Borderline personality disorder

Background

• A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity

Clinical Features

• Five (or more) of the following criteria, beginning by early adulthood and present in a variety of contexts:
  • Frantic efforts to avoid real or imagined abandonment.
  • A pattern of unstable and intense interpersonal relationships characterized by alternat­ing between extremes of idealization and devaluation.
  • Identity disturbance: markedly and persistently unstable self-image or sense of self.
  • Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  • Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  • Chronic feelings of emptiness.
  • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  • Transient, stress-related paranoid ideation or severe dissociative symptoms.
• Completed suicide rates 8-10%, 50 times higher than general population

Differential Diagnosis

• Depressive and bipolar disorders
• Other personality disorders
• Personality dysfunction due to another medical condition
• Substance use disorders
• Identity problems

Evaluation

• A clinical diagnosis; however if entertaining other organic causes may initiate workup below

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

Management

• Treat medical complications of self-harm behavior
• Consider psychiatry consult or admission if acutely suicidal
• Set boundaries
• Tolerate emotions but not outbursts
• Be empathetic yet direct and fact-based, avoid emotionality
• Referral for outpatient psychiatric treatment, as psychotherapy is the primary treatment. Antipsychotics, antidepressants and mood stabilizers can be used to control symptoms such as anger and affective instability.

Disposition

• Discharge

See Also

• Personality disorders