Borderline personality disorder

Synonym: borderline personality disorder

What is emotionally unstable personality disorder (EUPD)?

It is important to note that the International Classification of Diseases 11th edition (ICD-11) - which came into effect in January 2022 - does not identify different types of personality disorder, and instead focuses on personality traits and severity.¹ Previously the ICD-10 depicted different types of personality disorder, including emotionally unstable personality disorder. In the United States, the DSM-MD5 (the Diagnostic and Statistical Manual of Mental Disorders, 5th edition) continues to describe different types of personality disorder, of which borderline personality disorder (previously known as emotionally unstable personality disorder in the ICD-10) is one.

The ICD-11 classification of personality disorders focuses on core personality dysfunction, with three levels of severity (mild, moderate, or severe), and the option of specifying one or more prominent trait domain qualifiers (negative affectivity, detachment, disinhibition, dissociality, and anankastia). The classification also includes a borderline pattern qualifier.² See the separate article on Personality disorders for further details.

Whilst emotionally unstable or borderline personality disorder should not be diagnosed currently in the UK or Europe, according to the ICD-11, there will be many patients who have had this diagnosis previously. In addition, the ICD-11 does describe a borderline trait and the National Institute for Health and Care Excellence (NICE) continues to have a guideline for borderline personality disorder, although it states that NICE is reviewing its response to the changes in ICD-11.

Thus, for now, borderline personality disorder continues to be a diagnosis which has some value in being discussed.

Historically, emotionally unstable and borderline personality disorders have both described the same condition. The term borderline personality disorder will be used in this article as it is the more commonly used term.

First described in 1938,³ borderline personality disorder is a personality disorder characterised by pervasive instability of interpersonal relationships, self-image and mood, and impulsive behaviour.

The cause of borderline personality disorder is unknown but research suggests there is an interaction between genetic factors and adverse childhood experiences which influence brain development via hormones and neuropeptides. Adverse childhood experiences are thought to modulate gene expression and lead to personality traits that may predispose to borderline personality disorder. ⁴Neuroimaging shows frontolimbic dysfunction, in common with many other psychiatric conditions. ⁵

Borderline personality disorder causes significantly impaired functioning, including a feeling of emptiness, lack of identity, unstable mood and relationships, intense fear of abandonment, and dangerous impulsive behaviour, including severe episodes of self-harm. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair.⁶

Diagnosis of Borderline Personality Disorder⁴

In the ICD-11 (clinically used everywhere except the United States), borderline personality trait as a subset of personality disorder requires 5 of the following:

• Frantic efforts to avoid real or imagined abandonment.

• Unstable and intense interpersonal relationships, which may be characterised by vacillations between idealisation and devaluation.

• Identity disturbance, manifested in unstable self‐image.

• A tendency to act rashly in states of high negative affect, leading to potentially self‐damaging behaviours.

• Recurrent episodes of self‐harm.

• Emotional instability due to marked reactivity of mood.

• Chronic feelings of emptiness.

• Inappropriate intense anger or difficulty controlling anger.

• Transient dissociative symptoms or psychotic‐like features.

Further manifestations which may be present include a view of the inadequate, bad or guilty, an experience of the self as profoundly different and isolated or alienated from others, a proneness to rejection hypersensitivity, problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships, and frequent misinterpretation of social signals.

In the DSM-V (used clinically in the United States), borderline personality disorder can be diagnosed by 5 or more of the following 9 characteristics:

• Frantic efforts to avoid real or imagined abandonment.

• A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation 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 (eg, spending, sex, substance abuse, reckless driving, binge eating).

• Recurrent suicidal behaviour, gestures or threats, or self‐mutilating behaviour.

• Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).

• Chronic feelings of emptiness.

• Inappropriate, intense anger or difficulty in controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights).

• Transient, stress‐related paranoid ideation or severe dissociative symptoms.

Epidemiology of Borderline Personality Disorder^{47 8}

• Epidemiological data need to be interpreted with care, as diagnostic standards vary.

• Borderline personality disorder tends to present in early adulthood.

• In the general population, rates are thought to be between 0.7 and 2.7% but have been reported to be 6% of those presenting to general practice, 11% of those seen in psychiatric outpatients, and 22% of psychiatric inpatients.

