Treatment considerations for the patient with borderline personality disorder

Causative factors 

A large body of research suggests that BPD is a problem arising from numerous factors, such as trauma or abuse, genetic predisposition, and dysregulation of neurobiologic processes [10], [11], [12], [13]. Of particular interest is the relationship between causative factors and self-injurious behaviors. Numerous data indicate a host of biologic correlates of suicidal and other self-injurious behaviors related to decreased levels of serotonin (5-hydroxytryptamine) found in the brainstem of suicide victims and lower levels of cerebrospinal fluid 5-hydroxyindoleacetic acid found in attempters [10], [11], [14]. These data also indicate the importance of diverse treatment interventions, comprising pharmacologic and nonpharmacologic interventions, to treat this complex psychiatric disorder.

Assessment and diagnostic considerations 

Typically the patient seeks treatment during a perceived crisis that parallels a real or imagined valued relationship breakup. Patients with BPD have difficulty being alone, and relationship breakups worsen their anxiety and distress. Mood swings are common, resulting in a high state of agitation or irritability 1 minute and a dysphoric or depressed mood later. Their clinging or smothering behaviors tend to generate various emotions in nurses. During these periods, the nurse must convey empathy, maintain clear boundaries, and explain all procedures and work with other providers to maintain consistent and firm limit setting. Intense emotional states and clinging behaviors challenge nurses to control their own negative reactions and form therapeutic interactions.

Establishing a therapeutic relationship entails conveying empathy and concern, while maintaining clear boundaries. The nurse is challenged to recognize personal boundaries between self and patients. Nurses must define their role clearly as a health care provider and not “a buddy or friend.” A failure to do so increases the risk of blurred boundaries and confusion in the patient's expectations from the nurse and relationship. Patients with BPD are experts at determining and “pushing” the nurse's “buttons.” Pushing buttons often involves making personal attacks about the nurse's appearance and educational preparation and negative discussions from other staff. It behooves the nurse to recognize these behaviors as maladaptive interpersonal features of BPD and to refrain from responding defensively or angrily. Nurses must focus on the issues at hand by making statements such as “Mary, what does the size of my hips or my educational preparation have to do with the discussion concerning your behavior?” A failure to understand one's own “buttons” increases the risk of reinforcing negative and rejecting responses to the patient, who, ironically, needs empathy and understanding.

Another important aspect of the assessment process includes making a differential diagnosis of medical conditions, substance-related conditions, or psychiatric conditions and performing a mental status examination. Major components of a mental status examination include the following:

Suicidal assessment includes questions about present thoughts, plan, means, intent, and imminence of acting on thoughts; past suicide attempts; and other self-injurious behaviors (eg, wrist cutting). Functions of self-injurious behaviors vary, but most research indicates an absence of pain during the episode and that it seems to act as a dissociative defense (ie, depersonalization and perceptual distortions) or a release of endogenous (natural substance) opioids when severe emotional states occur.

The above-listed data must be documented and discussed with various members of the treatment team. When a differential diagnosis is made, which rules out medical, psychiatric, and substance-related conditions, the nurse and other team members can determine if the patient has BPD.

The essential features of the patient with BPD include the following:

It is imperative for the nurse to recognize that BPD is an Axis II disorder (personality disorder) and to recognize the high comorbidity of depression, anxiety disorders, and substance-related disorders (Axis I). There is overwhelming evidence that links Axis I disorders with BPD because of early childhood traumas and adversities. These disorders must be assessed and treated appropriately. A failure to assess Axis I conditions increases the risk of suicide and other self-injurious behaviors. The following discussion describes how the patient with BPD may present in primary care settings and emergency departments.

In primary care and other practice settings, the patient may go from one provider to another with various somatic and psychiatric complaints, generating chaos or “staff splitting,” which results in anger and frustration and a failure to address the patient's concerns appropriately. Nurses must maintain an empathetic and accepting demeanor and set firm and consistent limits with the demanding patient. Despite the tendency to focus on somatic complaints, these symptoms require a thorough physical evaluation. Because of patients' intense dependency needs and hostility toward staff when staff fails to meet them in a timely manner, nurses must anticipate intense rage and anger and respond appropriately and assertively.

