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 • Munchausen’s 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 other’s 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-frontal network • behavioral control

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