Read the following clinical description. Based on the pattern of symptoms, what category of disorder is most likely co-occurring with the patient's primary personality disorder? Justify your answer by referencing specific details from the text.

Clinical Scenario Analysis

Borderline personality disorder frequently co-occurs with other mental health conditions. It is particularly noted for its comorbidity with anxiety disorders, mood disorders, and substance use disorders.

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Borderline Personality Disorder (BPD) is primarily defined by a pervasive pattern of instability across interpersonal relationships, self-image, and mood, combined with significant impulsivity. Individuals with this disorder often experience intense emotions and may engage in frantic behaviors to manage their profound fear of abandonment.

Borderline Personality Disorder

Skodol, A. E., Gunderson, J. G., Pfohl, B., Widiger, T. A., Livesley, W. J., & Siever, L. J. (2002). The borderline diagnosis I: psychopathology, comorbidity, and personality structure. Biological psychiatry, 51(12), 936-950.

Comorbidity and Personality Structure in BPD

Skrzypińska, D., & Szmigielska, B. (2015). Dream-reality confusion in borderline personality disorder: a theoretical analysis. Frontiers in Psychology, 6, 1393.

Dream-reality Confusion in BPD

Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013)

DSM V

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

"Borderline personality disorder. What are the signs and symptoms of Borderline Personality Disorder?" (n.d.). https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/borderline-personality-disorder/
- This article provides an overview of BPD, including its associated symptoms, the potential causes and current treatments, risks and complications people with BPD experience, as well as modes of self-care for emotional regulation.
- Also provides further reading, additional resources, and important information for relatives and/or friends that have a loved one suffering from BPD.

BPD Signs and Symptoms

Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). The Guilford Press. https://survivingcptsd.files.wordpress.com/2018/01/dbt_skills_training_handouts_and_worksheets_-_linehan_marsha_srg_.pdf
- The manual has 3 modules: distress tolerance, emotion regulation, and interpersonal effectiveness. Each module has handouts, which are essentially the lesson plans with descriptions and teachings of the skill. 

DBT Skills Training Manual

In order to be diagnosed with BPD, an individual must exhibit at least 5 of the following 9 criteria:
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, or recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms

BPD Diagnostic Criteria

Individuals with BPD often have intense reactions to stimuli, especially in stressful situations. Quarantine and social distancing practices promote the feeling of loneliness and detachment from reality felt by BPD patients and can negatively impact their mental health. 

Impact of COVID-19 on Individuals with BPD

In this study, researchers try to determine the prevalence of Borderline Personality Disorder and self-injurious behaviors among suicidal army soldiers as well as if BPD diagnosis is correlated with higher rates of suicidality.

BPD and Self-Directed Violence Among Suicidal Army Soldiers

1. Dialectical behavior therapy (DBT)
2. Mentalization-based therapy (MBT)
3. Transference-focused therapy (TFP)
4. System training for emotional predictability and problem-solving (STEPPS)
5. Schema-focused therapy 
6. Standard cognitive therapy 
7. Good psychiatric management
8. Rogerian supportive therapy 

Evidence-based Treatments for BPD

1. high-functioning internalizing (quiet BPD)
2. depressive internalizing 
3. histrionic-impulsive
4. angry externalizing
5. schizotypal/paranoid
6. disturbed internalizing 

Subtypes of BPD 

It has been proposed that there are gender differences in BPD presentation - most notably, there are patterns of novelty seeking and explosive temperament in men with BPD that aren't in men.

BPD and Gender

The DSM-5 specifies nine symptoms of Borderline Personality Disorder:
1. Efforts to avoid real or perceived abandonment.
2. Intense, unstable personal relationships.
3. An unstable and shifting sense of identity.
4. Risky and potentially self-damaging impulsive behaviors.
5. Self-injurious or suicidal behaviors.
6. Unstable patterns of mood and affect.
7. Persistent feelings of emptiness.
8. Difficulty controlling anger.
9. Paranoid delusions.

Symptoms of BPD

Although contentious, one proposed classification of BPD highlights five different subcategories that vary by symptom presentation:

1. Affective: Mood-related symptoms such as depression and anxiety.
2. Impulsive: Characterized by impulsive and often self-injurious behavior.
3. Aggressive: Temperamental symptoms characterized by inappropriate levels of rage and irratibility.
4. Dependent: Characterized by an ntolerance of being alone and fear of abandonment.
5. Empty: Characterized by an instable self-identity and a sense of inner emptiness.

