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Borderline Personality Disorder

Tamara Vradiy

Submitted to Jennifer Riley, RN, MSN in partial fulfillment of

NR 448 Updates in Illness/Disease Management

Regis University

8/18/2010
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Borderline Personality Disorder

According to Kaplan & Sadock (1991), personality is composed of emotional and

behavioral aspects that define a person and is characterized by a degree of stability and

predictability. A personality disorder is a deviation from patter of character traits that are

considered the “norm” by the society. When these traits result in difficulty with self-

identity, maladaptive and self-destructive behaviors and cause severe distress and

severely impaired functioning, a personality disorder may be the cause. According to

American Psychology Association (1998), there are ten different personality disorders in

the Diagnostic and Statistical Manual IV (DSM VI) (O’Brien, 2001). One of the most

controversial disorders in psychology is known as Borderline Personality Disorder

(BPD). This paper will discuss the definition, prevalence, origins, causes, symptoms,

diagnostic tests and current treatments of BPD. This paper will also focus on nursing

management and goals of treatment of this fascinating mental illness. Updated medical

information about BPD will be presented as well.

Definition of Borderline Personality Disorder

According to Koehne & Sands (2008), BPD is a chronic mental illness and is the

most prevalent personality disorder seen in clinical setting. It occurs in about 2% of the

general population, in 10% of mental health problem afflicted outpatients and 20% of the

psychiatric inpatients. It is by far more prevalent in females, with women greatly

outnumbering men 3:1. According to DSM IV (2000), BPD is a cluster B personality

disorder clinically defined as “ pervasive pattern of instability of interpersonal

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relationships, self image, and affects and marked impulsivity beginning by early

adulthood and present I variety of contexts” (Koehne & Sands, 2008, p174)”.

Koehne & Sands (2008) also note that psychological clinical definition of BPD cannot

possibly include the actual toll the diagnosis can have on a life of an individual, and does

not even touch the tip of the actual experience of living with BPD. While a lot is

publically known about the hardships of living with major depression, BPD diagnosis

actually causes even more functional deficits, significantly larger use of psychosocial

treatments and higher amount of medication use.

Pathology and Origins of Borderline Personality Disorders

American psychoanalyst, Adolph Stern was the first to use the term “borderline” in 1938.

Some of the symptoms Stern correlated in a group of patients included problems with

impulse control and self identity, immature defense mechanisms, and features of

occasional psychotic episodes (O’Brien, 2001). According to Friedel (2010), in 1940’s,

Robert Knight introduced a concept of ego psychology and the relationship of our

emotional function to the social environment. Knight believed that some people suffered

from impairment of emotional functions calling them “borderline states”. In 1975,

Gunderson & Singer published an astonishing article. It defined major characteristics and

diagnosis criteria of borderline personality disorder. Gunderson is also credited with

production of a research instrument for verification of validity of BPD resulting in it

becoming a psychiatric diagnosis appearing in DSM III in 1980.

According to Bland, Tudor, & Whitehouse (2007), there are several theories about

the origins and pathology of BPD, including genetic, neurobiological and environmental
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influences. According to Friedel (2010), the belief that BPD was a product of poor and

uneducated parenting was popular in the past, but currently, persons at risk for

development of BPD have been influenced by a combination of biological and

environmental factors, especially genetic ones. For instance, people who are genetically

predisposed to BPD, combined with predisposing psychological and environmental

factors such as bad parenting are more at risk of developing BPD, and not just a single

factor or cause is responsible, but a combination of factors that leads to emotionally

unstable and disturbed person (Friedel, 2010).

Genetic and Neurobiological Origins of BPD

Current research have showed that more than 50% of the risk of

BPD is due to genetic anomalies that seem to affect the normal

functioning of the brain mechanisms involved in the behavior, emotion

information processing, control of impulses and cognition activity such

as perception and reasoning. There is no specific gene for the disorder,

but it may be passed on by individuals that have BPD or even other

related mental disorders including bipolar disorder, major depression,

substance abusers and post traumatic stress disorder (Friedel, 2010).

