Borderline Personality Disorder

1. Borderline Personality Disorder Dr Sathya Rao Clinical Director,Spectrum, the Personality Disorder Service for Victoria, 4th Sept 12 Medicare Local

2. BPD • BPD is a serious psychiatric illness. • Feel unsafe in their relationships with others. • Difficulties in having healthy thoughts and beliefs about themselves, and others. • Difficulty controlling emotions and impulses. • Problems with work, family and social life • Self-harm and suicidality • Having BPD is not the person’s own fault – it is a condition of the brain and mind.

3. Borderline Personality Disorder • 1% prevalence, 20 % in psych systems • Diagnosed predominantly in women- 75% • Sampling bias • Women are 3 times more likely to seek help for psychological help than men • Clinician diagnostic bias- ASPD

4. BPD • Highly stigmatized, misunderstood • Ignorance • Lack of scientific evidence • Lack of clinical skills • Mortality and morbidity is high • Significant co-morbidity with other Axis I,II and III • The patients live painful and miserable lives • Severe functional impairment

5. BPD is a highly stigmatized disorder “BPD is to psychiatry what psychiatry is to medicine” John Gunderson

6. Stigma • MH professionals are the biggest stigmatizers. • Clinicians are often reluctant to diagnose BPD because they believe those with this disorder are doomed for chronicity. • “Frequent flyers”

7. Marsha Linehan had BPD Expert on Mental Illness Reveals Her Own Fight New York Times 2011

8. BPD patients evoke strong emotional response from health systems • Frustration to clinicians- therapeutic pessimism • Significant utilization of hospital resources • High costs to society Tolkien II WHO 2010

9. But…….we now know that… • Genetic and environmental factors contribute to causation of BPD • Clinical remission is common • Effective treatments are now available • Treatments principles can be learnt • Psychotherapy is the mainstay of treatment • Pharmacotherapy is only minimally effective

10. Australia 2011

11. National Expert reference group on BPD

12. NHMRC National BPD management guidelines

13. National BPD Foundation

14. Spectrum • State-wide service for personality disorders • Residential service- 4 bedded unit • Treatment service- MBT, BMT, ACT groups, individual therapy • Secondary consultation service • Research- Medications, ACT, BMT, MBT, psychosis, culture etc. • 30 staff, Two registrar positions

15. Access to services for BPD • At 1% prevalence rates, potentially there are 60,000 persons who may have BPD in Victoria. • AMHS care for ? 6000 patients • Spectrum provides services to 400 patients Spectrum

16. Cost of treating BPD • Currently we treat 15% of BPD- chaotic • Ideal treatment with 30% coverage (15, 400 patients)- stepped care -GP to Specialist care and education would cost $ 4156 per patient and a total of $ 64 million Tolkien II Report by Gavin Andrews 2010 for WHO

17. Borderline Personality Disorder DSM IV 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.  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

18. Characteristics of a BPD patient • Female • 20’s and 30’s • Childhood abuse, neglect, invalidating background • Fear of abandonment • Dysregulated emotions • Hyper reactive emotionality • Intolerance to loneliness • Crave for IP relationships, have poor IP skills • Rejection sensitive • Often attract dysfunctional relationships • About 40 % are in abusive relationships • Unstable interpersonal relationships • Idealization and devaluation

19. ZAN BPD Scalefor the assessment of change in DSM-IV borderline psychopathology In the past week have you: • Have any of your closest relationships been troubled by a lot of arguments or repeated breakups? • Have you deliberately hurt yourself physically (e.g.,punchedyourself, cut yourself, burned yourself)? How about made a suicide attempt? • Have you had at least two other problems with impulsivity(e.g., eating binges and spending sprees, drinking too much and verbal outbursts)? • Have you been extremely moody? • Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner? • Have you often been distrustful of other people? • Have you frequently felt unreal or as if things around you were unreal? • Have you chronically felt empty? • Have you often felt that you had no idea of who you are or that you have no identity? • Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?

20. BEST

21. Have you…. • found that your mood changes suddenly? • felt you unsure of who you really are or what you are really like? • felt spaced out or numb? • felt as though you were abandoned even though you really weren't • deliberately hurt yourself with out meaning to kill yourself? • are you able to like yourself

22. Co occurring disorders • Depression • Bipolar disorder • PTSD • Eating Disorders • Psychosis • SUD • Kind of comorbid Kingdom

23. Sub types of BPD • Given the fact that you require only 5 of 9 criteria to make a diagnosis of BPD according to DSM IV, one can make a diagnosis of BPD in 256 ways!!!!!

