Treatment considerations for the patient with borderline personality disorder

Borderline personality disorder (BPD) refers to a personality disorder whose primary symptoms include significant emotional distress and impairment of interpersonal or occupational functioning or both [1]. The age of onset varies but often ranges from adolescence to early adulthood (age 18 to 25 years) [2]. Typically the patient with BPD has a history of a pervasive pattern of chaotic interpersonal relationships, unstable mood and self-image disturbances, self-injurious behaviors, and other maladaptive coping behaviors. Major concerns of nurses and other health care providers involve the high use of health care resources among patients with BPD, normally arising from self-destructive and demanding behaviors. The precise prevalence of BPD is obscure, but estimates are about 2% in community samples and 6% of a primary care population [3] and approximately 15% to 20% of psychiatric inpatients [1,4-6]. Severity of symptoms may range from moderately disabling to severely incapacitating. BPD also is likely to co-occur with other psychiatric conditions, including anxiety disorders, major depressive disorders, eating disorders, and substance-related disorders, and medical conditions (eg, somatization disorders). Women are two times more likely to be diagnosed with BPD than men [1,4-6]. A major issue confronting nurses and other health care providers is the high suicidality and other self-injurious behaviors among patients with BPD. One in 10 patients with BPD completes suicide, but suicide is not readily preventable, and it does not necessarily occur during treatment [7]. Chronic suicidal behavior is best understood as a barometer of the patient's level of distress. Hospitalization has not been shown to reduce suicide and often has negative results. Community studies have shown that the rates of suicide peak between the ages of 18 and 30 years [8]. The highest risk of suicide among patients with BPD occurs in those with comorbid substance-related and depressive illness and histories of past attempts. Normally, patients presenting with acute suicidality also meet criteria for depressive illness. In comparison, patients presenting with chronic suicidal ideations are seeking treatment [9]. Because patients with BPD are high users of health care resources, most nurses have had contact with these patients. The patient with BPD often challenges the patience of nurses-hence the risk of rejection and poor treatment outcomes. This article focuses on strategies that can improve treatment outcomes. It also describes the role of the nurse in developing therapeutic environments that convey empathy, establish clear and healthy boundaries, and facilitate appropriate limit settings and an optimal level of functioning. Finally, this article provides an overview of the complexity of this challenging personality disorder, causative factors, assessment and diagnostic considerations, and holistic and interdisciplinary treatment.