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Pearls


‘DARE’ to spot borderline personality disorder

BPD patients seem unable to break free of their unsuccessful patterns and fail to maintain healthy, productive relationships.

Vol. 6, No. 8 / August 2007

Patients with borderline personality disorder (BPD) exhibit a pattern of instability in interpersonal relation-ships, self-image, and affects, and marked impulsivity beginning in early adulthood.1 These patients may experience other symptoms, such as mood swings or transient psychotic episodes, that are exacerbated by stress.

A BPD patient likely has additional diagnoses from previous clinicians—such as bipolar disorder, dysthymic disorder, panic disorder, major recurrent depression, substance abuse, posttraumatic stress disorder, intermittent explosive disorder, or any variety of adjustment, anxiety, eating, impulse control, mood, somatoform, or personality disorders.2 However, a BPD diagnosis best describes many of these patients, and the mnemonic “DARE” enumerates the most commonly encountered clinical picture.

Depression, Destruction, Denial. Chronic low-grade depression is the baseline mood for BPD. The patients might not report suicidal ideation or might deny a desire to die. But the predilection and potential for risky behavior that could result in accidental injury or death tends to confirm the presence of an underlying self-destructive wish.

Anger, Abandonment, Abuse. Typically, BPD patients are angry at the world. Anger simmers just below the threshold of self-control. When it boils over, BPD patients are apt to take their anger out on themselves by committing suicide or a self-mutilative act, or on others with passive aggression or the kind of physical or emotional abuse they themselves suffered.

BPD patients’ histories often include physical or emotional abandonment or abuse.

Relationships, Regrets, Repetition. Repeated patterns of unstable relationships are characteristic. Often BPD patients have multiple romantic partners, frequent job turnover, interrupted education, and few long-term, mature friendships. These patients’ friends and partners frequently suffer from similar problematic personality characteristics. BPD patients seem unable to break free of their unsuccessful patterns and repeatedly fail to maintain healthy, productive relationships.

Extremes, Emergencies, Ennui. Overuse of prescription drugs, alcohol, or other substances result in frequent emergency room visits. Bulimia, sexual promiscuity, and multiple body piercings or tattoos are emblematic of BPD. Ennui—a feeling of weariness or discontent—is fought off by engaging in extreme behaviors, such as reckless driving.

Many BPD patients improve and show greater stability in jobs and relationships with therapeutic intervention, although they often have a lifelong tendency toward impulsivity and intense relationships and emotions.

Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL.

References

1. Diagnostic and statistical manual of mental disorders 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.

2. Roth L. The DSM-V: simplify, clarify. Psychiatry 2005. 2005;2(8):11-12.

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