Treatment considerations for the patient with borderline personality disorder

      Borderline personality disorder (BPD) refers to a personality disorder whose primary symptoms include significant emotional distress and impairment of interpersonal or occupational functioning or both [
      • American Psychiatric Association
      ]. The age of onset varies but often ranges from adolescence to early adulthood (age 18 to 25 years) [
      • Gunderson J.G.
      Borderline personality disorder: a clinical guide.
      ]. Typically the patient with BPD has a history of a pervasive pattern of chaotic interpersonal relationships, unstable mood and self-image disturbances, self-injurious behaviors, and other maladaptive coping behaviors. Major concerns of nurses and other health care providers involve the high use of health care resources among patients with BPD, normally arising from self-destructive and demanding behaviors.
      The precise prevalence of BPD is obscure, but estimates are about 2% in community samples and 6% of a primary care population [
      • Bateman A.
      • Fonagy P.
      Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized control trial.
      ] and approximately 15% to 20% of psychiatric inpatients [
      • American Psychiatric Association
      ,
      • Ellison J.M.
      • Blum N.R.
      • Brasky A.J.
      Frequent repeaters in a psychiatric emergency service.
      ,
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ,
      • Sansone R.A.
      • Wiederman M.W.
      • Sansone L.A.
      Medically self-harming behavior and its relationship to borderline personality symptoms and somatic preoccupations among internal medicine patients.
      ]. Severity of symptoms may range from moderately disabling to severely incapacitating. BPD also is likely to co-occur with other psychiatric conditions, including anxiety disorders, major depressive disorders, eating disorders, and substance-related disorders, and medical conditions (eg, somatization disorders). Women are two times more likely to be diagnosed with BPD than men [
      • American Psychiatric Association
      ,
      • Ellison J.M.
      • Blum N.R.
      • Brasky A.J.
      Frequent repeaters in a psychiatric emergency service.
      ,
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ,
      • Sansone R.A.
      • Wiederman M.W.
      • Sansone L.A.
      Medically self-harming behavior and its relationship to borderline personality symptoms and somatic preoccupations among internal medicine patients.
      ].
      A major issue confronting nurses and other health care providers is the high suicidality and other self-injurious behaviors among patients with BPD. One in 10 patients with BPD completes suicide, but suicide is not readily preventable, and it does not necessarily occur during treatment [
      • Paris J.
      Chronic suicidality among patients with borderline personality disorder.
      ]. Chronic suicidal behavior is best understood as a barometer of the patient's level of distress. Hospitalization has not been shown to reduce suicide and often has negative results. Community studies have shown that the rates of suicide peak between the ages of 18 and 30 years [
      • Stone M.H.
      The fate of borderline patients.
      ]. The highest risk of suicide among patients with BPD occurs in those with comorbid substance-related and depressive illness and histories of past attempts. Normally, patients presenting with acute suicidality also meet criteria for depressive illness. In comparison, patients presenting with chronic suicidal ideations are seeking treatment [
      • Leasage A.D.
      • Boyer R.
      • Gunberg F.
      • et al.
      Suicide and mental disorders: a case-control study of young men.
      ].
      Because patients with BPD are high users of health care resources, most nurses have had contact with these patients. The patient with BPD often challenges the patience of nurses—hence the risk of rejection and poor treatment outcomes. This article focuses on strategies that can improve treatment outcomes. It also describes the role of the nurse in developing therapeutic environments that convey empathy, establish clear and healthy boundaries, and facilitate appropriate limit settings and an optimal level of functioning. Finally, this article provides an overview of the complexity of this challenging personality disorder, causative factors, assessment and diagnostic considerations, and holistic and interdisciplinary treatment.

