Borderline Personality Disorder Demystified, Revised Edition

An Essential Guide for Understanding and Living with BPD


By Robert O. Friedel

With Linda F. Cox

With Karin Friedel

Formats and Prices




$22.99 CAD



  1. Trade Paperback (Revised) $17.99 $22.99 CAD
  2. ebook $11.99 $15.99 CAD

This item is a preorder. Your payment method will be charged immediately, and the product is expected to ship on or around February 20, 2018. This date is subject to change due to shipping delays beyond our control.

The authoritative guide to understanding and living with borderline personality disorder, now fully revised and updated

Millions of Americans suffer from borderline personality disorder (BPD), a psychiatric condition marked by extreme emotional instability, erratic and self-destructive behavior, and tumultuous relationships. Though it was once thought to be untreatable, today researchers and clinicians know that there is every reason for hope. Dr. Robert Friedel, a leading expert and pioneer in pharmacological treatment for BPD, combines his extensive knowledge and personal experience into this comprehensive guide. Borderline Personality Disorder Demystified shares:

  • The latest findings on the course and causes of the disorder
  • Up-to-date information on diagnosis
  • An accessible overview of cutting-edge treatment options
For those who have been diagnosed and those who think they may have the illness, and for the family and friends who love and support them, this book illuminates new information and points the way to an ever more hopeful future.

The revised edition includes new forewords from Donald W. Black, MD, and Nancee S. Blum, MSW, and family educators James and Diane Hall.



Jim and Diane Hall

AFTER OUR VISITS WITH OUR ELDERLY AUNT, A RETIRED LIBRARIAN in Mentor, Ohio, she always dispatched us to Barnes and Noble with a list of new books she needed—so that’s what took us to the bookstore one day in the summer of 2004, armed with her latest list. That task completed, we wandered into the psychology aisle, as we had been searching for quite awhile to see if something had reached the shelves on borderline personality disorder.

At that time, our family was in the midst of despair with the recent yet long overdue diagnosis of BPD for our beloved adult daughter. Our lives had been consumed for the past fifteen years with turmoil and chaos, as we tried to understand her tormenting illness while she worked and sought therapy yet suffered to survive. The diagnostic criteria seemed to clearly fit her symptoms, but skilled and informed treatment was scarce. So we were ever hopeful to find a resource but had never found much—until that summer day, when there it was: Borderline Personality Disorder Demystified by Robert O. Friedel, MD. With one glance at the Table of Contents, starting with “You Are Not Alone” and ending with “The Ultimate Reason for Hope,” we bought and read it immediately.

Dr. Friedel’s book began to unravel the nagging questions: What really was borderline personality disorder? What treatment and medications address the misery? What caused it? How can we help as family members? Our questions and deep concern for our loved one had developed into what felt to be an insurmountable mountain.

To us, this book was a sturdy ladder, and we started to climb.

Dr. Robert Friedel had an email address listed in his book, and we began to communicate. With the resources in his book plus the corresponding website,, our education on borderline personality disorder began in earnest.

Fortunately, our daughter lived on the East Coast, where some therapies existed for BPD. With extensive searching and a household move, she began in-depth dialectical behavior therapy (DBT) treatment. She has chosen to continue to anchor her life with the guidance and principles of DBT in conjunction with targeted medications.

Dr. Friedel’s book contained the inherent and essential concepts that borderline personality disorder is indeed a serious mental illness, that effective therapies do exist, and—most important for us—that families matter! This was a revelation to us. When a family seeks education about the illness, they can help change their family’s dynamic to support and facilitate their loved one’s treatment.