Other genetic origins of BPD that were investigated through research

include several studies of twins and BPD that showed strong evidence

for development of BPD. Often BPD patients have been born with

aggressive temperaments and there are believed to be genes for that

temperament that are currently the subject of research and that may

be isolated in the future. Also there are studies that found that
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relatives of BPD are more likely than general population to exhibit

depression and substance abuse problems due to lack of abilities of

impulse control (Bland, et al., 2007). According to Mayo Clinic (2009),

research showed that patients with BPD may have neurological

dysfunctions such as changes in brain areas responsible for regulation

of emotions, aggression and impulses and improper functioning of

neurotransmitters such as serotonin, which regulates mood. Bland, et

al. (2007) also note that that learning disabilities, such as Attention

Deficit Hyperactive Disorder and disturbed brain wave patterns like in

disorders such as Epilepsy and head traumas have been BPD patients.

These neurobiological factors can also have effect on disabling

emotional and impulse control and misinterpretation of social situation.

Environmental Origins of BPD

Many environmental factors in childhood can affect development of BPD. Factors

may include early parental loss, separation and parental neglect. Environmental factors

are often responsible for irrational and severe fears of abandonment BDP patients suffer

from later in life. (Bland, et al, 2007). According to Gunderson & Berkowitz (2003),

BPD patients often feel detached, alien and misunderstood by the people closest to them

and often their fears of abandonment may be based on real physical abandonment or

imaginary abandonment as a result of emotional detachment. Families usually reject these

fears of BPD patients and attempt to dismiss and invalidate them by punishing the

patients and ignoring their efforts of expression of desires and attempts of

communication. In extreme cases, as Gunderson & Berkowitz (2003) point out: “An
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extreme form of invalidation is sexual or physical child abuse. Childhood abuse is

reported by 40-71% of inpatients with BPD, and the severity of sexual abuse suffered in

childhood has been linked to severity of borderline personality pathology found in

adulthood” (p.3). Many BPD patients come from dysfunctional families and as

developmental theorists point out that thoughts and feelings of patients with borderline

personality disorder resemble those of a child, so if there was some sort of a childhood

trauma suffered, the emotional development will stall and remain on that level through

adulthood.

Presenting Symptoms and Diagnostic tests of BPD

Diagnosing BPD is somewhat controversial to this day. According to Mayo Clinic

(2010), BPD is diagnosed through recognition of signs and symptoms and an in depth

psychological evaluation. Diagnostic and Statistical Manual of Mental Disorders 4th

Edition, revised in 2000 by American Psychological Association contains diagnostic

criteria composed of nine points. To be diagnosed with BPD, one must meet at least five

out of nine criteria, which covers four fields: affective, cognitive, behavioral and

interpersonal.

According to Lieb, et al. (2004), affective criteria includes intense dysphoric

affects including instability, anxiety, emptiness, rage, sorrow, shame, loneliness and

panic. One distinguishing characteristic in these individuals is severe poly-dimensional

emotional turmoil and distress. Mood instability can also be a problem for these people.

Disturbed cognition is the second criteria, and it includes dissociative symptoms or

separation from self, psychotic and delusional symptoms and severe identity disturbance.
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The third area according to Lieb, et al (2004) is behavioral, mostly resulting in severe

impulsivity. The impulsive behavior is usually very self destructive and may include

things like drug use, cutting, talks of suicide and even actual suicidal attempts that are

successful in approximately 10% of BPD patients. Individuals may also engage in

activities such as extreme spending during multiple shopping trips and reckless driving.

The interpersonal criteria is the forth area, and it is marked by unhealthy and volatile

relationships that shift between adoration and hate, plagued by frequent arguments and

break ups. BPD patients in this area also have an irrational fear of abandonment

manifested in clinginess and fear of being alone. It is common to not only conduct a

clinical assessment of BPD symptoms, but to look for coexisting conditions as well,

through a series of semi structured interviews (Lieb, et al., 2004). Mayo Clinic (2010),

also notes that it is important to remember that BPD diagnosis is only mad in adults,

because the signs and symptoms in children may disappear as they age.

According to Harvard Medical School (2009), some typical symptoms of BPD include

erratic moods and wild mood swings, turbulent personal relationships, poor anger

management and self-destructive actions. People with BPD are angry and defensive.

They may be severely depressed, irritable, frustrated and anxious without a probable

cause. They have a hard time adapting neither being alone or in a group. Their defense

mechanisms are fast to burst into actions and are primitive and immature. BPD patients

are at risk for financial problems, sexually transmitted disease, alcoholism and auto

accidents as a result of the risky behaviors they often get involved in such as excessive

spending, promiscuous sex, reckless driving and substance abuse.

