Borderline PD
Dec 25, 2015
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 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
Prognosis (Stone, 1993)
20s – do poorly 30s to 40s – mellowing
50s – outcome variable Poor Prognosis
Divorce and lack of support *Hostility
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
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
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
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
Assessment
MMPI: 3, 4, and 7
MCMI-III: BDL, DEP, HIS
Diagnostic Interview for BDL PD (DIB) Gunderson and others
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
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