The purpose of this activity is to enable the learner to assess, diagnose, and treat borderline personality disorder using the most up to date scientific evidence.
Borderline personality disorder (BPD) is a mental health condition characterized by:
These symptoms typically emerge during late adolescence and early adulthood . Borderline personality disorder is one of 10 personality disorders classified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM 5) . These individuals suffer considerable distress due to their difficulty relating to the world around them, and their diagnosis is associated with a significant social stigma .
Borderline personality disorder is the most common personality disorder in clinical settings, and it is seen across different cultures . Unfortunately, it is often misunderstood and misdiagnosed by health care providers including registered nurses and nurse practitioners [3, 4]. Furthermore, qualitative research has discovered that nurses view those with BPD as challenging, difficult, manipulative, destructive, and threatening .
This education module reviews best practices for assessing, diagnosing, and treating this complex mental health condition. Upon completing this module, nurses and nurse practitioners will be able to develop a differential diagnosis and comprehensive treatment plan that includes both pharmacologic and non-pharmacologic interventions.
Throughout the history of psychiatry, experts have debated the boundary between BPD and other mental health conditions like schizophrenia, depression, post-traumatic stress disorder, and bipolar disorder . The diagnostic criteria for BPD was first published in the 1970s and then officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) . In 1992, the World Health Organization added the condition to the ICD-10. Today, researchers and psychiatric experts agree that BPD is a distinct illness .
Although experts mostly agree on the diagnostic criteria, the etiology of BPD remains unknown . A range of different theories describe the pathogenesis of this complex condition. This education module will discuss the biological, psychodynamic, interpersonal, and cognitive perspectives of BPD, and it will also cover Marsha Linehan’s famous biosocial theory.
Studies approaching BPD from a biological perspective focus their inquiries on genetic epidemiology and heritability, neurotransmitters and their associated genes, hypothalamus pituitary adrenal (HPA) axis, and neuroimaging. These studies have found that BPD is moderately inheritable; BPD is five times more common is first degree relatives that the general population . Heritability of BPD ranges from 35% to 69%; however, it involves a complex interplay between both genetic and environmental factors . Furthermore, investigators have demonstrated that BPD is associated with:
Early experts believed that people functioned in one of three levels: normal, neurotic, or psychotic. Over time, Sigmund Freud, the founding father of psychoanalytic theory, recognized that some patients did not fit neatly into these three categories, but were rather at the border between neuroses and psychoses .
By the 1950s, the term borderline was used to describe those with weak ego functions resulting from both traumatic events and pathological relationships. To compensate, experts believe that borderlines would fuse their weaker egos with the egos of others. Those with BPD are believe to view things in their world as either good or bad. This leads to a rapid fluctuation between adoration and hatred toward the same object and results in many of the borderline symptoms .
Individuals with BPD are typically characterized by their stormy relationships with others. They are notorious for their intense adoration for someone that then rapidly turns into resentment. Lorna Smith-Benjamin is well-known for her interpersonal model, Structural Analysis of Social Behavior (SASB), which identifies four features that lead to the develop of BPD:
This model understands that those with BPD experience intense fear of abandonment, which distorts their understanding of others. Their rapid shifts in emotion and chaotic relationships set the stage for depression, anxiety, and suicidal ideation .
From a cognitive perspective, those with BPD are viewed as having a fluid consciousness. This fluidity worsens as their interpersonal relationships worsen . Their thoughts are typically dichotomous, meaning they hold two opposite views (i.e. good and evil) of themselves and others at the same time. Either of these views can be in effect at any time depending on the circumstances. Processing the world in this manner leads to rapid changes in behaviors and mood lability. This dichotomous thinking is often referred to as split object-representations .
Linehan’s biosocial theory is probably one of the most well-recognized etiological models for BPD . This framework views BPD as a disorder of mood dysregulation and results from specific invalidating environments. These environments are characterized by:
As a result of these environments, children do not learn how to define, regulate, or tolerate their emotional responses to others. Instead, these children learn to shift rapidly between extreme emotional inhibition and extreme emotional expression .
The median prevalence of BPD in the general population ranges from 1.6% to 5.9% . It is the most common personality disorder seen in clinical settings . The prevalence is estimated to be 6% in primary care offices, 10% in outpatient mental health clinics, and 20% in psychiatric hospitals . The prevalence decreases in older age groups.
