Kara R. Wong, PharmD, BCPP
Senior Editor, Recertification Editorial Board
Borderline personality disorder (BPD) is an extremely heterogeneous disorder characterized by a pervasive pattern of unstable relationships, avoidance of abandonment, identity disturbance, impulsivity, recurrent suicidal behavior, affective instability, intense anger and stress-related paranoia. BPD impacts between two to six percent of the population and is commonly encountered in practice. Unfortunately, BPD is a highly stigmatized diagnosis and is significantly underrepresented in discussions about mental illness. In the opening session of CPNP’s 2019 Annual Meeting, Dr. Katharine "Kaz" Nelson shared her expertise in providing evidence-based care to those with BPD.
Dr. Nelson acknowledged that BPD has a reputation of being “untreatable.” However, she emphasized that BPD can improve over time with appropriate treatment. A comprehensive treatment plan for BPD should include non-pharmacologic interventions. There is no FDA approved medication for the treatment of BPD and medication is not an essential component of treatment. However, some medications have been shown to target specific symptom domains of BPD, and may be considered after the patient has been thoroughly educated about the risks and benefits, including off-label use. Co-morbid mental health disorders may dictate medication selection and meta-analyses provide guidance in medication selection based on BPD symptom domains.
The symptoms of BPD make it challenging for patients to feel heard by their providers. Certain communication strategies can assist with building a therapeutic relationship. Dr. Nelson stressed the importance of never minimizing a patient’s symptoms; it is essential to frequently repeat what is legitimate to the patient (i.e. pain, suffering, disappointment). Another strategy is to replace “but” with “and.” For example, “This medication feels helpful in the short term and makes things worse over time.” Lastly, frequent and regular appointments can assist with earning a patient’s trust.
Following Dr. Nelson’s session many members approached her for additional resources. She recommended the following tools to support further learning and clinical practice:
Take Home Points