Borderline personality disorder (emotionally unstable personality disorder)
Borderline personality disorder (BPD), also called emotionally unstable personality disorder, is a mental health condition in which emotions are intense and change quickly, relationships swing between closeness and conflict, fear of abandonment is strong, and impulsive acts such as self-harm are common. It is linked to a mix of genes and difficult early experiences, often trauma. The main treatment is specialist talking therapy such as DBT or mentalisation-based therapy; medicines are not the first-line treatment. The outlook is far better than many people think: most people improve a great deal over the years.
Health writers · Aslam Clinic
Borderline personality disorder (BPD) is a in which emotions are very intense and change fast, relationships feel all-or-nothing, the fear of being left is overwhelming, and impulsive or self-destructive acts — including — are common. In ICD-10 and in UK services it is called emotionally unstable personality disorder (EUPD); the two names describe the same condition.
It is a real, diagnosable condition, not “drama”, weakness or attention-seeking, and it is treatable. Long-term studies show that most people with BPD improve substantially. That message matters, because the diagnosis has long carried a stigma that the evidence does not support.
Symptoms
The NHS groups the symptoms into four areas. A clinician using looks for at least five of nine features, lasting for years rather than weeks.
| Area | What it can look like |
|---|---|
| Emotional instability | Intense anger, sadness, shame, panic or emptiness; moods that swing within hours; a chronic feeling of being empty inside |
| Disturbed thinking and sense of self | An unstable sense of who you are; harsh thoughts about yourself; under severe stress, brief paranoid thoughts, hearing voices, or |
| Impulsive behaviour | Self-harm such as cutting or burning; reckless spending, substance use, binge eating or risky sex; suicide attempts |
| Unstable relationships | Frantic efforts to avoid being abandoned; idealising someone then feeling bitterly let down; intense, stormy relationships |
Many people with BPD describe feeling emotions “with no skin” — a comment others would shrug off can trigger hours of distress. The difficulty is not having emotions; it is , the ability to bring them back down once they rise.
The risk is serious. are very common in BPD, many people make at least one suicide attempt, and studies estimate that between about 3% and 10% of people with the diagnosis eventually die by suicide. Most do not — and treatment lowers the risk — but no threat or act of self-harm should be dismissed.
What causes it?
There is no single cause. BPD runs in families, which suggests some inherited vulnerability, and brain-imaging studies show differences in areas involved in emotion such as the . Most people with BPD have experienced difficult early environments: abuse, neglect, prolonged fear, losing a parent, or growing up with a parent who had serious mental illness or addiction. These experiences do not cause BPD on their own, and not everyone with BPD has a history of .
How it is diagnosed
A psychiatrist or clinical psychologist makes the diagnosis through detailed interviews, often with input from family, over more than one appointment. They also look for conditions that can look similar or occur alongside it: , , , ADHD, eating disorders and substance use.
Treatment: therapy comes first
Specialist psychological therapy is the main treatment, and it usually lasts a year or more. A Cochrane review in 2020 found that therapy reduced the severity of BPD symptoms and suicidality compared with usual care, although the certainty of the evidence was low. The best-studied therapies are:
- — weekly individual therapy plus group skills training in managing emotions, tolerating distress, mindfulness and relationships, with phone coaching between sessions. It has the strongest evidence for reducing self-harm and suicidal behaviour.
- Mentalisation-based therapy (MBT) — helps you notice and make sense of your own and other people's thoughts and feelings, especially in heated moments. It often runs for around 18 months, with individual and group sessions.
- Other structured approaches include schema therapy and transference-focused psychotherapy.
Full DBT or MBT programmes are hard to find in Pakistan and are mostly available privately in big cities. Many psychologists use DBT-informed skills in ordinary therapy, and some offer sessions online. Psychiatry departments in teaching and DHQ hospitals can assess and plan care, including for self-harm.
Medicines are not the first-line treatment
No medicine is licensed for BPD itself. The UK's National Institute for Health and Care Excellence (NICE) says drug treatment should not be used specifically for BPD or for its individual symptoms such as self-harm or mood swings. Medicines may be used for conditions that occur alongside it, such as depression, and a sedative may be used briefly in a crisis — NICE advises no longer than a week. Antidepressants, and are sometimes prescribed, but expert opinion on their value for BPD is divided.
Recovery is common
BPD used to be described as lifelong. Long-term research has overturned that. The McLean Study of Adult Development followed people with BPD for 16 years: between 78% and 99% reached symptom (depending on how long the remission had to last), although a smaller share — 40% to 60% — also achieved full recovery with steady work and relationships. Relapses happen, and many people still need support, but the direction for most is improvement.
Skills that help in the moment
DBT teaches practical skills for getting through surges of emotion without making things worse. They take practice and work best learned with a therapist, but some can be started now:
- Cool the body. Splashing cold water on the face or holding something cold can quickly lower intense arousal.
- Slow the breath. Breathing out more slowly than you breathe in, for a few minutes, calms the .
- Delay the urge. Tell yourself you will wait 15 minutes before acting on an urge to self-harm, send an angry message or leave. Urges peak and pass.
- Name the feeling. Putting a word to it — “this is shame”, “this is fear of being left” — helps you step back from it.
- Have a crisis plan. Write down your warning signs, what helps, and who to call, and share it with someone you trust.
Stigma and the family
People with BPD are often called manipulative or attention-seeking, including sometimes by health workers. Self-harm is far more often a way of coping with unbearable feelings than a performance for others. In Pakistan, outbursts and self-harm in a young woman may be put down to jinn, nazar or “bad upbringing”, or hidden because of what people will say. Prayer and faith can be a real comfort, and they are not in conflict with treatment — but self-harm, suicidal talk or voices need a doctor as well.
How to help someone with BPD
- Stay calm and validate the feeling, even when you do not agree with the reaction: “I can see you are very hurt.”
- Keep your word and be predictable. Last-minute changes and silence feel like abandonment.
- Set limits kindly and consistently — you can care for someone and still refuse to be shouted at.
- Learn the crisis plan: what helps, who to call, and when to go to hospital.
- Never ignore talk of suicide or self-harm because “she always says that”.
- Look after yourself too; family members of people with BPD often need support of their own.
When to get help
- Emergency now: a serious injury, an overdose, or stated intent to die — 1122 or the emergency department.
- See a doctor soon: repeated self-harm, frequent suicidal thoughts, or moods and relationships so unstable that work, study or family life is breaking down.
- Ask for an assessment: if the patterns in this article have been present for years and you recognise yourself in them.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