We began to seek out support, and the knowledge we gained through this book and through learning more about mental illness has held our family together. We first attended meetings of the National Alliance on Mental Illness (NAMI) and the National Education Alliance for Borderline Personality Disorder (NEA-BPD). NEABPD offers a program called Family Connections. It includes current information and research on BPD and family functioning, individual coping skills based on DBT, family communication and problem-solving skills, and group support that builds a network for family members. Family Connections gave us the specific tools for change, and through our efforts to learn and use the skills taught in the course, our family dynamic began to change, starting with us. NAMI has a wonderful free family course called Family-to-Family, which is structured to help caregivers understand and support individuals with serious mental illness while maintaining their own well-being. It is specifically designed for parents, siblings, spouses, adult children, and significant others of people with severe and persistent mental illness, including borderline personality disorder. (For more information, see After taking these powerful courses, we took training to teach them, learning more about ourselves with each class.

Through this process of learning and training, we became active volunteers and family educators working to combat the stigma and biases about this illness that persist despite decades of research. Today, we head a local chapter of NAMI in Corpus Christi, Texas.

Families are extremely important in the lives of our loved ones with mental illness. We’re all in this together, and as the individual works on a wellness path, the family can help or hurt. In many cases, families are the constant for our loved ones. Learning how to build the right family support system can be life-changing, and if you have picked up this book, we’ll bet you’re looking for change.

As we have worked to educate families and increase awareness of BPD, we have remained devoted fans of Dr. Friedel, carrying his books to meetings, conferences, and conventions.

A highly respected clinician, professor, researcher, and editor, Dr. Friedel continues to present on borderline personality disorder worldwide. We have had the privilege of being present with him at congressional briefings involving NEA-BPD and NAMI, NEABPD conferences, NAMI conventions, and the NAMI Expert Focus Group Meeting on BPD. Like us, Dr. Friedel has devoted his life and work to helping people who have experienced a mental illness, and sharing essential knowledge with their loved ones. His popular presentations reveal not only his wisdom but his deep sense of caring and considerate respect for those with the diagnosis and their families. We’re confident his patients recognize his kindness and concern as well as his ability to interpret their pain and gently guide their growth into wellness.

Dr. Friedel’s life and exemplary career have been dedicated to those who struggle to understand and throw off the shackles of BPD. Driven by familial love and a special fondness for his sister Denise, he has continued his work even into retirement—and shared the continuing research and new findings on BPD in this wonderful revised edition of his book. And so we will now begin another fulfilling ten years or more carrying this new edition to meetings, conferences, and conventions. Thank you, Dr. Friedel, for reinforcing our ladder!


DURING THE FOURTEEN YEARS SINCE THE FIRST EDITION OF Borderline Personality Disorder Demystified was published, many significant advances have been made in our knowledge about borderline personality disorder (BPD), including the genetic and environmental risk factors of BPD, the neurobiological underpinnings of the disorder, and changes in its diagnosis and treatment. The total body of information has resulted in a major increase in interest and research about this disabling and potentially fatal disorder, which affects an estimated 4 to 6 percent of the general population in the United States. For example, the number of research citations listed under “borderline personality disorder” by the National Library of Medicine search engine (PubMed) has approximately doubled during this fourteen-year interval. That increase is even more striking when you consider that the initial 50 percent of articles on the topic were published over a period of seventy years. The federal and private funding of research grants allocated to the study of various aspects of the disorder has increased as well. In addition, the methods of treatment of BPD, which we will refer to as borderline disorder, with pharmacological, psychotherapeutic, group, and educational interventions have undergone significant change and improvement.

It’s not just the medical community that has taken more notice of BPD. The awareness and acceptance of the diagnosis of borderline disorder has increased dramatically in the general population, accompanied by the number of healthcare providers who are skilled and experienced in treating the disorder. Finally, patient and family advocacy organizations such as the recently established Black Sheep Project, the National Education Alliance for Borderline Personality Disorder (NEA-BPD), and the National Alliance on Mental Illness (NAMI) have widely distributed current information about BPD to those individuals much in need of hope for improvement in their lives, as well as to their loved ones. The Black Sheep Project is also developing a private foundation to focus on borderline personality disorder where additional information can be translated promptly into increased awareness and improved, more readily available treatment for the disorder.

