chapter 14: borderline personality disorder (bpd) jill m. hooley sarah a. st. germain

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Chapter 14: Borderline Personality Disorder (BPD) Jill M. Hooley Sarah A. St. Germain

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Chapter 14:Borderline Personality Disorder (BPD)

Jill M. Hooley

Sarah A. St. Germain

Diagnosis: Personality Overview

Lack of stable self-image, goals, relationships, and mood

Impulsive, erratic, risk seeking, and antagonisticTrouble with understanding the emotions and

desires of others, especially when threatenedMistrustful, demanding, and fear of

abandonmentFrequently sad, hopeless, pessimistic, and

ashamed

Diagnosis: Symptom Criteria

Pervasive and present since adolescenceFive or more of the following (no change in DSM-5)

Frequent feelings of emptinessDesperate attempts to avoid abandonment (real or otherwise)Unstable and intense relationships with periods of idealization and

deprecationPotentially self-harming impulsive behavior in at least two areasRecurring suicidal threats, gestures, or behavior, or self-mutilationUnstable mood, (especially frequent marked sadness, irritability, and

anxiety) that resolves in hours or a few daysDisproportionate, intense anger, or difficulty suppressing angerNotable and sustained lack of stable self-image or sense of selfShort, stress-induced paranoid thought or significant dissociative

symptoms

Diagnosis: Comorbidity and Heterogeneity

Significant comorbidityMajor depressive disorder (~61%)Dysthymia (~12%)Bipolar disorder (~20%)Eating disorders (~17%)PTSD (~36%) Substance abuse (~14%)

9 possible symptoms x 5 required symptoms = 126 possible symptom combinations will all get the diagnosis

Symptoms: Psychosis Like Experiences

~75% of patients report paranoid ideas and/or dissociative episodesStress-related psychotic episodes

BPD hallucinations and delusions differ from those in psychotic disordersUsually more insight than psychotic patientsParanoid ideas typically not so firmly held that they reach

delusional levels Dissociation episodes relatively brief and stress-related

Symptoms: Self-Harm

In some cases, suicidal and self-injurious behaviors are used as strategies to regulate strong negative emotions

Self-harm behaviors are most oftenCuttingBurning

Prognosis

Utilize significant treatment resources10% will successfully commit suicideAfter 2 years 30% will achieve lasting remission,

80% after 16 yearsHowever, rate of lasting recovery (e.g., symptom

remission + good functioning) after 16 years is 40% Positive indicators: Youth, no history of childhood sexual

abuse, no family history of substance abuse, good recent work history, agreeable temperament, low neuroticism, and low anxiety

Epidemiology

Prevalence in the general population: 1% to 2%

Prevalence in outpatient samples: 10% to 15%

Long-held belief that BPD is more common in women than in men, that is approximately 75% of cases However, population-based studies report no gender

differences in the prevalence of BPDMay be due to the fact that women are more likely to

seek treatment

Etiology: “Core Features of BPD”

LinehanAffective instability

Bateman and FonagyInstability in the self-structure

GundersonFear and intolerance of aloneness

Neurobiological FrameworkDisinhibition and general negative affectivity

Zanarini, Frankenburg, Hennen, and Silk Negative affectivity/dysphoria

Even though BPD is common, it is far from being clearly conceptualized and is likely multi-\dimensional

Etiology: Constitutional Aggression and Family

Interferes with integration of different perspectives (positive and negative) of the self and others.

Good representations are threatened by strong negative feelings such as rage or hostility

Borderline patients lack the ability to call upon memories of “good objects” (e.g., nurturing and empathic caretakers) to provide self-soothing in times of distress

Etiology: Linehan’s Biosocial- Developmental Model

Biological or temperamental vulnerabilities interact with failures in the child’s social environment to create or exacerbate problems with emotion regulation

Key environmental factor is an invalidating family environmentChild’s communications of actual internal experiences are

met by parental responses that are inappropriate, erratic, or out of touch with what is happening to the child• Child: “I’m hungry.”

Parent: “No you aren’t. You don’t want to eat that.”

Etiology: Trauma

Often high levels of early life trauma and adversity.

