borderline personality disorder. formerly called latent schizophrenia added to dsm iii (1980) as bpd...
TRANSCRIPT
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