Emotionally Dysregulated Personality Style

Style, Disorder, and the Space Between

This style is unusual in the PDM-3 because it is defined partly by its level. Everyone with an emotionally dysregulated personality functions at the borderline level of organization. The reverse is not true: many people at the borderline level have other styles, such as schizoid, paranoid, or narcissistic (McWilliams & Shedler, 2026, pp. 665, 696). The manual even uses the phrase “quiet borderline” for schizoid people at this level who look nothing like the stormy picture described here (p. 656).

Strictly speaking, then, there is no healthy or neurotic “emotionally dysregulated personality.” Emotional intensity and dysregulation are still matters of degree, though. McWilliams notes that every person at the neurotic level has some borderline tendencies, and vice versa (2011, p. 83). Across the range, it looks like this:

At the healthy end, a person may feel things strongly and react sharply under unusual stress, but recovers, can soothe themself or accept comfort, and can later reflect on what happened.

At the neurotic level, a person may be emotionally vivid, sensitive to rejection, and prone to dramatic conflict, but has a coherent identity and can see others as mixtures of good and bad. Such people are usually better described by another style, often hysterical-histrionic or dependent. McWilliams points out that the DSM borderline concept was built largely from people most analysts would have seen as hysterical or histrionic at the borderline level (2011, p. 53).

At the borderline level, where the style itself belongs, identity is unstable, splitting and projective identification dominate, relationships swing between extremes, and impulsive or self-destructive actions are common.

Toward the border with the psychotic level, intense stress can bring paranoid ideas, dissociation, and even brief psychotic experiences (Tanzilli & Sharp, 2026, p. 510; Gunderson & Singer, 1975). McWilliams, following Grinker and colleagues, notes that the borderline range itself runs from the border with the neuroses to the border with the psychoses (2011, p. 83).

Signs that emotional intensity has become a disorder include:

• Emotions that compromise functioning and cannot be soothed without another person (p. 697).
• Black-and-white views of self and others under stress.
• A sense of self that shifts with mood.
• Chaotic relationships and work lives.
• Self-destructive impulses, especially when an attachment is threatened (p. 698).
• Difficulty reflecting on these patterns afterward.

In DSM-5-TR the corresponding diagnosis is borderline personality disorder. ICD-11, which otherwise abandoned named types, kept an optional “Borderline Pattern” qualifier. It describes a pervasive pattern of instability in relationships, self-image, and emotions, with marked impulsivity, identified by five or more features such as frantic efforts to avoid real or imagined abandonment (Bach & First, 2018).

Inner World

The central preoccupation is the need-fear dilemma: needing others desperately while fearing what closeness will bring. Adler placed “aloneness” at the core. In his account, people with this style have trouble keeping a soothing inner image of important people alive when they are apart from them, so a separation can feel like an absence of comfort altogether (Adler, 1993). McWilliams adds that the characteristic anxiety at this level is separation anxiety (2011, p. 55).

Characteristic emotions are intense and fast-changing: sadness, anxiety, rage, shame, and a painful inner “void” or emptiness. Some people enter dissociated, trance-like states (McWilliams & Shedler, 2026, p. 697). Linehan described three temperamental features (Crowell et al., 2009):

• Heightened emotional sensitivity.
• Difficulty regulating intense emotional responses.
• A slow return to emotional baseline.

The PDM-3 cites evidence for genetic vulnerability. It also cites findings that early trauma can damage capacities for affect regulation and executive control, and it adds that the relative weight of these factors varies from person to person (p. 696). Brain-imaging findings exist but are, in the manual’s words, contradictory and hard to interpret (p. 511).

Identity is a central struggle. People with this style lack a cohesive sense of self, move between self-states without noticing the inconsistency, and can leave both themselves and others feeling disoriented (p. 697). Mentalizing means understanding behavior in terms of underlying thoughts, feelings, and intentions. It tends to break down under stress: others are seen in all-good or all-bad, self-referential terms, either too naively or with unwarranted suspicion (p. 697). Peter Fonagy and colleagues describe an “epistemic hypervigilance,” a guardedness about trusting what others communicate, that protects against danger but blocks healthy intimacy (p. 511).

Pathogenic beliefs are the unconscious convictions that shape behavior. Read from the clinical descriptions above, they might include:

• If I am alone, I will fall apart.
• Anyone I need will eventually leave or hurt me.
• My feelings are dangerous.
• I am fundamentally bad. ICD-11 lists a view of oneself as inadequate, bad, or contemptible among the other possible manifestations of the borderline pattern (Bach & First, 2018).

