Identifying and Managing Borderline Personality Disorder Raul Morffi PGY3 September 24, 2009

Epidemiology 2008 National Epidemiologic Survey on Alcohol and Related Conditions reports 5.9% in general population of U.S. Primary care clinic: 7-10% Inpatient psychiatry: 50-80% Suicide rate ~10% Chronic cutters, swallowers, ODers acute suicidal ideation? Mean age of 1st psych contact: 18-22yo

Its kind of a girl thing? Google, You Tube, and other great sources report ~75% of borderline personality d/o occurs in women, yet 2008 survey mentioned in first slide , showed equal prevalence in men and women.

Clinical Presentation Marked mood swings throughout the day Triggered by perceived environmental stimuli Splitting: all good or all bad Selectively attends to information in a way that confirms current opinion/ mood Anger/ impulse control issues Volatile relationships Unstable self image Self destructive behavior Self harm for attention Insight +/-

Clinical presentation Video clip

Comorbidities MDD Panic d/o with agoraphobia Any somatization d/o OCD Bipolar PTSD Polysubstance abuse

DSM-IV criteria for a personality d/o A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in 2 (or more) of the following areas: 1. Cognition (ie, ways of perceiving and interpreting self, other people, and events) 2. Affectivity (ie, the range, intensity, labiality, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse control

Personality d/o criteria cont’d B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder F. The enduring pattern is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, head trauma)

Borderline Diagnosis 5 or more + criteria for personality d/o: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating)

Borderline Dx cont’d 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. Affective instability due to a marked reactivity of mood 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Cases You are called to ER @ 3am for third time in past 4 months to admit 32 yo F who this time has swallowed 4 wood screws. The previous 2 admissions were for swallowing nails.

Cases 28 yo F in clinic with suspected 28 wk pregnancy, says she hates doctors, she already has 3 kids with 3 different fathers and she only needs to have 2 appts for prenatal care. She comes to next appt in 2 weeks and tells you how glad she is to have you as her doctor then tells you she better be induced by 36 WGA because fob going to jail around 37 WGA. You explain why not and she storms out.

Cases 27 yo F calls clinic repeatedly asking to speak with doctor regarding various pain complaints which you have already evaluated and followed up regularly. At times she is pleasant with staff, other times she is abrasive. She sometimes follows treatment plan, other times is very manipulative in seeking narcotics. She has h/o “attention seeking” prescription drug overdose.

Management Psychotherapy Meds: SSRIs/ mood stabilizers/ benzos? Supported by RCTs Meds: SSRIs/ mood stabilizers/ benzos? Little data to support, let psych manage, avoid polypharmacy Frequent visits Set boundaries ie, Guidelines for how to contact you

Managament Avoid emotional reactions even when they are threatening to hit you with a cane Avoid becoming a passenger on the patient's emotional roller coaster. Choose your battles, negotiate, compromise Discuss/ report test results promptly Communicate clearly with your care team

Referral Everyone with this diagnosis should be considered for referral to psychiatrist and psychologist for therapy. If poor access to psych, call psych for help

Prognosis Will you have it forever? F/u of 290 BPD patients who were initially inpatients found that 88 percent achieved diagnostic remission at the end of 10 years, with almost 40 percent achieving remission two years after the initial hospitalization Many of these patients are not willing to participate in therapy.

Take home Borderline is common enough you will see it. Try to make appropriate dx: Splitting, severe mood swings, paranoia, emptiness, unstable self image, recurrent self harm, impulse/ control issues… Mgmt: set boundaries set close fu plan communicate w/ care team avoid emotional responses negotiate be prompt early referral for psychiatrist / psychologist positive encouragement These patients may get better, don’t give up on them.

References Grant, BF, Chou, SP, Goldstein, RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008; 69:533. Zimmerman, M, Rothschild, L, Chelminski, I. The Prevalence of DSM-IV Personality Disorders in Psychiatric Outpatients. Am J Psychiatry 2005; 162:1911. http://www.uptodate.com/online/content/topic.do?topicKey=psychiat/5580&selectedTitle=1~71&source=search_result#13 Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Intern Med. 2002. 16253–60 [PubMed]