Borderline PD

BDL Intro Prevalent – 2% Widely studied – more articles than any other

PD Controversial – what is it? High consumers of services 70-75% at least 1 self-injurious act Suicide potential Suffering

Epidemiology

DSM-IV-TR : 2% 10% of outpatients 20% of inpatients

Synopsis of Psychiatry : 1-2%

Torgensen (2001): 0.7%

Borderline PD

Neurosis Psychosis

Borderline

Cullen, 1807

Kernberg, 1967Sense of Identity is Weak

Reality Testing is Preserved

Knight, 1953Form of Schizophrenia

DSMMore AffectiveThan Psychotic

Borderline PD

Gunderson and Singer, 1975

ImpulsivityBrief psychotic EpisodesManipulative Suicide GuesturesPoor Work HistoryAdequate SocializationDepressed mood in face of rejection

Borderline Syndrome

DSM Core Definition

Instability interpersonal relationships self-image affects

Impulsivity

DSM Criteria – 5/9 Frantic efforts to avoid real or imagined abandonment Unstable and intense interpersonal relationships Markedly and persistently unstable self-image or sense

of self Impulsivity in areas that are potentially Recurrent suicidal gestures, threats, or self-mutilation Affective instability or anxiety  Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling

anger Paranoid ideation or severe dissociative symptoms

2-3%

3:1 Women to Men

Stone, 1993 – BDL TRAITS alternating adoring and contemptuous,

chaotic, childish, clingy, cranky, demanding, going to extremes, fickly, fragile, hostile, inconstant, *irritable, manipulative, flighty, *mercurial, moody, possessive, reckless, restless, seductive, shallow, unpredictable, *unreasonable, volatile

*jealous

 DSM-IV  ICD-10

 Avoidant PD  Anxious PD

 Antisocial PD  Dissocial PD

 Borderline PDEmotionally UnstableType 1: impulsiveType 2: borderline

 Dependent PD  Dependent PD

 Histrionic PD  Histrionic PD

 Narcissistic PD  no equivalent

 Obsessive Compulsive PD  Anankastic PD

 Paranoid PD  Paranoid PD

 Schizoid PD  Schizoid PD

 Schizotypal PD  no equivalent

 

ICD - BDL• Impulsive type - 3 of following, one of which must be *

• acts unexpectedly without consideration of the consequences• *quarrelsome behaviour, conflicts with others• outbursts of anger or violence, with inability to control behavior• difficulty in maintaining any course of action that offers no immediate reward• unstable mood

ICD - BDL• Borderline type - At least 3 of the following:

• disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);

• intense and unstable relationships, often leading to emotional crisis• excessive efforts to avoid abandonment• recurrent threats or acts of self-harm• chronic feelings of emptiness

BDL as style Mercurial

always romantically attached intense, emotionally active and reactive Uninhibited, spontaneous high energy, open-minded

style

disorder

Does not represent a distinct taxon

History

Hoch and Polatin (1949) – “pseudoneurotic schizophrenia”

Also called latent and simple schizophrenia

DSM-III (1980) - BDL first appeared as category

DSM-IV – addition of criterion 9

Linehan (1980s and 1990s) - developed DBT (dialectical behavior therapy) for the treatment of this condition

Kernberg (1967) – “borderline personality organization”(see next slide)

Kernberg

• Psychotic Personality Organization

• Identity Diffusion• Primitive Defenses• Loss of Reality Testing

• Not PDs, but atypical psychosis

Kernberg

• Low Borderline Organization

• Identity diffusion• Primitive defenses• Reality Testing is intact• Distortions in the interpretation of others• Lack of consistent goals• Lack of direction in their lives

Kernberg

• Low Borderline Organization• All severe PDs here• Superego deterioration

• High Borderline OrganizationBetter social and work adaptation

Different types of PDs

Kernberg

• Neurotic Organization• Normal identity• Anxiety tolerance• Effective work, capacity for love

