1. Assessing Borderline Personality Disorder in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 11/13/2014

2. Disclosures and Learning Objectives Learning Objectives – Be able to list the diagnostic criteria for Borderline Personality Disorder – Know at least 3 mental health comorbidities of BPD – Know at least 3 physical health comorbidities of BPD Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

3. Assessing Borderline Personality Disorder Review epidemiology Review mental health comorbidities Review physical health comorbidities Review Prognosis Review diagnostic criteria Next Week's Topic

4. Borderline Personality Disorder 1-4% of the general population 8-27% in outpatient mental health (15-51% inpatient) 6% of a primary care clinic population (or 26%???) – 21% current suicidal ideation – 21% Bipolar Disorder – 36% Major Depressive Disorder – 57% Anxiety Disorder – 50% had no mental health treatment that year – 43% not recognized by PCP has having any emotional or mental health problems. http://archinte.jamanetwork.com/article.aspx?articleID=210746

5. Borderline Personality Disorder Co-Occurs 60% have MDD 70% have Dysthymic Disorder 25% have Eating Disorders 35% meet criteria for Substance Abuse 15% Bipolar Disorder 25% Antisocial Personality Disorder 25% Narcissistic Personality Disorder Up to 80% have suicidal behaviors 4-9% die from suicide http://www.nimh.nih.gov/health/publications/borderline-personality- disorder/Borderline_Personality_Disorder_508_141959.pdf http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54& ContentID=44780

6. Borderline Personality Disorder Higher rates of common health problems – Diabetes – Hypertension – Chronic Back Pain – Arthritis – Fibromyalgia May be due to medication-induced obesity http://www.nimh.nih.gov/health/publications/borderline-personality- disorder/Borderline_Personality_Disorder_508_141959.pdf http://www.nimh.nih.gov/health/publications/borderline-personality- disorder/Borderline_Personality_Disorder_508_141959.pdf

7. Borderline Personality Disorder Fewer PCP visits per year Lower mental/emotional health ratings Similar physical health self-rating Much higher rates of hospitalization Much higher rates of mental health care Much higher rates of psychiatric medications http://archinte.jamanetwork.com/article.aspx?articleID=210746

8. Borderline Personality Disorder, Prognosis First five years are most crisis-ridden 60% readmitted within the first 6 months 35% readmission in 18-24 months 40-50% remission in 2 years 85% remission in 10 years After remission, only 6% relapse 25% achieve social stability http://www.borderlinepersonalitydisorder.com/documents/A_BPD_Brief_REV2011.pdf http://www.nimh.nih.gov/health/publications/borderline-personality- disorder/Borderline_Personality_Disorder_508_141959.pdf

9. Borderline Personality Disorder, DSM-IV TR A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Frantic efforts to avoid abandonment A pattern of unstable, intense relationships Identity disturbance Impulsivity in potentially damaging areas Recurrent suicidal behaviors Chronic feelings of emptiness Inappropriate intense anger or difficulty controlling anger Transient paranoia or severe dissociative symptoms http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe rsonalidad_psicosis/material/dsm.pdf

10. Borderline Personality Disorder, DSM-5 Impairments in personality (self and interpersonal) functioning AND the presence of pathological personality traits. These criteria must be met: Significant impairments in personality functioning Impairments in self functioning (a or b) Identity (unstable self image, chronic emptiness, dissociative states, self-criticism) Self-direction (instability in goals, aspirations, values or career plans) AND Impairments in interpersonal functioning (a or b) Empathy (and hypersensitivity) Intimacy (intense, unstable, and conflicted close relationships, alternating extremes) Pathological Personality Traits in the following domains Negative Affectivity, characterized by Emotional lability Anxiousness Separation insecurity Depressivity http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe rsonalidad_psicosis/material/dsm.pdf

11. Borderline Personality Disorder, DSM-5 Disinhibition, characterized by Impulsivity Risk-taking Antagonism, characterized by Hostility These impairments are relativity stable across time and consistent across situations The impairments are not better understood as normative for developmental stage or socio-cultural environment The impariments are not solely due to the direct physiologic effects of a substance or a general medical condition http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe rsonalidad_psicosis/material/dsm.pdf

12. Summary Borderline Personality Disorder – More common in Primary Care settings – Commonly misunderstood – Can disrupt care Borderline Personality Disorder – Gets better! – Accurate recognition increases chances for recovery http://www.nami.org/Template.cfm?Section=Borderline_Personality_Disorder_(BPD)&Template=/ContentManagement/ ContentDisplay.cfm&ContentID=81017

13. The End! Next Week's Topic: Treatment of Borderline Personality Disorder