II. Epidemiology

  1. Prevalence: 1.6% of U.S. Adults
  2. May represent >6% of primary care visits
  3. Multifactorial including Family History, Trauma (other third have been raped)

III. Findings: General

  1. Emotional dysregulation
    1. Mood lability (changes within hours from intense transient dysphoria to irritability to anxiety)
    2. Inappropriate intense outbursts of anger, displaying a temper and may get into physical fights
    3. Recurrent suicidal behavior, gestures, threats or self-mutilation
    4. Impulsive (spending, sex, Drug Abuse, Binge Eating)
  2. Interpersonal problems
    1. Unstable relationships, self image, and affect
    2. Loneliness, boredom and sense of emptiness
    3. Unstable and intense interpersonal relationships fluctuating between idealization to devaluation ("splitting")
  3. Disturbed self-identity
    1. Unstable self-image persists
    2. Lacks integrated sense of self

IV. Findings: Healthcare Specific

  1. Impulsive behaviors that impact health
    1. Suicidality
    2. Binge Eating
    3. High-risk sexual behavior
  2. High healthcare utilization
    1. May present with frequent multiple vague somatic complaints
    2. May present with Chronic Pain
      1. Borderline Personality Disorder patients frequently rate their pain as more severe
  3. Altered interpretation of illness and physician
    1. Often considered to be "difficult patients" with frequent turn-over of primary care providers
    2. Fears rejection and isolation
    3. Self-destructive behavior (e.g. exercising on an injury)
    4. Alternates admiration and devaluation of physician ("splitting")

VI. Evaluation

  1. Screening
    1. McLean Screening Instrument for Borderline Personality Disorder
      1. Self-report tool used for screening, but not diagnosis
  2. Diagnosis
    1. See DSM-5 below
    2. Based on interview with patient, friends and family, and medical record review
    3. Structured interviews
      1. Revised Diagnostic Interview for Borderlines
      2. DSM-5 Alternative Model for Personality Disorders

VII. Diagnosis: DSM-5

  1. Pervasive Pattern by early adulthood in a variety of contexts
    1. Instability in Interpersonal relationship, self image and affect
    2. Marked impulsivity
  2. Criteria (diagnosis requires 5 or more):
    1. Frantic efforts to avoid real or imagined abandonment
      1. Does not include suicidal or self-mutilation behavior (included under different criterion)
    2. Pattern of unstable and intense interpersonal relationships
      1. Alternates between extremes of idealization and devaluation
    3. Identity disturbance
      1. Markedly and persistently unstable self-image or sense of self
    4. Impulsivity in at least 2 areas that are potentially self-damaging (examples below)
      1. Does not include suicidal or self-mutilation behavior (included under different criterion)
      2. Spending
      3. Sex
      4. Substance Abuse
      5. Reckless Driving
      6. Binge Eating
    5. Recurrent suicidal behavior, gestures, threats or self-mutilating behavior
    6. Affective instability due to a marked reactivity of mood lasting only hours to days (examples below)
      1. Intense episodic dysphoria
      2. Irritability
      3. Anxiety
    7. Chronic feelings of emptiness
    8. Inappropriate intense anger or difficulty controlling anger (examples below)
      1. Frequent displays of temper
      2. Constant anger
      3. Recurrent physical fights
    9. Transient stress-related paranoid ideation or severe dissociative symptoms
  3. References
    1. (2013) DSM 5, APA, p. 663

VIII. Associated Conditions

  1. Increased risk of Suicidality
  2. Obesity is more common (in Personality Disorders in general)
  3. Often associated with other mental health disorders
    1. Persistent Depressive Disorder
    2. Panic Disorder with Agoraphobia
    3. Social Anxiety Disorder and other phobias
    4. General Anxiety Disorder
    5. Alcohol Use Disorder
    6. Nicotine use disorder

