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Last Updated: 12/30/2014  

Borderline Personality Disorder

  • Recognize that the patient must meet five of the following nine DSM-5 criteria to confirm a diagnosis of BPD:

    • Frantic efforts to avoid real or imagined abandonment (i.e., the inability to tolerate aloneness)

    • A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization, in which another individual is over-idealized, and devaluation, in which the same individual is precipitously depreciated

    • Identity disturbance, manifested by marked or persistent unstable self-image or sense of self

    • Impulsivity in at least two areas that are potentially self-damaging, such as spending, sex, substance abuse, reckless driving, or binge eating

    • Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior, such as cutting, scratching, or burning oneself

    • Affective instability due to a marked reactivity of mood, such as intermittent intense dysphoria, irritability, or anxiety, which lasts a few hours but rarely more than a few days

    • Chronic feelings of emptiness

    • Inappropriate intense anger or difficulty controlling anger, expressed by frequent rages, constant anger, or recurrent physical fights

    • Transient, stress-related, quasi-psychotic events, which include paranoid ideation and/or severe dissociative symptoms

  • Review the family history of psychiatric disease including BPD, mood and anxiety disorders, and disorders characterized by impulsivity.

  • Perform a complete physical exam, including a genital exam, looking for evidence of abuse or self-mutilation.

  • Recognize that comorbid psychiatric disorders are common in patients with BPD.

  • Define the limits of the patient-physician relationship to facilitate overall management.

  • Recommend specific effective approaches to psychotherapy, particularly dialectical behavioral therapy.

  • Prescribe SSRIs or venlafaxine for affect and mood symptoms, such as chronic dysphoria, anxiety, or emptiness.

  • Consider mood stabilizers and anticonvulsants for mood lability or impulsivity.

  • Consider atypical antipsychotics for cognitive and perceptual symptoms.

  • Suggest daily omega-3 fatty acid supplementation.

  • Expect only modest effects from drug therapy.

DOI: 10.7326/d595
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Thomas M. Kelly, PhD has nothing to disclose. Lianne Marks, MD, PhD has nothing to disclose.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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