Borderline Personality Disorder

Definition of Personality Disorders

• Personality disorders are “enduring patterns of perceiving, relating to, and thinking about the environment and oneself” that “are exhibited in a wide range of important social and personal contexts,” and “are inflexible and maladaptive, and cause either significant functional impairment or subjective distress” (DSM-IV, p. 630)

The “Big 5” Personality Traits Openness to experience (v. premature closures) Conscientiousness (v. irresponsibility) Extraversion (v. introversion) Agreeableness (v. uncooperativeness) Neuroticism (v. a healthy world view and positive adjustments)

personality disorders represent extreme variations of OCEAN

Main Features of PDs

• Extreme patterns of thinking, feeling, and behaving that deviate from a person’s culture

• Listed on Axis II of the DSM-IV-TR• Begin early in life and remain stable

- not contextual or transient• Inflexible and maladaptive• Cause significant functional impairment and

subjective distress - ego-syntonic vs. ego-dystonic

Impulsivity &Aggression

PTSD

Impulse Control

Disorders

Bipolar Spectrum

Cluster B Personality Disorders

ADHD Spectrum Tourette’s/

OCD

Developmental Disorders

SubstanceUse

Disorder

Sexual Compulsions

Impulsive-Aggressive Spectrum

Borderline Personality Disorders Autism

Spectrum Disorders

Personality Disorder

- Inflexible patterns of behavior (maladaptive)

- Begins early in adulthood (lifelong)

- Results in social, occupational problems or distress (pervasive)

• 11% of Psychiatric Outpatients and 19% of Psychiatric Inpatients

• Of all PD’s 33% of outpatients are BPD and 63% of Inpatients are BPD

• Severe problems and marked misery, 70-75% have engaged in self-destructive activities

• 74% of those diagnosed are female. Females are more likely to engage in self harm.

• 75% of self harm behaviors occur between the ages of 18 and 45.

• Characteristic Behaviors: Emotional Vulnerability, Self Invalidation, Unrelenting Crises, Inhibited Grieving, Active Passivity, Apparent Competence

Cluster A Personality DisordersParanoid, schizoid, and schizotypal personality

disorders

Marked by eccentricity, odd behavior, not psychosis

Share a superficial similarity with schizophrenia (as if a milder version)

Cluster B Personality DisordersAntisocial, borderline, histrionic, and

narcissistic personality disorders

Being self-absorbed, prone to exaggerate importance of events

Having difficulty maintaining close relationships

Poor capacity to engage in ongoing cooperative relationships

Cluster B: Dramatic, Emotional, or Erratic

• Antisocial PD – is a pattern of disregard for, and violation of, the rights of others

• Borderline PD – is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity

• Histrionic PD – is a pattern of excessive emotionality and attention seeking

• Narcissistic PD – is a pattern of grandiosity, need for admiration, and lack of empathy

Primary Cluster B Personality Disorders

• Borderline 56%• NOS 22%• Narcissistic 14%• Antisocial 7%• Histrionic 1%

– “Borderline Personality Organization”

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BORDERLINE PDUnstable Relationships, Affect, Self-

Image Plus Impulsiveness

5 + of :Fears Abandonment Mood Shifts

Unstable Relationships Feels Empty

Changing Self-Image Anger

Impulsive Sex, Spending, Temporary Etc Paranoia

Suicidal Behavior

Borderline and comorbidity

• High degree of overlap with both Axis I and Axis II disorders

• 24%-74% also diagnosed with major depression; 4% to 20% bipolar

• 25% of bulimics also diagnosed with BPD• 67% also diagnosed with substance use

disorder

Borderline Personality Disorder• marked instability of mood, relationships,

self-image• intense, unstable relationships • uncertainty about sexuality• everything is “good” or “bad”• chronic feeling of “emptiness”• recurrent threats of self-harm/ “slashers”

John Gunderson, MD

• Psychotic Borderline• The Borderline Syndrome• The As – If Borderline• The Neurotic Borderline

Grinker, Werble and Drye, 1968

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ANTISOCIAL PD (ASPD)

Disregard Rights of Others (and meet Conduct Disorder)

3 + of :

Unlawful Reckless

Deceitful Irresponsible

Impulsive Lack Remorse

Aggressive

ASPD

“I’m the most cold-hearted son of a b---- you will ever meet”– Ted Bundy

Cluster C Personality Disorders

Avoidant, obsessive-compulsive, dependent disorders

Individuals are often anxious, fearful, and depressed

Cluster AOdd, Eccentric

Cluster BAngry

Cluster CAnxious

Psychosis

R – Reality TestingE – Empathic DysfunctionM – Mechanisms of Defense (Primitive, Immature)I – ImpulsiveN – Narcissistically Focused (Pathologically)D – Diffuse Ego BoundariesE – Empathic FailureR – Rational Thought Dysfunction