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Treatment and Nursing Management of BPD

According to Lieb, et al. (2007), in their lifetime, 97% of BDP patients will

receive some kind of outpatient treatment, 95% will receive individual therapy, 56%

group therapy, 42% couples or psychotherapy, 37% will receive day treatment, and 72%

will b admitted to a psychiatric hospital. There are several types of treatment that are

common in BPD patient’s recovery. Treatments commonly used can be traditional

(medical), pharmacological, psychotherapy (rehabilitative), and alternative. Nursing

management of BPD patient presents many challenges and can be quite difficult to

manage their care and challenging to address their multiple needs. In every type of

treatment, nurse can play a pivotal role and assist a BPD patient with faster and easier

recovery

Medical Treatment of BPD

Medical treatment may be necessary for BPD patients hospitalized and admitted

as inpatients as a result of BPD leading to suicide attempted and even completed at times.

According to Antai-Otong (2003), a one in ten patient with BPD completes a suicide.

Hospitalization may be necessary during a psychiatric crisis and medical help will be

administered depending on the need. The patient may be suffering from emergencies

such as a drug overdose, blood loss from slit wrists or self inflicted gun shot wound,

traumatic injury from an auto accident resulting from reckless driving, and many other

types of injuries resulting from suicide attempts or other BPD risk behaviors. Major goal
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of medical treatment includes preventing harm, stabilization of presenting symptoms and

injuries and addressing patient emotional and psychiatric needs. Nursing management in

this case will include showing concern for the patient, removing sharp objects from

reach, setting limits and administering prescribed medications. It is common for

medication changes to take place during hospital stay, so nurses can also monitor the

impact and side effects of new medications in a controlled environment. Nurses can also

provide patient and family teaching in order to prevent injury and repeat hospitalization

in the future. According to Bland, et al (2007), There must be a concise treatment plan

laid out for BPD and everyone one the multidisciplinary team must follow it without

deviations. Nurses must keep patient in the present and reality and bring attention to self-

destructive behaviors and outline their consequences. Safety will also be a very important

priority in nurses’ management of BPD patients.

Pharmacological Treatment of BPD

According to Fagin (2004), pharmacological management benefits of BPD remain

small, however they are significantly beneficial in combination with cognitive-behavioral

and Dialectic Behavioral therapies (DBT). In pharmacological treatment, three different

types of disturbance are treated with different classes of medication. Fagin (2004), notes

that affective dyregulation symptoms or symptoms of mood labilty, feelings of anger and

depression and sensitivity to rejection are treated with high doses of Floxetine, and if that

was ineffective, can be switched to antidepressants such as Velataxine or Monoamine

Oxidase Inhibitors are used. For impulse control management of symptoms such as self-

mutilation, promiscuity, substance abuse, SSRI antidepressants in combination with

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Lithium, Carbamezipime, and Valproate, or other low dose neuroleptics can help. For

more severe symptoms, such as psychotic behaviors and features, antipsychotic

medications such as Olanzapine and Risperidal can be used. Clonasepam may also be

give for anxiety. Nursing management of pharmacological treatment of BPD includes

administration and management of the medication regiment. A nurse must do evaluation

of side effect and patent response to medications. Patient teaching about any new

medications or medication interactions and side effects is also a nursing responsibility.

Psychotherapy or Rehabilitative Treatment for BPD

The core treatment for BPD is Psychotherapy. Only psychotherapy can

rehabilitate the borderline mind and teach BPD patients to break through dysfunctional

patterns of thinking. Two types of psychotherapy that have been successful in

rehabilitating the minds of BPD patients include Dialectic Behavioral Therapy (DPT) and

Transference Focused Psychotherapy (TFP). DBT is done through one on one, group

therapy or telephone conversations, and its core purpose is skill building and achieving

appropriate balances and responses to conflicting tensions such as emotional control vs.

emotional tolerance, trust vs. suspicion and dependency vs. independence and its primary

aims are decreasing suicidal behaviors, increasing behavioral skills, decreasing behaviors

that interfere with quality of life (Friedel, 2010). DBT can also help with regulation of

emotions, coping with difficulties and relationship enhancement. DBT was designed

solely as a treatment for BPD.

