Personality disorders differ from other mental disorders in that they are durable and stable over time. In the case of a depressive disorder, there is a clear, staged onset and evolution of the condition. Personality disorders are persistent. They appear once the personality is finalized, that is, during late adolescence. The Diagnostic Manual of Mental Disorders (DSM) defines borderline personality disorder as a pattern of inner life and behavior that deviates significantly from the expectations of the target person’s culture.

Borderline disorder is defined as a pattern of instability of interpersonal relationships, self-image and feelings, as well as marked impulsivity.

The DSM also mentions that the disorder is diagnosed in  75% of women.

This percentage represents a major discrepancy between the sexes. It is found in only a few other psychiatric disorders, such as histrionic or antisocial personality disorder. However, recent research shows that this gender difference is not determined by a constitutional predisposition of women to this disorder. It is the case only in other conditions such as breast cancer or autoimmune diseases. It is due exclusively to errors in the way these calculations are made.

Why are more women diagnosed with borderline?

• The wrong choice of the population for the performance of these statistics. Studies indicating a higher rate of BPD in women are mostly done in psychiatric clinics. Here, in general, women are the majority population. They turn to psychiatric medical care much more frequently than men. When the general population is evaluated, as in a Norwegian study , there are no relevant differences according to sex. Another study from 2009 , which collected data from 34,000 adults from the general population, discovered, once again, the following obvious fact:

there is no significant difference between the rate of BPD in men and women.

According to this study, 6.2% of women and 5.6% of men met the criteria for diagnosis. So the difference between the two sexes is a little over half a percent.

• The diagnostic criteria are mainly developed by men. They may have sexist preconceptions and stereotypes regarding female behavior and what constitutes pathological behavior in women versus men. There is a lower probability for men to be considered promiscuous if they sleep with many women, than vice versa. Despite the sexual liberation movements of women from the second feminist wave.
• The criterion of intense and inappropriate anger is extremely subjective. The cultural expectation from women in patriarchal societies is to never express their anger in public. In men it is a common manifestation, even a sign of masculinity. Thus, a woman’s angry outburst is much more likely to be interpreted as pathological, while in men it is underestimated.
• Last but not least, the simple assumption of doctors that women are more prone to BPD, and men are somewhat rare.

They may cause them to diagnose this disorder more often in patients than in patients. All this leads to an underdiagnosis of borderline personality disorder in men, which ultimately results in their reduced access to adequate treatment. BPD is a disorder that affects a person’s entire existence, especially the relational sphere. 

If borderline men don’t get the right diagnosis, then they can’t get the help they need to lead a balanced life.

That is why it is extremely important to recognize the signs for the borderline man and to help him in the therapeutic process.

The borderline man

A 1990 studyfound that when students are asked to label borderline symptoms as masculine or feminine, almost all (with the exception of anger) are interpreted as intrinsically feminine. Therefore, bordeline is a stereotypically female condition, at least in the way it is presented in the DSM. This does not mean that it occurs only in women. It is possible that researchers have put too much emphasis on the manifestations specific to women and ignore those specific to borderline men. The basic features are common to both sexes (fear of abandonment, impulsivity, self-harm, relational and self-related instability). But they can manifest themselves very differently, due to the distinct way in which boys and girls are raised and taught to behave.

 The main manifestations of borderline in men

The borderline man – Fear of abandonment

Just like women, men feel an acute fear of abandonment, which they try to avoid at all costs. If in women this is manifested by clinging to the partner and an overdependence on him, in men it is rather reflected by an exacerbated possessiveness and a desire to control the partner (what he does in his free time, what friends he has, relationships with family, how they dress/make-up). 

Fear of abandonment is the main force that guides the behavior of men with BPD in relation to others. At first, they tend to be conquering and polite, but when the relationship seems to work, they tend to self-sabotage, because of the belief that they can’t trust anyone and that abandonment is inevitable, so they start to behave chaotically and unpredictable, sometimes even violent. The other person is extremely confused, not understanding what caused the 180-degree change, suspecting that the BPD man was faking it at first. However, this is not inauthentic, his behavior is a defense mechanism of which he is usually not even aware. Both the poor person from the beginning and the unpredictable and aggressive man coexist inside him, taking control at different stages of the relationship.

When he feels the danger of being abandoned (mostly imagined), he takes over to be in control and break the relationship before his partner has the chance to do so. Thus, they can resort to gestures such as cheating on their partner, threatening to leave her or violent behavior.

