Condition

Emotionally unstable personality disorder

Also known as Boderline personality disorder

Emotionally unstable personality disorder is a psychiatric condition characterised by a pervasive and persistent pattern of unstable moods, marked impulsivity, suicidal behaviours and self-harm. Emotionally unstable personality disorder is also termed borderline personality disorder by the American Psychiatric Association.

Article by Katie Loader

First published: 13 Sep 2023 Last updated: 31 Oct 2023

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Definition

Emotionally unstable personality disorder (EUPD) is a psychiatric condition characterised by a pervasive and persistent pattern of unstable moods, marked impulsivity, suicidal behaviours and self-harm (World Health Organisation (WHO), 2019). The symptoms can cause significant distress and disruption to usual functioning.

Emotionally unstable personality disorder is also termed borderline personality disorder (BPD) by the American Psychiatric Association (2013), and both terms describe the same clinical presentation.

Emotionally unstable personality disorder is among the most common subtype of personality disorders, affecting around 1.6% of the general population, 11% of psychiatric outpatients and up to 20% of the psychiatric inpatient population (Chapman et al, 2021).

Symptoms

The International Classification of Diseases (ICD-10) (WHO, 2019) describe the following symptoms of emotionally unstable personality disorder:

impulsivity with lack of concern for consequences
unpredictable and highly changeable mood
difficulty regulating emotions
interpersonal conflict
excessive efforts to avoid real or imagined abandonment

There are two subtypes of emotionally unstable personality disorder, as described below.

Impulsive type, characterised by:

marked emotional instability
poor impulse control

Borderline type, additionally characterised by:

unstable self-image
chronic feelings of emptiness
intense and unstable relationships
self-destructive behaviours, such as self-harm and suicidal behaviours

Some patients report perceptual disturbances, such as auditory and visual hallucinations. These symptoms are usually linked to periods of extreme distress and emotional instability (National Institute for Health and Care Excellence (NICE), 2009) and are associated with past experiences of trauma, rather than resulting from a psychotic illness (Belohradova Minarikova et al, 2022).

There are some differences in the symptoms of emotionally unstable personality disorder in men and women. Men are more likely to exhibit anger, impulsivity and substance misuse issues, whereas women are more likely to present with mood, anxiety and trauma symptoms (Sansone and Sansone, 2011; Sher et al, 2019).

Emotionally unstable personality disorder is highly comorbid with other psychiatric illnesses, such as depression, anxiety, post-traumatic stress disorder and eating disorders (NICE, 2009). emotionally unstable personality disorder symptoms can also be confused with or misdiagnosed as other psychiatric disorders, such as psychosis or bipolar affective disorder. Compared to other psychiatric disorders, emotionally unstable personality disorder symptoms are more variable and fluctuating, where emotional and mood instability, perceptual disturbances and self-destructive behaviours are intense but short lived. However, other psychiatric illnesses show more consistent symptoms (NICE, 2009).

Patients with emotionally unstable personality disorder can experience chronic symptoms as well as periods of acute and crisis symptoms. During these periods, they present with significant self-harm and suicide risk. An estimated 70– 80% of patients with emotionally unstable personality disorder have attempted suicide and up to 10% of patients die by suicide (Warrender et al, 2021). Given the fluctuation and intensity of symptoms, some patients with emotionally unstable personality disorder frequently use mental health and emergency services for support and treatment while in crisis (NICE, 2009).

Aetiology

The cause of emotionally unstable personality disorder is not completely understood, but several biological, psychological and social factors are thought to be involved.

Genetics

There are no specific genes or gene patterns associated with emotionally unstable personality disorder (Cattane et al, 2017). Twin and family studies have established a genetic link (Chapman et al, 2021); however, these results may also be influenced by environmental factors shared by people with similar upbringings. Further research is needed to better understand the extent to which genetics affects the development and course of emotionally unstable personality disorder (Cattane et al, 2017).

Neurochemical

There is some evidence of reduced serotonin levels in patients with emotionally unstable personality disorder (NICE, 2009). However, contemporary research views the serotonin theory, which associates mood changes with lower serotonin levels, with caution. For example, Moncrieff et al (2022) found a poor scientific basis for the serotonin theory in patients with depression.