My main intent in writing this book is to provide a comprehensive review of this maligned and frequently misunderstood medical disorder. The many myths about it are seldom challenged, and when they are, the realities are often unheeded. To some extent, myths about BPD are becoming less frequent and are more often discredited, but many of them remain. Among the most damaging of them are that borderline disorder is almost always severely disabling and untreatable and that the diagnosis cannot be made in individuals who are younger than eighteen, when symptoms are likely to first appear. (Other psychiatrists and I have evaluated and treated many patients with BPD who meet the diagnostic criteria for the disorder in their teens and early twenties.) The effects of these and other myths cause unnecessary and intolerable suffering and an overwhelming loss of hope for those affected directly or indirectly by the disorder.

My younger sister suffered from borderline personality disorder, so I have also personally experienced just how damaging misunderstandings of the disorder can be and the resulting heartache for every member our family (Chapter 2). In my sister’s case, the manifestations of the disorder were initially thought to be willful, causing additional harm. However, experiences with other patients and families have shown me that this disorder is significantly more treatable now than it was two generations ago and manageable with proper care. Since the first edition of this book was published, there is even more reason for hope.

It has been very gratifying to receive communications from readers of the first edition who rediscovered hope and the motivation to find the help of skilled professionals that ultimately enabled them to live happy and productive lives. It is my hope that this updated version of the book will help you achieve the same results.


What Is Borderline Personality Disorder and How Is It Diagnosed?

THE CAUSES OF BORDERLINE PERSONALITY DISORDER OFTEN vary in type and degree from one person to another, so it makes sense that the symptoms also vary considerably in type and severity. In other words, there’s not a one-size-fits-all description for why any one person has BPD or how it causes them to feel, think, and act. Even so, once the basic symptoms are understood, it usually becomes apparent to the individual and family that borderline personality disorder (BPD) is present, and that it is a major contributor to the difficulties they are experiencing. Simply recognizing that you have BPD is the critical first step in gaining control over your life.

There is very good research evidence that borderline personality disorder (referred to as borderline disorder) is the result of physiological and chemical disturbances in certain pathways in the brain that control specific brain functions. You are born with these disturbances, and they usually are amplified by events that occurred after birth. According to the most recent survey conducted in the United States, borderline disorder affects approximately 6 percent of the population. It appears to be more common than schizophrenia and bipolar (also known as manic-depressive) disorders. Borderline disorder was once thought to occur more frequently in women than in men, but that data is now in question. Therefore, it may now be estimated that approximately one in every seventeen people in the United States suffers from borderline disorder.


To be diagnosed with borderline disorder, you must experience and demonstrate a minimum of five of the nine symptoms listed in Table 1.2 here. These symptoms are separated into four different groups (Table 1.1), or as many experts in the field of personality disorders refer to them, behavioral dimensions or domains.


1. Poorly regulated emotions

2. Impulsivity

3. Impaired perception and reasoning

4. Markedly disturbed relationships

Most people with borderline disorder don’t have all of the symptoms in each of the four domains of affected behaviors listed above, but most do have at least one symptom from each. Many of my patients find that the arrangement of the symptoms of the disorder into these four domains makes it easier for them to recognize and remember their symptoms and the consequences. Overall, individuals with borderline disorder may be characterized as appearing dramatic, hyperemotional, and erratic.


A number of experts in the field believe that an inherent difficulty in regulating emotions is the driving force behind many of the other symptoms of borderline disorder. If you have borderline disorder, your emotions may change quickly, and you may find it difficult to accurately perceive and express your emotional responses, especially to unpleasant events. You may often overreact emotionally to daily events. However, at other times your emotional responses may seem blunted, only to be followed by hyperemotional reactions at a later time. Descriptions of other major symptom indicators of poorly regulated emotions in borderline disorder follow.

