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CLINICAL Q&A
Diagnosing and Treating Borderline Personality Disorder
By and large, psychiatrists aren’t terribly comfortable when it comes to diagnosing and treating borderline personality disorder (BPD). The clinical picture is challenging, and the stigma attached to the term makes it difficult for patients to hear—in fact, many clinicians end up not making the diagnosis at all! But BPD, characterized by DSM-5 as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity,” is curable. It’s also more common than you might think. Estimates state that 1%–2% of adults have BPD, yet among clinical samples—ie, people who will actually show up in your practice—the clinical prevalence is about 9% (Zimmerman M et al, Am J Psychiatry 2005;162(10):1911–1918).
With those numbers in mind, and because with DSM-5 all personality disorders were “promoted” to Axis 1 disorders, we thought it would be good to review the basics of diagnosis and treatment so you can feel more confident in helping these patients.
Fortunately, diagnosing BPD is relatively easy and can often be done in 20–30 minutes. The key is to have a systematic approach, to ask high-yield questions, and to know how to efficiently follow up on responses. In the corresponding table, we go through each of the nine DSM criteria in turn, organized by the “IDESPAIRR” mnemonic (Carlat D. The Psychiatric Interview, 4th ed. The Netherlands: Wolters Kluwer; 2017).
Identity disturbance
How do you ask about something as vague as an identity disturbance? Asking something like, “Do you know who you are?” may not get you anywhere. Instead, ask, “Do you have a sense of where you’re going in life?” Probe for whether your patient has a dream, a purpose, or an ambition—all of which are inextricably tied to one’s sense of identity. The BPD patient’s response is often, “No, I don’t have an ambition; I’m just caught up in my pain.” Patients with BPD who are working toward a goal, such as college students, tend to do better in treatment. Having goals helps strengthen the wish to continue living.
Disordered mood
Disordered mood is what DSM calls mood instability, and it is one of the key features of BPD. Ask, “Do you find that your mood changes a lot in the course of the day?” Typically patients will reply with, “My emotional life is a roller coaster.”
Emptiness
Ask patients, “Do you feel empty inside, as if there’s nothing there?” Among BPD patients, a common answer is, “Definitely.” The emptiness of BPD is different from depression. Patients with depression feel sad, like they’ve lost something, and can usually describe a time when they didn’t feel depressed. BPD patients, on the other hand, will often say, “I’ve never been happy; my life is pointless.”
Suicidality
BPD patients often have chronic suicidal ideation, though the rate of actual suicides is lower than many think—most estimates are in the 5%–10% range (Soloff P and Chiapetta L, J Pers Dis 2012,26(3):468–480).
Often patients have urges to inflict self-harm by means such as cutting, burning themselves, or banging their heads against the wall. People have varying motivations for these actions, but they often feel overwhelmed by their lives and are unable to regulate their emotional responses; if they harm themselves, they feel the act breaks the cycle and serves as a distraction. One of our patients said, “When I see the blood dripping out, I immediately feel better.”
As you should do for any patient in whom you suspect suicidal ideation, be straightforward in your questions: “Have you ever thought of committing suicide? Have you ever tried? What have you done? Have you done it more than once? Do you cut yourself? If so, how long have you been doing it and how often?” Ask patients whether they have ever threatened to harm themselves during an argument—a common practice in BPD.
Our preferred intervention for BPD patients discussing suicide is to acknowledge their pain and to assure them that their condition can be treated: “You must have unbearable pain if you’re thinking about suicide. But know this is something I can help you with.” The reality is that most people who commit suicide do so when they are not in active treatment. Patients who are in your office trying to get help are demonstrating that they would prefer to get better rather than kill themselves.
Note that sometimes, BPD patients don’t think clinicians will listen to them unless they turn up the volume and talk about suicide in an attempt to scare the clinician. Don’t get scared; instead, let patients know that you hear them.