• “unconscious guilt feelings” in relation to sexual intimacy

Kernberg

• Schizoid and BDL simplest PDs

• Schizoids – Introversion• Pathology in fantasy life and social withdrawal

• BDL – Extraversion• Pathology in impulsivity and social interactions

Co-morbidity

BDL

Substance Use Mood

Psychosis

AnxietyEating Sexual

Dissociation

Impulse

ASPD

AVD

PAR

DEP

90% have two diagnosis, 40%+ have three or more

Oldham et al. 1992 Profile 1 BDL plus

NAR ASPD HIS

Profile 2 BDL plus

DEPRESSIVE AVD PASSIVE-

AGGRESSIVE

BORDERLINE

SCHIZOID

CLUSTER B

CLUSTER C

Prognosis (Stone, 1993)

20s – do poorly 30s to 40s – mellowing

50s – outcome variable Poor Prognosis

Divorce and lack of support *Hostility

Borderline PD and Movies

Unpredictable Emotional Vindictive Intense

Main characters –female

Media Examples

*Fatal Attraction Glenn Close’s character

Single White Female Jennifer Jason Leigh’s character

Fatal Attraction DVD Scenes 7:00 – 8:00 13:00 – 16:50 18:29 – 19:00 24:44 – 39:00 48:00 – 49:27 54:15 - 59:45 1:04:24 – 1:11:23 1:14:34 – 1:20:40 1:41:18 – 1:44:00 1:50:00 – 1:52:50

Etiology

No single explanatory factor

Etiology

lots of opinions...

biological genetic basis temperamental factors? dysregulation of serotonin? limbic system abnormalities?

Torgersen, 2000 – 0.69 heritability

Etiology

Separation and Loss

Lengthy separations from parents 20 - 40% have experienced loss

Tend to have fewer children by age 30(Stone, 1990) 9/78

Etiology Repetitive abuse

Cumulative Trauma

Physical, sexual, and emotional

Increases risk for all PDs Especially Cluster B Abuse does not equate to PDs

Etiology Family Environment

Unstable, nonnurturing

tendency to misunderstand people’s intentions is correlated with number of times family moved

(r = .5)

Interaction between sexual abuse and unstable family predicts BDL

Etiology Faulty attachment, unstable family predicts

BDL

Sexual abuse predicts severity of symptoms Self-mutilation, suicide attempts,

promiscuity

Etiology Different types of Trauma

Type I – incidental life events Type II – emotional, verbal abuse Type III – clear sexual, physical abuse

50% BDLs Type I and or Type II 50% BDL Type III

Etiology Attachment Theory (Bowlby)

Types (Ainsworth) Secure Avoidant Ambivalent/Resistant/Anxious*

Disorganized* (Main)

Etiology

Cognitive factors

Recall bias – operates to color childhood memories to reflect how things are going in the present

Psychoanalytic Mahler

Fixated at rapproachement subphase of separation-individuation

Failure to develop object constancy

Transitional objects – that which provides security – e.g., stuffed animal

Evolutionary Psychology

Evolutionary Psychology

Subtypes

Discouraged (avd, depressive, dep) Petulant (negativistic) Impulsive (histrionic or antisocial) Self-destructive (depressive,

masochistic)

Marsha Linehan’s Theory

Highly Emotional Vulnerability

Poor Emotional Regulation

Emotional Dysfunction (biological)

Invalidation(environment)

