Is adults’ borderline personality disorder associated with their attachment experiences, rejection and mental security? A cross-sectional study

Abstract

Background
Borderline personality disorder (BPD) is highly correlated with other mental disorders and poses significant psychological and social risks both to individuals and to society. This study aims to investigate the relationship between attachment, perceived rejection, and psychological security with BPD.

Methods
This cross-sectional correlational study was conducted on 89 BPD patients. The BPD patients was selected using a convenience sampling method. The instruments used in this study included the demographic characteristics form, the Rejection Sensitivity Perception Scale (RSPS), the Revised Adult Attachment Scale (RAAS), the Maslow’s Psychological Security scale and the Borderline Personality Inventory (BPI). Data were analyzed using SPSS version 22, employing Pearson correlation and regression analysis methods.

Results
The mean scores of BPI were 25.59 ± 5.19. The mean scores for perceived rejection and attachment were 7.71 ± 3.52 and 35.76 ± 6.64, respectively. We found a positive significant correlation between perceived rejection (r = 0.35, p = 0.001), attachment (r = 0.25, p = 0.017) and psychological and social security (r = 0.55, p < 0.001) with BPI. The results of multivariate linear regression indicated that psychological and social security, perceived rejection, and gender predicted 40% of the variance in BPD (R² = 40%) (p < 0.05).

Conclusions
In the present study, attachment, rejection, and sense of security were found to be associated with BPD. To prevent BPD, it is essential to consider factors such as attachment, rejection, and security. Therefore, mental health care providers are advised to plan and implement appropriate interventions to identify and improve these variables, thereby enhancing related health outcomes.

Full text

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Askari et al. BMC Psychiatry (2025) 25:490
https://doi.org/10.1186/s12888-025-06900-6 BMC Psychiatry
*Correspondence:
Reza Mohammadmehr
rezamohammadmehr@gmail.com
1Clinical Psychology, Islamic Azad University Qom Branch, Qom, Iran
2Association of Psychologists, Counselors and Educational Sciences
of Qom Province, State Welfare Organization, Ministry of Science and
Research, Qom, Iran
3Non-Communicable Diseases Research Center, Rafsanjan University of
Medical Sciences, Rafsanjan, Iran
4Clinical Research Development Unit, Ali-Ibn Abi-Talib Hospital, Rafsanjan
University of Medical Sciences, Rafsanjan, Iran
5AL-Dewaynia, Nursing College, Al-Qadisiyah University, Diwaniya, Iraq
6Department of Nursing, Nantong Health College of Jiangsu Province,
Nantong, China
7Department of Nursing, Faculty of Health Sciences, University
Muhammadiyah of Malang, Malang, Indonesia
8Health Psychology, Islamic Azad University Qom Branch, Qom, Iran
Abstract
Background Borderline personality disorder (BPD) is highly correlated with other mental disorders and poses
signicant psychological and social risks both to individuals and to society. This study aims to investigate the
relationship between attachment, perceived rejection, and psychological security with BPD.
Methods This cross-sectional correlational study was conducted on 89 BPD patients. The BPD patients was selected
using a convenience sampling method. The instruments used in this study included the demographic characteristics
form, the Rejection Sensitivity Perception Scale (RSPS), the Revised Adult Attachment Scale (RAAS), the Maslow’s
Psychological Security scale and the Borderline Personality Inventory (BPI). Data were analyzed using SPSS version 22,
employing Pearson correlation and regression analysis methods.
Results The mean scores of BPI were 25.59 ± 5.19. The mean scores for perceived rejection and attachment were
7.71 ± 3.52 and 35.76 ± 6.64, respectively. We found a positive signicant correlation between perceived rejection
(r = 0.35, p = 0.001), attachment (r = 0.25, p = 0.017) and psychological and social security (r = 0.55, p < 0.001) with BPI.
The results of multivariate linear regression indicated that psychological and social security, perceived rejection, and
gender predicted 40% of the variance in BPD (R² = 40%) (p < 0.05).
Conclusions In the present study, attachment, rejection, and sense of security were found to be associated with BPD.
To prevent BPD, it is essential to consider factors such as attachment, rejection, and security. Therefore, mental health
care providers are advised to plan and implement appropriate interventions to identify and improve these variables,
thereby enhancing related health outcomes.