      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 [
      • Coccaro E.F.
      • Kavoussi R.J.
      • Hauger R.L.
      • et al.
      Cerebrospinal fluid vasopressin levels correlate with aggression and serotonin function in personality disordered subjects.
      ,
      • Coccaro E.F.
      Neurotransmitter function in personality disorders.
      ,
      • Kernberg O.F.
      Borderline conditions and pathological narcissism.
      ,
      • Paris J.
      Childhood precursors of borderline personality disorder.
      ]. 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 [
      • Coccaro E.F.
      • Kavoussi R.J.
      • Hauger R.L.
      • et al.
      Cerebrospinal fluid vasopressin levels correlate with aggression and serotonin function in personality disordered subjects.
      ,
      • Coccaro E.F.
      Neurotransmitter function in personality disorders.
      ,
      • Coccaro E.F.
      • Kavoussi R.J.
      Fluoxetine and impulsive-aggressive behavior in personality disordered subjects.
      ]. 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:
      • Chief complaint or reasons for seeking treatment
      • General appearance, including mode of arrival, cooperativeness, and eye contact
      • Mood and affect
      • Speech
      • Thought content and processes
      • Sensorium and other higher brain function, including memory, judgment, reliability, and insight into present illness and treatment
      • Level of danger to self and others
      • Substance abuse history, treatment, and legal history
      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:
      • A pervasive pattern of intense chaotic or unstable interpersonal relationships
      • Marked emotional distress and lability
      • Intense fears of abandonment
      • Low self-esteem
      • Marked identity disturbances
      • Poor or fluid boundaries
      • Hypersensitivity to object loss
      • Intolerance of being alone
      • Chronic dysphoria (intense sadness)
      • Intense anger and rage
      • Chronic history of impulsivity and mood instability
      • Chronic feelings of emptiness
      • Recurrent maladaptive coping responses, including self-destructive behaviors
      • Transient brief reactive psychosis [
        • American Psychiatric Association
        ,
        • Gunderson J.G.
        Borderline personality disorder: a clinical guide.
        ,
        • Kernberg O.F.
        Borderline conditions and pathological narcissism.
        ,
        • Masterson J.
        Treatment of the borderline adolescent: a developmental approach.
        ]
      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 [
      • Gunderson J.G.
      Borderline personality disorder: a clinical guide.
      ,
      • U.S. Census Bureau
      Statistical abstracts of the United States.
      ].
      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 [
      • Antai-Otong D.
      Psychiatric emergencies.
      ]. 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” [
      • Gunderson J.G.
      Borderline personality disorder: a clinical guide.
      ] often includes the following:
      • Asking the patient to give explicit agreement not to harm themselves, sometimes putting it in writing (invokes a “word of honor” principle as a deterrent to “acting out behaviors”)
      • Reinforcing the responsibility of safety to the patient and not the therapist to work out with others during a crisis situation
      • Providing a list of safety interventions that include telephone calls to mental health centers and hotlines, designated family and friends, and emergency department and local emergency services [
        • Gunderson J.G.
        Borderline personality disorder: a clinical guide.
        ]
      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 [
      • Paris J.
      Chronic suicidality among patients with borderline personality disorder.
      ]. 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.

