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The hardest mental illness to treat (Top 3)

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The current blogspot will answer the question “what is the hardest mental illness to treat?”.  We will discuss the facts, symptoms and factors that show that a particular disorder is hardest to treat regarding mental illness. 

What is the hardest mental illness to treat?

Depending upon the client’s resistance, the severity of the disorder and the defense mechanisms of the clients, a number of mental illnesses might appear hard to be treated; however, Borderline personality disorder is believed to be one of the toughest mental illnesses to be treated.

Borderline personality disorder is a type of mental illness among the  disorders that are mentioned in the diagnostic and statistical manual of mental disorders- 5 edition. Among the clusters A,B and C of the personality disorder, the borderline personality disorder is classified in the cluster B of the personality disorders from the cluster

The classification of personality disorders along the clusters is as below:

  • Cluster A is known as the Odd/ eccentric cluster of personality disorders. It includes the disorders that  are based on an individual behaving in a way that appears odd or unusual. The individuals under the disorders of this cluster have eccentric beliefs. Cluster A of personality disorders includes Schizotypal personality disorder, schizoid personality disorder and paranoid personality disorder.
  • The cluster B of personality disorder is also known as the dramatic/erratic cluster. It includes the disorders that are based on the behaviors that may appear to other people as dramatic, erratic or emotional. Individuals under the dramatic / erratic cluster have a difficulty in regulating their thoughts, emotions and behaviors. The disorders included in this cluster are  borderline personality disorder, antisocial personality disorder, histrionic personality disorder and narcissistic personality disorder.
  • Cluster C of the personality disorders is the anxious and avoidant cluster. It is based on underlying anxiety and avoiding it as the best exercise strategy to overcome the anxiety.  The disorders included in this cluster are avoidant personality disorder, dependent personality disorder and obsessive compulsive personality disorder.

What is borderline personality disorder?

Borderline personality disorder is a personality disorder that is classified in the dramatic/erratic cluster of personality disorders in the diagnostic and statistical manual of mental disorders 5 edition. 

Borderline personality disorder is a personality disorder that affects the ways an individual perceives the events and thinks about the self and others. The borderline personality disorder is characterized by self image issues, distorted relationships, black and white thinking (polarized thinking), difficulty in managing emotions and behaviors.

The borderline personality disorder usually begins in the late teens and is worst at the age of young adulthood and early adulthood. However the symptoms tend to become less intense as the age progresses.

Borderline personality disorder often has prominent associated conditions of :

  • An intense fear of abandonment
  • An inner conflict of trust vs mistrust
  • Emotional instability
  • Need for emotional change
  • Conflicts with close relationships
  • Difficulty tolerating being alone
  • Inappropriate anger outbursts
  • Mood swings
  • Impulsivity
  • Manipulation
  • Love/hate relationship patterns
  • Suicidal ideation

What are the major features of borderline personality disorder?

The major features of borderline personality disorder include:

  • Extreme behaviors to avoid real or imagined feelings of abandonment
  • A pattern of unstable relations that make individuals fantasize about someone for some time in life and then leaving them or disliking them for not being caring enough or loving enough.
  • Rapid changes in self identity and self image that makes an individual shift his goals frequently in life.
  • Stress induced due to paranoid feelings and thoughts that may last from a few minutes to hours.
  • Getting involved in thrill seeking impulsive and risky behaviors. The behaviors may include gambling, unsafe sex, rash driving, impulsive shopping, drug abuse and self sabotaging behaviors.
  • Self mutilation by making cut marks on the arm with a pen on arm or leg.
  • Suicidal threats, suicidal ideation or suicidal attempts in response to real or imagined fear of rejection
  • Severe mood swings lasting from a few hours to days involving guilt, remorse, happiness, sadness and anger.
  • Inadequate and intense anger outbursts that may involve physical aggression or verbal aggression
  • Pervasive feelings of emptiness

What is the diagnostic criteria for borderline personality disorder?

The diagnostic criteria for borderline personality disorder as mentioned in the diagnostic and statistical manual of mental disorder is as below:

  • Chronic feelings of emptiness
  • Emotional instability in reaction to routine life events for example increased irritability, anger issues and pervasive feelings of frustration
  • Frantic efforts to avoid real or imagined abandonment
  • Identity disturbance due to inappropriate self image
  • Impulsivity in two areas among the following :
  • Spending
  • Sex
  • Substance abuse
  • Reckless driving 
  • Binge eating
  • Inappropriate anger feelings that are way too extreme to the trigger and are based on anger outbursts
  • Splitting pattern with regards to the interpersonal relationships based on idealization of other people and devaluation of other people
  • Recurrent episodes of suicidal behavior and self damaging behavior
  • Paranoid ideation that is based on stress related to daily life and further reduces the functionality of interpersonal skills

The above mentioned symptoms need to exist during the late adolescence period and manifest in the individual during the young adulthood as pervasive and enduring patterns of personality. Before 18 years of age, the onset of symptoms is visible that goes on to development of the complete diagnostic criteria by the age of 18 years.

