Borderline Personality Disorder

Question 1

A 28 year old woman is BIBA, tearful and threatening self harm. She denies having taken any drug overdoses. There are superficial lacerations to her right wrist. She is irritable and crying. How would you assess and manage her?

A 24 year old woman presents following her 4th episode of deliberate self harm in two months. She usually takes a small quantity of paracetamol tablets with some alcohol. How would you assess and manage?

Answer 1

Impression
With history of self harm am concerned about acute risk of suicide, plus evidence of previous self-harm. There would be a wide list of differentials for this presentation including;
Affective psychiatric
- MDD/melancholic/psychotic
- Bipolar disorder
- Anxiety disorder
Non-affective psychiatric
- schizophrenia
- schizoaffective
Personality disorder
- BPD, cluster B

Would want to acutely assess her for risk of harm to self and others, as well as conduct full psychiatric assessment and make management decisions about whether to manage on inpatient or outpatient basis.

Question 2

BPD - History

Answer 2

History

• PC: suicidal ideation, plans, intent, self harm, history, current and future risk, protective factors
• Screen mania, depressive, psychotic, anxiety sx
• Ask about personality: how are you in relationships? Affective lability, self-harm history,
• BPD: I DESPAIR - (Identity crisis, Dysphoria, Emotional instability, Suicide/self harm, psychotic/dissociative, Anger, Impulsivity, Relationships - separation anxiety, splitting)
• Screen substance use disorder, other comorbidities
• past psych, fam hx, med hx, developmental, forensic

Question 3

BPD - Examination

Answer 3

Examination
MSE

Formulation:

• predisposing
• perpetuating
• precipitating
• protective

Question 4

BPD - Invstigations

Answer 4

Investigations

• Bedside: urine drug screen, ECG
• Bloods: BAC, LFT, UEC - consider full panel for organic causes of presentation if indicated/suspicious

Question 5

BPD - Management

Answer 5

Management
1) Active and ongoing risk assessment: risk of suicidality, harm to others, and risk of

2) Consider location of further treatment: Hospital vs outpatient treatment. If hospital, then consider whether voluntary or involuntary. Of particular note, admission for BPD patients can be unhelpful for several reasons:
- increases reliance on institutions
- reinforces behaviours
- patients de-skill in their own management
- locus of control is shifted to HCWs when it should be the patient
- increases escalation of the ‘game’

Acute

• psychiatry consult
• Crisis management -> verbal de-escalation, follow hospital protocol (verbal -> chemical -> physical)
• Address co-morbidities (psychiatric illness, substance use disorder), any acute withdrawal
• safety planning - involve social worker
• clozapine/lithium are anti-suicidal, can be used in acute setting

Ongoing
- develop a crisis plan
psychological therapy is mainstay:
- psychoeducation
- psychotherapy - DBT: working with acceptance and change - acceptance oriented skills, and change oriented skills

Biological
- adjunct pharmacotherapies for co-morbidities - do not change the nature and course of BPD

Social

• therapeutic alliance
• lifestyle changes
• regular counseling
• Transference and counter-transferance