Borderline Personality Disorder Irving Kuo, M.D. Central Arkansas Veterans Healthcare System

Case Study

A 24 year old separated white female presents to court attempting to obtain custody of her 4 year old child. She has been married for 3 years to a gentleman who she has accused of physically assaulting her throughout their relationship. They have been separated on numerous occasions, during which times she would cut her arms and thighs with a razor blade and she has overdosed on psychotropic medications on 3 occasions.

She has a history of alcohol, cannabis and cocaine use. She has had multiple sexual partners since the age of 13 was sexually abused by her 2 nd and 4 th step-fathers between the ages of She has had 5 psychiatric admissions over the past 5 years for suicide/self-harm behaviors. She has multiple tattoos, including over both wrists covering self-inflicted scars.

Personality Disorder Axis II in DSM Onset in adolescence or young adulthood Stable in appearance Pervasive in effects Impacts functioning in a clinically significant manner

Borderline Personality Disorder Diagnosis – DSM-IV A pervasive pattern of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood. Includes at least 5 of the following diagnostic criteria:

Borderline Personality Disorder Diagnosis – DSM-IV A pattern of intense and unstable interpersonal relationships Frantic efforts to avoid real or imagined abandonment Identity disturbance Impulsivity that is potentially self-damaging Recurrent suicidaal or parasuicidal behavior Affective instability with marked mood reactivity

Borderline Personality Disorder Diagnosis – DSM-IV Chronic feelings of emptiness Inappropriate, intense anger or lack of control of anger Transient, stress-related severe dissociative symptoms or paranoid ideation

Borderline Personality Disorder Reorganized Emotional dysregulation - affective instability - affective instability - problems with anger - problems with anger Interpersonal dysregulation - chaotic relationships - chaotic relationships - fears of abandonment - fears of abandonment Self dysregulation - identity disturbance/difficulties - identity disturbance/difficulties - sense of emptiness - sense of emptiness

Borderline Personality Disorder Reorganized Behavioral dysregulation - parasuicidal behavior - parasuicidal behavior - impulsivity - impulsivity Cognitive dysregulation - dissociative responses - dissociative responses - paranoid ideation - paranoid ideation

Borderline Personality Disorder 11% of psychiatric outpatients and 19% of psychiatric inpatients meet BPD criteria BPD is the personality disorder most associated with suicidal behaviors Patients with BPD % commit suicide % commit suicide - up to 75% attempt suicide - up to 75% attempt suicide % self-mutilate % self-mutilate

DBT Research Findings Multiple studies comparing DBT with treatment as usual for BPD Reduced parasuicidal behaviors, less anger and better social adjustment Fewer psychiatric inpatient days Reduced 12 month healthcare costs

Biosocial Theory of BPD Biological dysfunction of the emotion regulation system Invalidating environment Pervasive emotion dysregulation

Invalidating environment Pervasively negates or dismisses behavior independent of the actual validity of the behavior

Invalidating responses - examples - rejects self-description as inaccurate - rejects response to events as incorrect or ineffective - dismiss or disregard - directly criticize or punish - neglect - pathologize normal responses - reject response as attributable to socially unacceptable characteristic

Parasuicide Intent to cause self-harm Deliberate action Acute injury - tissue damage - ingestion of poisons or drugs over a reasonable prescription - serious risk without outside intervention

Parasuicide Non-deliberate self injuryDeliberate action with intent injure Accident Self Ambivalent Suicide Accident Self Ambivalent Suicide injury suicide attempt attempt PARASUICIDE

Problems Associated with Parasuicide Negative emotional states Interpersonal conflict Being alone Abandonment Life events and changes

Treatment Psychotherapy - Dialectical Behavior Therapy - Dialectical Behavior Therapy - Object relations partial hospitalization - Object relations partial hospitalizationPharmacotherapy

What is DBT? Evidence supported treatment for borderline personality disorder and reduction of parasuicidal behavior Team-based approach Eclectic approach including mindfulness, CBT, skills training with both individual and group therapy modalities

Why DBT? Reduce suicidal and paracuicidal behaviors in BPD patients Cost reduction with reduced ER visits and inpatient hospitalization Reduce suffering and improve psychosocial functioning in BPD patients May extend to other diagnoses – PTSD, substance abuse/dependence

DBT Research Findings Multiple studies comparing DBT with treatment as usual for BPD Reduced parasuicidal behaviors, less anger and better social adjustment Fewer psychiatric inpatient days Reduced 12 month healthcare costs

The Dialectical World View Relationship between parts of the system and the whole – parts and wholes evolves in consequence of the system, and the relationship itself evolves Principle of polarity – reality is comprised of internal opposing forces Principle of continuous change – tension between opposing forces that produce change

Dialectical Synthesis Truth is sought through efforts to discover what is left out of current ways of ordering events – the truth is a synthesis of opposing positions Dialectical lifestyle is walking the middle path with balanced behavioral patterns

A Dialectic: Change vs. Acceptance

Dialectical Dilemmas Emotional vulnerability Emotional vulnerability UnrelentingActive UnrelentingActive crisespassivity crisespassivitybiological social ApparentInhibited ApparentInhibited competence experiencing competence experiencing Self-invalidation Self-invalidation

DBT Treatment Modalities Individual therapy - weekly Group therapy – skills training - weekly Telephone consultation - PRN Consultation team - weekly

Individual therapy Eliciting commitment Diary card and review of target behaviors Chain analysis Contingency management and behavioral skills training Exposure therapy and cognitive modification

Diary Cards Daily monitor of target symptoms and skills usage Target symptoms include: - self harm urge and action - substance use - suicidal ideation - level of misery Allows individual therapist to target most urgent target symptoms for a session

Chain Analysis VulnerabilityProblem behavior VulnerabilityProblem behavior Prompting event Links LinksConsequences

Chain Analysis Analysis is of chain of events moment to moment over time Examine vulnerabilities, antecedents and consequences of problem behavior Allow for determination of patterns of behaviors Examine options for getting on a different path away from problems behaviors

Skills Training Procedures Skills acquisition Skills strengthening Skills generalization

Teach Skillful Behavior to Replace Problem Behaviors Core mindfulness – identity confusion and emptiness Interpersonal effectiveness – interpersonal chaos and fear of abandonment Emotion regulation – affective lability and inappropriate anger Distress tolerance – impulsivity, suicidal threats, parasuicide

Importance of mindfulness Central to the theory and execution of DBT Ability to “be in the moment” Allow distance from emotions and situations Dialectical synthesis of emotional mind and reasonable mind

Skills training Group therapy to learn, strengthen, and help generalize/monitor skills Individual therapy to model skills and help reinforce skills Telephone consultations to generalize skill use into the community

Telephone consultation Availability of therapist via phone Focus on skills generalization Patients are expected to call before they engage in parasuicidal behavior – 24/7 Providing feedback on calls Recognizing therapist limits

Conference to the Therapist Weekly team meeting Confer on treatment Cheerlead and support one another Education Provide dialectical balance

Pharmacotherapy Depends on co-morbid Axis I diagnosis Treat target symptoms - depression - anxiety - brief psychotic symptoms Don’t medicate transient symptoms