The Practitioner Connection
Volume XXVIII, 4th Quarter

IDENTIFYING BORDERLINE PERSONALITY DISORDER

Although the prevalence rate varies somewhat in the literature, the DSM-IV-TR states that the prevalence rate of BPD is around 2 % in the general population, 10% in those people seen in outpatient mental health clinics and 20 %, or 1 out of 5, of those in inpatient mental health units.

At times, making a diagnosis of BPD as a stand-alone or as a co-occurring disorder can be difficult. In part, this is because many BPD symptoms can overlap with those of other disorders, including Major Depressive Disorder, Bipolar Disorder, ADHD, Anxiety Disorders and PTSD. In addition, it is not uncommon to see BPD as a co-occurring disorder, particularly with Major Depressive Disorders (in some literature, co-occurence is reported as high as 60-70 %), PTSD, Substance-Related disorders and Eating Disorders. Some of the overlapped symptoms include: anxiety, irritability, racing thoughts, suicidal thinking, self-injurious behaviors, anger, cognitive-perceptual disturbances, unstable self-image, impulsivity (excessive spending, reckless behaviors, substance abuse, sexual promiscuity, etc.), affective dysregulation and mood shifts. It is therefore important that a comprehensive psychiatric evaluation be completed. This evaluation should also include collateral information from family, friends and treating practitioners, past and present psychosocial history and family dynamics information, which can help the practitioner evaluate whether the symptoms are due to a BPD, another disorder or both. It is not always possible to do a very comprehensive evaluation during an initial assessment, when the practitioner may need to take more of a triage-like approach. However, a more comprehensive follow-up evaluation should be done as soon as possible following the initial assessment.

Although the DSM-IV-TR includes a list of criteria for making a diagnosis of Borderline Personality Disorder, some clinicians feel that some of the core characteristics in the DSM-IV-TR should be revised, while others feel additional criteria should be considered. However, for the time being, the DSM IV-TR, along with the APA practice guidelines, are the standard criteria to follow when diagnosing BPD. Although the DSM-IV-TR lists nine criteria for BPD, it is important to emphasize that a diagnosis of BPD should include a history of “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 5 (or more) of the listed criteria (please see DSM-IV –TR for the 9 criteria).

Certain symptoms and behaviors that are likely to point to a diagnosis of BPD often can (but not necessarily) be traced back to early adolescence or teenage years, including inappropriate and intense anger, difficulty controlling anger, chronic feelings of emptiness, self-destructive behaviors, identity disturbances, mood swings triggered by interpersonal stressors and frantic efforts to avoid abandonment, especially when there are no clear-cut criteria being met for other major Axis I diagnoses during these times. Therefore, a comprehensive evaluation along with collateral information from friends and family are helpful in making the BPD diagnosis. Although a history of trauma, such as physical or sexual abuse while growing up, is commonly seen with BPD, it is not universally seen and therefore should not be a criteria for making a BPD diagnosis.

If a co-occurring diagnosis exists with BPD, it is important that the treatment plan addresses all diagnoses, regardless of the primary diagnosis. Missing or not treating a co-occurring BPD may contribute to a less effective result or even a failure of a specific treatment modality being used for another disorder.

For more information on borderline personality disorder see the APA practice guideline for the treatment of BPD or go to the link provided below:

http://www.psychiatryonline.com/pracGuide/pracGuideTopic_13.aspx

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