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8.163: Borderline Personality Disorder

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    DSM-IV-TR 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. This is indicated by having 5 or more of the following characteristics:

    1. Being frantic to avoid abandonment, either real or imagined
      • NOTE: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
    2. A pattern of intense, unstable interpersonal relationships characterized by alternating between extreme variances 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, 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

    Associated features

    • One of the most prominent features is instability in interpersonal relationships, self-image, and affects.
    • Severe instability can be seen in their fluctuating views and feelings about him or herself. They often feel really good about themselves, their progress, and their futures to only have a seemingly minor experience turn their world upside-down with concomitant plunging self-esteem and depressing hopelessness (SAMHSA, 2009).
    • Another prominent feature is marked impulsivity that begins by early adulthood and is present in a variety of contexts.
    • Individuals with BPD will often give up on something just before the goal is attained.
    • It is often difficult to maintain relationships, a job, or educational goals since their basic instability extends to work and school.
    • Psychotic-like symptoms may occur when an individual is under stress. These symptoms include hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena.
    • They typically don’t do well with personal relationships and may feel more comfortable with pets or inanimate objects. If they do have relationships, they are unstable, with reports of how wonderful an individual is one day and then the next expressions of intense anger, disapproval, condemnation, and even hate towards the same person (SAMHSA, 2009).
    • The risk of suicidal, self-mutilating, and/or brief psychotic states increases when they are experiencing an emotional state that they cannot handle (SAMHSA, 2009).
      • The risk for suicide increases when the individual also has a co-occurring Mood or Substance Related Disorder.
      • 10 percent of adults with BPD commit suicide
      • A person with BPD has a suicide rate 400 times greater than the general public
      • 33 percent of youth who commit suicide have features of BPD
      • (Kreger, 2008)
    • Patients suspected of BPD also exhibit symptoms of Depressive mood disorders, addictions to various things from drugs to binge eating, and Anti-Social Behaviors. Other co-morbid disorders include Mood, Substance Related, Eating, Post-Traumatic Stress, Attention Deficit/Hyperactivity, and other Personality Disorders.
    • To the sufferer, BPD is about deep feelings, such as:
      • If others really get to know me, they will find me rejectable and will not be able to love me and will leave me
      • I need to have complete control of my feelings otherwise things go completely wrong
      • I have to adapt my needs to other people’s wishes, otherwise they will leave me or attack me
      • I am an evil person and I need to be punished for it
      • Other people are evil and abuse you
      • If someone fails to keep a promise, that person can no longer be trusted
      • If I trust someone, I run a great risk of getting hurt or disappointed
      • If you comply with someones request, you run the risk of losing yourself
      • If you refuse someones request, you run the risk of losing that person
      • I will always be alone
      • I can’t manage by myself, I need someone I can fall back on
      • There is no one who really cares about me, who will be available to help me, and whom I can fall back on
      • I don’t really know what I want
      • I will never get what I want
      • I’m powerless and vulnerable and I can’t protect myself
      • I have no control of myself
      • I can’t discipline myself
      • My feelings and opinions are unfounded
      • Other people are not willing or helpful
      • (Facing the Facts, 2009)

    BPD Traits Organized by Thoughts, Feelings, and Actions (Kreger, 2008)

    DSM Traits

    THINKING:

    Impaired perception and reasoning

    Spitting (extremes of idealization and devaluation)

    Brief moments of stress-related paranoia or severe

    dissociative symptoms (being very “out of it”)

    FEELING:

    Poorly regulated, highly changeable emotions

    Intense, unstable moods and strong reactions to

    shifts in the environment. Irritability or anxiety,

    usually lasting for a few hours or days. Feelings of

    acute hopelessness, despair, and unhappiness

    Frantic efforts to avoid real or imagined abandonment

    A feeling of emptiness and a lack of identity, which

    complicate moods and emotions

    ACTING:

    Impulsive behaviors

    Imulsiveness in at least 2 areas that are potentially

    self-damagine (spending, sex, substance abuse,

    reckless driving, or binge eating)

    Inappropriate, intense anger or difficulty controlling

    anger (frequent displays of temper, constant anger,

    or recurrent physical fights)

    “Pain management” behaviors such as overspending,

    aggression toward others suicide, self-harm, substance

    abuse, and eating disorders

    Impaired Thinking (Kreger, 2008)

    Cognitive Distortion Cognitive Distortions in BPs

    FEELINGS EQUAL FACTS:

    Emotions color interpretations of people and situations

    The BP makes jaw-dropping interpretations, assumptions,

    and inferences that may bear little resemblance to reality

    JUMPING TO CONCLUSIONS:

    Negative interpretation without supporting facts

    The BP jumps to conlusions even when past experiences

    with the person/situation have been positive.

    The BP dismisses contrary supporting facts.

    MIND READING:

    Assuming others think badly of you

    The BP assumes others think she’s scum on the garbage

    scow of the world

    CATASTROPHIZING:

    Thinking the worst-case scenario will occur and nothing

    can be done to help the situation

    The BPs catastrophizing can lead to poor, rash decisions

    or dangerous actions, such as self-harm or suicide attempts

    Small molehills become Mt. Everest

    BLAME:

    Holding others totally accountable for negative situations

    The BP not only dismisses contrary supporting facts but also

    thrashes, mutilates, and pummels them into submission

    The BP will not be held accountable for anything

    DISCOUNTING THE POSITIVE

    In a way similar to splitting, some BPs discount anything

    good in themselves and in others

    MENTAL FILTER:

    Dwelling on criticism of the self while repelling compliments

    For the BP, the soaking in is deeper – to the bone instead

    of the pores.

