Borderline Personality Disorder (BPD) Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia
BPD is a major driver of psychiatric admissions, repeated self-harm presentations to ED, and high utilisation of healthcare resources. You need to know this because these patients are at a very high, non-negligible risk of suicide (~10% completed suicide rate) and you will be the first-line assessor managing that acute risk at 3 AM.
High-Yield Definition
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts. (DSM-5)
Clinical One-Liner
"Pervasive instability in relationships, self-image, and emotions, with marked impulsivity and a chronic fear of abandonment."
II. Etiology & Risk Factors
Etiology
It's understood through a biopsychosocial model. There is a strong link between:
Genetic/Biological: Inherited predisposition to emotional dysregulation (e.g., limbic system hyperactivity).
Environmental: Overwhelmingly associated with early adverse experiences (e.g., childhood physical or sexual abuse, neglect, early parental loss, or growing up in an 'invalidating' environment where their emotional experiences were consistently dismissed or punished).
Risk Factors
History of childhood trauma (abuse, neglect).
First-degree relative with BPD.
Insecure attachment patterns.
Co-morbid substance use or other psychiatric disorders.
III. Quick Pathophysiology
A simple way to think about it:
Amygdala (Emotion Centre) Hyperactivity: Reacts too fast, too strongly. This drives the intense, labile emotions.
Prefrontal Cortex (Control Centre) Hypoactivity: Fails to "put the brakes" on the amygdala. This leads to poor emotional regulation and high impulsivity.
This imbalance explains the core feature: intense emotional sensitivity plus an inability to regulate that emotion, leading to impulsive, often self-destructive, coping behaviours.
IV. Classification
We use the DSM-5 criteria (Cluster B). It's a polythetic diagnosis, meaning you only need to meet five out of the nine criteria. This is why BPD can present so differently between two patients.
A person must show a pervasive pattern of instability by meeting 5 or more of:
Frantic efforts to avoid abandonment (real or imagined).
Unstable and intense relationships (alternating between idealisation and devaluation, i.e., "splitting").
Identity disturbance (unstable self-image or sense of self).
Impulsivity in at least two self-damaging areas (e.g., spending, sex, substance use, reckless driving, binge eating).
Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour.
Affective instability (intense mood swings, usually lasting hours to a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling it.
Transient, stress-related paranoid ideation or severe dissociative symptoms.
V. Clinical Assessment
🚩 Red Flags & Immediate Actions
Active Suicidal Ideation with Plan/Intent:
Action: Initiate Form 1 (if criteria met), 1-to-1 observation (SNE/SN), secure environment (remove all potential ligatures/sharps), urgent psychiatric referral.
Reason: High imminent risk of death.
Recent Self-Harm (e.g., deep cuts, overdose):
Action: Medical stabilisation first (ABCDE). Suture wounds, manage overdose (e.g., N-acetylcysteine for paracetamol). Then, apply psychiatric red flag actions.
Reason: Medical stability is the prerequisite for psychiatric assessment.
Transient Psychotic Symptoms (paranoia, dissociation):
Action: Secure environment, provide re-orientation. Consider low-dose antipsychotic (e.g., IM Haloperidol 5mg or IM Droperidol 5-10mg) if severely agitated and a danger to self/others, after discussion with your senior.
Reason: Patient has lost contact with reality and is highly distressed; their behaviour is unpredictable.
Severe Agitation/Aggression:
Action: De-escalation (verbal first). If failing, chemical restraint (as above) and/serta physical restraint (by trained security/staff).
Reason: Staff and patient safety.
History
Key Diagnostic Clues (Pathognomonic/Classic Presentations)
"My life is a soap opera.": A history of chaotic, intense, and short-lived relationships.
"Splitting": Describing people (including staff) as "all good" or "all bad." The MO you spoke to yesterday was "the best doctor ever," and you are "useless" today.
Fear of Abandonment: This drives most of the behaviour. They may self-harm to "test" if you care, or to prevent you from leaving your shift.
