1. Lockhart, Lisa MHA, MSN, RN, NE-BC
  2. Davis, Charlotte BSN, RN, CCRN
  3. Miller, Latha Diane BSN, RN


As nurses, we encounter mental health disorders in every practice area. Learn how to properly identify and manage BPD to ensure that your patients' needs are safely and effectively met.


Article Content

Most prevalent in female patients (75%), borderline personality disorder (BPD) is characterized by mood instability, volatile interpersonal relationships, poor self-image, and major behavioral episodes such as destructive social behaviors. Approximately 1.6% of the U.S. population, or 1 out of every 143 people, has BPD, according to the National Institute of Mental Health (NIMH). The number of affected individuals may actually be as high as 5.9% because male patients with BPD may be misdiagnosed with clinical (major) depression or another mental disorder.

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The NIMH reports that 40% to 71% of patients with BPD report having been sexually abused in the past, usually by a noncaregiver. Recent research shows that 60% to 70% of all patients diagnosed with BPD will attempt suicide at least once during their lifetime and approximately 10% will succeed in their first or subsequent suicide attempt. The completed suicide rate among patients with BPD is 50% higher than the general population. This alarmingly high statistic means that all healthcare personnel must be able to recognize the signs and symptoms of BPD, and intervene early to properly manage this patient population and reduce mortality.


Defining BPD

BPD is most often characterized by the emotional turmoil experienced by the patient and those around him or her. These individuals feel emotions intensely and over extended periods of time. They lack the ability to move on from their emotions, which often results in prolonged periods of unrest. For this reason, the risk of suicide and/or self-destructive or self-harming behaviors (including sexual promiscuity, substance abuse, and other addictive behaviors such as eating disorders) is elevated in this patient population and may be a recurring risk throughout the patient's life.


The most common signs and symptoms of BPD include:


* anxiety


* depression


* feelings of inadequacy


* isolation


* poor coping skills and/or aggressive behavior when stressed.



Additional symptoms or behaviors may include:


* unstable relationships (The patient may have multiple failed relationships or marriages that ended quickly; he or she doesn't accept responsibility for any part in the failed relationship or may attempt to dramatically minimize his or her actions that led to the relationship ending.)


* poor social skills and decision making


* behavioral minimization (having no accountability for actions or behaviors) or hiding social behaviors from family and friends that the patient feels won't be supported


* volatile mood swings ranging from elation to feelings of rejection


* impulsivity


* hypersexuality


* "splitting" of family, friends, and coworkers (The patient with BPD functions best by isolating others to minimize feelings of inadequacy and may view people as "all good" or "all bad," which can rapidly shift from one to the other.)


* difficulty maintaining consistent employment.



The causes of BPD are multifactorial, including:


* genetics. BPD is often referred to as a maladaptation disorder because it's commonly viewed as a product of environmental exposure; however, several recent research studies show a potential genetic component to BPD, specifically chromosome 9 anomalies.


* environmental factors. Traumatic life events, such as neglect, abandonment, sexual abuse, or illness, may be an associated cause.


* brain function. Current research studies are evaluating the link between chemical imbalances of serotonin, dopamine, norepinephrine (noradrenaline), and acetylcholine monoamine oxidase that may result in BPD symptoms. Initial findings reveal that dopamine deficiency can accentuate BPD clinical features.



Understanding the drama triangle

The Karpman drama triangle is a model of three dysfunctional and destructive social behaviors, with each corner of the triangle representing a cyclical, toxic role commonly exhibited by patients with BPD: the persecutor, the rescuer, and the victim.


The persecutor asserts, "It's all your fault." According to the American Psychological Association (APA), the persecutor is typically "controlling, blaming, critical, oppressive, angry, authoritative, rigid, and superior." The patient with BPD embraces this role to avoid accepting any personal or professional responsibility for impulsive behavior or decisions. Patients with BPD respond poorly to professional or personal suggestions for improvement and often utilize the persecutor role as an opportunity to deflect their behavior by shifting blame to another. Anyone who expresses a thought process that deviates from the patient's can be automatically shifted into the role of "adversary/enemy."


The rescuer asserts, "Let me help you." Classic enablers, rescuers feel guilty if they don't come to the rescue because they receive secondary gains from this role. However, the rescuing behavior has negative effects: It keeps the victim dependent and gives him or her permission to fail. This takes the focus off of the rescuer's concerning dysfunctional behavior. When patients with BPD focus their energy on someone else, it enables them to ignore their own negative behaviors and/or anxiety, and helps them avoid any responsibility for poor decision making. According to the APA, the rescuer role is pivotal because the patient's actual primary interest is avoidance of his or her own behaviors disguised as concern for the victim's needs.


The victim asserts, "Poor me!" Patients with BPD often voice feelings of being helpless, victimized, oppressed, hopeless, powerless, and ashamed. They may be unable to make decisions and often try to draw in others to do so for them as they assume a passive role. The patient with BPD often states that he or she is unable to independently solve problems, take pleasure in life, or achieve insight without the assistance of another. The patient, if not being persecuted, will seek out a persecutor and also a rescuer to validate his or her victimization. If this role is challenged, the patient with BPD may exhibit hypersensitive feelings of rage, anger, shock, disbelief, and mistrust.


Making the correct diagnosis

Patients with BPD are frequently misdiagnosed with depression, an anxiety disorder, an addictive disorder, or narcissistic personality disorder. Some of the symptoms of BPD and other mood disorders overlap, so accurate diagnosis is important.


