Individuals with BPD have a very fragile sense of self. They tend to view themselves as victims and expect others to hurt and reject them. They crave support and a sense of belonging yet inadvertently sabotage relationships through unreasonable demands, unrealistic expectations, and splitting. Splitting is a very common defense mechanism used by persons with BPD, who tend to overidealize and alternately devalue others or view others as either all good or all bad. The maladaptive pattern of thinking and behaviors and the inability to sustain meaningful relationships may stem from growing up in an environment in which beliefs about self and relationships with others were constantly devalued and invalidated.


Diagnosis of BPD can be difficult because the symptoms may overlap with other mood, anxiety, and personality disorders. Approximately 90% of persons with BPD have co-occurring dependent, obsessive compulsive, or antisocial personality disorders.6 Diagnosis is based on history and the severity of symptoms that impact emotions, behavior, identity, and relationships. At least five of the following criteria must be present for BPD to be diagnosed:1

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  • Emotions
  • Labile mood
  • Displaced anger
  • Behavior
  • Impulsiveness
  • Suicidal ideations and gestures
  • Identity
  • Identity disturbance (self-image, sexual orientation, career choices and/or values)
  • Chronic feelings of emptiness
  • Relationships
  • Intense efforts to avoid real or imagined abandonment
  • History of impaired/unstable relationships
  • Transient paranoid ideation or dissociative symptoms.

Crisis management

Persons with BPD utilize a great many health-care resources, particularly during real or perceived periods of crisis. Given the high prevalence of BPD in the primary-care setting, nurse practitioners and physician assistants are likely to encounter a patient with BPD in crisis. A crisis situation may be triggered by seemingly minor incidents or precipitated by threats of separation, fear of rejection, or expectations that BPD patients assume responsibility for themselves. During the crisis, patients with BPD may present to the primary-care facility in a disinhibited state (i.e., impulsive, angry, raging, verbally and/or physically aggressive) and may display transient psychotic symptoms. Self-injurious behaviors and suicidal ideations are the main reasons people with BPD present for health-care services.