Paranoia
This DSM criterion refers to “transient, stress-induced paranoid ideation” and includes “severe dissociative symptoms.” In our experience, some degree of paranoia is very common in BPD patients.
If you were to ask, “Do you feel when you’re outside that strangers are looking at you, commenting on you, and probably criticizing you?” most patients will respond, “Yes, I’ve been like that as long as I can remember.” Some will say they have trouble getting onto a bus or engaging in other activities because of that feeling. These symptoms are not usually amenable to antipsychotic treatment. However, some patients experience transient auditory hallucinations when they get upset, and antipsychotics may be helpful in these cases.
To assess dissociation, ask, “When you get upset, do you feel outside your body, like everything looks peculiar or different?”
Abandonment intolerance
Ask patients, “When you start a relationship, do you feel that you’re going to be dumped from day one?” Most say yes and go on to explain that every rejection throws them into a crisis.
Impulsivity
Impulsivity includes a range of behaviors, such as over-spending, substance abuse, reckless sexual behavior often associated with drinking, reckless driving, and bulimia. You can ask about each of these behaviors in turn: “Do you ever spend so much money that you go deeply into debt? Do you get drunk, and have you done things you’re sorry for while you’re drunk? Do you binge eat? Have you ever forced yourself to throw up after binge eating?”
Rage
Ask patients, “Would people describe you as having a short temper? When you get angry, do you lose it completely? Do you yell, scream, break things, or throw things?” Rage is one of the most characteristic features of BPD.
Relationship problems
Finally, ask patients, “Have you had the experience that when somebody disappoints you, you just can’t stand them?” One of our patients responded, “The moment somebody disappoints me—even in the smallest way—I never want to see them again.”
Relationships, particularly intimate relationships, play a key role in getting BPD patients into psychiatric trouble, so you should spend some time understanding patients’ relationship history. Ask questions like, “Are you in a relationship? What happens to you in a relationship? Are there a lot of quarrels?”
Most BPD patients have not been able to sustain relationships for long periods. One reason is their inability to tolerate their fear of abandonment, or less extreme forms of rejection or criticism.
Distinguishing between BPD and bipolar disorder
Given that both borderline and bipolar disorder are characterized by mood instability, it’s no wonder the two conditions can easily be confused. According to research, 40% of patients with BPD have been diagnosed as bipolar at some point (Ruggero VJ et al, J Psychiatr Res 2010;44(6):405–408).
It’s critical to distinguish the two for several reasons. Meds are the cornerstone treatment for bipolar, whereas therapy is the cornerstone for borderline. Contrary to popular opinion, prognosis is much better for borderline personality disorder than for bipolar. Most people don’t meet diagnostic criteria for borderline 10 years after first diagnosis. In addition, the suicide rate for borderline is 5%–10% vs 6%–20% for bipolar (Goodwin FK & Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Vol. 1. Oxford University Press; 2007).
How to differentiate between the two in an interview? In patients with bipolar II, you must document a hypomanic episode that lasts at least 4 days, after which patients return to their baseline mood. Borderline patients also have mood swings, but they are usually brought on by difficult interpersonal events, and the fluctuations happen more quickly—sometimes several times throughout the day.
Communicating the diagnosis to patients
Because of the stigma attached to the term “borderline personality disorder,” some clinicians find themselves tongue-tied when trying to explain the diagnosis to their patients.
