Title: Borderline Personality Disorder
1Borderline Personality Disorder
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
3Four 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
5DSM-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
7Can look like..
- Schizophrenia
- hallucinations, illusions, paranoia
- Bipolar Affective Disorder
- mood lability and anger
- Major Depressive Disorder
- suicidal, depressed
- Antisocial Personality Disorder
- legal problems
8Epidemiology
- 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)
9Interface 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
10Borderline Personality Disorder
11Genetic 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
12Trauma
- 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?
13Family Interactions
- Neglect
- Emotional uninvolvement
- Invalidation
14Models
- 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
16Linehan Biosocial Theory
Emotion Vulnerability
Pervasive History of Invalidating Responses
Heightened Emotional Arousal
Inaccurate Expression (maladaptive behavioral
responses)
Invalidating Responses
(Fruzzetti, Shenk, Hoffman, 2005)
17Emotion Regulation
- process by which individuals influence which
emotions they have, when they have them, and how
they experience and express these emotions.
18Emotion 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
19Emotion Vulnerability
- Heightened emotional sensitivity
- Emotion reactivity
- Slow return to baseline
20Invalidation
- Validation
- Convey legitimacy and acceptance of the others
experience or behavior - Invalidation
- Delegitimize valid experiences or fail to
acknowledge their existence and/or legitimacy
21Invalidating Family Environment
- Invalidation of
- Emotions, thoughts, desires
- Over public behavior
- Difficult tasks, developmental milestones
- Sense of self and self initiated behavior
22Consequences 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
23Risk factors for invalidation
- Unexpected experience or behavior
- Behavior creates unwanted demands
- Caretaker has insufficient ability to help or
understand
24Neurobiology
- 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
25Frontolimbic Circuitry
- Prefrontal and limbic systems mediate the
processing of and responses to emotional stimuli
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