There are some mental health diagnoses that carry a great deal of misunderstanding and stigma. Borderline Personality Disorder (BPD) is unfortunately one of them.
The word “borderline” can itself sound confusing, and the diagnosis has historically been associated with labels such as “dramatic,” “manipulative,” “attention-seeking,” or “difficult.” But when we look beyond the stereotypes and begin to understand what someone with BPD may actually be experiencing internally, a very different picture emerges.
At the heart of BPD is often an intense struggle with emotions, relationships, identity and a deep sensitivity to rejection or abandonment.
It is not simply about being “moody” or having strong emotions.
For some people, emotions can arrive with enormous intensity and can feel almost impossible to regulate. A relatively small interpersonal event—such as a delayed text message, a change in someone's tone of voice, or feeling excluded—can trigger a wave of fear, anger, sadness or shame that feels overwhelming.
And when emotions become overwhelming, people may respond in ways that they later regret.
Understanding this is not about excusing harmful behaviour. It is about understanding what is happening underneath the behaviour so that meaningful change becomes possible.
What is Borderline Personality Disorder?
Borderline Personality Disorder is a mental health condition associated with difficulties in emotional regulation, relationships, self-image and impulse control.
According to the National Institute of Mental Health (NIMH), people with BPD may experience intense and rapidly changing emotions, an unstable sense of identity, difficult interpersonal relationships, impulsivity, chronic feelings of emptiness, intense anger, dissociation and fears of abandonment. Not everyone experiences every symptom, and people can vary considerably in the way BPD presents.
One of the most important things to remember is that BPD does not look exactly the same in everyone.
Two people may both meet diagnostic criteria but have very different experiences.
One person might struggle primarily with abandonment fears and unstable relationships. Another might experience severe self-criticism, emptiness and self-harm. Someone else may experience intense anger, impulsivity or dissociation.
The diagnosis describes a pattern of difficulties. It does not describe the entirety of a person's personality.
When emotions feel bigger than the situation
Imagine receiving a message from someone you love:
“Can we talk later?”
For one person, that might simply mean, “They are busy.”
For someone who is highly sensitive to rejection or abandonment, the same message might trigger thoughts such as:
“I've done something wrong.”
“They're angry with me.”
“They're going to leave me.”
“They don't love me anymore.”
The emotional response may then become much larger than the original event.
This isn't necessarily because the person is choosing to overreact.
Their nervous system may be responding to the situation as though something deeply threatening is happening.
This is one reason emotional regulation is such an important part of understanding BPD.
The person may intellectually know that the situation is probably not as catastrophic as it feels, but knowing something rationally and feeling it emotionally are two very different things.
The fear of abandonment
One of the most painful experiences associated with BPD can be the fear of being abandoned.
This fear can involve both real and perceived abandonment.
Someone might become extremely distressed when a partner becomes emotionally distant, when a friend doesn't respond, when a relationship changes, or when someone important seems less available.
The person may desperately want reassurance:
“Do you still love me?”
“Are you going to leave me?”
“Are you angry with me?”
“Is everything okay between us?”
Sometimes the fear can become so intense that the person may behave in ways that unintentionally create difficulties in the very relationship they are trying desperately to protect.
For example, they may repeatedly seek reassurance, become angry, withdraw, send numerous messages, threaten to end the relationship first, or suddenly push the other person away.
From the outside, this can be confusing.
From the inside, it may feel like:
“Please don't leave me.”
Understanding the emotional need underneath the behaviour can completely change the way we approach it therapeutically.
“I love you” and “I hate you” — why relationships can feel so intense
Relationships for someone with BPD can sometimes feel extraordinarily intense.
A person may experience someone as wonderful, safe and deeply connected one moment, and then feel hurt, betrayed or rejected by that same person later.
This can sometimes result in what is described as splitting—a tendency to experience people, situations or oneself in more extreme, all-or-nothing ways.
Someone may think:
“You're the only person who understands me.”
And after feeling hurt:
“You never cared about me.”
The shift can feel dramatic to others, but it may reflect a dramatic shift in the person's emotional experience.
Importantly, this doesn't mean that the person is deliberately pretending.
