Borderline personality disorder across the lifespan.

Borderline personality disorder is characterized by affective dysregulation, intense, unstable interpersonal relationships, impulsivity and unstable identity. It overlaps considerably with both PTSD and bipolar spectrum disorders. Research on true late-life BPD is limited, but suggests that some of the core features of BPD including interpersonal difficulties, unstable affect and anger remain relatively unchanged, while impulsivity and identity disturbance decline or change their mode of expression in late life. Diagnosis of BPD in late life requires both flexible application of the standard diagnostic criteria as well as a thorough longitudinal history. The etiology of BPD is best explained as a combination of genetic, neurobiological vulnerability combined with childhood trauma, abuse or neglect that leads to dysregulated emotions, distorted cognitions, social skills deficits, and few adaptive coping strategies. Treatment options include pharmacotherapy (especially mood stabilizers, SSRIs and atypical antipsychotics) and psychotherapeutic interventions that focus on distress tolerance, affective regulation, changing distorted beliefs, and introducing new social and relationship problem solving skills (especially Dialectical Behavior Therapy and Schema Focused Cognitive Therapy). In late life care environments, such as nursing homes and other residential facilities, staff need to be empowered to set appropriate limits on problematic behavior while maintaining empathy and validating the painful affect patients often experience.