It’s best to simply describe the symptoms and behaviors as you heard them from the patient and repeat them. This deemphasizes the idea that the patient has some deep-seated defect, which is a common misinterpretation of the term “personality disorder.” For example: “You described to me that your emotions are very unstable; you often lose control of your temper; you cut yourself; you have made suicide attempts; you use too many drugs; and your relationships are conflictual and don’t work—that’s borderline personality disorder. “
A brief note on treatment
Psychopharmacology treatment can be helpful when targeted carefully. We recommend you check out this thoughtful review of current treatment options published this year: Choi-Kain WL et al, What Works in the Treatment of Borderline Personality Disorder. Curr Behav Neurosci Rep 2017;4(1):21–30. The bottom line is that antidepressants, while very commonly prescribed for BPD in the community, don’t appear to help much with core BPD symptoms such as the feeling of emptiness and the fear of abandonment. Antipsychotics can be effective for symptoms including affective dysregulation, impulsivity, and hallucinations. The efficacy of mood stabilizers is more controversial. Some meta-analyses have concluded that meds like lamotrigine and valproate are helpful for impulsivity and anger. But a recent large-scale study (Crawford MJ et al, Trials 2015;16:308) presented at the North American Association for the Study of Personality Disorders found no benefit of lamotrigine.
Psychotherapy is the most effective treatment for BPD. While many associate dialectic behavior therapy (DBT) with specific efficacy for BPD, it turns out that in head-to-head trials, DBT is no more effective than several other manualized therapies, such as transference focused therapy (TFT), mentalization based therapy (MBT), and others. The trend now is to devise treatments that don’t require as many sessions and can more easily be led by clinicians who don’t have training in specific structured techniques. For example, general psychiatric management (GPM) involves no more than one session per week. The individual therapist coordinates treatment between the psychopharmacologist and a family therapist, if needed. A randomized comparison of GPM with DBT found that both techniques were effective at 2-year follow-up, with less patient dropout in the GPM group (McMain SF, Am J Psychiatry 2009;166(12):1365–1374).
Dr. Paris, one of this article’s authors, has used a form of therapy called “DBT-light” for many years. It incorporates some elements of standard DBT but is less time-consuming. The essence of the treatment is a combination of psychoeducation and skills development. The goal is to teach patients to regulate their emotions and to gain the skills needed to improve their relationships. Getting along better with people helps patients be less impulsive, since much of their impulsivity has to do with relationship issues. Most patients can be treated in just a few months, making treatment more accessible and less expensive (Paris J. Stepped Care for Borderline Personality Disorder. New York: Academic Press; 2017).
TCPR Verdict: Time to sharpen your BPD diagnostic skills. Use meds conservatively (they don’t work very well), and focus on helping patients learn the skills needed to form lasting relationships.
General PsychiatryWith those numbers in mind, and because with DSM-5 all personality disorders were “promoted” to Axis 1 disorders, we thought it would be good to review the basics of diagnosis and treatment so you can feel more confident in helping these patients.
Fortunately, diagnosing BPD is relatively easy and can often be done in 20–30 minutes. The key is to have a systematic approach, to ask high-yield questions, and to know how to efficiently follow up on responses. In the corresponding table, we go through each of the nine DSM criteria in turn, organized by the “IDESPAIRR” mnemonic (Carlat D. The Psychiatric Interview, 4th ed. The Netherlands: Wolters Kluwer; 2017).
Table: IDESPAIRR: A Mnemonic for Diagnosing BPD(Click to view full size PDF)
Identity disturbance
How do you ask about something as vague as an identity disturbance? Asking something like, “Do you know who you are?” may not get you anywhere. Instead, ask, “Do you have a sense of where you’re going in life?” Probe for whether your patient has a dream, a purpose, or an ambition—all of which are inextricably tied to one’s sense of identity. The BPD patient’s response is often, “No, I don’t have an ambition; I’m just caught up in my pain.” Patients with BPD who are working toward a goal, such as college students, tend to do better in treatment. Having goals helps strengthen the wish to continue living.
Disordered mood
Disordered mood is what DSM calls mood instability, and it is one of the key features of BPD. Ask, “Do you find that your mood changes a lot in the course of the day?” Typically patients will reply with, “My emotional life is a roller coaster.”