Borderline personality disorder symptoms usually emerge during late adolescence and early adulthood . Prior to their first diagnosis, individuals with BPD may present to the emergency room in crisis showing signs of emotional distress, recurrent self-harm, suicidal thoughts, and the mention of various relationship problems.
It is often challenging to accurately diagnosis BPD because many of the symptoms overlap with other mental health conditions such as depression, substance abuse, eating disorders, post-traumatic stress disorder, bipolar disorder, psychoses, and other personality disorders . Individuals might present with a diagnosis of BPD and show signs of an additional co-morbid psychiatric condition. For an accurate assessment, nurses and nurse practitioners need to be able to identify at-risk factors, precursors, and associated clinical features.
Environmental risk factors are known to increase a person’s chance of developing BPD. A large-scale prospective cohort investigation called The Children in the Community conducted in the United States found the following environmental risk factors for BPD:
Another prospective study conducted in the United States called The Minnesota Longitudinal Study of Risk and Adaptation found the following risk factors for developing BPD:
Many longitudinal studies suggest that adults with psychiatric disorders possess mental state abnormalities (i.e. precursors) that are traceable back to childhood . Similarly, recent scientific research has demonstrated that BPD symptoms like impulsivity, negative affectivity, and interpersonal aggression begin in childhood. Precursors associated with the later development of BPD include:
In addition to the traditional BPD symptomology, these individuals tend to present with other associated clinical features that have deeply impacted their lives . Associated features supporting a diagnosis of BPD include:
A diagnosis of BPD is made using the criteria outlined in the DSM 5; however, evidence supports the use of self-report screening tools to help identify individuals with BPD. The Borderline Personality Questionnaire (BPQ) has the highest diagnostic accuracy and test-retest reliability of all instruments used to assess for BPD . The BPQ is an 80 question true/false assessment that subcategorizes the patient’s level of impulsivity, affective lability, abandonment concerns, relationship stability, self-image, suicide and self-harm behaviors, emptiness, anger intensity, and psychotic states .
Clinicians should follow the criteria outlined in the DSM 5 in order to make an accurate diagnosis of BPD . Many symptoms of BPD overlap with other psychiatric conditions, so the assessment process should be both careful and comprehensive. Clinicians should carefully consider the differential diagnosis and be able to identify the core diagnostic features of BPD.
The diagnostic criteria from the DSM 5 for BPD is listed below .
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
The symptoms associated with BPD are seen in a variety of cultures across the world . About 75% of those diagnosed are females . The core features of BPD are:
Those with BPD tend to uncontrollably avoid both real and imagined abandonment. They exhibit intense and inappropriate anger when faced with realistic separation from someone who is important to them. For example, someone with BPD might panic when a clinician announces the end of their hour appointment. They have a deep intolerance for being alone and their impulsivity can lead to self-mutilation and suicidal behaviors .
Those with BPD display unstable and intense interpersonal relationships. They frequently idealize potential caregivers or romantic partners at first; however, this infatuation rapidly shifts to hatred, believing that the other person does not love them enough. Those with BPD are prone dramatic and quick changes in their views of others, which in turn often leaves them isolated and abandoned .
Individuals suffering from BPD display a persistent, unstable self-image. Their goals, values, and career choices may change day to day. They alter between playing the role of a needy victim to that of a righteous avenger. Those with BPD tend to view themselves as either all good or all evil, and when undergoing severe stress, they may feel as though they do not exist at all .
Furthermore, people with BPD exhibit marked impulsivity that is potentially self-damaging. For example, they may gamble, irresponsibly spend money, binge eat, abuse harmful substances, engage in unsafe sex, or drive recklessly. Furthermore, these individuals may repeatedly self-mutilate or make suicidal threats or gestures. Around 8%-10% of those with BPD complete suicide .
Finally, individuals with BPD present with marked reactivity of mood that usually manifests as intense episodic dysphoria, irritability, and anxiety. They also tend to report chronic feelings of emptiness, panic, anger and despair. When they feel as though they are being abandoned they may exhibit extreme sarcasm or verbal outbursts that then leave them feeling guilty. During times of extreme stress, those with BPD tend to report paranoid ideation or dissociative symptoms .
A clinician should only give a diagnosis of BPD when they are able to document a persistent pattern of BPD behavior over a long period of time . The differential diagnosis of BPD should include but not be limited to:
The diagnosis of BPD often co-occurs with both depressive disorders and bipolar disorders. When a patient presents with either depressive or bipolar symptoms, clinicians should avoid giving an additional BPD diagnosis unless it is clear that their BPD-related behaviors are enduring over time .
