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Borderline personality disorder and anorexia nervosa

Borderline personality disorder (BPD) and eating disorders, such as anorexia nervosa (AN), often occur together. (1) Until recently, not much was known about the relationship between the two disorders but new research is showing how often BPD and eating disorders occur, why they may be related, and how to treat the two types of disorders when they occur together.

Last updated on 
May 31, 2023
In this article

What is borderline personality disorder?

Borderline personality disorder (BPD) is a personality disorder in which people have trouble processing and managing their emotions. A person with BPD can suffer changeable moods, self-image issues, behavioral changes, and feelings of insecurity and instability. (2)

BPD is believed to affect approximately 1.4% of the US population, with around 75% of the diagnosed cases being in women. (2) Researchers are still unsure of the exact causes of BPD, but the most likely cause is an interaction of genetic, environmental, and biological factors.

Symptoms of BPD

BPD doesn’t always present in the same way in people living with the disorder. However, several signs and symptoms point to a BPD diagnosis, including:

  • Self-harming behaviors and ideation
  • A pattern of intense and unstable relationships
  • A fear of abandonment
  • Rushing into emotional and/or physical relationships with others
  • Distorted self-image
  • Impulsive behaviors such as binge eating or drinking, spending sprees, unprotected sex, etc.
  • Anger issues, including irrational anger and an inability to control anger
  • A persistent feeling of emptiness

The symptoms of BPD can cause a person to act impulsively and can put a strain on significant relationships.

Prevalence of borderline personality disorder and anorexia

People with BPD have a higher prevalence of eating disorders than the general population. (3) A well-known study by Zanarini et al. found that 53.8% of patients with BPD also met the diagnostic criteria for an eating disorder, compared to 24.6 % of patients with other personality disorders. The same study found that 21.7% of patients with BPD also met the criteria for an anorexia nervosa (AN) diagnosis. (3)

This doesn’t mean that people with eating disorders necessarily have BPD. The prevalence of BPD in those with anorexia nervosa, binge-eating purging type is 25%, which is way above the expected rate of 6% in the general population. (4)

How are BPD and anorexia related?

One possible explanation for the relationship between borderline, and eating disorders like anorexia, is that they share a common risk factor. Both eating disorders and BPD are associated with histories of childhood trauma, such as emotional, physical, or sexual abuse. (5)

Furthermore, it could be that the symptoms of BPD put a person at risk of developing AN. 

Research has shown that those with the binge-eating purging type of AN are particularly at risk of co-occurring BPD. This could be because the characteristics of BPD are easily reflected in some disordered eating pathology. (4)

Specifically, impulsivity is evidenced in binge eating and a tendency towards self-harm is seen in potential destructive eating behaviors such as self-induced vomiting, laxative or diuretic misuse, and excessive exercise. Over time, these behaviors may progress to the level to meet the diagnostic criteria of AN. (1)

In addition, one of the identifying symptoms of BPD is an unstable sense of self. For people with anorexia nervosa, their sense of self can heavily depend on their weight. A person’s unstable identity (due to BPD) may intensify their anxieties about their weight and eating habits and, therefore, losing weight and controlling food may develop as an attempt to establish a secure identity. (6)

Conversely, disordered eating thoughts and behaviors can lead to extreme stress (such as feelings of shame, family issues, hospitalization, and more), which may contribute to the development of BPD, particularly in those with a genetic predisposition to the personality disorder.

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Treating co-occurring anorexia and BPD

Treatment is available for both BPD and AN and if you’re struggling with both, it’s important that you seek treatment that has expertise to treat both. This can help tackle how the co-occurring disorders feed into each other and may also prove to be an effective relapse prevention technique. (6) Various treatment methods can be used in combination to treat both disorders in tandem.

Therapy for BPD and anorexia

There are therapeutic approaches that are specifically designed to treat BPD and eating disorders like anorexia nervosa. There is one approach that has been used to successfully treat both disorders, dialectical behavioral therapy (DBT). A form of talking therapy, DBT focuses on the following four core skills:

  • Mindfulness
  • Interpersonal relationships
  • Distress tolerance
  • Emotional regulation

Typically, the goal of DBT is to help a person limit and stop any harmful behaviors. Once disordered behaviors are under control, the therapy can progress to help a person deal with their unresolved emotions or beliefs that have a negative impact.

Medication for BPD and anorexia

There aren’t currently medications that are used exclusively to treat BPD or anorexia nervosa. Medications typically used in those living with these disorders are used to address symptoms associated with depression or anxiety, which co-occur significantly in eating disorders. 

Furthermore, people with BPD may be prescribed medication to help with mood fluctuations or reactivity. 

Which condition should be treated first?

It could be that both disorders could be treated at the same time, but this will be decided on a case-by-case basis. For example, if a person’s anorexia symptoms are life-threatening, then they may require hospitalization to address the eating disorder symptoms before treatment for BPD can begin.

By contrast, if a person has particularly severe BPD symptoms that are life-threatening or affect their ability to engage in eating disorder treatment, the BPD symptoms may be prioritized for treatment.

Relapse prevention and aftercare

Since impulsivity is a common feature in those with BPD, having a solid relapse prevention plan in place is crucial to recovery. During recovery, setbacks are normal but preventing a complete relapse can stop someone from going back to their old behaviors. A relapse plan can include:

  • Warning signs that indicate you’re struggling
  • A list of triggers and methods for coping with them
  • A contact list of people you can reach out to when you need to

After treatment, you may find it helpful to continue with therapy for medication management, implementing skills you’ve learned, join a support group, and have regular self-care activities.

Final thoughts

Coping with BPD and AN at the same time can feel overwhelming, but these conditions are treatable. That’s why it’s so important to seek treatment and support as soon as you feel able.

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Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.

Resources

  1. Kristalyn Salters-Pedneault, P. D. (2021, June 25). Eating disorders and borderline personality. Verywell Mind. Retrieved October 27, 2022, from https://www.verywellmind.com/eating-disorders-and-borderline-personality-425424 
  2. Fletcher, J. (2017, March 31). Borderline personality disorder: Causes, diagnosis, treatment. Healthline. Retrieved October 27, 2022, from https://www.healthline.com/health/borderline-personality-disorder 
  3. Zanarini, M.C., Reichman, C.A., Frankenburg, F.R., Reich, D.B. and Fitzmaurice, G. (2010), The course of eating disorders in patients with borderline personality disorder: A 10-year follow-up study. Int. J. Eat. Disord., 43: 226-232
  4. Sansone, R. A., & Sansone, L. A. (2011). Personality pathology and its influence on eating disorders. Innovations in clinical neuroscience, 8(3), 14–18.
  5. Authors, A., & Weng, Z. (H. (n.d.). Probing the nature of soil organic matter. Taylor & Francis. Retrieved October 27, 2022, from https://www.tandfonline.com/doi/full/10.1080/10643389.2021.1980346 
  6. Treat co-occurring eating disorders and borderline personality disorder. Eating Disorder Hope. (2021, December 3). Retrieved October 27, 2022, from https://www.eatingdisorderhope.com/treatment-for-eating-disorders/co-occurring-dual-diagnosis/borderline-personality-disorder

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