Subtypes of Borderline Personality Disorder

Over the years, many studies have been conducted to examine whether individuals with borderline personality disorder have an empathy deficit and have had conflicting results. However, a recent systematic review examined forty five different studies on the topic and found that thirty six of these studies found a deficit of empathy in their participants with borderline personality disorder. These findings suggest that it may be a characteristic of borderline personality disorder after all.

Borderline Personality Disorder and Empathy 

Reference for Stress Generation

Stress generation is a term given to the propensity of individuals with borderline personality disorder to generate stressful situations in their lives because of their interpersonal problems and instability. 

Stress Generation

References for Neuropsychological Effects of Childhood Trauma in Individuals with Borderline Personality Disorder

Borderline Personality Disorder is a mental illness that is indicated by instability within interpersonal relationships and drastic emotional reactions to stimuli. Some of these reactions include aggression and self-inflicting actions. Aggression can take the form of criminal behaviors, seeing as people with BPD are unable to regulate their actions and impulses. Connections have then been made between childhood trauma and criminal behaviors based on the different effects on a person’s mental state. This is due to the way trauma plays a role in altering functioning within brain areas and responses to situations.

Neuropsychological Effects of Childhood Trauma in Individuals with Borderline Personality Disorder

Costa, J., Marôco, J., Pinto-Gouveia, J., Ferreira, C., & Castilho, P. (2016). Validation of the Psychometric Properties of the Self-Compassion Scale. Testing the Factorial Validity and Factorial Invariance of the Measure among Borderline Personality Disorder, Anxiety Disorder, Eating Disorder and General Populations. Clinical Psychology and Psychotherapy, 23(5), 460–468. https://doi.org/10.1002/cpp.1974

Bozzatello, P., Garbarini, C., Rocca, P., & Bellino, S. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics (Basel, Switzerland), 11(11), 2142. https://doi.org/10.3390/diagnostics11112142
Khosravi, M. Eating disorders among patients with borderline personality disorder: understanding the prevalence and psychopathology. J Eat Disord 8, 38 (2020). https://doi.org/10.1186/s40337-020-00314-3

Dyson Tori, Thomas Susan J., Townsend Michelle L., Finch Adam, South Alexandra, Barkus Emma, Walter Emma, Mendonca Carley, Grenyer Brin F. S., Pickard Judy A. (2023). Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention. Frontiers in Psychology, 14(14). https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2023.1195187

Federici, A. (2009). Dialectical Behaviour Therapy for the Treatment of Eating Disorders. NEDIC, NEDIC Eating Disorders Bulletin.

Lee, K. S., & Vaillancourt, T. (2024). Trajectories, comorbidity, and risk factors for adolescent disordered eating and borderline personality disorder features. Development and Psychopathology, 36(4), 1546–1557. doi:10.1017/S0954579423000792

Lee, S. S. M., Keng, S.-L., & Hong, R. Y. (2024). Validating the biosocial model of borderline personality disorder: Findings from a longitudinal study. Development and Psychopathology, 36(4), 1752–1762. doi:10.1017/S0954579423001116

Lester, R. J. (2009). Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic. Current Anthropology, 50(3), 281–302. https://doi.org/10.1086/598782

Miller, A. E., Hotte-Meunier, A., Bain, T., Macdonald, E. P., Steiger, H., & Racine, S. E. (2025). A Qualitative Study of the Lived Treatment Experiences of Women With an Eating Disorder and Comorbid Borderline Personality Disorder. The International journal of eating disorders, 58(5), 860–867. https://doi.org/10.1002/eat.24390

Navarro-Haro, M. V., Botella, C., Guillen, V., Moliner, R., Marco, H., Jorquera, M., Baños, R., & Garcia-Palacios, A. (2018). Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting. Cognitive Therapy and Research, 42(5), 636–649. https://doi.org/10.1007/s10608-018-9906-9

Newton, J. R. (2019). Borderline personality disorder and eating disorders: a trans-diagnostic approach to unravelling diagnostic complexity. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(6), 556–558. https://doi.org/10.1177/1039856219852297

Ni, X., Chan, D., Chan, K., McMain, S., & Kennedy, J. L. (2009). Serotonin genes and gene–gene interactions in borderline personality disorder in a matched case-control study. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(1), 128–133. https://doi.org/10.1016/j.pnpbp.2008.10.022.

