Continuing Education Activity

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists ten personality disorders that are divided into three clusters, clusters A, B, and C. Borderline personality disorder (BPD) is a cluster B disorder that is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect and behavior. Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. Surveys have estimated the prevalence of borderline personality disorder to be 1.6% in the general population and 20% in the inpatient psychiatric population. This activity examines the presentation and evaluation of borderline personality disorder and highlights the role of the interprofessional team in its management.

Objectives:

• Identify the epidemiology of borderline personality disorder.
• Describe the presentation of a patient with borderline personality disorder.
• Outline the treatment options available for borderline personality disorder.
• Explain interprofessional team strategies for improving care coordination and communication to advance the management of borderline personality disorder and optimize patient outcomes.

Introduction

A personality disorder is a disorder involving a rigid and unhealthy pattern of thinking. Personality disorders are prevalent in the general population and more so in clinical populations. In the pediatric population, all personality disorders can be diagnosed, except antisocial personality disorder, as long as the pathologic behavior has been present for a year or more. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists ten personality disorders divided into the 3 clusters (A, B, and C).[1] Borderline personality disorder (BPD) is 1 of 4 cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior.[2] Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. Surveys have estimated the prevalence of borderline personality disorder to be 1.6% in the general population and 20% of the psychiatric inpatient population.[3]

In contrast, obsessive-compulsive personality disorder (OCPD) appears to be the most prevalent personality disorder, with rates around 5% of the general population in some studies.[4] Patients with borderline personality disorder have been shown to utilize extensive treatment resources and are at increased morbidity and mortality compared with the general population. This is perhaps the reason why borderline personality disorder has been studied more extensively than other personality disorders.

Etiology

Borderline personality disorder is multifactorial in etiology. There is a genetic predisposition. Twin studies show over 50% heritability (greater than that for major depression).[5] Twin studies performed in 2000 and 2008 both demonstrated higher concordance of the rate of borderline personality disorder for monozygotic versus dizygotic twins. Environmental factors that have been identified as contributing to the development of borderline personality disorder include primarily childhood maltreatment (physical, sexual, or neglect), found in up to 70% of people with BPD, as well as maternal separation, poor maternal attachment, inappropriate family boundaries, parental substance abuse, and serious parental psychopathology.

There are many theories about the development of borderline personality disorder. In the mentalizing model of Peter Fonagy and Anthony Bateman, borderline personality disorder is the result of a lack of resilience against psychological stressors. In this framework, Fonagy and Bateman define resilience as the ability to generate adaptive re-appraisal of negative events or stressors; patients with impaired re-appraisal accumulate negative experiences and fail to learn from good experiences.[6] In the biosocial model popularized by Dr. Marsha Linehan, genetic vulnerability interacts with a "chronically invalidating environment" to produce the constellation of borderline personality disorder symptoms. In another theory, borderline personality disorder arises from the inability to regulate effect and the lack of formation of appropriate coping mechanisms in response to stress.[7] Otto Kernberg theorized that lack of integration in the early maternal relationship led to borderline personality disorder.[8] Kernberg hypothesized that the infant experiences the maternal figure in a dichotomous framework, the loving and nurturing mother who provides for the child and the punishing, hateful mother who deprives the child. This contradiction causes intense anxiety and, if not integrated into a more moderate unitary concept, ultimately leads to the development of splitting. The term "splitting" refers to the defense mechanism in which the patient cannot form a realistic view of another person. At any given time, the other person is viewed as entirely good or entirely bad. This inability to view others as having both positive and negative attributes impairs personal relationships.

