Alicia is a 35-year-old woman who has been your primary care patient for 1 year. She requests appointments frequently, often cancels last minute or doesn’t show up, and is rude to the front desk staff. She says that intense conflict with her ex-partner prevents her from taking care of herself. You leave Alicia’s appointments drained, thinking about how nothing has moved forward in her care.
As a teenager, Alicia managed her anger and sadness by cutting her leg with a box cutter. She has been unable to maintain employment due to conflicts with bosses, and she is currently going through a divorce. You suspect that Alicia has a personality disorder but have focused the visits on managing her asthma and obesity along with short term treatments for insomnia and anxiety.
How do you diagnose and manage borderline personality disorder in primary care?
Epidemiology and Diagnosis
Borderline personality disorder (BPD) affects 0.7-2.7% of American adults (Leichsenring 2023). BPD is usually diagnosed in the psychiatric setting based on behavioral observation and the clinical interview (Wu 2022). It is frequently underdiagnosed or misdiagnosed. PCPs can also make this diagnosis, especially in the context of a longitudinal relationship with a patient.
BPD is defined by a persistent display of emotional dysregulation (intense, rapidly changing emotions), impulsivity, inconsistent and unstable sense of self, and disturbed interpersonal function and relationships. Patients with BPD may be particularly sensitive to interpersonal rejection. They may have chronic suicidal ideation, struggle with impulsive aggression, and frequently self-harm, which is understood as a coping strategy for the instability in the patient’s life (Bohus 2021).
Prognosis
Recovery from BPD is possible. In one prospective study of patients with BPD who had required psychiatric hospitalization, half of patients achieved recovery within 10 years, with recovery defined as symptomatic remission with good social and vocational functioning for at least 2 years. Another 30-40% experienced sustained remission of symptoms but continued to have functional impairments in social or vocational functioning (Zanarini 2010).
Approach to Care
The tables below describe the initial steps in the diagnosis of BPD and the management of the clinician-patient relationship.
Diagnosing and Disclosing Borderline Personality Disorder
| Action | Description | Challenges |
| Diagnosis | Evaluate for impairments in personality functioning, using DSM-5 in the context of the patient’s story. Consider reading each of the DSM-5 criteria to your patient and asking them if it fits with their experience. If your patient has 5/9 symptoms and these symptoms have been enduring, pervasive and inflexible to different situations in their life, they may have BPD. | ~85% of patients with BPD have at least 1 other mental health disorder, most commonly mood, anxiety, and/or substance use disorders. |
| Disclosure: telling someone that they have BPD | Summarize briefly and state the diagnosis: You’ve told me that these descriptions resonate with you. Read the relevant criteria to the patient. Because you meet X out of 9 criteria for BPD and these traits have influenced your life and relationships in significant ways over years, you have borderline personality disorder, according to our diagnostic system. Listen and offer space for the patient’s reactions. Ask permission to provide information: Do you want to hear more about borderline personality disorder? What do you know already? PCPs should share what BPD is and how it is relevant to the patient’s experience. Notably, patients with BPD are often relieved to hear the diagnosis as an explanation that ties together their difficulties. Next steps (if appropriate now): There are specific treatments for patients with borderline personality disorder that can help with X, Y, Z (patient specific challenges). Are you open to connecting with treatment that can help people with borderline personality disorder? | PCPs may not feel confident with their diagnosis. Significant stigma exists surrounding this disorder. |
| Refer to psychotherapy treatment | Psychotherapy is the first-line treatment for BPD. Dialectical behavioral therapy and mentalization based therapy have been shown to be effective for BPD. | There is limited access to mental health experts. |
Managing the Patient-Clinician Relationship
| Action | Description | Challenges |