Mood Swings and Emotional Lability

The emotions of people with borderline disorder are often very unstable and undergo rapid changes that are difficult to control. This is referred to as emotional lability. These labile emotions can include negative feelings of anxiety, anger, fear, loneliness, sadness, and depression. Less often, labile emotions can also include positive feelings such as happiness, joy, enthusiasm, and love. Your emotions may fluctuate quickly from feeling good to feeling bad, sometimes for reasons that are obvious to you but at other times for reasons that are not apparent. Because of these rapid fluctuations in mood, and because you are more likely to develop feelings of depression and episodes of major depressive disorder than individuals who do not have borderline disorder, at some point you may have been diagnosed as having bipolar disorder (which psychiatrists previously referred to as manic-depressive disorder).

Your feelings may also be hyperreactive; that is, you may significantly overreact to some situations. For example, you may become very upset over constructive criticisms, unavoidable separations, or disagreements that other people seem to take in stride. Such events may cause a wave of anxiety, sadness, anger, or desperation. In addition, you may find that you have great difficulty calming down your emotions and soothing yourself by focusing on reassuring thoughts or by engaging in usually pleasant and healthy activities. During these periods of severe hyperemotionality, or “emotional storms,” as they’re called, you may feel so desperate that you turn to alcohol or drugs for relief, lash out in anger or rage, or engage in other destructive behaviors such as cutting.

Recent research also suggests that people with borderline disorder have difficulty in accurately identifying their emotional responses and those of other people, cannot appropriately balance mixed feelings, and have intense responses to negative emotions. For example, you may find that you overidentify with the emotions of others and may become overly upset when they have negative experiences. You may even feel as if these events are occurring to you. In other words, you react too strongly to the plight of others, such as their living situation, their difficulties, or any negative situation they are experiencing.

One patient told me that at such times “it is like someone is putting a dagger in my heart.” This person also told me that the situation did not even have to be happening to real people; it could affect her if she were watching a movie or even a television commercial. She knew the situation was not real, but she felt as if it were and that it was happening to her. She added that at these times, the pain from her emotional involvement in these situations lasted for quite some time. This is another characteristic of emotional dyscontrol in borderline disorder. In addition, you may find that once upset your emotions do not return to their normal level as quickly as they do in people who don’t have the disorder.

You may also be hypersensitive to the real or perceived negative behaviors of others toward you: you’re always on the lookout for the slight frown, raised eyebrow, or minor change in a person’s tone of voice that indicates that they are irritated or angry with you. When you believe you detect such critical reactions, no matter how subtle, your response may often be considerably out of proportion to the situation. You may feel anxiety, self-recrimination, and anger that are simply not warranted under the circumstances. While you may be vaguely aware that you are overreacting, the feelings are just too real and too strong to ignore.


Episodes of severe anxiety are common symptoms of borderline disorder. One of the first psychiatrists to write in detail about borderline disorder believed that “anxiety is the motor” that drives the other emotional symptoms of the disorder, such as anger, and behavioral symptoms such as impulsivity. Anxiety can produce tension-related physical symptoms, including a migraine headache, backache, stomach pain, irritable bowel, rapid heartbeat, cold hands, hot flashes, and excessive sweating.

Anxiety may even reach the level of the massive and disabling symptoms referred to as panic attacks that are so severe you feel you are dying and may go to the emergency room for immediate care. When less severe than a panic attack, the anxiety may be more pervasive and last for a longer duration. Or the anxiety may evolve into anger, despair, and physical symptoms. You may also attempt to relieve the anxiety by engaging in impulsive behaviors that I discuss below.

Intense Anger or Difficulty Controlling Anger

Poorly controlled anger is one of the most common and destructive symptoms of borderline disorder—so much so that it occurs in two of the nine diagnostic criteria of the disorder. You may feel irritable and angry much of the time, and you often can be argumentative, quick-tempered, and sarcastic. You may even become furious, or sometimes enraged, in circumstances that do not warrant such responses. The slightest event or exchange can result in an angry outburst. You may then say and do things that are quite destructive and later regret that you did so. Individuals with borderline disorder have more numerous and intense episodes of anger and depression than other individuals, and their emotions may fluctuate between anger, anxiety, and other emotions more readily as well.

