Borderline Personality Disorder Milton Brown Behavioral Research

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Borderline Personality DisorderMilton
BrownBehavioral Research Therapy
ClinicsUniversity of Washington
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Borderline Personality Disorder

• What is BPD?
• How to assess BPD
• How does BPD develop?
• BPD in adolescence
• Intervention options
• How to respond to challenging BPD clients

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What is a Personality Disorder? DSM-IV
diagnostic criteria

• A. An enduring pattern of inner experience and
  behavior that deviates markedly from the
  expectations of the individuals culture. This
  pattern is manifested in two (or more) of the
  following areas
• (1) cognition (i.e., ways of perceiving and
  interpreting self, other people, and events)
• (2) affectivity (i.e., the range, intensity,
  lability, and appropriateness of emotional
  response)
• (3) interpersonal functioning
• (4) impulse control

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What is a Personality Disorder? DSM-IV
diagnostic criteria

• B. The enduring pattern is inflexible and
  pervasive across a broad range of personal and
  social situations
• C. The enduring pattern leads to clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning
• D. The pattern is stable and of long duration,
  and its onset can be traced back at least to
  adolescence or early adulthood
• E. The enduring pattern is not better accounted
  for as a manifestation or consequence of another
  mental disorder
• F. The enduring pattern is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition (e.g., head trauma).

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Borderline Personality Disorder DSM-IV
diagnostic criteria

1. Frantic efforts to avoid real or imagined
   abandonment. Note Do not include suicidal or
   self-mutilation 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-mutilation
   behavior covered in Criterion 5

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Borderline Personality Disorder DSM-IV
diagnostic criteria

1. Recurrent suicidal behavior, gestures, or
   threats, or self-mutilation
2. 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)
3. Chronic feelings of emptiness
4. Inappropriate, intense anger or difficulty
   controlling anger (e.g., frequent displays of
   temper, constant anger, recurrent physical
   fights)
5. Transient, stress-related paranoid ideation or
   severe dissociative symptoms

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BPD is Prevalent and Chronic

• Prevalence
• 16 of adolescents
• 10 of adults
• Stability
• 25 of adolescents still have BPD after 2 years
• 53 of severe BPD cases
• 60 of adults still have BPD after 6 years
• 35 of adults still have BPD after 15 years

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What is BPD

• The multidiagnostic, difficult-to-treat patient
• Chronic suicidality and self-harm
• A diverse patient population

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Parasuicidal Behaviors in BPD

• 75 have a history of parasuicide
• 10 lifetime suicide rate
• more repeated suicide attempts than other
  disorders
• more likely to have persistent and intense
  suicide ideation between parasuicide episodes,
  whereas
• individuals with only depression are more likely
  to have long periods of normal mood and episodic
  suicide ideation/behavior.
• nonsuicidal self-injury is common in BPD, and
  rare in most other disorders (except mental
  retardation).

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Diagnoses for Parauicide Study
Diagnosis Lifetime Current Depressive
disorder 97 89 Substance abuse/depend. 60 3
1 PTSD 57 51 Social phobia 22 16 Pani
c disorder 52 40 Eating disorder 41 24 A
ntisocial PD - 11 Avoidant - 21
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Diagnoses for Substance Abuse Study
Diagnosis Current Depressive disorder 39 Any
anxiety disorder 52 Eating disorder 18 Antiso
cial PD 44
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Diagnoses for Anger Study
Diagnosis Current Depressive disorder 63 Any
anxiety disorder 83 Eating disorder 13 Antiso
cial PD 17 Substance use disorder 4
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The Core of BPD

• Emotion dsyregulation
• High sensitivity
• High intensity
• Slow return to baseline
• Pervasiveness
• Chronicity
• Impulsive behaviors
• Because emotions are out of control
• Because the behaviors regulate emotions
• Pervasive experiential avoidance

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Borderline Personality Disorder
EMOTION DYSREGULATION
Action Dysregulation
Self Dysregulation
Suicidal Action
Interpersonal Dysregulation
-Death -Distraction -Sleep -Biochemical -Cue
Removal
Cognitive Dysregulation
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The Clients View
Cue
Consequences
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Basic Paradigm
Cue
Consequences
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For Example
Cues Prescription picked up earlier that day, in
room alone, ruminating about criticism roommate
made of her earlier in the day
Emotion Dysregulation of shame
Problem Behavior overdose
Consequences sleep, stop ruminating, wake reduced
shame
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Methods of Experiential Avoidance

