Borderline personality disorder: recognising symptoms, understanding causes, finding therapy

What is behind borderline personality disorder – and why is it so stressful for those affected and their families, especially in clinical contexts?

Borderline personality disorder is one of the most misunderstood mental illnesses and places a significant burden on those affected. It is characterised by intense feelings, unstable relationships and impulsive behaviour – which can be very challenging for everyone involved, especially for therapists. However, the better the dynamics are understood, the more opportunities for change arise.

This article provides a comprehensive overview of symptoms, causes and current therapeutic approaches such as dialectical behavioural therapy (DBT), mentalisation-based therapy and structural psychodynamic psychotherapy. Why this article is helpful for you:

• You will learn how borderline personality disorder presents itself and how it is diagnosed.

• You will learn which biographical and neurological factors can contribute to its development.

• You will discover specific forms of therapy that have proven effective in practice.

What is borderline personality disorder?

Borderline personality disorder (BPD) – also known as emotionally unstable personality disorder – is a pervasive mental disorder characterised by a pattern of intense internal tension, instability in self-image, impulsive behaviours, and intense, often conflicted interpersonal relationships, which can lead to self-harm in patients with borderline personality disorder.

According to the DSM-5 and ICD-10, borderline personality disorder is classified as a personality disorder. It usually begins in young adulthood and affects about 1 to 2 per cent of the population – with women more frequently diagnosed than men.

What are the symptoms of borderline personality disorder?

The symptoms of borderline personality disorder are diverse and affect different areas of life. The most common signs include:

• Pronounced mood swings are characteristic of borderline syndrome.

• Impulsive behaviour (e.g. risky driving, substance abuse)

• Self-harming behaviour or suicidal thoughts

• Unstable relationships, characterised by idealisation and devaluation, are often observed in patients with borderline personality disorder.

• Pronounced fear of being abandoned

• feeling of inner emptiness and an unstable self-image

These symptoms often lead to considerable psychological strain – both for the affected individuals and for their social environment.

What does ‘splitting’ mean for people with borderline personality disorder?

A central phenomenon of borderline personality disorder is what is known as ‘splitting’. This involves perceiving other people – but also one's own self – alternately as exclusively ‘good’ or ‘bad’, which often goes hand in hand with paranoid thinking. Differentiated assessments or ambivalences are often not accessible in emotionally stressful situations.

This split serves a subconscious self-protective function: anyone who hurts is perceived as completely negative – anyone who offers closeness is idealised. This can lead to frequently changing assessments of caregivers and severely strains interpersonal relationships, especially for relatives of patients with borderline personality disorder.

In a therapeutic context, it is important to raise awareness of these black-and-white patterns and to promote emotional integration.

How does emotional instability manifest itself in borderline personality disorder?

A key feature of borderline personality disorder is emotional instability. Feelings change rapidly and are difficult to control. The emotional response to everyday events can be overly intense and often difficult to control.

This instability affects:

• Self-image: Who am I and what do I really feel?

• Relationships: intimacy is sought but also feared

• Inner state: emotions seem overwhelming and unpredictable

What does the fear of abandonment mean?

The fear of being abandoned is particularly pronounced in many people with borderline personality disorder. Even minor situations – such as someone cancelling an appointment at short notice – can be experienced as threatening by those affected, which is often observed in child and adolescent psychiatry.

Typical reactions include:

• reproach or withdrawal

• self-harming behaviour

• overly strong emotional reactions

These patterns often arise from earlier attachment experiences and can have a strong impact on interpersonal relationships in everyday life.

How is borderline personality disorder diagnosed?

Borderline personality disorder is diagnosed on the basis of a detailed psychological or psychiatric examination. In doing so, specialists are guided by the diagnostic criteria for borderline personality disorder set out in the ICD-10 of the DSM-5.

The following are important:

• A careful anamnesis, including the biography, is important

• Differentiation from other mental disorders such as depression, psychosis or other personality disorders

• The assessment of stability, emotion regulation and impulsive behaviour over a longer period of time

What is the connection between borderline disorder and complex post-traumatic stress disorder (CPTBS)?

Borderline personality disorder overlaps with complex post-traumatic stress disorder (CPTSD) in many ways, especially when childhood traumas such as neglect or abuse are present.

Both disorders are associated with affective instability, problems in emotion regulation, dissociative states and relationship dynamics.

One key difference is that CPTBS is more often caused by chronic traumatisation in childhood and often includes symptoms such as persistent feelings of guilt and shame, as well as difficulties with self-esteem and trust.

In practice, both diagnoses often occur together – an integrated therapeutic approach is then particularly important.

What factors contribute to the development of the disorders?

The causes of borderline personality disorder are complex. In many cases, there is a combination of genetic predisposition, neurobiological sensitivity and stressful childhood experiences.

Possible triggers:

• Neglect in early childhood can trigger the onset of borderline personality disorder.

• Traumatic experiences such as emotional or sexual abuse are common triggers for the clinical picture of borderline personality disorder.

• Repeated attachment breakdowns or a lack of emotional security

These influences can contribute to limited affect regulation and an unstable self-concept in the long term.

What forms of treatment are available at the clinic?

In acute crises or in the case of severe symptoms, inpatient treatment in a specialised clinic can be useful. There, structured daily routines, a multi-professional team and methods for crisis management are available, which are important for therapists and patients.

