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Borderline personality disorder

Definition
Borderline personality disorder is a mental health disorder characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image.
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Pathophysiology
The pathogenesis of borderline personality disorder is complex and not fully understood. It is believed to involve interactions among genetic, neurobiological, and environmental factors. Genetic factors and adverse life events, such as physical and sexual abuse during childhood, are thought to contribute to the development of the disorder.
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Epidemiology
The lifetime prevalence of borderline personality disorder in the US is estimated at 5.9%.
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Disease course
Clinically, borderline personality disorder is marked by emotional dysregulation, impulsive aggression, repeated self-injury, and chronic suicidal tendencies. Other key manifestations include intense mood swings, fear of abandonment, unstable relationships, and a distorted self-image.
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Prognosis and risk of recurrence
The prognosis of borderline personality disorder is variable. While the disorder is traditionally considered chronic and intractable, up to 85% of patients remit over a 10-year period.
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Key sources
The following summarized guidelines for the evaluation and management of borderline personality disorder are prepared by our editorial team based on guidelines from the National Health and Medical Research Council of Australia (NHMRC 2019).
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Guidelines

1.Screening and diagnosis

Identification and diagnostic assessment, adults: consider assessment for borderline personality disorder or referral for psychiatric assessment in patients with any of the following:
frequent suicidal or self-harming behavior
marked emotional instability
multiple co-occurring psychiatric conditions
nonresponse to established treatments for current psychiatric symptoms
a high level of functional impairment
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  • Identification and diagnostic assessment (children and adolescents)

2.Medical management

Setting of care
Use community-based mental health services (public and private) for the majority of a patient's treatment for borderline personality disorder.
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Offer treatment for borderline personality disorder through a range of services, as appropriate to the individual's current clinical presentation, course of illness, needs and (if applicable) preferences.
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  • Multimodal therapy

  • Pharmacotherapy

  • Management of co-occurring health conditions

3.Inpatient care

Indications for inpatient admission: consider acute inpatient admission to provide structured crisis intervention for the treatment of patients who are suicidal or have significant co-occurring mental health conditions.
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  • Family, partner, and carer needs

4.Nonpharmacologic interventions

Structured psychological therapy: provide structured psychological therapies that are specifically designed for borderline personality disorder to patients with borderline personality disorder, conducted by one or more adequately trained and supervised health professionals.
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  • Dialectical behavior therapy

5.Specific circumstances

Adolescent patients: offer time-limited structured psychological therapies that are specifically designed for borderline personality disorder to patients 14-18 years old with borderline personality disorder or with clinically significant features of borderline personality disorder.
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6.Follow-up and surveillance

Referral for specialized service: consider referring patients with severe and/or enduring borderline personality disorder to a suitable specialized borderline personality disorder service (where available) for assessment and ongoing care, if appropriate.
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  • Supporting family, partners, and caregivers

  • Caring for families, partners, and caregivers

7.Quality improvement

Health professionals' roles: health professionals at all levels of the healthcare system and within each type of service setting should:
acknowledge that borderline personality disorder treatment is a legitimate use of healthcare services
be able to recognize borderline personality disorder presentations
be aware of general principles of care for patients with borderline personality disorder and specific effective borderline personality disorder treatments
provide appropriate care (including non-specific mental health management, specific treatments for borderline personality disorder and treatment for co-occurring mental illness) according to their level of training and skill
refer the patient to a specialized borderline personality disorder service or other services as indicated
undertake continuing professional development to maintain and enhance their skills
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  • Coordinating care

  • Supporting healthcare professionals