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

Treatment of Borderline Personality Disorder Sadie Cole, M.A. Abnormal Psychology Harvard University Department of Psychology November 19 th, 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 THESISANTITHESIS SYNTHESIS

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 Mindfulness Distress Tolerance Emotion Regulation Interpersonal 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 disorder  DSM-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 (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-injury Examples 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 Close Michael Douglas