BORDERLINE PERSONALITY DISORDER

Diagnostic criteria for F60.31Borderline Personality Disorder

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, or 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

DEFINITION

DSM4 - a very good descriptor of the condition and is quoted because of that.

CASUAL FEATURES

There can be a wide range of causal features that encourage the development of the BPD. However, there are a number of factors that are considered to be most significant and most of them occur during childhood. It is generally agreed that the condition is established by early childhood, and some researchers suggest that it can be as early as 8 years old.

• The parenting techniques of the parents - the way parents apply discipline, set limits, create expectations, provide love and caring, and promote bonding, all are very significant determinants in the likelihood of the development of BPD.

• Parental types — the kind of personalities that parents have is most significant in the formation of BPD in the children. The alcoholic or drug dependent parent, whether either parent themselves have a pre existing mental condition, disciplinarian vs. soft touch, does everything parent.

• The size of the family— often the demands of a large family can quite stress out the parents and they may not have the resources (time, energy, patience) to give to the children that they would like

• The families’ socio/economic circumstances — any kind of obsession or fanaticism, such as religious zeal, can encourage the development of the condition. However, a lower economic environment is no indicator of the condition, rather the family environment is the determinate.

• Outside factors - sexual & psychological abuse, being bullied at school, illness in the family. The BPD is often struggling with deep seated bad thoughts about themselves that they are struggling to keep out of their awareness — hence many aspects of their behaviour eg blaming others, the distraction of crisis, substance abuse, eating disorders are designed to act as a distraction, often mixed with other gratifications.

    DIAGNOSIS

• DMS 4 Criteria

• Characteristics - Mood swings, Impulsivity, emotional vs logic based decisions, sabotaging behaviour, critical, negativity, demanding

• Presenting Symptoms - Often the patient will present with complaints of depression, anxiety, stress, victimisation at work, marital problems, police issues etc.

• Self Image - this is often distorted, and will fluctuate from low to high very quickly.

• Self Esteem - similarly, with self image, this is often distorted.

• Differential Diagnosis - Depression, Anxiety, Stress, Relationships, Drug & Alcohol abuse. Binge drinking is often a problem with this condition.

• BPD & other PDs - they often overlap!

• BPD & Bipolar Disorder - a common occurrence

• Resistance to the Diagnosis - they don’t want to know about it!

• Over diagnosis - its often a trap to diagnose someone who is difficult or problematic, as a BPD. However, even thought they may have similar patterns of behaviour to BPD, it may be for another reason entirely, eg Trauma (MVAs), Closed Head Injury, Disease, Drug Abuse.

    TREATMENT REGIME

• Containment - fixing the problem immediately is often not an option, rather one tries to minimise the disruptive behaviour first, such as dealing with suicidal ideation, self mutilation, violent behaviour.

• Support - BPD’s quickly decompensate when they have little support, so it is important to try to get some support structures in place as early as possible. Often the spouse will be suffering burn out, and may need some guidance as well.

• Structure - use of goals, both short and long term with rewards and reinforcers built in.

• Counselling - This is often a long term approach, but can be useful in bringing about stability, development and change. It is also very useful for the support and benefit of family members who live with the patient. This is often a long term process with the patient following up treatment with “top up” sessions months and years later.

• Countertransference - BPD’s are quick to develop this situation, often creating opportunities rather than just seizing those opportunities that present themselves.

• Recognition - recognition that there is an issue is important, but often the patient will be manipulating the situation to get a recognition of the diagnosis they want, rather than the one you may make.

• Medication - a range of medications are often prescribed for BPD’s when they present, but are often ineffectual in addressing the abhorrent behaviour. An antidepressant does not address the abhorrent behaviour, but may be necessary to stop or reduce related adverse behaviours such as self mutilation or other destructive behaviour. However, it will not affect the personality disorder.

• Primary clinician - There is a need for agreement as to who is the primary clinician. The patient can often play one off against the other, called splitting the treaters, it’s a favourite activity.

• Hospitalisation - this is often resorted to as a quick option, particularly in cases of self mutilation or self harm, but does not necessarily enhance treatment. It depends upon the way the patient is decompensating. Sometimes hospitalisation can play into the hands of the patient.

• Changing Treatment — the treatment strategy for the condition at the start of treatment is not permanent. Rather, it changes as the patient improves and develops. That is, at the beginning of treatment we may need to be supportive and non directive, to get trust and commitment from the patient, but as time progresses it may be necessary to change the tone of treatment, and perhaps push the patient a bit more.

• The value of Crisis — crisis can be a strong motivator for change, and often the patient with BPD will attend with marital difficulties, for example, and in this situation are highly motivated to change their ways. So a crisis can often be a valuable therapeutic tool!

    LEGAL LIABILITY ISSUES

• Safety – Some times a patient decompensates by being violent. It can and does happen. You need to take precautions for your own safety and that of your staff.

• Threats — BDP’s often make veiled threats (also open ones) about lodging complaints to authorities, Registration Boards etc. It’s a matter of judgement of whether to ignore the threat as amanipulation or address it as realistic.

• Complaints — When this occurs, saying the patient is a BDP is no defence. The bureaucratic process requires accountability and it will follow the complaint through. It is imperative to get legal advice. Making comprehensive notes is a very good action as they have a great deal of credibility with most authorities.

• Setting Boundaries  It is important to clearly establish what you are prepared and not prepared to do in treatment. BPD’s will try and make you their friend at first and then later they will test that friendship to make sure you are sincere. After a while, the relationship stops being a professional one and starts to become a personal one, despite all of your efforts to stop this occurring. So, it is important to be clear at the very beginning on what the limits and boundaries are. Do not discuss your own life or circumstances, no matter how convivial the discussion is. By all means be caring, but you are still the professional and you are there to do a job, you are not friends

OTHER ISSUES

• Resistance to being involved in treatment. Often the patient will not take kindly to being given a diagnosis that they have BPD, rather they want a diagnosis of their presenting symptom such as depression or anxiety or stress. For the patient, often the diagnosis of BPD means inadequacy, failure, rejection, “its all in my mind”, and this elicits the anger, accusation etc (which is a defence mechanism) that we are trying to overcome.

• Dealing with any kind of personality disorder patient is very demanding and draining. It is important to ensure that you are doing all the right things in looking after yourself through the process.

• The purpose of the exercise may not be about treatment at all. You may be an unwitting participant in a process where the patient is using you to beat up the spouse, boss at work, work colleague etc. So it is important to be clear in your mind what the issues are and to decide what you think is the right action to be taken for the issues.

• HELP - All personality disorders are pleading for help. They just don’t know how to ask and they don’t know how to accept it! However, they are still asking for help, and it is our job to provide that help.

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