Self-esteem tends to rise and fall with the state of key relationships, swinging between idealizing others and feeling devastated by them.

In the language of PDM-3 capacities, the style centers on difficulties in affect regulation, mentalization, differentiation and integration, and impulse regulation. It also affects self-esteem regulation and trust and intimacy.

Defenses

The PDM-3 lists the classic defenses of this style as splitting, projection, and projective identification (p. 696). Splitting means seeing oneself or others as all good or all bad. Through projective identification, people with this style tend to evoke in others the emotions they themselves are feeling or disowning (p. 697). The PDC-3 chart adds the other defenses typical of the borderline level: idealization alternating with devaluation, denial, omnipotent control, and acting out (Gordon & Bornstein, 2025). Dissociation is common too.

Emergency workers know the pattern McWilliams calls “help seeking–help rejecting behavior,” related to the defense the site calls help-rejecting complaining (2011, p. 66). Self-destructive acts often serve as desperate efforts at self-regulation. The PDM-3 notes that people describe them as ways to soothe unbearable states or to feel real again (p. 697).

Two clarifications help reduce stigma. First, what others call “manipulation” in this style is usually not the deliberate, ego-syntonic using of people seen in the psychopathic style, meaning use that feels acceptable to the person. It is an indirect, largely unconscious effort to keep a relationship (McWilliams, 2011, pp. 160–161). Bateman and colleagues make the same distinction: similar-looking behavior aims at eliciting care in one case and at gain and power in the other (Bateman et al., 2016). Second, these defenses are not choices made in calm reflection. They are how a mind protects itself when feelings outrun the capacity to hold them.

Relationships

Relationships tend to start fast and burn hot. People with this style attach quickly and intensely, become hypervigilant for signs of rejection, and may misread neutral behavior as abandonment. As closeness grows, they may feel controlled and need to escape (McWilliams & Shedler, 2026, p. 697). The PDM-3 prototype notes that they often stir intense emotions in others and may draw them into roles that feel alien, such as acting uncharacteristically cruel or making “heroic” rescue efforts. They may also stir up conflict among the people around them (p. 698). Hospital staff can split into opposing camps, one group seeing a deprived person who needs more care and another seeing a demanding person who needs firmer limits, and an outpatient therapist may swing internally between the two positions (McWilliams, 2011, p. 67).

Theories of origin have changed over time, and none should be read as blame:

• Masterson saw the problem as an arrest at the stage when a toddler alternates between “I can do it myself!” and collapsing in tears. He linked it to caregivers who discouraged separation or failed to support regression after independence (McWilliams, 2011, pp. 66–67). McWilliams adds that whether or not his ideas about cause are correct, his observations about the separation dilemma make sense of the behavior (p. 67).
• Kernberg emphasized constitutional aggression meeting a traumatic environment (Tanzilli & Sharp, 2026, p. 511).
• Linehan described an “invalidating environment,” one intolerant of a child’s expressions of private emotional experience. She saw the disorder as arising from a back-and-forth transaction between that environment and a sensitive temperament (Crowell et al., 2009).
• Attachment researchers point to disorganized attachment, in which caregivers are sources of both safety and fear. This leaves people treating later attachment figures, therapists included, with confusing combinations of clinging, attack, and detachment (McWilliams & Shedler, 2026, p. 696).
• Trauma, especially relational trauma, has drawn increasing attention (McWilliams, 2011, pp. 54–55).

McWilliams concludes that borderline psychology is probably not a single entity and has multiple causes (p. 54).

In Therapy

Two terms help here. Transference is the set of expectations and feelings a person brings from earlier relationships into the therapy relationship. Countertransference is the therapist’s emotional response.

People with this style rarely come to therapy wanting to change their personality. They usually come because they want to stop hurting. Early on, interventions the therapist means as helpful are often received as attacks, which McWilliams calls the usual first clue to the underlying structure (2011, pp. 65–66). The aim, in her account, is an integrated, dependable, and positively valued sense of self, together with the capacity to love people despite their flaws and to tolerate a wide range of emotions (pp. 83–84).