Chronic Emptiness: A pervasive, painful internal feeling of hollowness.
Symptom Breakdown (based on DSM-5)
Common: Affective instability, intense anger, chaotic relationships, chronic emptiness, recurrent self-harm/suicidality.
Less Common (but specific): Stress-related paranoia, severe dissociation (e.g., "I felt like I was watching myself from the ceiling").
Pertinent Negatives
Absence of discrete, prolonged mood episodes (weeks/months): Argues against Bipolar Disorder. BPD mood swings are rapid, often triggered, and last hours/days.
Stable self-image and relationships: Makes any personality disorder unlikely.
No history of trauma: Less common, but BPD can occur without it.
Symptoms only in one context (e.g., only at home): Argues against a pervasive personality disorder.
Physical Examination (OSCE Approach)
General Inspection
From the end of the bed: May be agitated, tearful, angry, or deceptively calm.
Look for signs of self-harm: Look at forearms, thighs, abdomen.
Old: Healed linear or "z-pattern" scars.
New: Fresh cuts, ligature marks, burn marks.
Vitals
Usually stable unless there's an overdose, severe agitation (tachycardia, hypertension), or iatrogenic (e.g., sedation).
Disease-Specific Examination (Mental State Examination - MSE)
Appearance & Behaviour: May be dishevelled (if in crisis), guarded, eye-contact poor OR intensely staring, restless, psychomotor agitation.
Mood & Affect:
Mood (Subjective): "Empty," "Depressed," "Angry," "Panicked."
Affect (Objective): Labile (switches rapidly from tears to anger to laughter), reactive, intense.
Thought:
Form: May be circumstantial.
Content: Preoccupations with perceived abandonment, relationship conflicts, low self-worth. May have suicidal ideation. Transient paranoid ideation under stress ("The nurses are planning to hurt me").
Perception: Usually normal. May have transient, stress-related pseudo-hallucinations (e.g., hearing their name called, hearing a voice comment on them—often in 2nd/3rd person).
Cognition: Intact. Orientation is normal.
Insight & Judgement: Often poor, especially during crisis. They may not see their behaviours as problematic, but rather as justified reactions to their environment.
Examination for Differentials
Look for signs of substance use (e.g., track marks, pinpoint pupils, intoxication) as this is a common co-morbidity and differential.
A formal thyroid exam (goitre, tremor, exophthalmos) to rule out thyrotoxicosis presenting as anxiety/lability.
Clinical Pearl
Do not be "fooled" by a patient who seems calm and engaging after a serious self-harm attempt. This is called "post-crisis calm." The risk is still extremely high. Always take self-harm and suicidal threats seriously, even if the patient has "cried wolf" 10 times before. The 11th time may be fatal.
VI. Diagnostic Workflow
Differential Diagnosis
Bipolar Disorder (Type II or Cyclothymia)
Points For: Mood instability, impulsivity.
Points Against: BPD mood shifts are "moment-to-moment" or "day-to-day" and are reactive to interpersonal stressors. Bipolar episodes (hypomania/depression) are discrete, sustained (days to weeks), and often have a more autonomous, biological feel (e.g., classic changes in sleep, energy, libido).
How to Differentiate: A detailed longitudinal mood history (use a mood chart).
Complex PTSD (C-PTSD)
Points For: History of trauma, emotional dysregulation, relationship difficulties.
Points Against: This is a very difficult differential. C-PTSD has core features of avoidance and negative self-concept (e.g., "I am worthless"). BPD has core features of fear of abandonment and splitting. They are not mutually exclusive.
How to Differentiate: Specialist assessment. For your level, identify the trauma and the core BPD symptoms; the psychiatric team will delineate.
Other Cluster B (Histrionic, Narcissistic)
Points For: Emotional, erratic, relationship-focused.
Points Against: The core motivation differs.
Histrionic: "I need to be the centre of attention."