• Denial of problems (rather than problem-solving)
• Dissociation and emotional numbing
• Isolation
• Drug and alcohol abuse
• Suicide attempts (and suicide)
• Nonsuicidal self-injury
• Self-punishment, self-criticism
• Secondary emotions to avoid primary emotions
• Hospitalization to escape stressful circumstances

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Reasons for Parasuicide

• Emotion Relief (92, at least one)
• To stop bad feelings
• To stop feeling angry or frustrated or enraged
• To relieve anxiety or terror
• To relieve feelings of aloneness, emptiness or
  isolation
• To stop feeling self-hatred, shame
• To obtain relief from a terrible state of mind
• To punish yourself (63 of nonsuicidal
  self-injury)

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Development of BPD

• BPD becomes noticeable in early adolescence, but
  begins long before that.
• A difficult temperament may be a sign of
  vulnerability during infancy
• Suicidal ideation, threats, and behavior during
  childhood and adolescence
• Conduct disorder, antisocial behavior, mood
  disorders, anxiety disorders
• 16 of adolescents meet BPD criteria

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Development of BPDEnvironmental Factors

• Pathological parenting is an important risk
  factor.
• emotional neglect
• parental over-involvement
• inconsistent care by a primary caretaker
• disrupted attachment patterns
• parental psychopathology
• physical and sexual abuse
• early separation and loss?

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Development of BPDBiological Correlates

• Biological correlates of emotional instability
  and impulsivity have been identified
• Patients with emotional instability may have
  higher levels of noradrenaline activity
• Patients with impulsive disorders may have lower
  levels of serotonin activity.
• Patients with major depressive disorder and BPD
  both have shorter and more variable REM
  latencies.
• Some brain differences have been found in BPD.
• A twin study supports a psychosocial model more
  than a genetic model of BPD transmission.

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Development of BPD Linehans Biosocial Theory
(1993)

• Biological and environmental factors account for
  BPD.
• BPD individuals are born with emotional
  vulnerability
• highly sensitive to emotional stimuli
• more intense in their emotional reactions
• slower to return to their emotional baseline
• BPD individuals grow up in invalidating
  environments
• childhood abuse
• poorness-of-fit between the child and the family
• Transactions between biological vulnerabilities
  and an invalidating environment lead to a
  dysfunction in the emotion regulation system.

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Development of BPD Linehans Biosocial Theory
(1993)

• The path to BPD is a process of reciprocal
  influences.
• invalidating environments worsen dysregulation of
  vulnerable children.
• emotionally intense children may exacerbate the
  invalidating environment.
• mutual coercion can escalate emotion, violence,
  and self-harm.

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Does it make sense to diagnose BPD in adolescence?

• BPD in adolescents accurately reflects current
  distress and dysfunction
• Social impairment/isolation
• School problems
• Work problems
• Comorbid axis I diagnosis
• Contact with police for antisocial behavior
• As expected, BPD co-occurs with PTSD, conduct
  disorder, depression (construct validity)
• Overall, BPD diagnosis is not stable
• 53 of moderate/severe cases of BPD persist

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What to look for

• Caucasian female
• Severe BPD (predicts chronicity)
• Parasuicide, identity disturbance, intense anger
  (predicts chronicity)
• Co-occurring mood and conduct disorder
• Bipolar II disorder
• History of childhood maltreatment

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Disability in BPD

• What are the functional limitations?
• What are reasonable accommodations in academic
  settings?

