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Borderline Personality Disorder
Personality disorders can be difficult to manage by the PMHNP. These individuals many times have poor insight into their illness, and they can be difficult to treat. Borderline personality disorder (BPD) is one of these challenging diagnoses. Knowing the criteria to properly diagnosis is important for the provider. According to American psychiatric association (2013), BPD begins by early adulthood presenting with an instable pattern of impulsivity, interpersonal relationships, affects, and self-image in different contexts with at least five of these symptoms: dramatic attempts to avoid abandonment whether real or imagined, intense and unstable interpersonal relationships, distorted self-image, at least two possible self-damaging impulsivities like binge eating, sex, spending, reckless driving, or substance abuse., self-harming, suicidal behavior, threats or gestures, mood swings only lasting hours or a few days, anger issues, strong emptiness feelings or severe dissociative or stress related paranoia. These feelings are intense for the client and surrounding people.
In practice, a client comes to mind that met this criterion. The client had frequent self-harming behaviors, several suicide attempts, had unstable relationships with her childrens father, her mother and father and grandmother. She was impulsive, many times quitting her jobs and starting a new one to realize she wanted the old job. She had dramatic beliefs of her boyfriend and family abandoning her and a negative self-image. This client had been hospitalized several times for suicidal ideations or attempts and attended intensive outpatient therapy. Her children were in DCFS custody and she frequently came to the hospital when it was time for visits instead of going to see them and then reporting how sad she was not to see them. This pattern of intense emotional instability is congruent with borderline personality disorder. Aouidad et al. (2020) wrote, BPD marked by intense relational and emotional instability, self-injury, impulsivity, and suicidal behaviors starting in adolescence is a severe mental illness. These traits were seen in this client and further supports the diagnosis.
These severe, intense emotional responses without proper insight can make the treatment difficult. According to Cases et al. (2020), these individuals require specialized care that adapts to their needs and responses to treatment including acute hospitalization with appropriate follow up tailored to their current symptoms as they can frequently change. They may present to the ED in a crisis with suicidal ideations that needs immediate care or outpatient with intense emotional dysregulation needing intensive therapy or many other scenarios. Ditlefsen et al. (2020) wrote psychoeducation can be beneficial to BPD clients as it provides practical, systemic teaching of the features, challenges and important features of the therapy provided in a group setting which promotes continued therapy and motivation for these clients. Giving them a better understanding of their illness and providing a group environment so they can have a sense of belonging can improve outcomes. According to Hancock-Johnson, Griffiths, and Picchioni (2017), there are no FDA approved pharmacological treatment, but studies have shown improvement in some symptoms such as depression, instability, anxiety, impulsivity and anger with antipsychotics, mood stabilizers and omega-3 fatty acids compared to placebos. Psychotherapy would be the most recommended treatment with possibly added medications to reduce certain symptoms individualized to the client.
Aouidad, A., Cohen, D., Mirkovic, B., Pellerin, H., Garny de La Rivire, S., Consoli, A., Grardin, P., & Guil, J.-M. (2020).
Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide
attempters. BMC Psychiatry, 20(1), 525.
Cases, C., Lafont Rapnouil, S., Gallini, A., Arbus, C., & Salles, J. (2020). Evidence of practice gaps in emergency psychiatric care for
borderline personality disorder: how can this be explained? BMC Psychiatry, 20(1), 476.
Ditlefsen, I. T., Nissen-Lie, H. A., Andens, A., Normann-Eide, E., Johansen, M. S., & Kvarstein, E. H. (2020). Yes, there is actually
hope!A qualitative investigation of how patients experience mentalization-based psychoeducation tailored for borderline
personality disorder. Journal of Psychotherapy Integration.
Hancock-Johnson, E., Griffiths, C., & Picchioni, M. (2017). A focused systematic review of pharmacological treatment for borderline
personality disorder. CNS Drugs, 31(5), 345356.