Narcissistic: "I need to be admired."
Borderline: "I need you to not abandon me."
How to Differentiate: Assess the primary driver of their interpersonal behaviour.
Investigations Plan
This is a clinical diagnosis. Investigations are to rule out differentials and manage acute complications.
Bedside / Initial (First 15 Mins)
Urine Pregnancy Test (UPT): Mandatory for any female of childbearing age before giving medication.
Urine Drug Screen (UDS): Rule out intoxication as a cause of impulsivity/lability.
ECG: Especially in overdose (e.g., TCA) or before giving antipsychotics (check QTc).
Blood Sugar (Dextrostix): Rule out hypoglycaemia.
First-Line Labs & Imaging
Paracetamol Level: Mandatory in ALL overdose cases.
FBC, RP, LFTs, VBG/ABG: Baseline, assess for co-ingestants or end-organ damage from overdose.
TSH: Rule out thyroid dysfunction.
CT Brain (non-contrast): Only if there is a history of recent head trauma or new-onset focal neurological deficits.
Confirmatory / Gold Standard
Specialist Clinical Interview: A detailed psychiatric history and MSE by a psychiatrist or clinical psychologist.
Structured Interviews (Specialist tools): E.g., SCID-5-PD (Structured Clinical Interview for DSM-5 Personality Disorders). Not your job, but good to know.
VII. Staging & Severity Assessment
We don't "stage" BPD like cancer. We assess severity based on:
Symptom Count: Number of DSM-5 criteria met (5 is minimum, 9 is maximum).
Functional Impairment: Inability to hold a job, maintain stable housing, or have any lasting relationships.
Frequency/Severity of Self-Harm/Suicidality: E.g., superficial cutting vs. life-threatening overdoses requiring ICU admission.
Co-morbidity: E.g., co-morbid substance use disorder, severe depression, or eating disorder makes it more complex and severe.
VIII. Management Plan
A. Principle of Management
Safety First: Manage acute risk (suicidality, self-harm, aggression).
Psychotherapy is Mainstay: Long-term, structured psychotherapy is the only definitive treatment.
Pharmacotherapy is Adjunctive: We treat co-morbidities (e.g., depression) or specific symptoms (e.g., anger, transient psychosis), not the disorder itself. There is NO "BPD pill."
B. Immediate Stabilisation (The ABCDE Plan)
This is for the acute crisis (e.g., patient brought to ED for overdose/self-harm).
A - Airway: Clear? Vomitus?
B - Breathing: Saturations? RR?
C - Circulation: BP, HR, capillary refill time. Get IV access. Manage overdose as per protocol (e.g., activated charcoal, N-acetylcysteine).
D - Disability: GCS. Check pupils. Give Naloxone if opiate overdose suspected.
E - Exposure/Environment: Examine for injuries (cuts, burns, head trauma). Remove all clothing (in a private space) to search.
Psychiatric 'E': Once medically stable, move to a safe, observable area ('Green Zone'). Remove all potential ligatures/sharps (shoelaces, belts, bra wires, phone cables). Assign a SNE or SN for 1-to-1 observation.
C. Definitive Treatment (The Ward Round Plan)
This is a psychiatric-led plan.
1. Non-Pharmacological (The Mainstay)
Psychotherapy: This is the primary treatment.
First-Line: Dialectical Behavioural Therapy (DBT). This is the most evidence-based. It teaches 4 modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.
Other Options: Mentalisation-Based Therapy (MBT), Schema-Focused Therapy.
Availability in Malaysia: This is the main challenge. DBT is available in some major KKM psychiatric centres (e.g., HKL, Hospital Permai) and private centres, but waiting lists are long and resources are limited.
2. Pharmacological (The Adjunct)
NO specific medication is approved for BPD. We target symptoms.
Affective Dysregulation (lability, anger):
Mood stabilisers (e.g., Lamotrigine, Sodium Valproate).