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Treatment OptionsThe Main Dialectic

• Short-term Long-term
• avoid stress block avoidance
• tolerate distress
• remove cues challenge fears
• isolation build a structured life
• distraction problem-solving
• focus on emotions
• hospitalization alternative coping

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An Ideal Treatment for BPD

• is one that balances
• Acceptance and Change
• Soothing versus pushing the client
• Validation versus demanding

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Most Good Treatments Dont Work for BPD

• BPD has been associated with worse outcomes in
  treatments of Axis I disorders such as
• major depression
• anxiety disorders
• eating disorders
• substance abuse
• because BPD patients have low tolerance for
  change in the absence of validation

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Treatment Goals

• Reduce out of control behavior
• Build a structured/productive life consistent
  with values
• Change (increase tolerate for) emotions
• Treat Axis I disorders
• Treat effects of childhood trauma
• Personal goals

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Treatment Objectives

• Enhance capabilities
• Reduce emotion vulnerability
• Activate non-mood-dependent behavior
• Enhance motivation
• Generalization
• structuring of the environment
• Enhance capability and motivation of therapists

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Treatment Strategies

• Intervene early before maladaptive patterns
  become crystallized and refractory to treatment.
• Problem-solving
• Skills-focus
• Exposure and opposite action
• Reinforcement
• Cognitive modification
• Support/Validation/Acceptance
• Keep lethal means out of reach (e.g., pills)

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Treatment of BPDCommitment to not parasuicide
Verbal commitment Commitment strengthening Devil's
advocate Motivational interviewing Pros and cons
analysis Provide help Provide incentives for no
parasuicide
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Problem-Solving

1. Understand the problem
2. Identify the trigger (event)
3. Identify the key emotions and thoughts
4. What problem did the behavior solve?
5. Generate alternative solutions
6. Practice solutions

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Treatment of BPD

• Significant Outcomes from DBT Study
• DBT vs. TAU

• Parasuicide Episodes
• Treatment Drop Out
• Psychiatric Inpatient Admissions/Days
• Anger
• Global Adjustment
• Social Adjustment

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Treatment of BPD
UW Replication Study

• Effects of DBT were similar to the previous study
  despite
• rigorous control condition of expert therapists
• high allegiance to the alternative treatment
• DBT is effective in six randomized controlled
  trials
• DBT is particularly effective with suicidal
  behavior
• Expert therapists are better than treatment as
  usual

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Ways to fail with a BPD client

• Insufficient validation
• Judgmental attitude toward client
• Burnout
• Insight therapy
• Back down too easily
• Reinforce dysfunctional behavior
• No learning in context

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How should a provider interact with a BPD client?

• Validate and acknowledge what is valid
• Adopt a compassionate and nonjudgmental view of
  the patient
• Dont ignore your personal or institutional
  limits, but stay objective
• Believe in the patient
• Encourage mastery provide practical help
• Get support and consultation

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Levels of Validation

• Listen and pay attention
• Show you understand paraphrase
• Communicate how their behavior/emotions make
  sense
• given their past experiences
• given their thoughts/beliefs
• Communicate how their behavior/emotions are
  normal or make sense now
• Dont fragilize them or treat them like a
  patient

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When to Refer

• When the clients problems exceed your skill
• When you are approaching burnout
• If you cannot control judgmental thinking about
  the client
• If the client does not improve

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Medications for BPD

• SSRIs improve mood and impulsivity
• May reduce nonsuicidal self-injury
• May increase suicide attempts
• Olanzapine improves irritability/anger
• Anticonvulsants (Tegritol) decrease behavioral
  dyscontrol
• Alprazolam (Xanax) increases behavioral
  dyscontrol and suicidality ratings
• Opiate blockers

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Medication Recommendations

• Combine pharmacotherapy with an active
  psychosocial treatment
• Focus on safety and effectiveness
• Do not give lethal drugs to lethal people
• Avoid benzodiazepines
• Amitriptyline makes some subjects worse
• Attend to medication non-compliance
• Consult with the patient

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Medications for BPD

• Dimeff, L.A., McDavid, J., Linehan, M.M. (1999).
  Pharmacotherapy for borderline personality
  disorder A review of the literature and
  recommendations for treatment. Journal of
  Clinical Psychology in Medical Settings, 6(1),
  113-138.
• Grossman, R. (2002). Psychopharmacologic
  treatment of patients with borderline personality
  disorder. Psychiatric Annals, 32(6), 357-370.
• Healy, D. (2003). Lines of evidence on the risks
  of suicide with selective serotonin reuptake
  inhibitors. Psychotherapy and Psychosomatics,
  72(2), 71-79.