E v i d e n c e - B a s e d C a re o f t h e

P a t i e n t w i t h B o rd e r l i n e
P e r s o n a l i t y D i s o rd e r
Deborah Antai-Otong, MS, APRN, PMHCNS-BC, FAAN

KEYWORDS
 Borderline personality disorder  Nonsuicidal self-injury (NSSI)  Parasuicide
 Impulsivity  Dialectal behavioral therapy  Mentalization-CBT  Attachment theory

KEY POINTS
 It is important to examine major underpinnings of borderline personality disorder (BPD).
 There are many nursing implications for caring for patients with BPD.
 It is vital to assess suicide risk factors and self-injurious behaviors in patients with BPD.
 There are evidence-based pharmacologic and psychotherapeutic approaches used in the
treatment of BPD.

INTRODUCTION

Borderline personality disorder (BPD) refers to a personality disorder whose primary

symptoms include significant emotional distress, striking impulsivity, and impairment
of interpersonal and occupational functioning or both.1 The age of onset varies, but
it often ranges from adolescence to early adulthood (ages 18–25 years). Typically
the patient with BPD has marked reactions to rejection and abandonment, chaotic
patterns of interpersonal relationships, unstable mood and self-image disturbances,
self-harm behaviors, and other maladaptive coping behaviors.1–3 Major concerns of
nurses and other health providers involve the high use of health care resources among
patients with BPD normally arising from suicide attempts and other self-harm and
demanding behaviors.
The precise prevalence of BPD is obscure, but estimates are about 2% in commu-
nity samples and 6% in primary care populations, and approximately 15% to 20% of
patients seen in outpatient mental health settings.1,3,4 Severity of symptoms may vary
from moderately disabling to severely incapacitating. A large percentage of patients

This article is an update of an article previously published in Nursing Clinics of North America,
Volume 38, Issue 1, March 2003.
The author has no financial interests to disclose.
Department of Veterans Affairs, Veterans Integrated Service Networks-(VISN-17), 2301 E. Lamar
Boulevard, Arlington, TX 76006, USA
E-mail address: Deborah.Antai-Otong@va.gov

Nurs Clin N Am 51 (2016) 299–308

http://dx.doi.org/10.1016/j.cnur.2016.01.012 nursing.theclinics.com
0029-6465/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
300 Antai-Otong

with BPD, approximately 75%, have a history of self-harm or deliberate nonsuicidal

self-injury (NSSI) and 10% lifetime risk of completed suicides.2,4 BPD is like to co-
occur with other psychiatric conditions, including anxiety disorders, major depressive
disorders, eating disorders, and substance use disorders and medical conditions (eg,
somatization disorders, chronic pain disorder). Estimates indicate that 75% of patients
diagnosed with BPD are women.1,4–6
A major challenge confronting nurses and other health care providers is the high sui-
cidality and other self-harm behaviors among patients with BPD. One in 10 patients
with BPD completes suicide, but suicide is readily preventable, and it does not neces-
sarily occur during treatment.2,4 Chronic suicidal behavior is best understood as a
barometer of the patient’s level of distress and ability to modulate negative emotions.
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 and decrease with age.2–4,7 The highest risk of suicide among patients with
BPD occurs in those with co-occurring substance use disorders and mood disorders
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.8
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 therapeutic environments that
convey empathy, establish clear and health boundaries, and facilitate appropriate
limit settings and an optimal level of functioning. Finally, this article provides an over-
view of the complexity of this challenging personality disorder, causative factors,
assessment and diagnostic considerations, and person-centered and interdisciplinary
treatment.

CAUSATIVE FACTORS

A large body of research suggests that BPD is a problem arising from numerous fac-
tors, such as trauma or abuse, genetic predisposition, and dysregulations of neurobio-
logic processes.9–11 Of particular interest is the relationship between causative factors
and self-injurious behaviors. Numerous data indicate a host of biologic correlates of
suicidal and other self-injurious behaviors related to decreased levels of serotonin
(5-hydroxytryptamine) found in the brainstems of suicide victims and lows levels of ce-
rebrospinal fluid 5-hydroxyindolaecetic acid found in attempters.11,12 A plethora of
data also supports the assumption that underpinnings of BPD arise from dysregulation
of the prefrontal cortex, which is the focal point of self-direction, self-organization, and
emotional regulation.13 These data also indicate the importance of diverse treatment
interventions, comprising pharmacologic and nonpharmacologic interventions, to
treat this complex psychiatric disorder.

