Borderline Personality Disorder – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Beginning no later than adolescence or early adulthood, borderline personality disorder (BPD) is a consistent and pervasive pattern of an unstable affect and sense of self, impulsivity, and volatile interpersonal relationships (1):

• Common behaviors and variations:
  • Self-mutilation (pinching, scratching, cutting)
  • Suicide (ideation, history of attempts, plans)
  • Splitting (idealizing then devaluing people and relationships)
  • Presentation of helplessness or victimization
  • Emotional pain (may look for physical diagnoses)
  • May be high utilizer of medical services
  • High rate of associated mental disorders (see Associated Conditions)
• Patients with this disorder typically display little insight into their behavior.

Geriatric Considerations

Illness (both acute and chronic) may exacerbate BPD behaviors and may lead to intense feelings of fear and helplessness. Manifestations may decrease with age.

Pediatric Considerations

Diagnosis is rarely made in children. Must first rule out Axis I disorders and behavior related to a general medical condition or to the developmental cycle of the child.

Pregnancy Considerations

Physical and social changes may induce stress or increased fears, resulting in possible escalation of borderline behaviors.

Epidemiology

• Predominant age: Onset no later than adolescence or early adulthood (may go undiagnosed for years)
• Predominant sex: Female > Male

Prevalence

• General population: 2%
• Estimated lifetime prevalence: 10–13%
• 20–30% of patients in primary care outpatient settings have a personality disorder.
• 20% of patients in psychiatry inpatient settings have BPD.

Risk Factors

• Biological relatives with the disorder
• Childhood sexual and/or physical abuse and neglect
• Physical illness and external social factors may exacerbate borderline personality behaviors.

Genetics

1st-degree relatives are at greater risk for this disorder (undetermined whether due to genetic or psychosocial factors).

General Prevention

• Tends to be a multigenerational problem
• Children, caregivers, and significant others should have some time and activities away from the borderline individual, which may protect them.

Etiology

Undetermined, but generally accepted that PDs are due to a combination of the following:

• Hereditary temperamental traits
• Environment (i.e., history of childhood sexual and/or physical abuse, history of childhood neglect, ongoing conflict in home)
• Developmental traits

Commonly Associated Conditions

Other psychiatric disorders, including:

• Co-occurring PDs, frequent
• Mood disorders, common
• Anxiety disorders, common
• Substance-related disorders, common
• Eating disorders, common
• Post-traumatic stress disorder, common

Diagnosis

• The comprehensive evaluation should focus on (2):
  • Comorbid conditions
  • Functional impairments
  • Needs/goals
  • Adaptive/maladaptive coping styles
  • Psychosocial stressors
  • Patient strengths
• Initial assessment should focus on determining treatment setting (2):
  • Establish treatment agreement with patient and outline treatment goals.
  • Assess suicide ideation and self-harm behavior.
  • Assess for psychosis.
  • Hospitalization is necessary if patient presents a threat of harm to self or others.

History

• Clinic visits for problems that do not have biological findings
• Problems with medical staff members
• Idealizing or unexplained anger at physician
• History of unrealistic expectations of physician (e.g., “I know you can take care of me.” “You’re the best, unlike my last provider.”)
• Obtain collateral information (i.e., from family, partner) about patient behaviors.

Physical Exam

Possible scarring from self-mutilation (look on arms and legs where hidden by clothing, but can occur on other parts of the body)

Diagnostic Tests & Interpretation

• Consider age of onset. To meet criteria for BPD, borderline pattern will be present from adolescence or early adulthood.
• Formal psychological testing
• Rule out personality change due to a general medical condition (GMC) (1):
  • Traits may emerge due to the effect of a GMC on the central nervous system.
• Rule out symptoms related to chronic substance use.
• If symptoms begin later than early adulthood or are related to trauma (e.g., after a head injury), a GMC, or substance use, then consider other diagnoses.
• Increased diagnostic accuracy may be facilitated by utilizing the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) (3).