Hendrick, 2009

Neurosis

• Core Conflict• Paradoxical Behavior• Neural and Glial Cell Genesis• Synaptogenesis and Pruning• Neuritic Extensions• Long Term Potentiation (LTP)• Axonal Remodeling

Personality & Impulse Control Disorders

General characteristics of PD’sCluster A Disorders

Paranoid, Schizoid, Schizotypal

Cluster B DisordersAntisocial, Borderline, Histrionic, Narcissistic

Cluster C DisordersAvoidant, Obsessive-Compulsive, Dependent

Impulse Control Disorders

Childhood Antecedents Of Severe Impulsivity and Subsequent Adult Violence

• Impulsive self-centered children with a low tolerance of criticism who tend to project blame on others are at risk of developing borderline or antisocial personality disorders as adults and have increased incidences of violence

• Reckless drivers often have little concern for others or are immature as adolescents and do not foresee or consider consequences well

• Adjudicated as juvenile delinquents or as adolescent “adult offenders” increase risk in adulthood

Facts About Personality DisordersOnset usually late childhood, early adolescence

Causes others distress – dysfunctional theory of mind

Pathological uncooperativeness

Effects behavior in many situations

Poor insight

Little behavior change over time

Coded on Axis II

General Diagnostic Criteria for PD’sEnduring pattern of inner experience or behavior that

deviates from expectations of culture, manifested in two or more of the following: - cognition (perception of self, others)– affectivity (intensity, range of emotions)– interpersonal functioning– impulse control

• Enduring pattern is inflexible, pervasive in many situations

• Chronic, debilitating• High morbidity and mortality• Several forms of psychotherapy for BPD (i.e., DBT)

– Patients often refractory

Personality Disorders: Why Axis 2?Axis II disorders:

long-lasting,chronic patterns of interactions not discreet episodesbegin by adolescence frequently co-occur with Axis I diagnosescomplete recovery not possible

Enduring pattern leads to distress, impairment in important areas of functioning

Pattern is stable and of long duration, generally can be traced back to childhood

Pattern not better explained by another disorder

Pattern not due to substance abuse or medical condition

Two Basic Affects -Anger and Fear-

• These are the most likely emotional antecedents of violence• If associated with paranoid delusions the magnitude of harm

also is increased• Systematized paranoid ideation – as opposed to a

monosymptomatic delusional idea – also increases the risk of violence

• A specific delusion of being poisoned is related to a high incidence of violence

• In summary, risk is greater for delusions than for hallucinations combined with delusions and both are greater than for hallucinations by themselves

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Early Environment Alters Neurochemistry

Delville et al, J Neurosci 1998;18(7):2667-2672

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Parental or Adult Brutality

• “Today’s catcher is tomorrow’s pitcher” – Prison saying• Brutalized or molested boys tend to repeat the cycle,

especially by aggressing on the vulnerable• Similarly victimized girls tend to repeat the victimization• Girls who have been molested are twice as likely to be

rape victims as those who have not had a similar history• Girls and women arrested for prostitution – as opposed

to all other crimes – are 23 X more likely to have been molested

• Victims of childhood abuse have a 6 X greater incidence of Borderline Personality Disorder and 20 X greater incidence of psychopathology

• Fears of abandonment• Unstable intense interpersonal relationships• Identity disturbances• Self-damaging impulsivity (e.g., spending, sex)• Recurrent suicidal or self-mutilating behavior • Affective instability• Feelings of emptiness• Inappropriate intense anger• Transient paranoia or dissociation

DSM-IV, 1994

Diagnostic Criteria for 301.83 BPD

Preparation for Therapy• Assessment• Data Collection on Current Behaviors• Precise Operational Definitions of Treatment Targets• A collaborative working relationship between

patient and therapist• Orientation to the therapy and a commitment to

mutually defined treatment goals• Use of cognitive, behavioral, metaphorical and

paradoxical technique• Reframing and acceptance of the here and now• Tolerance of affects and recognition of their impact

Treatment of Personality Disorders• Psychotherapy

– people who complain about lack of confidence and have difficulties in making relationships are usually motivated for psychotherapy

– in emotionally unstable and dyssocial personalities disorders the patient should recognize the situations which provoke his/her pathological reactions and should work tomanage them

