Borderline personality disorder in the perinatal period

What is borderline personality disorder? 

Borderline personality disorder (BPD) is a long-term complex condition characterised by a pattern of instability of emotions, relationships, sense of identity and impulse control. It is consistently associated with severe functional impairment. Borderline personality disorder often co-exists with depression, anxiety and substance use disorders and is associated with high levels of morbidity and mortality. 

The label ‘borderline personality disorder’ should be used with caution as it often has negative connotations and may be associated with substantial stigma. Conversely, it is important to identify women with this condition, as they, their family and treating health professionals will need additional resources and support over the perinatal period.

Prevalence of borderline personality disorder

Estimates of the prevalence of borderline personality disorder range from 1% among all Australian adults and 3.5% among Australians aged 24–25 years. A more recent study estimated prevalence among women aged ≥25 years to be 2.7%.
 

Causes

Women who have borderline personality disorder have often experienced sexual, physical or emotional abuse or neglect in childhood.

Symptoms

In addition to emotional dysregulation (poorly modulated emotional responses), the behaviour of women with borderline personality disorder is characterised by:

• Efforts to overcome their fear of abandonment
• Intense and unstable relationships
• Engaging in impulsive activities (e.g. substance use)
• Talking about or engaging in self-harm and/or suicidal behaviours
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid ideation or severe dissociative symptoms
• Symptoms experienced over a period of time, typically 2 weeks or more.

Planning and providing antenatal and postnatal care

Planning care

In planning care for women with borderline personality disorder, give priority to ensuring that health professionals involved take into account the complexity of the condition and the challenges of living with severe mental illness. Where available, involve specialist perinatal mental health services.

Preconception planning should include discussion of pharmacological treatments to be used after the birth. This will involve decision-making by the woman about whether she will breastfeed.

For women with borderline personality disorder, a multidisciplinary team approach to care in the perinatal period is essential, with clear communication, a documented care plan and continuity of care across different clinical settings.

Antenatal care

Health professionals involved in the antenatal care of women with borderline personality disorder should be aware that: 

• Women who have experienced physical or sexual abuse or complex traumas may experience distress when touched (e.g. when vaginal examination is conducted).
• Bonding with the baby during pregnancy may be challenging.
• Birth may be anticipated as traumatic and early or caesarean delivery is frequently requested.
• The woman’s emotional dysregulation may cause distress for 
  herself, her family and treating health professionals. 

Postnatal care

Women with borderline personality disorder may: 

• Have difficulties in the emotional care of the infant and in promoting secure attachment.
• Find the early postnatal period particularly distressing as normal infant crying is perceived as intrusive and unsettling and may be experiencing isolation and poor support due to interpersonal difficulties.

Health professionals involved in postnatal care of women with borderline personality disorder can provide support by:

• Understanding the importance of partner, family or paid (e.g. nanny) support, particularly overnight so the woman can sleep.
• Arranging intensive maternal and child health care (i.e. maternal and child health care for families requiring additional support).
• Considering targeted mother–infant therapy (individual or with a group of women with similar requirements for help with their emotional dysregulation) after other more acute symptoms are controlled.
• Ensuring that child protection risks are understood and addressed, if necessary.

Management and treatment

Psychological and psychosocial therapies are the preferred treatment for borderline personality disorder.

Psychological therapies 

Evaluated psychological therapies for borderline personality disorder include:

• Cognitive behavioural therapy (CBT)
• Interpersonal psychotherapy (IPT)
• Dialectical behaviour therapy (DBT)
• Mentalisation-based therapy (MBT)
• Schema-focused psychotherapy (SFT)
• Systems training for emotional predictability and problem solving (STEPPS)
• Transference-focused psychotherapy (TFP).

DBT is the most evaluated and has been found to decrease inappropriate anger, reduce self-harm and improve general functioning. Long-term therapy may be required.
 

Psychosocial support

While specialist psychological therapies are the preferred treatment for borderline personality disorder, these take time to have an ECT and other psychological approaches - mindfulness and/or relaxation
training - are also required.

Pharmacological treatments 

Overall, pharmacological treatments do not appear to alter the nature and course of borderline personality disorder. However, they may be useful in the short-term in controlling acute symptoms. 

If a pharmacological treatment is prescribed to a woman with borderline personality disorder, consideration should be given to avoiding medications that:

• May be lethal in overdose (because of the high risk of suicide).
• Are associated with substance dependence.

Tips for providing support

Listen and reassure

• Encourage the woman to discuss any symptoms she may be experiencing.
• Assure the woman that borderline personality disorder can be managed.

 
Provide information

• Refer all women to Ready to COPE – to receive ongoing information and support strategies throughout her pregnancy and /or the postnatal period.
• Provide the woman with quality information about borderline personality disorder – see COPE consumer fact sheet.
• Provide details of helplines if she is feeling distressed and needs support.
• Offer information to the woman’s partner/others

Direct to care and support

• Encourage the woman to consult with her general practitioner (GP) or other qualified health professional.
• Encourage the woman to identify and draw on possible supports and services that may be available to her for practical and/or emotional support.
• Remind the woman that she can go to her doctor or local hospital if she is at risk of harming herself or others.