Borderline personality disorder

Borderline personality disorder is hard to define because no-one agrees how to define it.

• features include impulsivity, unpredictability, unstable and intense interpersonal relationships, with inappropriate, sudden outbursts of anger and loss of temper with suicidal gestures, self mutilation and fighting. There may be chronic feelings of loneliness and boredom, resulting in a striving to be in company. There may be confused identity and goals
• NICE suggest that borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour (1)
  • pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm
  • also transient psychotic symptoms, including brief delusions and hallucinations, may be present
  • associated with substantial impairment of social, psychological and occupational functioning and quality of life
  • particularly at risk of suicide
  • extent of the emotional and behavioural problems experienced by people with borderline personality disorder varies considerably
    • some people with borderline personality disorder are able to sustain some relationships and occupational activities
    • people with more severe forms experience very high levels of emotional distress. They have repeated crises, which can involve self-harm and impulsive aggression. They also have high levels of comorbidity, including other personality disorders, and are frequent users of psychiatric and acute hospital emergency services
      
      
• borderline personality disorder is present in just under 1% of the population
  • most common in early adulthood
    
    • women present to services more often than men. Borderline personality disorder is often not formally diagnosed before the age of 18, but the features of the disorder can be identified earlier
• course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties
• often comorbid with depression, anxiety, eating disorders, post-traumatic stress disorder, alcohol and drug misuse, and bipolar disorder (the symptoms of which are often confused with borderline personality disorder)
  
  
• recognition and management in primary care
  • recognition of borderline personality disorder
    • if a person presents in primary care who has repeatedly self-harmed or shown persistent risk-taking behaviour or marked emotional instability, consider referring them to community mental health services for assessment for borderline personality disorder. If the person is younger than 18 years, refer them to CAMHS for assessment
  • crisis management in primary care
    • when a person with an established diagnosis of borderline personality disorder presents to primary care in a crisis:
      • assess the current level of risk to self or others
      • ask about previous episodes and effective management strategies used in the past
      • help to manage their anxiety by enhancing coping skills and helping them to focus on the current problems
      • encourage them to identify manageable changes that will enable them to deal with the current problems
      • offer a follow-up appointment at an agreed time
  • referral to community mental health services
    • consider referring a person with diagnosed or suspected borderline personality disorder who is in crisis to a community mental health service when:
      • their levels of distress and/or the risk to self or others are increasing
      • their levels of distress and/or the risk to self or others have not subsided despite attempts to reduce anxiety and improve coping skills
      • they request further help from specialist services

Notes:

• community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder
  • role of drug treatment
    • drug treatment 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)
      • antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder
      • drug treatment may be considered in the overall treatment of comorbid conditions
      • short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with borderline personality disorder in a crisis. The duration of treatment should be agreed with them, but should be no longer than 1 week
    • drug treatment during crises
      • management of crises apply to is undertaken via secondary care and specialist services for personality disorder - also be undertaken by GPs with a special interest in the management of borderline personality disorder within primary care
        • short-term use of drug treatments may be helpful for people with borderline personality disorder during a crisis
        • when prescribing short-term drug treatment for people with borderline personality disorder in a crisis:
          • choose a drug (such as a sedative antihistamine ) that has a low side-effect profile, low addictive properties, minimum potential for misuse and relative safety in overdose
          • use the minimum effective dose (note that Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented)
          • prescribe fewer tablets more frequently if there is a significant risk of overdose
          • agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment
          • agree with the person a plan for adherence
          • discontinue a drug after a trial period if the target symptoms do not improve
          • consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish
          • arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided.

For detailed advice then consult the full NICE guideline (1).

Reference:

• 1. NICE (January 2009).Borderline personality disorder - treatment and management