Compared to patients with other Axis I and Axis II disorders, patients with BPD are significantly more likely to report physical abuse, sexual abuse, or neglect during childhoodThose who experienced early abuse or neglect more

than 7x more likely to be diagnosed with BPD later on

Etiology: Attachment

Vast majority are insecurely attached; only minority (6% to 8%) have secure attachment pattern

Often emotionally attached to artificial safe and stable attachment objects such as stuffed animals, even in adulthood

Patients with BPD struggle to sustain a mental representation of their clinician as helpful and the treatment relationship as caring and supportive

Etiology: Executive Neurocognition (EN)

Executive Neurocognition (EN): Family of cognitive processes that delay or terminate a response in order to achieve a less immediate goal/rewardInterference Control: Conscious attempt to control

attention and motor behaviorCognitive Inhibition: Suppress information from working

memoryBehavioral Inhibition: Repressing frequent response

(e.g., hit spacebar for every letter except “Y”)Motivational or Affective Inhibition: Interruption of

tendency or behavior arising from an emotional state

Etiology: Executive Neurocognition (EN)

BPD patients show deficits on tasks tapping EN processes

Symptom severity correlated with deficitMay be partially explained by depressive

symptoms

Impairments in immediate and delayed memory linked to increased impulsivity

Biological Etiology: Heritability

Monozygotic twin concordance rate = 35% Dizygotic = 7%

Prevalence rate for BPD in relatives is 3.4 % when the relatives are assessed in person (15.1% when patient report is used) BPD traits more common in relatives than diagnosis itself

• Neuroticism, cognitive dysregulation, anxiety, affective lability, and impulsivity

Relatives also show increased rate of mood and anxiety disorders, impulse control disorders, and personality disorders such as antisocial PD

Biological Etiology: Role of Serotonin System

Serotonin related genes associated with BPD type behaviors, for example, suicide, impulsivity, and emotional lability

Physical and sexual abuse history in BPD women associated with reduced response to serotonin agonist challenge Suggests reduced receptor activity

Low levels of 5-hydroxyindolacetic acid (5-HIAA; metabolite of serotonin) associated with increased risk of impulsive aggression and suicide (especially violent forms of suicide)

Biological Etiology: Dopamine and Novelty Seeking

High novelty seeking (associated with BPD) is related to altered dopaminergic function in the brain. High levels of comorbidity between substance abuse

disorders and BPD9 repeat version of DAT1 gene is more likely to be found

in depressed patients with BPD then those without BPD Antipsychotic medications, which block dopamine

receptors, clinically benefit BPD patients

Biological Etiology: Neuroanatomy

Orbital frontal cortex (OFC): Plays a role in emotion regulation, the stress response, and impulse controlBPD is associated with lower metabolic activity in the OFC

Abnormalities in frontolimbic circuitry may underlie many of the key clinical features of BPD

Treatment

Treating patients who suffer from BPD is not easySelf-harming behaviors in 60% to 80% of casesMean number of lifetime suicide attempts is 3.4

Difficulty establishing trust and therapeutic alliance

Effective treatment may require long-term and intensive treatment

Treatments: Medications

SSRIs may help with mood stability; however, benefits are usually modest

Antipsychotic medications have beneficial effects on impulsivity and aggressionSignificant side effects (weight gain, etc.) limit usefulness

Mood stabilizers, for example divalproex sodium, help with anger and mood instabilityDo not help impulsivity, aggression, or socialityLithium not shown to be effective

Treatments: DBT

Developed by Marsha Linehan specifically to treat BPD

Cognitive behavioral approachWeekly psychotherapy Weekly skills training in group formatTherapist available 24 hours by phoneTherapist attends weekly team

consultation meetings

Treatments: DBT Efficacy

Improves mood and symptomsReduces suicidal ideation and increases

will to liveReduces self-injurious behaviors Reduces suicide attempt rate when

compared with expert non-DBT treatment (~23% vs. 46%)

Less likely to drop out and less likely to require hospitalization

Treatments: Psychodynamic Approaches

Mentalization TherapyBased on attachment theory Use therapeutic relationship to help patient develop skills to

understand emotions of themselves and othersEfficacy shown in double-blind trials and maintained for years

afterward

Transference Focused Psychotherapy (TFP)Use therapeutic relationship to understand and correct distortions

in perceptions of othersPrimary techniques: Clarification, confrontation, and interpretationImproves depression, anxiety, anger social adjustment, overall

functioning, suicidality

Treatment: Schema Focused Therapy (SFT)

Uses CBT techniques to modify constellations of underlying beliefs (i.e., schemas)

Prevents maladaptive schemas from distorting perceptions and causing maladaptive behavior

Decreases symptoms, improves quality of life, and decreases dysfunctional behaviors

May be more effective than transference-focused psychotherapy: less dropout, greater success rates