Borderline personality

Question 1

Screening questions for borderline personality

Answer 1

MOOD
* How is your mood overall ? what is the pattern
- rapid shift in emotions ?
- feelings of emptiness most of the time

Impulse control
o When you’re in an emotional bad state, what kind of things do you do?
“I’m going to list behaviours that
sometimes cause problems for people”
- “Gambled more money than you could afford to lose?”
- “Spent money impulsively on things you didn’t need or couldn’t afford?”
- “Had one night stands or brief sexual affairs?”
- “Been intoxicated with alcohol? Stoned or high on other drugs?”
- “Driven while intoxicated or high?”
- “Gone on eating binges?”
- “Done anything impulsive where you could have gotten hurt?”

ANGER
o Would you ever lose your temper?
what causes that?
What do you do when you are angry?
Do you ever throw things, break things start physical fights ?

Relationships
How is your current relationship like for you?
- stable? rollercoaster ?
o Do your friendships and relationships tend to be intense, with many ups and
downs?
o “Have there been times when you’ve been very upset, almost to the point of being distraught, because you thought someone you loved or needed very much may leave you?”
- “How often?”
- “What do you do to keep them from leaving?”

SUICIDAL BEHAVIOIR
o Have you ever been so upset that you told someone that you wanted to hurt or kill yourself?

Identity disturbance
o Does the way you think about yourself change very often? Do you feel like you
know who you are?

PSYCHOTIC FEATURES
o Some people, when they are under stress, have experiences that are hard to explain to others
- Have you ever felt your body or part of you was changed or not real?
- Have you felt that things around you have changed shape, somewhat strange?
- Do you get paranoid or suspicious or people you usually trust?”
- “Afraid someone is spying on you or planning to hurt you?”

Question 2

What is the DSM criteria for borderline personality disorder (9)

Answer 2

Pervasive pattern of instability of interpersonal relationships, self-image, affects and marked impulsivity, evidenced by ≥ 5 of the following:
(AEUUIIISP)
1. Efforts to avoid abandonment (real or imagined) but not suicidal behaviour
2. Chronic feelings of emptiness
3. Unstable self-image / sense of self
4. Unstable mood/affect (intense periods of dysphoria irritability, anxiety, usually lasting only a few hours)
5. Intense and unstable interpersonal relationships (characterised by alternating between extremes of idealisation and devaluation)
6. Impulsivity in at least 2 potentially damaging areas (spending, sex, substance abuse, reckless driving, binge eating)
7. Inappropriate/Intense anger that can be difficult to control
8. Recurrent suicidal behaviours / gestures / threats / self-harm
9. Transient stress-related paranoid ideation or severe dissociative sx

Question 3

What is the safey management of borderline+ ddx and investigations

Answer 3

Immediate Safety
- Suicidal or self-harm attempts: differentiate between chronic low risk vs. high self-harm risk
- Assess lethality and reachability of attempt and previous attempts
- Minimise length of hospital stays - frequent admission can interrupt lifestyle causing worsening defence mechanisms
- Community follow-up if not hospitalised

Differentials
o Bipolar
o Schizophrenia
o Substance abuse

Examination & Investigations
Exclude medical cause : Urine tox

Question 4

Treatment of borderline personality disorder -bps

Answer 4

1. Build rapport with simple communication and clear boundaries

Psych
- Psychoeducation
- DBT : To improve emotional regulation and suicidal
behaviour
- Coping skills and relaxation techniques
- Provides structure, clear plans, consistency between teams, therapists and caregivers
- Mentalisation based therapy :
- Transference focused therapy

Social
- Family/friends support
- Work/school
- Home/living conditions improvement
- Alcohol/drug rehabilitation
- Spiritual/cultural

Bio not usually indicated unless there is clinical indication for other conditions

Question 5

Explain borderline personality to a layman

Answer 5

• You are here today because of your family’s concern for your wellbeing/ low mood.
• It is not uncommon to experience strong emotions when having difficulties in our close relationships, however sometime people can fall into a pattern of coping with these emotions by engaging in behaviours that put yourself or others at risk.
• These patterns fall under a diagnosis called borderline personality disorder which unlike the name does not mean there is something inherently wrong with you but identifies that some of the patterns you have learned to use in your life are affecting your functioning and causing you significant distress. Many people with BPD have fear of rejection and find their view of themselves and others can switch very easily.
• Research has not yet discovered exactly how a person develops BPD, but it is thought that some people with a family hx may be predisposed and traumatic experiences during childhood such as abuse, separation from caregivers and neglect can play a part. Studies show that people with BPD can have structural and functional changes in the brain, especially in the areas that control impulses and emotional regulation.
• A diagnosis can help you access the support and treatment you need to learn new ways to manage these experiences and live a full and happy life.
• The mainstay of treatment involves talking therapies which help to give you new tools and strategies to cope with emotions in a safer way. One of the common therapies is called dialectical behavioural therapy - it is based on the idea that two seemingly opposite things can both be true: for example, you can accept your feelings and behaviour while also wanting to change some aspects of them. DBT involves four main components: learning distress tolerance, emotional regulation, interpersonal effectiveness and mindfulness strategies. DBT therapy often includes group skills training and individual sessions