TFP is based on a one on one relationship between the patient and therapist
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dealing with emotions and difficulties that develop in that particular relationship. TFP,

like DBT was developed specifically for patients with BPD and is a kind of

psychodynamic psychotherapy that holds a belief that symptoms of BPD are a result of

specific disturbances in person’s personality structure that cause the elimination of

middle ground and make perceptions only either good or bad. TFP works on analyzing

patients’ experience of reality. Therapy focuses on behavioral contracts and patient’s

relationship with therapist (Friedel, 2010) Patient is able to use what they have learned in

other one on one relationship in their life.

With Rehabilitative treatment, nursing management includes establishing goals,

adhering to the plan. Nurses must be positive, committed and have good interpersonal

skills in order to work with BPD patients. Nursing management of BPD patients during

psychotherapy treatment include creating a therapeutic milieu. Patient teaching can

include coping techniques, and focus on identifying stressors and ways to manage them.

Alternative Therapy for BPD

Van der Kolk, Hostetler, Herron, & Fisler (1994), suggested using art and role-

playing to develop language and skills needed for effective communication. There has

been research that showed that children that suffered a trauma have difficulty expressing

how they feel inside. This can progress into adulthood and interfere in adult relationships.

Nursing care should focus on encouraging assertive behaviors and socially acceptable

responses, and limiting aggression. Assisting in teaching client ways to control anxiety

and promote effective coping skills. Nurses can also help client learn alternative methods

of interacting with others.

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Conclusion

Borderline Personality Disorder is a difficult burden to live with. Patients that suffer from

BPD are handicapped by it emotionally. BPD can cripple almost every aspect of a

person’s life and take over alienating the individual sufferer from the rest of the world.

BPD puts patients at risk for many dangerous behaviors such as extreme spending and

gambling, promiscuity, self-mutilation and reckless driving and may even result in

suicide. That is why it is crucial to treat BPD, before serious harm arises from it. There

are different theories on what causes BPD, but most experts concur that BPD is a result

of combination of genetic and environmental factors. Treatment for BPD can be medical,

pharmacological and psychological. Nurses can play a big role in helping clients with

BPD rehabilitate and return to a more productive and normal life. Research is conducted

in many areas of BPD and hopefully a complete cure is not far off, once BPD is better

understood.
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References

Antai-Otong, Deborah (2003). Treatment considerations for patient with borderline

personality disorder. Nursing Clinics of North America, 38, 101-109

Bland, A., Tudor, G., & Whitehouse, D. (2007). Nursing care of patients with borderline

personality disorder. Perspectives in Psychiatric Care, 43(4), 204-212.

Burkle, F., Rae, R., & Rice M., (1985). Borderline personality disorder. Annals of

Emergency Medicine, 14, 996-1001

Gunderson, J., & Berkowitz, C. (2003). A BPD brief: An introduction to borderline

personality disorder-diagnosis, origins, course and treatment. New York :

National Alliance for Borderline Personality Disorders.

Fagin, Leonard (2004). Management of personality disorders in acute in-patient settings.

Part 1: Borderline personality disorders, Advances in Psychiatric Treatment, 10,

93-99
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Friedel, Robert (2010). Borderline personality disorder demystified, What Is BPD?

Retrieved on August 17, 2010 from http://www.bpddemystified.com

Harvard Medical School (2006). Borderline personality disorder: origins and symptoms,

Harvard Mental Health Letter, 22 (12), 1-3

Kaplan, H., & Sadock, B. (1991). Synopsis of psychiatry, behavioral Science, clinical

psychiatry, Williams & Wilkins: Baltimore.

Koehne,K., & Sands,N. (2008). Borderline personality disorder-An overview for

emergency clinicians. Australaisian Emergency Nursing Journal, 11, 173-177

Lieb, K., Zanarini, M., Schmahl, C. Linehan, M., & Bohus, C. (2004) Borderline

personality disorder. Lancet Seminar, 364, 453-461

Mayo Health Clinic (2010). Borderline personality disorder overview. Retrieved August

19, 2010 from http://www.Mayoclinic.com/health/borderline personality disorder

O’Brien, Louise (1998) Inpatient nursing care of patients with borderline personality

disorder: a review of the literature. Australian and New Zealand Journal of

Mental Health Nursing, 7(4), 172-183

Van Der Kolk, B., Hostetler, A., Herron, N., & Fisler, R. (1994). Trauma and the

development of borderline personality disorder. Psychiatric Clinics of North

America, 17(4), 715-731

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