Keywords Personality disorder, Attachment experiences, Rejection, Mental security, Borderline personality disorder
Is adults’ borderline personality disorder
associated with their attachment experiences,
rejection and mental security? A cross-
sectional study
MojdehAskari1,2 , Mohammad AliZakeri3,4 , Alaa HamzaHermis5, XiaoXu6, SriWidowati7 and
RezaMohammadmehr8*
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Askari et al. BMC Psychiatry (2025) 25:490
Introduction
Personality disorders are among the most signicant
social and medical issues [1]. e prevalence of these
disorders in the general population ranges from 11 to
23%, which is alarming [2]. BPD is one type of personal-
ity disorder in Cluster B [3]. It is a major psychological
disorder characterized by severe clinical manifestations,
with an approximate prevalence of 1–2% over a lifetime
and 0.5–4.1% in the general population, demonstrating a
pattern of instability in relationships, mood, impulsivity,
and self-image [4]. BPD is a severe mental health condi-
tion characterized by emotional instability, identity dis-
turbances, and interpersonal diculties. Recently, factors
inuencing the development and maintenance of BPD
have gained signicant attention [5]. BPD is marked by
excessive emotional reactivity, interpersonal instability,
excessive sensitivity to abandonment, and inadequate
self-perception in adulthood [6]. Fear of abandonment,
sensitivity to rejection, and intolerance of loneliness may
underlie many common interpersonal diculties in BPD,
leading to turmoil, maladaptive behaviors, and conicts
in interpersonal and marital relationships [7]. It can be
argued that individuals with BPD experience insecurity
precisely when they are most intimate with others due
to concerns about dependency and rejection, yet they do
not express these concerns openly [8].
Another component contributing to turmoil in indi-
viduals with BPD is their attachment style [9]. Some
research indicates a relationship between attachment
style and BPD, with attachment style being one of the
most important factors in interpersonal interactions that
develops in childhood and persists into later years, inu-
enced by the environment in which one grows up [10].
Attachment theory suggests that early interactions with
caregivers shape an individual’s relationships. Insecure
attachment, particularly disorganized and preoccupied
styles, has been consistently associated with BPD [11].
Some studies have shown that adults with BPD often
report a history of childhood trauma or inconsistent
caregiving, which disrupts the development of secure
attachment [9]. In adulthood, these insecure attachment
patterns can manifest as fear of abandonment, chronic
feelings of emptiness, or diculties in maintaining stable
relationships [12].
Securely attached individuals trust the world and their
loved ones, engaging in intimate and eective relation-
ships with others and friends [13]. In contrast, insecurely
attached individuals refrain from intimate relationships
with others due to a fear of rejection, keeping a distance
from others [14].
Individuals with BPD often interpret ambiguous social
cues as signs of rejection, leading to intense emotional
reactions and maladaptive behaviors such as self-harm
or impulsive aggression [15]. is hypersensitivity to
rejection stems from early experiences of invalidation
or abandonment, which reinforce a fear of interpersonal
rejection [16]. Recent empirical studies have demon-
strated a strong association between rejection sensitivity
and BPD symptoms. For instance, a longitudinal study
by Di Pierro et al. (2022) found that rejection sensitivity
predicted increased emotional instability and interper-
sonal conict in individuals with BPD [16]. Furthermore,
rejection sensitivity has been shown to mediate the rela-
tionship between childhood trauma and BPD symptoms
[17]. ese ndings highlight the need for interven-
tions that target rejection sensitivity in BPD treatment.
On the other hand, individuals with BPD, due to their
fear of abandonment, do not wish to be alone. Splitting
experienced in a potential situation can create signicant
interpersonal diculties and individuals with BPD may
self-harm, which can jeopardize their mental disorder
and social security [18].
Mental security, or the sense of emotional and psycho-
logical safety, is another critical factor in understanding
BPD. Individuals with BPD often experience chronic
feelings of insecurity, which exacerbate their emotional
instability and interpersonal diculties [19]. Psychologi-
cal security is considered one of the basic human needs
and motivations, such that its reduction eliminates peace
of mind and replaces it with agitation, anxiety, and rest-
lessness [20]. Reviewing the texts shows that psycho-
logical security aects how individuals cope with stress
signicantly and has a noticeable impact on their activi-
ties and relationships [21]. Given the increasing psycho-
logical pressures imposed by work and life stressors on
individuals, it raises the question of whether individu-
als with BPD can cope with psychological pressures and
maintain psychological security in such conditions.
e interplay between attachment experiences, rejec-
tion sensitivity, and mental security provides a compre-
hensive framework for understanding BPD [22, 23]. Early
attachment disruptions contribute to heightened rejec-
tion sensitivity and diminished mental security, which
in turn exacerbate BPD symptoms. is dynamic under-
score the need for integrated therapeutic approaches that
address these interrelated factors.
Examining the relationship between BPD and attach-
ment experiences, rejection, and psychological secu-
rity is crucial for several reasons. First, it enhances our
understanding of how insecure attachment and rejection
experiences contribute to the development of BPD’s char-
acteristic emotional and behavioral patterns [24]. More-
over, analyzing the complex interactions among these
environmental factors is essential for establishing a com-
prehensive model of BPD’s etiology and persistence [25,
26]. is investigation holds signicant clinical, research,
and social value as it both facilitates individual diagno-
sis and treatment, and informs mental health strategies
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Askari et al. BMC Psychiatry (2025) 25:490
at the community level. e clinical implications include
improving therapeutic interventions, while the broader
impact extends to developing preventive approaches
and mental health policies. is dual focus addresses
both individual patient care and population-level mental
health promotion.