Neurobiological

Neuroimaging highlights differences in the structure and function of the amygdala (involved in regulating emotions), the hippocampus (supports self-control) and the orbitofrontal cortex (associated with decision making). These differences suggest that patients with emotionally unstable personality disorder experience difficulties regulating their emotions and understanding other people’s emotional responses (Chapman et al, 2021).

Psychosocial

Adverse childhood experiences, including trauma, abuse and neglect, are very common in patients with emotionally unstable personality disorder (Bozzatello et al, 2021). Biopsychosocial theories suggest that emotionally unstable personality disorder is a result of an invalidating environment in childhood and a lack of nurturing relationships (NICE, 2009). People with emotionally unstable personality disorder often also experience issues with family dynamics, alcohol and substance misuse, and mental illness in the home environment (Bozzatello et al, 2021). As a result, the child does not learn to understand, label and regulate emotions and lacks an ability to problem solve, leading to potentially developing emotionally unstable personality disorder symptoms in later life (NICE, 2009).

Emotionally unstable personality disorder commonly manifests in early adulthood and shows high rates of improvement and remission over time. At least 50% of patients no longer fit the diagnostic criteria 10 years after diagnosis, with low rates of relapse in later life (NICE, 2009).

Diagnosis

Diagnosis is based on clinical symptoms as detailed above. Diagnosing emotionally unstable personality disorder requires careful assessment to determine the symptoms, their severity and impact on functioning, as well as a thorough risk assessment (NICE, 2009). Accurate assessment is crucial to provide the best and most effective treatment options (Williams et al, 2020). Specific rating scales can be used to aid diagnosis, although none have been found to be superior (NICE, 2009). It is important to gain a holistic understanding of the patient’s experience, alongside the use of rating scales to understand the nature and degree of symptoms (Williams et al, 2020).

Diagnosing emotionally unstable personality disorder is complicated by the broad range of symptoms and high rates of comorbidity and overlap in symptoms with other psychiatric illnesses (Williams et al, 2020). Some of these difficulties have been addressed in the new ICD-11 (WHO, 2022), which introduced categories of symptom severity, ranging from:

none to mild
moderate
severe

These categories are based on the extent of presenting symptoms and the impact on the patient’s functioning and risks (Mulder, 2021). The ICD-11 is currently under review by NHS England.

Management

The NICE guidelines for emotionally unstable personality disorder advise that patients presenting with symptoms should be assessed in mental health secondary care. Patients with an existing diagnosis can be treated in primary care or mental health services, dependant on their needs (NICE, 2009).

Primary care

Treatment in primary care should focus on supporting the patient with problem-solving and enhancing coping strategies. A thorough assessment of symptoms and risks is needed to consider whether referral to secondary services is needed.

Crisis management

Treatment should be person-centred and non-judgemental, focusing on understanding what led to the crisis and exploring solutions. Managing periods of crisis should be supported with a crisis care plan (NICE, 2009). Inpatient admission should be a last resort and all other options to support self-management should be explored first (NICE, 2009). Short-term use of medications while in crisis can be explored, although no specific recommendations are made in the guidelines. If medication is agreed, this must be at the lowest therapeutic dose and provided for short-term relief during the crisis period with follow up arranged to review treatment once the crisis has subsided.

Medication

NICE guidelines (2009) state that medication should not be used to treat emotionally unstable personality disorder or the associated symptoms and currently, there are no medications licenced in the UK for its treatment. However, medication can be used for any comorbid psychiatric illnesses, highlighting the importance of a thorough assessment.

Despite the guidelines, patients with emotionally unstable personality disorder are often prescribed a range of psychotropic medications for both chronic and acute symptoms (Loader, 2022). NICE (2009) caution that use of psychotropic medications could increase risks, and has the potential for side effects and dependency. Therefore, it is important to accurately assess and weigh the risks and benefits of any pharmacological treatment.

