Mental Health

Borderline Personality Disorder (BPD)

Emotional dysregulation, identity disturbance, and the evidence-based treatments — especially DBT — that have transformed outcomes for BPD.

AM
Medically reviewed by Dr. Alicia Moreno, PhD
Co-Occurring Disorders Editor & Mental Health · Last reviewed January 2025

Borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image, affect, and marked impulsivity. According to the NIMH, BPD affects approximately 1.4% of U.S. adults, though some studies suggest prevalence closer to 5.9%. It is significantly more frequently diagnosed in women (75% of diagnoses), though research suggests that gender bias in diagnosis may account for some of this disparity.

BPD has historically been one of the most stigmatized mental health diagnoses — sometimes dismissed as untreatable or viewed as willful manipulation. This framing is both inaccurate and harmful. BPD is treatable, and the development of Dialectical Behavior Therapy has dramatically improved outcomes for people with the disorder.

Symptoms

DSM-5 criteria for BPD require five or more of the following:

  • Frantic efforts to avoid real or imagined abandonment
  • Unstable and intense interpersonal relationships alternating between idealization and devaluation
  • Identity disturbance — unstable self-image or sense of self
  • Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance use, reckless driving, binge eating)
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • Affective instability — marked reactivity of mood
  • Chronic feelings of emptiness
  • Inappropriate, intense anger or difficulty controlling anger
  • Transient stress-related paranoid ideation or severe dissociative symptoms

BPD and Substance Use Disorders

Substance use disorders co-occur with BPD at high rates — estimated at 50–70% lifetime comorbidity. The impulsivity dimension of BPD drives much of this risk. Substance use in BPD often functions as emotional regulation — substances temporarily reduce the intense emotional dysregulation that is the hallmark feature of BPD. This creates a challenging treatment interaction: effective DBT treatment reduces the emotional drivers of substance use, but active substance use interferes with the skills practice that makes DBT effective. See our article on BPD and addiction treatment.

Treatment: Dialectical Behavior Therapy (DBT)

Developed by Marsha Linehan at the University of Washington, DBT is the gold-standard treatment for BPD. DBT combines individual therapy, skills training groups, phone coaching, and therapist consultation teams. The skills curriculum covers four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Multiple randomized controlled trials have demonstrated DBT's efficacy for BPD — reducing self-harm, suicide attempts, hospitalizations, and treatment dropout compared to control conditions. DBT has also been adapted for substance use disorders (DBT-SUD), with demonstrated efficacy for BPD with co-occurring SUD. See our article on DBT for co-occurring disorders.

Other evidence-supported treatments include Mentalization-Based Treatment (MBT) and Transference-Focused Psychotherapy (TFP).

Related: BPD & Addiction · DBT for Co-Occurring Disorders · Trauma-Informed Care