Their feelings can be very real in the moment.
Therapy can help someone develop the ability to hold two seemingly contradictory truths at the same time:
“I'm hurt by you, and I still care about you.”
“You disappointed me, but that doesn't necessarily mean you don't love me.”
“I'm angry right now, but I don't have to destroy the relationship.”
This capacity to tolerate complexity can become an important part of recovery.
An unstable sense of identity
Another important feature of BPD can be difficulty developing a stable sense of self.
The person may struggle with questions such as:
Who am I?
What do I actually want?
What are my values?
What do I believe?
What kind of person am I?
Their sense of themselves may change depending on their circumstances or relationships.
They might feel confident one day and worthless the next.
They might change their goals, interests, appearance, values or plans depending on who they are with or how they are feeling.
This can be incredibly unsettling.
Imagine not having a strong internal sense of who you are and instead relying heavily on your relationships to tell you whether you are lovable, acceptable or worthwhile.
A disagreement with someone important could then feel like more than a disagreement.
It could feel like evidence that:
“There must be something fundamentally wrong with me.”
The painful experience of emptiness
People sometimes assume that emotional difficulties are always about feeling too much.
With BPD, there can also be periods of feeling nothing at all.
Chronic emptiness is commonly reported.
A person might describe it as:
“I feel hollow.”
“I don't know who I am.”
“Nothing feels meaningful.”
“I feel like I'm watching my life rather than living it.”
This emptiness can sometimes lead people to search intensely for something that makes them feel alive.
That might involve relationships, sex, spending, substances, food, risk-taking, conflict or other impulsive behaviours.
The behaviour may provide temporary relief from emotional pain or emptiness, even if it creates additional problems later.
This creates an important therapeutic question:
“What function is this behaviour serving?”
Rather than simply asking:
“How do we stop the behaviour?”
Impulsivity and self-destructive behaviours
Some people with BPD experience significant impulsivity.
This might include:
- excessive spending
- substance misuse
- unsafe sexual behaviour
- reckless driving
- binge eating
- sudden relationship decisions
- aggression
- self-harm
Not everyone with BPD experiences these behaviours.
And importantly, impulsive behaviour does not automatically mean BPD.
The broader pattern and context need to be considered during assessment. BPD can also occur alongside other conditions, including anxiety disorders, depression, PTSD, eating disorders and substance use disorders.
Self-harm: looking beneath the behaviour
Self-harm can be one of the most frightening aspects of BPD for families and professionals.
It can be tempting to ask:
“Why would someone do that to themselves?”
A more useful therapeutic question may be:
“What happens immediately before the self-harm, and what does the person experience immediately afterwards?”
For some individuals, self-harm may temporarily reduce overwhelming emotional distress.
For others, it may communicate pain that they cannot put into words.
It may provide a sense of control, interrupt emotional numbness, or function as a way of coping with intense shame, anger or abandonment fears.
None of this means self-harm should be dismissed or minimised.
Quite the opposite.
Self-harm and suicidal thoughts require careful assessment and appropriate support. NICE recommends that risk assessment should form part of a broader assessment and should distinguish immediate risks from longer-term risks, with collaborative safety and risk-management planning.
Anger and what may be underneath it
Anger can be another misunderstood aspect of BPD.
Someone may appear extremely angry, reactive or confrontational.
But anger is often not the first emotion.
Underneath it may be:
- fear
- shame
- rejection
- sadness
- loneliness
- helplessness
- feeling misunderstood
- feeling unimportant
For example:
Surface emotion:
“You don't care about me!”
Possible underlying experience:
“I feel like I'm not important to you, and that scares me.”
This is one reason emotional formulation can be so valuable.
Instead of focusing only on the visible behaviour, therapy can explore what happened emotionally just before the behaviour occurred.
Dissociation
Some people with BPD experience dissociation.
This can involve feeling disconnected from oneself or from the surrounding environment.
A person might describe feeling:
“I'm outside my body.”
“Everything feels unreal.”
“I feel like I'm watching myself.”
“I feel completely detached.”
Dissociation can sometimes occur during periods of extreme emotional distress.
Learning grounding strategies and recognising early warning signs can help people develop alternatives to becoming completely overwhelmed.