24. Etiology • Biological vulnerability • Environmental factors • Stress diathesis model

25. Genetics • Family history of Mood Disorders and SUDs are more common in BPD than would be expected by chance (Widiger and Trull 1992) • Trans-generational patterns • BPD is significantly heritable • Strongly genetic. Genetic model-Heritablility effect 0.69 (1.0 would indicate complete heritability) (Torgersen et al. Compr Psychiatry 2000; 41: 416-425)

26. HERITABILITYLyons & Plomin/Smoller • Schizophrenia 85% • Bipolar 80% • BPD 55-68% -(impulsivity/ mood instability) • MDD 45% • Panic Disorder 40% • PTSD 30%

27. Hyperactive and hyper responsive Amygdala

28. Patients with BPD frequently interpret neutral stimuli as negative. Theyover react to negative or even neutral facial expression. Hyperactivity of Amygdala. • A study examining the neural circuitry of emotion-processing deficits in BPD involving fMRI while viewing a series of photographic images that vary in affective valence (unpleasant, neutral, and pleasant).

29. Once aroused the hyperemotional state of Amygdala takes longer to revert to baseline in BPD when compared with normal controls.

30. Usual cortical control over Amygdala is reduced

31. Cortical modulation of Amygdala is reduced • Study: BPD patients processing high arousal stimuli did not show cortical suppression of Amygdala activity even after the stimuli was removed, compared for controls

32. Driving a car with hypersensitive accelerator and poor breaks

33. Attachment • Disorganised attachment • BPD patients have an hypersensitive attachment system

34. Trauma • Trauma- neglect, abuse • Child hood sexual abuse is 10 times more common in women than men • Large scale studies of childhood sexual abuse in general population show that 80% of adults do not develop any psychological problems • Sexual abuse and BPD

35. Interpersonal sensitivity

36. What sets patients off? • Pushing their buttons • Triggering attachment systems • Being misunderstood • Make them understood • We need to take responsibility to clear the misunderstanding

37. PROGNOSIS

38. Management of BPD • BPD is a treatable condition (Gabbard-AJP 2007) • It is a myth that BPD is untreatable • Specific effective treatments are now available

39. Psychotherapy • Dialectical-Behavioral Therapy (DBT) • Mentalization-Based Therapy (MBT) • General Psychiatric Management(GMT) • Transference Focused Therapy (TFT) • Schema-Focused Therapy (SFT) • Cognitive Analytic Therapy (CAT) • Supportive Psychotherapy (SP) • Systems Training for Emotional Predictability and Problem Solving (STEPPS) • Cognitive Behavior Therapy (CBT) • Acceptance and Commitment therapy (ACT) • Mears- Self Psychology

40. Psychotherapy outcome research • Specific technique/model of therapy- 0nly 15% • Expectancy 15% • Common factors 30% • Non specific factors 40%

41. Matching therapies • Therapist factors • Patient factors • Resources • Common treatment principles Curr Psychiatry Rep (2011) 13:60–68

42. Most patients get better- (45% by 2 years and 85% by 10 years) - no more than 2 diagnostic criteria • 15 % relapse. • Aim of psychotherapy is to hasten recovery and aid those who do not recover spontaneously and work on functional recovery

43. Spectrum outcome 1.5 to 2 years of group and or individual psychotherapy results in significant recovery for complex BPD patients.

44. Prognosis • Spontaneous remission - 75% recover by 35 -40 yrs • 90% recover with improved functioning by age 50(CMAJ-2005) • Treatment speeds up remission • Treatment as usual - Remission rates: 1/3rd at 2 yrs 1/2 at 4 years 2/3rd at 6 years 3/4th at 10 years • Good treatment leads to faster remission • MBT- 60% remission by 1 year

45. Zanarini studyAJP 2006 -10 years of follow-up -290 patients • 242 of 290 patients (88%) withat least one follow-up interview had a remission (Remission was defined as nolonger meeting either of our study criteria sets for borderlinepersonality disorder: DIB-R or DSM-III-R.) • Timeto remission (defined as the follow-up period at which remission was first achieved). • 39.3% - 2nd year follow-up • 22.3% - 4th year follow-up • 21.9% -6th year follow-up • 12.8% -8th year follow-up • 3.7% - 10th year follow-up. • Recurrences-rare-6% • 25 patients-8.6% lost for follow-up before remission

46. 10 year F/U studyGunderson AGP 2011 • High rates of remission (85%) • Low rates of relapse (12%) • Severe and persistent impairment in social functioning • Even after remission only 25%- full time work 40% receiving disability payments at 10 years • 80% of BPD sample had life time MDD.

47. Collaborative Longitudinal Personality Disorders Study- 10 year F/U • Most patients eventually get a life • They find a place in the world • Stop wanting to kill themselves • KEEP THEM ALIVE…….

48. 16 year follow up study • Remission: 99% achieved symptomatic remission for a 2 year period and 78% for a 8 year period • Recovery: 60% achieved recovery lasting for 2 years • Recurrence:10% after 8 year period-36% after 2 year period Zanarini et al, AJP May 2012

49. Remission is not equivalent to recovery • Few people with BPD require life long treatment

50. Summary • High rates of remission • Takes long to remit • Relatively low recurrence • BPD has a better symptomatic outcome than MDD or Bipolar Disorder