Given the increasing prevalence of BPD in contempo-
rary societies and considering the dimensions of this dis-
order, a more appropriate and precise clinical approach
can lead to valuable insights for employing interventions
to prevent and mitigate social harms. e ndings of
this research can imply practical implications for family
education. erefore, the present study was conducted
with the following specic objectives: (a) to assess the
four variables of attachment, rejection sensitivity, sense
of security, and BPD; (b) to examine correlations among
attachment, rejection sensitivity, sense of security, and
BPD; (c) to investigate the relationship between demo-
graphic characteristics and BPD; and (d) to explore how
demographic variables, psychological and social security,
perceived rejection, and attachment might predict BPD.
Methods
Study design and participants
e current study is cross-sectional and aimed to inves-
tigate the relationship between attachment, rejection
sensitivity, and mental security with BPD. e research
environment included two treatment centers in Qom city
(Farghani Hospital and Farahan Counseling Center) ali-
ated with Qom University of Medical Sciences. Farghani
Hospital, with 250 beds, and Farahan Counseling Center,
staed by 7 psychologists providing daily consultations in
morning and afternoon shifts, admit patients. ese cen-
ters are among the busy facilities in central Iran.
Sample size and sampling
Patients attending Farghani Hospital in Qom and those
visiting Farahan Counseling Center, diagnosed with BPD
by a specialist physician, formed the population of this
study. Inclusion criteria encompassed individuals aged
18 to 70 years with adequate verbal communication skills
and conrmation of BPD diagnosis by their treating phy-
sician. Patients with hearing impairments or those unable
to complete questionnaires were excluded from the
study. Data collection took place from January to April
2019. e study sample comprised 89 patients diagnosed
with BPD, selected through convenience sampling. Ques-
tionnaires were completed by patients over a four-month
period, with an average completion time of 45min per
questionnaire. Data were gathered using demographic
questionnaires, the RSPS, the RAAS, the Maslow’s Psy-
chological Security scale, and BPI.
Measurement
Demographic information
Demographic information of the participants included
age, gender, marital status, occupation, education level,
economic status.
The rejection sensitivity perception scale (RSPS)
RSPS consists of 4 items designed to measure the per-
ception of rejection. ese items are derived from the
denition by Downey and Feldman. Crossley et al. [27]
described this scale as a global assessment tool that eec-
tively measures employees’ mental experiences. Indi-
viduals are asked to indicate how they experience these
feelings using a 7-point Likert scale ranging from “Never”
[1] to “Always” [7]. Examples include statements such as
“I feel abandoned,” “I feel socially deprived,” “I feel dis-
liked,” and “I feel rejected.” In Iran, the reliability coef-
cient of this questionnaire was calculated as α = 0.83
using Cronbach’s alpha method in the study by Rajabi
et al. It has been reported to possess high reliability and
is considered a suitable instrument for assessing rejec-
tion sensitivity [28]. In this study, the reliability obtained
using Cronbach’s alpha was α = 0.93.
Revised adult attachment scale (RAAS)
e RAAS by Collins and Read assesses self-evaluation of
skills in forming relationships and shaping close attach-
ments. is scale comprises 18 items, each rated on a
6-point Likert scale ranging from 1 (Not at all) to 5 (Com-
pletely), with scores of 0 to 4 assigned respectively to
options 1 through 5. e items are categorized into three
subscales: Secure Attachment is measured by questions
6, 1, 8, 13, 12, and 17. Avoidant Attachment is evaluated
by questions 5, 2, 16, 14, 7, and 18. Finally, Ambivalent/
Anxious Attachment is assessed by questions 3, 9, 4, 10,
11, and 15. Collins and Read demonstrated that the sub-
scales of Closeness (C), Dependence (D), and Anxiety
(A) remained stable over a period of 2 to 8 months. ey
reported Cronbach’s alpha reliability coecients of 0.85,
0.78, and 0.81 for subscales A, C, and D, respectively, in
a sample of students [29]. Moreover, Vejdani et al. (2020)
found this scale to be reliable with a Cronbach’s alpha of
0.91 in a one-month test-retest study conducted in Iran
[30]. In this study, the reliability obtained using Cron-
bach’s alpha was α = 0.95.
The Maslow’s psychological security scale
e aim of the maslow’s psychological security scale
(complete form) is to assess various dimensions of psy-
chiatric security through 62 items and 15 components
including environmental discomfort, paranoia, self-
belief, zest for life, depression, feelings of contentment,
social security, self-awareness questions, self-condence,
feelings of anger, despair and hopelessness, interest in
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Askari et al. BMC Psychiatry (2025) 25:490
life, compatibility with others, feelings of health, and
feelings of inferiority. e items in this scale are scored
on a Likert scale ranging from 1 for “yes” to 0 for “no”
for each component. is questionnaire has been widely
used in various countries, hence translated into multiple
languages and employed in numerous nations, standard-
ized accordingly. Cronbach’s alpha reliability coecient
for this scale has been reported as 0.85, 0.84, and 0.86 in
three dierent studies [31]. In this study, reliability was
calculated to be 0.75 using the Cronbach’s alpha method.