Psychological treatment

The main treatment for emotionally unstable personality disorder is psychological therapies (NICE, 2009), where the aim is to support the patient in understanding and containing their emotions and developing effective coping strategies (NHS, 2022). Two main therapies for EUPD are presented below (NHS, 2022). The NICE borderline personality disorder guidelines (2009) provide an overview of evidence for various therapies and psychological interventions for emotionally unstable personality disorder.

Dialectical behavioural therapy

Dialectical behavioural therapy has been specifically developed to treat patients with emotionally unstable personality disorder. This works to validate emotions while challenging the patient’s thinking processes and behavioural responses (NHS, 2022). Dialectical behavioural therapy uses coaching in one-to-one and group settings. The core skills taught in dialectical behavioural therapy are:

mindfulness
interpersonal effectiveness to help establish and maintain healthy relationships
distress tolerance
emotional regulation

Mentalisation-based therapy

This approach also uses one-to-one and group sessions, and supports the patient to think about and challenge their beliefs about themselves and assumptions they make about others (NHS, 2022). The aim is to develop a more stable self-image and regulate emotions.

Resources

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th edn. Washington DC: American Psychiatric Publishing; 2013

Belohradova Minarikova K, Prasko J, Holubova M, et al. Hallucinations and other psychotic symptoms in patients with borderline personality disorder. Neuropsychiatr Dis Treat. 2022;18:787-799. https://doi.org/10.2147/NDT.S360013

Bozzatello P, Rocca P, Baldassarri L, Bosia M, Bellino S. The role of trauma in early onset borderline personality disorder: a biopsychosocial perspective. Front Psychiatry. 2021;12:721361. https://doi.org/10.3389/fpsyt.2021.721361

Cattane N, Rossi R, Lanfredi M, Cattaneo A. Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms. BMC Psychiatry. 2017;17(1):221. https://doi.org/10.1186/s12888-017-1383-2

Chapman J, Jamil RT, Fleisher C. Borderline personality disorder. StatPearls. Treasure Island (FL): StatPearls Publishing; 2021

Loader K. Antipsychotics and emotionally unstable personality disorder: a literature review. Journal of Prescribing Practice. 2022;4(12). https://doi.org/10.12968/jprp.2022.4.12.528

Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. The serotonin theory of depression: a systematic umbrella review of the evidence [published online ahead of print, 2022 Jul 20]. Mol Psychiatry. 2022;10.1038/s41380-022-01661-0. https://doi.org/10.1038/s41380-022-01661-0

Mulder RT. ICD-11 Personality disorders: utility and implications of the new model. Front Psychiatry. 2021;12:655548. https://doi.org/10.3389/fpsyt.2021.655548

National Institute for Health and Care Excellence (NICE). Borderline personality disorder: The NICE guideline on treatment and management. 2009. https://www.nice.org.uk/guidance/cg78/evidence/bpd-full-guideline-242147197 (accessed 8 September 2023)

NHS. Borderline personality disorder. 2022. https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/ (accessed 8 September 2023)

Sansone RA, Sansone LA. Gender patterns in borderline personality disorder. Innov Clin Neurosci. 2011;8(5):16-20.

Sher L, Rutter SB, New AS, Siever LJ, Hazlett EA. Gender differences and similarities in aggression, suicidal behaviour, and psychiatric comorbidity in borderline personality disorder. Acta Psychiatr Scand. 2019;139(2):145-153. https://doi.org/10.1111/acps.12981

Warrender D, Bain H, Murray I, Kennedy C. Perspectives of crisis intervention for people diagnosed with “borderline personality disorder”: an integrative review. J Psychiatr Ment Health Nurs. 2021; 28: 208–236. https://doi.org/10.1111/jpm.12637

Williams J, Cain R, Arnone D, Kyratsous M. The one and the many: A case highlighting comorbidity and complexity in psychiatry. British Journal of Psychiatry Bulletin. 2020;44(4):169-173. https://doi.org/10.1192/bjb.2020.23

World Health Organization (‎WHO)‎. ICD-10: international statistical classification of diseases and related health problems. 2019. https://icd.who.int/browse10/2019/en (accessed 8 September 2023)

World Health Organization (WHO). International statistical classification of diseases and related health problems (ICD). 2022. https://www.who.int/standards/classifications/classification-of-diseases (accessed 8 September 2023)