Emptiness
Ask patients, “Do you feel empty inside, as if there’s nothing there?” Among BPD patients, a common answer is, “Definitely.” The emptiness of BPD is different from depression. Patients with depression feel sad, like they’ve lost something, and can usually describe a time when they didn’t feel depressed. BPD patients, on the other hand, will often say, “I’ve never been happy; my life is pointless.”
Suicidality
BPD patients often have chronic suicidal ideation, though the rate of actual suicides is lower than many think—most estimates are in the 5%–10% range (Soloff P and Chiapetta L, J Pers Dis 2012,26(3):468–480).
Often patients have urges to inflict self-harm by means such as cutting, burning themselves, or banging their heads against the wall. People have varying motivations for these actions, but they often feel overwhelmed by their lives and are unable to regulate their emotional responses; if they harm themselves, they feel the act breaks the cycle and serves as a distraction. One of our patients said, “When I see the blood dripping out, I immediately feel better.”
As you should do for any patient in whom you suspect suicidal ideation, be straightforward in your questions: “Have you ever thought of committing suicide? Have you ever tried? What have you done? Have you done it more than once? Do you cut yourself? If so, how long have you been doing it and how often?” Ask patients whether they have ever threatened to harm themselves during an argument—a common practice in BPD.
Our preferred intervention for BPD patients discussing suicide is to acknowledge their pain and to assure them that their condition can be treated: “You must have unbearable pain if you’re thinking about suicide. But know this is something I can help you with.” The reality is that most people who commit suicide do so when they are not in active treatment. Patients who are in your office trying to get help are demonstrating that they would prefer to get better rather than kill themselves.
Note that sometimes, BPD patients don’t think clinicians will listen to them unless they turn up the volume and talk about suicide in an attempt to scare the clinician. Don’t get scared; instead, let patients know that you hear them.
Paranoia
This DSM criterion refers to “transient, stress-induced paranoid ideation” and includes “severe dissociative symptoms.” In our experience, some degree of paranoia is very common in BPD patients.
If you were to ask, “Do you feel when you’re outside that strangers are looking at you, commenting on you, and probably criticizing you?” most patients will respond, “Yes, I’ve been like that as long as I can remember.” Some will say they have trouble getting onto a bus or engaging in other activities because of that feeling. These symptoms are not usually amenable to antipsychotic treatment. However, some patients experience transient auditory hallucinations when they get upset, and antipsychotics may be helpful in these cases.
To assess dissociation, ask, “When you get upset, do you feel outside your body, like everything looks peculiar or different?”
Abandonment intolerance
Ask patients, “When you start a relationship, do you feel that you’re going to be dumped from day one?” Most say yes and go on to explain that every rejection throws them into a crisis.
Impulsivity
Impulsivity includes a range of behaviors, such as over-spending, substance abuse, reckless sexual behavior often associated with drinking, reckless driving, and bulimia. You can ask about each of these behaviors in turn: “Do you ever spend so much money that you go deeply into debt? Do you get drunk, and have you done things you’re sorry for while you’re drunk? Do you binge eat? Have you ever forced yourself to throw up after binge eating?”
Rage
Ask patients, “Would people describe you as having a short temper? When you get angry, do you lose it completely? Do you yell, scream, break things, or throw things?” Rage is one of the most characteristic features of BPD.
Relationship problems
Finally, ask patients, “Have you had the experience that when somebody disappoints you, you just can’t stand them?” One of our patients responded, “The moment somebody disappoints me—even in the smallest way—I never want to see them again.”
Relationships, particularly intimate relationships, play a key role in getting BPD patients into psychiatric trouble, so you should spend some time understanding patients’ relationship history. Ask questions like, “Are you in a relationship? What happens to you in a relationship? Are there a lot of quarrels?”
Most BPD patients have not been able to sustain relationships for long periods. One reason is their inability to tolerate their fear of abandonment, or less extreme forms of rejection or criticism.
