Borderline personality disorder

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Background

  • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity

Clinical Features

  • Five (or more) of the following criteria, beginning by early adulthood and present in a variety of contexts:[1]
    • Frantic efforts to avoid real or imagined abandonment.
    • A pattern of unstable and intense interpersonal relationships characterized by alternat­ing between extremes of idealization 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 (e.g., spending, sex, substance abuse, reckless driving, binge eating).
    • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
    • Affective instability due to a marked reactivity of mood (e.g., 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 controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
    • Transient, stress-related paranoid ideation or severe dissociative symptoms.
  • Completed suicide rates 8-10%, 50 times higher than general population[2]

Differential Diagnosis

Evaluation

  • A clinical diagnosis; however if entertaining other organic causes may initiate workup below

General ED Psychiatric Workup

Management

  • Treat medical complications of self-harm behavior
  • Consider psychiatry consult or admission if acutely suicidal
  • Set boundaries
  • Tolerate emotions but not outbursts
  • Be empathetic yet direct and fact-based, avoid emotionality
  • Referral for outpatient psychiatric treatment, as psychotherapy is the primary treatment. Antipsychotics, antidepressants and mood stabilizers can be used to control symptoms such as anger and affective instability.

Disposition

  • Discharge

See Also

External Links

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl 10):1-52.