In this style, transferences tend to be strong, unambivalent, and resistant to ordinary interpretation. The therapist may be experienced as godlike one day and contemptible the next. When a therapist tries a classic interpretation (“perhaps you feel toward me what you felt toward your father”), the client may simply agree that the therapist really is like the earlier figure (McWilliams, 2011, p. 67). With adolescents, the PDM-3 describes hostility, seductiveness, and recurrent ruptures of the alliance (pp. 511–512).

Countertransference is also intense. Therapists may feel consuming rescue fantasies, or swing between being oversolicitous and punitive. McWilliams compares the feeling to being the exasperated parent of a two-year-old who will not accept help yet collapses without it (2011, p. 67). Helplessness, fear, confusion, anger, and dread around self-harm are common, along with strong wishes to rescue and reparent that can pull a therapist into overinvolvement (Tanzilli & Sharp, 2026, p. 512). McWilliams also warns about a devaluing countertransference toward people given this diagnosis, a modern echo of the condescension once aimed at patients labeled hysterical (2011, pp. 324–325).

Despite very different theories, treatments share a broad consensus. The PDM-3 lists these principles (pp. 697–698):

• A clearly defined treatment frame.
• A central working alliance, with active repair of its inevitable ruptures.
• Firm boundaries, held while tolerating the anger they provoke.
• Discouraging regression.
• Expecting intensity and dilemmas that feel either-or.
• An emotionally genuine therapist.
• The gradual building of self-reflection and mentalization.
• Ongoing supervision for the clinician.

McWilliams explains why boundaries help. They communicate that the therapist sees the client as an adult able to tolerate frustration, and that the therapist will not be exploited (2011, p. 85). Early in her career, the more she gave, the more her clients regressed and the more resentful she became (p. 86). She also stresses that with this style, the ongoing work on the conditions of treatment is the therapy (p. 86).

Several structured treatments have research support (McWilliams, 2011, pp. 71, 84):

• Linehan’s dialectical behavior therapy (DBT), which blends cognitive-behavioral methods with ideas from Zen Buddhism.
• Bateman and Fonagy’s mentalization-based treatment (MBT).
• Kernberg’s transference-focused psychotherapy (TFP).
• Young’s schema therapy.

The PDM-3 notes that each departs from standard practice in its own tradition (p. 698). McWilliams observes that full structural change can take years, but the most disabling behaviors often fade along the way (2011, p. 66).

Suicidal communications are always taken seriously in treatment. The PDM-3 notes that their meaning can differ from person to person and shift over time, and that real attempts can come from deep hopelessness (McWilliams & Shedler, 2026, p. 697). McWilliams adds that they often express loneliness and pain. Rushing straight into a checklist can leave the person feeling unheard, while sincere interest in what they are going through is usually welcomed (2004, pp. 79–80).

Variations

• No formal subtypes. Neither the PDM-3 nor its diagnostic chart (the PDC-3) lists subtypes for this style (Gordon & Bornstein, 2025). Instead, the manual stresses oscillation. People with this style cannot be placed on either the internalizing spectrum, where suffering is mostly turned inward, or the externalizing spectrum, where it is mostly turned outward. They are “stably unstable,” moving between the two modes (McWilliams & Shedler, 2026, p. 667, quoting Schmideberg).
• The SWAP picture. In research with the Shedler-Westen Assessment Procedure (SWAP), a “borderline-dysregulated” grouping emerged as one of three higher-order clusters, alongside internalizing and externalizing (Westen et al., 2012).
• Blends. Common blends are with hysterical-histrionic, dependent, depressive, narcissistic, and dissociative styles. A smaller group combines emotional dysregulation with antisocial features, a combination linked to greater severity (Bateman et al., 2016).
• Adolescence. The PDM-3 describes an emerging version in adolescence. It notes that the “second individuation” of adolescence can reactivate early separation struggles, and that some adolescents may show transient paranoia or psychotic-like experiences under stress (pp. 510–511).
• Later life. Self-harm and stormy relationships become less common, and several other features appear less often or less intensely. Intense emotion, the centrality of anger, feelings of emptiness, and fear of abandonment tend to persist. Distress may instead show up as sabotage of medical care, substance misuse, or physical symptoms. The PDM-3 adds that it is unclear whether calmer behavior in old age reflects real improvement or physical limits (pp. 949–950).
• Gender. Clinical samples have traditionally been about 75% women. Community studies give mixed results, and a large U.S. survey found similar rates in men and women. Proposed explanations include differences in help-seeking and possible bias in diagnostic thresholds, sampling, and assessment instruments (Bozzatello et al., 2024).

