Borderline Personality Disorder

Borderline personality disorder is characterised by pervasive instability of interpersonal relationships, self-image and mood, and impulsive behaviour. The term 'borderline' is perhaps misleading as it implies that patients 'almost have a personality' disorder. In fact it is an established category of personality disorder in the DSM-IV classification.

There is a pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection. There is a particularly strong tendency towards suicidal thinking and self-harm.

Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. It is also associated with substantial impairment of social, psychological and occupational functioning and quality of life.

People with borderline personality disorder are particularly at risk of suicide.
Its course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties.

There are nine categories of ICD-10 personality disorder and ten categories of DSM-IV personality disorder. The classification scheme is unwieldy as personality disordered patients rarely belong to just one category of personality disorder. However, the DSM clustering system provides a useful solution to this problem by grouping the subcategories of DSM-IV personality disorder into three broad ‘clusters’ ( A, B and C).¹ This is detailed in the article Personality Disorders and Psychopathy.
The important feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulses are poorly controlled. At times they may appear psychotic because of the intensity of their distortions. It is a commonly overused diagnosis in DSM-IV.

• Epidemiological data needs to be interpreted with care as diagnostic standards vary.
• Personality disorders as a whole are common conditions. There is considerable variation in severity, and in the degree of distress and dysfunction caused.
• Studies indicate prevalence of 10-13% of the adult population for all types of personality disorder.
• Personality disorders are more common in younger age groups (25-44 yrs).
• Personality disorders are particularly prevalent amongst inpatients with drug, alcohol, and eating disorders.
• The prevalence of personality disorders in psychiatric hospital populations ranges between 36%-67%.
• Although overall personality disorders are distributed equally between males and females, borderline personality disorder is commoner amongst females.
• Black people attract a diagnosis of personality disorder relatively infrequently. It is still unclear whether this reflects a true difference in prevalence or errors of diagnostic practice.

Patients with the disorder can present with:

• Relationship difficulties
• Recurrent self-harm
• Threats of suicide
• Depression
• Bouts of anger
• Impulsivity
• Social difficulties
• Transient psychotic symptoms

• Alcoholism
• Mental disorders secondary to medical conditions (head injuries, seizure disorders)
• Other personality disorders
• Anxiety disorders
• Mental retardation
• Brief psychotic disorder
• Post-traumatic stress disorder
• Depression
• Schizoaffective disorder
• Schizophrenia
• Ganser's syndrome

• Toxicology screen because substance abuse is common (as with many personality disorders). Intoxication can lead patients to present with some features of personality disorders.
• Screening for HIV and other sexually transmitted diseases may be appropriate because of the poor impulse control and disregard of risk associated with personality disorder.
• Psychological testing may support or direct the clinical diagnosis. For example:
  • The Minnesota Multiphasic Personality Inventory (MMPI)
  • The Eysenck Personality Inventory (EPI)
  • The Personality Diagnostic Questionnaire (PDQ)
  These have not been reliably validated against DSM-IV-TR diagnoses.
  The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.

• Anxiety
• Alcohol misuse
• Drug misuse
• Depression
• Recurrent self-harm

Funding should have been made available since 2003 to develop personality disorder services. All Trusts need to consider how to meet the needs of patients with a personality disorder who experience significant distress or difficulty as a result of their disorder.¹ Recent NICE guidance specifically for the treatment and management of patients with borderline personality disorder has now been issued to help shape the provision and integration of these services.³

General considerations

Care should involve collaboration between different agencies and professionals.
Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plan with the service user (and their family or carers, where agreed with the person). The care plan should:

• Identify clearly the roles and responsibilities of all health and social care professionals.
• Identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them.
• Identify long-term goals (including employment), that the person would like to achieve. These should underpin the overall long-term treatment strategy.
• Develop a crisis plan which:
  • Identifies potential triggers that could lead to a crisis
  • Specifies self-management strategies likely to be effective
  • Establishes how to access services (including support numbers for out-of-hours teams and crisis teams)
• Be shared with the GP and the service user.

Psychological treatment

It is important NOT to use brief psychological interventions (of less than 3 months’ duration) for borderline personality disorder or for the individual symptoms of the disorder outside a service that has the characteristics outlined below. Psychological treatment for people with borderline personality disorder (especially those with multiple comorbidities and severe impairment) should include:

• An explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user.
• Structured care in accordance with this guideline.
• Provision for therapist supervision.
• Twice-weekly sessions (although the frequency of psychotherapy sessions should be adapted to the person’s needs).

Drug treatment^4,5

• Drugs should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms).
• Consider drug treatment in the overall treatment of comorbid conditions.
• Consider cautiously short-term use of sedative medication as part of the overall treatment plan for people with borderline personality disorder in a crisis. Agree the duration of treatment with them, but it should be no longer than 1 week.
• Review the treatment of those who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs. Aim to reduce and stop unnecessary drug treatment.

In primary care

• Suicide⁶
• Substance abuse
• Accidental injury
• Depression
• Homicide

The course of borderline personality is variable and, although many people recover or improve over time, many continue to experience social and interpersonal difficulties.

It is not clear how much early recognition and management improve prognosis and prevent long-term morbidity.