       Pharmacologic interventions

      American Psychiatric Association practice guidelines [
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ] concerning the treatment of borderline personality disorder confirm that patients with BPD require a comprehensive, holistic, and long-term treatment (ie, psychotherapy and symptom-targeted adjunctive pharmacotherapy). Most pharmacologic interventions are symptom specific [
      • Markowitz P.J.
      • Calabrese J.R.
      • Schultz S.C.
      • et al.
      Fluoxetine in the treatment of borderline personality and schizotypal personality disorders.
      ]. Target symptoms for pharmacologic interventions of the patient with BPD include three dimensions: cognitive-perceptual disturbances, affective lability, and impulsive-behavioral dyscontrol [
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ,
      • Paris J.
      Childhood precursors of borderline personality disorder.
      ].
      Cognitive-perceptual disturbances include stress-induced psychosis, paranoia, suspiciousness, dissociation, and illusions. Management of these symptoms includes low-dose and short-term neuroleptics, such as haloperidol (Haldol) and olanzapine (Zyprexa). Implications for nurses include assessing for adverse side effects, such as extrapyramidal effects and tardive dykinesia. A failure to respond to these medications suggests an inaccurate diagnosis.
      Symptoms of affective lability, or mood disturbances, include depressed or irritable mood and loss of interest in activities that were once pleasurable. Pharmacologic agents of choice include antidepressants. Studies indicate that newer antidepressant agents, such as selective serotonin reuptake inhibitors, including fluoxetine (Prozac) or sertraline (Zoloft), have proven efficacy in the treatment of depressive illness, anxiety disorders, aggression, irritability, and self-injurious behaviors [
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ,
      • Coccaro E.F.
      • Kavoussi R.J.
      Fluoxetine and impulsive-aggressive behavior in personality disordered subjects.
      ,
      • Markowitz P.J.
      • Calabrese J.R.
      • Schultz S.C.
      • et al.
      Fluoxetine in the treatment of borderline personality and schizotypal personality disorders.
      ].
      Impulsive-behavioral dyscontrol consists of self-injurious behaviors, such as parasuicides, aggressiveness, substance abuse, and self-cutting or self-burning. In addition to antidepressants, other medications with proven efficacy in the management of specific symptoms include anticonvulsant agents and lithium and anxiolytic agents [
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ,
      • Paris J.
      Childhood precursors of borderline personality disorder.
      ,
      • Coccaro E.F.
      • Kavoussi R.J.
      Fluoxetine and impulsive-aggressive behavior in personality disordered subjects.
      ,
      • U.S. Census Bureau
      Statistical abstracts of the United States.
      ,
      • Markowitz P.J.
      • Calabrese J.R.
      • Schultz S.C.
      • et al.
      Fluoxetine in the treatment of borderline personality and schizotypal personality disorders.
      ,
      • Swenson C.R.
      • Torrey W.C.
      • Koerner K.
      Implementing dialectical behavior therapy.
      ].
      Symptom management is multifaceted and is determined by the patient's present symptoms. Most studies indicate a holistic approach that integrates pharmacologic and psychotherapeutic interventions is the most effective. This plan of care must identify clearly the primary psychotherapist, expected roles and responsibilities of the patient and nurse psychotherapist, a plan to respond to crises, and monitoring the patient's safety and coordination of treatment planning by an interdisciplinary team [
      • American Psychiatric Association
      Practice guideline for the treatment of patients with borderline personality disorder.
      ].

       Psychotherapeutic interventions

      The decision to use specific psychotherapeutic interventions depends on the patient's clinical presentation and preferences. Poor treatment candidates are patients who exhibit severe antisocial behaviors and comorbid substance-related disorders. Additional prognostic factors include adherence to treatment and reducing high-risk behaviors, high intelligence, a lack of early childhood abuse, and a lack of comorbid substance-related disorders [
      • Swenson C.R.
      • Torrey W.C.
      • Koerner K.
      Implementing dialectical behavior therapy.
      ].
      Studies indicate growing promise in the treatment of BPD using cognitive and behavioral interventions [
      • Linehan M.M.
      Cognitive-behavioral treatment of borderline personality disorder.
      ,
      • Linehan M.M.
      • Schmidt III, H.
      • Dimeff L.A.
      • et al.
      Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence.
      ]. One such model is dialectical behavior therapy [
      • Stone M.H.
      The fate of borderline patients.
      ,
      • Soloff P.H.
      Algorithms for pharmacological treatment of personality dimensions: symptom specific treatments of cognitive-perceptual, affective, and impulsive-behavioral dysregulation.
      ]. Dialectical behavior therapy is a cognitive behavioral model that entails active and structured work to analyze and modify target behaviors through cognitive restructuring, skills training, exposure techniques, and a contingency plan. The premise behind this treatment modality is that persons with BPD lack the capacity to modulate emotions or feelings. An inability to regulate emotions is reinforced by a continuous transaction between the patient's emotional vulnerability and external world of invalidation. This approach involves three concurrent modes of treatment: weekly individual sessions, a weekly group specifically for skills training, and telephone contacts by the primary nurse psychotherapist on an as-needed basis.
      Psychodynamic psychotherapy also is being used to treat BPD. Compared with dialectical behavior therapy, this approach enables the nurse psychotherapist to explore patterns of feelings and underlying behavior to help the patient clarify various aspects of unconscious feelings and behaviors. This treatment modality also involves individual psychotherapy and group therapy that focuses on skills training [
      • Bateman A.
      • Fonagy P.
      Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized control trial.
      ,
      • Batemen A.
      • Fonagy P.
      Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up.
      ].

      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.

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        Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized control trial.
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        Medically self-harming behavior and its relationship to borderline personality symptoms and somatic preoccupations among internal medicine patients.
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        Borderline conditions and pathological narcissism.
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        Fluoxetine and impulsive-aggressive behavior in personality disordered subjects.
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        Cognitive-behavioral treatment of borderline personality disorder.
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