BORDERLINE PERSONALITY DISORDER
DSM-IV
301.83 Borderline personality disorder
“Borderline” has been used to identify clients who seem to fall on the border between the standard categories of neuroses or psychoses. The term has been refined to indicate a client with a pervasive pattern of instability of interpersonal relationships, self-image, affect, and control over impulses beginning in early adulthood, and includes such factors as feelings of abandonment, impulsivity, reactivity of mood, chronic feelings of emptiness, and problems with anger.
ETIOLOGICAL THEORIES
Psychodynamics
Unconscious processes that are believed to shape personality are set in motion by drives or instincts that are then influenced by conflicts among them as well as instinctual wishes and demands of reality. Defensive maneuvers are unconsciously developed to protect against anxiety arising from this conflict. This personality is seen as a painstaking but poorly constructed defense.
It is also seen as resulting from a fixation of libido at stages of psychosexual development associated with certain body parts. Although it is difficult to agree on how personality is formed, severe personality disorders are believed to begin early in childhood and milder forms are thought to be influenced by factors during later development.
Biological
Personality is believed to have a hereditary basis known as “temperament” and biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-contained, outgoing, impulsive, cautious). There is little agreement about how this affects the development of personality disorders.
Family Dynamics
The child’s social environment, particularly that within the family, is assumed to be the main force that shapes personality. The theory of object relations provides a basis for personality development and an explanation of the dynamics that manifest the borderline characteristics. The individual with borderline personality may be fixed in the rapprochement phase of development (18–25 months of age). In this phase, the child is experiencing increasing autonomy, while still requiring “emotional refueling” from the mothering figure. Because the mother feels threatened by the child’s efforts at independence, she strives to keep the child dependent. Nurturing and emotional support become bargaining tools. They are withheld when the child exhibits independent behaviors and are used as rewards for clinging, dependent behaviors. This engenders a deep fear of abandonment in the child that persists into adulthood as the child continues to view objects (people) as parts—either good or bad. This is called “splitting,” which is the primary dynamic of borderline personality.
Current studies suggest that borderline personality disorders are strongly associated with a history of physical or sexual abuse by family members, and incest may be a major reason for the disproportionate ratio (2:1) of female clients.
CLIENT ASSESSMENT DATA BASE
Ego Integrity
Markedly disturbed/distorted sense of self
Experiences ambivalence toward being independent; does not like to be alone (frantic attempts to avoid real or imagined abandonment)
Reports feelings of emptiness and boredom; depression, sadness
May conform to current companions, sharing beliefs and values based on imitation
Food/Fluid
Binge eating may be reported (impulsivity)
Neurosensory
Mental Status:
Behavior: May be erratic, impulsive, intense, clinging; may indulge in unpredictable/impulsive behaviors (e.g., irresponsible spending, reckless driving, gambling, substance abuse)
Mood: Marked reactivity of mood (e.g., intense episodes of anxiety, irritability, dysphoria)
Emotions: Intense emotions with rapid, unpredictable, strong mood swings; quick to anger (may be intense, inappropriate), lacks ability to control; may exhibit hostile attitude
Affect: May appear genuine but not necessarily be appropriate to the situation
Thought Processes: Displays overall poor reality base with difficulty making decisions; engages in concrete “all-or-nothing”/black-or-white thinking; lacks insight and does not learn from past experience; unable to form long-term goals or values
Magical thinking, difficulty in identifying the self; severely impaired self-concept
Lying and fabrication habitual, almost delusional
Self-centered, often to the point of narcissism, inordinantly hypersensitive, and inflexible; relationships may be transient, shallow, and/or demanding, with little flexibility and unstable interpersonal behavior; may use and exploit others; lacks empathy for others
Major defense mechanism used is projection (seeing in others those attitudes one fails to see in self)
May border on neuroses and psychoses, exhibiting transient psychotic symptoms when experiencing extreme stress; transient episodes of paranoid ideation or severe dissociative symptoms
May be associated with other personality disorders that have histrionic, narcissistic, schizotypal, or antisocial features
Safety
May reveal evidence of self-mutilative acts, usually nonlethal actions (e.g., cutting, burning)
History of recurrent suicidal behavior, gestures, threats
Sexuality
May present a profound disturbance in gender identity
Sexual promiscuity
Possible history of incest/sexual abuse
Social Interactions
Significant impairment in social, marital, and occupational functioning
Interpersonal relationships unstable and intense, alternating between extremes of overidealization and devaluation
Frequently attempts to provoke guilt in others, making endless demands
History of recurrent physical fights
Teaching/Learning
More prevalent in females
Substance abuse (especially alcohol) may be reported
Higher incidence found in families with history of both chronic schizophrenia and major affective disorders
DIAGNOSTIC STUDIES
P-300: A change in brain electrical activity that occurs in most people about 300 milliseconds after they perceive a tone, light, or other signal indicating that they have to perform a task; may be abnormal, smaller than average, and slightly delayed.
