By and large, psychiatrists aren’t terribly comfortable when it comes to diagnosing and treating borderline personality disorder (BPD). The clinical picture is challenging, and the stigma attached to the term makes it difficult for patients to hear—in fact, many clinicians end up not making the diagnosis at all! But BPD, characterized by DSM-5 as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity,” is curable. It’s also more common than you might think. Estimates state that 1%–2% of adults have BPD, yet among clinical samples—ie, people who will actually show up in your practice—the clinical prevalence is about 9% (Zimmerman M et al, Am J Psychiatry 2005;162(10):1911–1918).
With those numbers in mind, and because with DSM-5 all personality disorders were “promoted” to Axis 1 disorders, we thought it would be good to review the basics of diagnosis and treatment so you can feel more confident in helping these patients.
Fortunately, diagnosing BPD is relatively easy and can often be done in 20–30 minutes. The key is to have a systematic approach, to ask high-yield questions, and to know how to efficiently follow up on responses. In the corresponding table, we go through each of the nine DSM criteria in turn, organized by the “IDESPAIRR” mnemonic (Carlat D. The Psychiatric Interview, 4th ed. The Netherlands: Wolters Kluwer; 2017).
How do you ask about something as vague as an identity disturbance? Asking something like, “Do you know who you are?” may not get you anywhere. Instead, ask, “Do you have a sense of where you’re going in life?” Probe for whether your patient has a dream, a purpose, or an ambition—all of which are inextricably tied to one’s sense of identity. The BPD patient’s response is often, “No, I don’t have an ambition; I’m just caught up in my pain.” Patients with BPD who are working toward a goal, such as college students, tend to do better in treatment. Having goals helps strengthen the wish to continue living.
Disordered mood is what DSM calls mood instability, and it is one of the key features of BPD. Ask, “Do you find that your mood changes a lot in the course of the day?” Typically patients will reply with, “My emotional life is a roller coaster.”
Ask patients, “Do you feel empty inside, as if there’s nothing there?” Among BPD patients, a common answer is, “Definitely.” The emptiness of BPD is different from depression. Patients with depression feel sad, like they’ve lost something, and can usually describe a time when they didn’t feel depressed. BPD patients, on the other hand, will often say, “I’ve never been happy; my life is pointless.”
BPD patients often have chronic suicidal ideation, though the rate of actual suicides is lower than many think—most estimates are in the 5%–10% range (Soloff P and Chiapetta L, J Pers Dis 2012,26(3):468–480).
Often patients have urges to inflict self-harm by means such as cutting, burning themselves, or banging their heads against the wall. People have varying motivations for these actions, but they often feel overwhelmed by their lives and are unable to regulate their emotional responses; if they harm themselves, they feel the act breaks the cycle and serves as a distraction. One of our patients said, “When I see the blood dripping out, I immediately feel better.”
As you should do for any patient in whom you suspect suicidal ideation, be straightforward in your questions: “Have you ever thought of committing suicide? Have you ever tried? What have you done? Have you done it more than once? Do you cut yourself? If so, how long have you been doing it and how often?” Ask patients whether they have ever threatened to harm themselves during an argument—a common practice in BPD.
Our preferred intervention for BPD patients discussing suicide is to acknowledge their pain and to assure them that their condition can be treated: “You must have unbearable pain if you’re thinking about suicide. But know this is something I can help you with.” The reality is that most people who commit suicide do so when they are not in active treatment. Patients who are in your office trying to get help are demonstrating that they would prefer to get better rather than kill themselves.
Note that sometimes, BPD patients don’t think clinicians will listen to them unless they turn up the volume and talk about suicide in an attempt to scare the clinician. Don’t get scared; instead, let patients know that you hear them.
This DSM criterion refers to “transient, stress-induced paranoid ideation” and includes “severe dissociative symptoms.” In our experience, some degree of paranoia is very common in BPD patients.
If you were to ask, “Do you feel when you’re outside that strangers are looking at you, commenting on you, and probably criticizing you?” most patients will respond, “Yes, I’ve been like that as long as I can remember.” Some will say they have trouble getting onto a bus or engaging in other activities because of that feeling. These symptoms are not usually amenable to antipsychotic treatment. However, some patients experience transient auditory hallucinations when they get upset, and antipsychotics may be helpful in these cases.
To assess dissociation, ask, “When you get upset, do you feel outside your body, like everything looks peculiar or different?”