evidence-based

Care Sheet

Borderline Personality Disorder: Behavioral Manifestations

What We Know
 Borderline personality disorder (BPD) is a complex disorder of emotional regulation characterized by a distorted and rapidly changing self-image, lack of inner direction, instability of emotion and interpersonal relationships, and impulsivity(2, 3, 4, 5, 6) (see Quick Lesson AboutBorderline Personality Disorder) The lifetime prevalence of BPD in the general population is estimated to be 12%; BPD affects 10% of psychiatric outpatients and 1525% of psychiatric inpatients(3, 4) Signs and symptoms are usually present by late adolescence(4) BPD often occurs in individuals who have multiple coexisting psychiatric conditions (e.g., depression; mood, eating, substance abuse disorders)(4) Individuals with BPD are typically dissatisfied with their impairment in social, occupational, and/or academic functioning(2, 3, 4, 6) They may express uncertainty about self-image, sexual orientation, long-term goals, career choice, type of friends desired, and values Their relationships are unstable, and they have intense love-hate relationships People with BPD may idealize friends or lovers and later become disillusioned Their feelings can dramatically shift to devaluation of the other person and rage over minor misunderstandings or in response to a perceived flaw  This extreme variability is called splitting (i.e., mentally going back and forth between unrealistic extremes of idealization and devaluation of another person and/or oneself) Individuals with BPD have perceptions that are consistently black and white, and have difficulty perceiving gray areas in self and others  In a study of 95 female psychiatric inpatients, a large divergence between lowest and highest self-reported weights in adulthood was found to be a potential indicator of BPD(8) Individuals with BPD are afraid of real or imagined rejection and abandonment Behavioral manifestations of individuals with BPD include impulsivity and self-destructive behavior such as overspending; sexual promiscuity; substance abuse; shoplifting; reckless driving; binge eating; suicide attempts or threats, and other self-harming behavior; impulsive and self-destructive behaviors can be veiled attempts to elicit a caring response from another person(2, 3, 4, 6, 10) Self-mutilation behaviors include self-inflicted burns, cuts, and scratches Head-banging and intentionally losing a job are self-harm behaviors seen more commonly in men than in women; others (e.g., cutting, promiscuity, overdosing) appear to affect both genders at similar rates(10) 7075% of individuals with BPD have a history of 1 deliberate act of self-harm(4) Approximately 9% of patients diagnosed with BPD commit suicide; this rate is 50 times higher than in the general population(3) Individuals with BPD are typically irritable, anxious, and depressed; they have affective mood instability and rapid mood shifts, and typically experience overwhelming anger when they perceive themselves to be in crisis(5) When individuals with BPD are emotionally aroused, they may become impulsive, aggressive, or unable to remember things BPD is more common in individuals with self-reported road rage than in those without road rage(9) Inappropriate, intense anger may varyingly result in displays of bad temper and/or physical fights, or feelings of boredom or emptiness Individuals with BPD often place themselves in the victim role and may engage in behaviors that encourage others to act upon them in negative, rejecting, aggressive, or caretaking ways; they may sustain abuse from a romantic partner and behaviors may be self-sabotaging(7) Individuals with BPD may not seek medical treatment or take prescribed medications despite knowing that they should

authors
Sara Grose, MSN, RN, PHN, CNL, CLE Tanja Schub, BS

reviewers
Darlene A. Strayer, RN, MBA Cinahl Information Systems Glendale, California Nursing Practice Council Glendale Adventist Medical Center Glendale, California

editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems

April 29, 2011

Published by Cinahl Information Systems. Copyright2011, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

