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Borderline Personality Disorder (BPD)

Basics

  • Chronic psychiatric disorder marked by:
  • Emotional dysregulation
  • Distorted and unstable sense of self
  • Impulsivity
  • Chaotic interpersonal relationships including "splitting" (idealizing/devaluing others)
  • Usually manifests during adolescence, diagnosed in early adulthood
  • Frequent overuse of emergency services due to symptom severity

Epidemiology

  • Prevalence: ~1.6% general population
  • Accounts for 6% of primary care, 10% outpatient psych, and 20% inpatient psych visits
  • Onset typically adolescence to early adulthood

Etiology and Pathophysiology

  • Multifactorial: genetics + environment
  • Genetic risk increased in first-degree relatives
  • Childhood trauma (sexual, physical abuse, neglect), insecure attachment, and social stressors
  • Neurobiology: amygdala hyperactivity, decreased prefrontal cortex activation, reduced brain volumes and connectivity in frontal and limbic regions
  • Neurotransmitter dysregulation: serotonin, oxytocin, endogenous opioids

Risk Factors

  • Childhood sexual/physical abuse and neglect
  • Lack of secure early attachments
  • Ongoing social stressors

Prevention

  • Boundaries and time away for caregivers to protect well-being

Associated Conditions

  • High rates of comorbid depression, anxiety, panic disorder, substance abuse

Diagnosis

Screening

  • McLean Screening Instrument for BPD

Comprehensive Evaluation

  • Identify comorbidities, impairments, coping styles, stressors, strengths, and goals

History

  • Collateral from family/partners critical
  • Emotional instability, impulsivity, unstable relationships
  • Self-harm and suicidal threats/attempts

Physical Exam

  • Look for self-mutilation scars
  • Rule out medical causes for personality changes

Differential Diagnosis

  • Mood disorders (depression, anxiety, PTSD)
  • Psychotic disorders (hallucinations typically stress-related, no disordered thought)
  • ADHD
  • Substance use disorders
  • Medical causes (thyroid, neurological conditions)

Diagnostic Tests

  • Psychological testing to confirm DSM-5-TR criteria (≥5 of 9 criteria)
  • Labs as indicated (TSH, urine drug screen)
  • Rule out medical/chemical causes of personality change

Treatment

Psychotherapy

  • Dialectical behavior therapy (DBT) is most effective
  • Other therapies: transference-focused, CBT, mentalization, schema-focused, mindfulness-based
  • Longitudinal therapy required; not curable

General Measures

  • Manage expectations: focus on management not cure
  • Consistent appointments to reduce anxiety
  • Team communication to prevent splitting
  • Boundaries with provider

Medications

  • No FDA-approved meds for BPD specifically
  • Use meds to treat symptoms or comorbidities:
  • Second-generation antipsychotics (aripiprazole, olanzapine) for mood dysregulation, anger, psychotic-like symptoms
  • Mood stabilizers (valproic acid, lamotrigine, topiramate) with limited evidence
  • Omega-3 fatty acids may help depressive symptoms
  • Minimize risk of self-harm when prescribing

Admission

  • Limit hospitalizations; short stays for crisis stabilization and med adjustments
  • Consider inpatient for severe suicidality, substance use, nonadherence, or severe comorbidities

Ongoing Care

  • Frequent, focused, short visits to reduce anxiety and provider burnout
  • Monitor for suicidality and self-harm
  • Promote healthy lifestyle: exercise, nutrition, stress management

Patient Education

  • Include patients in treatment planning
  • Awareness of behavior impact

Prognosis

  • Symptoms often improve with age
  • Chronic management required

Clinical Pearls

  • BPD marked by emotional dysregulation, unstable self, and impulsivity
  • Establish clear provider boundaries
  • Psychotherapy (especially DBT) is mainstay; meds adjunctive
  • Use collateral history for accurate diagnosis