BORDERLINE PERSONALITY

DISORDERCorrections & Mental Health

HISTORY: WHERE DID BPD COME FROM? Nineteenth Century, “borderline” described a

condition that was “fuzzy” between two different psychiatric problems.

Bordered on or overlapped with schizophrenia and non-schizophrenic psychosis. “Wastebasket diagnosis”

Category 1: neurosis, patients aware of reality but had emotional problems (i.e., depression, anxiety).

Category 2: psychosis, patients who had unusual thoughts/experiences (hallucinations) not based on reality. These patients were diagnosed with disorders such as schizophrenia.

Psychiatrist used the term “borderline” for patients who had a hard time seeing both the good and bad qualities in people who led unstable and chaotic lives.

Problems not serious enough to be labeled psychotic, but too troubled to be neurotic.

WHAT IS IT? Borderline Personality disorder- A person

with borderline personality disorder often experiences a repetitive pattern of disorganization and instability in poor self image, mood, behavior, and personal relationships.

Can cause distress with friendships and work

SYMPTOMS Fear of being abandoned May have trouble with anger (have an

outburst, or scared of anger that they avoid it)

Have difficulty trusting others Manipulative Frequent shifts of lonely depression to

irritability and anxiety Unpredictable and impulsive behavior such

as: excessive spending, gambling, promiscuity, gambling, substance abuse, shoplifting, over-eating, and self-damaging actions.

WHO CAN DIAGNOSE BPD? A mental health professional

experienced in diagnosing and treating mental disorders

1. psychiatrist 2. psychologist 3. clinical social worker 4. psychiatric nurse Thorough medical exam can help to rule

out other possible causes of symptoms.

ETIOLOGY: WHAT CAUSES BPD? Unsure of the exact and precise causes-not

fully understood???? Factors: Genetics, Biological,

Environmental, and brain abnormalities. Genetics- Inherited among family members Biological- 60% of research suggest the

risk of developing BPD conveyed through genetic abnormalities. These abnormalities appear to effect the functioning of brain pathways that control the behavioral functions and emotion information, processing, impulse, and cognitive activity.

ETIOLOGY CONT; Environmental- poor parenting, early

separation from parents, emotion/physical/sexual abuse, incest.

DSM IV CRITERIA: A pervasive pattern of instability of

interpersonal relationships, self-image, affects, and marked impulsivity beginning by early age adulthood. Present by in a variety of context as indicated by five (5) or more below:

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes idealization and devaluation

DSM IV CONT; 3. Identity disturbance, markedly and

persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging

5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior

6. Affective mood instability

DSM IV CONT; 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or

difficulty controlling anger 9. Transient, stress related paranoid

ideation or severe dissociative symptoms

Must have 5 out of 9 criteria

STATISTICS BPD rarely stands alone. Typically co-

occurs with other disorders (i.e., Bipolar, depression, substance abuse)

BPD affects 1-2% of the population Estimates 10% of outpatients and 20%

of inpatients who present for Tx have BPD.

More females are diagnosed with BPD than males, 3 to 1.

STATISTICS CONT; Women's co-occuring disorder are

usually linked with major depression, anxiety d/o, or eating d/o. Men are linked with substance abuse or anti-social personality disorders

75% of patients self-injure Approximately 10% of individuals with

BPD complete suicide Up to 80% of people with BPD having

suicidal behaviors

CO-OCCURING D/O’S Major Depressive- 60% Dysthymia- 70% Eating Disorder- 25% Substance Abuse- 35% Bipolar Disorder- 15% Antisocial- 25% Narcissistic- 25%

STATISTICS CONT; 75-90 % of those diagnosed are women. Affects 6-10 million of Americans- or

about the size of New York City (twice that of Bipolar and Schizophrenia).

33% of youth who commit suicide have features or traits of BPD; this number is 400 times higher than the general population and young women with BPD have suicide rate of 800 times higher.

SUICIDALITY AND SELF HARMING BEHAVIOR Common dangerous and fear inducing

feature of BPD are self harming behaviors (cutting, burning, hitting, head banging, hair pulling).

Physical self harm generates a sense of relief to alleviate emotional pain.

This occurs by stimulating the production of endorphins. The release of the endogenous opiates produced by the brain provide a reward to the “self-inflicting” behavior.

TREATMENT: PSYCHOTHERAPY & MEDICATION MANAGEMENT Medications: Most effective when used in

conjunction with psychotherapy. Reduces symptoms of BPD, does not treat BPD

itself. Medications serve to improve chemical processes

required for optimal brain function. Anti-psychotic and Mood Stabilizers most useful.

