Borderline Personality Disorder (BPD) This factsheet will give you information on the symptoms, causes and possible treatments for borderline personality disorder (BPD). It explains what treatment you should be offered from the NHS if you are diagnosed with this condition. If you’re a carer, friend or relative of someone with BPD, it could help you too.     

Borderline personality disorder (BPD) can mean that you are prone to strong emotions, mood swings and feelings you can’t cope with easily and may feel distressed a lot of the time. Around 1 in 100 people have BPD. There may be different reasons why someone develops BPD. There are a number of different approaches to treating BPD, most of which include different types of one-to-one and group talking therapies. Complications can arise if you have BPD, including problems with substance misuse and self-harm.

This factsheet covers: 1. 2. 3. 4. 5. 6. 7. 8.

What is borderline personality disorder (BPD)? What are the symptoms of BPD and how is it diagnosed? What causes BPD? How is BPD treated? What are the treatments for BPD? What if I am not happy with my treatment? What risks and complications can BPD cause? Information for carers, friends and relatives

1. What is borderline personality disorder (BPD)? Generally speaking, your personality is defined by the way you think, feel and behave. These characteristics shape the way you view the world and the way you interact with others. It is when these characteristics have a 1

significant effect on the way you cope with life, manage relationships and respond emotionally that you may be diagnosed with a personality disorder. There are different types of personality disorders, which are divided into categories or ‘clusters’. BPD falls under the dramatic/ emotional/ erratic cluster. It is also referred to as ‘emotionally unstable personality disorder’. The term ‘borderline’ originally referred to the condition being on the borderline between psychosis (where someone is out of touch with their normal reality) and neurosis (experiencing emotional distress and anxiety). Around 1 in 100 people have BPD. It is thought to be one of the more widely recognised and researched personality disorders. Research suggests that more women than men have BPD.1 If you have BPD, you may find that you:        

Self harm or feel suicidal regularly Find it difficult to cope with stress Find it difficult being around and getting along with other people Experience strong emotions, mood swings and feelings you can’t cope with easily Try and change how you feel through drinking or using drugs Have very strong views on something and feel there is no middle ground Find it difficult to stay in work, have a long term relationship, or maintain a tenancy Feel isolated and fearful

Sam’s experience On a bad day, my distress levels go through the roof. The simplest of things like making breakfast will make me want to self harm. My emotions feel jumbled up and I don’t understand why I feel so upset. It makes me feel drained. It’s difficult to explain how I feel.

It can be different for everyone. You might realise you have problems, but assume nothing can be done. You can find more information on other personality disorders in our ‘Personality disorders’ factsheet, which you can download for free from www.rethink.org or call 0300 5000 927 and ask for a copy to be sent to you. Top

2. What are the symptoms of BPD and how is it diagnosed? If your GP thinks that you may have BPD, they should send your details to the community mental health team (CMHT). This is sometimes called a ‘referral’. You may then be seen by a specialist doctor, such as a psychiatrist, for an assessment. Doctors will diagnose a personality disorder based on guidelines which standardise decisions about diagnosing mental health problems. The main guidance doctors use is in the ‘International Classification of Diseases’ (ICD-10) by the World Health Organisation (WHO) and the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) by the American Psychiatric Association. For the doctor to diagnose you with BPD, he or she must be sure that you are experiencing five of the symptoms below:    

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Extreme reactions to abandonment, whether real or perceived A pattern of unstable and intense personal relationships with others Unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating) Recurring suicidal behaviour, gestures, threats, or self-harming Long lasting feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (for example, frequent displays of temper, constant anger, recurrent physical fights) Intense, highly changeable moods Stress related paranoid thoughts

All five must be severe for you to get a BPD diagnosis. Doctors will need to talk to you about your experiences and long term history or talk to others close to you, with your consent. As with all mental illnesses, there are no direct medical tests (such as a blood test) to check whether you have a personality disorder. It is not clear when people first experience BPD. People aren’t usually diagnosed with it before the age of 18, but some research suggests it can start at an earlier age.2 If you are under 18, you should still get treatment, but it will be from child and adolescent mental health services (CAMHS) rather than adult mental health services.3 If you feel unhappy with your diagnosis, you should discuss any concerns with health professionals involved in your care. You can ask why they have provided the diagnosis. An advocate could be helpful in this type of situation. You can find out more about advocates in section 6. Top