It is easy to confuse BPD with other personality disorders because some of the symptoms overlap .
As with any mental health condition, it is important to rule out the effects of any underlying medical condition or substance use disorder . Borderline personality disorder should be differentiated from an identity problem, which is a term used to describe a concern related to a developmental phase such as adolescence .
Treating an individual with BPD involves both psychological and pharmacological interventions. The first step is to develop a treatment plan. Treatment plans for BPD should follow five main principles:
First, treatment should be selected based on the best available scientific literature. Research has demonstrated that certain psychological and pharmacological interventions are more efficacious than others . Experts believe that those with BPD need long-term therapy to attain and maintain lasting results. The treatment plan should be focused to address both BPD symptoms as well as comorbid psychiatric conditions. Priority should be placed on the symptoms causes the greatest distress or self-harm risk .
The treatment plan should be flexible enough to respond to the changing needs of the patient over time . For example, the treatment plan might first focus on safety followed by improving interpersonal relationships at work. Patients and their provider should determine the treatment plan together . The nurse or nurse practitioner should explain the different treatment options, and allow the patient to take part in shared-decision making. Treatment led by one single clinician is preferable when treating those with BPD to prevent fragmentation of care .
Scientific research demonstrates that both psychodynamic psychotherapy and dialectical behavioral therapy (DBT) effectively treat symptoms of BPD . The best treatment outcomes are seen when the therapist is highly trained in either of these methods and remains with the same patient throughout the entire process. Both psychodynamic psychotherapy and DBT share these fundamental features:
Psychodynamic psychotherapy focuses on the therapist-patient interaction and uses the transference occurring within the relationship to make therapeutic change . This therapy draws from self-psychology, object relations, and ego psychology. Typically, the goals include:
To achieve these goals, therapists use exploratory and supportive interventions. Exploratory interventions include interpretation, confrontation, and clarification whereas supportive interventions include encouragement to elaborate, empathetic validation, advice and praise, and affirmation .
Psychodynamic therapists view interpretation as their strongest therapeutic tool. Interpretation involves connecting a patent’s feeling, thought, behavior, or symptom to the correct unconscious meaning . For example, a therapist might state, “I wonder if the tendency to undermine yourself when you are making progress in your treatment is a way to guarantee that your time with me will continue.” Psychodynamic therapists confront a patient about how their behavior impacts others, and they will help patients clarify their thoughts into a more coherent explanation .
These therapists will listen intently and encourage their patients to elaborate more broadly on their emotions . Empathetic validations are used to emphasize the importance and reality of the patient’s experiences. Therapists will also give advice in the form of specific suggestions to the patient regarding how they should behave in certain situations . Praise is used to reinforce positive behavior. Affirmation refers to succinct comments that support the patient’s statements or behavior that indicate progress in therapy.
Dialectical Behavior Therapy
Dialectical behavior therapy is a special form of cogitative-behavioral therapy designed by Marsha . It blends cognitive-behavioral approaches with acceptance-based practices, and it is highly structured. Dialectical behavior therapy usually lasts one year and follows a strict manual-guided process ]. Patients undergo individual counseling and group therapy on a weekly basis. The goals of DBT in order of priority include:
Dialectical behavior therapists use validation, mindfulness, and emotion regulation skills to achieve these goals . Therapists help patients change how they express their emotions through deep breathing, relaxation, and approaching rather than avoiding fearful stimuli. Therapists teach their patients new skills in order to reduce their vulnerability to unstable emotions and relationships. For example, DBT therapists will show their patients how to accurately observe, describe, and label their emotions. These therapists validate their patient’s emotions and help them explore their dysfunctional behavioral responses to these emotions .
Medication is used to manage the symptoms of BPD, and it should always be used concomitantly with psychosocial interventions . Symptoms that are treatable with medication fall into three main categories: affective dysregulation, impulsivity, and cognitive-perceptual difficulties . Please see table 1 for more details.