ASSESSMENT AND DIAGNOSTIC CONSIDERATIONS

Typically the patient seeks treatment during a perceived crisis that parallels a real or
imagined valued relationship breakup. Patients with BPD have difficulty being alone,
and relationship breakups worsen their anxiety and distress. Mood swings are com-
mon, resulting in a dysphoric or depressed mood later. Their clinging or “smothering”
behaviors tend to generate various emotions in nurses. During these periods, the
nurse must convey empathy, maintain clear and consistent boundaries, explain all
procedures, and work with other providers to maintain consistent and firm limit
 Patient with Borderline Personality Disorder 301

setting. Intense negative emotional states challenge nurses to control their own nega-
tive reactions and form therapeutic interactions.
Establishing a therapeutic relationship entails conveying empathy and concern,
while maintaining clear boundaries. The nurse has an opportunity to recognize per-
sonal boundaries between self and patients. Nurses must define their role as a health
care provider and not a “buddy or friend.” A failure to do so increases the risk of
blurred boundaries and confusion in the patient’s expectations from the nurse and
relationship. Patients with BPD are experts at determining and “pushing” the nurse’s
“buttons.” An example of “pushing buttons” may be seen when the patient makes per-
sonal attacks about the nurse’s appearance or questioning his or her educational
preparation. It behooves the nurse to recognize these behaviors as maladaptive inter-
personal features of BPD and to refrain from responding defensively or angrily. Nurses
must focus on the issues at hand by making statements such as, “Mary, what does the
size of my hips or my educational preparation have to do with our discussion concern-
ing your behavior?” A failure to understand one’s own “buttons” increases the risk of
reinforcing negative and rejecting responses to the patient, who ironically, needs
empathy and understanding.
Another important aspect of the assessment process includes making a differential
diagnosis of medical conditions, substance use disorder, or psychiatric conditions
and performing a mental status examination. Major components of a mental status ex-
amination are listed in Box 1.
Suicidal assessment includes questions about present thoughts, plan, means,
intent, and imminence of acting on thoughts/plans; past suicide attempts; and other
self-injurious or self-harm behaviors (eg, cutting, burning). Growing evidence indicates
that individuals with BPD report a history of deliberate NSSI, particularly among ado-
lescents and adults with co-occurring depression or anxiety disorders and BPD.13
NSSI refers to a purposeful and self-inflicted destruction of body tissue without the
wish to die. Functions of NSSI behaviors vary, but most research indicates an absence
of pain during the episode and that it seems to act as a dissociative defense (ie, deper-
sonalization and perceptual distortions) or to activate the release of the brain’s pain-
reward-processing neural pathways.14,15
The above-listed data must be documented and discussed with various members
of the treatment team. When a differential diagnosis is made, thus ruling out medical,

Box 1
Major components of a mental status examination

 Chief complaint or reasons for seeking treatment

 Current and previous coping skills related to crises
 Quality of support systems, including current relationships, employment, finances
 General appearance, including the mode of arrival, cooperativeness, and eye contact
(consider cultural factors)
 Mood and affect
 Speech that includes rate, quality, and clarity
 Thought content and processes
 Sensorium and other higher brain function, including memory, judgment, reliability, and
insight into present illness (crisis) and treatment
 Level of dangerousness to self and others
302 Antai-Otong