Borderline personality inventory (BPI)
e BPI is designed to assess borderline personality traits
in clinical and non-clinical samples. It is used as an initial
screening tool for individuals diagnosed with BPD. e
questionnaire consists of 53 yes-no questions. If an indi-
vidual scores above the cuto of 10 out of 20 items, they
are likely to be inuenced by BPD. e nal two ques-
tions of the questionnaire are not included in the indi-
vidual’s nal score, which is why they were omitted in the
Iranian version. e reliability and validity of the Persian
version of BPI have been reported to be adequate by
Mohammadzadeh and Rezaei (2011) with a Cronbach’s
alpha coecient of 0.70 [32]. In the study by Khosravi
and Hassan, Cronbach’s alpha coecient for the total BPI
scale in Iranian BPD patients was 0.70 [33].
Data collection and analysis
After obtaining the necessary permissions, the researcher
proceeded to sample from two research environments.
Subsequently, questionnaires were distributed among eli-
gible participants who completed them in the presence
of the researcher. e researcher provided instructions
on how to complete the questionnaires to the patients.
According to the completion guidelines, patients were
asked to respond to the questions based on their experi-
ences over the past four weeks.
e data collected were entered into the SPSS software
after coding, and after ensuring data entry accuracy, they
were analyzed using descriptive and analytical statistical
methods. Data analysis was conducted using SPSS ver-
sion 22. Measures of central tendency and dispersion
were employed to describe the data. Normality of vari-
able distributions was assessed using the Kolmogorov-
Smirnov test and examining standard score values.
Descriptive statistics (frequency, percentage, mean, and
standard deviation) were used to characterize partici-
pant demographics. Pearson correlation coecients
were utilized to assess relationships between quantita-
tive variables. Independent samples t-tests and analysis
of variance (ANOVA) were employed to determine the
association between BPD scores and qualitative variables.
Multiple linear regression with backward elimination was
used to identify determinants of BPD scores. In all statis-
tical tests, a signicance level of p < 0.05 was considered
statistically signicant.
Results
Sociodemographic
e majority of the participants were female (n = 55;
61.8%), 30–40 years old (n = 29; 32.6%), married (n = 69;
77.5%), diploma (n = 29; 32.6%), and unemployed (n = 45;
50.6%) (Table1).
Outcome
e mean score of psychological and social security was
29.14 ± 4.87, which was lower than the midpoint of the
questionnaire (score = 31). e mean scores for the sub-
scales of psychological and social security were as fol-
lows: self-belief (3.34 ± 0.85), feeling inferior (3.07 ± 0.81),
depression (2.57 ± 0.90), feeling happy (2.52 ± 0.73), anger
(2.33 ± 0.63), and disappointment (2.26 ± 0.67). e mean
scores for perceived rejection and attachment were
7.71 ± 3.52 and 35.76 ± 6.64, respectively. e mean score
Table 1 Demographic characteristics of the participants with
BPD (n = 89)
Variable Frequen-
cy (%)
Mean (SD) Borderline person-
ality disorder
Statistical
test
P
value
Gender
Male 34 (38.2) 25.94 (4.81) t = 0.49 0.62
Female 55 (61.8) 25.38 (5.45)
Age (years)
18–30 25 (28.1) 25.96 (4.98)
31–40 29 (32.6) 25.55 (5.97) F = 0.07 0.97
41–50 20 (22.5) 25.25 (4.64)
> 50 15 (16.9) 25.53 (5.08)
Educational level
Under diploma 13 (14.6) 25.15 (4.86)
Diploma 29 (32.6) 25.37 (4.93)
Associate degree 22 (24.7) 26.77 (5.64) F = 0.58 0.67
Bachelor 15 (16.9) 24.26 (5.41)
Masters/ P.H D 10 (11.2) 26.20 (5.43)
Marital status
Married 69 (77.5) 25.91 (4.93) t = 1.07 0.28
Single/ Divorced 20 (22.5) 24.50 (6.02)
Economic status
Poor 13 (14.6) 25.69 (5.86)
Medium 58 (65.2) 25.10 (5.17) F = 1.02 0.36
Good/ Excellent 20 (20.2) 27.11 (4.72)
Occupation
Employee 19 (21.3) 24.78 (5.24)
Unemployed 45 (50.6) 25.66 (5.07) F = 0.33 0.71
Housewife 25 (28.1) 26.08 (5.51)
Data were presented numerically (%). t = Independent t test; F = Analysis of
variance test
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Askari et al. BMC Psychiatry (2025) 25:490
for BPD was 25.59 ± 5.19, which was higher than the mid-
point of the questionnaire (score = 25.5) (Table2).
We found a positive signicant correlation between
perceived rejection (p = 0.001), attachment (p = 0.017)
and psychological and social security (p < 0.001) with
BPD. A positive signicant correlation was between per-
ceived rejection and attachment (p < 0.001). Also, we no
found a signicant correlation between perceived rejec-
tion (p = 0.58) and attachment (p = 0.09) with Psychologi-
cal and Social Security (Table3). e bivariate analysis
showed that the mean score of BPD was not signicantly
dierent according to the demographic of the partici-
pants (P > 0.05) (Table1).
