Borderline personality disorder: diagnosis and management in general practice

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What is borderline personality disorder (BPD)?

  • BPD is a common mental disorder characterised by pervasive and persistent instability of sense of self, intense and unstable emotionality, extreme sensitivity to perceived interpersonal slights, and by impulsive behaviours that are often self-destructive.[1,19]
  • Around 1–2% of the general population meet the criteria for BPD,[23]; the prevalence of BPD within primary care is about fourfold higher.
  • Symptoms of BPD typically emerge during adolescence and early adulthood.[7]
  • Australians with BPD experience difficulties gaining access to effective treatment and support services.[27]
  • Prognosis

    • Without treatment

    With treatment[4,20,24,42-44]

    BPD is associated with significant morbidity and mortality, including severe and persistent impairment of psychosocial function, high risk for substance abuse, self-harm, suicide, medical morbidity and premature mortality, a poor prognosis for co-existing mental health illness, and heavy use of healthcare resources.[22,31,32]

    The suicide rate among people with BPD is higher than that of the general population = 8% (similar to schizophrenia).[29]

    When people with BPD receive appropriate and evidence-based psychological treatments, 60–80% of individuals achieve clinical remission within 6 to 12 months’ time and only a minority relapse

    Clinical features

    • Health professionals should consider assessment for BPD for a person with any of the following:[28]
      • frequent suicidal, risk-taking or self-harming behaviour
      • marked emotional instability such as anger, irritability or impulsiveness
      • relationship issues such as conflicts, excessive dependency or high insecurity
      • difficulties with identity and sense of self, or lack of goals or direction in life
      • non-response to established treatments for current psychiatric symptoms
      • a high level of functional impairment including difficulties managing study, work or relationships.
    • BPD is usually diagnosed using American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th edition – text revision (DSM-5) [1] criteria.

    Aetiology[7,28,36,40]

    BPD has a complex aetiology as summarised in Figure 1. Some factors related to personality development can increase the risk of developing BPD.

    [Click image to enlarge]

    Figure 1 Etiological factors in the development of adolescent BPD


    Figure 1. Etiological factors in the development of adolescent BPD. Figure adapted from Figure 1. A tentative logic model delineating the pathogenesis of Borderline Personality Disorder (BPD) from conception onwards in, Winsper C. The aetiology of borderline personality disorder (BPD): contemporary theories and putative mechanisms. Curr Opin Psychol. 2018; 21:105-110. Copyright 2018, with permission from Elsevier.[40]

    BPD: missed diagnosis

    BPD is often under-recognised due to its presentation with common psychiatric comorbidities including substance abuse [19]

    The prevalence of BPD in general practice is high (4 fold higher than the general community)[18]

    GPs are well placed to identify individuals with BPD, provide education management and access to appropriate care, including crisis management, as needed[28]

    Effective management in a GP setting

    Patients should be treated by or referred to a psychiatrist/clinical psychologist/allied health clinician if risk escalates or complexity presents; or where specialised diagnosis and management is required

    Mental health services are unable to cope with the demand for care of individuals with BPD. GPs can play an important role by:

    • Identifying and diagnosing individuals with BPD; providing psychoeducation regarding diagnosis and management; referring as appropriate and; if agreed by patient, explaining the diagnosis and management to families/carers
      • Structured psychological interventions have been demonstrated to improve outcomes for BPD and are recommended by NHMRC guidelines;[28] it is important for GPs to be proficient in the principles of high quality care
    • Creating a ‘safe space'; therapeutic boundary setting and maintenance; ensuring all staff members are equipped to respond appropriately to individuals with BPD and their families
    • Prescribing appropriately – if BPD is unrecognised, prescribed treatments may be inappropriate or increase risk of suicide or self-harming
    • Facilitating integrated interventions by the same treatment team (/avoiding fragmentation of care)
      • Good communication between involved health professionals is imperative
      • Crisis management - ensure all involved health professional and relevant practice staff are aware of their roles in supporting a crisis management plan, including self-harm, threatened or attempted suicide
    • Providing advocacy for individuals at heightened risk to access appropriate therapy and acute care when needed and provide follow up after a crisis to reflect on strategies to incorporate into future safety plans
    • Practicing self-care with structures in place for regular peer review and/or debriefing essential.

    If an individual GP does not feel that they have the appropriate skills to provide treatment, or for individuals at high risk of suicide/presence of complex comorbidities, refer to a specialised mental health service/psychiatrist/clinical psychologist.

    Appropriate prescribing

    [Click image to enlarge]

    **Evidence for drug therapy

    Creating a safe place and setting therapeutic boundaries

    Relationship difficulties, such as fear of abandonment, are at the core of BPD. This means that the doctor- patient relationship is also likely to be challenging:[10]

    • individuals can appear to be excessively or unreasonably demanding, emotionally unstable and interpersonally inappropriate/overfamiliar
    • risk of blurring of therapeutic boundaries, which might result in GPs feeling involuntary compelled into difficult or compromising positions.

    GPs are likely to see individuals with BPD at their most vulnerable.[10]

    Making the interaction between the patient and the health service as consistent and predictable as possible can help the person feel safe and reduce the risks of blurred boundaries:

    Providing a safe, therapeutic environment for individuals with BPD can be challenging for many GPs and mental health professionals. When caring for individuals with BPD it is important to:

    • Monitor own emotional state
    • Refrain from responding inappropriately to verbal attacks and unreasonable requests
    • Review ability to cope, and ensure tolerance and sensitivity towards patients
    • Consider peer consultation and supervision.

    Crisis management

    During a crisis

    • Respond promptly
    • Listen to the person – use a validating interviewing technique
    • Be supportive, non-judgemental, and show empathy and concern
    • Assess the person’s risk
    • Stay calm and avoid expressing shock or anger
    • Plan for the person’s safety in collaboration with them

    After a crisis

    • Follow up by discussing all safety issues, including their effect on you, within the context of scheduled appointments.
    • Actively identify the factors that might have helped provide relief (eg the perception of being cared for).
    • Explain that it is not feasible to depend on the mental health service or GP to be available at all times. Help the person use a problem-solving approach to develop an action plan with practical alternatives for future crises.
    • Help the person deal with their anger whenever it becomes apparent.

    If you would like to do a short case study on this topic, you can enrol in the Borderline personality disorder: diagnosis and management in general practice activity on gplearning. Completion of the online activity is worth 2 CPD Activity points.

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    Acknowledgements

    This activity has been developed by the Royal Australian College of General Practitioners (RACGP) with expert input obtained through the Australian BPD Foundation Limited and Orygen, the National Centre of Excellence in Youth Mental Health.


    BPDOrygenSpectrumProjectAir

    References

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