Author: Daniel Carlat MD
Last Updated: 4/18/20
DIAGNOSIS
The DSM-5 defines borderline personality disorder as: “a pervasive pattern of instability of interpersonal relationships, self image, and affects, and market impulsivity.”
I find it helpful to imagine a prototypical patient making the following statement: “I feel empty and unloveable, and the only way I can fill that hole is to have people pay attention to me, and when they reject me, I fall apart completely, I rage, and I do impulsive things (such as using drugs), and I become suicidal.”
I created the following mnemonic for helping to recall the DSM-5 criteria for the diagnosis. For each criterion, I suggest a question and provide an answer that is illustrative of how a typical patient with BPD might respond.
IDESPAIRR: A Mnemonic for Diagnosing BPD (Five or more criteria required)
| DSM-5 Criteria | Suggested Diagnostic Questions | Common BPD Answer |
| Identity disturbance | “Do you have a sense of where you’re going in life?” | “No I don’t have any direction, I’m just caught up in my pain.” |
| Disordered mood | “Do you find that your mood changes a lot in the course of the day?” | “My emotional life is a roller coaster.” |
| Emptiness | “Do you feel empty inside as if there’s nothing there?” | “Definitely. I’ve never been happy, my life is pointless.” |
| Suicidality | “Have you ever thought of suicide, and have you made an attempt?” | “I sometimes cut myself to punish someone else.” |
| Paranoia | “Do you feel when you’re outside that strangers are looking at you, commenting on you, probably criticizing you?” | “Yes I’ve been like that as long as I can remember.” |
| Abandonment intolerance | “When you start a relationship do you feel that you’re going to be dumped from day one?” | Most say yes and go on to explain that every rejection throws them into a crisis |
| Impulsivity | “Have you engaged in reckless behavior around money, sex, driving, drugs or alcohol, or eating? | Many will have been admitted because of impulsive behavior. |
| Rage | “Would people describe you as having a short temper?” Do you lose control when you get mad?” | “When someone abandons me, I want to make them hurt.” |
| Relationship problems | “What happens to you in a close relationship?” | “The moment somebody disappoints me—even in the smallest way—I never want to see them again.” |
PATIENT EDUCATION
Explain the diagnosis to patients in lay terms, eg., “People with BPD have extreme mood swings, stormy relationships, and do not deal well with rejection. And to cope with bad feelings, they tend to use destructive strategies like using alcohol or drugs, self-harming (like cutting), or lashing out at others.”
A powerful statistic for many patients is that 70% of borderline patients attempt suicide or self harm, and 10% eventually commit suicide.
MEDICATIONS
Medications are helpful primarily for the comorbities associated with borderline personality disorder, such as impulsivity, rage, depression, and anxiety. The following are medications often used, along with suggested doses. Don’t expect miracles.
Antipsychotics
- Abilify 2.5-5 mg AM
- Geodon 20 mg AM
- Risperdal 1 mg AM
- Seroquel 25 HS (avoid if you can, given the possibility for weight gain).
Mood stabilizers
- Lithium up to 600 mg daily (no blood levels needed)
- Lamotrigine (up to 200 mg daily)
- Topiramate (up to 300 mg daily, usually BID)
- Gabapentin (up to 600 mg TID)
Self harm/depressed mood
- Omega three fatty acids (1 gm daily)
- Naltrexone (start at 25 mg day one then 50 mg Qd; it decreases the pleasure that people get from cutting.)
Antidepressants don’t work well for BPD, but SSRIs are often used for comorbid major depression.
THERAPEUTIC TECHNIQUES
Therapy for BPD relies on variations of dialectic behavior therapy (DBT) or cognitive behavior therapy (CBT). Some inpatient units offer DBT or CBT groups. The techniques below are generally adapted from these methods.
- Enhance stability and structure. Regular schedule, a job, volunteer activity, college, 12-step program etc… In hospital, go to groups, get up at a certain time etc….
- Prevent self harm. Clarify the chain of events/feelings/thoughts/memories leading to self harm.
- Cognitive/behavioral techniques
- Opposite Action. Do the opposite action from what you are tempted to do when you feel bad. Instead of yelling when you’re angry, talk quietly and behave politely.
- Check the facts. Ask yourself what events triggered your emotions, questioning if you are interpreting the situation correctly, and deciding if your emotions are actually justified based on the facts.
- Pay attention to the positive. When you catch yourself focusing on the negative, substitute the negative for something positive about yourself, and focus on that instead. Eg., you may not be able to keep a job, but you are able to keep a hobby going.
- Radical Acceptance. Instead of focusing on how you would like the situation to be different, recognize and accept the problem or situation as it is.
- Distress Tolerance/Emotion Regulation
- Journaling
- Diary of painful experiences.
- Gratitude journal.
- Monitoring improvement.
- Breathing exercises/meditation
- Sensory Self-Soothing
- Go for a walk in nature
- Listen to enjoyable, familiar music or nature sounds
- Take a warm bath
- Use aromatherapy or inhale some flowers or perfume
- Sensory Distraction
- Squeeze an ice cube
- Take a cold shower or put a cold wash cloth over your face
- Hold a hot water bottle to your neck
- Run, exercise, or dance to a favorite song
- Bite into something spicy, minty, or sour: Ginger, frozen fruit, wasabi, lemon peel, or a hot pepper.
- Pour school glue on your skin, allow it to dry, and peel it off. Make sure it’s school glue.
- Use body paint instead of self-cutting
- Get Active, Reach Out
- Call a friend and just talk
- Check in by phone with an elderly relative
- Pull weeds in the garden
- Journaling