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‘Borderline personality disorder’ in primary care

mental health


Labels can obscure the people they are attached to and when we see diagnoses instead of people, we can struggle to offer our most valuable nursing tool; human connection.

Whilst this article is written about ‘borderline personality disorder’ it is worth remembering and carrying through into your practice that people with this diagnosis are human beings.  It is a controversial diagnosis that many people are uncomfortable with, and can lead to stigmatising and poor experiences of care.  Labels can obscure the people they are attached to and when we see diagnoses instead of people, we can struggle to offer our most valuable nursing tool; human connection. Care should focus on a person’s needs in the moment.   

Relevance for primary care and general practice  

‘Borderline personality disorder’ (BPD) is attached to around 1% of the UK population.1  People diagnosed with ‘BPD’ (PdxBPD) are associated with frequent crisis, with people having multidimensional subjective overwhelming experiences which can lead to self-harm and suicide.2 Whilst evidence-based treatment for ‘BPD’ often involves long-term specialist psychotherapies, PdxBPD often present to generalist services where professionals may lack specialist training. These environments are often primary care services. 3, 4 It is therefore essential that all staff across primary care environments understand ‘BPD’, and how to effectively support people.  This short article introduces the diagnosis and lays out some of the key concepts for effective working relationships.

The ‘BPD’ diagnosis and its limitations  

The DSM-5 symptoms for ‘BPD’ 5 are presented here (see table 1), with people meeting any five or more criteria given the diagnosis. ‘BPD’ is synonymous with ‘emotionally unstable personality disorder’ in the ICD-10; borderline type’ in the ICD-10, 6 and now appears as ‘borderline pattern’ in the new ICD-11, with ‘personality disorders’ moving to a spectrum from mild, moderate to severe symptoms.

The incoming ICD-11 had an opportunity to review diagnostic criteria, and is now removing categories (eg borderline, antisocial, narcissistic etc) of ‘personality disorder’, instead moving to a broader spectrum of mild, moderate and severe ‘personality disorder’. 7 However, after professional debate ‘borderline pattern’ was added to aid description, so ‘BPD’ will still remain in clinical use for the foreseeable future.

Table 1: ‘Borderline Personality Disorder’ (5).  
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:   
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.   
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.   
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.   
4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.     
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.  
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).   
7. Chronic feelings of emptiness.  
8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights).  
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.  

Experts in the field agree that the core difficulties are centred around severe emotional dysregulation, strong impulsivity and difficulties in relationships, 8 and it has been suggested that ‘BPD’ would be better understood as an emotional dysregulation syndrome.9 ‘BPD’ has multiple comorbidities 10 and no core features 11 meaning that people with the same diagnosis can present very differently. 

It is worth remembering that a psychiatric diagnosis is a subjective judgement, and with no objective tests for these diagnoses they are criticised as lacking scientific validity 12 and unfairly framing;‘what people feel and do’;into;‘something they have or are’. 13, p. 28 Whilst diagnosis may aid access to treatment, if care focuses on the diagnosis, it is unlikely to be person centred. 

The impacts of being diagnosed with ‘BPD’  

A diagnosis would be made by a mental health professional, often a psychiatrist, if the aforementioned symptoms are problematic, persistent and pervasive;14 ie if symptoms are causing problems for the person and people around them, with problems present over a long period of time (normally around two years), and difficulties spanning across different areas of a person’s life, eg family, work and wider community.  

Where people may find the diagnosis useful is when they may feel relief at having their difficulties recognised, perhaps connecting them with peer support with others with the diagnosis, and potentially affording them access to appropriate long-term treatment.  Where the diagnosis can be unhelpful is that it leads to ‘closed minds rather than open arms’ 15, pe25 .  ‘BPD’ carries a damaging stigma and misunderstanding, with ideas that people are untreatable and manipulative, held by professionals who lack knowledge and understanding, and often feel powerless. 16

‘What happened?’  

Being trauma-informed means keeping in mind ‘what happened?’ to people.  PdxBPD have often experienced adversity and trauma including sexual abuse, emotional abuse, physical abuse and neglect, and symptoms bear more than a resemblance to difficulties associated with trauma. 17   Being trauma-informed can reframe psychiatric symptoms into understandable rather than ‘disordered’ behaviour. 13  Nurses who are educated on these matters are likely to have an awareness that PdxBPD may have good reason not to trust others given histories of trauma, and may have difficulty understanding others intentions, if they themselves have not been understood.  