• Borderline personality disorder is more common in women though estimates vary as to the difference between genders.

• NICE emphasises that borderline personality disorders should not be diagnosed under the age of 18, although characteristic personality traits can be detected at an earlier age.

• The rate of death by suicide is higher among individuals with borderline personality disorder than in patients with other personality disorders. A recent meta‐analysis reported suicide rates of 4% over follow‐up periods of 5 to 14 years among people with borderline personality disorder.⁴ Older studies suggest that suicide attempts occurred in more than 75% of BPD individuals ⁹

• Borderline personality disorder is also associated with higher mortality from other causes, particularly those who have not made a recovery.¹⁰

Differential diagnosis

• Alcohol dependency.

• Mental disorders secondary to medical conditions (head injuries, seizure disorders).

• Other personality disorders.

• Anxiety disorders.

• General learning disability.

• Brief psychotic disorder.

• Post-traumatic stress disorder.

• Depression.

• Schizoaffective disorder.

• Schizophrenia.

• Ganser's syndrome.

Investigations

• Psychological testing may support or direct the clinical diagnosis. Those cited by NICE are:

  • Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).

  • Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II).

  • Structured Interview for DSM-IV Personality (SIDP-IV).

  • International Personality Disorder Examination (IPDE).

  • Personality Assessment Schedule (PAS).

  • Standardised Assessment of Personality (SAP).

• Other investigations which may be required:

  • Toxicology screen because substance abuse is common in borderline personality disorder, particularly in men. ¹¹

  • Screening for HIV and other blood-borne viruses may be appropriate because of the poor impulse control and disregard of risk associated with personality disorder.¹²

Associated diseases¹³

• Anxiety (There is an 84.8% lifetime comorbidity between anxiety and borderline personality disorder.)¹⁴

• Alcohol and drug misuse. (The lifetime prevalence of a substance use disorder is 78% in patients with borderline personality disorder.)¹⁴

• Depression. (Up to 80% of patients with borderline personality disorder present with one or more major depressive episode.)¹⁴

• Recurrent self-harm.

• Eating disorders. (Borderline personality disorder has been found to be present in 28% of patients with bulimia nervosa (BN), 25% of those with anorexia nervosa binge-eating/purging subtype, and 10.8% of patients with restrictive anorexia nervosa. The prevalence of eating disorders among individuals with BPD has been found to be raised, ranging from 14% to 53%.)¹⁴

• Post-traumatic stress disorder.

• Physical conditions:¹⁰¹⁵

  • Arteriosclerosis.

  • Hypertension.

  • Hepatic disease.

  • Cardiovascular disease.

  • Gastrointestinal disease.

  • Osteoarthritis.

  • Sexually transmitted infections.

Borderline personality disorder treatment and management⁷

NICE guidance to inform clinical commissioning groups has been published to guide the commissioning of services for people with borderline personality disorder.⁸

General considerations

According to NICE, care should involve collaboration between different agencies and professionals. Teams working with people with emotionally unstable personality disorder should develop a comprehensive multidisciplinary care plan with the service user (and their family or carers, where agreed with the person). The care plan should:

• Identify clearly the roles and responsibilities of all health and social care professionals.

• Identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them.

• Identify long-term goals (including employment), which the person would like to achieve. These should underpin the overall long-term treatment strategy.

• Develop a crisis plan which:

  • Identifies potential triggers that could lead to a crisis.

  • Specifies self-management strategies likely to be effective.

  • Establishes how to access services (including support numbers for out-of-hours teams and crisis teams).

• Be shared with the GP and the service user.

It is important to recognise that, despite the recommendations, such services do not exist in much of the UK due to funding constraints.

Psychological treatment

Various psychotherapeutic approaches appear to be of value in borderline personality disorder, achieving clinically significant reductions in symptoms as well as reductions in self-harm, suicide and psychosocial functioning.⁴ Generic psychotherapy (including general psychiatric management, structured clinical management, client‐centred therapy, and supervised team management) were found to be inferior to specialised psychotherapies such as dialectical behaviour therapy, mentalisation-based therapy, or schema therapy.¹⁶Very few of these treatments are available on the NHS.

