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Borderline personality disorder is serious, life-threatening, and fairly common, yet it goes unrecognized by most physicians.
Lee Crandall Park, MD
Borderline personality disorder diagnostic criteria that engendered that BPD occurs in over 10% of psy- CLINICAL FEATURES
EPIDEMIOLOGY
phrenia (hence "borderline") or to ("pseudoneurotic schizophrenia").
son in the 1970s1 identified objective previous year. The authors report Dr Park is Associate Professor of Psychiatry, Johns Hopkins University School of Medicine. Baltimore.
D5M-IV diagnostic criteria for borderline
personality disorder*
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: and their severely damaged sense ofself manifests itself in great confu- 1. Frantic efforts to avoid real or imagined abandonment. (Do not include suicidal or self-mutilating behavior covered in value, and what they want in life.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and 3. Identity disturbance: markedly and persistently unstable self- this causes others to distance them-selves, suffer extremes of emptiness 4. Impulsivity in at least two areas that are potentially self- damaging (eg, spending, sex, substance use, reckless driving, binge eating). (Do not include suicidal or self- mutilating behavior covered in criterion 5.) ceptivity of people's feelings andmotives, which can manifest itself 5. Recurrent suicidal behavior, gestures, or threats or self- ence over others, termed "projec-tive identification." 6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
times associated with role-bound-ary violations by therapists, includ- 8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent tients commit suicide, usually rela-tively early in their illness. One ma- 9. Transient, stress-related paranoid ideation or severe *Criteria are numbered in order of decreasing diagnostic efficiency. Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric ETIOLOGY
Numerous etiologic theories havebeen advanced about BPD,9 andspecific clues are provided by two all cases of BPD, the search for a component, to the extent that the de- Recognizing BPD in the primary
care setting
When present in a cohesive head). Patients may have self- pattern, various signals can inflicted injuries, bruises, or alert the primary care physi- cuts that they may explain cian to the presence of BPD away as incurred in an accident and the need for immediate re- or caused by someone else.
who tend to present with a have an excessive need to talk combination of chronic moodi- about self-doubts and upset- ness and/or depression and ting personal relationships.
somatic complaints. The phys- They may be angry, self-sab- ical complaints frequently have otaging, impulsive, confusingly an inadequate objective basis appealing and charismatic, and may occasionally sound and anxiety-provoking all at bizarre (eg, the sensation that the same time. There is often the arms are falling off or that a history of suicidal thinking there is an itch inside the and failed mental health care.
had a talent for perceiving the feel- can be difficult to treat, even for ex- ings and motivations of others, which perienced therapists, largely be- Medication: Although there is
TREATMENT
In light of our current understand- pharmacotherapy is frequently nec- ing, it now seems that these chron- essary. The comorbid disorders that mental events rather than biologic stance-abuse, eating, and panic dis- fundamentally different from treat- propriate drugs.
vention is a major concern, partic- BPD that a trial of antidepressants than treating only disturbing symp- tonin reuptake inhibitors (ie, fluoxe- 4. Swartz M. Blazer D, George L, Winfield I: Estimating the prevalence of borderline personalitydisorder in the community. J Pers Disorders 4:257, depression, anger, impulsivity, andvulnerability to stressful events. If 5. A d l e r G: B o r d e r l i n e P s y c h o p a t h o l o g y a n d I t s Treatment. NorthVale. New Jersey, Jason Aronson, becomes a problem, bupropion canbe tried.
6. Kernberg OF: Borderline C o n d i t i o n s and Pathological Narcissism. New York, Jason Aronson,1975.
can be effective but require a strictdietary regimen. Heterocyclic anii- 7. Gutheil TG. Borderline personality disorder, boundary violations, and patient-therapist sex: medicolegal pitfalls. Am J Psychiatry 146:597, 1989.
8. Stone MH: The Fate of B o r d e r l i n e Patients: Successful Outcome and Psychiatric Practice. New York. Guilford Press. 1990. pp40-65. antagonists and anxiolytics can behelpful in selected cases, although 9. Gunderson JG, Zanarini MC: Pathogenesis of borderline personality, in Tasman D, Hales RE.
I many patients have a negative Frances AJ (eds): American Psychiatric Press Review of Psychiatry, vol 8. Washington, DC, American Psychiatric Press. 1989, ch 2. pp 25-49. PROGNOSIS
10. Gunderson JG, Sabo AN: The phenomenological and conceptual interface between borderline personalitydisorder and PTSD. Am J Psychiatry 150:19, 1993.
ered BPD patients unreliable and of-ten unresponsive to treatment, creat- 11. Herman JL, Perry JC, van der Kolk BA; Childhood ing crises and suicidal emergencies.
trauma in borderline personality disorder. Am JPsychiatry 146:490,1989.
However, long-term follow-up stud-ies have demonstrated the striking 12. Links PS. Steiner M, Offord DR, Eppel A: Characteristics of borderline personality disorder: a Canadian study. Can J Psychiatry 33:336, 1988.
ied were no longer "borderline" and 13. Z a n a r i n i M C , G u n d e r s o n J G , M a r i n o M F , e t a l : Childhood experiences of borderline patients. Compr 14. Park LC, Imboden JB, Park TJ, et al: Giftedness References
and psychological abuse in borderline personality disorder: their relevance to genesis and treatment. J I. Gunderson JG; Empirical studies of the borderline diagnosis, in Grinspoon L (ed): Psychiatry 1982: TheAmerican Psychiatric Association Annual Review. 15. Frances A: Foreword, in Stone MH: The Fate of Washington DC, American Psychiatric Press, 1982, ch Borderline Patients. New York, Guilford Press, 1990, 2. Rockland LH: Supportive Therapy for Borderline 16. Linehan MM: Cognitive-Behavioral Treatment of Patients; A Psyche/dynamic Approach. New York, Borderline Personality Disorder. New York, Guilford 3. Diagnostic and S t a t i s t i c a l Manual of Mental 17. Perry JC, Herman JL, van der Kolk BA, Hoke LA: Disorders, ed 4. Washington, DC, Amencan Psychotherapy and psychological trauma in borderline Psychiatric Association, 1994, p 654.
personality disorder. Psychiatr Ann 20:30, 1990.
HOSPITAL MEDIC1NE / SEPTEMBER 1994

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