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On the surface, it appeared as though Antoinette Del Rio was a successful 20-something. She had a flourishing career in advertising, took frequent vacations, and enjoyed an active social life.

But Ms. Del Rio was drinking too much, using weed as a coping mechanism, and spending weekends holed up in her New York City apartment. She had also fallen into debt from impulsive overspending and frequently fought with her friends.

Soon she began to notice a troubling pattern in all of her relationships: They felt either euphoric or devastating, with no middle ground. A seemingly small conflict could cause her to “completely lash out without thinking of any of the consequences,” said Ms. Del Rio, now 33. Sometimes she was so angry that she would pull out her hair or dig her nails into her skin “as hard as possible.”

In 2022, her primary care doctor pieced it all together: Ms. Del Rio was showing telltale symptoms of borderline personality disorder, or B.P.D., a condition characterized by volatile relationships and emotions, alongside reckless behavior and an empty sense of self.

B.P.D. is challenging to effectively treat, which can “scare the pants off therapists,” said Dr. Lois W. Choi-Kain, director of the Gunderson Personality Disorders Institute at McLean Hospital in Belmont, Mass. But people can — and do — get better, she added, even those with additional issues like substance use and disordered eating.

Dr. Choi-Kain said that she had seen people who were very ill develop the skills to “feel good about themselves, and then be able to manage a relationship differently,” she said.

What is a borderline personality?

Mental health practitioners define borderline personality disorder as a pattern of instability in someone’s relationships, self-image, and emotions.

People with B.P.D. have a tendency to do things without thinking, sometimes engaging in activities like reckless sex, substance abuse, or self-harm, which is often what leads them to treatment.

It is estimated that B.P.D. affects 1.6 percent of the population; it isn’t considered by mental health professionals to be rare, yet the disorder is often misdiagnosed at first because some of its symptoms can be mistaken for other conditions, such as bipolar disorder, depression, and attention-deficit hyperactivity disorder.

These conditions can also overlap with B.P.D., which further complicates the diagnosis. In fact, in 1938, B.P.D. was initially described as “borderline” by the psychoanalyst Adolph Stern because it borders on other conditions.

What are the signs and symptoms?

B.P.D. symptoms can include inappropriate outbursts of anger, feelings of emptiness, and desperate efforts to avoid feeling abandoned — for example, continually seeking reassurance or “testing” people to see if they will stay, said Sara Masland, an associate professor of psychological science at Pomona College and an expert in personality disorders.

Other features of B.P.D. include volatile relationships, an unclear sense of self, a tendency to self-harm, recklessness, and suicidal behavior. (Studies have found that as many as 10 percent of people who had B.P.D. died by suicide — a number far greater than that of the general population.)

Patients must have at least five symptoms to be diagnosed, according to the diagnostic manual used by mental health practitioners.

One of the defining features of borderline personality disorder is hypersensitivity — most people swing back and forth between being anxious or fearful of being criticized or disliked, and angry or paranoid when they feel as though people are rejecting them, Dr. Choi-Kain said.

One minute a patient might feel fine, then depressed, then intensely angry. This can lead to relationships that are full of conflict and devoid of peace, harmony, consistency, or depth, said Dr. Frank Yeomans, clinical professor of psychiatry at Weill Cornell Medical College, who has focused on the treatment and research of personality disorders for decades.

When things seem perfect, “you’re in heaven,” Dr. Yeomans added. But “as soon as there’s any flaw in what was nice, you go from heaven to hell.”

Despite the chaos in their personal relationships, people with B.P.D. often find it difficult to be alone, the experts said. This is partly because they don’t have a sense of who they are independent of other people.

“Oftentimes people with B.P.D. will over-rely on relationships to understand who they are, and that can make the relationship instability even more tenuous,” Dr. Masland said.

They may take on the traits of the people who they’re surrounded by or continually look to those people for validation. But deep down, they may feel empty.

How is B.P.D. treated?

Antidepressants and other medications can address B.P.D. symptoms, but only therapy will get to the root of the problem, the experts said. Many patients benefit from a “life renovation,” not only to help them get back on track but also to “change their concept of themselves and their relationship to other people,” Dr. Choi-Kain said.

In the United States, the most common modality to treat B.P.D. is dialectical behavior therapy or D.B.T., which focuses on helping people develop mindfulness and practical skills to manage their emotions.

Other evidence-based methods of treating B.P.D. include mentalization-based treatment, a type of therapy that aims to help people reflect realistically about what goes on in the minds of themselves or others during social interactions; and transference-focused psychotherapy, which uses the relationship dynamic between the therapist and client to explore how the client perceives others.

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Vanessa Saba

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https://www.nytimes.com

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