The effects of fear of abandonment

This behavior leads to a history of intense but unstable relationships that wear out quickly. The same is true not only for romantic relationships, but also for friendship or family relationships. If a close person makes them feel offended, it is very possible to suddenly break the relationship with them. During therapy sessions, it is possible for them to lose their temper and feel rejected if they detect fear in the psychotherapist. (which may be a misinterpretation of the therapist’s reaction). So he stops coming to therapy. The lack of lasting and healthy relationships is both a symptom and a debilitating factor in the lives of men with BPD. In the absence of a support system, they become more and more self-destructive, and the other manifestations of the disorder are accentuated.

Borderline personality disorder: what it is & treatment

Borderline personality disorder is a disorder that involves a rigid and unhealthy thought pattern, characterized by emotional instability, difficulty maintaining interpersonal relationships, self-mutilation, and risk of suicidal behavior. Many face legal, social and personal problems, very difficult to understand and tolerate by their relatives.

The name of the personality disorder – borderline – translates as “at the limit”, “at the border”, because the patient is on the border between psychosis and neurosis. Borderline personality disorder is characterized by hypersensitivity to rejection and the resulting instability of interpersonal relationships, self-image, intense fear of abandonment or instability, difficulty tolerating being alone, problems relating to others, and severe behavioral disturbances. 

Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric comorbidities. Surveys have estimated the prevalence of borderline personality disorder to be 1.6% in the general population and 20% in the psychiatric inpatient population.

In general, the manifestations of this condition cause problems for the patient, both personally and professionally. Anger, impulsiveness, and frequent mood swings can alienate others, even if they desire lasting, affectionate relationships.

Borderline personality disorder usually begins in early adulthood. The condition appears to worsen in young adulthood and may gradually improve over the years.

Causes of borderline personality disorder

The cause of this personality disorder is not known, but scientists believe that certain genetic factors, brain structure, as well as social, cultural and environmental factors may be to blame.

There is a genetic predisposition. Twin studies show a heritability of over 50% (higher than that for major depression). Twin studies conducted in 2000 and 2008 demonstrated a higher concordance in the rate of borderline personality disorder for monozygotic twins than dizygotic twins.

Environmental factors that have been identified as contributing to the development of borderline personality disorder primarily include childhood abuse (physical, sexual, or neglect), found in up to 70% of individuals with borderline disorder, as well as maternal separation, poor maternal attachment , family boundary inadequacy, parental substance abuse, and severe parental psychopathology.

Borderline personality disorder is the result of a lack of resilience against psychological stressors. In this framework, Fonagy and Bateman define resilience as “the ability to generate an adaptive reappraisal of negative events or stressors; patients with impaired reappraisal accumulate negative experiences and fail to learn from good experiences”.

 Otto Kernberg theorized that the lack of integration in the early material relationship led to borderline personality disorder. Kernberg hypothesized that “the infant experiences the mother figure in a dichotomous setting, the loving and nurturing mother who cares for the child and the punishing and hateful mother who deprives him. This contradiction causes intense anxiety and, if not integrated into a more unified concept moderately, it eventually leads to the development of cleavage”.

The term splitting or “splitting” refers to the defense mechanism in which the patient cannot form a realistic view of another person. At any given moment, the other person is viewed as either completely good or completely bad. This inability to see others as a whole, as having both positive and negative attributes affects personal relationships.

Neuroimaging studies have identified differences in the amygdala, hippocampus, and medial temporal lobes in patients with borderline personality disorder. Such studies also suggest that patients with borderline personality disorder misattribute negative emotions (fear, anger, disgust) to neutral faces more than others, despite having the same perception of happy and angry faces as others,

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Risk factors for borderline personality disorder 

Factors that increase the risk of developing borderline disorder include:

•    family history/genetics – personality disorders may be inherited or strongly associated with other mental health disorders in family members; people who have a close relative diagnosed with this disorder are at increased risk of developing this mental problem themselves;
•     brain structure/brain abnormalities – studies have shown that there are certain structural and functional changes in the brain of patients with borderline disorder.

The changes are mostly concentrated in the area that controls impulses and regulates emotions. In addition, certain brain chemicals that help regulate mood may not function properly. Neurobiological studies have suggested that impaired neuropeptide function, particularly serotonin, may be present in patients with borderline personality disorder. It is not known, however, whether these changes are the ones that cause the disease or whether the borderline disorder causes these changes to appear.

