Summary

Borderline Personality Disorder (BPD), also known as Emotionally Unstable Personality Disorder (EUPD), is characterised by a pervasive pattern of instability in interpersonal relationships, self-image, affects, and marked impulsivity beginning in early adulthood. Core features include fear of abandonment, unstable relationships (often with "splitting" between idealisation and devaluation), identity disturbance, impulsive behaviours, recurrent self-harm or suicidal behaviour, affective instability, chronic emptiness, intense anger, and transient paranoid ideation. BPD is strongly associated with childhood trauma and invalidating environments. Treatment is primarily psychological, with Dialectical Behaviour Therapy (DBT) as the gold standard. Medications have a limited role.

Key Facts

• Core Features: Fear of abandonment, Unstable relationships, Identity disturbance, Impulsivity, Self-harm, Affective instability, Emptiness, Anger, Paranoid ideation
• Mnemonic: IMPULSIVE
• Prevalence: 1-2% of population; F:M = 3:1
• Association: Childhood trauma, invalidation
• Treatment: DBT is gold standard; MBT also effective
• Medication: Limited role; avoid polypharmacy

Clinical Pearls

"IMPULSIVE" Mnemonic: Impulsive, Moodiness, Paranoia, Unstable self-image, Labile, Suicidal, Inappropriate anger, Vulnerability to abandonment, Emptiness.

"Splitting is the Defence": Patients often view people as all good or all bad. This can affect therapeutic relationships. Maintain consistent boundaries.

"DBT, Not Drugs": Medications have limited evidence. DBT (skills training + individual therapy) is the most effective treatment.

"Admission Often Worsens": Psychiatric admission can foster regression and dependency. Crisis management should focus on outpatient support where safe.

Mental State Examination

Risk Assessment

• Always assess suicide and self-harm risk
• Ask about means, plans, intent
• Consider impulsivity (increases unpredictability)

Natural History

• Symptoms often improve with age
• 50% no longer meet criteria by 40s-50s
• Self-harm and impulsivity tend to reduce

With Treatment

• DBT reduces self-harm by 50%
• Improved functioning and quality of life

Mortality

• Suicide rate: 8-10% (higher than general population)
• Risk highest in younger patients and those with comorbid depression

Key Guidelines

1. NICE CG78: Borderline Personality Disorder
2. APA Practice Guideline: Borderline Personality Disorder

Key Evidence

DBT

• RCTs show reduced self-harm, ED presentations, hospitalisations

MBT

• Also effective; may be better for attachment-related symptoms

What is Borderline Personality Disorder?

BPD (sometimes called Emotionally Unstable Personality Disorder or EUPD) is a mental health condition where you experience very intense emotions that are hard to manage. It can feel like you're on an emotional rollercoaster.

What Are the Main Features?

• Fear of being abandoned by people you're close to
• Intense relationships that can swing between love and hate
• Not being sure who you are
• Acting impulsively (spending, risky behaviour)
• Thoughts of hurting yourself or suicide
• Mood swings
• Feeling empty inside
• Anger that's hard to control
• Sometimes feeling paranoid or disconnected from reality

What Causes It?

Usually a combination of:

• Difficult experiences in childhood (trauma, neglect)
• Being in an environment where your emotions weren't taken seriously
• Biological factors (how your brain processes emotions)

How is it Treated?

The main treatment is talking therapy, especially:

• DBT (Dialectical Behaviour Therapy): Teaches skills to manage emotions
• MBT (Mentalisation-Based Therapy): Helps you understand your own and others' feelings

Medications can help with some symptoms (like depression) but are not the main treatment.

Can You Recover?

Yes. Many people with BPD see significant improvement over time, especially with the right therapy. It's possible to have a fulfilling life and relationships.