What are the causes of borderline personality disorder?

The causes of borderline personality disorder are :

  • Genetic causes 
  • Brain Abnormalities

Genetic causes of borderline personality disorder

Twin studies and family studies collect empirical evidence to support the genetic causes of borderline personality disorder. The borderline personality disorder can be genetically transferred from the parents to the newborn and has a hereditary nature.

Brain Abnormalities as cause of borderline personality disorder

The brain abnormalities related to amygdala often result in emotional irregularities that are a characteristic of borderline personality disorder. Further disturbance in the serotonin levels of the brain also induces impulsivity and aggression that are characteristic of borderline personality disorder.

What are the risk factors for borderline personality disorder?

The risk factors for borderline personality disorder are as follows :

  • Heredity factors
  • Childhood trauma

Heredity factors

An individual is more likely to develop borderline personality disorder and associated features if any of the parents or siblings have a borderline personality disorder.

Childhood trauma

Childhood trauma is associated with neglect, ignorance, physical or emotional abuse and childhood conflicts in the form of fear of abandonment or conflict among parents. All of these factors lead the individual to develop borderline personality features.

What are the effects of borderline personality disorder on individual life?

The effects of borderline personality disorder on individual life are:

  • Declined academic performance that may lead to inability in completing education
  • Impulsivity leading to various legal issues
  • Conflict in relationships that may lead to divorce and separations
  • Involvement in toxic relationships
  • Unplanned pregnancies leading to health issues
  • Self injury leading to various hospital visits
  • Frequent suicide attempts
  • Irrational thoughts and emotional states that often lead to drug abuse, depression, anxiety, eating disorders, inappropriate sleep, post traumatic stress disorder and disturbed focus.

What are the various treatment options for borderline personality disorder?

The various treatment options for borderline personality disorder are as follows:

  • Dialectical behavior therapy
  • Schema focused therapy
  • Mentalization based therapy
  • Emotional regulation
  • Drug therapy

Dialectical behavior therapy

Dialectical behavior therapy is a treatment choice through psychotherapy. It is specifically designed to  treat borderline personality disorder and facilitate learning of social skills and management of irrational thoughts and is based on mindfulness skills and psychoeducational the individual about the importance of the here and now.

Schema focused therapy

Schema focused therapy is a treatment option for borderline personality disorder. It tends to identify the negative life patterns of adults that might have been helpful for them in dealing with life stressors and replace them with more healthy coping strategies.

Mentalization based therapy

The mentalization based therapy helps the patients of borderline personality disorder by helping them identify their irrational thoughts and emotions and forming new alternate thoughts and emotions that are more rational and pleasant.

Emotional regulation

Training the individuals with borderline personality disorders to manage, express and regulate their emotions is achieved through emotional regulation training.  The individuals are able to identify their dramatic reactions to various triggers and change their reactions with responses that are more appropriate to the situation.

Drug therapy

Drug therapy for borderline personality disorder works by facilitating the individual to overcome the impulsive reactions, aggression, anxiety and associated features of depression

Why is it hard to treat Borderline personality disorder? 

It is usually hard to treat borderline personality disorder because : 

  • Borderline personality disorder makes people have a polarized view and thus they are unable to stick to one side of their views
  • Individuals with borderline personality disorder have negative schemas associated to self and others and are defensive to change
  • Individuals under borderline personality disorder are manipulative and have a tendency to coin stories to gain attention from the counselor or therapist.


In the current blogspot we answered the question “what is the hardest mental illness to treat?”. We learned that borderline personality disorder is regarded as the toughest mental illness to be treated due to the associated behavioral, emotional and cognitive features that are of intense nature.

Frequently asked question (FAQs) : The hardest mental illness to treat 

What is the dsm-5 criteria for borderline personality disorder?

The DSM -5 criteria for borderline personality disorder is based on the following : 

Markedly and persistently unstable self-image or sense of self. 
Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) 
Suicidal or self-mutilating behavior covered

Is there a mild form of borderline personality disorder?

Borderline personality disorder has another form that is known as “quiet borderline personality disorder”. Individuals belonging to the quiet borderline personality disorder tend to direct their struggles inward so that they are not observed by people around them.

Are personality disorders in DSM 5?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) lists the following 10 types of personality disorders :

Schizoid personality disorder
Schizotypal personality disorder
Paranoid personality disorder
Borderline personality disorder
Antisocial personality disorder
Avoidant personality disorder
Histrionic personality disorder
Obsessive compulsive personality disorder
Dependent personality disorder
Narcissistic personality disorder
Personality disorder not otherwise specified


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