Emotional Instability

Theory

Emotional Instability

Interpersonal Behavioral

SelfCognitive

Assessment

0

30

60

90

120

150

180

210

240

270

300

330

0 11 SDFPAR

AVD

HIS

DEPSZD

ANT

NAR

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming-Ingenuous

Aloof-Introverted

Arrogant-Calculating

N E O A CSZD L

AVD H L

DEP H

HST H

NAR H h l

ANT L L

COM h

SZT H L l

BDL H l l

PAR h L

See commentary below slide to understand letters and numbers

depression

compliance

deliberation

Assessment

MMPI: 3, 4, and 7

MCMI-III: BDL, DEP, HIS

Diagnostic Interview for BDL PD (DIB) Gunderson and others

Interview Considerations

Interview Considerations

1) appear normal 2) remarkably regressed

often verbal

intense affect and state of turmoil

Interview Considerations need to establish a good working relationship avoid misunderstandings set clear limits in therapy

transference issues patients get involved with their therapists boundary issues

countertransference issues therapists react – due to idealization and devaluation overprotection and rejection

seek regular consultation...

Interview Considerations difficult to keep these patients on track

a number of crisis to therapy

intense anger directed at therapist and others

micropsychotic episodes can occur

very challenging

suicidal behavior, phone calls, self-mutilation

Interview Considerations Chaotic Childhood Disrupted education Parental neglect and abuse Legal difficulties Marked impulsivity Substance problems Suicidal ideation (10% completed suicides) Poor Boundaries

Inpatient Management Reason?

Chronic destructive acts Wrist slashing, cutting, burning 75% use multiple methods (Hull, 1996)

24-72 hours sufficient

Repeated Admissions: (Hull, 1996) Suicidality, psychotic symptoms, anorexia nervosa

Predictors of multiple admissions

Zanarini (2001) Age 26+ Psychosis Number of self-mutilations Number of suicide attempts Childhood sexual abuse Adult physical and sexual assault

Long-term Inpatient Factors

Repeated hospitalization failures Co-existing Axis I conditions Escalating violent or self-

destruction Psychotic symptoms No support Substance withdrawal Overwhelming loss

Defenses Splitting abruptly switch alliances

idealize then devalue best therapist (builds your ego) to worst therapist

a) intrapsychically within oneself (I am bad, I am good)

b) interpersonally relative to others (she is good, you are bad)

c) transpersonally occurs when the patient’s intrapsychic organization gets

played out by others

TREATMENT

DBT Marsha Linehan

Dialectics

Technology of Change But clients sensitive to change

Technology of Acceptance

Dialectics

Defined: A process of achieving balance

Change/Acceptance Problem-solving/Validate Irreverence/Warmth Intervention/Consultation

Modes of Therapy

Individual

Group skills

Others Pharmacotherapy, Inpatient Outpatient, Support Groups Telephone calls, Consultation

Modes of Therapy Individual Therapy

Primary Therapist Orient patient to therapy Agree on treatment goals Target all life threatening behaviors Address quality of life issues Therapy interfering behaviors

(client.therapist) Generalize skills to everyday life

Core Strategies

Validate patient’s problems Empathy, listening, reflecting back Plus – validation of the present The grain of truth in present

Teaching new ways…

Teach ways to solve problems Behavioral analysis

What happened?

Solution analysis What could we do differently? Get client to commit to new solution.

Irreverence Confrontation, blunt, direct

Well-received by clients

Off the wall, outrageous Don’t sensor everything Paradox, exaggerating parts Used to push client Use carefully

Reciprocal Communication

Throw client off balance- “a dance”

Warmth, vulnerable (to be touchable)

Irreverent Model someone who is

Group Sessions

Psychoeducational training sessions

Replace negative emotions, beliefs, and behaviors with positive ones

Consultation Why? – therapist gets affected

Reinforces therapist for doing ineffective treatment, and punished for being effective

Therapist slides from effective to ineffective

Team Approach – provides balance, to reinforce therapy, provide feedback, reinforce therapist

Weekly component to therapy

Outcome Data

Lots of ideas on how treat PDs

DBT is the most thoroughly articulated treatment approach

DBT has empirical support

Pharmacotherapy

Antidepressants SSRIs, Tricyclics, MAOIs

Mood stabilizers lithium

Anxiolytics Benzodiazepines

Antipsychotics Clozapine