Borderline Personality Disorder (FL INITIAL Autonomous Practice - Differential Diagnosis)

Albert Taylor is a 28-year-old Hispanic male who is single and his own guardian. Albert was referred to the psychiatric outpatient clinic by his primary care provider due to ongoing mood instability, burning behaviors, and suicidal thoughts. Albert grew up in a tumultuous household characterized by neglect and emotional abuse. His parents struggled with substance abuse, and Albert often found himself in the role of caretaker for his younger siblings.

Throughout his adolescence and early adulthood, Albert exhibited patterns of impulsive behaviors (stealing and gambling), intense mood swings, and tumultuous relationships. He frequently engaged in substance abuse, risky sexual behaviors, and self-harming activities as a means of coping with his emotional turmoil. Despite possessing academic potential, Albert's educational and occupational pursuits were hindered by his inability to maintain stability and focus. He often would quit school or work when he was about to achieve success.

Albert's relationships were marked by extreme idealization followed by an intense fear of abandonment. He would oscillate between idolizing his girlfriend and friends to demonizing them when he perceived rejection or criticism. Consequently, many of his relationships ended abruptly, leaving him with a feeling of abandonment and misunderstanding.

Albert began therapy at the clinic and fell in love with his therapist. He would call the clinic several times a day, trying to reach her and bring gifts to his therapy sessions. When his therapist set boundaries, he became angry and resentful towards her and abandoned treatment after just a few weeks. Three days later, Albert committed suicide.

Studies approaching BPD from a biological perspective focus their inquiries on genetic epidemiology and heritability, neurotransmitters and their associated genes, the hypothalamus pituitary adrenal (HPA) axis, and neuroimaging. Although the diagnostic method of BPD is still a very controversial topic (Liu, 2023), these studies have found that BPD is moderately inheritable; BPD is approximately five times more common in full siblings, with the hazard ratio in identical twins estimated to be an 11.5-fold increase than the general population (Leischsenring et al., 2024). The heritability of BPD ranges from 46% to 69%; however, it involves a complex interplay between both genetic and environmental factors (Schulze et al., 2023). Furthermore, investigators have demonstrated that BPD is associated with (Leischsenring et al., 2024):

• 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
• Hyperactivity of the amygdala and hippocampal area during emotional processing
• Fronto-limbic imbalance and abnormal functioning of the prefrontal structures

Psychodynamic therapy is based on the idea that childhood experiences, past unresolved conflicts, and previous relationships significantly influence a patient's current situation in life and focuses on helping the patient develop insight around these themes (Lebow, 2022). 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 et al., 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 another person's stronger ego. Those with BPD are believed to view things in their world in absolutes, either entirely good or entirely bad; this leads to a rapid fluctuation between adoration and hatred toward the same object and results in many of the borderline symptoms (Millon et al., 2004).

Interpersonal therapy is an evidence-based treatment that addresses interpersonal difficulties that lead to a patient's psychological problems (Lebow, 2022). Individuals with BPD are typically characterized by stormy relationships with others. They are notorious for their intense adoration for someone (aka, "love bombing") by showering them with attention, compliments, and gifts that then rapidly turn resentful towards this same person. 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 (Lebow, 2022):

• Grief over loss
• Interpersonal disputes
• Role transitions
• Interpersonal skill deficits

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 et al., 2004).

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

Linehan's biosocial theory is probably one of the most well-recognized etiological models for BPD (Crowell et al., 2009; Jones, 2023; Mochrie et al., 2020).This framework views BPD as a disorder of mood dysregulation that occurs within an invalidating developmental context that is characterized by intolerance toward expressing private emotional experiences (Crowell et al., 2009). These environments are characterized by (Crowell et al., 2009; Marco et al., 2024):

• 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 with maladaptive parenting (Gupta et al., 2023), children do not learn how to define, regulate, or tolerate their emotional responses to others. Maternal psychopathology, including interpersonal functioning, plays a critical role in the precocious onset of BPD (Gupta et al., 2023). Instead, these children learn to shift rapidly between extreme emotional inhibition and extreme emotional expression (Crowell et al., 2009; Gupta et al., 2023).

Clinicians should follow the criteria outlined in the DSM-5 in order to make an accurate diagnosis of BPD (APA, 2013). 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.

DSM-5 Criteria

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, 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.

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). Co-existing mental health disorders such as major depression (83%), bipolar disorder (83%), anxiety disorders (85%), and substance use disorders (78%) are common (Leichsenring et al., 2023). 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 and 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 seek 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 react 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). BPD 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 (Leichsenring et al., 2024; Liu, 2023; National Institute of Mental Health [NIMH], 2023; Oldham et al., 2010). 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 (Leichsenring et al., 2024; Liu, 2023; NIMH, 2023; Oldham et al., 2010):

• 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

Psychodynamic psychotherapy is the oldest of modern therapies focusing on a relationship model where the therapist-patient interaction utilizes transference occurring within the relationship to make a therapeutic change (Liu, 2023; Lohani & Sharma, 2023). This therapy draws from self-psychology, object relations, and ego psychology. Typically, the goals include (Hill & Norcross, 2023, p 7-8; Oldham et al., 2010):

• Identifying unconscious patterns of thought and behavior
• Bringing these maladaptive patterns into the patient's consciousness
• Practicing the ability to delay impulsive actions
• Providing insight into interpersonal relationship problems
• Developing a greater capacity for self-reflection

To achieve these goals, therapists use exploratory and supportive interventions that are grounded in motivational interviewing (Cole et al., 2023). Exploratory interventions include interpretation, confrontation, and clarification, whereas supportive interventions include encouragement to elaborate, empathetic validation, advice and praise, and affirmation (Hill & Norcross, 2023, p 6-10; Cole et al., 2023).

