Diagnosing borderline personality disorder : examination of how clinical indicators are used by professionals in the health setting

This paper reviews the history of the recognition of borderline personality disorder as a clinical disorder, followed by a review of the contemporary practice of diagnosing borderline personality disorder in psychiatric settings. Many researchers have cautioned against the conflation of difficult patients with the diagnostic category of borderline personality disorder. The current study examines how clinical indicators used to screen for this complex disorder differ across service settings, professions, specialised training and years of clinical experience. A purpose-designed survey was administered to 108 mental and emergency medicine health practitioners across an Australian health service and a New Zealand health service to record the level of significance placed on different clinical indicators in the application of the diagnosis of borderline personality disorder. A heavy reliance was placed on observable behavioural symptoms, such as self-mutilation and impulsive behaviours that are self-damaging, in the screening of borderline personality disorder as a psychiatric diagnosis. Statistically significant differences were found between emergency medical staff and mental health clinicians in their use of diagnostic indicators of borderline personality disorder, χ²(4) = 17.248, p = .002. Implications of these findings for the screening, assessment and diagnosis of patients with borderline personality disorder are discussed.

Borderline personality disorder - an overview for emergency clinicians

The diagnosis of borderline personality disorder frequently underlies self-harm and suicidal presentations to the emergency department. Borderline pathology combined with high levels of comorbidity, stigma, and treatment uncertainty, increase the challenges of caring for someone with this diagnosis in an emergency setting. Attributes such as black-and-white thinking and splitting may compromise an already precarious situation. The maintenance of safety requires prioritisation and necessitates a practical and respectful approach, which avoids notions of attention-seeking behaviour. Clinical assessment should distinguish between self-harm and suicide attempts where possible and take into account acute on chronic risk. The emergency clinician will need to consider the degree of containment required in the emergency department and is encouraged to maintain transparency and honesty with the client regarding treatment decisions. If hospitalisation needs to be considered, clinicians should take into account immediate therapeutic benefit versus the counter-therapeutic risk of dependency and regression. Overall, it is reasonable for clinicians to aim for clients to return to their pre-crisis level of functioning, and beneficial for clinicians to approach this client group with therapeutic optimism.

Family interactions and the development of borderline personality symptoms

This thesis investigated the emergence of borderline personality disorder in adolescence. It found that adolescent sensitivity to, and maternal socialization of, aggressive behaviour is associated with borderline pathology. Change in pathology over time was related to adolescent dysphoric behaviour and sensitivity to inconsistent displays of maternal negative emotion.

Working around a contested diagnosis : borderline personality disorder in adolescence

This discourse analytic study sits at the intersection of everyday communications with young people in mental health settings and the enduring sociological critique of diagnoses in psychiatry. The diagnosis of borderline personality disorder (BPD) is both contested and stigmatized, in mental health and general health settings. Its legitimacy is further contested within the specialist adolescent mental health setting. In this setting, clinicians face a quandary regarding the application of adult diagnostic criteria to an adolescent population, aged less than 18 years. This article presents an analysis of interviews undertaken with Child and Adolescent Mental Health Services (CAMHS) clinicians in two publicly funded Australian services, about their use of the BPD diagnosis. In contrast with notions of primacy of diagnosis or of transparency in communications, doctors, nurses and allied health clinicians resisted and subverted a diagnosis of BPD in their work with adolescents. We delineate specific social and discursive strategies that clinicians displayed and reflected on, including: team rules which discouraged diagnostic disclosure; the lexical strategy of hedging when using the diagnosis; the prohibition and utility of informal ‘borderline talk’ among clinicians; and reframing the diagnosis with young people. For clinicians, these strategies legitimated their scepticism and enabled them to work with diagnostic uncertainty, in a population identified as vulnerable. For adolescent identities, these strategies served to forestall a BPD trajectory, allowing room for troubled adolescents to move and grow. These findings illuminate how the contest surrounding this diagnosis in principle is expressed in everyday clinical practice.

Managing borderline personality disorder and substance use : an integrated approach

Background : Although substance use is a common feature of borderline personality disorder, regular use is associated with greater levels of psychosocial impairment, psychopathology, self harm and suicidal behaviour and leads to poorer treatment outcomes. Management of co-occurring substance use disorder and borderline personality disorder within primary care is further compounded by negative attitudes and practices in responding to people with these conditions, which can lead to a fractured patient-doctor relationship.