Distinguishing between BPD and bipolar disorder
Given that both borderline and bipolar disorder are characterized by mood instability, it’s no wonder the two conditions can easily be confused. According to research, 40% of patients with BPD have been diagnosed as bipolar at some point (Ruggero VJ et al, J Psychiatr Res 2010;44(6):405–408).
It’s critical to distinguish the two for several reasons. Meds are the cornerstone treatment for bipolar, whereas therapy is the cornerstone for borderline. Contrary to popular opinion, prognosis is much better for borderline personality disorder than for bipolar. Most people don’t meet diagnostic criteria for borderline 10 years after first diagnosis. In addition, the suicide rate for borderline is 5%–10% vs 6%–20% for bipolar (Goodwin FK & Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Vol. 1. Oxford University Press; 2007).
How to differentiate between the two in an interview? In patients with bipolar II, you must document a hypomanic episode that lasts at least 4 days, after which patients return to their baseline mood. Borderline patients also have mood swings, but they are usually brought on by difficult interpersonal events, and the fluctuations happen more quickly—sometimes several times throughout the day.
Communicating the diagnosis to patients
Because of the stigma attached to the term “borderline personality disorder,” some clinicians find themselves tongue-tied when trying to explain the diagnosis to their patients.
It’s best to simply describe the symptoms and behaviors as you heard them from the patient and repeat them. This deemphasizes the idea that the patient has some deep-seated defect, which is a common misinterpretation of the term “personality disorder.” For example: “You described to me that your emotions are very unstable; you often lose control of your temper; you cut yourself; you have made suicide attempts; you use too many drugs; and your relationships are conflictual and don’t work—that’s borderline personality disorder. “
A brief note on treatment
Psychopharmacology treatment can be helpful when targeted carefully. We recommend you check out this thoughtful review of current treatment options published this year: Choi-Kain WL et al, What Works in the Treatment of Borderline Personality Disorder. Curr Behav Neurosci Rep 2017;4(1):21–30. The bottom line is that antidepressants, while very commonly prescribed for BPD in the community, don’t appear to help much with core BPD symptoms such as the feeling of emptiness and the fear of abandonment. Antipsychotics can be effective for symptoms including affective dysregulation, impulsivity, and hallucinations. The efficacy of mood stabilizers is more controversial. Some meta-analyses have concluded that meds like lamotrigine and valproate are helpful for impulsivity and anger. But a recent large-scale study (Crawford MJ et al, Trials 2015;16:308) presented at the North American Association for the Study of Personality Disorders found no benefit of lamotrigine.
Psychotherapy is the most effective treatment for BPD. While many associate dialectic behavior therapy (DBT) with specific efficacy for BPD, it turns out that in head-to-head trials, DBT is no more effective than several other manualized therapies, such as transference focused therapy (TFT), mentalization based therapy (MBT), and others. The trend now is to devise treatments that don’t require as many sessions and can more easily be led by clinicians who don’t have training in specific structured techniques. For example, general psychiatric management (GPM) involves no more than one session per week. The individual therapist coordinates treatment between the psychopharmacologist and a family therapist, if needed. A randomized comparison of GPM with DBT found that both techniques were effective at 2-year follow-up, with less patient dropout in the GPM group (McMain SF, Am J Psychiatry 2009;166(12):1365–1374).
Dr. Paris, one of this article’s authors, has used a form of therapy called “DBT-light” for many years. It incorporates some elements of standard DBT but is less time-consuming. The essence of the treatment is a combination of psychoeducation and skills development. The goal is to teach patients to regulate their emotions and to gain the skills needed to improve their relationships. Getting along better with people helps patients be less impulsive, since much of their impulsivity has to do with relationship issues. Most patients can be treated in just a few months, making treatment more accessible and less expensive (Paris J. Stepped Care for Borderline Personality Disorder. New York: Academic Press; 2017).
TCPR Verdict: Time to sharpen your BPD diagnostic skills. Use meds conservatively (they don’t work very well), and focus on helping patients learn the skills needed to form lasting relationships.
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