A personality disorder is a long-standing, rigid pattern of thinking, feeling and relating to others that starts by early adulthood and causes distress or problems at work and in relationships. Borderline personality disorder is the type seen most often in medical settings, with unstable mood, impulsive acts and self-harm.
Key symptoms
- Unstable relationships and intense fear of being abandoned
- Quick mood swings, anger outbursts or chronic emptiness
- Impulsive behavior: spending, substance use, reckless driving
- Self-harm, such as cutting, or repeated suicidal threats
- Distrust of others, odd beliefs or strong need for admiration, depending on type
What you find on exam
- Mental status exam: mood, affect, thought content and insight
- Look for cuts, burns or scars from self-harm
- Ask directly about suicidal thoughts and recent overdoses
- Screen for depression, anxiety, PTSD and substance use, which often coexist
Tests
- Diagnosis is clinical, based on a long-term pattern, not a single visit
- Collateral history from family or past records
- Urine drug screen and toxicology after an overdose or acute change
- Rule out medical or substance causes of new behavior change
Treatment basics
- Psychotherapy is the main treatment, such as dialectical behavior therapy for borderline type
- Calm, consistent and clear communication with set limits
- Treat coexisting depression, anxiety or substance use
- Medicines only for specific symptoms; avoid large supplies after an overdose
- Safety plan and crisis contacts for patients who self-harm
Red flags
- Suicidal plan, recent attempt or escalating self-harm
- Threats of violence toward others
- Overdose or new psychosis
Practice it in Making Synapses
Making Synapses cases
Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.