Borderline Personality Disorder

Borderline Personality Disorder

• Formerly called latent schizophrenia

• Added to DSM III (1980) as BPD

• most commonly diagnosed in females (75%)

• 70-75% have a history of at least 1 parasuicidal act

• 10-15% complete suicide

DSM-IV Criteria of Borderline PD

A pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:  

  1. frantic efforts to avoid real or imagined abandonment 2. a pattern of unstable and intense interpersonal relationships

alternating between extremes of idealization and devaluation  3. markedly/persistently unstable self-image or sense of self  4. impulsivity that is potentially self-damaging  5. recurrent suicidal behavior, threats, or self-mutilating behavior   6. affective instability  7. chronic feelings of emptiness   8. inappropriate, intense anger or difficulty controlling anger  9. transient, stress-related paranoid ideation or dissociative symptoms

Mnemonic

P - Paranoid ideas

R - Relationship instability

A - Angry outbursts, affective instability, abandonment fears

I - Impulsive behaviour, identity disturbance

S - Suicidal behaviour

E - Emptiness

Borderline Personality Disorder

• overlap (in DSM IIIR) with histrionic, narcissistic, dependent, avoidant, and paranoid PDs

• comorbid with Axis I somatization, PTSD, ASPD or substance abuse, depression

Different from Bipolar Disorder

Rapid mood changes are often mistaken for bipolar disorders. Main differences: In Borderline PD…

a) Mood can change within hours (weeks-months in bipolar)

b) Baseline mood: dysthymia and emptiness (but also anger and anxiety)

c) Mood is highly responsive to environmental changes.

d) Prevalence of non-suicidal self-injury

e) Prevalence of splitting

Splitting

• deals with emotional conflict or stressors by compartmentalizing opposite affect states

• fails to integrate the positive and negative qualities of self or others into cohesive images

• because ambivalent affects cannot be experienced simultaneously, view of self and others tends to alternate between polar opposites: – exclusively loving, powerful, worthy, nurturant, and kind

– or exclusively bad, hateful, angry, destructive, rejecting, or worthless.

Etiology

• Genetic – 20 family studies suggest BPD is more prevalent in families

with the disorder

– may have some heritable components

– predisposition may be associated with predisposition to mood disorders

– BPDs are extremely high in neuroticism (which has known heritability factor)

– Impulsivity also heritable

Childhood Sexual Abuse

Studies noting abuse (physical and sexual) in childhood of BPD: Study N Physical Sexual Herman et al (1989) 24 71% 67% Ogata (1990) 24 42% 71% Shearer et al, (1990) 40 25% 40% Stone et al (1990) 29 28% 35% Westen et al (1990) 23 52% 52% Paris (1992) 78 70% 70%

Treatment of Borderline Personality Disorder

Sadie Cole, M.A. Abnormal Psychology

Harvard University Department of Psychology

November 19th, 2009

Challenges in Treating BPD

• Complex and heterogeneous syndrome– 256 possible combinations of symptoms

• Perception of BPD clients as difficult– Interpersonal issues carry to therapy– Early termination

• Suicide attempts and self-harm common– Lifetime suicide attempts in BPD: 3.4– Self-harm occurs in 60-80% of cases

(Hooley & St. Germain, 2008)

Outcomes in BPD

• Long-term outcome: Better than expected– At 10 –year follow-up, 88% of patients saw

significant reduction in symptoms(Zanarini, et al., 2006)

• 10% of BPD patients will complete suicide if untreated

(Oldham, 2006)

Major Treatment Approaches

• Pharmacological• Psychodynamic

– Transference-focused psychotherapy

• Cognitive-behavioral therapy– Schema-focused therapy

• Dialectical behavior therapy

(Hooley & St. Germain, 2008)(Linehan & Dexter-Mazza, 2008)

Treatment: Pharmacological

• Medication often used, but efficacy unclear

• SSRIs– BPD patients are often depressed– Data link aggression and suicidality to low levels of

serotonin (Asberg, 1997)