Risk factors for borderline personality disorder

•     hereditary predisposition: you may have a higher risk if a close relative – your mother, father, brother or sister – has the same or a similar disorder.
•     traumatic childhood: Many people with this disorder report being sexually or physically abused or neglected as children. Some people lost or were separated from a parent or close caregiver when they were young, or had parents or caregivers who struggled with substance abuse or other mental health problems. Others have been exposed to major conflicts or unstable family relationships, dysfunctional bonds. 

However, there are also situations in which people who are not in these risk categories end up developing borderline personality disorder.

In the biosocial model popularized by Dr. Marsha Linehan, “genetic vulnerability interacts with a ‘chronically disabling environment’ to produce the constellation of symptoms of borderline personality disorder.”

Borderline personality disorder symptoms

DSM-5 diagnostic criteria for borderline personality disorder

A general pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five or more of the following:

• Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered by criterion 5.
• A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
• Identity disorders: marked and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-harming, eg spending, substance abuse, reckless driving, risky or reckless sexual activity, binge eating, etc. Note: Do not include suicidal or self-mutilating behavior included in criterion 5.
• Affective instability caused by marked mood reactivity, eg, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days.
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger, eg, frequent temper tantrums, constant anger, recurrent physical fights.
• Transient paranoid ideation or severe dissociative symptoms.

The patient suffering from borderline personality disorder may have some or all of these symptoms. 

Symptoms are not permanent, they come and go. They are generally triggered by certain events. For example, separation from loved ones triggers the exacerbation of borderline disorder.

Neurobiological studies have suggested that impaired neuropeptide function, particularly serotonin, may be present in patients with borderline personality disorder. In terms of neuropsychological testing, a meta-analysis published in 2005 showed that patients with borderline personality disorder performed lower on neurocognitive testing in the following domains: attention, cognitive flexibility, learning and memory, planning, rapid processing, and skills spatial visuals.

When to go to the doctor

If you are aware that something is wrong with you or those around you suggest this, seek a psychological consultation, which can help you discover what it is about. 

If you experience the aforementioned symptoms, a psychological consultation is indicated.

On the other hand, if you self-mutilate or have suicidal thoughts, it is imperative that you seek professional help as soon as possible! 

Go to a psychologist, a psychiatrist and talk to the people close to you about what is happening to you. Ask for help and you will manage to beat the moment!

Diagnosis of borderline personality disorder 

A psychologist or psychiatrist can diagnose borderline personality disorder.

Following a discussion with the patient, as well as a psychiatric evaluation based on the completion of some questionnaires, the doctor can identify this disorder. 

Sometimes borderline personality disorder appears in association with bipolar disorder, anxiety or depression, which makes diagnosis more difficult.

A diagnosis of borderline personality disorder is usually made in adults, not in children or adolescents. That’s because what appear to be signs and symptoms of borderline personality disorder may disappear as children grow and reach adulthood.

Treatment of borderline personality disorder

Psychotherapy is the main way of treating borderline personality disorder, but drug treatment is also used in parallel, if necessary. 

If there are suicidal thoughts, the doctor may recommend hospitalization to protect the patient.

Cognitive-behavioral therapy will help the patient to know the disease (psychoeducation) and to cope with its manifestations.

There is no special drug treatment for borderline disorder, but the doctor can use antidepressant, antipsychotic or anxiolytic drugs to stabilize the patient. Medications such as SSRIs, mood stabilizers, and antipsychotics have shown limited efficacy in studies aimed at controlling symptoms such as anxiety, sleep disorders, depression, or psychotic symptoms.

Anxiety can be difficult to treat because patients may label their internal experiences with the word anxiety, even when they are not truly based on fear. Thus, “anxiety” may need to be accurately relabeled, with treatment recommendations arising from the patient’s specific internal experience. The exception to the misleading use of the word anxiety is that patients with borderline personality disorder often fear being alone; in other words, they have attachment anxiety. However, attachment anxiety is not necessarily similar in etiology or treatment to recognized anxiety disorders.

Any other mental health disorders that often co-occur with borderline personality disorder, such as depression or substance abuse, need to be treated. 

With treatment, you can feel better about yourself and live a more stable, fulfilling life.