Drug treatment¹⁴

• No drug has been approved for treatment of borderline personality disorder.

• Many drugs, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), mood stabilisers, second-generation antipsychotics, and even benzodiazepines, are routinely prescribed off label without clear guidance

• Recent reviews have suggested that drug therapy should only be considered as an adjunct to psychotherapy and only when specific comorbidities (affective, anxiety, eating, and drug use disorders) exist.

• Polypharmacy and the use of unsafe drugs (those with a risk of overdose) should be avoided.

• Despite the lack of evidence, one study showed that almost 80% of comorbidity-free patients with borderline personality disorder were also receiving pharmacological treatment (62.9% received antidepressants, 59.7% benzodiazepines, 22.6% mood stabilisers, and 27.4% antipsychotics) with 42% on polypharmacy.¹⁷

• Guidance suggests that:

  • Patients with borderline personality disorder who also have a mood disorder should initially be offered psychotherapy. There is little evidence of benefit for anti-depressants in this cohort but, if psychotherapy has not been effective then SSRIs (including fluoxetine, sertraline, citalopram, or escitalopram) should be the first line of drug treatment. Second generation anti-psychotics may also be of some value where there is treatment-resistant mood disorder. Medications with high risks in overdose should be avoided, as should polypharmacy.

  • Patients with borderline personality disorder who also have anxiety disorder respond best to cognitive behavioural therapy but SSRIs and SNRIs can be useful when combined with psychotherapy. All clinical guidelines advise against the use of benzodiazepines due to their addictive potential as well as their capacity to increase suicidal tendencies and disinhibition.¹⁸

  • Patients with borderline personality disorder who also have an eating disorder should initially be offered psychotherapy. Some guidelines suggest that short-term treatment with SSRIs or low-dose antipsychotics (especially olanzapine) may be justified. The current evidence base is weak for pharmacotherapy but psychotropic medications, which may affect appetite and body weight, including SSRIs, antipsychotics, and anticonvulsants could be prescribed as an adjunct to psychotherapy.

  • Patients with borderline personality disorder who also have substance use disorder should initially be offered psychotherapy. Studies have shown that patients with substance use disorder respond to medication in the same way, whether or not they have borderline personality disorder. Therefore the usual medications for substance misuse should be offered in specialised settings.

• If off-licence medications are prescribed by mental health services which are felt to cause unacceptable risks for those prescribing in primary care, it is reasonable to expect these medications to be prescribed long-term by secondary care.

Management in primary care

• Recognise likely borderline personality disorder in those who:

  • Repeatedly self-harm.

  • Display persistent risk-taking behaviour.

  • Have marked emotional instability.

• Refer:

  • To community mental health services for assessment for personality disorder with borderline traits.

  • If the person is younger than 18 years, refer them to The Child and Adolescent Mental Health Services (CAMHS) for assessment.

• Crisis management: consult the patient's crisis plan (a plan devised to identify trigger factors, advise on self-help strategies and identify when the individual should seek professional help).

  • Refer in crisis to community mental health services especially when:

    • Levels of distress and/or the risk of harm to self or to others are increasing.

    • Levels of distress and/or the risk of harm to self or to others have not subsided despite attempts to reduce anxiety and improve coping skills.

    • Patients request further help from specialist services.

Prognosis

Borderline personality disorder tends to improve over time. Many of the most troubling symptoms reduce in the first few years, although underlying personality traits often remain. ¹⁹ Within this, men tend to improve more than women. ²⁰

Adolescents who meet the diagnostic criteria for borderline personality disorder tend to show problems adjusting to the transition to young adulthood. ²¹ However, patients who present younger tend to improve more than those who present older.²⁰

Prevention of Borderline Personality Disorder²²

There is evidence that novel indicated prevention and early intervention programmes may be useful in reducing the risk of developing borderline personality disorder.

Indicated prevention involves identifying individuals who exhibit early signs of early conduct problems and/or have an increased risk for a disorder but currently do not have a diagnosable disorder.

Given the ubiquity of adverse childhood events in the development of borderline personality disorder, early intervention programmes, which involve a system of co-ordinated services that promotes a child's age-appropriate growth and development and supports families during the critical early years, are likely to have the most impact. This approach is promising but requires further research.