Psychodynamic therapists view interpretation as their strongest therapeutic tool. Interpretation involves connecting a patient's feelings, thoughts, behavior, or symptoms to the correct unconscious meaning (Lorenzo et al., 2022). For example, utilizing motivational interviewing techniques and open-ended questions, 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 patients about how their behavior impacts others and will help patients clarify their thoughts into a more coherent explanation (Cole et al., 2023; Gabbard & Crisp, 2022).

These therapists will listen intently and encourage their patients to elaborate more broadly on their emotions (Cole et al., 2023; Gabbard & Crisp, 2022). 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 (Gabbard & Crisp, 2022). 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 (Gabbard & Crisp, 2022).

DBT is a special form of cognitive-behavioral therapy designed by Marsha Linehan (Goleman, 2020; Mochrie et al., 2020) and is considered a first-line treatment modality for BPD (Skodol, 2022b). It blends cognitive-behavioral approaches with acceptance-based practices, and it is highly structured for patients who are the most regressed or for those with high levels of self-destructiveness (Skodol, 2022b). Patients undergo individual counseling and group therapy on a weekly basis. The goals of DBT in order of priority include (Iwakabe et al., 2023; Oldham et al., 2010):

• Enhancing the ability to be aware of and accept emotional experience
• Cultivating the ability to regulate emotions and tolerate distress
• Changing negative emotions through new learning experiences with exposures

Dialectical behavior therapists use validation, mindfulness, and emotion regulation skills to achieve these goals (Goleman, 2020; Oldham et al., 2010). 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 observe, describe, and label their emotions accurately. These therapists validate their patient's emotions and help them explore their dysfunctional behavioral responses to these emotions (Goleman, 2020).

Medication is useful to manage symptoms that interfere with overall functioning, and it should always be used concomitantly with psychosocial interventions (Skodol, 2022b). Remember that BPD co-occurs with a number of psychiatric disorders at a higher rate compared to the general population (Skodol, 2022b; Skodol, 2022b). Symptoms that are treatable with medication fall into three main categories: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual symptoms (Skodol, 2022b; Nelson, 2024).

Factors used to inform medication selection include the following decision tree: which symptoms are most impairing and efficacious in treating the targeted domain; which of these medications have the least amount of side effects; and what is the patient's past drug history and responsiveness (Nelson, 2024). The provider must avoid changing medication each time there is a crisis or change in mood symptoms, which may occur frequently, and avoid any medications that can induce physiological dependence and tolerance, including benzodiazepines (Nelson, 2024).

Patients with BPD manifest symptoms of affective dysregulation through depressed mood or dysphoria, mood lability, anxiety, and anger (Skodol, 2022b; Nelson, 2024). Mood stabilizers or antipsychotic medications are used in patients with more severe symptoms. Antidepressants were not demonstrated in clinical trials (compared with placebo) to be effective in managing anxiety, depression, or anger (Nelson, 2024).

Patients with impulsive aggression, anger, irritability, binge eating, gambling, and self-mutilation may benefit from mood stabilizers such as lithium or lamotrigine when symptoms impair the patient's ability to engage in psychotherapy or when psychotherapy is ineffective (Nelson, 2024). Lithium in low doses manages these symptoms well, in contrast to the treatment of bipolar disorder, where much higher doses are required to effect mood stabilization (Nelson, 2024). Lamotrigine may also be an option, but the practitioner must consider the reliability of the patient to take medications consistently, and it is not appropriate for patients with barriers to regular medication adherence due to the risk of Stevens-Johnson Syndrome (Nelson, 2024).

For clients with recurrent self-injurious behavior, clinical research supports the addition of omega-3 fatty acids to manage better the symptom domains of impulsivity and affective dysregulation (Nelson, 2024).

Partial hospitalization describes a day treatment program where patients receive care during work hours but return home at night. These programs, commonly referred to as intensive outpatient programs (IOPs), typically last one to two weeks and involve counseling, medication management, and group therapy (Mochrie et al., 2020; Restek-Petrovic et al., 2023). Indications for partial hospitalization include (Schreiber & Culpepper, 2023):

• Harmful and impulsive behavior unable to be managed with outpatient treatment
• A worsening clinical picture with a persistent lack of adherence to outpatient care
• Moderately severe symptoms that are interfering with functioning at 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 (Mochrie et al., 2020; Oldham et al., 2010; Sharan et al., 2023):

• 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 O'Malley is a 27-year-old, unemployed, single Caucasian female. She arrives at your clinic today for a psychiatric evaluation, presenting with symptoms of dysphoria, chronic suicidal thoughts, and relationship problems with her boyfriend that have been ongoing for the past five 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 had 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 appeared well-groomed, alert, and oriented. She denies any illicit substance abuse but smokes about one pack of cigarettes per day and drinks two 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 sometimes 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.

Discussion

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 the 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 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 three 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 toward 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 toward his sisters. He has not received psychiatric treatment since he was 11 years old.

Discussion

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.