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Borderline Personality Disorder. Dr. Matthew Sager Psychiatric Medical Director St. Mary’s Hospital, Madison, WI. Borderline Personality Disorder (BPD). What is it? Perceptions and current diagnosis History Causes Facts Co-occurring diagnoses and differential Treatment

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borderline personality disorder

Borderline Personality Disorder

Dr. Matthew Sager

Psychiatric Medical Director

St. Mary’s Hospital, Madison, WI

borderline personality disorder bpd
Borderline Personality Disorder (BPD)
  • What is it? Perceptions and current diagnosis
  • History
  • Causes
  • Facts
  • Co-occurring diagnoses and differential
  • Treatment
  • Evaluating safety concerns/suicidality
  • Initial impressions
  • Stigma
  • Better descriptive terms?

Emotional Regulation Disorder

current diagnosis
Current Diagnosis
  • DSM IV-need to have 5 of 9 criteria (pervasive)

Unstable relationships-splitting example

Impulsive behaviors

Mood swings

Intense anger

Feelings of emptiness

Fear of abandonment

Identity disturbance, ‘poor sense of self’

Suicidal behavior or self-injury

Transient paranoia/dissociative states

diagnostic issues
Diagnostic Issues
  • Problems with DSM IV
    • 5 of 9-there are 256 different variations
    • 4 of 9-no diagnosis, but would look very similar clinically


    • Revisions to look at dimensional aspects of personality
    • BPD on same axis as depression, anxiety
    • In end-too complex for clinical practice-yet
diagnostic issues cont
Diagnostic Issues cont.’
  • Issues that affect making diagnosis:
    • Transient states
    • Medical illnesses
    • Situational stress
    • Sex and cultural beliefs/biases
    • Clinician feelings-anger, disappointment, frustration
diagnostic issues cont1
Diagnostic Issues cont.’
  • In the end-the diagnosis focuses on ways of thinking and feeling about oneself and others that ends up affecting a persons ability to function
bpd history
BPD History
  • 1930s Psychoanalysts (i.e. Sigmund Freud)

divided psychosis (delusions, hallucinations) from neurosis (anxiety/distress). The area between, the borderline was the difference that explained why some patients did not act one way or the other.

  • 1960s Psychiatrist Otto Kernberg

personality organization to syndrome to disorder

bpd history cont
BPD History cont.’
  • 1980s and 90s

Increased research

From analytical to medicalization

DSM III (1980)

DSM IV (1994)

DSM V (2013)

bpd causes
BPD Causes


  • Twin studies show strong inheritance


  • Unstable family relationships

Social and cultural factors

  • 1900s-less unstructured time with more work/survival instincts
  • i.e. Eating Disorders indifferent countries
bpd causes1
BPD Causes
  • Abnormal Brain functioning
    • Amygdala – center of emotion
    • Prefrontal Cortex – complex problem solving
  • Whatever the cause, data shows the impact of this illness
bpd facts
BPD Facts
  • 2% of US population have BPD

(equal to population of New York City)

  • Twice that of bipolar disorder or schizophrenia
  • 10% of mental health outpatient clinics
  • 20% of inpatient psychiatric hospital units
bpd facts1
BPD facts
  • 75-90% of those diagnosed are women
    • Do women seek treatment more than men?
    • Men with similar symptoms may end up in jail or with another diagnosis.
  • 10% complete suicide in their lifetime
  • Comorbidities are rampant-mood disorders (depression, bipolar) anxiety disorders (PTSD) and substance abuse disorders
  • Probably ‘burns out’ or dissipates over time
bpd facts2
BPD Facts
  • Face Studies: people with BPD are inclined to see anger in neutral emotion faces
  • Word Studies: people with BPD are inclined to attach a stronger reaction to neutral words
comorbidities and differential diagnoses
Comorbidities and differential diagnoses
  • Mood Disorders (bipolar disorder I and II, major depression, dysthymia)
  • Anxiety disorders including PTSD
  • Eating Disorders
  • Substance Abuse Disorders
  • Other personality Disorders
comorbidities and differential
Comorbidities and differential
  • Lots of overlap with impulsive behaviors and mood instability
  • Different diagnoses from different providers
explaining diagnosis
Explaining diagnosis
  • John Gunderson MD quote

As an example that focuses on jargon free explanation that patients can understand

bpd treatment
BPD Treatment
  • BPD-High utilization of health care $

ER visits, inpatient medical/psych care

  • Hallmark of good care-multiple modalities
  • Alliance building to foster improved mood, behavior, social functioning and relationships
treatment goals
Treatment Goals
  • Containment of any safety issues
  • Structure
  • Provide support
  • Involve patient in decision making
  • Validation
treatment levels
Treatment Levels


‘Step Down or Up’ Partial hospital(PHP) or Intensive Outpatient Program(IOP)

Outpatient Therapy + Med Management

Sociotherapies (group, family)

treatment levels1
Treatment Levels
  • Focus on the least restrictive means of effective treatment
bpd treatment1
BPD Treatment
  • Hospital care
    • Often contraindicated and can worsen behavioral issues
    • Hospital provides external control which can become habit forming and cause BPD patient to attempt to gain control in negative fashion
    • Should be used only for acute safety stabilization
bpd psychotherapy
BPD Psychotherapy
  • Mainstay of BPD treatment
  • Specific types may be more effective
bpd psychotherapy1
BPD Psychotherapy
  • DBT (Dialectical Behavioral Therapy)
    • Pioneered by Marsha Linehan PhD
  • Focuses on mindfulness, acceptance and awareness of situations and feelings
  • decreases intensity of emotions
bpd psychotherapy2
BPD Psychotherapy
  • CBT(Cognitive Behavioral Therapy)
  • Focus: Changing thinking will change behavior
  • Skill building/practice
  • Relaxation
  • Exposure therapy
bpd psychotherapy3
BPD Psychotherapy
  • Schema therapy

Reframing ways people view themselves

bpd psychotherapy4
BPD Psychotherapy
  • Group Therapies




Others (problem focused)

bpd medications
BPD Medications
  • Role of meds: manage symptoms, though benefit is often uncertain due to ‘symptom chasing’
  • Goal is to treat comorbidities
  • Avoid dependence, abuse, risk of overdose
  • Classes: Antidepressants


Mood stabilizers


AODA meds-antabuse/naltrexone/methadone

bpd medications1
BPD Medications

Treat comorbidities!

treatment plans
Treatment Plans
  • Contracts with patients
    • Makes expectations explicit
    • From Crisis Intervention, when to call providers, when to go to hospital to roles of those involved

i.e. family/friends

bpd safety issues
BPD Safety issues
  • Suicide and borderline personality
  • 10% completed lifetime
  • Safety plans-limited pill supply, family support, crisis contact
  • Highest risk are those with depression and alcohol/drug problems
bpd safety issues1
BPD safety issues

‘Feeling Unsafe’

Goal is for patient to recognize when they need more active help and trust they will get it

Typical Crisis-express concern, allow patient to ventilate, avoid taking actions but let patient be explicit about situation

Follow-up after crisis

bpd and suicidal acts
BPD and suicidal acts
  • John Gunderson, MD
  • “Suicidal acts are a dangerous distraction from the patient working on attaining a better life”.

Dr Gunderson views suicidal statements/acts as affecting a patient’s dependence on others and an effort to be cared for.



1. Gunderson, John G, M.D. ‘Borderline Personality Disorder A Clinician’s Guide’, 2001.

2. DSM IV, American Psychiatric Association, 2000.

3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.