Borderline Personality Disorder

What is borderline personality disorder?

Borderline personality disorder (BPD) is a cluster B personality disorder characterized by emotional dysregulation, a pattern of unstable interpersonal relationships, and high impulsivity and recklessness. Its prevalence rate is 1.6-6%, but its rate can be as high as 20% in inpatient psychiatric care settings. BPD is more commonly diagnosed in women than in men.

What does borderline personality disorder look like?

Signs & Symptoms

Impulsive and risky behavior, such as having unsafe sex, gambling, or binge eating
Unstable or fragile self-image
Unstable and intense relationships
Up and down moods, often as a reaction to interpersonal stress
Suicidal behavior or threats of self-injury
Intense fear of being alone or abandoned
Ongoing feelings of emptiness
Frequent, intense displays of anger
Stress-related paranoia that comes and goes

DSM-5 Criteria

Criterion A. 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 at least 5 of the following:

Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
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.)
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
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).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g. - frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.

Risk Factors

Childhood adversities - physical and sexual abuse, neglect, hostile conflict, early parental loss
First-degree relative with BPD (increases risk fivefold)

Differential Diagnosis

Identity problems
Depressive disorders
Bipolar disorders
Histrionic personality disorder
Schizotypal personality disorder
Antisocial personality disorder
Paranoid personality disorder
Narcissistic personality disorder
Dependant personality disorder
Personality changes due to another medical condition
Substance use disorders

Micropsychosis or Quasipsychosis

Micropsychosis is a psychotic episode that lasts for a very brief duration of time, such as for a few minutes to a few hours, and is usually triggered by heightened emotions or stress. Any auditory hallucinations would typically be negative in tone, and there could be dissociative symptoms.

How is borderline personality disorder treated?

Medications should not be considered for first-line treatment for borderline personality disorder. If used, the focus of the medications should be to target certain symptoms, and they should be for short-term relief.

According to a 2010 Cochrane Review, some medications are recommended for the following symptom clusters:

Interpersonal pathology:
- Aripirazole, valproate, topiramate
Affective dysregulation:
- Topiramate, lamotrigine, valproate, haloperidol, aripiprazole, olanzapine
Impulse-behavioral dyscontrol:
- Topiramate, lamotrigine, flupentixol, aripiprazole, omega-3 fatty acids
Cognitive-perceptual:
- Aripiprazole, olanzapine

Antipsychotics should not be used for medium- and long-term management of borderline personality disorder.

Nursing Management

Risk for self-mutilation

Causes & Behaviors:

Desperate need for attention
Emotionally disturbed or battered children
Feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization
History of self-injury
History of physical, emotional, or sexual abuse
High-risk populations, such as those with borderline personality disorder
Impulsive behavior
Inability to verbally express feelings (alexithymia)
Ineffective coping skills

Interventions:

Assess the client’s history of self-mutilation: types of mutilating behaviors, frequency behaviors, and stressors preceding behavior. Identifying patterns and circumstances surrounding self-injury can help with planning interventions and teaching strategies suitable to the client.
Identify feelings experienced before and around the act of self-mutilation.
Feelings are a guideline for future intervention (e.g. rage at feeling left out or abandoned).
Explore with the client what these feelings might mean. Self-mutilation might also be a way to gain control, a way to feel alive through pain, or an expression of self-hate or guilt.
Secure a written or verbal no-harm/safety contract with the client. Identify specific steps (e.g. people to call upon when prompted to self-mutilate). The client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases.
Set and maintain limits on acceptable behavior and make clear the client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules. Clear and nonpunitive limit setting is essential for decreasing negative behaviors.
Be consistent in maintaining and enforcing the limits, using a nonpunitive approach. Consistency can establish a sense of security.
Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy. A neutral approach prevents blaming, which increases anxiety, giving special attention that encourages acting out.
After the treatment of the wound, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating. Identifies dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.
Work out a plan identifying alternatives to self-mutilating behaviors. The plan is periodically reviewed and evaluated, and it offers a chance to deal with feelings and struggles that arise.

Impaired social interaction

Causes & Behaviors:

Difficulties with emotional regulation
Lack of empathy for others
Poor impulse control
Disruptive or abusive early family background
Rigid and inflexible thinking patterns
Immature interests
Unacceptable social behavior or values
Alienating others through angry, clinging, demeaning, and/or manipulative behavior or ridicule toward others
Destructive behavior toward self or others
Dysfunctional interaction with peers, family, and/or others
Observed use of unsuccessful social interaction behaviors

Interventions:

Monitor your own thoughts and feelings constantly regarding your response to the client. Supervision is strongly recommended for new and seasoned clinicians alike when working with clients with personality disorders. Strong and intense countertransference reactions are bound to occur. When the nurse is enmeshed in his or her own strong reactions toward the client (either positive or negative), nurse effectiveness suffers, and the therapeutic alliance might be threatened.
Set limits on any manipulative behaviors such as arguing or begging, angry, demanding behaviors, flattery or seductiveness, instilling guilt, clinging, constantly seeking attention, pitting one person, staff, or group against another, frequently disregarding the rules, and constant engagement in power struggles. From the beginning, limits need to be clear. It will be necessary to refer to these limits frequently because it is to be expected that the client will test these limits repeatedly.
- All limits should be adhered by all staff involved
- Objective physical signs in managing clinical problems should be carefully documented
- Provide clear boundaries and consequences
- Enforce the consequences
Understand that PD clients in particular will be resistant to change and that this is symptomatic of PDs. This is particularly true in the beginning phases of therapy. Responding to the client’s resistance and seeming lack of change in a neutral manner is part of the foundation for trust. In other words, the nurse does not have a vested interest in the client “getting better.”. The nurse remains focused on the client’s needs and issues in any event.

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Lieb, K., Völlm, B., Rücker, G., Timmer, A., & Stoffers, J. M. (2010). Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. The British Journal of Psychiatry, 196(1), 4–12.

[4] Schultz, H. E. & Hong, V. (2017). Psychosis in borderline personality disorder: How assessment and treatment differs from a psychotic disorder. Current Psychiatry, 16(4).

[5] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.