You may realize in the midst of these outbursts of anger that you are overreacting, but seem unable to control the strong emotions sweeping over you. As one patient put it, “I know my husband does not deserve all of the anger and abuse that I heap upon him, but he’s the one around most of the time and I’m fairly sure he won’t leave me. I don’t seem to be able to control the anger. At the time, I think he deserves it—so he gets it.” Your family, your spouse or partner, and others close to you have learned that they must be very careful about what they say or do. Many comment, “It’s like I’m walking on eggshells all the time. I never know what I will do to cause her [or him] to blow up.” This apprehensiveness on the part of your family can result in a persistent, elevated level of tension in your home. Because you are very sensitive to the negative feelings of others, this can make an already tense living situation even worse.

Chronic Feelings of Emptiness

Another strong feeling you may experience is a sense of persistent emptiness. This sense of emptiness is often accompanied by feelings of boredom and loneliness. In turn, these feelings may lead to dissatisfaction with the people in your life and with your life in general. Dissatisfied with your life, you may be prone to change friends and jobs frequently, and even to engage in brief affairs. For a time, these changes can feel very exciting and temporarily relieve the emptiness, loneliness, and boredom. But the feelings return after a while, and the life patterns of inconstancy repeat themselves.

During our initial meeting, one young patient told me that these feelings of emptiness and boredom were so strong that she felt as if she had a big hole inside her that wouldn’t go away. It did diminish when she was involved in a relationship with a young man, at least for a while, but then would return in full force when they fought or when he left her. She added that, when severe, this feeling was so emotionally painful she would do almost anything to relieve it, even cut or burn herself, although the emotional pain always returned shortly thereafter.

Another patient, whom I describe in more detail in Chapter 2, told me early in her treatment that when she felt empty and bored for a long period, she would leave her husband without notice and travel to another city. There she would see a former teacher for a brief two-or three-day affair, then fly home again. Although she temporarily felt excited, desired, and satisfied by these escapades, ultimately she was plagued by guilt and remorse for her behavior, and she dreaded having to deal with her husband about her absences. Nonetheless, the pattern continued until she was able to understand the nature of the feelings and the life situations that triggered this behavior, then take measures to gain control over it. Fortunately, her husband was able to tolerate the behavior until she was able to develop much more effective responses to the emptiness and boredom she often felt.


The tendency toward impulsive, self-damaging behavior is so common and so strong in people with borderline disorder that some experts in the field consider it the most harmful symptom of the disorder. They believe it is more damaging than the symptoms of emotional instability and impaired reasoning. Impulsivity alone, as well as the overall severity of symptoms, appear to be the best predictors of the long-term outcome of the disorder. Untreated, people with borderline disorder who are very impulsive tend to have a worse prognosis than those who are not as impulsive. Research suggests that impulsivity in people with borderline disorder is the result of an imbalance between the neural systems (nerve cell pathways) of emotion and reasoning that regulate impulsive behavior (Chapter 6). Following are the major groups of symptoms of borderline disorder that are included in the category of impulsivity.

Impulsive Self-Harming Behaviors

If you have borderline disorder, there are many ways that you may behave impulsively, such as binge eating and spending money recklessly on clothes or other items. You may also engage in more harmful, impulsive acts like uncontrolled gambling; excessive drinking and drug abuse; unprotected sexual promiscuity; violent, aggressive acts or repetitious, illegal acts such as speeding, driving while intoxicated, and shoplifting.

For example, when one of my patients felt especially anxious and empty inside, she would go shopping at expensive stores and then steal clothing and other items, even though she could easily afford to buy them. Before these actions could be brought fully under her control, she was arrested for shoplifting and convicted of a felony. When another patient felt particularly neglected and abandoned, or was criticized by her husband, she would go to bars, drink excessively, and strike up conversations with men. She stated that she did this in an attempt to feel better about herself and to “get even” with her husband. These episodes would occasionally lead to brief sexual encounters that were very destructive to her self-esteem and to her relationship with her husband. These episodes also exposed her to a considerable risk of being seriously harmed, as she knew little about the men she picked up, and she did not protect herself properly from sexually transmitted diseases.