3. What causes BPD? We don’t know exactly why some people develop BPD. Some research shows that genes play a part, and that it does sometimes seem to run in families.4 Many people diagnosed describe experiences of past traumas or events. These can often include difficulties growing up, including childhood neglect or physical, emotional or sexual abuse. This is not the same for everyone though. Some people find that problems get worse after a chain of stressful life events, such as bad relationships, problems with work or the loss of someone close. The most important thing is to try and get help and support if you are experiencing any of the symptoms of BPD. Top 4. What are the treatments for BPD? Professionals from the CMHT, along with you and your family (if you agree to them being involved), should together decide what treatment to give you. Your GP should still be involved with your physical health needs and support in a crisis. You may find that you get treatment from a specialist personality disorder service or unit. These services are made up of professionals such as psychologists, psychiatrists and therapists who will have specialist experience in helping people with personality disorders. Sometimes you might be able to go direct to one of these services instead of seeing your GP. You can call us to find out what services are in your area and how you can access them. Most treatments for BPD include one-to-one and group psychological treatments or ‘talking therapies’. All involve talking with a therapist, but are slightly different from one another. Some have a defined structure to them, while others are more flexible. Some of these are specifically for people with BPD. Others are also helpful for anxiety or depression. In some areas, there are long NHS waiting lists for these treatments. Some common treatments are: Dialectical Behaviour Therapy (DBT) DBT is a psychological treatment that focuses on enhancing your skills in regulating emotions and behaviour. It aims to address and change patterns of behaviour by finding a balance, or resolving differences (this is what is meant by ‘dialectical’). The therapy can help you gain control of behaviour such as self-harm and substance misuse. Recent studies show that DBT can significantly help people diagnosed with BPD.5 The therapy usually takes place over a year with weekly one-to-one and group meetings. Normally, you access individual one-to-one therapy appointments, education groups and telephone support.6

Cognitive Analytical Therapy (CAT) CAT focuses on changing repeating patterns that were set up in childhood as a way of coping with emotional difficulties. You and the therapist will work together to recognise these patterns and then to try and change them. CAT helps you recognise relationship patterns that continue throughout life and are difficult to change. You will identify goals from the start. Mentalisation-Based-Therapy (MBT) Mentalising is about making sense of people’s behaviour in terms of their likely thoughts, intentions, needs and desires. It is about being aware of what’s going on in your own head and in the minds of others (known as ‘mentalising’). Sometimes when you feel distressed, your ability to 'mentalise' can be severely reduced. It can be nearly impossible to think in a reasoned way about others, which can lead to problems. MBT combines group and individual therapy and aims to help you better understand yourself and others. The approach assumes that mentalising is a learned skill, and that people can learn it through therapy. Dynamic psychotherapy This is one of the longest established therapies and is a term that covers therapy of an analytical nature. It is a form of in-depth therapy which focuses on the unconscious and past experiences and the effect on current behaviour and thinking. For people with BPD the therapist provides more structure and is more ‘active’ than usual. You are encouraged to talk about childhood relationships and experiences during the sessions. The aim is to help you understand how experiences in the past can unconsciously affect your behaviour and thinking.7 Therapeutic Communities These are places people with long-standing emotional problems can go to (or sometimes stay) for several weeks or months. Sometimes you may visit for just a few hours a week. Most of the treatment happens in groups. People learn from trying to get on with other people in the treatment group. It differs from 'real life' in that any disagreements or upsets happen in a safe place. People in treatment often have a lot of say over how the community runs.8 Medication There is no recommended or licensed medication as treatment for BPD. However, due to the nature of BPD and how it often overlaps with one or more other mental health problems, you might receive medication to help with symptoms such as anxiety and depression. If your doctor prescribes any medication, he or she should tell you how it might help and what side effects to expect. Different types of medication include:

