Borderline Personality Disorder

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 in first degree relatives than the general population (Reichborn-Kiennerud, 2010). Heritability of BPD ranges from 35% to 69%; however, it involves a complex interplay between both genetic and environmental factors (Reichborn-Kiennerud, 2010). Furthermore, investigators have demonstrated that BPD is associated with (Goodman et al., 2013):

• Impaired genes that control both serotonin and its complex system in the brain
• Enhanced cortisol suppression, resulting in an excessive inhibition of the HPA axis
• Decreased gray matter volume and increased white matter volume in the rostral and subgenera cingulate of their brains
• Reduced amygdala volume, possibly reflecting excitotoxicity

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 (Millon, 2004).

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 those with BPD would fuse their weaker egos with the egos of others. Those with BPD are believed 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 (Millon, 2004).

Individuals with BPD are typically characterized by 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 development of BPD (Millon, 2004):

• Family chaos
• Traumatic abandonment
• Family values that impede autonomy and expression of happiness while encouraging dependency and misery
• A family that only offers nurturance once a member is miserable

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 (Millon, 2004).

From a cognitive perspective, those with BPD are viewed as having a fluid consciousness. This fluidity worsens as their interpersonal relationships worsen (Millon, 2004). 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 (Millon, 2004).

Linehan’s biosocial theory is probably one of the most well-recognized etiological models for BPD (Crowell et al., 2009). This framework views BPD as a disorder of mood dysregulation and results from specific invalidating environments. These environments are characterized by (Crowell et al., 2009):

• Intolerance toward emotional expression
• Intermittently reinforcing extreme emotional reactions
• Communicating that emotions are unwarranted
• Reinforcing that children should cope with their emotions without support

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 (Crowell et al., 2009).

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 (Carlson et al., 2009):

• Childhood sexual abuse, physical abuse, and/or neglect
• Maladaptive parenting
• Maladaptive school experiences
• Low family socioeconomic status
• Family welfare support recipient status
• Single-parent family status.

Another prospective study conducted in the United States called The Minnesota Longitudinal Study of Risk and Adaptation found the following risk factors for developing BPD13:

• Early attachment disorganization
• Maltreatment in childhood
• Maternal hostility and boundary dissolution
• Family disruption related to the father's presence
• Family life stress

Many longitudinal studies suggest that adults with psychiatric disorders possess mental state abnormalities (i.e., precursors) that are traceable back to childhood (Chanen & Kaess, 2011).. 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 (Chanen & Kaess, 2011):

• Alcohol use disorders during adolescence
• Disruptive behavior disorders (i.e., conduct disorder, ADHD, or oppositional defiant disorder)
• Major depressive disorder
• Repetitive self-harm behaviors

In addition to the traditional BPD symptomology, these individuals tend to present with other associated clinical features that have deeply impacted their lives (APA, 2013). Associated features supporting a diagnosis of BPD include (APA, 2013):

• A pattern of undermining their goal right before they are successful (e.g., dropping out of school right before graduation)
• The use of comfort objects during times of stress (e.g., stuffed animal)
• Physical handicaps from self-inflicted abuse behaviors
• Repeated suicide attempts
• Childhood histories of physical and sexual abuse, neglect, hostile conflict, and early parental loss

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 (Poreh, 2006). 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 (Poreh, 2006).

The diagnostic criteria from the DSM 5 for BPD are listed below (APA, 2013).

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:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger, or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

The symptoms associated with BPD are seen in a variety of cultures across the world (APA, 2013). About 75% of those diagnosed are females (APA, 2013). The core features of BPD are (APA, 2013):

• Fear of abandonment
• Intense interpersonal relationships
• Unstable self-image
• Self-damaging impulsivity
• Affective instability

Those with BPD tend to avoid both real and imagined abandonment uncontrollably. 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 (APA, 2013).

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 to dramatic and quick changes in their views of others, which in turn often leaves them isolated and abandoned (APA, 2013).

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 (APA, 2013).

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 (APA, 2013).

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 (APA, 2013).