Another assessment and diagnostic feature of BPD is suicidality and other self-injurious behaviors. Nurses in various mental health settings need to accept these symptoms and focus treatment planning on dealing with underlying causes. It is imperative for the nurse to respond empathetically rather than judgmentally, while assessing the patient's imminent risk of danger to self or others. When a patient attempts suicide, it is imperative to avoid reinforcing this behavior, but rather to strengthen adaptive coping behaviors. The level of care necessary after an attempt parallels the seriousness or lethality of the attempt. Often the patient threatens suicide or other self-destructive behaviors, and the patient must be taken seriously and assessed and managed appropriately. When caring for the patient with BPD who expresses suicidal intent, a failure to misjudge the risk may be tragic. Studies indicate an 8% to 10% incidence of suicide in patients with BPD and a prevalence of more than 400 times higher than in the general population and more than 800 times higher than in adolescent girls [2], [16].

Patients with BPD are likely to have a different presentation when they arrive in emergency departments in a crisis than in primary care settings. During a psychiatric crisis, the patient may have overdosed, may have cut a wrist, or may exhibit other self-destructive behaviors or threats. Because of the high risk of self-harm, nursing staff must search carefully for sharp objects or other harmful items. Major goals in the emergency department include preventing harm, stabilization, and addressing the patient's emotional and psychiatric needs. Nurses must convey concern and provide consistent and firm limit setting during a psychiatric emergency [17]. When the patient is medically cleared, psychiatric interventions can be implemented. Additional treatment considerations during a psychiatric emergency include verbal de-escalation, pharmacologic interventions, and other psychotherapeutic interventions. When the patient's emotional and psychiatric conditions are stable, the nurse and other team members must make an appropriate referral and disposition. An in-depth discussion of specific pharmacotherapy and psychotherapeutic interventions follows later.

Normally the patient is involved in a treatment program with a team or primary therapist. The central role of the primary therapist is to oversee safety and contract for safety and hospitalization as necessary. Contacting the therapist is helpful in validating information and ensuring adequate follow-up. If the patient is not in treatment, consultation with a mental health professional or center is crucial to ensure follow-up. A “no-harm” or safety contract is necessary during a crisis situation to avail options to the patient and family in the event of recurrent suicidal thoughts and self-injurious behaviors. “Contracting for safety” [2] often includes the following:

Thorough documentation of the decision-making process is crucial. Although hospitalization may be considered, as a result of managed care guidelines, certain parameters have been established that support hospitalization (ie, imminent danger to self or others, unstable psychiatric or medical conditions). Although hospitalization is unproven to be effective in the prevention of suicide, it has some limited indications. Specific indications for acute psychiatric hospitalization of the patient with BPD include brief psychosis, life-threatening suicide attempts, threats, and self-injurious behaviors [7]. Sometimes a brief hospitalization enables the mental health team to review the treatment planning and medication stabilization. Negative consequences of hospitalization include dependency and reinforcement of maladaptive behaviors.

An important point to remember about the patient at risk for suicide is assessing the level of nurse involvement. Specifically, nurses must refrain from “rescuing” the patient who threatens suicide and focus more on assessing the need for involvement behind the thoughts and threats.

Pharmacologic and psychotherapeutic considerations 

Because of the complexity of BPD and continual risk of suicide, nurses must enlist a holistic and interdisciplinary approach to facilitate adaptive coping behaviors and an optimal level of functioning. Depending on the nurse's educational preparation and clinical expertise, the nurse is likely to provide an array of mental health services. Likely mental health services often comprise medication administration or management, psychoeducation, intensive case management, and various psychotherapies. Nurses in primary care and other non–mental health settings must collaborate with mental health nurses and other mental health professionals to avoid becoming part of the “splitting behaviors” that generate tension and interpersonal conflicts between staff. Pharmacologic and psychotherapeutic interventions are key components of treatment planning and have proven efficacy in helping patients cope with intense emotional states, dysphoria (intense sadness), and dyscontrol behaviors.

Summary 

BPD is a major health problem. The high prevalence of patients with BPD in primary care and mental health settings contributes to their high use of resources in these practice settings. Recurrent suicidal behaviors and threats and self-injurious behaviors increase demands on nurses and other health care providers. Regardless of how often the patient presents with these behaviors, nurses must assess acute risk. Because suicidal behavior is often a cry of distress, nurses must avoid personalizing their reactions and monitor their own responses to ensure a therapeutic nurse-patient relationship. This article has focused on the challenge of caring for the patient with BPD. It has delineated important nursing interventions that enable the nurse to assess the patient's immediate needs and manage distressful and overwhelming emotional states and impulsivity.