Ntshingila, N., Poggenpoel, M., Myburgh, C. P. H., & Temane, A. (2016). Experiences of women living with borderline personality disorder. Health SA = SA Gesondheid, 21(1), 110–119. https://doi.org/10.1016/j.hsag.2016.01.001

Sansone, R. A., & Sansone, L. A. (2007). Childhood Trauma, Borderline Personality, and Eating Disorders: A Developmental Cascade. Eating Disorders, 15(4), 333–346. https://doi.org/10.1080/10640260701454345

Sansone, R. A., & Sansone, L. A. (2010). Personality Disorders as Risk Factors for Eating Disorders: Clinical Implications. Nutrition in Clinical Practice, 25(2), 116–121. https://doi.org/10.1177/0884533609357563.

Steiger, H. (2004). Eating disorders and the serotonin connection: state, trait, and developmental effects. Journal of psychiatry & neuroscience: JPN, 29(1), 20–29.

Power, R. A., & Pluess, M. (2015). Heritability estimates of the Big Five personality traits based on common genetic variants. Translational psychiatry, 5(7), e604. https://doi.org/10.1038/tp.2015.96

Reference List: Comorbidity of Borderline Personality Disorder and Eating Disorders

There is significant overlap between Borderline Personality Disorder (BPD) and Eating Disorders (specifically bulimia and binge eating) symptoms, suggesting that they may stem from similar environments, events, or chemistry. Additionally, learning more about the similarities and effects of each disorder on the other can lead to the development of new, effective treatment protocols. The intersection of BPD and EDs brings up deep psychological questions: Is disordered eating a form of affect regulation in those who can’t tolerate intense emotions? Does controlling food become a substitute for controlling unstable identity, a core issue in BPD? This makes the comorbidity a rich area for exploring self-concept, autonomy, and emotional survival strategies.

Comorbidity of BPD and ED

The term 'borderline' was first used in the late 1930s to describe patients who exhibited anxiety but were also susceptible to brief psychotic episodes. These individuals were considered to be on the 'borderline' between anxiety and psychosis, a meaning that differs from the modern understanding of the disorder.

Historical Origin of the Term 'Borderline' in BPD

A central feature of Borderline Personality Disorder is a profound intolerance for being alone. This leads to desperate efforts to prevent separation or abandonment, whether it is real or merely perceived. These efforts can include extreme actions such as suicidal gestures or self-mutilation.

Fear of Abandonment in BPD

Individuals with Borderline Personality Disorder typically have intense and volatile relationships. A common pattern involves initially idealizing a partner, followed by intense devaluation or criticism at the slightest indication of waning interest or disapproval.

Unstable Interpersonal Relationships in BPD

A person with Borderline Personality Disorder has an unstable sense of self, which can manifest as sudden and dramatic shifts in personal attitudes, interests, career goals, and social circles. For instance, a student who has invested significant time and money into a specific career path, like law, might abruptly decide to abandon it for something entirely different.

Unstable Self-Image in BPD

Marked impulsivity is a key feature of Borderline Personality Disorder, often leading to reckless and self-destructive actions. These behaviors can include activities such as excessive gambling, irresponsible spending, substance abuse, engaging in unsafe sex, and reckless driving.

Impulsivity in BPD

Individuals with Borderline Personality Disorder often exhibit emotional dysregulation, characterized by intense and inappropriate anger that they struggle to control. This can manifest as moodiness, sarcasm, bitterness, and verbal abuse.

Emotional Dysregulation in BPD

Borderline personality disorder is estimated to affect about 1.4% of the general U.S. population. However, its prevalence is significantly higher within clinical settings, with approximately 10% of mental health outpatients and 20% of psychiatric inpatients meeting the diagnostic criteria for the disorder.

Prevalence of Borderline Personality Disorder

Comorbidity of Borderline Personality Disorder

Individuals with borderline personality disorder are characterized by significant instability across their mood, behavior, and self-image. They often exhibit impulsivity, have a profound fear of being alone, and experience unpredictable and turbulent relationships. A common feature is the display of intense and inappropriate anger.

Characteristics of Borderline Personality Disorder

The development of Borderline Personality Disorder is understood to be a complex process influenced by multiple factors. Key contributors include genetic predispositions and adverse childhood experiences, such as sexual abuse. The interplay between these genetic and environmental elements, along with neurobiological and epigenetic mechanisms, are all considered important in its etiology.

Etiology of Borderline Personality Disorder

A client describes a history of intense and chaotic relationships. They report frequently alternating between seeing a new partner as 'perfect' and then, after a minor disagreement, viewing them as 'terrible.' The client also mentions suddenly changing their career goals and personal style, feeling unsure of 'who they really are.' They engage in impulsive spending and express a deep-seated fear of being left alone. Which of the following best synthesizes these behaviors into a single, underlying psychological pattern?

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