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 (APA, 2013). The differential diagnosis of BPD should include but not be limited to (APA, 2013):

• Depressive disorders
• Bipolar disorders
• Other personality disorders
• Personality change due to an underlying medical condition
• Substance use disorders
• Identity problems

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 (APA, 2013).

It is easy to confuse BPD with other personality disorders because some of the symptoms overlap (APA, 2013).

• Both BPD and histrionic personality disorders include attention-seeking, manipulative behavior; however, BPD has more prominent self-destructive features.
• Paranoid illusions are seen in BPD and schizotypal personality disorder; however, these ideations are more transient and related to interpersonal conflict in BPD.
• While narcissistic and paranoid personality disorders present with angry outbursts similar to BPD, they lack the unstable self-image and self-destructiveness of someone with BPD.
• Those with antisocial personality disorder are more likely to manipulate others for power or material gratification, whereas those with BPD are seeking the concern of caregivers.
• Both BPD and dependent personality disorder fear abandonment; however, those with BPD react to it with rage and unreasonable demands, whereas those with dependent personality disorder reactive with appeasement and submissiveness.

As with any mental health condition, it is important to rule out the effects of any underlying medical condition or substance use disorder (APA, 2013). 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 (APA, 2013).

Scientific research demonstrates that both psychodynamic psychotherapy and dialectical behavioral therapy (DBT) effectively treat symptoms of BPD (Gabbard, 2014). 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 (Gabbard, 2014):

• Ongoing treatment for a minimum of one year
• Weekly meetings with an individual counselor
• One or more weekly group therapy sessions
• Meetings in-between appointments with therapists to reinforce treatment goals

Medication is used to manage the symptoms of BPD, and it should always be used concomitantly with psychosocial interventions (Gabbard, 2014). Symptoms that are treatable with medication fall into three main categories: affective dysregulation, impulsivity, and cognitive-perceptual difficulties (Oldham et al., 2010). Please see table 1 for more details.

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 (Gabbard, 2014). 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 (Gabbard, 2014):

• Gaining trust
• Managing emotions
• Setting boundaries
• Managing transitions of care
• Assessing self-harm risk

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 (Gabbard, 2014).

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 discharge 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 (Gabbard, 2014).

Those with BPD are at an increased risk for suicidal ideation and self-harm behaviors (NHMRC, 2013). 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 (NHMRC, 2013):

• First contacts a health service
• Begins a course of structured psychotherapy
• Develop another psychiatric illness
• Transitions between care settings
• Experiences a major social change

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 (Oldham et al., 2010):

• Have a clear plan for suicide
• Intent to use a lethal method
• Have access to the means they intend to use
• Do not hope to be rescued during their plan
• Express profound feelings of hopelessness about their future
• Have delusions that make them believe they must die
• Have co-occurring depression or substance abuse
• Lack a strong social network
• Have a co-occurring antisocial personality disorder
• Have a history of childhood sexual abuse, particularly incest
• Were recently discharged from a psychiatric facility
• Appear regressed and uncommunicative

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 (Oldham et al., 2010):

• Harmful and impulsive behavior unable to be managed with outpatient treatment
• A worsening clinical picture with a persistent lack of adherence to outpatient care
• A complex comorbid condition that appears to be worsening to not responding to outpatient treatment
• Moderately severe symptoms that are interfering with functioning work and life

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 (Oldham et al., 2010):

• Imminent danger to self or others
• A complete loss of control over suicidal impulses
• Recent suicide attempt
• Transient psychotic episodes and the resulting loss of impulse control
• Severe symptoms interfering with work and life functioning that are unresponsive to outpatient or partial hospitalization

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 (Oldham et al., 2010):

• Ongoing and severe suicidal ideation, self-mutilation, or suicidal gestures
• An additional comorbid psychiatric condition that is potentially life-threatening such as a severe mood or eating disorder
• A co-occurring substance use condition that is worsening or unresponsive to outpatient treatment
• Risk of violent or aggressive behavior towards others despite previous inpatient hospitalizations
• Severe symptoms that are interfering with functioning that were previously unresponsive to outpatient, partial hospitalization, and inpatient hospitalization

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 put 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 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 require 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.