psychiatric, and substance-use disorders, the nurse and other team members can
determine if the patient has BPD.
The essential features of a patient with BPD include the following:
 A pervasive pattern of intense chaotic or unstable interpersonal relationships
 Marked emotional distress and lability
 Intense fears of abandonment
 Low self-esteem
 Marked identity disturbances
 Hypersensitivity to object loss
 Intolerance of being alone
 Chronic dysphoria (intense sadness and other negative emotions)
 Intense anger and rage
 Chronic history of impulsivity and mood instability
 Chronic feelings of emptiness and lack of nurturing and support
 Recurrent maladaptive coping responses, including self-harm behaviors
 Transient, stress-induced delusional ideation, or intense and brief dissociative
reactions1–4
It is imperative for the nurse to recognize that BPD is an axis II disorder (personality
disorder) and to recognize the high co-occurrence of depression, anxiety disorders,
and substance use disorders (axis I). There is overwhelming evidence that links axis
I disorders with BPD because of early childhood traumas and adversities. These dis-
orders must be assessed and treated appropriately. A failure to assess axis I diagno-
ses increases the risk of suicide and other self-harm behaviors. The following
discussion describes how the patient with BPD may present in primary care settings
and emergency departments.
In primary care and other practice settings, the patient may go from one provider to
another with various somatic and psychiatric complaints, generating chaos and “staff
splitting,” which result in anger and frustration and a failure to address the patient’s
concerns appropriately.16,17 These patients are sometimes referred to as “difficult pa-
tients.” Nurses must maintain an empathetic and accepting demeanor and set firm
and consistent limits with the demanding patient. Despite the tendency to focus on so-
matic complaints, these symptoms require a thorough physical evaluation. Because of
patients’ intense dependency needs and hostility toward staff when staff fails to meet
them in a timely manner, nurses must anticipate intense rage and anger and respond
appropriately and assertively.
An assessment and diagnostic feature of BPD is suicidality and other self-harm be-
haviors. Nurses in various mental health settings need to accept these symptoms and
focus on treatment planning on dealing with underlying causes. It is imperative for the
nurse to respond emphatically rather than judgmentally, while assessing the patient’s
imminent risk of danger to self or others. When a patient attempts suicide, it is imper-
ative to avoid reinforcing this behavior, but rather to strengthen adaptive coping be-
haviors. The level of care necessary after an attempt parallels the seriousness or
lethality of the attempt. Often the patient threatens suicide or other self-harm behav-
iors, and the patient must be taken seriously and assessed and managed appropri-
ately. When caring for the patient with BPD who expresses suicidal intent, a failure
to misjudge the risk may be tragic.
Patients with BPD are likely to have a different presentation when they arrive in
emergency departments than primary care settings. During a psychiatric crisis, the
patient may be overdosed, may have cut a wrist, or may exhibit self-destructive be-
haviors or threats. Because of the high risk of self-harm, nursing staff must search
 Patient with Borderline Personality Disorder 303

carefully for sharp objects, illicit and licit medications, and other harmful items. Major
goals in the emergency department include harm-prevention, medical and psychiatric
stabilization, and addressing the patient’s emotional and psychiatric needs. Nurses
must convey concern and provide consistent and firm limit setting during a psychiatric
emergency.18 When the patient is medically cleared, psychiatric interventions can be
implemented. Additional treatment considerations during a psychiatric emergency
include verbal de-escalation, pharmacologic interventions, and other psychothera-
peutic interventions. When the patient’s emotional and psychiatric conditions are sta-
ble, the nurse and other team members must make an appropriate mental health
referral and disposition. An in-depth discussion of specific pharmacotherapy and psy-
chotherapeutic approaches follows in later discussion.
Normally the patient is involved in a treatment program with a team or primary ther-
apist. The central role of the primary therapist is to oversee safety and contract
for safety and hospitalization if necessary to stabilize acute medical and psychiatric
conditions. Contacting the therapist is helpful in validating information and ensuring
adequate follow-up. If the patient is not in treatment, consultation with a mental
health professional or center is crucial to ensure appropriate and timely follow-up.
A “no-harm” or safety contract is necessary during a crisis situation to avail
options to the patient and family in the event of recurrent suicidal thoughts and immi-
nent danger to self or others with a caveat that the merits of this intervention are ques-
tionable.19 Safety contracts, which lack empirical support for the effectiveness
concerning in the prevention of suicide, do not replace a comprehensive suicide
risk assessment because overreliance on them may jeopardize the patient’s safety
and suicide risk.19
Likewise, suicide assessment scales have little prognostic value and are unreliable
in forecasting suicide. Contracting for safety often includes the following:
 Ask the patient to give explicit agreement not harm him or herself
 Generate a safety plan with written and verbal instructions of what to do in the
event of recurrent and imminent thoughts (eg, close friend/family member, sui-
cide crisis line, 911)
 Inquire about access to firearms
 Reinforce the responsibility of safety to the patient and not the nurse to work out
with others during a crisis situation
 Collaborate with family members or friends who may help to resolve the crisis
 Make appropriate mental health referrals and schedule follow-up18
 Screen all patients for suicidal risk during initial contact and remain alert to this
issue throughout assessment process.
Thorough documentation of the decision-making process is crucial. Although hos-
pitalization may be considered, as a result of primary care guidelines, certain param-
eters have been established that support hospitalization (ie, imminent danger to self or
others, unstable psychiatric and medical conditions). A plethora of research indicates
that hospitalization is unproven to be effective in the prevention of suicide, and it has
limited indications. Specific indications for acute psychiatric hospitalization of the
patient with BPD include transient stress-induced psychosis, life-threatening suicide
attempts, and NSSI behaviors.20 Sometimes a brief hospitalization enables the inter-
disciplinary treatment team to review treatment planning and allows for medication
stabilization. Negative consequences of hospitalization include dependency and rein-
forcement of maladaptive behaviors.
An important point to remember about the patient at risk for suicide is assessing the
level of the nurse involvement. Specifically, nurses must refrain from “rescuing” or
304 Antai-Otong

