Borderline Personality Disorder: Symptoms, Diagnosis and Treatment

Borderline personality disorder (BPD) is a long-standing pattern of unstable relationships, an unstable sense of self, and intense, fast-changing emotions, along with impulsive behavior. It starts by early adulthood and shows up across many parts of a person's life (American Psychiatric Association [APA], 2022). People with BPD tend to feel interpersonal slights very sharply, and their emotions can swing hard and fast, often toward behavior that hurts them (Gunderson et al., 2018).

BPD is common, it is treatable, and most people with it get better over time. Those three facts get lost easily, including among clinicians, who are often intimidated or put off by patients with the diagnosis (Gunderson et al., 2018). This page covers what the diagnosis means, how it is assessed, and what the treatment evidence says.

If you are having thoughts of suicide or self-harm, call or text 988 to reach the 988 Suicide & Crisis Lifeline, any time. If you are in immediate danger, call 911.

A diagnosis requires at least five of the following nine (APA, 2022). Clinicians look for a lasting pattern across years and settings. One hard month does not qualify.

1. Frantic efforts to avoid being abandoned, whether the abandonment is real or feared.

2. Intense, unstable relationships that swing between putting someone on a pedestal and seeing them as all bad.

3. A markedly unstable self-image or sense of who you are.

4. Impulsive behavior in at least two areas that can cause harm, such as spending, sex, substance use, reckless driving or binge eating.

5. Repeated suicidal behavior, gestures or threats, or self-harm.

6. Emotional instability: intense episodes of low mood, irritability or anxiety that usually last a few hours and rarely more than a few days.

7. Chronic feelings of emptiness.

8. Intense anger that is out of proportion to the situation or hard to control.

9. Brief, stress-related paranoid thoughts or severe dissociation.

Because five of nine are enough, two people with the same diagnosis can look very different. One may be quietly empty and self-harming. Another may be outwardly angry and impulsive. Both meet the criteria.

Estimates vary with how BPD is measured. Across community studies, the median point prevalence is roughly 1%, rising to about 10% to 12% of people seen in outpatient psychiatric clinics and 20% to 22% of psychiatric inpatients (Ellison et al., 2018). It is often thought of as a women's diagnosis, partly because treatment studies have enrolled mostly women (Storebø et al., 2020). In a large US survey, though, men and women had BPD at about the same rate, 5.6% and 6.2% over a lifetime (Grant et al., 2008).

Genes account for part of the risk. A study of more than 5,000 twins in three countries found that genetic influences explained 42% of the variation in BPD features, in men and women alike (Distel et al., 2008). DBT's biosocial theory describes how that sensitivity can combine with life experience: a person born with strong, fast and slow-to-settle emotions grows up in an environment that dismisses or punishes those emotions, and never gets the chance to learn how to manage them (Linehan, 1993). The theory explains the problem without blaming the person or their family, and it points straight at what treatment has to teach.

The long-term course is more hopeful than the diagnosis's reputation. The McLean Study of Adult Development followed 290 people who had been hospitalized with BPD for 16 years. By the end, 78% to 99% had reached a symptomatic remission lasting two to eight years. Recovery, which also required good social and work functioning, came more slowly, for 40% to 60% (Zanarini et al., 2012). Symptoms came back for some, at rates of 10% to 36%.

Two practical points follow. Symptoms usually ease with time, and evidence-based therapy can speed that up (Gunderson et al., 2018). Work, friendships and a stable daily life take longer to rebuild, and that slower part is where much of the treatment effort belongs.

Assessment usually starts with a screen and ends with a clinical interview. The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a 10-item yes-or-no questionnaire. In its validation study, a score of 7 or more identified 81% of people who had BPD on interview and correctly ruled out 85% of those who did not (Zanarini et al., 2003). You can take the free MSI-BPD screen on this site, and our guide to MSI-BPD scoring and the 7-point cutoff explains what a positive screen means.

A screen cannot diagnose. A positive result means a full assessment is worth doing, usually a clinical interview that checks each criterion against the person's history, often with a structured interview. That validation study, for instance, confirmed diagnoses with the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (Zanarini et al., 2003).

BPD often comes with other conditions. Mood and anxiety disorders co-occur at high rates, and the link with bipolar disorder stays strong even after other conditions are accounted for (Grant et al., 2008). The two are easy to confuse. In BPD, mood shifts usually last hours and often follow something that happened between people. In bipolar disorder, mood episodes last days to weeks (APA, 2022). The distinction matters: missing BPD tends to lead to medication trials that rarely succeed (Gunderson et al., 2018).

Psychotherapy is the main treatment. A Cochrane review of 75 randomized trials with 4,507 participants found that therapies designed for BPD reduced BPD symptom severity compared with usual care, by an amount large enough to matter clinically. Effects on self-harm, suicide-related outcomes and day-to-day functioning also favored therapy, though the evidence for those was lower in quality (Storebø et al., 2020).

