Borderline Personality Disorder

According to the DSM-IV, borderline personality is characterized by problems in relationships, self-image, affects and impulsivity. The most significant area of impairment is related to problems in capacity for attachment and very maladaptive behaviors related to separation. When in a relatively stable and safe relationship, the depressive features are evident. When a disruption occurs in their sense of safety and nurturance, these individuals often decompensate and may experience psychotic like symptoms, such as hallucinations or depersonalization. Rage and sometimes-violent behavior may result. At theses times, the underlying depression may be replaced with impulsive acting out (substance abuse, sexual promiscuity, or suicidal gestures). Further, a person who was once an idealized, nurturing figure may become a hated persecutor in their mind. This polar shift in perception is called splitting.

Originally, the term borderline developed out of early clinical work in  an attempt to classify a condition that was not either “neurotic” or  “psychotic”, but somewhere in between. Early on, it was seen how a person who appeared quite stable and normal could become so disorganized and fragmented. Often people with this disorder do well in work settings but have significant trouble interpersonally, especially under stress. Close, intimate relationships are often difficult to tolerate for any length of time.


Theoretical orientations for treatment include psychodynamic, behavioral and cognitive behavioral. Dialectical Behavior Therapy, or DBT, is a relatively new treatment that appears to have some good research findings. DBT often includes both group and individual therapy. DBT is similar to Cognitive behavioral therapy and focuses on techniques of support, education, contingency management, and construction of alternative. Patients are asked to diminish self-destructive behaviors and to change “bad habits”.

A referral to a physician will be necessary to obtain a medication evaluation. While no medication has been shown helpful in all cases, some psychotropic medications are helpful in reducing impulsivity, affective lability, and cognitive or perceptual disturbances. Finally, discuss the treatment suggestions to the patient. Make sure you are supportive and find out what type of support the patient has and elicit community resources.