Treatment  

Whilst there are no medications licensed specifically for the treatment of ‘BPD’ they are still frequently utilised.18 The use of medication may be made more likely given ‘BPD’ is comorbid with several other psychiatric diagnoses, 10 and due to a lack of more appropriate crisis treatment resources. 2  Short term use of sedative medication has been suggested as potentially useful in a crisis, but only under cautious consideration, and in agreement with the person.18  Crisis care of people in distress can be can be ethically complex, and the prescription of medication can be as much about patients intense desire to feel like something is being done, as the professionals need to feel like they are doing something.19  Requests for medication changes may be justifiable at times, but may also be a communication of the desperation a person feels.  There is the potential that this focus on medication may allow both professional and PdxBPD to over look the underlying psychological needs, which cannot be adequately addressed by psychiatric drugs.

The best evidence for treatment is in psychological therapies, with the strongest evidence base for mentalisation based therapy (MBT) and dialectical behavioural therapy (DBT). DBT was the first psychotherapy shown to be effective with ‘BPD’. It is based on cognitive behavioural therapy, and comprises group and individual psychotherapy.  DBT skills are aimed at addressing emotional dysregulation, impulsivity, self-image and interpersonal relationships.20 MBT was developed in the 1990’s.  It also involves group and individual psychotherapy, though focuses on mind rather than behaviour, and how mental states influence self and others. 21

However, no therapy shows superiority over another and it has been proposed that the common factor to good treatment is a solid therapeutic relationship based on trust where people feel like they matter.8 The fact there is a common ingredient to all good therapy means this is a key interpersonal skill, and not unique to psychotherapy.  Therefore, all human interactions can be helpful. Whilst PdxBPD  have often experienced trauma and adversity and may merit referral to more long-term specialist services, helpful interactions should not be exclusive to specialists. Positive empathic responses from all professionals across all contexts can make a difference.

Crisis care  

People have such different experiences of crisis that the diagnosis may not be useful in terms of guiding care. 2  Therefore, nurses should focus on the unique individual’s needs.  NICE suggest crisis care should risk assess, explore reasons for distress, provide empathy and refer to mental health services if necessary.18 A common reason for attendance at primary care may be suicidal or self-harming behaviour.  Whilst this needs to be addressed appropriately in terms of a person’s safety, where care can fail is when professionals focus on behaviour and the diagnosis, rather than the person and their underlying distress. 2 Examples of this are where a nurse focuses on the physical care of self-harm, without exploring thoughts and feelings which may have contributed to it, where staff may be so acutely aware of the diagnosis that they see a stereotype and fail to see the uniqueness of the human being in front of them. In these instances PdxBPD may receive a physical intervention, though may not feel cared for, nor understood.

The role of primary care nurses in managing/caring for BPD patients  

Nurses may worry they lack expertise to care for PdxBPD, though advice would be to forget ‘BPD’, see the person, and identify their needs in the moment.  If they have physical health issues, these should be addressed, but the care often missed is the psychic pain and underlying distress.2  Nurses may worry about not knowing what to do, though the things we offer people can be simple. See below.

Box 

Care should follow some key principles :2, 18, 22, 23

  • See the person, not the diagnosis  
  • Keep in mind the person may have experienced trauma  
  • Ensure the person feels safe  
  • Attend to any physical care needs  
  • Seek contact with them and offer time to talk  
  • Provide empathy and explore their underlying distress  
  • Be honest and transparent  
  • Collaborate and share decision making 
  • Nurses should engage in active reflection and clinical supervision 

Summary   

A final point, and perhaps the most important, is that if professionals keep their mind on the needs people have in the present moment, and difficult life experiences rather than the ‘BPD’ label, it likely means responses will be more empathic and understanding, and thus more useful. Nurses need to look beyond the diagnosis and explore a person’s underlying distress. All human interactions can be helpful.  

Acknowledgement  

Many thanks to Emma Canning, student in adult nursing at Robert Gordon University, for a useful discussion which helped with the contextualisation of this article for the intended target audience.  