Impulsivity / Aggression:
Mood stabilisers or low-dose second-generation antipsychotics (e.g., Risperidone 0.5-1mg, Olanzapine 2.5-5mg).
Transient Psychosis / Paranoia:
Low-dose antipsychotics (as above).
Co-morbid Depression/Anxiety:
SSRIs (e.g., Fluoxetine, Sertraline). Use with caution: Monitor closely, as they can sometimes increase impulsivity or agitation in BPD patients.
WHAT TO AVOID:
Benzodiazepines (e.g., Diazepam, Lorazepam): Avoid long-term. High risk of dependence, abuse, and paradoxical disinhibition (can make impulsivity and aggression worse).
D. Long-Term & Discharge Plan
Safety Plan: Patient develops this with the psych team. Includes:
Warning signs of a crisis.
Internal coping strategies (e.g., DBT skills).
Social contacts for support.
Crisis hotline numbers (e.g., Befrienders) and how to present to ED.
Follow-up:
Urgent follow-up with the nearest psychiatric clinic.
Referral for psychotherapy (DBT).
Psychoeducation: For the patient and, with consent, for the family.
IX. Complications
Immediate: Suicide, severe self-harm, accidental death from overdose, iatrogenic harm (e.g., complications from restraints).
Action: Acute medical and psychiatric admission.
Short-Term: Relationship breakdown, job loss, hospital admission, substance abuse.
Action: Social work referral, crisis intervention.
Long-Term: "Burnout" of social support, chronic unemployment, development of other co-morbidities (substance use, eating disorders, depression), high suicide mortality.
Action: Long-term engagement in psychotherapy.
X. Prognosis
This is not a "hopeless" diagnosis.
Mortality: High. ~10% will die by suicide.
Morbidity: High. Significant functional impairment.
Long-Term Course: Symptoms, particularly impulsivity and self-harm, tend to "burn out" and decrease with age (after 40s-50s).
With Treatment (DBT): Prognosis is much better. Many patients can achieve significant symptom reduction and "remission," leading functional lives.
Poor Prognostic Factors: Co-morbid substance use, antisocial traits, poor insight.
XI. How to Present to Your Senior
"Hi Dr. [Senior's Name], I am [Your Name] in ED. I am calling about a patient, [Patient's Name/Age/Sex], who presented with [chief complaint, e.g., 'an overdose of 20 paracetamol tablets 2 hours ago'].
S (Situation): She is currently [state risk, e.g., 'agitated, tearful, and expressing strong suicidal ideation with a plan to jump']. She has multiple old and new superficial cuts on her left forearm.
B (Background): She has a known psychiatric history of BPD, with multiple previous admissions for self-harm. The trigger today was [e.g., 'a fight with her boyfriend who she fears is leaving her'].
A (Assessment): Vitals are stable. ABCs are secure. We are managing the paracetamol overdose as per protocol. My main concern is her high imminent suicide risk and agitation.
R (Request): I am requesting an urgent psychiatric assessment for suicide risk and potential admission. In the meantime, we have her on 1-to-1 nursing, but I need your advice on managing her agitation. Would IM Droperidol be appropriate if she escalates?"
XII. Summary & Further Reading
Top 3 Takeaways
Safety First, Always: Your first job is to manage the acute medical and suicide risk. Medically stabilise first.
It's a Disorder of Emotion Regulation: The behaviour (self-harm, anger) is a maladaptive coping mechanism for overwhelming emotional pain.
Psychotherapy is Key: Medication is only a temporary, adjunctive tool. The only thing that "cures" BPD is long-term, specific psychotherapy like DBT.
Key Resources
Malaysian Guidance: There is no specific national CPG for BPD. We follow standard psychiatric principles. The Malaysian CPG on Management of Suicidal Behaviour (2021) is essential reading for managing the acute risk.
UpToDate: "Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis" and "Borderline personality disorder: Treatment".
Amboss: "Borderline personality disorder".
