Borderline Personality Disorder

Symptoms and signs

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

• somatic complaints such as headaches, abdominal pain or malaise; 

• autonomic instability as indicated by cold hands, nausea, vomiting, diarrhea; 

• a tendency to demonstrate factitious illnesses, which may lead to overuse of medical resources; 

• a pattern of undermining themselves just as a goal is about to be achieved; 

• psychotic-like features, especially in times of stress; 

• a history of suicide attempts or self-mutilation; 

• a history of a history of substance misuse. 

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:

• interrupted education; 

• frequent job changes and job losses; 

• money problems and bankruptcy; 

• broken marriages and interrupted relationships; 

• physical handicaps from self-inflicted abuse; 

• premature death from suicide. 

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

• mood disorders; 

• substance-related disorders; 

• panic and anxiety disorders; 

• eating disorders (especially bulimia nervosa); 

• post-traumatic stress disorders; 

• attention deficit-hyperactivity disorder; 

• other personality disorders. 
  

Prognosis

A better prognosis seems to be indicated by:

• high intelligence; 

• artistic talent; 

• physical attractiveness; 

• good education; 

• absence of transgenerational sexual or physical abuse; 

• lack of substance abuse; 

• no history of problems with the legal system.
  

Treatment and Outcome 

Treatment aims

The aims of treatment are:

• to provide crisis stabilization and situational support to prevent or reduce self-destructive behaviors and to enhance functioning (in the short term); 
• to enhance the consistency of adaptive psychosocial functioning and stress tolerance (in the long term). 

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:

• low-dose atypical antipsychotic agents (e.g. risperidone**, olanzapine**, quetiapine**, amisulpride**) 
• mood stabilizers (e.g. valproate**, lithium**); 
• antidepressants - selective serotonin reuptake inhibitors (e.g. fluoxetine**, fluvoxamine**, paroxetine**, sertraline**) and other antidepressants (e.g. mirtazapine**, nefazodone**, venlafaxine**). 
  

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:

• risperidone: 2-6mg/day in divided doses (range 2-10mg/day), beginning at 2mg/day and increasing over the next 3-4 days; 
• olanzapine: 10mg/day (range 5-20mg/day); 
• quetiapine: 200-400mg/day in two divided doses (maximum dose 750mg/day), beginning 50mg/day and increasing over the next 4 days or so; 
• amisulpride: 200-800mg/day (range 200-1200mg/day), with lower doses (50-300mg) for patients with predominantly negative symptoms 
  

Contraindications

The atypical antipsychotic agents should be used with caution in:

• cardiovascular disease; 
• epilepsy; 
• Parkinson's disease. 
  

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

• risperidone and quetiapine are contraindicated in breast-feeding patients and should therefore be avoided if the patient is to breast-feed her child; they should be used with caution in pregnancy, hepatic disease and renal disease; 
• olanzapine is contraindicated in closed angle glaucoma and should be used with caution in pregnancy, hepatic or renal disease, paralytic ileus and hematological disorders; 
• amisulpride is contraindicated in breast-feeding patients and should therefore be avoided if the patient is to breast-feed her child; it is also contraindicated in pregnancy, pheochromocytoma and prolactin-dependent tumors; caution is required renal impairment. 
  

Main side effects

The atypical antipsychotic agents may cause:

• extrapyramidal symptoms (e.g. tremors, restlessness, muscle rigidity), especially with higher doses; 
• drowsiness; 
• orthostatic hypotension; 
• weight gain; 
• decreased libido and sexual side effects; 
• neuromalignant syndrome, which is rare but fatal in up to 15% of cases; 
• tardive dyskinesia (rare). 
  

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:

• risperidone is more likely to cause orthostatic hypotension, tachycardia, extrapyramidal symptoms at higher doses, tardive dyskinesia, insomnia, agitation, anxiety, and headache; 
• olanzapine is especially likely to cause weight gain and orthostatic hypotension, but extrapyramidal symptoms (including parkinsonism) are not common; 
• quetiapine is especially likely to cause somnolence and hypotension and may cause lens changes (although this is rare); 
• amisulpride is especially likely to cause sleep disturbances and anxiety or agitation, sexual dysfunction, and hyperprolactinemia with galactorrhea, amenorrhea and gynecomastia; weight gain is less of a problem than with other agents. 
  