Results of regression
We used multiple regression models with the backward
method to explore how demographic variables, psy-
chological and social security, perceived rejection, and
attachment could predict BPD. e results are presented
in Table 4. Psychological and social security, perceived
rejection, and gender predict 40% of the variance in BPD
(R² = 40%), with psychological and social security being
the best predictor based on β (p < 0.001).
Discussion
e present study aimed to investigate the relationship
between attachment, rejection, and sense of security
with BPD. e ndings revealed signicant relation-
ships between these factors and BPD. A signicant rela-
tionship between attachment and BPD was observed in
this study. Consistent with the ndings of the current
research, Smith and South (2020) demonstrated that dis-
organized attachment style is a predictor of BPD [34].
Similarly, the results align with Kaurin et al. (2020), who
compared attachment styles among individuals with bor-
derline, avoidant, and narcissistic personality disorders to
those of non-clinical individuals in hospitals. ey con-
cluded that signicant dierences exist in these variables
between clinical and non-clinical groups [35]. Aronson et
Table 2 Distribution of the perceived rejection, attachment,
psychological and social security and BPD in participant (n = 89)
Variable Mean SD Min Max
1. perceived rejection 7.71 3.52 4 19
2. Attachment 35.76 6.64 18 51
Closeness 11.64 2.82 4 20
Dependency 12.07 2.84 6 20
Anxiety 12.04 5.47 4 24
3. Psychological and Social Security 29.14 4.87 16 38
Social incompatibility 1.56 0.63 1 3
Paranoia 1.60 0.65 1 3
Self-belief 3.34 0.85 1 5
Life expectancy 1.39 0.49 1 2
Depression 2.57 0.90 1 4
Feeling happy 2.52 0.73 1 4
Social security 1.33 0.47 1 2
Self-awareness 1.39 0.53 1 3
Self-condence 1.35 0.48 1 2
Anger 2.33 0.63 1 3
Disappointment 2.26 0.67 1 3
Life expectancy 1.29 0.48 1 3
Compatibility with others 1.60 0.53 1 3
Feeling healthy 1.46 0.52 1 3
Feeling inferior 3.07 0.81 1 4
4. Borderline personality disorder 25.59 5.19 17 37
Table 3 Correlation among the perceived rejection, attachment,
psychological and social security and BPD in participant (n = 89)
Variable 1 2 3 4
1. Perceived rejection 1
2. Attachment 0.36*
(< 0.001)
1
3. Psychological and Social Security 0.59
(0.58)
0.17
(0.09)
1
4. Borderline personality disorder 0.35*
(0.001)
0.25*
(0.017)
0.55*
(< 0.001)
1
Data were pres ented as Pearson’s correlati on coecient, *p < 0.05
Table 4 Predictors of BPD by multiple liner regression analysis
Predictors of borderline personality disorder Unstandardized coecients Standardized coecients t p value R
B Std. error 95% CI for B Beta
(Constant) 4.64 4.85 -5.02 _ 14.31 - 0.95 0.342 40%
Psychological and social security 0.52 0.09 0.34 _ 0.70 0.49 5.71 < 0.001
Perceived rejection 0.56 0.13 0.30 _ 0.83 0.41 4.24 < 0.001
Gender -2.13 0.99 -4.11 _ -0.15 -0.20 -2.14 0.035
Economic status 1.17 0.77 -0.36 _ 2.71 0.13 1.52 0.132
Occupation 0.94 0.75 -0.55 _ 2.44 0.12 1.25 0.213
Educational level 0.34 0.42 -0.49 _ 1.17 0.08 0.80 0.421
Marital status -0.77 1.16 -3.09 _ 1.54 -0.06 -0.66 0.509
Age -0.24 0.42 -1.08 _ 0.59 -0.05 -0.58 0.563
Attachment 0.01 0.07 -0.14 _ 0.17 0.01 0.18 0.851
Data were pres ented as multiple regre ssion analysis. Only sig nicant results were sho wn; CI, Condence interv als for B
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Askari et al. BMC Psychiatry (2025) 25:490
al. conducted a clinical study and found a signicant rela-
tionship between insecure-ambivalent attachment style
and BPD [36]. In study, Levy et al. found that individu-
als with BPD were more likely to be evaluated as having a
disorganized attachment style by those around them (e.g.,
parents, teachers, and peers) [37]. Similarly, Meyer et al.
found a signicant relationship between insecure-ambiv-
alent and disorganized attachment styles and BPD traits
in non-clinical samples. ese attachment styles were
more prevalent in individuals with BPD than in other
groups [38]. Moreover, Beeney et al. (2017) demonstrated
a positive relationship between insecure-ambivalent and
disorganized attachment styles and BPD in non-clinical
samples [39].
A relationship between rejection and BPD was also
observed in this study. Previous research has shown that
experiences of rejection contribute to unstable behav-
iors in individuals with BPD and may exacerbate nega-
tive emotions [40]. According to Foxhall et al. (2019),
individuals with BPD are more likely to interpret social
situations as instances of social rejection [41]. Based on
attachment theory, experiences of rejection are more
likely to occur in individuals with insecure attachment
styles [42]. Further research is recommended to explore
the causal relationship between rejection and BPD traits.