– psychotherapy of personality disorders is a very difficult task and to reach a partial effect requires a patient’s thorough motivation

• Pharmacotherapy helpful in emotional disorders

– anxiolytics and SSRI antidepressants suppress anxiety and depressive symptoms

– lithium and other thymoleptics (carbamazepine, valproic acid) reduces mood fluctuation and aggressive tendencies

Dialectical Behavior Therapy• Mindfulness• Marsha Linehan, PhD Commitments in dialectical behavior therapy• Patient agreements• Stay in therapy for the specified time period• Attend scheduled therapy sessions• Work toward reducing suicidal behaviors as a goal of therapy• Work on problems that arise that interfere with the progress of therapy• Participate in skills training for the specified period• Therapist agreements• Make every reasonable effort to conduct competent and effective therapy• Obey standard ethical and professional guidelines• Be available to the patient for weekly therapy sessions and provide needed

therapy back-up• Maintain confidentiality• Obtain consent when needed

Core Treatment Procedures

• Problem Solving• Exposure Techniques• Skill Training• Contingency Management• Cognitive Modification

Neurotransmitters associated with prosocial attitudes and behaviors

• Dopamine• Serotonin• Vasopressin• Oxytocin

Medications Which Have Been Used Off Label in Borderline Personality Disorder

• SSRIs• 5-HT1A agonists, 5-HT2 antagonists• Lithium• Anticonvulsants• Atypical and typical neuroleptics• Beta blockers• Alpha antagonists (e.g., clonidine, guanfacine)• Opiate antagonists (e.g., naltrexone)• Dopamine agonists (e.g., stimulants, bupropion)

* All off-label uses

Divalproex Treatment in BPDRandomization

Randomization

ClinicalAssessment

N=21

Referral10 WeeksPlacebo

Divalproex sodium

Methods Outcome Measures

21 individuals with BPD

Global Assessment Scale (GAS)

Clinical Global Impression Improvement Scale (CGI)

Initial dose 250 mg/d, titrated to blood level of 80 g/mL

Aggression Questionnaire (AQ)

Overt Aggression Scale-Modified (OASM)

Beck Depression Inventory (BDI)

Hollander E et al, J Clin Psychiatry 2001

Divalproex Sodium/Placebo in Cluster B Personality Disorders

Study Schematic

Double-BlindScreening Tapering

2 Weeks 12 Weeks 1 Week

Taper off excludedpsychotropic meds

Divalproex (N=47)

Placebo (N=49)

Randomized in 1:1 ratio within diagnostic groups

Hollander et al, 2002 (APA)

Double-Blind Divalproex Sodium in BPD

Baseline (SD) End Mean (SD) P

CGI Improvement 4.0 2.2 (0.9) 0.006

GAS 52.2 66.7 (4.1) 0.003

Analysis of Completers

Hollander et al, J Clin Psychiatry 2001

Fluoxetine in Borderline Personality Disorder

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Olanzapine in Borderline Personality Disorder

Schulz et al, Biol Psychiatry 1999

Measure NMean Base

Mean Last

% Change t P

GAF 11 53.0 67.0 26 -3.86 .004

SCL-90 global CSI 11 2.12 1.09 49 3.37 .007

BPRS global 10 43.10 30.80 29 5.79 .0005

SIB total 11 1.91 1.63 14 2.54 .029

Buss-Durkee total 11 48.3 40.8 16 2.13 .059

BIS11 total 11 2.26 1.93 15 2.50 .032

Psychotic and Pathological Defenses

The mechanisms on this level, when predominating, almost always are severely pathological. These defenses, in conjunction, permit one to effectively rearrange external experiences to eliminate the need to cope with reality. The pathological users of these mechanisms frequently appear crazy or insane to others. These are the "psychotic" defenses, common in overt psychosis. However, they are found in dreams and throughout childhood as well.

Immature Defenses

These mechanisms are often present in adults and more commonly present in adolescents. These mechanisms lessen distress and anxiety provoked by threatening people or by uncomfortable reality. People who excessively use such defenses are seen as socially undesirable in that they are immature, difficult to deal with and seriously out of touch with reality. These are the so-called "immature" defenses and overuse almost always leads to serious problems in a person's ability to cope effectively. These defenses are often seen in severe depression and personality disorders. In adolescence, the occurrence of all of these defenses is normal.

Splitting

A primitive defense. Negative and positive impulses are split off and unintegrated. Fundamental example: An individual views other people as either innately good or innately evil, rather than as a whole continuous person.