Patients are diagnosed with BPD according to symptomology. When a psychologist reviews the patient's profile, he or she looks for five or more of the following nine symptoms, which are indicative of BPD:


* frantic efforts to avoid being abandoned by friends and family


* unstable personal relationships that alternate between idealization-"I'm so in love!"-and devaluation-"I hate her!"


* distorted and unstable self-image, which affects moods, values, opinions, goals, and relationships


* impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, inappropriate sexual relations at work, substance or alcohol abuse, and reckless driving


* suicidal and/or self-harming behavior


* periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days


* chronic feelings of boredom or emptiness


* inappropriate, intense, or uncontrollable anger that's often followed by shame and guilt


* stress-related paranoid thoughts, such as being suspicious of family, friends, and peers; severe cases of stress may lead to brief psychotic episodes.



Choosing treatments

There's no known cure for BPD, but a combination of treatment options can be effective in reducing the suicide rate in this patient population. Treatment plans for patients with BPD include medications and talk therapy, such as dialectical behavioral therapy, cognitive behavioral therapy, and psychodynamic psychotherapy, as well as family, peer, and/or group counseling. The primary goal is to find a combination of treatment options to optimize the patient's quality of life, maintain safety, and minimize the destructive impact of his or her actions on others.


Although talk therapy is the main treatment choice, adjunctive therapy with medications can be beneficial. There's no gold standard medication; however, drugs that treat symptoms of BPD, such as depression, impulsivity, anxiety, and aggression, may be prescribed. Some patients may benefit from antidepressants, antianxiety drugs, and antipsychotic medications. Short-term hospitalization may be useful if the patient is in an extreme state of distress; during these times, patients with BPD are at high risk for self-harm or suicide.


Either in a group or individually, the purpose of dialectical behavioral therapy is to specifically target the patient's negative behaviors by teaching and enforcing the skills needed to address these behaviors. Examples include teaching coping skills to reduce stress and manage emotions, and relationship counseling.


Cognitive behavioral therapy focuses on assisting the patient to see difficult experiences, interactions, or relationships more clearly. The goal is to achieve better control of the anxiety and stress associated with these situations.


Psychodynamic psychotherapy is the most well-known and widely accepted treatment for BPD. This type of therapy relies heavily on the relationship between the therapist and the patient. It's crucial that the relationship be built on trust, with open communication, to identify the patient's tension triggers and methods for coping with them. Seemingly mundane events may trigger symptoms; for example, the patient with BPD may feel angry and distressed over minor separations, such as vacations, business trips, or sudden changes of plans, from people to whom they feel close.


Systems training for emotional predictability and problem solving (STEPPS) is a type of group therapy led by a trained social worker. In STEPPS, the patient works in a group to openly discuss goal setting and problem solving, and experience meaningful interactions with others. Typically, STEPPS consists of 20 2-hour sessions. It's believed that, when used in conjunction with other types of treatment, such as medications and individual therapy, STEPPS can aide in reducing BPD symptoms and behaviors, such as depression, anxiety, and suicidal ideation, and improve the patient's quality of life.


Both group and individual family treatment are essential for the well-being of those close to the patient with BPD. They may experience stress and depression themselves, and may also be enabling the patient's behavior. Families participating in therapy learn about goal setting and limitation or boundary setting, along with coping strategies for their own responses to the individual with BPD.


Long-term goals for the patient with BPD include active participation in and commitment to individual therapy, participation in family or group therapy (as indicated), and setting routines and a schedule that includes healthy eating and exercise. The patient successfully living with BPD will know his or her triggers and what works to provide comfort. When caring for patients with BPD, assess for suicide risk and strive to maintain a safe environment.


Success is possible

Patients and families must empower themselves with the facts concerning BPD and actively seek treatment. Although there's no cure for BPD, treatment options are available and effective. The most important factors are patient participation and dedication to treatment, and adherence to therapy. Family support also plays a large role in successful treatment. A diagnosis of BPD can be devastating, but proper treatment allows patients to have meaningful relationships and experience healthy, mutually satisfying bonds. Additionally, patients can gain a sense of control over their responses to life's changes without engaging in harmful or reckless behavior.


Diagnostic criteria

cheat sheet

Five or more of these nine symptoms are indicative of BPD.

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* Frantic efforts to avoid being abandoned by friends and family


* Unstable personal relationships that alternate between idealization and devaluation


* Distorted and unstable self-image, which affects moods, values, opinions, goals, and relationships


* Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, inappropriate sexual relations at work, substance or alcohol abuse, and reckless driving


* Suicidal and/or self-harming behavior


* Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days


* Chronic feelings of boredom or emptiness


* Inappropriate, intense, or uncontrollable anger that's often followed by shame and guilt


* Stress-related paranoid thoughts, such as being suspicious of family, friends, and peers; severe cases of stress may lead to brief psychotic episodes



consider this

You're working in a busy medical clinic with Nurse M, whom you've worked with for many years. She frequently exhibits unprofessional attention seeking and provocative behavior with male coworkers. She has a long history of short-lived and unstable relationships, distorted self-image, extremely volatile emotions, impulsivity, and difficulty managing financial affairs. Her professional relationships are toxic; she often idealizes someone and then suddenly exhibits unfounded rage against the person. You also observe that Nurse M exhibits the roles in the Karpman drama triangle. Proper referral, diagnosis, and interventions are essential so that Nurse M can learn how to engage in healthy, productive relationships, both professionally and personally.

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on the web

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