CSF5-HIAA (5-hydroxyindoleacetic acid): Decreased in some clients.
Prolacting Response: Diminished response to serotonin-releaser fenfuramine.
Drug Screen: Identifies substance use.
NURSING PRIORITIES
1. Limit aggressive behavior; promote socially acceptable responses.
2. Encourage assertive behaviors to attain sense of control.
3. Assist client to learn healthy ways of controlling anxiety/developing positive self-concept.
4. Promote development of effective coping skills.
5. Help client learn alternate, constructive methods of interacting with others.
DISCHARGE GOALS
1. Impulsive behavior(s) recognized and controlled.
2. Establishes goals and asserts control over own life.
3. Problem-solving techniques used constructively to resolve conflicts.
4. Interacts with others in socially appropriate manner.
5. Client/family involved in behavioral therapy/support programs.
6. Plan in place to meet needs after discharge.
DSM-IV
301.83 Borderline personality disorder
“Borderline” has been used to identify clients who seem to fall on the border between the standard categories of neuroses or psychoses. The term has been refined to indicate a client with a pervasive pattern of instability of interpersonal relationships, self-image, affect, and control over impulses beginning in early adulthood, and includes such factors as feelings of abandonment, impulsivity, reactivity of mood, chronic feelings of emptiness, and problems with anger.
ETIOLOGICAL THEORIES
Psychodynamics
Unconscious processes that are believed to shape personality are set in motion by drives or instincts that are then influenced by conflicts among them as well as instinctual wishes and demands of reality. Defensive maneuvers are unconsciously developed to protect against anxiety arising from this conflict. This personality is seen as a painstaking but poorly constructed defense.
It is also seen as resulting from a fixation of libido at stages of psychosexual development associated with certain body parts. Although it is difficult to agree on how personality is formed, severe personality disorders are believed to begin early in childhood and milder forms are thought to be influenced by factors during later development.
Biological
Personality is believed to have a hereditary basis known as “temperament” and biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-contained, outgoing, impulsive, cautious). There is little agreement about how this affects the development of personality disorders.
Family Dynamics
The child’s social environment, particularly that within the family, is assumed to be the main force that shapes personality. The theory of object relations provides a basis for personality development and an explanation of the dynamics that manifest the borderline characteristics. The individual with borderline personality may be fixed in the rapprochement phase of development (18–25 months of age). In this phase, the child is experiencing increasing autonomy, while still requiring “emotional refueling” from the mothering figure. Because the mother feels threatened by the child’s efforts at independence, she strives to keep the child dependent. Nurturing and emotional support become bargaining tools. They are withheld when the child exhibits independent behaviors and are used as rewards for clinging, dependent behaviors. This engenders a deep fear of abandonment in the child that persists into adulthood as the child continues to view objects (people) as parts—either good or bad. This is called “splitting,” which is the primary dynamic of borderline personality.