* Tellin’ a man to go to hell and makin’ him do it are two entirely different propositions

Acting OutActing Out is performing an extreme behavior in order to

express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child’s temper tantrum is a form of acting out when he or she doesn’t get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

ProjectionProjection is the misattribution of a person’s

undesired thoughts, feelings or impulses onto another person who does not have those thoughts, feelings or impulses. Projection is used especially when the thoughts are considered unacceptable for the person to express, or they feel completely ill at ease with having them. For example, a spouse may be angry at their significant other for not listening, when in fact it is the angry spouse who does not listen. Projection is often the result of a lack of insight and acknowledgement of one’s own motivations and feelings.

Projective IdentificationProjective Identification is a term first introduced by Melanie Klein of the

object relations school of psychoanalytic thought in 1946. It refers to a psychological process in which a person engages in the ego defense mechanism projection in such a way that their behavior towards the object of projection invokes in that person precisely the thoughts, feelings or behaviors projected.

Projective identification differs from simple projection in that projective identification is a self-fulfilling prophecy, whereby a person, believing something false about another, relates to that other person in such a way that the other person alters their behavior to make the belief true. The second person is influenced by the projection and begins to behave as though he or she is in fact actually characterized by the projected thoughts or beliefs. This is a process that generally happens outside the awareness of both parties involved, though this has been debated.

* When you give a lesson in meanness to a critter or a person, don’t be surprised if they learn their lesson.

• •

This one deserves a couple of extra East Tennessee insights:

Never drop your gun to hug a bear.

A man who wants to loan you a slicker when it ain’t raining ain’t doing much for you

Wisdom

• Frontostriatal and frontolimbic circuits involving very specific neurotransmitters may be required.

• An optimal balance of phylogenetically older (limbic) and the later developing prefrontal cortex may be the key to understanding the nature of wisdom.

Subcomponents of Wisdom

• Prosocial Attitudes and Behaviors• Social Decision Making/Pragmatic Knowledge

of Life• Emotional Homeostasis• Reflection/ Self – Understanding• Value Relativism/Tolerance• Acknowledgment of and dealing effectively

with uncertainty

Prosocial Attitudes and Behaviors

• Achievment of social good• Wisdom serves the common good• Altruism is a dimension of wisdom• Affective wisdom is “positive emotion and

behavior towards others and the absence of indifferent or negative emotions towards others (Ardelt)

• An aspect of wisdom is warmth (Jason, et al)

Social Decision Making/Pragmatic Knowledge of Life

• Rich Factual Knowledge regarding human nature and life course

• Rich procedural knowledge regarding ways of dealing with life’s problems (Baltes, et al)

• Knowing but also knowing when, where, why and how to apply knowledge (Sternberg)

• Practical knowledge is a dimension of wisdom (Meachum)• Practical wisdom is “good interpersonal skills and

understanding, expeditious use of information, and expertise in advice giving” (Wink and Helson)

• 3 dimensions of wisdom include judgment, life knowledge and Life skills (Brown and Greene)

Emotional Homeostasis

• Emotional stability despite uncertainty (Brugman)

• Emotional Management (Brown and Greene)

Reflection/ Self – Understanding

• Reflective abilities• Reflective judgment• Interest in Self Understanding –

Transcendental Wisdom• Self – Knowledge and Reflective Wisdom

Value Relativism/Tolerance

• Tolerance and value relativism• Reflective wisdom “ability and willingness to

examine phenomenon from multiple perspectives; absence of projections (Ardelt)

• Tolerant and Understanding (Practical Wisdom Scale)

Acknowledgment of, and dealing effectively with, uncertainty

• Handling of uncertainty, including limits of knowledge• Comprehension of and dealing with uncertainty• Meta – Cognition: acknowledging uncertainty and

ability for dialectical thinking• Personality/affect: emotional stability despite

uncertainty and openness to new experience• Behavior: ability to act in the face of uncertainty• Cognitive wisdom includes an awareness of life’s

inherent uncertainty yet having the ability to make decisions in spite of this.

I hate to think what it says on the front

References• Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA.

Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 39.

• Borderline Personality Disorder Demystified by Robert O. Friedel, M.D., Marlowe & Co., 2004

• National Education Alliance for Borderline Personality Disorder’s Teachers Manual for Family Connections, 2006

• A BPD Brief, An Introduction to Borderline Personality Disorder by John G. Gunderson, M.D., 2006

• A REMINDER for assessing psychosis- John Hendrick, MD- CURRENT PSYCHIATRY April 2010 Volume 9, No. 4