Antidepressants These can help with low mood and emotional difficulties, while some of the selective serotonin reuptake inhibitor antidepressants (SSRIs) can help you be less impulsive and aggressive.9 Mood stabilisers Medication such as lithium, carbamazepine, and sodium valproate can make you feel less impulsive and aggressive. Antipsychotics You might receive antipsychotics if you are experiencing symptoms of psychosis, which is when you might be hearing or seeing things that aren’t there. You can get more information about antidepressants, mood stabilisers, antipsychotics and psychosis at www.rethink.org. Top 5. What treatment should I be offered? The National Institute for Health and Care Excellence (NICE) produces guidance on recommended treatments for BPD. You can find this guidance at www.nice.org.uk. NICE guidance states that if your BPD causes you significant problems, you may be offered a psychological treatment in a special programme. How often you have sessions will depend on your needs and what is suitable for you. Psychological treatment lasting about a year or longer is best for people with BPD.10 Women with borderline personality disorder who self-harm on a regular basis may be offered dialectical behaviour therapy (DBT).11 The type of therapy or treatment you can access will depend on your difficulties and where you live. This should be based on an approach that you, the therapist and your healthcare team agree to in advance. NICE guidance states that doctors should not give anyone medication specifically to treat BPD. Crisis In crisis, you can contact your GP or healthcare team. They should understand the crisis from your point of view, and explore with you why you are distressed. They should be sensitive about why you are having a crisis and encourage you to think about solutions for your problems. They should try to help you to work through your problems rather than immediately offering you a place in a crisis unit or hospital.

If you feel you are having a mental health crisis, or if you need physical attention (due to self harm, injury or overdose), you can also go to the Accident & Emergency (A&E) or casualty department of the local hospital or call emergency services. Top 6. What if I am not happy with my treatment? If you ever feel unhappy with how your treatment or care is being handled, or feel that the relationship between yourself and a professional is not working well, you could call the Patient Advice and Liaison Service (PALS) at your NHS trust. They can try to resolve any problems or questions you have. You can find your local PALS’ details at http://www.nhs.uk/ServiceSearch/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363 or the Rethink Mental Illness Advice Service could search for you. You can contact us on 0300 5000 927. You might find a general/community advocate helpful if you are unhappy with your treatment. Advocacy can help you understand the mental health system and enable you to be fully involved in decisions about your care. An advocate is someone independent from mental health services who can help to make your voice heard when you are trying to resolve problems. They may be able to help with writing letters for you or attending appointments or meetings. You can find more information about advocacy in our ‘Advocacy’ factsheet. There may be a local advocacy service in your area which you can contact for support. There may be a local advocacy service in your area which you can contact for support. You can search online for a local service or the Rethink Mental Illness Advice Service could search for you. If you are not happy with your treatment, you can refer to the NICE guidance to see if you are being offered the recommended treatments. You can find all of their guidelines at www.nice.org.uk. If you are unhappy with the fact that you have been given a diagnosis of BPD, or feel that it is incorrect, then you could consider requesting a second opinion. No one has a legal right to getting a second opinion, but it may be worth exploring if there are doubts or questions. You can find out more about getting a second opinion, having a choice in your medication or making a complaint at www.rethink.org. It might also help to contact one of our specialist advisers to discuss problems you are having with your care and treatment. You can call us on 0300 5000 927 between 10 and 2pm Monday to Friday or email [email protected]. Top

7. What risks and complications can BPD cause? Diagnosis of BPD

Being told that you have BPD might leave you feeling confused, upset and distressed. Some people feel that BPD symptoms can sound like being deliberately difficult, bad-natured and manipulative. For this reason, some people reject the diagnosis and feel it is stigmatising. Others however find that having the diagnosis allows them to recognise a set of problems that they can work on and overcome. Healthcare professionals should be sensitive about the impact of diagnosing someone with BPD. People often have other mental health problems alongside BPD. This can sometimes lead to mistakes in diagnosis. People might have symptoms of depression, anxiety, eating disorders, post-traumatic stress disorder (PTSD), substance misuse disorders and bipolar disorder. The similarities between BPD and PTSD have led some to suggest that BPD should be regarded as a form of delayed PTSD.12 Some doctors feel that giving someone the diagnosis of a personality disorder can cause problems getting support in the future. They may feel there is still some stigma attached to the condition. You yourself may feel that a diagnosis of personality disorder can cause barriers to receiving the right support. However, this does not mean that your diagnosis should be changed just to get the right support. The Department of Health produced guidance in 2003, making it clear that people with personality disorders should receive appropriate care and should not be excluded from services just because of their diagnosis.13 Self-harm Self-harm is common amongst people who have BPD.14 Self-harm can help people to manage painful feelings that may be triggered by specific events or strong negative emotions. It can also act as a way of coping with distressing events and communicating that stress. You can find more information about self-harm from www.rethink.org. Drugs and alcohol People coping with difficult emotions and feelings sometimes drink too much or take drugs. People can behave impulsively after drinking or taking drugs, and might self-harm or threaten suicide. People who are dependent on alcohol or drugs are much more likely to have BPD.15 More women who drink a lot or take drugs will have a BPD diagnosis than men.16 If you drink heavily or use drugs, you may find it difficult to get specialist BPD treatment. You may also get long-term physical health problems. Health professionals call having a mental illness and a problem with drink or drugs ‘dual diagnosis’. You can find more information about dual diagnosis in our ‘Dual diagnosis’ factsheet. Recovery People with BPD who experience significant problems may require a large amount of support from services and from family and friends.