References:

  1. Coid, J., et al. (2006). Prevalence and correlates of personality disorder in Great Britain. The British Journal of Psychiatry, 188, 423–431. https://doi.org/10.1192/bjp.188.5.423  
  2. Warrender, D. et al. 2021. Perspectives of crisis intervention for people diagnosed with “borderline personality disorder”: An integrative review. Journal of Psychiatric and Mental Health Nursing, 28 (2), pp.208-236. https://onlinelibrary.wiley.com/doi/full/10.1111/jpm.12637
  3. Moran, P. et al. (2000). The prevalence of personality disorder among UK primary care attenders. Acta Psychiatrica Scandinavica, 102, 52–57.
  4. Gross, R. et al. (2002). Borderline personality disorder in primary care. Archives of Internal Medicine, 162, 53–60.  
  5. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM‐V. Arlington, TX: American Psychiatric Association. 
  6. World Health Organization (1992). The ICD‐10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization.  
  7. World Health Organization (2020). ICD‐11 for mortality and morbidity statistics – Personality disorders and related traits.  
  8. Fonagy, P., Luyten, P. and Bateman, A. (2017). Treating borderline personality disorder with psychotherapy: Where do we go from here? JAMA Psychiatry, 74(4), 316-317. 
  9. Tyrer, P. (2018). Taming the beast within: Shredding the stereotypes of personality disorder. London, UK: Sheldon Press.  
  10. Bateman, A. W., & Krawitz, R. (2013). Borderline personality disorder: An evidence‐based guide for generalist mental health professionals. Oxford, UK: Oxford University Press. 
  11. Trull, T. J., Distel, M. A., & Carpenter, R. W. (2011). DSM‐5 borderline personality disorder: At the border between a dimensional and a categorical view. Current Psychiatry Reports, 13(1), 43–49.
  12. Johnstone, L. (2014). A straight talking introduction to psychiatric diagnosis. Monmouth, UK: PCCS books. 
  13. Johnstone, L. and Boyle, M. et al. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester, UK: British Psychological Society.  
  14. Royal College of Psychiatrists, (2018). CR214: Personality disorder in Scotland: raising awareness, raising expectations, raising hope. 
  15. Harding, K. 2020. Words matter: the Royal College of Psychiatrists’ position statement on personality disorder, The Lancet, 7(5), E25. 
  16. Ring, D., & Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of Mental Health, 1–21.
  17. Porter, C. et al. (2019). Childhood adversity and borderline personality disorder: A meta‐analysis. Acta Psychiatrica Scandinavica, 141(1), 6–20.
  18. NICE. (2009). GC78: Borderline personality disorder – Treatment and management. [Online] Retrieved from: https://www.nice.org.uk/guidance/CG78 
  19. Warrender, D. (2018). Borderline personality disorder and the ethics of risk management: The action/consequences model. Nursing Ethics, 25(7), 918–927.
  20. Linehan, M. (2015). DBT skills training manual, 2nd edition. New York, USA: The Guildford Press. 
  21. Bateman, A. and Fonagy, P. (2016). Mentalization-based treatment for personality disorder. Oxford, UK: Oxford University Press. 
  22. Sweeney, A. et al. (2018). A paradigm shift: Relationships in trauma‐informed mental health services. Bjpsych Advances, 24(5), 319–333.
  23. Bland, A. R., & Rossen, E. K. (2005). Clinical supervision of nurses working with patients with borderline personality disorder. Issues in Mental Health Nursing, 26(5), 507–517.  

Further reading:  

For further information, please explore these weblinks, videos and resources.  

Dan Warrender – a critical introduction to ‘borderline personality disorder’ – NIP Conference 2020  

Dan Warrender and Scott Macpherson – Principles of therapeutic engagement: https://www.youtube.com/watch?v=vY8EtK9WjRU  

Brené Brown on Empathy https://www.youtube.com/watch?v=1Evwgu369Jw   

Challenging the culture of psychiatric diagnosis, exploring trauma informed alternatives http://www.adisorder4everyone.com/about/   

‘Personality Disorder in the Bin’ https://personalitydisorderinthebin.wordpress.com/author/pdinthebin/   

Jon G. Allen, PhD, on What We All Need to Know About Attachment https://www.youtube.com/watch?v=RdCBip-8pC8   

What is Mentalizing & Why Do It with Jon G. Allen, PhD https://www.youtube.com/watch?v=NLT7ieO3hTk   

Trauma and the brain https://www.youtube.com/watch?v=4-tcKYx24aA   

Opening Doors Trauma Informed Practice for the Workforce https://www.youtube.com/watch?v=zg8ahtHIRxU