How Different Thinkers See It

Stern, Knight, and Schmideberg: patients on the border

In 1938 Adolph Stern described a “border line group” of patients who got worse rather than better in standard psychoanalysis (Stern, 1938; McWilliams, 2011, p. 52). Knight’s 1953 paper on “borderline states” and Schmideberg’s description of patients who were “stably unstable” helped define a population too troubled for ordinary analysis yet not psychotic (McWilliams, 2011, p. 52; McWilliams & Shedler, 2026, p. 667).

Kernberg: organization versus disorder

Otto Kernberg’s concept of borderline personality organization, first set out in 1967, defined a level marked by identity diffusion, primitive defenses, and intact but fragile reality testing (Kernberg, 1967; McWilliams & Shedler, 2026, p. 655). After the DSM adopted “borderline” for a specific disorder, Kernberg distinguished borderline personality organization from DSM borderline personality disorder (McWilliams, 2011, p. 53). His transference-focused psychotherapy aims to reduce reliance on primitive defenses such as splitting and to foster more integrated representations of self and others (Tanzilli & Sharp, 2026, p. 513).

Masterson, Adler, and Buie: developmental deficit

Masterson tied the pattern to the separation–individuation phase (McWilliams, 2011, pp. 66–67), and the PDM-3 draws on his work for the deep fear of rejection and abandonment (McWilliams & Shedler, 2026, p. 697). Adler and Buie belong to the group that saw the condition as a developmental arrest (McWilliams, 2011, p. 84). Adler later described a deficit in inner capacities for self-soothing, with aloneness at the core (Adler, 1993). Kernberg, by contrast, emphasized innate aggression interacting with a traumatic environment (Tanzilli & Sharp, 2026, p. 511). McWilliams notes that theorists with different explanations emphasized different aspects of treatment, but she sees the theories as compatible, since the condition probably has multiple causes (2011, p. 84).

Gunderson: the descriptive turn

Gunderson and Singer’s 1975 review identified six features for recognizing these patients in an interview: intense affect, impulsive behavior, a certain social adaptiveness, brief psychotic experiences, loose thinking in unstructured situations, and relationships that swing between superficiality and intense dependency (Gunderson & Singer, 1975). The DSM-III diagnosis drew heavily on Gunderson’s work (McWilliams, 2011, p. 53). Later, Gunderson and Lyons-Ruth emphasized interpersonal hypersensitivity (Tanzilli & Sharp, 2026, p. 511).

Linehan: a disorder of emotion regulation

Marsha Linehan argued that the condition is primarily a disorder of emotion dysregulation, arising from transactions between a biologically sensitive temperament and an invalidating environment (Crowell et al., 2009). Her dialectical behavior therapy, which McWilliams notes acknowledges a debt to Kernberg but rests on cognitive-behavioral and Zen ideas rather than a dynamic unconscious (2011, p. 71), focuses on skills for modulating emotion and reducing harmful behavior (Tanzilli & Sharp, 2026, p. 513). The PDM-3’s new name for the style arguably echoes this emphasis.

Bateman and Fonagy: mentalization and attachment

Bateman and Fonagy see the core problem as a fragile capacity to mentalize, linked to disorganized attachment, that is most likely to fail under distress. Mentalization-based treatment aims to regain and strengthen reflective capacity (Tanzilli & Sharp, 2026, pp. 511, 513; McWilliams & Shedler, 2026, p. 697).

A real disagreement runs between these traditions about mechanism. Kernberg treats the problem as unintegrated internal object relations, Linehan as a deficit in emotion regulation, and Fonagy as a failure of mentalization. They nonetheless converge on structured frames and active, engaged therapists.

Empirical and official systems

Shedler and Westen found that DSM borderline and histrionic personality disorders were nearly indistinguishable empirically (McWilliams & Shedler, 2026, p. 656; Shedler & Westen, 2004). This finding supports McWilliams’ view that the DSM category fuses a style with a level. ICD-11 now treats personality pathology mainly in terms of severity, and keeps the borderline pattern as an optional qualifier (Bach & First, 2018).

Examples

Ending the session on time

McWilliams recalls that early in her career she was struck by the deprivation in the histories of her clients in the borderline range and extended herself beyond her usual limits. The more she gave, the more they regressed and the more resentful she felt. She learned to end sessions gently but firmly at the usual time, even when a client had just begun to grieve, and then to listen in the next session for anger at being “kicked out.” Clients who could tell her off about her “rigid, selfish rules” did better than when she tried to earn their gratitude for her generosity.

