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Evaluating for Borderline Personality Disorder

The Carlat Psychiatry Blog, Volume , Number ,
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According to DSM-5, BPD is “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.” Based on the eight DSM-5 criteria for BPD, here are some questions you can ask patients to confirm a diagnosis:

Identity disturbance
Ask patients, “Do you have a sense of where you’re going in life?” Probe for whether your patient has a dream, a purpose, or an ambition. The BPD person’s response often is: “No, I don’t have an ambition, I don’t have a dream, I’m just caught up in my pain.”

Disordered mood
“Do you find that your mood changes a lot during the day?” Typically, patients will reply with, “my emotional life is a roller coaster.” They’ll say that their moods are different in the morning, afternoon and evening, depending on circumstances and their environment.

Emptiness
“Do you feel empty inside as if there’s nothing there?” Among BPD patients, a common answer is “definitely.” This emptiness of BPD is different from depression. Patients with depression feel sad, like they’ve lost something, and can usually describe a time when they didn’t feel depressed. BPD patients, on the other hand, will often say, “I’ve never been happy, I feel empty inside, my life is pointless.”

Suicidality
As you should do for any patient you suspect of suicidal ideation, be straightforward in your questions: “Have you ever thought of committing suicide? Have you ever tried? What have you done? Have you done it more than once?” Depending their answers, consider doing a full suicide risk assessment. Then, determine whether the patient be hospitalized, involuntarily committed, or sent home with a written safety contract.

Paranoia
“Do you feel when you’re outside that strangers are looking at you, commenting on you, probably criticizing you?” Many patients with BPD will respond, “Yes, I’ve been like that as long as I can remember.”

Abandonment intolerance
“When you start a relationship, do you feel that you’re going to be dumped from day one?” Patients with BPD might say, “yes,” and then explain that every rejection throws them into a crisis.

Impulsivity
Impulsivity includes a range of behaviors, such as over-spending, substance abuse, reckless sexual behavior often associated with drinking, reckless driving, and bulimia. You can ask, “Do you ever spend so much money that you go deeply into debt? Do you get drunk, and have you done things you’re sorry for when you do get drunk? Do you binge eat?”

Rage
“Would people describe you as having a short temper? When you do get angry do you lose it completely? Do you yell, scream, break things, throw things?”

Relationship problems
Relationships play a key role in getting BPD patients into psychiatric trouble. So, spend time understanding relationship history: “Are you in a relationship? What happens to you in a relationship? Are there a lot of quarrels?”

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