Current studies suggest that borderline personality disorders are strongly associated with a history of physical or sexual abuse by family members, and incest may be a major reason for the disproportionate ratio (2:1) of female clients.
CLIENT ASSESSMENT DATA BASE
Ego Integrity
Markedly disturbed/distorted sense of self
Experiences ambivalence toward being independent; does not like to be alone (frantic attempts to avoid real or imagined abandonment)
Reports feelings of emptiness and boredom; depression, sadness
May conform to current companions, sharing beliefs and values based on imitation
Food/Fluid
Binge eating may be reported (impulsivity)
Neurosensory
Mental Status:
Behavior: May be erratic, impulsive, intense, clinging; may indulge in unpredictable/impulsive behaviors (e.g., irresponsible spending, reckless driving, gambling, substance abuse)
Mood: Marked reactivity of mood (e.g., intense episodes of anxiety, irritability, dysphoria)
Emotions: Intense emotions with rapid, unpredictable, strong mood swings; quick to anger (may be intense, inappropriate), lacks ability to control; may exhibit hostile attitude
Affect: May appear genuine but not necessarily be appropriate to the situation
Thought Processes: Displays overall poor reality base with difficulty making decisions; engages in concrete “all-or-nothing”/black-or-white thinking; lacks insight and does not learn from past experience; unable to form long-term goals or values
Magical thinking, difficulty in identifying the self; severely impaired self-concept
Lying and fabrication habitual, almost delusional
Self-centered, often to the point of narcissism, inordinantly hypersensitive, and inflexible; relationships may be transient, shallow, and/or demanding, with little flexibility and unstable interpersonal behavior; may use and exploit others; lacks empathy for others
Major defense mechanism used is projection (seeing in others those attitudes one fails to see in self)
May border on neuroses and psychoses, exhibiting transient psychotic symptoms when experiencing extreme stress; transient episodes of paranoid ideation or severe dissociative symptoms
May be associated with other personality disorders that have histrionic, narcissistic, schizotypal, or antisocial features
Safety
May reveal evidence of self-mutilative acts, usually nonlethal actions (e.g., cutting, burning)
History of recurrent suicidal behavior, gestures, threats
Sexuality
May present a profound disturbance in gender identity
Sexual promiscuity
Possible history of incest/sexual abuse
Social Interactions
Significant impairment in social, marital, and occupational functioning
Interpersonal relationships unstable and intense, alternating between extremes of overidealization and devaluation
Frequently attempts to provoke guilt in others, making endless demands
History of recurrent physical fights
Teaching/Learning
More prevalent in females
Substance abuse (especially alcohol) may be reported
Higher incidence found in families with history of both chronic schizophrenia and major affective disorders
DIAGNOSTIC STUDIES
P-300: A change in brain electrical activity that occurs in most people about 300 milliseconds after they perceive a tone, light, or other signal indicating that they have to perform a task; may be abnormal, smaller than average, and slightly delayed.
CSF5-HIAA (5-hydroxyindoleacetic acid): Decreased in some clients.
Prolacting Response: Diminished response to serotonin-releaser fenfuramine.
Drug Screen: Identifies substance use.
NURSING PRIORITIES
1. Limit aggressive behavior; promote socially acceptable responses.
2. Encourage assertive behaviors to attain sense of control.
3. Assist client to learn healthy ways of controlling anxiety/developing positive self-concept.
4. Promote development of effective coping skills.
5. Help client learn alternate, constructive methods of interacting with others.
DISCHARGE GOALS
1. Impulsive behavior(s) recognized and controlled.
2. Establishes goals and asserts control over own life.
3. Problem-solving techniques used constructively to resolve conflicts.
4. Interacts with others in socially appropriate manner.
5. Client/family involved in behavioral therapy/support programs.
6. Plan in place to meet needs after discharge.
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