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Borderline Personality Disorder
Daniel E. Melville, MD
William G. Elder, PhD
image BASICS
Beginning no later than adolescence or early adulthood, borderline personality disorder (BPD) is a consistent and pervasive pattern of labile affect and sense of self, impulsivity, and volatile interpersonal relationships (1):
  • Common behaviors and variations:
    • Self-mutilation: pinching, scratching, cutting
    • Suicide: ideation, history of attempts, plans
    • Splitting: idealizing then devaluing others
    • Presentation of helplessness or victimization
    • High utilization of emergency department and resultant inpatient hospitalizations for psychiatric treatment
    • BPD patients are frequent users of primary care (2).
  • High rate of associated mental disorders
  • Typically display little insight into behavior
Geriatric Considerations
Illness (both acute and chronic) may exacerbate BPD and may lead to intense feelings of fear and helplessness.
Pediatric Considerations
Diagnosis is rarely made in children. Axis I disorders and general medical conditions are more probable.
Pregnancy Considerations
Physical, emotional, and social concerns may transiently mimic symptoms of BPD: Consider delay in diagnosis until pregnancy completed. Pregnancy may also induce stress or increased fears, resulting in escalation of borderline behaviors.
Predominant age: Onset no later than adolescence or early adulthood (may go undiagnosed for years)
  • General population: 0.5-5.9% of U.S. population (2)
  • Estimated lifetime prevalence: 10-13% (2)
  • 10% of all psychiatric outpatients and between 15% and 25% of patients in psychiatry inpatient settings have BPD (2).
  • 20-30% of patients in primary care outpatient settings have a personality disorder.
Undetermined, but generally accepted that psychiatric disorders are due to a combination of the following:
  • Hereditary temperamental traits
  • Environment (i.e., history of childhood sexual and/or physical abuse, history of childhood neglect, ongoing conflict in home)
  • Stress is theorized to exert damaging effects on the brain, specifically the hippocampus (2,3).
  • Neurobiologic research of BPD continues to increase the understanding of the etiology:
    • Abnormalities of the frontolimbic circuitry in relation to poor emotional stability (2)
    • Potential alterations in the sensitivity of opioid receptors and/or deficiencies with endogenous opioids (4)
    • Heightened activity in brain circuits involved in the experience of negative emotions and reduced activation that normally suppresses negative emotion once it is generated (5).
First-degree relatives are at greater risk for this disorder (undetermined if due to genetic or psychosocial factors).
  • Genetic factors contribute; however, no specific genes have yet been identified as causative (2).
  • Childhood sexual and/or physical abuse and neglect
  • Disrupted family life
  • Physical illness and external social factors may exacerbate borderline personality behaviors.
  • Tends to be a multigenerational problem
  • Children, caregivers, and significant others should have some time and activities away from the borderline individual, which may protect them.
Other psychiatric disorders, including:
  • Co-occurring personality disorders, frequent
  • Mood disorders, common
  • Anxiety disorders, common
  • Substance-related disorders, common
  • Eating disorders, common
  • Posttraumatic stress disorder, common
  • BPD does not appear to be independently associated with increased risk of violence.
  • The comprehensive evaluation should focus on (6)[B]:
    • Comorbid conditions
    • Functional impairments
    • Adaptive/maladaptive coping styles
    • Psychosocial stressors
    • Patient strengths; needs/goals
  • Initial assessment should focus on determining treatment setting (6)[B]:
    • Establish treatment agreement with patient and outline treatment goals.
    • Assess suicide ideation and self-harm behavior.
    • Assess for psychosis.
    • Hospitalization is necessary if patient presents a threat of harm to self or others.
  • BPD patients should have a thorough physical examination to help lower suspicion of organic disease (especially thyroid disease) (1,2).
  • Often physical examination reveals no gross abnormalities, other than related to scarring from self-mutilation.
  • Mood disorders:
    • Look at baseline behaviors when considering BPD versus mood disorder.
    • BPD symptoms increase the likelihood of misdiagnosing bipolar disorder.
    • In particular, disruptive mood dysregulation disorder, a new diagnosis appearing in DSM-5 and characterized by severe recurrent temper outbursts manifesting verbally or behaviorally and grossly out of proportion to the situation, may appear quite similar to the acting out and intense emotions seen in BPD. Look for other symptoms characteristic of BPD to differentiate (1).