Anti-depressants: 1. Nardil (phenelzine 2.Prozac (fluoxentine) 3. Zoloft (sertraline) 4. Effexor (venlafaxine) 5. Wellbutrin (bupropion)

MEDICATIONS:

Anti-Psychotics: 1. Haldol (haloperidol) 2. Zyprexa (olanzapine) 3.Clozaril (Clozapine) 4. Seroquel (quetiapine) 5. Risperdal (risperidone)

Mood Stabilizer: 1. Lithobid 2. Depakote

MEDICATIONS:

3. Lamictal 4. Tegratol

Anxiolytics (Anti-anxiety): 1. Ativan (lorazapam) 2. Klonopin (clonazpam) 3. Xanax (alpazolam) 4. Valium (diazepam) 5. Buspar (buspirone) Anxiety to treat anxiety symptoms, not BPD. Caution for SUD; benzodiazepines

PSYCHOTHERAPY: Dialectical behavior therapy (DBT) Cognitive behavioral therapy (CBT) Schema-focused therapy Mentalization Based Therapy Transference Focused Psychotherapy General Psychiatric Management Systems Training for Emotional

Predictability and Problem Solving (STEPPS)

PSYCHOTHERAPY: WHAT IS DBT? A modification of CBT for the treatment of

chronically suicidal and self-injurious individuals with BPD.

DBT differs from traditional CBT in its emphasis on validation. The therapist and patient work on “accepting” uncomfortable feelings, thoughts, behaviors v.s. struggling with them.

Once an identified thought, emotion, behavior is validated, the process of change no longer appears impossible, and the goals of gradual transformation becomes reality.

DBT focuses on developing coping skills.

DBT- WHAT DOES DBT ACCOMPLISH???

1. Decrease the frequency and severity of self destructive behaviors

2. Increase motivation to change 3. Teach new coping skills 4. Provide treatment environment that

emphasizes the strengths of both individual and their treatments.

5. Enhance therapist’s motivation to treatment the client effectively

PSYCHOTHERAPY: WHAT IS CBT? A form of treatment that focuses on

examining the relationship between thoughts, feelings, and behaviors.

Explore patterns of thinking that lead to self destructive actions and the beliefs that direct these thoughts, people can modify their patterns of thinking to improve coping.

Involves homework Can be used in a variety of disorders

such as mood disorders, anxiety, personality, eating, sleep, and psychotic, and substance abuse.

PSYCHOTHERAPY: SCHEMA-THERAPY An integrative approach to treatment that

combines the aspect of cognitive behavioral, experiential, interpersonal, and psychoanalytic therapies into one model.

Focuses on self-defeating, dysfunctional, and negative patterns/thoughts & feelings that have been an obstacle for accomplishing goals in life.

3 stages: 1.assessment phase- identify schemas 2.emotional awareness & experiential phase 3. behavioral change phase

PSYCHOTHERAPY: MENTALIZATION Mentalization Therapy- The process by

which we makes sense of each other and ourselves, implicitly(implied, indirect) and explicitly(direct, demonstrated, nothing implied).

The object of treatment is that BPD patients increase mentalization capacity which should improve affect regulation and interpersonal relationships.

PSYCHOTHERAPY: TRANSFERENCE-FOCUSED PSYCHOTHERAPY Highly structured, twice-weekly modified

psychodynamic treatment. It views the individual with borderline personality D/O as holding unreconciled and contradictory internalized representations of self and significant others. The defense against these contradictory internalized views leads to disturbed relationships with others and with self.

The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference).

The intended aim of the treatment is focused on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

WHY IS BPD A PROBLEM??? BPD Is one of the top reported disorders

prison inmates are diagnosed with linking the disorder with criminal behavior.

25-50% of inmates in prison suffer from BPD, mostly in women

Prison based mental health care is problematic because the lack of resources, difficulty in making referrals, scarcity of good mental health providers, and the inappropriateness of prison as a setting for care.

WHY IS IT A PROBLEM??? It is not uncommon within forensic mental health

services for regional secure units to actively exclude patients with a primary diagnosis of personality disorder because they do not consider this to be their core business.

In many parts of the country there are no specific services and when services are offered they tend to be individualistic.

In general, people with BPD have difficulty controlling their emotions and distorted perceptions of themselves and others. The result is impairment in functioning at home, work, and relationships. These impairments all too often can lead to a life of incarceration.

ANY QUESTIONS? Thanks for listening!