Additionally, a relationship between the sense of secu-
rity and BPD was found in this study. e ndings are
consistent with Norlander et al. (2015), who investigated
whether adults with BPD recognized an improvement
in their sense of security following one or two years of
dialectical behavior therapy. eir results indicated that
after treatment, patients experienced greater security,
improved mental health, and broader well-being. ese
improvements in perceived security persisted one to two
years post-treatment. e study concluded that the per-
ceived sense of security might oer a new dimension to
current methods of evaluating therapeutic outcomes in
BPD patients and could be utilized for further treatment
improvements [8].
In the present study, gender was found to have a rela-
tionship with BPD. e ndings align with those of
Amerio et al. (2023), who concluded that gender plays
a strategic moderating role in the relationship between
parental attachment and BPD [43]. Similarly, the results
are consistent with Bozzatello et al. (2024), who found
that BPD is more prevalent among women than men
[44]. Furthermore, the study by Mahmoud Alilou et al.
(2014) indicated that women, compared to men, exhibit
more extreme and impulsive behaviors when experi-
encing rejection and suer from higher levels of depen-
dency [45]. Another study examining gender dierences
in BPD, conducted by Choubsaz and Abedin (2017),
found no signicant dierences in the prevalence of BPD
between Iranian men and women. However, specic
traits diered; women exhibited signicantly higher lev-
els of impulsivity, withdrawing from relationships quickly
and engaging in impulsive behaviors such as substance
use. For men, the only signicant trait was an intense
fear of being alone and self-care concerns. Although
both genders displayed dierent symptoms, most were
more pronounced in women, a nding attributed to
cultural factors. Contrary to some studies, this research
highlighted greater impulsivity in women. Additionally,
unmarried individuals scored higher on BPD measures
compared to their married counterparts [46]. ese nd-
ings also align with the current study. Lastly, Johnson and
Zuccarini (2010) found that women with BPD are more
likely than men to engage in substance use due to feelings
of emptiness, indicating a gender dierence in this aspect
of the disorder [47].
Limitations
is study has several limitations. In the current study,
it is not possible to determine what may serve as a pro-
tective factor, not only through psychotherapy but also
through counseling interventions. erefore, caution is
necessary when interpreting the results. Given the small
sample size of the present study, caution should be exer-
cised in generalizing the ndings. Future studies should
include larger and more diverse samples to enhance the
generalizability of the results. Due to the use of conve-
nience sampling in the current study, there may be a risk
of selection bias. us, it is recommended that future
studies employ random sampling techniques to verify
our ndings and reduce potential bias. Undoubtedly,
intervening variables such as the inuence of subcultures
and socio-economic conditions could aect the results of
the present research. Regarding the measurement tools,
the large number of questionnaire items caused fatigue
and reluctance among participants, which we tried to
mitigate by explaining the study’s objectives and encour-
aging participant cooperation. e use of self-report
questionnaires is another limitation, potentially impact-
ing the generalizability of the results to other popula-
tions. Future research should also examine the inuence
of socio-economic conditions and other intervening vari-
ables. Additionally, it is recommended that future studies
investigate these factors in other groups with personality
disorders. Given the broad age range (19–60 years) and
heterogeneous treatment histories within our sample,
coupled with the need for more comprehensive clinical
variable assessment, ndings should be interpreted with
appropriate caution. Future studies would benet from
employing more homogeneous age cohorts while sys-
tematically documenting treatment histories and incor-
porating detailed clinical measurements to enhance the
generalizability of results.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 7 of 8
Askari et al. BMC Psychiatry (2025) 25:490
Conclusion
Based on the results of the present study, attachment,
rejection, and a sense of security are related to BPD.
erefore, it is essential to consider factors that can inu-
ence attachment, rejection, and security to prevent BPD.
Additionally, gender is another inuencing factor that
should be given more attention to address potential chal-
lenges in dealing with BPD. Mental health care providers
are advised to plan and implement appropriate inter-
ventions to improve these variables and related health
outcomes.
Acknowledgements
This article is derived from a Master’s thesis in Clinical Psychology. The
researchers would like to thank all the study participants for their kind
cooperation. Additionally, the researchers express their gratitude to the
authorities of Islamic Azad University, Qom, for their nancial and moral
support of this research.
Author contributions
MA and RM designed the study and collected data. MAZ, AHH, and SW
provided critical feedback on the study. MAZ analyzed the data. MA and
MAZ wrote the manuscript. All authors have read and approved the nal
manuscript.
Funding
There was no funding for this study.
Data availability
The datasets used and analyzed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This research was conducted under the ethical code number IR.IAU.QOM.
REC.1401.058 from Qom University of Medical Sciences. Prior to sampling,
written informed consent was obtained from the patients, and the study’s
objectives and the condentiality of the information were explained to them.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Conicts of interest
None.
Received: 13 December 2024 / Accepted: 23 April 2025
References
1. Widiger TA, Smith M. Personality disorders: current conceptualizations and
challenges. Ann Rev Clin Psychol. 2025;21.
2. Newlin E, Weinstein B. Personality disorders. CONTINUUM: Lifelong Learn
Neurol. 2015;21(3):806–17.
3. Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, et al. Bor-
derline personality disorder: a comprehensive review of diagnosis and clinical
presentation, etiology, treatment, and current controversies. World Psychiatry.
2024;23(1):4–25.
4. Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, Zanarini MC. Borderline
personality disorder. Nat Reviews Disease Primers. 2018;4(1):1–20.
5. Leichsenring F, Heim N, Leweke F, Spitzer C, Steinert C, Kernberg OF. Border-
line personality disorder: a review. JAMA. 2023;329(8):670–9.
6. Hein KE, Folger LF, Dennis SJ, Mullins-Sweatt SN. Personality disorders. Diag-
nostic Interviewing: Springer; 2025. pp. 429–54.
7. Karimi H, Koulaeian S. Predicting spouse conict resolution strategies based
on borderline personality disorder symptoms mediating by emotion regula-
tion. J Clin Psychol. 2020;3(47):13–24. h t t p s : / / d o i . o r g / 1 0 . 2 2 0 7 5 / J C P . 2 0 2 0 . 1 9 9 4
8 . 1 8 4 0. D0i:.
8. Norlander T, Ernestad E, Moradiani Z, Nordén T. Perceived feeling of security:
A candidate for assessing remission in borderline patients? Open Psychol J.
2015;8(1).
9. Erkoreka L, Zamalloa I, Rodriguez S, Muñoz P, Mendizabal I, Zamalloa MI, et
al. Attachment anxiety as mediator of the relationship between childhood
trauma and personality dysfunction in borderline personality disorder. Clin
Psychol Psychother. 2022;29(2):501–11.
10. Ghaari M, Rezaei A. Investigating the relation of attachment and identity
styles with borderline personality disorder of adolescents. J Ilam Univ Med
Sci. 2013;21(6):23–32. h t t p : / / s j i m u . m e d i l a m . a c . i r / a r t i c l e - 1 - 5 3 9 - f a . h t m l.
11. Charnas CV. Attachment styles and borderline personality disorder: A cor-
relational study. The Ohio State University; 2024.
12. Yuan Y, Lee H, Newhill CE, Eack SM, Fusco R, Scott LN. Dierential associations
between childhood maltreatment types and borderline personality disorder
from the perspective of emotion dysregulation. Borderline Personality Disor-
der Emot Dysregulation. 2023;10(1):1–14.
13. Liu Q, Wang Z. Associations between parental emotional warmth, parental
attachment, peer attachment, and adolescents’ character strengths. Child
Youth Serv Rev. 2021;120:105765.
14. Delgado E, Serna C, Martínez I, Cruise E. Parental attachment and peer rela-
tionships in adolescence: A systematic review. Int J Environ Res Public Health.
2022;19(3):1064.
15. Fertuck EA, Stanley B, Kleshchova O, Mann JJ, Hirsch J, Ochsner K, et al. Rejec-
tion distress suppresses medial prefrontal cortex in borderline personality
disorder. Biol Psychiatry: Cogn Neurosci Neuroimaging. 2023;8(6):651–9.
16. Di Pierro R, Amelio S, Macca M, Madeddu F, Di Sarno M. What if I feel rejected?
Borderline personality, pathological narcissism, and social rejection in daily
life. J Personal Disord. 2022;36(5):559–82.
17. Stadnik RD. The relationship between childhood invalidation and borderline
personality disorder symptoms through rejection sensitivity and experiential
avoidance. Xavier University; 2021.
18. Graumann L, Duesenberg M, Metz S, Schulze L, Wolf OT, Roepke S, et al. Facial
emotion recognition in borderline patients is unaected by acute psychoso-
cial stress. J Psychiatr Res. 2021;132:131–5.
19. Woodard NM. Dierentiating borderline personality disorder from bipolar
disorder: A systematic review of current literature. The Chicago School of
Professional Psychology; 2023.
20. Biyimbetov J. Philosophical analysis of the problem of information psycho-
logical security. Адам Әлемі. 2021;88(2):3–9.
21. Lazorko O, Koval S, Olena H, Shkrabiuk V, Kulesha-Liubinets M, Bihun N.
Psychological security of the individual as a functional component of profes-
sional activity. BRAIN Broad Res Artif Intell Neurosci. 2021;12(4):455–73.
22. Rudge S, Feigenbaum JD, Fonagy P. Mechanisms of change in dialectical
behaviour therapy and cognitive behaviour therapy for borderline personal-
ity disorder: a critical review of the literature. J Mental Health. 2017.
23. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in
a community sample. Personality and Personality Disorders: Routledge; 2013.
pp. 132–8.
24. Knapen SR, Mensink W, Hoogendoorn AW, Swildens WE, Duits P, Hutse-
baut J et al. Associations between childhood trauma and epistemic trust,
attachment, mentalizing, and symptoms of borderline personality disorder.
Psychopathology. 2025:1–22.
25. Runions KC, Wong J, Pace G, Salmin I. Borderline personality disorder and
peers: A scoping review of friendship, victimization and aggression studies.
Adolesc Res Rev. 2021;6(4):359–89.
