II. Epidemiology
- Prevalence: 1.6% of U.S. Adults
- May represent >6% of primary care visits
- Multifactorial including Family History, Trauma (other third have been raped)
III. Findings: General
- Emotional dysregulation
- Mood lability (changes within hours from intense transient dysphoria to irritability to anxiety)
- Inappropriate intense outbursts of anger, displaying a temper and may get into physical fights
- Recurrent suicidal behavior, gestures, threats or self-mutilation
- Impulsive (spending, sex, Drug Abuse, Binge Eating)
- Interpersonal problems
- Unstable relationships, self image, and affect
- Loneliness, boredom and sense of emptiness
- Unstable and intense interpersonal relationships fluctuating between idealization to devaluation ("splitting")
- Disturbed self-identity
- Unstable self-image persists
- Lacks integrated sense of self
IV. Findings: Healthcare Specific
- Impulsive behaviors that impact health
- Suicidality
- Binge Eating
- High-risk sexual behavior
- High healthcare utilization
- May present with frequent multiple vague somatic complaints
- May present with Chronic Pain
- Borderline Personality Disorder patients frequently rate their pain as more severe
- Altered interpretation of illness and physician
- Often considered to be "difficult patients" with frequent turn-over of primary care providers
- Fears rejection and isolation
- Self-destructive behavior (e.g. exercising on an injury)
- Alternates admiration and devaluation of physician ("splitting")
V. Differential Diagnosis
VI. Evaluation
- Screening
- McLean Screening Instrument for Borderline Personality Disorder
- Self-report tool used for screening, but not diagnosis
- McLean Screening Instrument for Borderline Personality Disorder
- Diagnosis
- See DSM-5 below
- Based on interview with patient, friends and family, and medical record review
- Structured interviews
- Revised Diagnostic Interview for Borderlines
- DSM-5 Alternative Model for Personality Disorders
VII. Diagnosis: DSM-5
- Pervasive Pattern by early adulthood in a variety of contexts
- Instability in Interpersonal relationship, self image and affect
- Marked impulsivity
- Criteria (diagnosis requires 5 or more):
- Frantic efforts to avoid real or imagined abandonment
- Does not include suicidal or self-mutilation behavior (included under different criterion)
- Pattern of unstable and intense interpersonal relationships
- Alternates between extremes of idealization and devaluation
- Identity disturbance
- Markedly and persistently unstable self-image or sense of self
- Impulsivity in at least 2 areas that are potentially self-damaging (examples below)
- Does not include suicidal or self-mutilation behavior (included under different criterion)
- Spending
- Sex
- Substance Abuse
- Reckless Driving
- Binge Eating
- Recurrent suicidal behavior, gestures, threats or self-mutilating behavior
- Affective instability due to a marked reactivity of mood lasting only hours to days (examples below)
- Intense episodic dysphoria
- Irritability
- Anxiety
- Chronic feelings of emptiness
- Inappropriate intense anger or difficulty controlling anger (examples below)
- Frequent displays of temper
- Constant anger
- Recurrent physical fights
- Transient stress-related paranoid ideation or severe dissociative symptoms
- Frantic efforts to avoid real or imagined abandonment
- References
- (2013) DSM 5, APA, p. 663
VIII. Associated Conditions
- Increased risk of Suicidality
- Obesity is more common (in Personality Disorders in general)
- Often associated with other mental health disorders
- Persistent Depressive Disorder
- Panic Disorder with Agoraphobia
- Social Anxiety Disorder and other Phobias
- General Anxiety Disorder
- Alcohol Use Disorder
- Nicotine use disorder
IX. Management
- Recommended physician approach
- Avoid being overly familiar with patient
- Set clear boundaries from the start
- Encourage frequent clinic visits
- Counters patient attempts to interact outside of established clinical encounters
- Be aware of patient's feelings
- Offer clear, nontechnical explanations
- Tolerate angry outbursts
- Set firm limits on manipulative behavior
- Respond without judgment or anger
- Provider should try to be self-aware of their own anger or hurt in response to manipulative behavior
- Respond appropriately to threats of self-harm or harm to others
- Redirect discussion to current concerns, when patient is focusing on prior experiences
- Consider psychiatry Consultation
- May respond to psychotherapy
- Assess for Suicidality routinely
- See Suicide Screening
- Establish a Suicidality Safety Plan
- Identify support systems and restrict means to commit Suicide (weapons, medications)
- Avoid being overly familiar with patient
- Psychotherapy
- Psychotherapy is first-line management in Borderline Personality Disorder
- Unfortunately, almost one third of patients drop out of therapy in the first half of program
- DBT and MBT decrease symptom severity, improves psychosocial functioning and decreases Major Depression scores
- Dialectical Behavior Therapy (DBT)
- Cognitive-Behavioral Therapy Technique
- Decreases emotional lability and impulsivity
- Efficacy
- Improves psychosocial functioning, reduces severity and self harm
- Decreases Suicide attempts and hospitalizations
- Mentilization-Based Therapy (MBT)
- Increases patient awareness of impact of mental state on actions
- Decreases emotional lability and impulsivity
- Efficacy
- Decreases Suicidality and self harm
- Lower quality evidence than for Dialectical Behavior Therapy
- References
- Psychotherapy is first-line management in Borderline Personality Disorder
- Medications
- No reliable evidence for any medication in Borderline Personality
- Borderline Personality is often treated with an approach similar to Bipolar Disorder
- Approach is often symptom specific management
- Mood stabilizers and Atypical Antipsychotics are frequently used
- Insufficient evidence for benefit
- Selective Serotonin Repuptake Inhibitors (SSRI)
- Frequently used for depression symptoms
- Other agents that have been used with possible benefit
- Quetiapine (Seroquel)
- Valproate
- Omega 3 Fatty Acids
- References
X. Prognosis
- Persists lifelong in most patients, but remission to less severe status is common
- Poor prognostic factors
- Higher severity
- Longer chronicity
- Comorbid illness
- Childhood adversity history
- Global functioning is often diminished despite remissions
- Lack of full-time employment in 75% of patients