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Title: Borderline Personality Disorder Milton Brown Behavioral Research


1
Borderline Personality Disorder Milton
Brown Behavioral Research Therapy
Clinics University of Washington
2
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

3
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

4
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).

5
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

6
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

7
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

8
What is BPD
  • The multidiagnostic, difficult-to-treat patient
  • Chronic suicidality and self-harm
  • A diverse patient population

9
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).

10
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
11
Diagnoses for Substance Abuse Study
Diagnosis Current Depressive disorder 39 Any
anxiety disorder 52 Eating disorder 18 Antiso
cial PD 44
12
Diagnoses for Anger Study
Diagnosis Current Depressive disorder 63 Any
anxiety disorder 83 Eating disorder 13 Antiso
cial PD 17 Substance use disorder 4
13
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

14
Borderline Personality Disorder
EMOTION DYSREGULATION
Action Dysregulation
Self Dysregulation
Suicidal Action
Interpersonal Dysregulation
-Death -Distraction -Sleep -Biochemical -Cue
Removal
Cognitive Dysregulation
15
The Clients View
Cue
Consequences
16
Basic Paradigm
Cue
Consequences
17
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
18
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

19
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)

20
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

21
Development of BPD Environmental 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?

22
Development of BPD Biological 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.

23
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.

24
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.

25
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

26
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

27
Disability in BPD
  • What are the functional limitations?
  • What are reasonable accommodations in academic
    settings?

28
Treatment Options The 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

29
An Ideal Treatment for BPD
  • is one that balances
  • Acceptance and Change
  • Soothing versus pushing the client
  • Validation versus demanding

30
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

31
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

32
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

33
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)

34
Treatment of BPD Commitment to not parasuicide
Verbal commitment Commitment strengthening Devil's
advocate Motivational interviewing Pros and cons
analysis Provide help Provide incentives for no
parasuicide
35
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

36
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

37
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

38
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

39
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

40
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

41
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

42
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

43
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

44
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.
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