  • Psychotic disorder:
    • With BPD, typically only occurs under intense stress and is characterized as “micropsychotic.”
  • Other PD:
    • Thoughts, feelings, and behavior will differentiate BPD from other PDs.
  • GMC:
    • Traits may emerge due to the effect of a GMC on the CNS.
  • Substance use
  • Consider age of onset. To meet criteria for BPD, borderline pattern will be present from adolescence or early adulthood.
  • Formal psychological testing
  • Rule out personality change due to a general medical condition (GMC) (1)[C]:
    • Traits may emerge due to the effect of a GMC on the CNS.
  • Rule out symptoms related to substance use.
  • If symptoms begin later than early adulthood or are related to trauma (e.g., after a head injury), a GMC, or substance use, then consider other diagnoses.
Diagnostic Procedures/Other
According to DSM-5 criteria, patient must meet at least five of the following criteria (1)[C]:
  • Attempt to avoid abandonment
  • Volatile interpersonal relationships
  • Identity disturbance
  • Impulsive behavior:
    • In ≥2 areas
    • Impulsive behavior is self-damaging.
  • Suicidal or self-mutilating behavior
  • Mood instability
  • Feeling empty
  • Is unable to control anger, or finds it difficult
  • Paranoid or dissociative when under stress
  • With advent of DSM-5, an alternative model is being promulgated that may come to define the diagnosis as impairments in personality functioning AND the presence of pathologic traits. Attention to these features may ultimately enhance provider understanding, diagnosis, and treatment of patients with personality dysfunction.
    • Criteria regarding personality functioning refer to impairments of self-functioning (i.e., identity or self-direction) AND interpersonal functioning (i.e., empathy or intimacy).
    • Pathologic personality traits refer to characteristics in the domains of negative affectivity (i.e., emotional liability, anxiousness, separation insecurity, depressivity); disinhibition (i.e., impulsivity, risk taking); OR antagonism (1).

  • Outpatient psychotherapy for BPD is the preferred treatment (2,6)[B]:
    • Dialectical behavior therapy (DBT) combines cognitive-behavioral techniques for emotional regulation and reality-testing with concepts of distress tolerance, acceptance, and self-awareness.
      • Following a dialectal process, therapists are tough-minded allies, who validate feelings and are unconditionally accepting, while also reminding patients to accept their dire level of emotional dysfunction and to apply better alternative behaviors.
      • DBT may be done individually and in groups.
  • Consider transference-focused psychotherapy.
  • Patient may need to be placed on suicide watch.
  • Brief inpatient hospitalizations are ineffective in changing Axis II disorder behaviors:
    • Hospitalizations should be limited, and of short duration to adjust medications, implement psychotherapy for crisis intervention, and to stabilize patients from psychosocial stressors.
  • Extended inpatient hospitalization should be considered for the following reasons (6)[B]:
    • Persistent/severe suicidal ideation or risk to others
    • Comorbid substance use and/or nonadherence to outpatient or partial hospitalization treatments
    • Comorbid Axis I disorders that may increase threat to life for the patient (i.e., eating disorders, mood disorders).
Focus on patient management rather than on “fixing” behaviors:
  • Schedule consistent appointment follow-ups to relieve patient anxiety.
  • Meet with and rely on treatment team to avoid splitting of team by patient, and to provide opportunity to discuss patient issues.
  • Treatment is usually most effective when both medications and psychotherapy are used simultaneously.
  • Although no specific medications are approved by the FDA to treat BPD, American Psychiatric Association (APA) guidelines recommend pharmacotherapy to manage symptoms (2)[A],(6)[B].
  • Treat Axis I disorders (6)[B].
  • Consider high rate of self-harm and suicidal behavior when prescribing (2)[A].
  • APA guideline recommendations (6)[B]:
    • Affective dysregulation: mood stabilizers, SSRIs, and monoamine oxidase inhibitors (MAOIs)
    • Impulsive-behavioral control: SSRIs and mood stabilizers
    • Cognitive-perceptual symptoms: antipsychotics
  • With more neurobiologic causes considered in relation to BPD, there is more emphasis on mood stabilizers and atypical antipsychotics, but research is uncertain and inconclusive (8)[B].
