Borderline Personality Disorder: What Predicts Recovery?

With an estimated prevalence rate somewhere between 1.6% and 5.9% (APA, 2013), Borderline Personality Disorder (BPD) may be the third-most-common personality disorder and it is unexpectedly over-represented in clinical populations. In fact, 12% of people in inpatient care; 25% of people in outpatient care; and 30% of forensic patients present with this disorder (Grenyer et al., 2022). Roughly half of those who seek treatment for BPD experience recovery, but as Biskin (2015) noted, it's all too easy for recovery to slip away without the proper supports. BPD can be a lifelong challenge.

There are nine key symptoms of BPD:

1. Unstable relationships; arguments and break-ups may be frequent.
2. Abandonment issues, based on fact or just imagined.
3. Self-harm or suicidality (thoughts or behaviors).
4. Impulsivity: overspending, substance use, gambling, or risky behaviors.
5. Moodiness that can include shifts between depression and anxiety.
6. Anger problems, including “going off” at people out of proportion to situations or physical attacks.
7. Paranoid thinking related to stress.
8. Feelings of emptiness, worthlessness, and sadness.
9. Absence of a sense of identity.

Each symptom has the potential to cause significant psychological distress as well as create real obstacles to being able to enjoy a relatively routine, predictable life. Individuals may experience not only a compromised sense of self, they may also be unable to form and maintain healthy relationships. They cannot trust themselves to know themselves and they are challenged to trust others as well. We know that social connection and interpersonal relationships contribute to our overall well-being, health, and longevity. When symptoms of an illness impact everything from sense of self to suicidal ideation to personal engagement pattens, it is no wonder that such individuals can suffer greatly over the course of the illness, not just from the symptoms but from fractured relationships and insufficient support systems.

Attachment Styles

Ideally, infants are raised by primary caregivers who respond reliably to their needs—food, engagement, hygiene, and so on. When this is the situation, a secure attachment style tends to develop: A child learns to trust others and believe that people are generally caring and kind. When circumstances are different, a variety of less-than-ideal attachment styles can emerge, including anxious, or anxious preoccupied, attachment.

The roots of borderline personality disorder aren’t fully understood, but it seems to be caused by complex interactions between one’s biology and environment. The disorder has a strong genetic component, because the condition is five times more common in people whose first-degree relatives have BPD. But childhood experiences of parental neglect and emotional, physical, or sexual abuse are among the most important risk factors for BPD. When caregivers are unreliable due to unavailability, distraction, or other factors, children become anxious that their needs are not prioritized by the person whose role it is to meet them.

Not surprisingly, the attachment styles learned during infancy and childhood carry over to influence adult romantic relationships. The description of preoccupied/anxious attachment on the Relationship Questionnaire (RQ; Bartholomew & Horwitz, 1991) describes it as follows: “I want to be completely emotionally intimate with others, but I often find others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them.”

Individuals with an anxious/preoccupied attachment style cannot relax in relationships and are constantly worried that they will be abandoned by others or that the people they depend on won’t be there to meet their needs. When this pattern is deeply ingrained, it is difficult as an adult to learn to trust others as well as difficult to accept that while no partner can be the “perfect partner/parent” that you didn’t have, that person can be “good enough.”

What Inhibits Recovery?

With any disorder or illness, we often wonder why some people recover and others don’t. It’s likely due to pre-existing factors rather than specific treatments. In fact, one study (Woodbridge et al., 2021) found that there are two factors that are most likely to keep someone from fully recovering from BPD: Anger problems, and having a preoccupied attachment style.

The therapeutic alliance is often cited as the most influential factor in determining the client’s outcome from therapy. But if a person is unable to form mature and healthy attachments with others, this can be detrimental to the client-therapist relationship. BPD negatively affects a client’s perspective and their assessment of their therapist, which can derail treatment before it can begin. Addressing attachment issues in therapy may therefore be essential for recovery to take place and a support system to be established beyond the therapist’s office.

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Anger can also be a powerful deterrent to efforts to build or maintain relationships. The extreme anger often associated with BPD has been called “BPD rage” by some. This anger can seemingly emerge out of nowhere and lead to altercations that can involve physical attacks and the involvement of law-enforcement personnel. Learning to control this type of anger takes effort and requires that the person have a strong support network that includes family, partners, or friends who are able to withstand the out-of-proportion and often unprovoked attacks that may be visited upon them.

The Bottom Line

BPD is a personality disorder that disrupts a person’s life and the lives of those who care for them. Recognizing the damage that this disorder can wreak is as important as understanding the symptoms. There are multiple treatment protocols for BPD, including Dialectical Behavior Training, Cognitive Behavioral Therapy, Schema-Focused Therapy, and medication. However, treatment is only likely to work when a client is committed to self-care and following protocol.

To find a therapist, visit the Psychology Today Therapy Directory.