Key points
Borderline personality disorder (BPD) is a relatively common problem, and often difficult to treat.
Because there are hundreds of possible symptom clusters, a classification system for BPD is recommended.
New research using “latent class analysis” identifies 3 distinct types of BPD.
This information is useful for clinical treatment, self-assessment, and research and development.
Borderline personality disorder (BPD) is one of several personality disorders described in the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association. BPD belongs to a group called “Cluster B” personality disorders, along with antisocial, narcissistic, and histrionic personality disorders.
These disorders are grouped together because they share common features of emotional dysfunction, altered sense of self, a tendency to be disorganized and dramatic in their perceptions and behavior, and long-standing patterns of interpersonal problems associated with an insecure and often disorganized attachment style. These disorders are classified as “disorders” if and only if they are associated with chronic distress or dysfunction of clinical significance.
The term “borderline personality” has its origins in psychoanalysis (Stern, 1938), not as a diagnosis per se but as a description of personality organization—in the borderland between high-functioning neurosis and more profound psychosis. People with borderline personality disorder tend to have difficulty thinking about their thoughts and behaviors. This difficulty with cognitive perception makes self-regulation more difficult and limits the therapeutic effectiveness of insight (Martin & Del Monte, 2023).
While borderline personality disorder is sometimes romanticized, and even glorified, in the media because of the excitement that accompanies the often joyful and euphoric mood swings, the downside of the disorder is often tragedy and isolation. People with borderline personality disorder are at significantly increased risk for suicide, significant physical and mental health difficulties, relationship and occupational problems, and a host of other negative outcomes.
What is Borderline Personality Disorder?
A borderline personality disorder is diagnosed when an individual has at least five of nine traits1 that are chronically and persistently present in work, personal life, or with themselves—from emotional instability in response to ordinary events and a chronic sense of emptiness to frantic efforts to avoid real or imagined abandonment and fleeting paranoid thoughts.
Borderline personality disorder appears to be caused by a combination of genetic and environmental factors, which often but not exclusively overlap with symptoms of post-traumatic stress disorder associated with developmental adversity. BPD often co-occurs with other problems including major depression, anxiety disorders, post-traumatic stress disorder, drug and alcohol use disorders, and others.
Given that there are hundreds of possible combinations of symptoms that may meet the criteria for a diagnosis of borderline personality disorder, identifying clinically significant subtypes would represent a tremendous advance, providing significant potential clinical benefit in personalizing care and advancing what is known as “precision medicine.”
Latent Class Analysis of Borderline Personality Disorder
Despite efforts to investigate the subtypes of borderline personality disorder, there has been no consensus. Antoine and colleagues (2023) reported in Psychiatry Research that previous work has looked at symptom-based subtypes, distinguished BPD from other disorders including ADHD and bipolar disorder, or classified BPD according to its severity, but BPD subtypes have not yet been defined.
To this end, the researchers used data from more than 500 people with borderline personality disorder in treatment in different specialized clinical settings (eg, a hospital mental health clinic) over three studies and applied latent class analysis to determine whether statistically significant subgroups existed and, if so, what distinguished them from each other. The measures used in the study included the borderline personality disorder section of the International Personality Disorder Screening, the Childhood Trauma Questionnaire, the Beck Depression Inventory, and the 90-symptom checklist.
They tested several models to see how many clusters or categories of symptom groups fit the data in this sample of 504 patients. The modeling found that a three-factor solution had the greatest validity: the categories of immutable (more stable), schizotypal/paranoid, and interpersonally unstable.
Immutable (10.5 percent). People in this group showed less emotional dysfunction and were less likely to dissociate when distressed, with a tendency toward impulsivity that did not quite reach statistical significance. This group had lower associations with childhood adversity, including sexual abuse.
Dissociative/Paranoid (55.4 percent). People in this group had significantly higher levels of dissociative and paranoid symptoms, but had a more stable sense of self and were less likely to try to do anything to avoid abandonment. This group was associated with an increased risk of comorbidity, that is, having additional diagnoses throughout their lives. There were higher rates of childhood maltreatment in this group than in the unstable group, including a higher association with childhood sexual abuse.
Interpersonally unstable (34.1 percent). This group had the highest level of frantic efforts to avoid abandonment, with increased symptoms of anger, aggression, and relationship instability. Rates of child maltreatment were higher in this group than in the unstable group, including a higher association with childhood sexual abuse, although not as strong as in the dissociative/paranoid group.
Implications
Although preliminary, the research is noteworthy for people with BPD, those close to them, and clinicians. There are implications for specific treatment options, including psychotherapeutic approaches, medications, and adjunctive approaches such as meditation, lifestyle/contextual modification, and self-regulation practices.
People in the unstable group are affected by different environmental influences, with lower rates of childhood trauma. They may benefit from a focus on reducing impulsive behaviors by building executive function. Awareness of this smaller, less stereotypical subgroup is important because treatment approaches may be quite different.
The dissociative/paranoiac group has the highest rates of childhood trauma, including sexual abuse. There may be a higher association with complex PTSD, which requires clinical focus. Being aware of potential threats and remaining aware of them without becoming overly distrustful or needing emotional detachment is key for them to make effective choices about relationships.
With reduced avoidance behaviors (the frantic efforts to avoid abandonment in classic BPD), such as excessive texting, acting “needy,” and an inability to tolerate rejection or separation, individuals in this group may instead have learned to shut down when threatened by separation, a form of “learned helplessness” that predisposes to certain forms of trauma and depression. This dissociative reaction reduces perceived distress but may increase their vulnerability to perpetrators by making the individual indifferent to others’ efforts to manipulate and abuse.
Restoring awareness, both emotional and cognitive, reduces revictimization and retraumatization by allowing us to recognize “red flags” in others, rather than to associate with someone unlikely to bring health, happiness, and healing.
The unstable interpersonal group was similar to the detached/paranoid group in some ways, with higher rates of trauma and abuse, but the opposite in terms of frantic efforts to avoid abandonment and classic stereotyping.2 They exhibited splitting, or thinking/or a tendency to shift from seeing others as all good or bad (“idealization and devaluation”), and greater hostility and aggression, leading to problems in relationships.
Future work will help determine whether the findings are applicable more broadly and whether different treatment approaches and additional work, such as different forms of meditation or environmental modification, are more or less effective as a function of the type of BPD. At the same time, the research is relevant and interesting as it is now, and may allow clinicians to think more clearly about BPD and determine the focus of treatment, helping BPD patients live fully by embracing challenges and opportunities with compassion for self and others.
