Borderline Personality Disorder Dr. Matthew Sager Psychiatric Medical Director St. Mary’s Hospital, Madison, WI

Borderline Personality Disorder (BPD) What is it? Perceptions and current diagnosis History Causes Facts Co-occurring diagnoses and differential Treatment Evaluating safety concerns/suicidality

BPD Initial impressions Stigma Better descriptive terms? Emotional Regulation Disorder

Current Diagnosis DSM IV-need to have 5 of 9 criteria (pervasive) Unstable relationships-splitting example Impulsive behaviors Mood swings Intense anger Feelings of emptiness Fear of abandonment Identity disturbance, ‘poor sense of self’ Suicidal behavior or self-injury Transient paranoia/dissociative states

Diagnostic Issues Problems with DSM IV 5 of 9-there are 256 different variations 4 of 9-no diagnosis, but would look very similar clinically DSM V Revisions to look at dimensional aspects of personality BPD on same axis as depression, anxiety In end-too complex for clinical practice-yet

Diagnostic Issues cont.’ Issues that affect making diagnosis: Transient states Medical illnesses Situational stress Sex and cultural beliefs/biases Clinician feelings-anger, disappointment, frustration

Diagnostic Issues cont.’ In the end-the diagnosis focuses on ways of thinking and feeling about oneself and others that ends up affecting a persons ability to function

BPD History 1930s Psychoanalysts (i.e. Sigmund Freud) divided psychosis (delusions, hallucinations) from neurosis (anxiety/distress). The area between, the borderline was the difference that explained why some patients did not act one way or the other. 1960s Psychiatrist Otto Kernberg personality organization to syndrome to disorder

BPD History cont.’ 1980s and 90s Increased research From analytical to medicalization DSM III (1980) DSM IV (1994) DSM V (2013)

BPD Causes Genetics Environmental Social and cultural factors Twin studies show strong inheritance Environmental Unstable family relationships Social and cultural factors 1900s-less unstructured time with more work/survival instincts i.e. Eating Disorders indifferent countries

BPD Causes Abnormal Brain functioning Amygdala – center of emotion Prefrontal Cortex – complex problem solving

BPD Whatever the cause, data shows the impact of this illness

BPD Facts 2% of US population have BPD (equal to population of New York City) Twice that of bipolar disorder or schizophrenia 10% of mental health outpatient clinics 20% of inpatient psychiatric hospital units

BPD facts 75-90% of those diagnosed are women Do women seek treatment more than men? Men with similar symptoms may end up in jail or with another diagnosis. 10% complete suicide in their lifetime Comorbidities are rampant-mood disorders (depression, bipolar) anxiety disorders (PTSD) and substance abuse disorders Probably ‘burns out’ or dissipates over time

BPD Facts Face Studies: people with BPD are inclined to see anger in neutral emotion faces Word Studies: people with BPD are inclined to attach a stronger reaction to neutral words

Comorbidities and differential diagnoses Mood Disorders (bipolar disorder I and II, major depression, dysthymia) Anxiety disorders including PTSD Eating Disorders Substance Abuse Disorders Other personality Disorders

Comorbidities and differential Lots of overlap with impulsive behaviors and mood instability Different diagnoses from different providers

Explaining diagnosis John Gunderson MD quote As an example that focuses on jargon free explanation that patients can understand

BPD Treatment BPD-High utilization of health care $ ER visits, inpatient medical/psych care Hallmark of good care-multiple modalities Alliance building to foster improved mood, behavior, social functioning and relationships

Treatment Goals Containment of any safety issues Structure Provide support Involve patient in decision making Validation

Treatment Levels Hospital ‘Step Down or Up’ Partial hospital(PHP) or Intensive Outpatient Program(IOP) Outpatient Therapy + Med Management Sociotherapies (group, family)

Treatment Levels Focus on the least restrictive means of effective treatment

BPD Treatment Hospital care Often contraindicated and can worsen behavioral issues Hospital provides external control which can become habit forming and cause BPD patient to attempt to gain control in negative fashion Should be used only for acute safety stabilization

BPD Psychotherapy Mainstay of BPD treatment Specific types may be more effective

BPD Psychotherapy DBT (Dialectical Behavioral Therapy) Pioneered by Marsha Linehan PhD Focuses on mindfulness, acceptance and awareness of situations and feelings decreases intensity of emotions

BPD Psychotherapy CBT(Cognitive Behavioral Therapy) Focus: Changing thinking will change behavior Skill building/practice Relaxation Exposure therapy

BPD Psychotherapy Schema therapy Reframing ways people view themselves

BPD Psychotherapy Group Therapies Interpersonal Family DBT Others (problem focused)

BPD Medications Role of meds: manage symptoms, though benefit is often uncertain due to ‘symptom chasing’ Goal is to treat comorbidities Avoid dependence, abuse, risk of overdose Classes: Antidepressants Antipsychotics Mood stabilizers Anti-anxiety AODA meds-antabuse/naltrexone/methadone

BPD Medications Treat comorbidities!

Treatment Plans Contracts with patients Makes expectations explicit From Crisis Intervention, when to call providers, when to go to hospital to roles of those involved i.e. family/friends

BPD Safety issues Suicide and borderline personality 10% completed lifetime Safety plans-limited pill supply, family support, crisis contact Highest risk are those with depression and alcohol/drug problems

BPD safety issues ‘Feeling Unsafe’ Goal is for patient to recognize when they need more active help and trust they will get it Typical Crisis-express concern, allow patient to ventilate, avoid taking actions but let patient be explicit about situation Follow-up after crisis

BPD and suicidal acts John Gunderson, MD “Suicidal acts are a dangerous distraction from the patient working on attaining a better life”. Dr Gunderson views suicidal statements/acts as affecting a patient’s dependence on others and an effort to be cared for.

BPD References: 1. Gunderson, John G, M.D. ‘Borderline Personality Disorder A Clinician’s Guide’, 2001. 2. DSM IV, American Psychiatric Association, 2000. 3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.