| Establishing a productive relationship | Foster calmness in the face of emotional volatility. Affirm that you care for and are committed to caring for the patient even if you disagree with one another. Empower patients to find solutions to their problems through gentle guidance: they are responsible for their life choices and problem solving. | Patients with BPD may feel their symptoms are not taken seriously and may be dissatisfied with their care. In response to a patient’s recurrent hostility and emotional lability, clinicians may feel frustrated, resentful, or hopeless. |
| Team based care | Emphasize open communication and a consistent approach across the team. Schedule regular appointments regardless of symptoms to create a reliable treatment frame and clear expectations. Educate team and staff on a neutral approach to the patient. Inform the patient of clinic policies and the importance of respect for all members of the healthcare team. | Patients with BPD may display splitting behaviors, in which they identify team members as entirely good or bad. Splitting is an unconscious psychological defense mechanism that helps people cope with difficult emotions. Splitting behaviors can create conflict between team members and challenge the team’s ability to provide a unified response. |
| Boundary setting | Set clear boundaries for appointment cadence. Set clear expectations for the patient’s behavior in the clinic. | Patient’s behavior can contribute to maladaptive boundary setting (i.e. limiting care in the setting of frustration or resentment, or adding extra appointments in response to angry outbursts). |
| Avoiding stigmatization | What initially presents as a “difficult patient” is often a “difficult clinician-patient encounter.” Clinicians should attend to what they are bringing to the relationship and the ways in which the clinic policies affect the interaction. Returning to Marsha Linehan’s comment can help maintain empathy: “People with borderline personality disorder are like people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” | |
| Clinician self-care | Cultivate awareness and reflection on feelings of resentment and frustration. | PCPs are not given the support they need to care for patients with BPD, in particular, sufficient time to discuss difficult encounters with team members. There can be significant stigma around a clinician feeling negativity towards a patient that prevents the acknowledgement of normal feelings, including anger, revulsion, dread, and fear. |
Back to Alicia
To further evaluate Alicia’s psychiatric symptoms, you schedule a follow up appointment. At this appointment, you start by asking broad questions about her mood: do you often feel angry, empty or extremely moody? You ask about her feelings of identity: does your identity feel like it shifts or does not always fit you? (Leichsenring 2023) Through your discussion, you bring in different aspects of her life you have witnessed over the last year – frequent job changes, unstable partnerships, anxiety, hostility towards staff, emotional lability during clinic visits – and her history of self-harming behavior.
You share the DSM-5 criteria for BPD with Alicia. Her history of unstable relationships, self-harming behavior, marked reactivity in mood, impulsivity, and intense anger meet the criteria for the diagnosis of BPD. Alicia shares with you that she was given this diagnosis as a teenager.
You recommend starting psychotherapy and provide her with a list of therapists who specialize in therapy for patients with BPD. You propose meeting monthly while she establishes with a therapist. You also meet with the front desk staff and medical assistants to discuss a team-approach to Alicia’s care.
Look out for a future PsychSnap focused on risk and crisis management in patients with BPD.
Key Points
- If you suspect the diagnosis of BPD, ground your conversation in the DSM-5 criteria, share the diagnosis, and refer the patient to psychotherapy; most patients appreciate having a diagnosis and receiving treatment for distressing symptoms.
- Caring for patients with BPD can be challenging: establish a productive relationship, utilize team-based care, set boundaries, pay attention to your own negative/stigmatizing attitudes, and attend to your own self-care.
References
Bohus, M., Stoffers-Winterling, J., Sharp, C., Krause-Utz, A., Schmahl, C., & Lieb, K. (2021). Borderline personality disorder. The Lancet, 398(10310), 1528–1540.
Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., & Kernberg, O. F. (2023). Borderline Personality Disorder: A Review. JAMA, 329(8), 670.
Wu, T., Hu, J., Davydow, D., Huang, H., Spottswood, M., & Huang, H. (2022). Demystifying borderline personality disorder in primary care. Frontiers in Medicine, 9, 1024022.
Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. Am J Psychiatry. 2010 Jun;167(6):663-7.