Why does BPD develop?
There is no single cause.
Research suggests that BPD develops through an interaction between biological, psychological and environmental factors. NIMH notes that researchers are examining how biology, environment and social and cultural factors contribute to the condition.
Some people with BPD report experiences of childhood adversity, neglect, abuse, invalidation or unstable relationships.
However, it is important not to make the assumption that everyone with BPD has experienced trauma, or that trauma automatically causes BPD.
Human development is complex.
Genetic vulnerability, temperament, emotional sensitivity, attachment experiences, environmental circumstances and learning history can all interact in different ways.
Rather than searching for one single cause, therapy often focuses on understanding the person's individual developmental story.
The importance of validation
One of the most powerful therapeutic principles when working with BPD is validation.
Validation does not mean agreeing with everything someone thinks or does.
It means communicating:
“I can understand why this feels painful to you.”
For example:
Instead of:
“You're overreacting.”
Try:
“I can see that this situation has brought up a very strong fear of being rejected.”
Instead of:
“There's no reason to be this upset.”
Try:
“The situation may seem small from the outside, but I can see that it has brought up something very painful for you.”
Validation creates emotional safety.
And emotional safety makes it easier to introduce change.
Validation and boundaries can coexist
This is particularly important for family members, partners and therapists.
Validation does not mean accepting abusive behaviour.
We can say:
“I understand that you're extremely angry, and I'm willing to talk about what happened. I won't continue the conversation while we're shouting at each other.”
Both parts matter.
Validation:
“I understand your emotional experience.”
Boundary:
“This behaviour is not okay.”
Healthy relationships need both compassion and boundaries.
Treatment: can BPD improve?
Yes.
This is perhaps one of the most important messages to communicate.
A diagnosis of BPD does not mean someone is destined to struggle forever.
NICE specifically recommends working from an atmosphere of hope and optimism and states that recovery is possible and attainable.
Psychotherapy is the main treatment approach.
Several psychological therapies have been developed or adapted for people with BPD, including:
- Dialectical Behaviour Therapy (DBT)
- Mentalisation-Based Treatment (MBT)
- Schema Therapy
- Transference-Focused Psychotherapy (TFP)
- Cognitive Behavioural Therapy (CBT)
- other structured psychological approaches
Research supports psychotherapy as an important treatment for BPD, although evidence does not establish one psychotherapy as universally superior to all others. A systematic review published in 2024 found that commonly used psychotherapies can improve BPD symptoms, severity and functioning, while also noting limitations in directly comparing different therapies.
Dialectical Behaviour Therapy
DBT was specifically developed for people experiencing severe emotional dysregulation and BPD.
It teaches practical skills in areas such as:
Mindfulness
Learning to notice thoughts, emotions and sensations without immediately reacting to them.
Distress tolerance
Learning how to survive intense emotional moments without making the situation worse.
Emotion regulation
Understanding emotions, identifying vulnerabilities and learning strategies to reduce emotional intensity.
Interpersonal effectiveness
Learning how to communicate needs, maintain relationships and establish boundaries.
DBT can be particularly useful for people who experience recurrent self-harm, suicidal behaviour or intense emotional dysregulation. NICE recommends considering a comprehensive DBT programme for women with BPD when reducing recurrent self-harm is a priority.
Research has also found evidence supporting DBT and other structured psychotherapies for BPD, although the certainty of evidence varies across outcomes and treatments.
Mentalisation-Based Treatment
Mentalisation refers to our ability to understand our own behaviour and the behaviour of others in terms of thoughts, feelings, intentions and beliefs.
For example:
“What am I feeling right now?”
“What might they be feeling?”
“What evidence do I have for what I'm assuming?”
“Could there be another explanation?”
This can be particularly valuable when interpersonal situations become emotionally charged.
Instead of automatically thinking:
“They haven't replied because they don't care about me.”
Mentalisation encourages curiosity:
“I feel rejected because they haven't replied. What else might be happening?”
That small shift—from certainty to curiosity—can create space for a different response.
Schema Therapy and BPD
Schema Therapy can also be particularly relevant when working with longstanding patterns involving abandonment, defectiveness, mistrust, emotional deprivation, subjugation or social isolation.