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:

• dehydration; 
• thyroid disease; 
• diabetes mellitus. 
  

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

• renal impairment; 
• Addison's disease; 
• hematological disorders. 
  

Main side effects

Side effects of lithium include:

• prominent hand tremor; 
• significant weight gain; 
• lethargy and tiredness; 
• dizziness; 
• hair loss; 
• gastrointestinal effects (nausea, diarrhea, vomiting); 
• arrhythmias. 
  

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

• sedation; 
• tremor; 
• hair loss; 
• gastrointestinal effects; 
• liver toxicity; 
• blood dyscrasias. 
  

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:

• fluoxetine: 20mg/day (maximum dose 60mg/day); 
• fluvoxamine: up to 300mg/day (initially 100mg/day); 
• paroxetine: 20mg/day (maximum dose 50mg/day); 
• sertraline: up to 200mg/day (initially 50mg/day); 
• mirtazapine: 15mg/day for the first two days, then 30mg/day, increased if necessary up to 45mg/day in a single dose or in two divided doses; 
• nefazodone: 400mg/day in two divided doses (initially 200mg/day; maximum dose 600mg/day); 
• venlafaxine: 75mg/day in two divided doses (maximum dose 150mg/day). 
  

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:

• epilepsy; 
• cardiac disease; 
• hepatic impairment; 
• renal impairment. 
  

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:

• psychosis; 
• patients with a history of mania; 
• seizure disorder; 
• cardiac disease; 
• hepatic impairment; 
• renal impairment; 
• hypotension; 
• closed-angle glaucoma; 
• diabetes mellitus. 
  

• patients with a history of mania; 
• seizure disorder; 
• hepatic impairment; 
• renal impairment. 
  

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

• seizure disorder; 
• hepatic impairment; 
• renal impairment; 
• patients with a history of myocardial infarction or other heart disease. 
  

• early (usually transient) anxiety; 
• gastrointestinal effects (common); 
• tremor; 
• sleep disturbances; 
• headache; 
• dyskinesias; 
• sexual dysfunction; 
• a withdrawal syndrome, which is seen in up to 60% of patients in whom a specific serotonin reuptake inhibitor (especially paroxetine) is stopped suddenly. This syndrome can cause dizziness, anxiety, agitation, confusion, tremor, paresthesiae, nausea and sweating. 
  

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:

• supportive psychoeducational therapy, which is the most common form of therapy used; it is designed to enhance the patient's understanding of specific manifestations, and to help the patient to develop less impulsive and emotionally over-reactive responses; 
• psychodynamic therapy (including transference-focused psychotherapy), which is useful in a few patients; 
• cognitive-behavioral therapy, biofeedback and dialectical behavioral therapy, which may be particularly helpful for controlling headaches and symptoms of panic or anxiety and autonomic instability; 
• group therapy, which may be effective in a few patients. 
  

Follow-up and management

In the acute phase:

• hospitalization may be required during periods of acute decompensation to prevent self-destructive behaviors and to stabilize the patient, although it has not been shown to prevent suicide in this population; 
  
• upportive therapy may be required two or three times a week to stabilize mood, maintain control over self-destructive behaviors, assure medication compliance and provide counseling on reducing situational stresses; 
• family counseling can determine stresses and interventions to reduce stress and provide information on the nature, management and expected course of the illness. 
  

In the long term:

• patient education should be given on appropriate titration of mood stabilizer to accommodate fluctuations in stress levels and to minimize total burden of medication; 
• psychotherapy should develop stable working relationship with patient and provide a safe holding environment to reduce maladaptive, impulsive behaviors during evaluation and management of patterns of situational stresses; 
• continued patient education should be given on the nature, course and management of the disorder; 
• new, adaptive behaviors should be established to lead to more stable interpersonal relationships and improved vocational and social functioning. 
• group therapy may help to reduce the patient's sense of isolation. 
  

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:

• 2% in the general population; 
• 10% in psychiatric outpatients; 
• 20% in hospitalized psychiatric inpatients. 
  

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