Compass
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BPD

Borderline Personality Disorder

Cluster B. Dramatic / Emotional / Erratic · Table 5.2 [1]

Pervasive instability of affect, identity, and relationships with marked impulsivity and frantic efforts to avoid abandonment.

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Characteristics (Table 5.2) [1]

Triggering Event(s)Expectation of meeting personal goals and/or maintaining close relationships
Behavioral Style
  • Impulsivity
  • Acting out behaviors
  • Helpless, empty “void”
Interpersonal Style
  • Fear of abandonment
  • Unstable, intense relationships
  • Alternates between extremes of idealization and devaluation
Cognitive Style
  • Inflexible, rigid thinking
  • Failure to learn from experience
  • External loss of control
Affective Style
  • Emotionally reactive and dysregulated
  • Inappropriate, intense anger
  • Extreme lability of mood and affect
Temperament
  • Dependent type: passive infantile pattern, low autonomic nervous system reactivity
  • Histrionic type: hyperresponsive infantile pattern, high autonomic reactivity
  • Passive-Aggressive type: “difficult” infantile pattern, affect irritability
Attachment StyleDisorganized
Parental Injunction
  • Received the implicit message that growing up and separating would harm the parent.
  • Overprotective or demanding or inconsistent parenting
Self-View
  • Feels unsure of who they are or what direction their life is taking.
  • Identity problems involving gender, career, loyalties, and values
  • Self-esteem fluctuates with current emotion
World-ViewSwings between opposing appraisals, people and goals seem wonderful one moment and worthless the next, cannot bear it when life goes off-script, and shies away from firm commitments.
Maladaptive Schemas
  • Abandonment
  • Defectiveness
  • Abuse/mistrust
  • Emotional deprivation
  • Social isolation
  • Insufficient self-control
Optimal Diagnostic CriterionDesperate maneuvers to head off abandonment, whether real or only imagined.

DSM diagnostic criteria

Essential feature

A far-reaching instability across relationships, self-image, and mood, coupled with pronounced impulsivity, evident from early adulthood.

Criteria, 5 or more of 9 criteria
  • Desperate attempts to prevent abandonment, whether actual or merely feared.
  • Turbulent, intense relationships that swing between putting others on a pedestal and tearing them down.
  • A disturbed sense of identity, with a self-image that is strikingly and enduringly unstable.
  • Impulsive behavior in two or more areas with potential for self-harm, such as spending, sex, substance use, reckless driving, or binge eating.
  • Repeated suicidal acts, gestures, or threats, or episodes of self-injury.
  • Mood that is highly reactive, producing pronounced emotional instability.
  • A persistent inner sense of emptiness.
  • Anger that is disproportionate and intense, or hard to rein in.
  • Brief, stress-triggered episodes of paranoid thinking or serious dissociation.
Key differentials
  • Bipolar disorder (sustained episodes vs. rapid, reactive mood shifts)
  • Histrionic PD (attention-seeking without self-harm/abandonment terror)
  • Narcissistic PD (instability driven by self-esteem injury, not abandonment)
  • Complex PTSD
  • Substance-induced mood instability

Treatment

Goals
  • Reduce self-harm and suicidality (life-threatening behaviors first)
  • Build affect-regulation and distress-tolerance skills
  • Stabilize identity and interpersonal functioning
  • Reduce treatment-interfering behaviors
Strategy

Hold a validating yet change-oriented stance (the dialectic of acceptance and change). Use a clear target hierarchy, a consistent frame, and explicit crisis/safety planning. Manage idealization-devaluation splits without retaliating or rescuing; coordinate care to prevent splitting across providers.

Modalities
  • Dialectical Behavior Therapy (DBT)
  • Mentalization-Based Treatment (MBT)
  • Transference-Focused Psychotherapy (TFP)
  • Schema therapy / Good Psychiatric Management (GPM)
Interventions
  • Behavioral chain analysis of self-harm and crisis behaviors.
  • Distress-tolerance and emotion-regulation skills (e.g., TIPP, opposite action).
  • Validation paired with explicit invitations to change.
  • Collaborative safety planning and clear between-session contact rules.
Common obstacles
  • Idealization → devaluation ruptures and risk of dropout
  • Self-harm and suicidality that pull the frame off-target
  • Splitting between treatment providers
  • Therapist burnout / countertransference
Prognosis

Good with structured, evidence-based treatment. Most patients no longer meet criteria over time, though functional recovery lags symptom remission.

Practise this presentation

Sophie: After a breakup, a crisis that swings within the hour
26-year-old presenting after self-harm following a breakup; idealises then devalues the assessor within a single session.
Advanced

For training only. Diagnostic criteria are summarised, consult the full sources [1,2] for the complete text; see References. Not a substitute for supervised clinical assessment.