Borderline personality disorder

Longitudinal diagnostic formulation #

Assess persistent difficulties in affect regulation, identity, relationships and impulsivity across time and contexts. Explore abandonment sensitivity, emptiness, self-injury and stress-related dissociative or suspicious experiences. Explain the formulation collaboratively and distinguish the diagnosis from a moral judgment about behaviour.

Current state and enduring pattern #

Take a developmental and treatment history and identify strengths, existing supports and personally meaningful goals. Establish the immediate precipitant, current intent or plans, access to means, intoxication and medical consequences when the person presents in crisis. Review prior treatment responses rather than assuming repeated presentation means that treatment cannot help.

Comorbidity and diagnostic boundaries #

Investigate the presentation #

Investigations address suspected poisoning, injury, medical illness or medication effects; they do not diagnose personality disorder. Coordinate physical treatment with psychosocial assessment when self-harm has occurred. Do not let the existing diagnosis obscure a new medical problem.

Psychotherapy and prescribing boundaries #

Choose a structured psychotherapy with an explicit formulation and agreed targets. DBT emphasizes emotion regulation, distress tolerance and interpersonal skills; MBT develops understanding of mental states; schema therapy and transference-focused psychotherapy offer other structured approaches. Selection depends on needs, preference and available competent treatment.

NICE advises against drugs for the disorder itself or its individual associated behaviours. APA permits a more limited adjunctive approach: a measurable target, time-limited use and concurrent psychotherapy. These positions do not establish a universal medication sequence or dose table for BPD.

Doses & prescribing #

Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.

This presentation does not have a routine diagnosis-based drug regimen. Indication-specific prescribing and its limitations are described in the treatment section.

Review before adding medicines #

Examine whether a coherent therapy programme was accessible and delivered, and whether goals, attendance barriers or comorbidity need revision. Lack of response to one approach does not demonstrate that all psychotherapy has failed. Avoid stacking medicines in response to each crisis without reviewing the original targets.

Continuity and medication review #

Use a shared care plan and prepare for transitions or endings. APA recommends medication review and reconciliation at least every 6 months to identify ineffective treatments and opportunities for tapering. NICE limits crisis sedative treatment, when used, to an agreed short period no longer than 1 week.

Comorbidity and dependent care #

Treat a confirmed comorbid disorder within the overall psychological treatment programme. Include dependent children’s needs and family involvement where appropriate. Avoid extrapolating an adult formulation to an adolescent without a developmentally appropriate assessment.

Meaningful outcomes #

Track function, relationships, crises, self-harm and treatment burden alongside symptom severity. Update the crisis plan with strategies that helped and an agreed next contact. Improvement can occur; long-term care should support recovery and autonomy.

Avoid diagnostic overshadowing #

Do not use a symptom score to predict suicide or decide discharge. A calm interview or chronic history does not remove the need to assess current circumstances. Arrange physical care, a psychosocial formulation and follow-up according to the actual presentation.

Assessment tools #

Choose the instrument for its intended purpose; interpretation accompanies the linked tool.

Patient discussion #