• Atypical antipsychotics (e.g., olanzapine)– Beneficial for impulsivity and aggression

• Antiepileptics (e.g., divalproex sodium)– May reduce mood instability

Treatment: Psychodynamic

• Transference-focused psychotherapy (TFT; Clarkin, et al. 2004)– Help patient understand and correct distortions– Focus on transference, or enactment of patient’s

external relationships in therapy– Clinical improvement shown after TFT

• Mentalization therapy (Bateman & Fonagy, 2004)– Attachment theory-BPD seen as attachment disorder– Centers on perception of actions as intentional

Treatment: CBT

• Schema-focused therapy (SFT; Young, et al., 2003)– Modifies 4 organized sets of beliefs– Detached protector, punitive parent,

abandoned/abused child, and angry/impulsive child

-RCTs show that SFT has a significant benefit above TFT (Giesen-Bloo, et al., 2006)

Treatment: Dialectical Behavior Therapy

• Specifically designed for treating BPD (Linehan, 1993; Linehan, et al., 2006)

• Works from a combination of CBT, psychodynamics, and influences from Zen practice– Theoretical orientation balances acceptance and

change (the dialectic)

Treatment: Dialectical Behavior Therapy

• Combines:– Psychotherapy– Skills training– Telephone consultation– Therapist consultation team meetings

• Works toward building “a life worth living”

Treatment: Dialectical Behavior Therapy

THESIS ANTITHESISSYNTHESIS

Treatment: Dialectical Behavior Therapy

• Biosocial theory of BPD– High emotional sensitivity + high emotional

reactivity• Sensitive to emotional stimuli and takes much longer to

return to baseline

– Invalidating environment• “What you’re feeling is wrong”– Dysregulated emotions and behaviors• Person feels out of control and misunderstood

4 Skills Modules in DBT

MindfulnessDistress Tolerance

Emotion RegulationInterpersonal Effectiveness

Synthesis ACCEPTANCE CHANGE

Treatment: Dialectical Behavior Therapy

• Validation=understanding and accepting another person’s experience, without judging or even agreeing with it

• Patients often say that DBT is the only therapy that has ever “made sense”

Non-Suicidal Self-Injury (NSSI)• NSSI: damage to bodily tissue in the

absence of intent to die– Cutting, burning, ingestion of objects– Risk factor for suicide: 30x increased risk (Cooper,

et al., 2005)– Not restricted to BPD

Non-Suicidal Self-Injury (NSSI)

• NSSI: symptom, not disorderDSM-V may add

• Prevalence: 4% in adults, but as high as 17% in adolescents/young adults– Adolescents may be at particular risk– 8x higher in girls than boys in adolescence– 56% prevalence in girls 10-14 (Hilt, et al., 2008)

Functions of NSSI

• Not “for attention” or acceptance• Emotion regulation function:

– High emotion self-injury reduction in negative affect

• Social influence function– It provides an intense social signal that the

individual needs help– Poorer verbal fluency in NSSI (Gratz, 2006)– This is reinforced and then repeated

New Concept: Indirect Self-injury

• Direct vs. indirect self-injury (Hooley & St. Germain, in press)– Cutting vs. chronic alcohol use, ED behavior,

or remaining in abusive relationships– Person believes they are bad and deserving

of punishment

New Concept: Indirect Self-injuryExamples that Count as Indirect Self-Injury• Clinically significant eating

disordered behavior• Clinically significant

substance abuse• Reckless behavior:

promiscuity with neg physical/psychological effects

• Purposefully not taking meds

Doesn’t Count as Indirect Self-Injury• Occasionally skipping a

meal• Drinking too much at a

party• Two random “hook-ups”

with no notable consequences

• Not taking meds due to expense or lack of access

(Hooley & St. Germain, in press)

Question of the Week

Should Borderline Personality Disorder be reclassified as a mood disorder?Why or why not?

Movie of the Week:Fatal Attraction

starring Glenn CloseMichael Douglas