Adult nurse practitioners (NPs) encounter patients with a wide range of challenging behaviors. Some of these behaviors can be especially hard to manage and may even preclude successful treatment. One group of such behaviors occurs in persons with borderline personality disorder (BPD), marked by behavioral and emotional traits that can disrupt treatment.

BPD is one of the most common personality disorders seen in clinical practice. It occurs in an estimated 2% of the general population, 10% of psychiatric outpatients, and 30% to 60% of persons with all types of personality disorders.

Patients with BPD have a significant deficit in problem-solving skills and have trouble developing strategies to manage difficult situations effectively. Generally, they are able to function in society but their interpersonal interactions are maladaptive, disturbing, and possibly destructive to themselves and others.

Evidence suggests BPD stems from multiple biopsychosociological influences resulting in maladaptive and disruptive behaviors. This article reviews current research on the etiology of BPD, discusses how to identify the disorder, and provides information to help generalist NPs meet the needs of patients who present to primary-care providers with BPD.

The difficult case of Eva

Eva, age 32, has been a patient in a general NP practice for the past year. She has a history of depression, anxiety, and stormy relationships, and says her stepfather sexually abused her between ages 8 and 10. She described her mother (now deceased) as unpredictable, angry, and critical of her; however, Eva reported a close adult relationship with her. Eva has made two suicide attempts during the past 5 years, the first occurring shortly after her mother’s death.

Today, Eva presents with depression, fatigue, and musculoskeletal discomfort. She reports recent interpersonal conflicts with supervisors and feels out of place with her coworkers. She consistently calls the clinic for appointments every 2 to 3 months, complaining of vague symptoms; yet her diagnostic results have been unremarkable. During her initial visit with the NP, Eva reported a history of depression, anxiety, and prescription drug addiction, along with a social history of having many sexual partners over the past several years.

During her appointments, Eva asks many questions and expects the NP to take an inordinate amount of time with her. She seems to function in a black-and-white zone—one of extreme thinking and opinions with little grey area for compromise. Although she requests treatment, she has difficulty adhering to treatment recommendations and becomes easily angered when she perceives a lack of support.

Eva’s adult NP has no specific expertise in dealing with these psychological issues, but is aware that Eva is experiencing emotional distress and wants to support her in the most effective manner. At the same time, she is frustrated and confused about her apparent failure to meet Eva’s physical health needs (vague symptoms in more than one body system) and psychological needs. She is considering referring Eva to a mental health practitioner but is sensitive to her possible reaction to this suggestion. Given Eva’s history of disruptive relationships and a core fear of abandonment, she may see the well-intentioned referral as a personal rejection and thus experience the strong emotions common in persons with BPD.

The practitioner’s challenge

So what is going on? Eva is exhibiting the challenging behaviors typical of BPD, as described by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Patients with BPD can be challenging to work with; like Eva’s generalist NP, practitioners may experience frustration and anxiety when dealing with them. Nonetheless, they have a responsibility to prepare themselves to interact with all patients in a productive and therapeutic manner. Doing this requires a basic understanding of the needs and dynamics of patients with BPD, as well as the self-awareness to avoid externalizing their frustrations with the patient.

Various symptoms and characteristics have been attributed to BPD. However, this article focuses on the DSM-IV-TR criteria for the disorder, with the goal of helping readers understand the personality dynamics that challenge those providing care to BPD patients.

Research on BPD

Current research on BPD focuses on its biosociopsychological underpinnings and related treatment. The literature includes research on serotonin and other neurotransmitters, electroencephalographic abnormalities, positron emission tomography studies showing hypometabolic brain activities, and anatomic structural differences seen in magnetic resonance imaging studies. For instance, researchers have found significant volume reduction in the left hemispheric hippocampus area and the amygdala of BPD patients. Because these anatomic structures are involved with emotional memory and long-term memory, it is thought that childhood sexual or physical trauma may affect the neurotransmitters implicated in depression and impulsivity. Research also suggests early abuse can impair developing brain structures in a way that makes one more vulnerable to stress reactions, impulsivity, flashbacks, and anxiety. These findings have implications for both a psychotherapeutic and pharmacologic role in BPD management and treatment.

Personality disorders are developmental in nature. Patients with BPD commonly have a history of trauma between middle childhood and early adolescence, which may include sexual, physical, or emotional abuse and/or perceived rejection from a parent or other caregiver. This childhood trauma can influence personality development, making the person more susceptible to misunderstanding and misinterpreting their experiences and environment. Typically, these deficits occur across all aspects of the person’s life.

People with BPD are vulnerable to deep feelings of depression and loneliness. They tend to be impulsive and unpredictable in their emotional expression and inconsistent in modulating both positive and negative emotions. Their deep feelings of abandonment, loneliness, and emptiness plague them on a daily basis and serve as a foundation for maladaptive behaviors.

Common presentation

Patients with BPD may present with multiple vague physical ailments and commonly use these symptoms to express their emotional or psychic pain. They report symptoms related to substance abuse, self-mutilation, suicide attempts, promiscuity, and eating disorders. To promote successful care, practitioners need to understand these behaviors and how to better maintain a supportive and productive relationship with patients like Eva.