IX. Management

  1. Recommended physician approach
    1. Avoid being overly familiar with patient
      1. Set clear boundaries from the start
    2. Encourage frequent clinic visits
      1. Counters patient attempts to interact outside of established clinical encounters
    3. Be aware of patient's feelings
    4. Offer clear, nontechnical explanations
    5. Tolerate angry outbursts
    6. Set firm limits on manipulative behavior
      1. Respond without judgment or anger
      2. Provider should try to be self-aware of their own anger or hurt in response to manipulative behavior
      3. Respond appropriately to threats of self-harm or harm to others
    7. Redirect discussion to current concerns, when patient is focusing on prior experiences
    8. Consider psychiatry Consultation
    9. May respond to psychotherapy
    10. Assess for Suicidality routinely
      1. See Suicide Screening
      2. Establish a Suicidality Safety Plan
      3. Identify support systems and restrict means to commit Suicide (weapons, medications)
  2. Psychotherapy
    1. Psychotherapy is first-line management in Borderline Personality Disorder
      1. Unfortunately, almost one third of patients drop out of therapy in the first half of program
      2. DBT and MBT decrease symptom severity, improves psychosocial functioning and decreases Major Depression scores
        1. Storebo (2020) Cochrane Database Syst Rev (5):CD012955 [PubMed]
    2. Dialectical Behavior Therapy (DBT)
      1. Cognitive-Behavioral Therapy Technique
      2. Decreases emotional lability and impulsivity
      3. Efficacy
        1. Improves psychosocial functioning, reduces severity and self harm
        2. Decreases Suicide attempts and hospitalizations
    3. Mentilization-Based Therapy (MBT)
      1. Increases patient awareness of impact of mental state on actions
      2. Decreases emotional lability and impulsivity
      3. Efficacy
        1. Decreases Suicidality and self harm
        2. Lower quality evidence than for Dialectical Behavior Therapy
    4. References
      1. Cristea (2017) JAMA Psychiatry 74(4): 319-28 [PubMed]
      2. Storebo (2020) Cochrane Database Syst Rev (5): CD012955 [PubMed]
  3. Medications
    1. No reliable evidence for any medication in Borderline Personality
    2. Borderline Personality is often treated with an approach similar to Bipolar Disorder
      1. Approach is often symptom specific management
      2. Mood stabilizers and Atypical Antipsychotics are frequently used
      3. Insufficient evidence for benefit
    3. Selective Serotonin Repuptake Inhibitors (SSRI)
      1. Frequently used for depression symptoms
    4. Other agents that have been used with possible benefit
      1. Quetiapine (Seroquel)
      2. Valproate
      3. Omega 3 Fatty Acids
    5. References
      1. Black (2014) Am J Psychiatry 171(11): 1174-82 [PubMed]
      2. Stoffers (2010) Cochrane Database Syst Rev (6):CD005653 [PubMed]

X. Prognosis

  1. Persists lifelong in most patients, but remission to less severe status is common
  2. Poor prognostic factors
    1. Higher severity
    2. Longer chronicity
    3. Comorbid illness
    4. Childhood adversity history
  3. Global functioning is often diminished despite remissions
    1. Lack of full-time employment in 75% of patients

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Ontology: Borderline Personality Disorder (C0006012)