Many people stop going to therapy services.17 Although often wanting help, people with BPD often fear rejection from health professionals, especially if they have had previous negative experiences. Assessments can be traumatic and upsetting, because people have to talk about their experiences. In some areas, people do pre-therapy preparation to understand the link between emotions and decisions. This helps people recognise their emotions before starting therapy. Top 8. Information for carers, friends and relatives As a carer, friend or family member of someone living with BPD, you might find that you also need support. You may find it useful to learn about the disorder as much as possible. This will help you gain a better understanding of why things are happening the way they are and to also know when the person might need extra support. This may help you be more aware of possible triggers or actions and create an environment you can discuss things more openly. You can find out information on things like risky behavior, self-harm and how to support someone with a mental illness at www.rethink.org. It is important to seek emotional support for yourself if are struggling to cope. You could try contacting one of the organisations listed in the ‘useful contacts’ section below and also check whether there are any local support groups for carers, friends and relatives in your area. New education and support programmes for families are starting in some parts of the country. You can contact us to find out what services or groups are in your area. Top

National Personality Disorder Website provides information and resources relating to personality disorders. There is also a discussion forum. Web: http://www.personalitydisorder.org.uk/ Emergence is an organisation that supports people living with personality disorder and carers, friends and relatives. Web: www.emergenceplus.org.uk

BPD World is committed to raising awareness and reducing the stigma of mental health with a focus on borderline personality disorder. It provides online information, advice and support and has an online forum. Email: [email protected]

Web: www.bpdworld.org Tara (Treatment and Research Advancements) for BPD is an American education-based and support community for carers and families of people living with BPD. Web: www.tara4bpd.org Secret Shame is a comprehensive website dealing exclusively with selfharm. It is a valuable information resource with an up to date list of support groups in the UK, but also a place to talk to people with similar experiences through chat rooms and bulletin boards. Web: www.selfharm.net Turning Point is a social care organisation working with individuals and their communities across England and Wales in the areas of drug and alcohol misuse, mental health and learning disabilities. Standon House 21 Mansell Street London E1 8AA Tel: 020 7481 7600 Email: [email protected] Web: www.turning-point.co.uk 1

National Institute for Health and Clinical Excellence (2009) Borderline Personality Disorder. The management of Borderline Personality Disorder in adults, children and adolescents, in primary and secondary care. CG78. London: National Institute for Health and Clinical Excellence. 2 Chanen, A. and McCutcheon, L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. British Journal of Psychiatry. 202, s24-29 3 See reference 1 4 See reference 1 5 McMain SF. et al. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Centre for Addiction and Mental Health, Canada. 2012 6 See reference 1 7 UK Council for Psychotherapy. Psychodynamic psychotherapy. http://www.psychotherapy.org.uk/iqs/dbitemid.644/sfa.view/different_types _of_psychotherapy.html (Accessed Jan 2013) 8 Royal College of Psychiatrists. Personality disorders http://www.rcpsych.ac.uk/mentalhealthinfo/problems/personalitydisorders/ personalitydisorder.aspx (Accessed Jan 2013) 9 See reference 6 10 See reference 1 11 See reference 1 12 See reference 1

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National Institute for Mental Health for England. Personality Disorder No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder, Gateway Reference 1055. London- NIMH(E). 2003 14 See reference 6 15 Welch, S. (2007) Substance use and personality disorders. Psychiatry. 6(1), 27-29 16 See reference 1 17 McMurran M., Huband M., Overton, E. Non-completion of personality disorder treatments: A systematic review of correlates, consequences and interventions. Institute of Mental Health, University of Nottingham, United Kingdom. 2010

© Rethink Mental Illness 2013 Last updated May 2013 Next update May 2015 Version 2

This factsheet is available in large print. Last updated 01/10/2010