|Symptom Category||Symptom Category||Medication Name||Considerations|
|Affective Dysregulation ||SSRI||Fluoxetine, sertraline||Safe in overdose with few side effects |
Rapid onset for acute treatment 
|Impulsivity ||SSRI||Fluoxetine, sertraline||Effects on anger and impulsivity occur early and independently from effects on depressed mood and anxiety |
|MAOI||Phenelzine, tranylcypromine||Second-line treatment only after SSRI failure; the initial SSRI must be completely eliminated from body before starting MAOI treatment; patient must remain adherent to special tyramine-free diet |
|Mood Stabilizer||Lithium carbonate||Can be used as a primary or adjunctive treatment; required close blood-level monitoring; can be lethal in overdose |
|Typical Antipsychotic||Haloperidol||Rapid onset for acute treatment |
|Cognitive-Perceptual Difficulties |
Typical Antipsychotic (low-dose)
|Haloperidol, perphenazine, thioridazine||Positive treatment effects are demonstrated in short-term studies (5-16 weeks) with poor long-term tolerance; increased risk of akinesia, tardive dyskinesia, and depression |
Adjunctive only; especially effective is cognitive-perceptual symptoms overlap with affective dysregulation symptoms 
|MAOI||Any||Adjunctive only; requires strict adherence to a tyramine-free diet |
Patients with BPD manifest symptoms of affective dysregulation through mood lability, rejection sensitivity, anxiety, inappropriate intense anger, dysphoria, hostility, and temper outbursts. The American Psychiatric Association recommends that these symptoms be treated with a selective serotine reuptake inhibitors (SSRI) including either fluoxetine or sertraline . The typical antipsychotic, haloperidol, may be used for assaultive behavior that requires a rapid effect onset .
Patients with impulsive aggression, anger, irritability, and self-mutilation may benefit from either fluoxetine or sertraline. If these SSRIs fail, the American Psychiatric association recommends either phenelzine or tranylcypromine, both of which are monoamine oxidase inhibitors (MAOI) and require a special tyramine-free diet [19, 20]. Lithium can be used as an adjunctive treatment to manage impulsivity; however, this medication can be lethal in overdose and requires strict blood-level monitoring [19, 20]. Again, haloperidol may be used in instances of acute anger or impulsivity.
Cognitive-perceptual difficulties include ideas of reference, illusions, and paranoid ideation associated with anger. Low-dose typical antipsychotics are the best treatment for these symptoms especially when they are associated with a depressed mood, anxiety, and recurrent suicidal ideation . Research has found positive treatment effects with haloperidol, perphenazine, or thioridazine when they are used for less than 22 weeks . Long-term use results in nonadherence and increased risk for akinesia, tardive dyskinesia, and depression . Furthermore, SSRIs and MAOIs can be used adjunctively to manage affective symptoms .
Throughout their lives, people with BPD have experienced rejection, trauma, abuse, and social stigma. They have likely had difficulty working with previous healthcare professionals due to their unstable emotions and fear of abandonment . Nurses and nurse practitioners should be ready to address the unique needs of those with BPD. Five general principles should guide every encounter with individuals with BPD:
The first step in forming an effective relationship with someone with BPD is to form a trusting relationship. Nurses should always approach these patients with an open, non-judgmental attitude. Nurses should be careful to remain consistent and reliable with scheduled appointments. At the beginning of treatment, the nurse must set firm boundaries with the patient. The person with BPD should understand when and how he or she is able to access healthcare services .
Because those with BPD are sensitive to rejection and feelings of abandonment, any transition out of care should be managed carefully. Nurses should make sure the transfer or discharged is planned well in advance, and communication remains open and transparent with the patient. The patient should always leave with a crisis plan. During the transition, the nurse should emphasize how much progress the patient has made in their treatment .
Those with BPD are at an increased risk for suicidal ideation and self-harm behaviors . A thorough risk assessment will include any changes in suicidal behavior, self-harm behaviors, co-occurring mental illnesses, current substance abuse, sources of psychosocial support, and feelings of hopelessness. Nurses should conduct comprehensive risk assessments whenever the patient:
Many individuals with BPD experience chronic feelings of emptiness and suicidal ideation. Those with BPD often attempt suicide repeatedly over many years. They may also experience persistent thoughts of self-mutilation and acute periods of impulsively harming themselves. In general, someone with BPD is at an increased risk of attempting suicide if they:
Individuals with BPD can be treated in a variety of psychiatric settings, including outpatient, partial hospitalization, inpatient psychiatric hospitalization, and residential. Each treatment setting offers its advantages and should be selected based on the needs of the patient at that time.