“rejecting” the patient who threatens suicide and focus more on assessing the need
for involvement behind the thoughts and threats (Box 2).

PHARMACOLOGIC AND PSYCHOTHERAPEUTIC CONSIDERATIONS

Because of the complexity of BPD and continual risk of suicide, nurses must enlist a
person-centered, strength-based intervention and interdisciplinary approach to facil-
itate adaptive coping skills and optimal level of functioning. Depending on the nurse’s
educational preparation and clinical expertise, the nurse is likely to provide an array of
mental health services. Likely mental health services often comprise medication
administration or management, psychoeducation, intensive case management, and
various psychotherapies. Nurses in primary care settings and other non-mental health
settings must collaborate with mental health nurses and other mental health profes-
sionals to avoid becoming part of the “splitting” behaviors, which are common in
patients with BPD. These behaviors generate tension and interpersonal conflicts be-
tween staff and interfere with optimizing treatment modalities. Pharmacologic and
psychotherapeutic interventions are key components of treatment planning and
have proven efficacy in helping patients cope with intense emotional states, dysphoria
(intense sadness), and impulsivity or dyscontrol behaviors.
Pharmacologic Interventions
Prevailing evidence indicates that the treatment of BPD necessitates a comprehensive,
person-centered, holistic, and long treatment (ie, psychotherapy and symptom-
targeted adjunctive pharmacotherapy).21,22
Pharmacologic treatment is frequently used to treat BPD, although there are no
practice guidelines that recommend or approve of use to treat this disorder. Most
pharmacologic interventions are symptom specific.23,24 Target symptoms for pharma-
cologic interventions of patients with BPD include 3 dimensions: cognitive-perceptual
disturbances, affective lability, and impulsive-behavior dyscontrol behaviors. Growing
evidence reveals that antidepressants, mood-stabilizing anticonvulsants (ie, valproate
acid), and atypical antipsychotics (ie, quetiapine) improve core symptoms of BPD, but
they are not a cure-all.23,24 Based on prevailing evidence, pharmacologic agents are
not recommended first-line treatment for BPD and are used as an adjunctive treatment
with psychotherapeutic approaches.
Cognitive-perceptual disturbances include transient stress-induced psychosis,
paranoia, suspiciousness, distrust, dissociation, and illusions. Management of these

Box 2
How to assess for suicide risk

 Establish rapport and provide a supportive nonjudgmental environment

 Ensure safety—remove sharps and other dangerous items and secure belongings
 Keep questions simple, clear, and direct
 Use open-ended questions
 Assess for level of lethality (eg, increased risk with a highly specific plan, means, previous
attempts, previously rehearsed)
 Never leave a person at risk for suicide alone
 Do not promise the person threatening suicide that you will keep this information
confidential
 Patient with Borderline Personality Disorder 305

symptoms includes low-dose and short-term atypical antipsychotic medications,

such as olanzapine and aripiprazole.23,24 Implications for nurses include assessing
for adverse side effects, such as sedation, significant weight gain, extrapyramidal
side effects, and other movement disorders associated with antipsychotic medica-
tions. Despite the high use of these agents, studies fail to demonstrate consistent ev-
idence of their efficacy in the treatment of BPD.
Symptoms of affective instability or mood disturbances include depressed or irrita-
ble mood and loss of interest in activities that were once considered pleasurable. His-
torically, antidepressants, such as selective serotonin re-uptake inhibitors, have been
considered first-line treatment partly because they were also effective in the treatment
of co-occurring disorders, such as anxiety disorders and aggression, irritability, and
NSSI behaviors.23,24 Some researchers suggest that antidepressants cannot be
considered first-line treatment because they fail to demonstrate efficacy in managing
impulsive-dyscontrol behaviors.23,24
Impulsive-behavioral dyscontrol consists of self-harm behaviors, such as parasui-
cides, aggressiveness, substance use, and NSSI (eg, self-cutting, self-burning). In
addition to antidepressants, other medications with proven efficacy include anticon-
vulsant agents, lithium, and anxiolytic medications.20–23