Diagnostic Procedures/Surgery

Patient must meet at least 5 of the following criteria (1):

• Attempt to avoid abandonment
• Volatile interpersonal relationships
• Identity disturbance
• Impulsive behavior:
  • In ≥2 areas
  • Impulsive behavior is self-damaging.
• Suicidal or self-mutilating behavior
• Mood instability
• Feeling empty
• Is unable to control anger, or finds it difficult
• Paranoid or dissociative when under stress

Differential Diagnosis

• Mood disorders:
  • Look at baseline behaviors when considering BPD vs mood disorder.
  • BPD symptoms increase the likelihood of misdiagnosing bipolar disorder (4).
• Psychotic disorder:
  • With BPD, only occurs under intense stress and is not characteristic of disorder
• Other PD:
  • Consider patient’s thoughts, feelings, and behavior to differentiate borderline from other PDs.
  • High co-occurrence of borderline and other PDs
• General medical condition (GMC):
  • Traits may emerge due to the effect of a GMC on the central nervous system.
• Chronic substance abuse

Treatment

• Patient may need to be placed on suicide watch.
• Inpatient hospitalization is ineffective in changing Axis II disorder behaviors.
• Inpatient hospital services for conditions related to Axis II disorder should be limited and of short duration to decrease dependence. Hospitalization should be considered for:
  • Adjusting medications
  • Implementing psychotherapy for crisis intervention
  • Stabilizing patient (psychosocial stressors)
• Extended inpatient hospitalization should be considered for the following reasons (2)[C]:
  • Persistent/severe suicidal ideation or risk to others
  • Nonadherence to outpatient or partial hospitalization treatments
  • Comorbid Axis I disorders that may increase threat to life for the patient (i.e., eating disorders, mood disorders)
  • Comorbid substance abuse or dependence that is unresponsive to outpatient or partial hospitalization treatments

Medication

• While there are no specific medications approved by the U.S. Food and Drug Administration (FDA) to treat BPD, American Psychiatric Association (APA) guidelines recommend pharmacotherapy to manage symptoms (2)[B].
• Treat symptoms (5)[C].

• Treat Axis I disorders (2)[B].
• Consider high rate of self-harm and suicidal behavior in patients with BPD when prescribing (6)[C].
• Depression/anxiety (7)[A]:
  • SSRIs
• Impulsive, aggressive, or history of bipolar disorder (5)[C]:
  • Mood stabilizer
• Psychosis, paranoid or hostile behavior, debilitating anxiety (5)[C]:
  • Atypical antipsychotic
• APA guideline recommendations (2)[B]:
  • Affective dysregulation: SSRI and monoamine oxidase inhibitors (MAOIs)
  • Impulsive-behavioral control: SSRIs and mood stabilizers
  • Cognitive-perceptual symptoms: Antipsychotics

Additional Treatment

General Measures

• Focus on patient management rather than on “fixing” behaviors.
• Schedule consistent appointment follow-ups to relieve patient anxiety.
• Meet with and rely on treatment team to avoid splitting of team by patient and to provide opportunity for team to discuss issues with patient.
• Psychotherapy (referral to mental health therapist) is considered treatment of choice (2,8,9)[A].

Issues for Referral

• If hospitalized, probably for suicide risk, mood or anxiety disorders, or substance-related disorders
• Urgency for scheduled follow-up depends on community resources (i.e., Do outpatient day programs for suicidal patients exist? What substance abuse programs are available?):
  • With increased risk for self-harm or self-defeating behaviors and low community resources, the patient can/will use increased need for frequent visits.
• Treatment of Axis II disorder should include psychotherapy and/or psychiatry (2)[B].

Additional Therapies

Consider referring patient for specialty mental health behavioral services, including (2,10):

• Dialectic behavioral therapy (DBT)
• Psychoanalytic-oriented day hospital therapy
• Transference-focused psychotherapy

In-Patient Considerations

Hospitalization is necessary if patient presents a threat of harm to self or others.

Initial Stabilization

• Assess suicidal ideation.
• Consider inpatient treatment if crisis intervention is warranted.
• If psychotic, consider antipsychotic medications (5).

Admission Criteria

Refer to inpatient or outpatient psychiatry services if harm to self or others is expressed:

• Call police or admit for inpatient services immediately if patient is psychotic and/or presents risk of harm to self or others.