Nancy McWilliams, Psychoanalytic Diagnosis (2011), p. 86

Two professionals, one patient

As a trainee, McWilliams treated a woman with borderline dynamics who had canceled two sessions. Her supervisor insisted on a letter labeling the behavior manipulative and unacceptable. McWilliams was equally sure such a letter would feel contemptuous and drive the patient away. She wrote the letter, showed it to him, and never sent it. Only later did she recognize that such seemingly irreparable splits between professionals, each sure of being morally right, are a classic countertransference phenomenon with borderline dynamics.

Nancy McWilliams, Psychoanalytic Psychotherapy (2004), p. 57

How It Differs From Look-Alikes

Borderline level of organization

The level is the broader category. It includes people of many styles, among them “quiet” schizoid people, who share identity diffusion and primitive defenses but not the emotional storms. The emotionally dysregulated style is one way of living at that level (McWilliams & Shedler, 2026, pp. 656, 696).

Hysterical-histrionic style

Both styles are dramatic and relationship-focused, and the DSM categories are hard to separate empirically. Hysterical-histrionic people at the neurotic level have a stable identity and can hold mixed feelings about others. The emotionally dysregulated style, by definition, lacks those capacities (McWilliams, 2011, p. 53; McWilliams & Shedler, 2026, p. 656).

Dissociative style

Dissociative switches can look like splitting. The difference is amnesia. A dissociative person may not remember a previous session in which they felt differently, while a person with borderline dynamics is more likely to remember it and rationalize the swing from love to hate. The two are not mutually exclusive, since dissociation can occur at any level of severity (McWilliams, 2011, pp. 354–355).

Hypomanic style and bipolar disorder

Both involve impulsivity and unstable mood. Compared with adolescents with a hypomanic style, those with an emotionally dysregulated style show more identity disturbance, impulsivity, emotional dependency, hostility, shame, and guilt. Bipolar episodes are more time-limited, while personality patterns are stable (Tanzilli & Sharp, 2026, p. 485).

Psychopathic style

Impulsivity, anger, and behavior others call manipulative overlap. In the emotionally dysregulated style, these serve the effort to keep a needed person close. In the psychopathic style, they serve gain and power (McWilliams, 2011, pp. 160–161; Bateman et al., 2016).

History

As early as 1890, psychiatrists wrote of a “borderland” between sanity and insanity. Several mid-century proposals followed: Stern’s “border line group” (1938), Helene Deutsch’s “as-if personality” (1942), and Hoch and Polatin’s “pseudoneurotic schizophrenia” (1949). Knight’s “borderline states” followed in 1953. T. F. Main referred to similar pathology in hospitalized patients as “The Ailment” in 1957. Grinker and colleagues documented a “borderline syndrome” empirically in 1968 (McWilliams, 2011, p. 52).

Kernberg, Masterson, Gunderson, and M. H. Stone then established the borderline concept, and in 1980 DSM-III adopted borderline personality disorder (pp. 52–53). McWilliams argues that this legitimized a valuable idea “at the price of losing its original meaning as a level of functioning” (p. 53). The PDM’s first two editions tried to hold both meanings. In PDM-2, borderline personality appeared as a style, which the editors call “an imperfect and inelegant solution.” The PDM-3 renamed the style emotionally dysregulated personality and reserved “borderline” for the level (McWilliams & Shedler, 2026, pp. 656, 696).

Treatment history moved just as fast. The condition was long considered especially difficult to treat (p. 696). Then came DBT (Linehan, 1993), MBT (Bateman & Fonagy, 2004), and TFP, each tested in research. Long-term follow-up studies showed high rates of remission (Zanarini et al., 2012).

Two controversies run through this history. The first is gender. The diagnosis has been given far more often to women in clinics, and critics have questioned whether criteria and clinicians are biased (Bozzatello et al., 2024). McWilliams notes that devaluing talk about borderline patients echoes the old condescension toward patients labeled hysterical and, following Bollas, suggests that the contemporary concept of BPD is a “return of the repressed” of hysteria (2011, pp. 324–325). The second is trauma. By the 1990s, more writers were stressing the role of trauma, especially relational trauma, in borderline dynamics (pp. 54–55).

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