Partial hospitalization describes a day treatment program where patients receive care during work hours but return home at night. These programs typically last one to two weeks, and they involve counseling, medication management, and group therapy. Indications for partial hospitalization include:
Inpatient treatment at a psychiatric hospital is reserved for emergency 24-hour care. The patients stay in the hospital and receive acute treatment for their BPD symptoms. Indications for inpatient hospitalization include:
Residential treatment settings are usually long-term programs where individuals live with others who have similar conditions or symptoms. During these programs, those with BPD undergo intensive counseling and medication management services. Indications for residential treatment or extended inpatient hospitalization include:
Michelle O’Malley is a 27-year-old, unemployed, single, Caucasian female. She arrives to your clinic today for a psychiatric evaluation, presenting with symptoms of dysphoria, chronic suicidal thoughts, and relationships problems with her boyfriend that have been ongoing for the past 5 months. She brings her favorite stuffed animal with her. Her chief complaint is, “I hate my boyfriend because he never has time for me.”
Michelle was the oldest child in her family. Her father left her family when Michelle was very young, and she has not had contact with him since. Her mother suffered from bipolar disorder and on and off substance abuse. Her mother also attempted suicide on at least three occasions. Michelle describes her mother as inconsistent and chaotic.
She reports a history of previous psychiatric treatment beginning when she was a child. As a child she was treated for oppositional defiant disorder, and then as a teenager she was treated for major depression. She has received inpatient psychiatric treatment twice previously due to suicide attempts by overdose. Throughout her young adulthood, Michelle began burning her legs to cope with feelings of anger and worthlessness. She has been prescribed lithium carbonate, carbamazepine, and Seroquel in the past. She is not currently on any medication.
Throughout the psychiatric evaluation she appears well-groomed, and she is alert and oriented. She denies any illicit substance abuse but smokes about one pack of cigarettes per day and drinks 2 glasses of wine per week. She appeared down and depressed, but she was cooperative, coherent, and goal-directed. She admits to feeling empty, and at times having sex with random strangers to feel better about herself. She denies having any close friends, stating that all of her friends have turned out to be “frauds and losers.” She reports that she will at times burst out angrily at her boyfriend and then feel very guilty. She reveals superficial cuts on her forearms. She denies a current plan for suicide citing her 2-year-old son as a barrier.
Michelle presents with affective instability, difficulty controlling her anger, unstable interpersonal relationships, self-mutilation, chronic suicidal thoughts, and feelings of emptiness. She meets the DSM 5 criteria for BPD. During the brief discussion of her childhood, it appears as though her mother may have also met criteria for BPD, and it sounds as though Michelle was raised in an invalidating environment. Her early diagnosis of opposition defiant disorder and then major depression put her at risk for developing BPD as an adult.
Based on her presentation, continuing her treatment in an outpatient setting is appropriate. At this initial appointment, it is important to conduct a thorough suicide risk assessment. Her current self-mutilation and history of suicide attempts puts her at an increased risk. The treatment plan should include both medication and psychotherapy. Michelle will likely benefit most from a trial of an SSRI such as fluoxetine or sertraline. She should also begin either psychodynamic psychotherapy or DBT.
James is a 19-year-old single, unemployed, African American male presenting to the emergency room following a suicide attempt by overdose with 16 acetaminophen tablets. He arrives with his girlfriend reporting persistent suicidal ideation with a plan to “go home and try again.” Security has come to his room twice to intervene as he and his girlfriend shout uncontrollably at each other.
He complains of anxiety, anger, and “feeling out of control.” He complains that he knows his girlfriend is cheating on him just like all of his previous girlfriends. Over the past 3 months, he reports feelings of rage that lead to punching holes in the walls at his home. He describes himself as feeling outraged one day and then depressed and hopeless the next day. He engages in reckless driving and abuses alcohol. His stomach is covered in self-inflicted burn marks. He reports a chronic feeling of emptiness and hatred towards himself.
As a child, James was diagnosed with ADHD and treated with Adderall. He reports that his father was physically abusive towards him and sexually abusive towards his sisters. He has not received psychiatric treatment since he was 11 years old.
James presents with affective instability, transient paranoia, unstable interpersonal relationships, self-mutilation, and active suicidal ideation, all of which suggest a diagnosis of BPD. His recent suicide attempt and persistent ideation with a plan requires inpatient psychiatric treatment. During his hospitalization, it will be important to conduct a thorough risk assessment prior to discharge and begin a medication regimen to stabilize his mood and impulsivity.
Caring for individuals with BPD is challenging. The diagnosis frequently goes unrecognized and nurses tend to avoid these patients due to their erratic and hostile behavior. It is important for healthcare professionals to educate themselves about this difficult diagnosis in order to provide the most effective care for their patients. More information on BPD can be found on the National Institute of Mental Health.
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