Borderline Personality Disorder

1. The genuine text (quoted)

The patient with borderline personality disorder

“Because of a lack of previous successful continuity relationships, the patient with borderline personality disorder is usually poorly prepared to understand the nature of the social contact on which good primary medical care is predicated.” After even a cursory look at the diagnostic criteria for borderline personality disorder (BPD), many PAs are convinced

they have already encountered a patient, relative, or friend with the pattern of impulsivity and instability in interpersonal relationships, self-image, and affect that is the hallmark of this

condition. Perhaps they had not realized that the person in question had a personality disorder

with well-defined symptomatology. Maybe they simply thought of the person as “unstable” or of the relationship as “challenging.” BPD as a diagnosable condition is fairly new.

Only in 1980 did the Diagnostic and Statistical Manual of Mental Disorders (DSM), the authoritative guide to psychiatric conditions, adopt a final set of diagnostic criteria for BPD, after decades of studies attempted to define and refine the psychiatric community’s consensus. Given how recently this occurred, nonpsychiatric clinicians may still be uncertain of the identifying characteristics of BPD. Identification is the key to working successfully with patients with BPD, however, and once the clinician is aware of the diagnosis, strategies are available to improve the relationship with the patient.

Patients with BPD present to primary care for a variety of nonpsychiatric concerns and experience the full spectrum of physical ailments seen in the general population. However,

these patients present challenges beyond those of diagnosing and treating their physical conditions. They “often consume a disproportionate amount of the [clinician’s] time, they can

be extremely demanding, and they tend to experience complicated or incomplete recovery from illness, either organic or functional”.

This article provides a discussion of strategies that may be employed to enhance the therapeutic alliance with patients with BPD in a primary care setting. It is intended to complement a January 2000 JAAPA article that discussed the diagnosis of BPD in primary care settings. The assumption here is that the diagnosis has already been made and that the clinician now needs help in working with the patient.

STRATEGY 1: Structure, structure, structure

Consider providing the patient with a written treatment contract that outlines expectations and policies and that may clarify the responsibilities of both parties. Addressable issues might include the length of office visits, the number of visits allowed per given time period, patient options in the event of an emergency or after-hours crisis, and the consequences of noncompliance with the contract. Patient compliance may actually be secondary to the awareness that the medical provider is comfortable setting limits. This can send an important message to patients with BPD regarding stability and continuity, which has likely been lacking in their previous interpersonal experiences.

Studies suggest that patients with BPD are not offended by such boundary setting. In contrast, most are keenly aware of the excessive demands they may place on a provider and

may be surprisingly respectful of the clinician’s needs. “Selfinterest on the part of the [provider] can actually be reassuring to a borderline patient whose previous caretakers have fallen under the weight of the patient’s dependency needs.” With regard to office visits, the clinician should not hesitate to actively structure the interview. The diffuse thought processes of the BPD patient may be confusing and interfere with the clinician’s ability to efficiently conduct an interview.

Consequently, “the greater the organization around the interview, the greater the level of security experienced by the BPD patient. This security should, in turn, diminish some of the clinician’s anxiety regarding the patient’s unpredictable volatility.”

Other examples of borderline behavior requiring boundary setting might include repeated crisis or emergency appearances in the office without an appointment; repeated phone calls to the office or the provider’s home; and requests for inappropriate house calls or other special favors. These may be ways that a borderline patient “tests” the availability and patience of a clinician. The clinician should verbally describe this pattern to the patient and help the patient realize that such behaviors may relate to an underlying fear of abandonment or may be attempts to increase the intensity of the relationship by forcing the provider to demonstrate a commitment to the relationship.

Finally, it is not uncommon for borderline patients to bring a long list of issues that they feel need addressing. The clinician may find it helpful in this instance, as when patients bring up new issues and complaints at the tail end of a visit, to request that the patient return for another visit to extend the discussion. Scheduling patients for brief, frequent appointments and giving them a verbal outline of the territory to be covered in future visits can be extremely effective. The provider might ask the patient to pick, or prioritize, the top three issues. Reassurance can then be provided that additional concerns can be addressed over a series of subsequent visits.

STRATEGY 2: Remain calm to diffuse hostility

Patients with BPD may become angry or act out, often in response to seemingly small triggers. It is critical that the clinician acknowledge the anger and then request that borderline patients limit its expression. Providers should remain calm and avoid matching the patient’s escalating mood with their own; “paradoxically, expression of anger by the [clinician] reinforces and intensifies these patients’ engagement in the relationship.” The clinician should attempt to be as neutral and calm as possible, reminding the patient that the anger response is a “style of behavior” that is chosen and that it can be changed.

“The response to the patient’s emotional outbursts should include a recognition of the patient’s feelings with a clear request for appropriate behavior (‘I can see you are angry. I can talk with you if you will lower your voice’). If the patient does not respond, the [practitioner] should terminate the conversation with the message that it will be resumed later when the patient obtains some control.” When a patient appears angry with the provider, the provider might ask the patient what it is that he or she is doing to bother the patient. The answer to the question will often give insight into the patient’s thinking and “enhance the patient’s sense of control.”

STRATEGY 3: Beware of splitting

Splitting—the inability to integrate good and bad images of other people, or the oscillation between narcissistic entitlement and extreme self-criticism—is common in those with BPD. A patient may regale the clinician as the best practitioner ever while elucidating the perceived shortcomings of a previous provider. Or the patient may insist that a coworker was excessively rude or inappropriate in their treatment of the patient, as borderline patients are likely to “present themselves to a member of the health care team as abused and neglected by other members, apparently in the hope of getting extra attention from the provider to whom they are talking.”

Perhaps the patient expresses self-contempt in the face of what appear to be minor mistakes or setbacks, for BPD patients may split the perception of themselves. Splitting may help borderline patients test the waters, so to speak, within treatment teams by becoming aware of various team members’ frustrations and support. Splitting is often unconscious—the result, experts believe, of the preservation of primitive defense mechanisms. Practitioners must realize that reacting to a borderline patient’s splits may reinforce some behaviors. “When clinicians are aware that validating borderline patients’ projections of badness (ie, agreeing with their devalued view of another treater) can lead to splits, this awareness can lead members of teams to bond together by invalidating the borderline’s attributions (ie, being protective about the other treater’s goodness). Such responses negate the partial reality of the borderline patient’s perceptions. Moreover, the idea that, to prevent splits, staff members need to protect each other against negativity confers too much power on the patients’ hostility. This too is harmful.”

Practically speaking, if the patient routinely takes issue with some member of the health care team, providing continuity may help. Consider limiting the number of staff interacting with the patient; have the patient see one receptionist, one medical assistant, one nurse, and one practitioner, if possible. Take the time to alert members of the team as to salient features

of BPD and what to expect from such patients, including the tendency to split. If all else fails, consider consulting with a psychiatric specialist for help. Understand and expect that splitting may be an integral part of BPD—learn to acknowledge it without succumbing to patients’ idealization or devaluation of you or themselves.