Social Cognitive Disturbances

Researchers submit that individuals with BPD have social cognitive disturbances
related to dysregulation of mentalization and that this concept contributes to the
core symptoms of BPD (eg, emotional dysregulation, NSSI).25–27 Purportedly, patients
with BPD have impaired mentalization that stems from a failure to form early childhood
attachments or healthy relationships with primary caregivers and neurologic and psy-
chological development.25–27 Healthy relationships with primary caregivers are critical
in the development of these important processes that underlie mentalization, positive
self-esteem and self-image, modulation of stress and impulse control, and healthy re-
lationships across the lifespan. Mentalization is an ability to accurately appraise one’s
emotional states and subsequent psychological and behavioral responses and those
in others. It also helps individuals to discern how their own behavior affects
others.25–27 Growing evidence indicates that insecure attachments increase the risk
of BPD and other psychiatric conditions. This premise has indications for psychother-
apeutic interventions.
Symptom management is multifaceted and is determined by the patient’s present
symptoms, wishes, preferences, and individual needs. Poorer clinical outcomes are
associated with the quality of early childhood primary caregiver (eg, infant-mother) at-
tachments, coexisting substance-use disorder, and severity of early childhood adver-
sities.2,3,5 Bowlby’s attachment theory28 is based on the quality of relationships with
early childhood caregivers and healthy development. These relationships provide
the basis of lifelong interpersonal and intrapersonal interactions. Most studies indicate
a person-centered approach that integrates pharmacologic and psychotherapeutic
interventions is the most effective. This plan of care must identify clearly the primary
psychotherapist, identify a plan to respond to crisis, and monitor the patient’s safety
and coordination of treatment planning by an interdisciplinary team.22,29

Psychotherapeutic Interventions
Psychotherapeutic interventions are considered the primary approach for treating
patients with BPD. The decision to use specific psychotherapeutic interventions de-
pends on the patient’s clinical presentation and preferences. Poor treatment candi-
dates are patients who exhibit severe antisocial behaviors and coexisting substance
306 Antai-Otong

use disorders. Additional prognostic factors include adherence to treatment and

reducing high-risk behaviors, such as high intelligence, a lack of early childhood
abuse, and a lack of co-occurring substance use disorders.29–31
Studies reveal growing promise in the treatment of BPD using cognitive and behav-
ioral interventions.25,27,29–31 Dialectical behavior is a cognitive behavioral model that
entails active and structured work to analyze and modify target behaviors through
cognitive restructuring, skills training, exposure techniques, and a contingency plan.
The premise behind this treatment modality is that persons with BPD lack the capacity
to modulate emotions or feelings. An inability to regulate emotions is reinforced by a
continuous transaction between the patient’s emotional vulnerabilities and external
world of invalidation. This approach involves 3 concurrent modes of treatment: weekly
individual sessions, a weekly group specifically for skills training, and telephone con-
tacts by the primary nurse psychotherapist on an as-needed basis.29
Psychodynamic psychotherapy also is being used to treat BPD. Compared with
dialectical behavior therapy, this approach enables the nurse psychotherapist to
explore patterns of feelings and underlying behaviors. This treatment modality also in-
volves individual psychotherapy and group therapy that focuses on skills training.
Mentalizing-based treatment has been introduced in the treatment of BPD.25–27 This
approach helps the patient make sense of his or her own and others’ personal
emotional affect regulation and self-identity with the goal of improving interpersonal
relationships and social functioning.

SUMMARY

BPD is a serious and cost-consuming psychiatric disorder. The high prevalence of pa-
tients with BPD and co-occurring depression, eating disorders, and substance-use
disorders in primary care and mental health settings contributes to their high use of
resources in these practice settings. Recurrent suicidal behaviors and threats and
NSSI behaviors increase demands on nurses and other health care providers. Regard-
less of treatment challenges associated with BPD, researchers suggest a more posi-
tive outlook in the treatment of this complex psychiatric condition. Nurses must be
able to interact with individuals with BPD by using an empathetic and unbiased
approach while maintaining healthy boundaries. This article has focused on areas in
which nurses can understand major underpinnings of BPD; assess their client’s imme-
diate needs; and initiate evidence-based strategies to resolve distressful emotional
states and self-injurious behaviors.

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