Neuroimaging studies have identified differences in the amygdala, hippocampus, and medial temporal lobes in patients with borderline personality disorder. Such studies also suggest that patients with borderline personality disorder misattribute negative emotions (fear, anger, disgust) to neutral faces more so than controls or other patients, despite having the perception of happy and upset faces equivalent to those groups. Neurobiological studies have suggested that impaired neuropeptide function, particularly serotonin, may be present in patients with borderline personality disorder. On neuropsychological testing, a meta-analysis published in 2005 showed that patients with borderline personality disorder had lower performance on neurocognitive testing in the following domains: attention, cognitive flexibility, learning and memory, planning, speed processing, and visuospatial abilities.[9]

Epidemiology

Large, nationwide epidemiologic studies published in 2007 and 2008 estimated the point prevalence of borderline personality disorder in the general population at 1.6%, with a lifetime prevalence of 5.9%. No significant difference in rates of borderline personality disorder was found between females and males in the general population. In the clinical setting, however, the ratio of females to males has been reported as 3:1. These studies challenged previous reports that borderline personality disorder was more prevalent in women. The prevalence of borderline personality disorder in the psychiatric outpatient population has been estimated at 11%, and in the psychiatric inpatient population, as high as 20%. Multiple studies examining the relationship between ethnicity and borderline personality disorder have not produced similar results.[10][11]

Pathophysiology

The pathophysiology of borderline personality disorder is likely a combination of genetic predisposition combined with early childhood environmental factors and neurobiological dysfunction. A greater understanding of neurobiology and, specifically, neurotransmitter dysfunction may lead to improved therapeutic options for treating borderline personality disorder. A recent study published in 2015 examined the role of oxytocin in the regulation of social reward and empathy networks as a contributing cause of borderline personality disorder and other personality disorders. Specifically, serotonin dysregulation reducing the sensitivity of the 5HT-1A receptor may contribute to borderline personality disorder. Increased rates of learning disorders, attention-deficit/hyperactivity disorder, and neurocognitive deficits, as well as abnormal electroencephalographic findings, have also been reported in patients with borderline personality disorder.

History and Physical

A careful history and physical examination should be performed before performing a comprehensive psychiatric assessment. There are structured diagnostic screening tools that are used to assess personality disorders and specifically borderline personality disorder, for example, the Zanarini Rating Scale for borderline personality disorder.

The DSM-5 Diagnostic Criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, of self-image, and affects as well as 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, for example, spending, substance abuse, reckless driving, sex, binge eating, etc. Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.
5. Affective instability is caused by a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days.
6. Chronic feelings of emptiness.
7. Inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, constant anger, recurrent physical fights.
8. Transient paranoid ideation or severe dissociative symptoms.

Evaluation

Several diagnostic instruments are available to aid in the diagnosis, such as:

• The McClean screening instrument for borderline personality disorder
• Personality diagnostic questionnaire
• Structured clinical interview for DSM-5 personality disorders
• The Minnesota borderline personality disorder scale
• The personality assessment inventory-borderline features scale

Diagnostic tools may be separated into the general categories of the self-report and structured interview.

Patients with borderline personality disorder have been shown to have high rates of comorbid disorders:

• Mood disorders 80% to 96%
• Anxiety disorders 88%
• Substance abuse disorders 64%
• Eating disorders 53%
• Attention deficit hyperactivity disorder (ADHD) 10% to 30%
• Bipolar disorder 15%
• Somatoform disorders 10%

Treatment / Management

Treatment of borderline personality disorder relies on psychotherapy. Three evidence-based therapies are effective for patients with borderline personality disorder. First, mentalizing-based therapy (MBT) helps patients manage emotion dysregulation by feeling understood, allowing them to be more curious and make fewer assumptions about the intentions of the people around them. A second therapy, dialectical behavior therapy (DBT), combines mindfulness practices with concrete interpersonal and emotion regulation skills. Third, transference-focused psychotherapy (TFP) focuses on using the patient-therapist relationship to develop the patient's awareness of problematic interpersonal dynamics. MBT and DBT each incorporate individual and group treatment over 12 to 18 months. For adolescents, family therapy may be an appropriate substitute for group therapy, though not always.

No medications are FDA-approved for the treatment of borderline personality disorder. Medications such as SSRIs, mood stabilizers, and antipsychotics have shown limited effectiveness in trials aiming at the control of symptoms such as anxiety, sleep disturbance, depression, or psychotic symptoms. Anxiety can be challenging to treat because patients may label their internal experiences with the word anxiety, even when they are not truly based on fear. Thus, "anxiety" may need to be accurately re-labeled, with treatment recommendations stemming from the patient's specific internal experience. The exception to the misleading use of the word anxiety is that patients with borderline personality disorder often have a fear of being alone; in other words, they have attachment-related anxiety. However, attachment-related anxiety is not necessarily similar in etiology or treatment to recognized anxiety disorders.