  • Antipsychotics have short-lived benefit and offer no value other than transient treatment of cognitive perceptual symptoms (9)[B].
  • If hospitalized, consider for suicide risk, mood or anxiety disorders, or substance-related disorders.
  • Urgency for scheduled follow-up depends on community resources (e.g., outpatient day programs for suicidal patients; substance abuse programs):
    • With increased risk for self-harm or self-defeating behaviors and low community resources, the patient can/will have increased need for frequent visits.
Consider referring patient for specialized mental health behavioral services, including partial hospital therapy.
Omega-3 fatty acid dietary supplementation has shown beneficial effects (2)[B].
Admission Criteria/Initial Stabilization
Admit for inpatient services immediately in presence of psychosis or threat of injury to self or others; include police, as necessary, for safety measures.
  • Assess suicidal ideation.
  • Consider trial of antipsychotic medications for psychosis.
Nurses can be instrumental in managing and calling patients, potentially relieving patient stress.
Discharge Criteria
  • Patient should not present risk of harm to self or others and have a safety plan.
  • Follow-up should be scheduled with a mental health specialist and primary care provider.
  • Schedule visits that are short, more frequent, and focused to relieve patients' anxiety about relationships with their physician/provider and to help reduce risk of provider burnout.
  • Maintain open lines of communication with mental health professionals providing psychological support.
  • Emphasize importance of healthy lifestyle modifications (i.e., exercise, rest, diet).
Patient Monitoring
Monitor for suicidal or other self-harm behaviors.
Include patients in the diagnosis so they can make sense of their disease process and participate in the treatment strategy (6,9)[C].
  • Borderline behaviors may decrease with age and over time.
  • Patients in treatment improve at a rate of seven times compared with following natural course (10).
  • Treatment is complex and takes time.
  • Medical focus includes patient management and caring for medical and Axis I disorders.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
2. Leichsenring F, Leibing E, Kruse J, et al. Borderline personality disorder. Lancet. 2011;377(9759):74-84.
3. Ruocco AC, Amirthavasagam S, Zakzanis KK. Amygdala and hippocampal volume reductions as candidate endophenotypes for borderline personality disorder: a meta-analysis of magnetic resonance imaging studies. Psychiatry Res. 2012;201(3):245-252.
4. Bandelow B, Schmahl C, Falkai P, et al. Borderline personality disorder: a dysregulation of the endogenous opioid system? Psychol Rev. 2010;117(2):623-636.
5. Ruocco A, Amirthavasagam S, Choi-Kain LW, et al. Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis. Biol Psychiatry. 2013;73(2):153-160.
6. Oldham JA. Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Arlington, VA: American Psychiatric Association; 2005.
7. Zanarini MC, Laudate CS, Frankenburg FR, et al. Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up. J Pers Disord. 2013;27(6):783-794.
8. Feurino L III, Silk KR. State of the art in the pharmacologic treatment of borderline personality disorder. Curr Psychiatry Rep. 2011;13(1):69-75.
9. Sanislow CA, Marcus KL, Reagan EM. Long-term outcomes in borderline psychopathology: old assumptions, current findings, and new directions. Curr Psychiatry Rep. 2012;14(1):54-61.
10. Elder W, Walsh E. Personality disorders. In: South-Paul J, Matheny S, Lewis E, eds. Current Diagnosis & Treatment in Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2011.
F60.3 Borderline personality disorder
Clinical Pearls
  • View BPD as a chronic condition with waxing and waning features. It is important to adjust medications/treatments as clinically appropriate when symptoms change.
  • If there are problems with the patient disrespecting the physician or support staff, clear guidelines should be established with the treatment team and then with the patient.
  • When considering terminating care, the patient may improve if empathetically confronted about certain behaviors and is given clear guidelines on how to behave in the clinic. It is the patient's job to follow the guidelines, and it is you and your team's job to enforce the guidelines. Designate a case management nurse or well-trained support staff person who can be the primary contact person for the patient.
  • Have an agenda when you visit with BPD patients. Be cordial—they deserve the same professionalism any patient gets. Have and identify 1 to 2 issues to be discussed per clinic visit. Frequently scheduled visits can help with this.
  • Regularly scheduled psychotherapy treatment helps physician performance by becoming the “home” for mental health treatment, leaving the physician to focus on the patient's immediate medical issues.