Definition (NCI) A disorder characterized by an enduring pattern of unstable self-image and mood together with volatile interpersonal relationships, self-damaging impulsivity, recurrent suicidal threats or gestures and/or self-mutilating behavior.
Definition (NCI_NCI-GLOSS) A serious mental illness marked by unstable moods and impulsive behavior. People with BPD have problems with relationships, family and work life, long-term planning, and self-identity. Symptoms include intense bouts of anger, depression, and anxiety that may lead to self-injury or suicide, drug or alcohol abuse, excessive spending, binge eating, or risky sex. A person with BPD who is diagnosed with cancer may be at an increased risk of suicide.
Definition (MSH) A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. (DSM-IV)
Definition (PSY) Personality disorder with maladaptive patterns of behavior characterized by impulsive and unpredictable actions, mood instability, and unstable interpersonal relationships.
Definition (CSP) severe personality disorder that develops in early childhood; characterized by a lack of control of anger, intense and frequent mood changes, impulsive acts, disturbed interpersonal relationships, and life-threatening behaviors.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D001883
ICD9 301.83
ICD10 F60.3
SnomedCT 192488005, 20010003
DSM4 301.83
English Borderline Personality Disorder, Borderline Personality Disorders, Disorder, Borderline Personality, Disorders, Borderline Personality, Personality Disorder, Borderline, Personality Disorders, Borderline, Borderline personality, Borderline personality disord, DIS BORDERLINE PERSONALITY, BORDERLINE PERSONALITY DIS, PERSONALITY DIS BORDERLINE, borderline personality disorder (diagnosis), borderline personality disorder, Borderline Personality Disorder [Disease/Finding], borderline personality, borderline personality disorders, borderline personalities, [X]Borderline personality disorder, BPD, Borderline personality disorder, Borderline personality disorder (disorder), borderline; personality disorder, personality disorder; borderline
Italian Personalità borderline, Disturbo borderline
Dutch borderline persoonlijkheid, borderline; persoonlijkheidsstoornis, persoonlijkheidsstoornis; borderline, borderline persoonlijkheidsstoornis, Borderline persoonlijkheidsstoornis, Persoonlijkheidsstoornis, borderline
German Borderline-Persoenlichkeit, Borderline Persoenlichkeitsstoerung, Borderline-Persönlichkeitsstörung, Persönlichkeitsstörung, Borderline-
Portuguese Personalidade estado-limite, Transtorno de Personalidade Borderline, Perturbação Estado-Limite da Personalidade, Transtorno da Personalidade Limítrofe, Personalidade Estado-Limite, Caso-Limite, Perturbação estado-limite da personalidade, Transtorno da Personalidade Borderline
Spanish Personalidad en el límite de la normalidad, trastorno límite de la personalidad, Trastorno la Personalidad Borderline, Personalidad en el Límite de la Normalidad, Trastorno de la Personalidad Limítrofe, Trastorno de la Personalidad Borderline, Trastorno Fronterizo de la Personalidad, Trastorno Límite de la Personalidad, Trastorno Limítrofe de la Personalidad, trastorno de personalidad borderline, trastorno fronterizo de la personalidad, trastorno limítrofe de la personalidad (trastorno), trastorno limítrofe de la personalidad, trastorno límite de la personalidad (trastorno), Trastorno límite de personalidad, Trastorno de Personalidad Limítrofe
Japanese 境界性人格, キョウカイセイジンカク, 境界人格障害, キョウカイセイパーソナリティショウガイ, 境界性パーソナリティ障害, 境界性人格障害, 人格障害-境界性
Swedish Gränspsykos
Czech hraniční osobnost, hraniční porucha osobnosti, Hraniční osobnost, Hraniční porucha osobnosti
Finnish Rajatilahäiriö
French Trouble de la personnalité de type limite, Trouble de la personnalité limite, Personnalité borderline, Personnalité limite, Trouble de la personnalité de type borderline
Polish Borderline, Zaburzenia osobowości typu borderline, Osobowość z pogranicza, Osobowość typu borderline
Hungarian Borderline személyiség, Borderline személyiségzavar
Norwegian Personlighetsforstyrrelse, impulsiv, Impulsiv personlighetsforstyrrelse, Borderline personlighetsforstyrrelse, Personlighetsforstyrrelse, eksplosiv, Personlighetsforstyrrelse, ustabil, Personlighetsforstyrrelse, aggressiv, Personlighetsforstyrrelse, borderline, Ustabil personlighetsforstyrrelse, Aggressiv personlighetsforstyrrelse, Emosjonelt ustabil personlighetsforstyrrelse, Personlighetsforstyrrelse, emosjonelt ustabil, Eksplosiv personlighetsforstyrrelse, Grensepsykose