26. Arnett J. Exposure to physical intimate partner violence in childhood and
borderline personality disorder traits. The Mediating Role of Insecure Attach-
ment; 2024.
27. Penhaligon NL, Louis WR, Restubog SLD. Emotional anguish at work: the
mediating role of perceived rejection on workgroup mistreatment and aec-
tive outcomes. J Occup Health Psychol. 2009;14(1):34–45. h t t p s : / / d o i . o r g / 1 0 . 1
0 3 7 / a 0 0 1 3 2 8 8.
28. Rajabi A, Kazemian S, Esmaili M. To predict the patient’s perception of
physician empathy on the basis of perceived rejection and the perception
of aging in the elders at army retired community. Q Magazine Nurse Doctor
War. 2016;10(1):5–10.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 8 of 8
Askari et al. BMC Psychiatry (2025) 25:490
29. Collins NL, Read SJ. Adult attachment, working models, and relationship qual-
ity in dating couples. J Personal Soc Psychol. 1990;58(4):644–63. h t t p s : / / d o i . o r
g / 1 0 . 1 0 3 7 / 0 0 2 2 - 3 5 1 4 . 5 8 . 4 . 6 4 4.
30. Vejdani S, Karami M, Ahmadi S. The moderating role of religious beliefs in the
relationship between attachment styles and attitude towards indelity in
married women. Women’s Stud Sociol Psychol. 2020;18(2):193–220. h t t p s : / / d
o i . o r g / 1 0 . 2 2 0 5 1 / J W S P S . 2 0 2 0 . 3 0 7 5 0 . 2 1 8 7.
31. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological
stress in the united States in probability samples from 1983, 2006, and 2009
1. J Appl Soc Psychol. 2012;42(6):1320–34. h t t p s : / / d o i . o r g / 1 0 . 1 1 1 1 / j . 1 5 5 9 - 1 8 1
6 . 2 0 1 2 . 0 0 9 0 0 . x.
32. Mohammadzadeh A, Rezaei A. Validation of the borderline personality inven-
tory in Iran. Int J Behav Sci. 2011;5(3):269–77. (Persian).
33. Khosravi M, Hassani F. From emotional intelligence to suicidality: a mediation
analysis in patients with borderline personality disorder. BMC Psychiatry.
2022;22(1):231.
34. Smith M, South SJC. Romantic attachment style and borderline personality
pathology: A meta-analysis. 2020;75:101781.
35. Kaurin A, Beeney JE, Stepp SD, Scott LN, Woods WC, Pilkonis PA et al. Attach-
ment and borderline personality disorder: Dierential eects on situational
socio-aective processes. 2020;1:117– 27.
36. Aaronson CJ, Bender DS, Skodol AE, Gunderson JG. Comparison of attach-
ment styles in borderline personality disorder and obsessive-compulsive
personality disorder. Psychiatr Q. 2006;77:69–80.
37. Levy KN, Meehan KB, Weber M, Reynoso J, Clarkin JF. Attachment and border-
line personality disorder: implications for psychotherapy. Psychopathology.
2005;38(2):64–74.
38. Meyer B, Pilkonis PA, Beevers CG. What’s in a (neutral) face? Personality
disorders, attachment styles, and the appraisal of ambiguous social cues. J
Personal Disord. 2004;18(4):320–36.
39. Beeney JE, Wright AG, Stepp SD, Hallquist MN, Lazarus SA, Beeney JR et al.
Disorganized attachment and personality functioning in adults: A latent class
analysis. 2017;8(3):206.
40. Saunders KE, Jones T, Perry A, Di Florio A, Craddock N, Jones I, et al. The inu-
ence of borderline personality traits on clinical outcomes in bipolar disorder.
Bipolar Disord. 2021;23(4):368–75.
41. Foxhall M, Hamilton-Giachritsis C, Button K. The link between rejection
sensitivity and borderline personality disorder: A systematic review and
meta‐analysis. Br J Clin Psychol. 2019;58(3):289–326.
42. Howe D. Attachment theory. Social work theories and methods. 2012;75.
43. Amerio A, Natale A, Gnecco GB, Lechiara A, Verrina E, Bianchi D, et al. The role
of gender in patients with borderline personality disorder: dierences related
to hopelessness, alexithymia, coping strategies, and sensory prole. Medicina.
2023;59(5):950.
44. Bozzatello P, Blua C, Brandellero D, Baldassarri L, Brasso C, Rocca P et al.
Gender dierences in borderline personality disorder: a narrative review.
2024;15:1320546.
45. Mahmoud Alilou M, Hashemi T, Bairami M, Bakhshipour A, Shari MJPA. Inves-
tigation the relationship between childhood maltreatment, early losses and
separations and emotion dysregulation with. Borderline Personality Disorder.
2014;21(2):65–88.
46. Choobsaz A, Abedin A. Gender Dierence in Borderline Personality Disorder
in Iranian Culture. 2017.
47. Johnson S, Zuccarini D. Integrating sex and attachment in emotionally
focused couple therapy. J Marital Family Therapy. 2010;36(4):431–45.
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