Nursing

Nurses can be helpful in managing patient and calling the patient as needed (contact with the patient helps relieve patient stress).

Discharge Criteria

• Patient should not present risk of harm to self or others.
• Patient should have safety plan.
• Routine follow-up should be scheduled with psychiatrist, mental health therapist, or primary care provider.

Ongoing Care

Follow-Up Recommendations

• Schedule routine follow-up with patient (relieves patient anxiety about medical care relationship with physician).
• Focus primarily on medical conditions and comorbid Axis I disorders.
• Exercise to decrease stress
• Find time to relax: Remove self from daily problems (teaches self-management).

Patient Monitoring

Monitor for suicidal or other self-harm behaviors.

Patient Education

As appropriate, provide patient education about the disorder, treatment, and self-care (2).

Prognosis

• Borderline behaviors may decrease with age (1) and over time (9).
• Treatment is complex and takes time.
• Medical focus is on patient management and caring for medical and Axis I disorders (11).

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

2. American Psychiatric Association: Practice guideline for the treatment of patients with borderline personality disorder. Arlington, VA: American Psychiatric Association, 2001.

3. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II). Washington, D.C.: American Psychiatric Press, Inc., 1997.

4. Ruggero CJ, Zimmerman M, Chelminski I, Young D. Borderline personality disorder and the misdiagnosis of bipolar disorder. Journal of Psychiatric Research. 2010;44:405–408.

5. Ward RK. Assessment and management of personality disorders. Am Fam Phys. 2004;70:1505–12.

6. Makela EH, Moeller KE, Fullen JE, et al. Medication utilization patterns and methods of suicidality in borderline personality disorder. Ann Pharmacother. 2006;40:49–52.

7. Binks CA, Fenton M, McCarthy L, et al. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006;1. Art. No.: CD005653. DOI:10.1002/14651858.CD005653.

8. Kraus G, Reynolds DJ. The “A-B-C’s” of the cluster B’s: identifying, understanding, and treating cluster B personality disorders. Clin Psychol Rev. 2001;21:345–73.

9. Oldham JA. Guideline watch: practice guideline for the treatment of patients with borderline personality disorder. Arlington, VA: American Psychiatric Association, 2005.

10. Binks CA, Fenton M, McCarthy L, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2006;1. Art. No.: CD005652. DOI:10.1002/14651858.CD005652.

11. Koenigsberg HW, Woo-Ming AM, Siever LJ. Pharmacological treatments of personality disorders. In: Nathan PE, Gorman JM, eds. A Guide to Treatments that Work. 2nd ed. New York: Oxford University Press, 2002:625–41.

Additional Reading

Battle CL, Shea MT, Johnson DM, et al. Childhood maltreatment associated with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study. J Personal Disord.2004;18:193–211.

13. Bellino S, Paradiso E, Bogetto F. Efficacy and tolerability of pharmacotherapies for borderline personality disorder. CNS Drugs. 2008;22:671–92.

Codes

ICD9

301.83 Borderline personality disorder

Snomed

20010003 Borderline personality disorder (disorder)

Clinical Pearls

• Borderline PD should be viewed as a chronic condition.
• Borderline PD patients are at increased risk for suicide attempts.
• If there are problems with the patient disrespecting the physician or support staff, clear guidelines should be established with the treatment team and then with the patient.
• If you are considering terminating your relationship with the patient, the patient may improve if he or she is warmly confronted about certain behaviors and is given clear guidelines on how to behave in the clinic. As it is the patient’s job to follow the guidelines, it is you and your team’s job to enforce the guidelines. Finally, designate a case management nurse or well-trained support staff person who can be the primary contact person for the patient.
• Have an agenda when you visit with PD patients. Be cordial—they deserve the same professionalism any patient gets. Help your patient understand that she can have 1 to 2 issues discussed per clinic visit. Frequently scheduled visits can help with this.
• Patients will benefit from regularly scheduled psychotherapy treatment in conjunction with or in addition to regularly scheduled office visits. Psychotherapy can help maximize physician performance by becoming the “home” for mental health treatment, leaving the physician to focus on the patient’s immediate physical/medical issues.