and anankastia.⁴ Borderline survives there as an optional qualifier, a borderline pattern. It was kept partly to hold continuity of care through the change.

Whether it adds anything beyond the trait domains remains an open research question.⁴

What the treatments actually involve

Psychotherapy is the first-line treatment.¹ Therapies tailored to the diagnosis do better than treatment as usual. In clinical trials, psychotherapy improved psychosocial functioning and reduced symptom severity. Four structured therapies have evidence of efficacy.

Naming four therapies does not say what any of them involves. Two are described here.

Dialectical behaviour therapy, developed by Marsha Linehan, is not one thing. Standard DBT combines individual psychotherapy, group skills training, telephone coaching and a therapist consultation team.¹¹ The skills trainer teaches skills and gets people practising them. The individual therapist handles crises and helps apply those skills to real situations, including by telephone between sessions.

The therapists meet regularly to support each other and keep each other balanced.¹¹

Mentalization-based treatment is built to keep that mentalizing capacity working under stress. Bateman and Fonagy's own outpatient programme has a set shape. One individual session a week, lasting 50 minutes, with the same therapist each time.⁷

Alongside it runs a group of no more than six to eight people, for an hour and a half.⁷ People are asked to stay in treatment for a year.

Our page on dialectical behaviour therapy sets out how that one runs in practice.

Joel Paris, reviewing the trial evidence, reports a further finding. All well-structured methods do better than treatment as usual, but none is clearly superior to any other.¹⁰

The most important shared ingredient is the quality of the alliance between therapist and patient, because therapy is a relationship.¹⁰ He names the working mechanisms as validation, self-observation, and problem solving in the present.

His conclusion is a practical one. Therapists can help by applying these principles, and do not necessarily have to be trained in a specialised method.¹⁰ That matters where a named programme is not available; a skilled therapist who works this way is not a lesser option.

The evidence for adolescents is less certain, because high-quality studies are lacking.¹ NICE asks clinicians to explore treatment options in an atmosphere of hope and optimism. It states that recovery is possible and attainable.²

Where medication fits

NICE guidance for England and Wales is direct. Drug treatment should not be used specifically for borderline personality disorder.²

That also applies to the individual symptoms and behaviours associated with it. Antipsychotic drugs should not be used for medium-term or long-term treatment.² Medication may still be considered for conditions occurring alongside it. Short-term sedative medication may be considered cautiously during a crisis.

Decisions here belong with a prescribing clinician who knows your history.

What the long-term studies show

The long-term research answers the question of cure in two parts. Symptoms improve more than was once generally expected. A meta-analysis with 5 to 15 year follow-up found mean remission rates of 60%.¹

A systematic review of long-term studies reached a similar view. Symptomatic remission is common, and recurrence after a period of remission is unlikely.⁵ That review drew on 19 studies, across 11 unique cohorts and 1,122 people.

The second half is reported less often. Psychosocial functioning often remains impaired even as symptoms settle.¹ The review makes a related point about what recovery means. It involves broader changes in psychosocial function, over and above symptom relief.⁵

Judd and McGlashan note that considerable pessimism still surrounds treatment, despite convincing evidence that people improve with treatment and time.⁸

If you love someone with this diagnosis

Families and partners carry a great deal here. They are often told very little.

Gunderson describes a bind for people close to the person. When separation seems to be coming, the other person feels guilty about leaving, and at the same time finds the prospect of staying very difficult.⁶ It is a described feature of the situation, not a private failure of love.

Judd and McGlashan are direct about why understanding these behaviours matters. They wrote their account of the puzzling and sometimes frightening behaviours in order to increase the clinician's empathy and ability to maintain a working alliance.⁸ That aim was written for clinicians, though the reasoning is not confined to them.

Paris puts the practical point in one line. Families should be useful allies in treatment, not enemies. He describes family programmes whose basic idea is modest and achievable. Parents learn to avoid making bad situations worse, by responding without judgement to some of the behaviours involved.¹⁰

That is a smaller aim than fixing anything, and a more useful one.

Guidance asks services to involve families, subject to the person's consent.² It also notes that people with personality disorders may provide services themselves. That includes training professionals and facilitating peer support groups.

Finding support

Treatment for this diagnosis is specialised. It is worth asking about that directly.

Questions worth putting to a clinician:

• What experience do you have of working with this diagnosis?
• Which structured therapy do you work in, and how long does it usually run?
• What happens if I am in crisis between sessions?
• How will we know whether the work is helping?

The third question has a real answer in some programmes. Telephone coaching between sessions is a standard component of DBT rather than a favour.¹¹

Our page on therapy for personality disorders covers the wider group of diagnoses.

You can search for a clinician in your own country through our directory.

This article is for general information and is not a substitute for professional assessment or care. If this is affecting your life, consider reaching out to a qualified mental health professional.

References

1. [1] Chapman J, Jamil RT, Fleisher C, Torrico TJ. Borderline Personality Disorder. StatPearls. StatPearls Publishing; 2025. ncbi.nlm.nih.gov/books/NBK430883.
2. [2] National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management. Clinical guideline CG78. 2009 (last reviewed 2024). nice.org.uk.
3. [3] National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management. Clinical guideline CG78 overview. 2009 (last reviewed 2024). nice.org.uk/guidance/cg78.
4. [4] Reed GM, First MB, Kogan CS, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry. 2019;18(1):3-19. pmc.ncbi.nlm.nih.gov/articles/PMC6313247.
5. [5] Ng FYY, Bourke ME, Grenyer BFS. Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers. PLOS ONE. 2016;11(8):e0160515. journals.plos.org/plosone/article.
6. [6] Gunderson JG, Links PS. Borderline Personality Disorder: A Clinical Guide. 2nd ed. American Psychiatric Publishing; 2008. Chapter 1, "A Clinical Synthesis: Intolerance of Aloneness" (pp. 18-21) and "Misuses of the Borderline Diagnosis" (p. 23).
7. [7] Bateman A, Fonagy P. Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford University Press; 2004. Introduction, "Core component of treatment" (p. xxi); Chapter 3, "Psychic equivalence, shame, and the teleological stance" (p. 96); Chapter 5, "The treatment programmes" (p. 148); Appendix 5, intensive out-patient programme leaflet (pp. 319-320).
8. [8] Judd PH, McGlashan TH. A Developmental Model of Borderline Personality Disorder: Understanding Variations in Course and Outcome. American Psychiatric Publishing; 2003. Introduction (p. x); Chapter 1, "An Integrated Developmental Model" (pp. 4-7).
9. [9] Anonymous. Living With Borderline Personality Disorder: Two Firsthand Accounts. In: Gunderson JG, Hoffman PD, eds. Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families. American Psychiatric Publishing; 2005. Chapter 6 (pp. 105-107).
10. [10] Paris J. Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. The Guilford Press; 2008. Chapter 8, "Psychotherapy" (pp. 147-149).
11. [11] Linehan MM. DBT Skills Training Manual. 2nd ed. Guilford Press; 2015. Chapter 1, "Rationale for Dialectical Behavior Therapy Skills Training". guilford.com.