Borderline Personality Disorder Concept Map

Etiology
Borderline personality disorder (BPD) is multifactorial in etiology, studies have shown it could
be hereditary or environmental factors such as childhood maltreatment, maternal separation, poor
maternal attachment, inappropriate family boundaries, parental substance abuse and parental
psychopathology. In the mentalizing model of Peter Fonagy and Anthony Bateman they have
defined BPD as the result of the lack of resilience to psychological stressors. Another theory is
that BPD arises from an inability to regulate effects and the lack of formation of appropriate
coping mechanisms to stressors.
Diagnosis
The DSM-5 uses the following to make a diagnosis of BPD. A persistent pattern of instability
with interpersonal relationships, self-image, and affects as well as marked impulsivity beginning
by early adulthood and present in a variety of contexts as indicated by five or more of the
following: Frantic efforts to avoid real or imagined abandonment, pattern of unstable and
intense interpersonal relationships characterized by alternating between extremes of idealization
and devaluation, identity disturbance markedly and persistently unstable self-image or sense of
self, impulsivity in at least two areas that are potentially self-damaging, for example, spending,
substance abuse, reckless driving, sex, binge eating, etc., affective instability is caused by a
marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability,
usually lasting a few hours and rarely more than a few days, chronic feelings of emptiness,
inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of
temper, constant anger, recurrent physical fights and transient paranoid ideation or severe
dissociative symptoms.
When considering a diagnosis of borderline personality disorder, a differential diagnosis should
be considered as other personality disorders overlap and are common, especially within cluster B
category. Other diagnostic considerations include substance use disorder, non-suicidal self-injury
disorder, bipolar disorder and autism spectrum disorder.
Labs/Diagnostic Tests
There are no diagnostic tests or labs for the diagnosis of BPD. However, there are
several diagnostic instruments available to aid in the diagnosis, such as: McClean screening
instrument for borderline personality disorder, personality diagnostic questionnaire, structured
clinical interview for DSM-5 personality disorders, Minnesota borderline personality disorder
scale and personality assessment inventory-borderline features scale
Assessment Findings

Individuals with BPD will display signs and symptoms in the following domains emotional,
interpersonal, behavioral and cognitive. Emotional dysregulation is a core feature of BPD, the
individual will display heightened emotional sensitivity, impairments in regulation of emotional
responses and slow return to baseline from emotionally heightened states. Emotions may shift
rapidly, particularly in response to interpersonal interactions. Chronic feelings of emptiness or
hollowness may also be endorsed that may relate to a variety of factors. Emptiness in BPD is
closely related to feeling hopeless, lonely and isolated. Avoidance of engaging with activities
and relationships that have previously caused distress and disappointment and shutting out of
emotions may contribute to feelings of emptiness and lack of fulfilment. Difficulty controlling
angry feelings, characterised by low frustration tolerance and a pattern of discharging angry
feelings in verbal or physical aggression. Anger is typically inappropriately intense, with rapid
escalation in emotional intensity and a slow return to the baseline state. In the interpersonal
domain a seminal feature of BPD is relational instability. Typical symptomology in BPD
includes unstable mental representations of self and other, which at the extremes may rapidly
switch between love and hate. The individual may be sensitive within relationships this includes
a high number of intimate relationships over the years, characterised by easily falling in love,
rapid development of intimacy, followed by disillusionment and estrangement. Similarly,
relationships with parents, family members and friends may be conflictual and oscillate between
extremes of idealisation and denigration. Fears of abandoned or rejection in relationships may be
endorsed. Worries about perceived impending separation and loss may create expressions or acts
of suicide or self-harm in an effort to prevent abandonment. The behavioral domain of BPD the
individual has impulsive behaviours in an attempt to manage difficult emotional experiences. A
history of impulsivity with behaviours such as gambling, reckless driving and sexual activity that
is later regretted. In the cognitive domain signs and symptoms with identity, psychotic symptoms
and dissociation may be displayed. Identity disturbance or the experience of uncertainty or
instability about who one is may be displayed in BPD. This may manifest in difficulty
committing to goals and confusion about what one should do or believe. Factors that impede the
development of a coherent, stable sense of self-identity are being easily influenced by other
people and may not have clear distinctions between self and others. Psychotic symptoms may be
present in individuals with BPD according to the DSM-5 these people may experience transient
stress-associated psychotic symptoms. Dissociative symptoms in BPD are positively associated
with subjective experience of stress, defined as ‘disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion, perception, body representation, motor
control and behaviour’ may manifest clinically as depersonalisation, derealisation or amnesia.

Risk Factors
Risk factors for the development of BPD are adverse childhood experiences and trauma, poor
relationships with parents, low socioeconomic class and family history of mental illness.

Signs & Symptoms

The signs and symptoms that an individual with BPD may display include emotional instability
and extreme mood swings, unstable and intense interpersonal relationships, eextreme views of
others either all good or all bad, uunstable sense of identity, feeling of emptiness and lack of self-
worth, need to feel whole or looking to the outside world for fulfilment, paranoid symptoms like
a sense of conspiracy or people out to harm them, impulsive behavior/acting out, spending large
amounts of money, binge eating, using drugs or excessive alcohol use, reckless driving, suicidal
thoughts and attempts, difficulty keeping a job and frequent use of medical services (both
inpatient and outpatient) for mental or physical health symptoms.
Potential Complications
Complications for BPD include suicide, self-injury behavior, chronic instability, maladaptive
social and interpersonal skills, paranoid ideation and dissociative symptoms. Other complications
include engaging in risky behavior, drug abuse, not completing education, job loss, getting in
trouble with the law and problems with relationships.
Medical Management
No medications are approved for the treatment of borderline personality disorder.
Treatment of borderline personality disorder relies on psychotherapy. First, mentalizing-based
therapy (MBT) helps patients manage emotion dysregulation by feeling understood, allowing
them to be more curious and make fewer assumptions about the intentions of the people around
them. Second, dialectical behavior therapy (DBT), combines mindfulness practices with concrete
interpersonal and emotion regulation skills. Third, transference-focused psychotherapy (TFP)
focuses on using the patient-therapist relationship to develop the patient's awareness of
problematic interpersonal dynamics.
Borderline personality disorder is one of the most difficult mental health disorders to manage; it
is best managed with an interprofessional approach including psychiatrists, psychologists,
pharmacists, mental health nurses, and social workers.
Nursing Management/Care
Treatment for BPD can take place in an outpatient setting or inpatient admission. Short term
stays and crisis intervention are more therapeutic. Focus is on community interventions for better
long-term outcomes.

Teaching
Patients and their families should be educated about BPD and be provided with the necessary
literature to learn about the condition. The families should be advised that the patients may get
angry and suicidal and told to seek help immediately. In addition, patients should be encouraged
to seek and continue psychotherapy until they experience sustained benefits.