 They may gravitate toward unsafe or dangerous situations; they may want to be hurt in order to feel emotion, get attention, or act out negative feelings
  If they develop, psychotic symptoms are typically short-lived (e.g., lasting minutes or hours) or accompanied by the ability to distinguish internal distortion and fantasy from accurate representation of external events (i.e., good reality testing ability)(4) Diagnosis of BPD is based on clinical observations and patient-reported symptoms(2, 3, 4, 5, 6) (see Evidence-Based Care Sheet: Borderline Personality Disorder: Symptoms and Assessment) The Personality Assessment Inventory-Borderline Features Scale (PAI-BOR) and the Personality Diagnostic Questionnaire-Revised (PDQ-R) are available to evaluate BPD Psychotherapy and medications are the main components of BPD treatment(1, 2, 3, 4, 6) (see Evidence-Based Care Sheet: Borderline Personality Disorder: Treatment) Dialectical behavior therapy (DBT), a behavioral and skills-based approach to help patients learn to self-regulate emotions, tolerate negative emotions, change distorted beliefs, and improve interpersonal relationships, is effective for patients with BPD Cognitive behavioral therapy (CBT), rational emotive behavior therapy (REBT), cognitive analytical therapy (CAT) and schema-focused therapy (SFT) may be effective for some patients with BPD Pharmacotherapy is used for patients with BPD who are suicidal, depressed, dangerously impulsive, and/or psychotic. Although supported by limited data, a combination of medications is often prescribed, including low doses of atypical neuroleptics (e.g., olanzapine) for short-term control of psychotic or other crisis symptoms; selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine); and/or mood stabilizers (e.g., lithium). Benzodiazepines are contraindicated in patients with BPD because they reduce inhibitions and may lead to increased impulsivity

What We Can Do
   Learn about behavioral manifestations in patients with BPD so you can accurately assess your patients personal characteristics and health education needs; share this knowledge with your colleagues Complete a thorough patient history (e.g., current and previous diagnoses and surgeries, medications, alcohol or illicit drug use, allergies, sleep patterns, vocation, psychiatric history including symptoms, suicidality or violence, and previous treatments)(4, 5) When assessing patients suspected of having BPD, complete mental and physical assessments(4, 5) A psychiatric evaluation includes evaluation of appearance (groomed vs. disheveled), eye contact, facial expression, motor skills, cooperativeness, mood, affect, speech, suicidality (ask: Do you have thoughts of wanting to hurt yourself?), violent tendencies (ask: Do you have any thoughts of wanting to hurt anyone?), orientation to person, place, time, and situation, level of consciousness, ability to concentrate/pay attention (ask: Subtract 7 serially from 100), reading and writing, memory, delusions, hallucinations, and judgment Teach patients about living with BPD as a chronic illness(1, 2, 3, 4, 5, 6, 7) Take medications as prescribed Attend all therapy sessions Practice healthy ways to ease distress rather than acting out or inflicting self-injury Recognize personal responsibility for treatment Notice triggers for angry outbursts and impulsive behavior and how you feel afterwards Receive treatment for related problems such as substance abuse Abide by a daily routine or schedule and make one lifestyle change at a time

Coding Matrix
References are rated in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations

references
1. Abraham, P. F., & Calabrese, J. R. (2008). Evidenced-based pharmacologic treatment of borderline personality disorder: A shift from SSRIs to anticonvulsants and atypical antipsychotics? Journal of Affective Disorders, 111(1), 21-30. (RV) 2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.). Arlington, VA: Author. (G) 3. Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. Lancet, 377(9759), 74-84. (RV) 4. Lubit, R. H. (2011). Borderline personality disorder. Medscape Reference. Retrieved April 25, 2011, from http://emedicine.medscape.com/article/913575-overview (GI) 5. Rosenthal, M. Z., Gratz, K. L., Kosson, D. S., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (2008). Borderline personality disorder and emotional responding: A review of the research literature. Clinical Psychology Review, 28(1), 75-91. (RV) 6. Sadock, B. J., & Sadock, V. A. (Eds.). (2007). Personality disorders. Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (10th ed., pp. 799-801). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. (GI) 7. Sansone, R. A., Buckner, V. R., Tahir, N. A., & Wiederman, M. W. (2009). Early family environment, borderline personality symptoms, and somatic preoccupation among internal medicine outpatients. Comprehensive Psychiatry, 50(3), 221-225. (R) 8. Sansone, R. A., Chu, J. W., & Wiederman, M. W. (2010). Borderline personality and weight divergence in adulthood. Eating Behaviors, 11(4), 309-311. (R) 9. Sansone, R. A., Lam, C., & Wiederman, M. W. (2010). Road rage: Relationships with borderline personality disorder and driving citations. International Journal of Psychiatry in Medicine, 40(1), 21-29. (R) 10. Sansone, R. A., Lam, C., & Wiederman, M. W. (2010). Self-harm behaviors in borderline personality: An analysis by gender. Journal of Nervous and Mental Disease, 198(12), 914-915. (R)