Self-injurious behavior, boundary issues, and frequent suicidal threats present therapeutic challenges specific to the treatment of patients with borderline personality disorder. High rates of comorbid substance abuse may also confound the treatment of borderline personality disorder patients. Patients with borderline personality disorder do not typically require hospitalization; however, inpatient care may be required in certain situations, such as:

• Imminent risk of high lethality behaviors due to overt suicidal ideation or impulsivity
• Severe social stressors causing intense negative thoughts or transient psychosis
• The rapid escalation in the severity of self-injurious behavior
• Decompensation of comorbid psychiatric diagnoses or severe substance abuse

The traditional belief that prolonged (longer than one week) inpatient hospitalization is counterproductive or even deleterious for patients with borderline personality disorder was not supported in a recent study. The data showed equal improvement among inpatients with and without borderline personality disorder over several weeks of hospitalization.

Given high comorbidity with ADHD, all patients with borderline personality disorder should be screened for this condition. When dealing with adolescents, parents, and teachers should be asked to fill out a standardized questionnaire (Conners, SNAP, Vanderbilt). For adults, no standard of care is established for self-report or observer-report of inattentive or hyperactive symptoms. A combination of 2 self-reports to guide clinical decision-making, the ADHD Symptom Rating Scale (World Health Organization) and the Wender-Utah ADHD Rating Scale (WURS-25), provide more than 80% sensitivity and specificity.

Differential Diagnosis

When considering a diagnosis of borderline personality disorder, the differential diagnosis should always include other personality disorders since overlap is common, especially within cluster B. Other diagnostic considerations include:

• Substance use disorder
• Non-suicidal self-injury disorder (a time-limited phenomenon in many patients)
• Bipolar disorder (5-times less prevalent, but co-morbidity approaches 15%)
• Autism spectrum disorder (patients with congenital deficits in theory of mind may also show severe mood dysregulation)

Prognosis

There is a good prognosis for patients with borderline personality disorder. A longitudinal study of 290 inpatients diagnosed with borderline personality disorder and reassessed at 2-year intervals over 16 years yielded the following rates of remission:[12]

• 35% remission after 2 years
• 91% remission after 10 years
• 99% remission after 16 years

Unfortunately, the authors of this study noted that remission was associated with impoverished social relationships, leading them to suggest that patients may appear to remit because they avoid interpersonal relationships rather than gradually developing better interpersonal skills. Once achieved, remission was nonetheless sustained for over eight years in 75% of patients. Several factors were associated with the faster onset of remission, including lack of co-morbid, axis-1 disorders, no history of childhood sexual abuse, no history of family substance abuse, high baseline functioning (demonstrated at school or in the workplace), and less than 25 years. Sustained remission from borderline personality disorder has been demonstrated in several other studies as well.[13][14]

Complications

The complications of borderline personality disorder include:

• Engaging in risky behavior (e.g., rash driving)
• Drug abuse
• Not completing education
• Job loss
• Getting in trouble with the law
• Problems with relationships
• Suicide attempts

Deterrence and Patient Education

Patients and their families should be educated about borderline personality disorder and be provided with the necessary literature to learn about the condition. The families should be advised that the patients may get angry and suicidal and told to seek help immediately. In addition, patients should be encouraged to seek and continue psychotherapy until they experience sustained benefits.

Enhancing Healthcare Team Outcomes

Borderline personality disorder is one of the most difficult mental health disorders to manage; it is best managed with an interprofessional team, including psychiatrists, psychologists, pharmacists, mental health nurses, and social workers. Pharmacists review prescribed medications, check for drug-drug interactions and provide patient education. Mental health nurses and social workers provide care, monitor patients, participate in the education of patients and their families, and provide follow-up to the team. Unfortunately, there are no medications that seem to help; psychotherapy may help some patients, but compliance with treatment is low. The outcomes for most patients are poor, with many running into legal, social, and personal problems. [Level 5]