The table below, which is based on the DSM-IV-TR criteria, is meant to give generalist NPs a concise understanding how BPD presents. (For more complete diagnostic criteria, consult the DSM-IV-TR.)

Among the biggest challenges for the generalist NP is determining the appropriate way to handle the BPD patient who reports self-mutilating behavior or suicidal behavior or ideation. Although these behaviors are troublesome, they do not necessarily reflect an intent to commit suicide. Generally, self-mutilators do not seek death; instead, they seek stimulation, manipulation, or self-punishment or are intrigued with the idea of bleeding. They may hurt themselves as a way of dealing with feelings of emotional detachment, emptiness, or depersonalization. Some report feeling better after self-mutilating. Usually, they do not cause serious damage to a vessel and do not require medical attention.

Assessing suicide risk

Generalist NPs must be able to distinguish self-mutilating behavior from suicidal behavior—a challenge given that the behavioral and emotional characteristics of BPD include impulsivity, suicidal gestures, and emotional instability. Several studies and National Institute of Mental Health reports have found that 70% of older adults visit their primary care provider 1 month before a suicide attempt. This finding, together with BPD traits, merit a review of suicidal risk assessment in patients with BPD.

As generalist NPs are not expected to be a psychiatric specialists, and may benefit from access to a standard interview assessment tool to evaluate suicide risk. Several instruments are available, including the “SAD PERSONS” scale (the title is a mnemonic device), which measures 10 risk areas and is used in several medical settings.

Because previous suicide attempts are a major risk factor for subsequent attempts, begin with a patient history. When assessing emotional content, keep in mind that the literature reports a correlation between self-reported feelings of hopelessness and helplessness and a higher probability of suicide attempts. Generally, these two emotions are reported by any severely depressed or suicidal patient. Also, recent loss of a loved one is a prominent risk factor for a suicide attempt; in fact, separation and loss are the most powerful experiences leading to an altered state of functioning, alcohol and drug abuse, loss of contact with reality, and suicidal behavior in persons with BPD.

Assessing for suicide plan and opportunity

The more detailed and involved the suicide plan, the greater the probability that the patient has given considerable thought to committing suicide. Determine if the patient has access to a means of suicide, such as drugs, weapons, or a vehicle. Encourage the patient to openly discuss suicidal or self-harming thoughts by asking open-ended questions, such as: “Can you tell me about your thoughts of hurting yourself?” or “How are you handling what’s going on in your life?” This approach promotes communication and conveys the critical message that suicide is not a taboo topic of discussion.

After asking these general questions, you can move on to close-ended questions that require “perhaps,” “yes,” or “no” answers or call for specific information. Examples of the latter might include: “Did you take any of the pills?” or “Who came with you? Whom can we call?” The last question can elicit practical and logistical information that will expedite immediate referral to a mental health practitioner or emergency department if needed.

Ways to enhance patient interactions

The following recommendations can enhance productive interactions with patients who have BPD.

• Collaborate with mental health staff. Patients may require psychotropic medications and psychotherapy. When you collaborate with mental health staff, you become part of the holistic approach to treatment and gain the resources you need to interact with patients more effectively.
• Show interest and concern. This sends the message that you’re focused on the patient and willing to offer your expertise to help. Regardless of the behavior and challenges posed by the patient’s behavior, be sure to convey warmth while remaining neutral.
• Set the frame. Patients with BPD typically require boundaries to help them view the environment as more consistent and predictable. You can set the frame by starting and ending appointments on time and establishing clear, realistic treatment expectations.
• Provide clear, nontechnical answers. Patients with BPD may have distorted communication patterns, so take care to communicate clearly, concisely, and without jargon that could further distant the patient. Stay nonjudgmental and encourage the patient to express concerns and questions.
• Make sure a staff member is present to serve as a witness during a physical examination. Because many BPD patients are victims of child abuse, their fantasy boundaries may be extremely blurred. Therefore, a physical examination or any other activity that the patient may interpret as intrusive could lead to sexual or abusive fantasies.

Researchers continue to seek a greater understanding of BPD and explore the most effective approach to treatment. To date, the most effective treatment is dialectical behavior therapy (DBT), developed by Marsha Linehan, PhD, ABPP. This cognitive-behavioral approach focuses on reality testing and emotional control and uses individual, group, and telecommunications therapies.

Remember—as a generalist NP, you are not expected to treat BPD. However, due to the prevalence of BPD in general-practice patients, you can expect to encounter patients with this disorder. Use the information in this article to help you identify BPD characteristics and prepare you for the communication and treatment challenges these patients may pose.

Gregory J. Coram is graduate studies director at Monmouth University in West Long Branch, New Jersey. He also practices as a board-certified psychiatric NP at Ocean Bio-Behavioral Health in Toms River, New Jersey. Christine Schruntek is a board-certified clinical nurse specialist in child-adolescent and adult psychiatric and mental health. She practices at Preferred Behavioral Health in Lakewood, New Jersey.

Selected references

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