The aim of an inpatient stay is to:

• promote emotional stabilisation

• strengthening impulse control

• reducing acute self-harm or harm to others

Which psychotherapeutic approaches have proven effective?

Borderline disorder can be successfully treated with psychotherapeutic methods. Patience, continuity and a strong therapeutic relationship are important.

The proven approaches include:

• Dialectic-behavioural therapy (DBT)

• Mentalisation-based therapy (MBT)

• Structural psychodynamic psychotherapy (SPP)

• Schematic therapy

These methods help to understand emotional reactions, develop alternative behaviours and stabilise the self-image.

What does dialectical behavioural therapy (DBT) achieve?

DBT was developed specifically for people with borderline personality disorder. It combines behavioural therapy methods with mindfulness, emotion regulation and strategies to improve social skills.

DBT supports the treatment of borderline personality disorder.

• Dealing with strong feelings

• Reducing self-damaging behaviour is a central goal in the treatment of borderline personality disorder.

• building stable relationships

What does structural psychodynamic psychotherapy (SPP) offer?

SPP is aimed at people with a severely impaired self-structure. It aims to strengthen ego functions such as affect differentiation, reality testing and self-control.

Key features of SPP:

• working with relationship experiences in the here and now

• processing unconscious conflicts and defence processes

• Promoting inner stability through the therapeutic relationship

SPP is particularly suitable for chronic inner emptiness, identity diffusion and unstable relationship patterns.

What can relatives do?

As a relative or caregiver, you often face great challenges. At the same time, you can be a valuable resource.

Recommendations:

• Find out as much as you can about the disorder

• Stay in contact without overwhelming yourself

• Seek professional therapeutic support to reduce the burden.

Psychoeducative groups or family counselling can help you recognise your own limits while still being supportive.

Conclusion: What you should take away

• Borderline personality disorder is a serious but treatable mental illness that requires clinical support.

• Symptoms such as emotional instability, fear of abandonment, dissociation and impulsivity can be positively influenced by suitable forms of therapy.

• DBT, MBT and SPP offer structured treatment approaches that can lead to long-term stability.

• The link to complex post-traumatic stress disorder (CPTBS) shows the importance of a trauma-sensitive approach.

• Relatives play an important role in the healing process and often need support as well.

Frequently asked questions about borderline personality disorder (FAQ)

What is borderline personality disorder?

It is a serious mental illness associated with unstable feelings, an insecure self-image and interpersonal difficulties. It is one of the so-called emotional unstable personality disorders.

What does borderline type F60.31 mean?

This is the classification of borderline personality disorder according to ICD-10: ‘Emotionally unstable personality disorder, borderline type’.

What are the symptoms of borderline personality disorder?

The main symptoms include emotional instability, impulsivity, severe mood swings, unstable relationships, an insecure sense of self, chronic emptiness, a fear of being alone and recurrent self-harm.

What is typical of a borderline personality?

Typical symptoms include rapid changes of emotion, unstable relationships, impulsive actions, a strong fear of being abandoned and self-harming behaviour. Many sufferers report a feeling of inner emptiness and insecurity about their identity.

How does a borderline episode manifest itself?

A borderline episode is characterised by acute emotional crises – e.g. intense anger, panic, a compulsion to self-harm or sudden withdrawal. These can be triggered by interpersonal conflicts or perceived rejection.

How does borderline personality disorder manifest itself in women?

In women, emotional instability is often at the forefront. They tend to develop intense relationship patterns and react particularly sensitively to rejection. Studies show that women are diagnosed more often than men.

How does borderline personality disorder develop?

Common causes are early traumatic experiences, such as neglect, abuse or unstable caregivers. Neurobiological and genetic factors also play a role.

Is borderline personality disorder a trauma disorder?

It is often understood as such – especially when there are complex childhood traumas. However, a clear distinction from complex post-traumatic stress disorder (CPTSD) is necessary.

Is a personality disorder like borderline hereditary?

There is evidence of a genetic predisposition. However, borderline personality disorder usually arises from an interplay of biological, psychological and social factors.

Is borderline the same as multiple personality disorder?

No. Multiple personality disorder (dissociative identity disorder) is about the presence of multiple personality states. Borderline personality disorder is a separate diagnosis with different symptoms.

Is borderline personality disorder curable?

It is easily treatable, even if it is not ‘curable’ in the classic sense. Many sufferers achieve a significant improvement in their quality of life with the right therapy.

Which therapy is best?

That depends on your individual needs. The best results are usually seen with specific methods such as DBT, MBT, schema therapy or SPP – in conjunction with a strong therapeutic relationship.

What to do with borderline personality disorder?

Seek psychotherapeutic help. Proven forms of therapy include DBT, MBT and SPP. Relatives should also seek counselling and take advantage of psychoeducational offers.

How can relatives help?

Find out more, set clear boundaries and remain supportive. Professional support (e.g. family counselling) can provide relief and guidance.

What is the drama triangle in borderline personality disorder?

The drama triangle describes a typical interaction dynamic with the roles of victim, rescuer and persecutor – a model that often occurs in emotionally unstable relationships and is discussed in therapy.

What are the consequences of an untreated borderline personality disorder?

If left untreated, it can lead to chronic relationship problems, job loss, addictive behaviour, depression or repeated hospitalisations. Early therapy can counteract these developments.