Borderline Personality Disorder (BPD) is a personality disorder that describes the emotional dysregulation, impulsivity, recurrent self-harm and suicidal behaviour experienced by many individuals. People suffering from this personality disorder frequently live chaotic lives characterized by extreme stress, interpersonal conflict and maladaptive behaviours – leading them to frequent emergency department visits. BPD prevalence varies between 1.6  to 5.9% of the general population, up to 6% of the patients seen in primary care may have BPD 1.

borderline personality disorder

Borderline Personality Disorder

Definition

“A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following”

  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 (e.g., spending, sex, substance abuse, reckless driving, binge eating).
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.4

Aetiology

The aetiology of BPD is thought to be a combination of genetic predisposition coupled with:

  • Early trauma
  • Stress
  • Abandonment
  • Reinforcement of impulsive behaviour. 5

Risk of suicide

Up to 10% of patients with BPD commit suicide. As of 2017, Suicide is the 9th leading cause of death overall in Canada.

BPD in the Emergency Department

  • The management of individuals with BPD with recurrent self-harm and suicidal attempts varies dramatically from centre to centre and physician to physician.
  • The best practice for the management of these patients is not known.
  •  Common themes prevail in their management:
    1. Unnecessary inpatient hospitalizations
    2. Inadequate safety assessments
    3. Excessive use of medications
    4. Hostile or dismissive staff behaviour

borderline personality disorder

Case 1

Let’s look at a case:

A 19 year old female became intoxication at a house party and was left by the friends who accompanied her. She recently moved from out of province to Ottawa to distance herself from family. She returns to her apartment and calls her ex-boyfriend and threatens to kill herself. She starts cutting herself and states that she will throw herself off her balcony or jump in front of a car.

The ex-boyfriend, worried, notifies the police who ultimately accompany her to your emergency department. Following your encounter with this patient, you present the case to your staff who advises you that this patient must immediately be placed on a Form 1 and requires admission to psychiatry.

borderline personality disorder

Immediately a few questions come to mind:

  1. Does admitting patients with BPD prevent suicide? 
    • There is no evidence to support the admission of patients with borderline personality disorder prevents suicidal behaviour based on observational data.2,3,6
    • Many experts state that the admission of patients with BPD is counterproductive and actually harms them 2-7.  “Suicidal precautions used in hospital settings reinforce the very behaviour one is treating“ 3 Moreover, patients with BPD need to learn to manage acute stressors outside the hospital and admitting these patients reinforces maladaptive strategies for dealing with their emotional dysregulation.
    • There are no treatments provided in hospital for BPD that are not also available as an outpatient.
  2. Who may benefit from a psychiatric consultation in the emergency department? 
    • Lethal suicide attempts
    • Comorbid mental health disorders (depression, anxiety, psychosis etc.)
    • Diagnostic clarification
    • Medication simplification
  3. Does self harm always lead to suicidal ideation?
    • No, self harm does not always lead to suicidal ideation.
    • Self-harm is not unique to BPD, it may occur with other mental health disorders such as post traumatic stress disorder, depression and anxiety.
    • Many reasons are described by those who self-harm:
      • To get provided care from an individual
      • Anxiety reduction
      • An internalized belief that they will treat themselves the way they were previously treated
      • End an argument
      • Self-punishment
      • To relieve a sense of numbness
  4. What is the sequence of thoughts during self-harm?
    Steps in Self Harm  Strategies to mitigate
    Devaluation Build sense of self
    Engage in withdrawal  Go to a crowded public area (ie: arena, shopping centre, living room)
    Dissociate Practice mindfulness.

    Use techniques developed in DBT.

    The belief that what you are going to mutilate has no value Ask yourself: What gives you value?

    Being courteous, holding a door, running an errand, shoveling your neighbors’ driveway may promote that sense of value

    Engaging in the act of self-harm Get rid of the means of self-harm, make it potentially more difficult to obtain sharp objects.
    Relief from stressor Seek other avenues for fulfilling this need (i.e.: sports, art, music, hobbies).

    The chart above was adapted from a talk by Dr. Daniel Fox as part of the series – Self-Harm and Borderline Personality Disorder. https://www.youtube.com/watch?v=rDOl0iZi2wA

  5. Does every patient with a lethal suicide attempt require a Form 1? 
    • Form 1 allows for a patient to be held at a level 1 psychiatric facility for an assessment.
    • It also entails that a physician believes the person in question is incapable of consenting to treatment.
    • It does not mean a physician can treat this person without their consent.

Stay tuned for Borderline Personality Disorder – Part 2. We will take a deeper dive into the suicidal risk of patients with BPD, management in the emergency department and useful resources.

References

  1. 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(4):533-545. doi:10.4088/JCP.v69n0404
  2. Goodman M, Roiff T, Oakes AH, Paris J. Suicidal risk and management in borderline personality disorder. Curr Psychiatry Rep. 2012;14(1):79-85. doi:10.1007/s11920-011-0249-
  3. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder? J Pers Disord. 2004;18(3):240-247. doi:10.1521/pedi.18.3.240.35443
  4. Personality Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. DSM Library. American Psychiatric Association; 2013. doi:doi:10.1176/appi.books.9780890425596.dsm18
  5. Crowell SE, Beauchaine TP, Linehan MM. A Biosocial Developmental Model of Borderline Personality: Elaborating and Extending Linehan’s Theory. Psychol Bull. 2009;135(3):495-510. doi:10.1037/a0015616
  6. Hong V. Borderline personality disorder in the emergency department: Good psychiatric management. Harv Rev Psychiatry. 2016;24(5):357-366. doi:10.1097/HRP.0000000000000112
  7. Shaikh U, Qamar I, Jafry F, et al. Patients with borderline personality disorder in emergency departments. Front Psychiatry. 2017;8(AUG):1-12. doi:10.3389/fpsyt.2017.00136
  8. Fox D. Self Harm and Borderline Personality Disorder – BPD. Youtube. https://www.youtube.com/watch?v=rDOl0iZi2wA. Published 2019.
  9. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Arch Gen Psychiatry. 1991;48(12):1060-1064. doi:10.1001/archpsyc.1991.01810360024003
  10. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766. doi:10.1001/archpsyc.63.7.757
  11. Washington U of. Dialectical Behavior Therapy. Behavioral Research and Therapy Clinics. https://depts.washington.edu/uwbrtc/about-us/dialectical-behavior-therapy/. Published 2019.
Daniel Beamish

Daniel Beamish

Dr. Daniel Beamish is a 5th year Emergency Medicine Resident at the University of Ottawa whose interests include travelling, hockey, and surfing. He is currently a Pre-hospital Medicine and Transport Fellow.
Pascale King

Pascale King

Dr. Pascale King is an Emergency Medicine resident in the Department of Emergency Medicine, University of Ottawa. She is a junior editor with the Digital Scholarship and Knowledge Dissemination team for the EMOttawaBlog.