Dialectical behavior therapy (DBT) has the largest evidence base. It was the subject of a third of the trials in that review and beat usual care on BPD severity, self-harm and functioning, though the review rated that evidence low in quality (Storebø et al., 2020). In a landmark trial of 101 women with recent suicidal behavior, those who received DBT were half as likely to attempt suicide as those treated by expert community therapists, needed fewer hospital stays for suicidal thinking, and were less likely to drop out of treatment (Linehan et al., 2006). Mentalization-based treatment (MBT) is the next most studied, with benefits for self-harm and suicidality compared with usual care (Storebø et al., 2020).

Full DBT has four parts: individual therapy, a weekly skills group, phone coaching between sessions, and a consultation team for the therapists. The skills group teaches four modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness (Linehan, 2015). Other structured approaches, such as schema therapy, transference-focused psychotherapy and good psychiatric management, also appear in the trial literature, and the Cochrane review found no clear difference between therapy types when each was compared with usual care (Storebø et al., 2020). In practice, the right therapy is often the evidence-based one a person can actually get and stay in.

No medication treats BPD itself. A Cochrane review of 46 placebo-controlled and comparison trials found no medication that improved BPD severity, self-harm, suicide-related outcomes or functioning compared with placebo (Stoffers-Winterling et al., 2022). Medicines may still be prescribed for a co-occurring condition such as major depression, and that decision belongs with the prescriber.

DBT skills worksheets support a full program and help clients practice between sessions. The DBT worksheets collection has every sheet on this site, and our guide to DBT worksheets by module shows where each one fits.

A few sheets carry most of the early work. The DBT Diary Card tracks emotions, urges and skills used each day, and it sets the agenda for individual sessions. Mapping the Behavioral Sequence takes one problem behavior apart link by link to find where a skill could have changed the outcome. DBT TIPP Skills for Intense Distress gives fast, body-based ways to bring down a crisis-level emotion, and the guided TIPP walkthrough runs the steps on screen. Opposite Action and the DEAR MAN skill cover emotion regulation and asking for what you need.

For the ideas underneath the skills, see our articles on Wise Mind and radical acceptance. For clients, Understanding Borderline Personality Disorder explains the diagnosis in plain language and is a good first handout after an assessment.

Words matter here. Saying "a person with BPD" keeps the person in view in a way "a borderline" does not. It helps to name the diagnosis plainly, alongside the evidence that it improves, so the client hears a description of a treatable problem and a plan.

For a clinician, much of the work is staying steady. The behaviors that make BPD hard to treat, such as crises, anger at the therapist and fear of being left, are the symptoms the treatment targets. A team, supervision or consultation group protects both the clinician and the treatment, which is why DBT builds one in.

Is there a test for BPD? There is a screen. The MSI-BPD is a free, validated 10-item questionnaire, and a score of 7 or more suggests a full assessment is worthwhile. Only a clinical evaluation can diagnose BPD. You can take the MSI-BPD screen here.

Can BPD go away? For most people, the symptoms do. In a 16-year study, 78% to 99% of people reached a lasting remission of symptoms, and 40% to 60% also recovered their social and work functioning (Zanarini et al., 2012).

Is BPD the same as bipolar disorder? No. They can look alike because both involve mood changes. In BPD the shifts usually last hours and often follow interpersonal events, while bipolar mood episodes last days to weeks (APA, 2022). Some people have both.

What is the best therapy for BPD? Dialectical behavior therapy has the most research behind it, and mentalization-based treatment is next. Several structured, BPD-specific therapies help, and the Cochrane review found no clear difference between them when each was compared with usual care (Storebø et al., 2020).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Distel, M. A., Trull, T. J., Derom, C. A., Thiery, E. W., Grimmer, M. A., Martin, N. G., Willemsen, G., & Boomsma, D. I. (2008). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine, 38(9), 1219-1229. https://doi.org/10.1017/S0033291707002024

Ellison, W. D., Rosenstein, L. K., Morgan, T. A., & Zimmerman, M. (2018). Community and clinical epidemiology of borderline personality disorder. Psychiatric Clinics of North America, 41(4), 561-573. https://doi.org/10.1016/j.psc.2018.07.008

Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., Dawson, D. A., Pulay, A. J., Pickering, R. P., & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(4), 533-545. https://doi.org/10.4088/JCP.v69n0404

Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature Reviews Disease Primers, 4, Article 18029. https://doi.org/10.1038/nrdp.2018.29

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. https://doi.org/10.1001/archpsyc.63.7.757

Stoffers-Winterling, J. M., Storebø, O. J., Pereira Ribeiro, J., Kongerslev, M. T., Völlm, B. A., Mattivi, J. T., Faltinsen, E., Todorovac, A., Jørgensen, M. S., Callesen, H. E., Sales, C. P., Schaug, J. P., Simonsen, E., & Lieb, K. (2022). Pharmacological interventions for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2022(11), Article CD012956. https://doi.org/10.1002/14651858.CD012956.pub2

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Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2012). Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: A 16-year prospective follow-up study. American Journal of Psychiatry, 169(5), 476-483. https://doi.org/10.1176/appi.ajp.2011.11101550

Zanarini, M. C., Vujanovic, A. A., Parachini, E. A., Boulanger, J. L., Frankenburg, F. R., & Hennen, J. (2003). A screening measure for BPD: The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Journal of Personality Disorders, 17(6), 568-573. https://doi.org/10.1521/pedi.17.6.568.25355