The therapy explores deeply rooted beliefs that may have developed through earlier experiences.
For example:
“People will eventually leave me.”
“I'm fundamentally unlovable.”
“My needs don't matter.”
“I can't trust people.”
These beliefs can become activated during relationships.
Schema Therapy also works with different emotional states or modes, helping the person recognise when a vulnerable part of themselves has been activated and develop healthier ways of responding.
This can help move therapy beyond simply managing symptoms towards understanding the deeper patterns that maintain them.
What does recovery actually mean?
Recovery doesn't necessarily mean that someone will never experience intense emotions again.
It may mean:
- noticing emotional triggers earlier
- becoming better at regulating emotions
- developing a more stable sense of identity
- building healthier relationships
- reducing impulsive behaviour
- reducing or stopping self-harm
- tolerating rejection and disappointment more effectively
- communicating needs more directly
- learning that emotions do not always need to dictate behaviour
- developing self-compassion
- being able to experience distress without immediately acting on it
Perhaps most importantly, recovery can involve developing the ability to pause between feeling and doing.
That pause can become incredibly powerful.
The person is not the diagnosis
This may be the most important message of all.
A person with BPD is not “a borderline.”
They are a person who is experiencing a particular pattern of psychological difficulties.
They may also be:
A loving parent.
A loyal friend.
A creative person.
A talented professional.
A caring partner.
A funny person.
A sensitive person.
A person with dreams, hopes, fears and strengths.
The diagnosis is only one part of their story.
And because people can change, the diagnosis should never become a prediction of someone's future.
For families and loved ones
Living alongside someone experiencing severe emotional dysregulation can be exhausting.
Families can feel frightened, confused, angry, guilty or helpless.
It is important for loved ones to remember that they cannot regulate another person's emotions for them.
They can offer:
Validation without reinforcing harmful behaviour.
Support without taking responsibility for everything.
Compassion without abandoning their own boundaries.
Encouragement without trying to become the person's therapist.
Family members may also benefit from receiving support themselves.
NICE recommends involving families or carers when the person agrees and their confidentiality rights are respected.
A more compassionate way of looking at BPD
Perhaps instead of asking:
“Why are they behaving like this?”
we can sometimes ask:
“What pain might this behaviour be communicating?”
Instead of:
“Why can't they just calm down?”
we might ask:
“What happens inside them when their emotions become overwhelming?”
Instead of:
“Why do they keep pushing people away?”
we might wonder:
“Could pushing someone away be connected to how frightening it feels to be left?”
These questions don't remove responsibility.
They create understanding.
And understanding creates opportunities for change.
Final thoughts
Borderline Personality Disorder can be incredibly painful—not only for the person experiencing it, but also for the people who love and support them.
There may be intense emotions, difficult relationships, impulsive behaviours, self-harm, fear of abandonment and periods of profound emptiness.
But behind these experiences is a human being trying to cope with emotions that may sometimes feel impossible to manage.
With appropriate, structured psychological treatment, support and time, people can learn new ways of relating to themselves, their emotions and other people.
The goal isn't to turn someone into a person who never feels intensely.
It is to help them develop the skills and self-understanding to say:
“I can feel this emotion without becoming this emotion.”
“I can be hurt without destroying the relationship.”
“I can feel abandoned without abandoning myself.”
And perhaps, over time:
“My emotions are part of me, but they don't have to control my life.”
References
- National Institute for Health and Care Excellence (NICE). (2009, updated guidance available). Borderline personality disorder: recognition and management (CG78).
- National Institute of Mental Health (NIMH). Borderline Personality Disorder. U.S. Department of Health and Human Services, National Institutes of Health.
- Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., et al. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews.
- Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319–328.
- Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., et al. (2024). Psychotherapies for the treatment of borderline personality disorder: A systematic review. American Journal of Psychiatry.
- Francis, B., et al. (2026). A systematic review of dialectical behaviour therapy, mentalisation-based treatment and internal family systems therapy for borderline personality disorder with comorbid depression and/or anxiety. Journal of Psychiatric Research, 194, 221–232.