About Borderline Personality Disorder

Psychiatry Matters

Symptoms and signs

The clinical presentation of borderline personality disorder varies widely and can be very vague. Common features include:

Borderline personality disorder is usually accompanied by one or several `symptom disorders', such as an eating disorder, depression, post-traumatic stress disorder, premenstrual tension, dissociative disorder or anxiety disorder.

Investigations

A full psychiatric history should be obtained.

Psychological testing may be helpful - distinct patterns on Minnesota Multiphasic Personality inventory and other psychological tests can indicate behavioral instability and impulsivity, and some patients demonstrate a variety of disturbances on neuropsychological tests, especially those involving complex attentional functioning.

Complications

Common complications of borderline personality disorder include:

Several conditions are frequently comorbid with borderline personality disorder, including:

Prognosis

A better prognosis seems to be indicated by:

Treatment and Outcome 

Treatment aims

The aims of treatment are:

Diet and lifestyle

It is useful to eliminate or reduce the use of alcohol and recreational drugs. A healthy diet, a regular work and leisure routine and good sleep hygiene should also be encouraged.

Pharmacological treatment

Drugs that may be useful in enhancing mood stability, decreasing impulsivity and improving cognitive performance in borderline personality disorder include:

Generally antidepressants should not be used without a mood-stabilizing agent in this disorder.

** off-label use

Atypical antipsychotic agents

Standard dosage

Standard dose ranges for the atypical antipsychotic agents are:

Contraindications

The atypical antipsychotic agents should be used with caution in:

Each of the drugs also has its own profile of contraindications and cautions:

Main side effects

The atypical antipsychotic agents may cause:

Their sedative effects are enhanced when they are combined with other central nervous system depressants.

Each specific agent has its own profile of side effects:

Main drug interactions

The atypical antipsychotic agents potentiate the effects of other central nervous system depressants.

Mood stabilizers

Standard dosage

The dose of lithium carbonate should be titrated against the plasma concentration of lithium to achieve a level of 0.4-1mmol/l 12 hours after a dose on day 4-7 of treatment. Monitoring should continue weekly until the dose has remained constant for 4 weeks. Monitoring should be performed at least every 3 months after that.

The standard dose of valproate is 750mg/day initially, increased as required to achieve the desired effect up to either 60mg/kg/day or a trough plasma concentration of 50-125mcg/ml.

Contraindications

Lithium is contraindicated in breast-feeding, severe cardiovascular disease and severe renal disease. It should be used with caution in:

Valproate is contraindicated in liver disease. It should be used with caution in:

Main side effects

Side effects of lithium include:

Side effects of valproate are usually minimal, but they may include:

Main drug interactions

Some drugs increase lithium levels, notably diuretics (loop diuretics, potassium-sparing diuretics and thiazide diuretics) and non-steroidal anti-inflammatory drugs.

Valproate is metabolized by the liver and is highly protein-bound; therefore, care should be taken to watch for interactions with other medications that are also protein-bound, possibly causing toxicity.

Antidepressants

Standard dosage

Standard doses are:

Contraindications

Fluoxetine, fluvoxamine, paroxetine and sertraline are contraindicated in patients receiving monoamine oxidase inhibitors and in mania.

They are relatively contraindicated in pregnancy.

In addition, they should be used with caution in:

Mirtazapine is contraindicated in patients receiving concomitant monoamine oxidase inhibitors and in patients who have had a recent myocardial infarction.

Mirtazapine should be used with caution in:

Nefazodone should be used with caution in:

Venlafaxine is contraindicated in severe hepatic or renal disease. It should be used with caution in:

Main side effects

All the antidepressants lower the seizure threshold, and most inhibit all phases of the sexual response (nefazodone and mirtazapine the least).

The selective serotonin reuptake inhibitors are generally less sedating and have fewer antimuscarinic side effects than the tricyclic antidepressants. Side effects of the selective serotonin reuptake inhibitors include:

Mirtazapine can cause short-term sedation and weight gain.

Nefazodone can cause dizziness.

Venlafaxine can cause nausea and hypertension.

Main drug interactions

Selective serotonin reuptake inhibitors, mirtazapine, nefazodone and velnaxafine have a potentially fatal interaction with monoamine oxidase inhibitors.

Specific serotonin reuptake inhibitors should be not be used in combination with other serotonergic agents.

Non-pharmacological treatment

Non-pharmacological therapies play an important role in the treatment of borderline personality disorder. Treatment modalities include:

Follow-up and management

In the acute phase:

In the long term:

The prognosis is worse in patients with a history of self-cutting, alcohol abuse and unemployment.

Scientific Background

Etiology

The etiology of borderline personality disorder is not known.

Biological investigations suggest impairment of neuropsychological function and dysfunctions of specific neurotransmitters and electrophysiological mechanisms.

Psychosocial studies reveal a high prevalence of childhood trauma (especially physical and sexual abuse), early separation or loss, and abnormal parenting in patients with borderline personality disorder.

Epidemiology

The prevalence of borderline personality disorder is estimated at:

It is about three times more common in women than men.

References

Coccaro EF Clinical outcome of psychopharmacologic treatment of borderline and schizotypal personality disordered subjects. J Clin Psychiatry 1998; 30-35. 

Diagnostic and Statistical Manual of Mental Disorders, 4th ed Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association 2000; 706-710. 

Paris J Success and failure in the treatment of patients with borderline personality disorder. Sante Ment 1997; 16-29.

Quaytman M, Sharfstein SS Treatment for severe borderline personality disorder in 1987 and 1997. Am J Psychiatry 1997; 1139-1144.

Ryle A, Golynkia K Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000; 197-210.

Stone MH Clinical guidelines for psychotherapy for patients with borderline personality disorder. Psychiatr Clin North Am 2000; 193-210.

The ICD-10 Classification of Mental and Behavioural Disorders: clinical descriptions and diagnostic guidelines (ICD-10). Geneva: World Health Organization 1992; 204-205. 
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