For many years, international literature described patients with symptoms that fell somewhere between neurosis and psychosis, leading to considerable diagnostic confusion. These patients were given names and diagnoses that highlighted their borderline condition, such as "borderline state" or "borderline patient." Over time, however, a distinct diagnostic entity emerged—now classified as Borderline Personality Disorder (BPD) within the spectrum of personality disorders.

The key feature of this disorder is extreme instability in various areas of the individual's life, such as interpersonal relationships, self-image, emotional mood, and a tendency toward impulsivity.

One particularly defining characteristic of people with BPD is their intense reaction to real or imagined abandonment. As soon as they sense that someone is leaving them—whether due to a breakup, a temporary absence, travel, or even a delayed appointment or the end of a therapy session—they are flooded with fear or even panic, along with anger and rage. This reaction stems from their inability to tolerate being alone, and because abandonment is often perceived as rejection, implying that they are inherently "bad." In their frantic attempts to avoid abandonment, they may impulsively engage in suicidal gestures or self-harm, such as cutting or burning themselves.

Interpersonal relationships for people with BPD are intense but unstable. They may idealize and become completely attached to someone who offers them care or to romantic partners, only to quickly switch to devaluing them—believing that the person doesn't care enough or love them sufficiently. This shift from idealization to devaluation is central to their defense mechanism of splitting, in which others are viewed as all-good or all-bad. Their relationships are generally chaotic, and they can dramatically and abruptly change their opinions of others. When disappointed or when they feel abandoned, they often react with intense demands and anger, one of the primary emotions they experience.

There is also a significant disturbance in identity, manifesting as instability in their self-image or sense of self. Their goals, values, career aspirations, sexual identity, and even their choice of friends may change suddenly and dramatically.

Their behavior is impulsive, unpredictable, and often self-destructive. Repeated suicide attempts or self-harming behaviors are common (it is estimated that 8–10% of individuals with BPD die by suicide, especially if they also suffer from depression or substance abuse). These behaviors often occur in response to abandonment, rejection, or the threat of assuming responsibilities.

Emotionally, individuals with BPD exhibit extreme mood instability. They have strong emotional reactions to even minor stress. Their moods fluctuate between distress (the dominant mood), irritability, anxiety, anger, panic, and despair. As mentioned, they are prone to intense emotional outbursts, especially anger, which they find difficult to control. Additionally, they frequently report chronic feelings of emptiness and profound loneliness. Under significant stress (e.g., fear of abandonment or actual abandonment), they may experience temporary paranoid thoughts, hallucinations, or dissociative symptoms (such as depersonalization).

Diagnostic Criteria for Borderline Personality Disorder

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

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization 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 (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. 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).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Treatment

Psychotherapy (both Cognitive-Behavioral and Psychodynamic, individually or in groups) is the main therapeutic approach for these patients. Due to the strong emotional shifts toward the therapist (alternating between idealization and devaluation), both transference and countertransference are intense, making therapy challenging. Frequent outbursts of anger and suicide attempts are common and pose serious problems. Therapists often struggle with feelings of guilt, frustration, or even anger toward these patients.

There are also temporary episodes resembling psychosis (though not true psychosis). While hospitalization may sometimes be necessary, international guidelines recommend avoiding it when possible. If a mood disorder (such as major depressive disorder or bipolar disorder) coexists, appropriate medication may be required.

A significant aspect of psychotherapy for BPD is the relationship with the therapist, as analyzing and improving this relationship can reflect positively on the patient’s other relationships.

Psychotherapeutic approaches often include cognitive techniques to help correct the tendency of individuals with BPD to view others and themselves as either "all good" or "all bad." Behavioral techniques are also helpful in reducing self-injurious and impulsive behaviors.

Medications such as low-dose antipsychotics can help stabilize mood, while lithium can be useful for managing mood swings. Antidepressant medications can alleviate depressive symptoms, but they must be chosen carefully to avoid triggering mood fluctuations or anger outbursts. Monotherapy with antidepressants is generally discouraged, as it can lead to increased mood instability and risk of misuse.

In general, the medication strategy for BPD resembles that used for bipolar disorder, given the overlap between the two conditions.

Given the potential for suicidality in these patients, all medications should be prescribed with great caution and always within the context of a comprehensive psychotherapeutic approach tailored to their issues.

Day treatment programs that provide intensive, daily therapy often offer an ideal setting for treating individuals with BPD who require a thorough and systematic therapeutic approach.

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Scientific Editor:
Dr. Yanni Malliaris

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