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Borderline Personality Disorder

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Title: Borderline Personality Disorder


1
Borderline Personality Disorder
  • Definition

2
  • Borderline On the borderline between
    neurosis and psychosis
  • Not an accurate term though and not relevant to
    current nosology
  • Current trend is to call it Emotional Intensity
    Disorder
  • Better accepted by patients more meaningful

3
Four Categories for Borderline Symptoms
  • Poorly regulated emotions
  • Mood swings and unstable emotions
  • Anxiety
  • Inappropriately intense anger
  • Difficulty controlling anger
  • Chronic feelings of emptiness
  • Impulsivity
  • Reckless behavior
  • Suicidal behavior and self harm
  • Munchausens Syndrome and by Proxy
  • Suicide

4
  • Impaired perception or reasoning
  • Paranoid thinking
  • Dissociative episodes
  • Depersonalization
  • Unstable self image or sense of self
  • Markedly disturbed relationships
  • Intense and unstable interpersonal relationships
  • Black and white thinking
  • Frantic efforts to avoid real or imagined
    abandonment

5
DSM-IV Diagnostic Criteria
  • A pervasive pattern of instability of
    interpersonal relationships, self-image, and
    affects, and marked impulsivity beginning by
    early adulthood and present in a variety of
    contexts, as indicated by five (or more) of the
    following 1. Frantic efforts to avoid real or
    imagined abandonment. Note Do not include
    suicidal or self-mutilating behavior covered in
    Criterion 5. 2. A pattern of unstable and
    intense interpersonal relationships characterized
    by alternating between extremes of idealization
    and devaluation 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 (e.g.,
    spending, sex, substance abuse, reckless driving,
    binge eating). Note Do not include suicidal or
    self-mutilating behavior covered in Criterion 5.

6
  • 5. Recurrent suicidal behavior, gestures, or
    threats, or self-mutilating behavior 6.
    Affective instability due to a marked reactivity
    of mood (e.g., intense episodic dysphoria,
    irritability, or anxiety usually lasting a few
    hours and only rarely more than a few days) 7.
    Chronic feelings of emptiness 8. Inappropriate,
    intense anger or difficulty controlling anger
    (e.g., frequent displays of temper, constant
    anger, recurrent physical fights) 9. Transient,
    stress-related paranoid ideation or severe
    dissociative symptoms

7
Can look like..
  • Schizophrenia
  • hallucinations, illusions, paranoia
  • Bipolar Affective Disorder
  • mood lability and anger
  • Major Depressive Disorder
  • suicidal, depressed
  • Antisocial Personality Disorder
  • legal problems

8
Epidemiology
  • 2 of the general population
  • Females 4 times the rate of males
  • 11 of psychiatry outpatients
  • 25 of acute psychiatry inpatients
  • 50 of long term psychiatry inpatients
  • 60 with co-existing Major Depressive Disorder
  • 7 complete suicide. ( 7 X General population)

9
Interface with Health Care System
  • Inpatient Psychiatric Units
  • Top diagnosis for re-admissions to psych
    hospitals
  • Emergency Rooms
  • Cutting, burning, suicidal threats
  • Intensive Care Units and medical inpatient units
  • Overdoses and other sequelae of suicidal or
    parasuicidal behavior
  • Outpatient primary care setting
  • Psychosomatic complaints
  • Doctor shopping

10
Borderline Personality Disorder
  • Etiology

11
Genetic and Biological Factors
  • Genetics a modest contributor of BPD Diagnosis
    but may be more salient for specific symptoms of
    BPD
  • Reduced serotenergic activity in 5-HT system
    inhibits ability to modulate or control impulsive
    and aggressive behavior
  • Differences b/w BPD and nonBPD patients in
    serotenergic functioning
  • Repeated exposure to stress may blunt
    serotenergic activity (frequent increases in
    cortisol)
  • Stress ? frequent increases in cortisol ?
    blunting of serotenergic activity ? emotion
    dysregulation
  • Limitations
  • Lack of specificity for serotonin (i.e., MDD
    w/out impulsivity)
  • Pharmacology targeting serotonin has limited
    efficacy in treating BPD

12
Trauma
  • Childhood Sexual Abuse (CSA)
  • Historically considered a significant risk factor
    for BPD
  • 75 of patients with BPD have a hx of CSA but
    only 90 of CSA victims have BPD
  • Limitations
  • Current evidence suggests that emotion
    dysregulation mediates the relationship between
    CSA and BPD
  • Role of physical and emotional abuse which
    co-occurs with CSA?

13
Family Interactions
  • Neglect
  • Emotional uninvolvement
  • Invalidation

14
Models
  • Individual Difference
  • Biological or genetic explanations of problem
    behaviors
  • Lies within the individual
  • Temperament
  • Environmental
  • Stressful or traumatic event

15
  • Interactional
  • Interaction of two orthogonal factors
  • Diathesis-stress model
  • Predisposing factor interacts with environmental
    stressor
  • Ex. Individual with low baseline levels of
    dopamine and lives in a neighborhood with
    violence and drug use
  • Transactional
  • Two or more factors influence each other
    reciprocally resulting in a specific outcome

16
Linehan Biosocial Theory
Emotion Vulnerability
Pervasive History of Invalidating Responses
Heightened Emotional Arousal
Inaccurate Expression (maladaptive behavioral
responses)
Invalidating Responses
(Fruzzetti, Shenk, Hoffman, 2005)
17
Emotion Regulation
  • process by which individuals influence which
    emotions they have, when they have them, and how
    they experience and express these emotions.

18
Emotion Dysregulation
  • Vulnerability to negative emotion
  • High sensitivity, reactivity, and slow return to
    baseline
  • Influences emotional arousal
  • Poor coping skills
  • Inability to manage social interactions,
    awareness of relevant stimuli, identify and label
    emotional experiences, manage arousal
  • Maladaptive responses to others expressions of
    emotion
  • Wants, thoughts, goals. Others responses often
    trigger emotional arousal

19
Emotion Vulnerability
  • Heightened emotional sensitivity
  • Emotion reactivity
  • Slow return to baseline

20
Invalidation
  • Validation
  • Convey legitimacy and acceptance of the others
    experience or behavior
  • Invalidation
  • Delegitimize valid experiences or fail to
    acknowledge their existence and/or legitimacy

21
Invalidating Family Environment
  • Invalidation of
  • Emotions, thoughts, desires
  • Over public behavior
  • Difficult tasks, developmental milestones
  • Sense of self and self initiated behavior

22
Consequences of Invalidation
  • Heightened emotional arousal
  • Cognitive and attentional dysregulation
  • Emotion skill deficits
  • Secondary emotions
  • Emotion dysregulation
  • Passivity in problem solving
  • Self-invalidation
  • Social and interpersonal dysregulation

23
Risk factors for invalidation
  • Unexpected experience or behavior
  • Behavior creates unwanted demands
  • Caretaker has insufficient ability to help or
    understand

24
Neurobiology
  • Risk factors
  • Diminished serotonergic function in the
    prefrontal cortex
  • Potential biological risk factor for
    disinhibition, impulsivity, and affect
    dysregulation.
  • Dysfunction in the cortical-striatal-thalamic-fron
    tal network
  • behavioral control

25
Frontolimbic Circuitry
  • Prefrontal and limbic systems mediate the
    processing of and responses to emotional stimuli

26
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