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