BORDERLINE PERSONALITY DISORDER

BORDERLINE PERSONALITY DISORDER - Heath A. Grames, PhD
BASICS
DESCRIPTION
Beginning no later than adolescence or early adulthood, a consistent and pervasive pattern of an unstable affect and sense of self, impulsivity, and volatile interpersonal relationships. (1)[C]
• Common behaviors and variations (1)[C]
- 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
ALERT
Geriatric Considerations
Illness (acute and chronic) may exacerbate borderline personality disorder behaviors and may lead to intense feelings of fear and helplessness. Manifestations may decrease with age. (1)[C]
Pediatric Considerations
Diagnosis is rarely made for children (1)[C]. Must 1st rule out Axis I disorders and behavior related to a general medical condition or to the developmental cycle of the child. For diagnosis, baseline behaviors must be representative of borderline personality disorder.
Pregnancy Considerations
Physical and social changes may induce stress or increase fears, causing increased borderline behaviors.
GENERAL PREVENTION
Tends to be a multi-generational problem. Children, caregivers, and significant others should have time and activities away from the borderline individual, which may help protect them from the disorder.
EPIDEMIOLOGY
• Predominant age: Onset no later than adolescence or early adulthood (may go undiagnosed for years) (1)[C]
• Predominant sex: Female > Male (1)[C]
Prevalence
• General population = ~2% (1)[C]
• Estimated lifetime prevalence = 10-13% (1)[C]
• Estimates of 20-30% (all personality disorders) prevalence in primary care outpatient settings (2)[C]
RISK FACTORS
Physical illness and external social factors may exacerbate borderline personality behaviors.
Genetics
1st-degree relatives are at greater risk for also having this disorder (3)[C] (undetermined whether risk is due to genetics or psychosocial factors).
ETIOLOGY
Undetermined, but generally accepted, that is due to a combination of the following (2)[C]
• Hereditary tempermental traits
• Environment (i.e., history of neglect and abuse, ongoing conflict in home)
• Developmental traits
ASSOCIATED CONDITIONS
• Mood disorders, common (1)[C]
• Anxiety disorders, common (1)[C]
• Substance-related disorders, common (1)[C]
• Eating disorders, common (1)[C]
• PTSD, common (1)[C]
• Co-occurring personality disorders, frequent (1)[C]


DIAGNOSIS
PRE HOSPITAL
• Assess suicide ideation and self-harm behavior
• Assess for psychosis
SIGNS AND SYMPTOMS
See "Description"
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.")
Physical Exam
Scarring from self-mutilating (look on arms and legs where hidden by clothing, but can occur on other parts of the body)
TESTS
Diagnostic Procedures/Surgery
Patient must meet at least 5 of the following (1)[C]
• Attempt to avoid abandonment
• Volatile interpersonal relationships
• Identity disturbance
• Impulsive behavior
- In at least 2 areas
- Impulsive behavior is self-damaging
• Suicidal or self-mutilating behavior
• Mood instability
• Feeling empty
• Unable or difficult to control anger
• Paranoid or dissociative when under stress
DIFFERENTIAL DIAGNOSIS
• Mood disorders (1)[C]
- Look at baseline behaviors when considering borderline vs. mood disorder
• Psychotic disorder (1)[C]
- With borderline, only occurs under intense stress and is not characteristic of disorder
• Other personality disorder (1)[C]
- Consider patients thoughts, feelings, and behavior to differentiate borderline from other personality disorders
- High co-occurrence of borderline and other personality disorders
TREATMENT
PRE-HOSPITAL
• Appropriate psychiatric care must be available.
• Patient may need to be 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 (increased dependence may decrease likelihood of behavior change)
• Hospitalization should be considered for the following
- Adjust medications
- Implement psychotherapy for crisis intervention
- Stabilize patient (psychosocial stressors)
STABILIZATION
If psychotic, consider antipsychotic medications (2)[C]
GENERAL MEASURES
• Focus on patient management rather than "fixing" behaviors.
• Schedule follow-up to relieve patient stress. (4)[C]
• 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
• As necessary, refer patient to mental health therapist
Nursing
Nurses can be helpful in managing patient and calling the patient as needed (contact with the patient helps relieve patient stress)
SPECIAL THERAPY
Consider referring patient for specialty mental health services, such as Dialectic Behavioral Therapy (DBT)
MEDICATION (DRUGS)
• There are no medications that treat borderline personality disorder
• Treat symptoms and Axis I disorders (2)[C]
First Line
• Depression/anxiety (4)[C]
- SSRI, Selective Serotonin-reuptake Inhibitors
• Impulsive, aggressive, or history of bi-polar disorder (2)[C]
- Mood stabilizer
• Psychosis, paranoid or hostile behavior, debilitating anxiety (2)[C]
- Atypical antipsychotic
FOLLOW-UP
• Schedule routine follow-up with patient (relieves patient anxiety about medical care relationship with physician) (4)[C]
• Focus should be on medical conditions and co-morbid Axis I disorders (4)[C]
DISPOSITION
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
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
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.
PROGNOSIS
• Borderline behaviors may decrease with age (1)[C]
• Treatment is complex and takes time
• Medical focus is on patient management and caring for medical and Axis I disorders (5)[C]
PATIENT MONITORING
Monitor for suicidal or other self-harm behaviors
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Ward RK. Assessment and management of personality disorders. American Family Physician. 2004;70:1505-1512.
3. 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, NY: Oxford University Press; 2002:625-641.
4. Feder A, Robbins SW, Ostermeyer B. Personality disorders. In: Feldman MD, Christensen JF, eds. Behavioral medicine in primary care: A practical guide, 2nd ed. New York, NY: McGraw-Hill; 2003:231-252.
5. Makela EH, Moeller KE, Fullen JE, Gunel E. Medication utilization patterns and methods of suicidality in borderline personality disorder. The Ann Pharmacother. 2006;40:49-52.