There is considerable research on the prevalence and consequences of impulsive behavior in people with borderline disorder. However, there is a scarcity of research on the events and warning signs that lead up to such behavior, and on why some people with borderline disorder are more impulsive than others. In general, impulsive behaviors often follow episodes of emotional storms and disrupted close relationships, especially real or threatened abandonment. They also appear to be more common in people with borderline disorder who have been physically or sexually abused as children. To meet this particular diagnostic criterion, you would exhibit a pattern of impulsive behaviors in at least two of the self-destructive ways that I mentioned above.

Recurrent Suicidal Behavior, Gestures, and Threats or Self-Mutilating Behavior

Recurrent suicidal behaviors, gestures, and threats or self-mutilating or injurious behaviors are a particularly striking group of impulsive symptoms that occur among many, but by no means all, individuals with borderline disorder. They are referred to as parasuicidal acts. The severity of these behaviors ranges from very serious acts that may inadvertently be life-threatening to less serious acts that are often attempts to control painful symptoms or a situation, gain attention, or seek help. You may physically hurt yourself by hitting yourself; cutting or scratching your wrists, arms, thighs, or other parts of your body; burning your skin with cigarettes; or taking overdoses of medications. At times, you may do these things in the desperate desire to have others take care of you, to “get even” with them, or to impose your way on them.

Most often, you may hurt yourself to help reduce the emotional pain you feel when it reaches an intolerable level. As one patient who frequently cut her thighs with a razor blade explained to me, “When I see the blood and feel the pain, somehow the pain and dead feelings inside go away for a while, and I’m again back in control and in contact with the world.” At these times, these acts may seem to alleviate, at least to a degree, the severe internal pain you are feeling.

For those of you who engage in one or more of these manifestations of borderline disorder, they are most likely very distressing to you, and to family members as well. It’s also such a striking type of behavior that, in its rare extreme, it has been dramatized in movies. For example, the character played by Glenn Close in the classic 1987 movie Fatal Attraction


  • "This informative and compassionate book dispels myths and replaces misunderstanding with a wealth of knowledge so patients can get effective help. Clear, concise, and readable, Borderline Personality Disorder Demystified is helpful not only to those with BPD and their loved ones but also mental health professionals who want to know more about this disorder and what it is like to suffer from it."—John Livesley, MD, PhD
  • "This book is a sensitively written, scientifically informed overview of borderline personality disorder. Both caring and authoritative, Dr. Friedel is a rare academician who combines a touching humanistic perspective on this challenging clinical syndrome with a deep and wide grasp of the rapidly growing relevant scientific literature."—Kenneth S. Kendler, MD
  • "Wonderful! A doctor's doctor speaks clearly and compassionately about a disorder he's spent his career treating and studying. The stigma of borderline personality disorder is countered by hope and advocacy. Readers will be enlightened and inspired."—John G. Gunderson, MD, Professor in Psychiatry at Harvard Medical School and Senior Advisor, Borderline Services at McLean Hospital
  • "Dr. Friedel's enthusiasm and life-long experience treating patients with BPD are evident on every page. This book is a well-balanced mixture of necessary information for patients and families and up-to-date overviews of relevant fields, from neurobiology to treatment."—Christian Schmahl, MD, Professor and Director of the Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health (Mannheim, Germany)

On Sale
Feb 20, 2018
Page Count
320 pages

Robert O. Friedel

About the Author

Robert O. Friedel, MD, is Distinguished Clinical Professor of Psychiatry at Virginia Commonwealth University, and Professor Emeritus at the University of Alabama at Birmingham. He serves on the Scientific Advisory Board of the National Education Alliance for Borderline Personality Disorder, and was named a Psychiatrist of the Year in 2007 by the National Alliance on Mental Illness (NAMI). Dr. Friedel has published over 100 scientific articles, book chapters and books. He lives in Virginia.

Learn more about this author