Objective : This article provides an overview of how the general practitioner can provide effective support for patients with co-occurring borderline personality disorder and substance use disorder, including approaches to assessment and treatment, the therapeutic relationship, referral pathways and managing risk and chronic suicidality.

Discussion : Despite the complexities associated with this population, GPs are ideally placed to engage patients with co-occurring borderline personality disorder and substance use disorder in a long term therapeutic relationship, while also ensuring timely referral to other key services and health professionals. To provide the most effective responses to this patient group, GPs need to understand borderline personality disorder and its relationship to substance use, develop an ‘explanatory framework’ for challenging behaviours, implement mechanisms for reflective practice to manage negative countertransference, as well as learn skills to respond adequately to behaviours which jeopardise treatment retention.

Emotional invalidation and borderline personality disorder: a test of theory

Borderline Personality Disorder is a severe and debilitating mental health condition. The research conducted for this thesis demonstrated how invalidation in past and current meaningful relationships is associated with symptoms of the disorder in adulthood, and thereby advances our understanding of the disorder’s aetiology and targets for treatment.

Can neuroimaging be used as a support to diagnosis of borderline personality disorder? An approach based on computational neuroanatomy and machine learning

Several recent studies in literature have identified brain morphological alterations associated to Borderline Personality Disorder (BPD) patients. These findings are reported by studies based on voxel-based-morphometry analysis of structural MRI data, comparing mean gray-matter concentration between groups of BPD patients and healthy controls. On the other hand, mean differences between groups are not informative about the discriminative value of neuroimaging data to predict the group of individual subjects. In this paper, we go beyond mean differences analyses, and explore to what extent individual BPD patients can be differentiated from controls (25 subjects in each group), using a combination of automated-morphometric tools for regional cortical thickness/volumetric estimation and Support Vector Machine classifier. The approach included a feature selection step in order to identify the regions containing most discriminative information. The accuracy of this classifier was evaluated using the leave-one-subject-out procedure. The brain regions indicated as containing relevant information to discriminate groups were the orbitofrontal, rostral anterior cingulate, posterior cingulate, middle temporal cortices, among others. These areas, which are distinctively involved in emotional and affect regulation of BPD patients, were the most informative regions to achieve both sensitivity and specificity values of 80% in SVM classification. The findings suggest that this new methodology can add clinical and potential diagnostic value to neuroimaging of psychiatric disorders. (C) 2012 Elsevier Ltd. All rights reserved.

Endoscopy for repeatedly ingested sharp foreign bodies in patients with borderline personality disorder: an international survey

The general guidelines on the management of ingested foreign bodies (FBs) do not address specific aspects raised by psychiatric patients, particularly in patients with borderline personality disorders (BPD) who repeatedly ingest FBs. The aim of this survey was to collect data on experience and opinions on the management of FBs in psychiatric patients with BPD and to review the relevant literature.

Neural correlates of antinociception in borderline personality disorder

CONTEXT: A characteristic feature of borderline personality disorder (BPD) is self-injurious behavior in conjunction with stress-induced reduction of pain perception. Reduced pain sensitivity has been experimentally confirmed in patients with BPD, but the neural correlates of antinociceptive mechanisms in BPD are unknown. We predicted that heat stimuli in patients with BPD would activate brain areas concerned with cognitive and emotional evaluation of pain. OBJECTIVE: To assess the psychophysical properties and neural correlates of altered pain processing in patients with BPD. DESIGN: Case-control study. SETTING: A university hospital. PARTICIPANTS: Twelve women with BPD and self-injurious behavior and 12 age-matched control subjects. INTERVENTIONS: Psychophysical assessment and blood oxygen level-dependent functional magnetic resonance imaging during heat stimulation with fixed-temperature heat stimuli and individual-temperature stimuli adjusted for equal subjective pain in all the participants. MAIN OUTCOME MEASURE: Blood oxygen level-dependent functional magnetic resonance imaging signal changes during heat pain stimulation. RESULTS: Patients with BPD had higher pain thresholds and smaller overall volumes of activity than controls in response to identical heat stimuli. When the stimulus temperature was individually adjusted for equal subjective pain level, overall volumes of activity were similar, although regional patterns differed significantly. Patient response was greater in the dorsolateral prefrontal cortex and smaller in the posterior parietal cortex. Pain also produced neural deactivation in the perigenual anterior cingulate gyrus and the amygdala in patients with BPD. CONCLUSION: The interaction between increased pain-induced response in the dorsolateral prefrontal cortex and deactivation in the anterior cingulate and the amygdala is associated with an antinociceptive mechanism in patients with BPD.