Behavior

Borderline Personality

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Borderline Personality, Borderline Personality Disorder

  • 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)
  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
  • 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")
  • 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
  • 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
  • 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
  • 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. Dialectical Behavior Therapy
      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
      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]
  • 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