    Compliments are repelled faster and further away

    Lower-Functioning vs High Functioning (Kreger, 2008)

    Mostly Lower-Functioning

    Conventional BPs

    Mostly Higher- Functioning

    Invisible BPs

    COPING TECHNIQUES

    Acting in:

    Mostly self-destructive acts such as self-harm

    Acting out:

    Uncontrolled and impulsive rages, criticism,

    and blame. These may result less from a

    lack of interpersonal skills than from an

    unconcious projection of their own pain

    onto others

    FUNCTIONING

    Low functioning:

    BPD and associated conditions make it difficult to live

    independently, hold a job, manage finances, and so on.

    Families often step in to help

    High functioning:

    The BP appears normal, even charismatic,

    but exhibits BPD traits behind closed doors

    Has a career and may be successful

    WILLINGNESS TO OBTAIN HELP

    Self-harm and suicidal tendencies often bring these

    BPs into the mental health system (both as inpatients

    and outpatients)

    High interest in therapy

    A state of denial much like an untreated

    alcoholic

    The BP disavows responsibility for

    relationship difficulties, refuses treatment;

    when confronted, he or she accuses others

    of having BPD.

    May see a therapist if threatened, but rarely

    takes it seriously or stays long

    CO-OCCURRING (CONCURRENT)

    MENTAL HEALTH ISSUES

    Mental conditions such as bipolar and eating disorders

    require medical intervention and contribute to low

    functioning

    Concurrent illness most commonly a

    substance use disorder or another PD,

    especially Narcissistic PD

    IMPACT ON FAMILY MEMBERS

    The major family focus is on practical issues such as

    finding treatment, preventing/reducing BPs self-

    destructive behavior, and providing practical and

    emotional support.

    Parents feel extreme guilt and are emotionally

    overwhelmed

    Without the diagnosis of an obvious illness

    for the BP, family members blame

    themselves and try to get their emotional

    needs met

    They make fruitless efforts to persuade

    their BP to get professional help

    Major issues include high-conflict divorce

    and custody cases

    Substance Use Among People with BPD

    • They are often skilled in seeking multiple sources of medication that they favor, such as benzodiazepines.
    • They associate drugs with social interactions and use the same drugs of choice, method of administration, and frequency as the individuals that they interact with.
    • They often use substances in a chaotic and unpredictable pattern.
    • Polydrug use is common and may involve alcohol and other sedative-hypnotics taken for self-medication.
    • A the beginning of a crisis episode, they will often take a drink or use a different drug in order to subside the growing sense of tension or loss of control.
    • They usually have big appetites, and they often experience powerful, emotion-driven needs for something outside of themselves, such as drugs.
    • When they stop using drugs, they are extraordinarily vulnerable to meeting their needs through other compulsive behaviors.
      • Some of these behaviors include:
        • compulsive sexual behavior
        • compulsive gambling
        • compulsive spending/shopping
        • other out of control behaviors that result in negative or even dangerous consequences

    (SAMHSA, 2009)

    Hitler as an example

    The DSM-IV-TR describes Borderline Personality Disorder as 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 symptoms.

    The first symptom is frantic efforts to avoid real or imagined abandonment.

    The second is a pattern of unstable and intense, interpersonal relationships characterized by alternating between extremes of idealization and devaluation. When we look at most of the relationships in Hitler’s life, Gustl, Geli, Eva, they go back and forth between stable and rocky. He somewhat cares, he does not care at all, he is happy with them, he is angry with them, he loves them, he hates them. This back and forth happens quite often throughout all of those relationship.

    The third symptom is identity disturbance: markedly and persistently unstable self-image or sense of self. At times Hitler thought he was the greatest most prominent person in the world but others he thought of himself as a worthless failure. We can look at the period of trying to be an artist as an example, or the episode with the German film star. These switches between security were often.

    The fourth is impulsivity in at least two area that are potentially self-damaging.

    Recurrent suicidal behavior, gestures, threats, or self-mutilating behaviors is the fifth symptom.

    The sixth symptom is the affective instability due to a marked reactivity of mood such as an intense episodic dysphoria, irritability, or anxiety. Hitler had affective instability quite often. At any given moment Hitler could ‘fly off the handle’ so to speak in fits of rage.

    The seventh symptom is chronic feelings of emptiness.

    The eighth is inappropriate intense anger or difficulty controlling anger. Like previously stated, Hitler had anger problem which he could not control. There are accounts in which Hitler has been reported not just yelling but throwing objects in his fits of rage.

    The ninth and last symptom is transient, stress-related paranoid ideation or sever dissociative symptoms. Hitler was paranoid about a number of things. He was paranoid that people were out to get him. He was paranoid that the Jewish people were responsible for the evil, negative ambiance, and downfall of Germany. He was a hypochondriac who was paranoid that he was sick and had cancer any time something felt wrong or he was around a person he thought to be sick.

    Hitler displayed five of the nine symptoms. If there were knowledge about psychology in Hitler’s time like there is knowledge now, Hitler may have been diagnosed with Borderline Personality Disorder. (Kershaw, 2008)

    Child vs. Adult Presentation

    It should be noted that the DSM is not currently modified to diagnose patients under 18 with BPD. The generally accepted modifications to diagnosing underage patients are exhibitions of disruptive behavioral problems, and mood and anxiety symptoms. Adolescents and young adults with identity problems may display behaviors that could be mistaken as Borderline Personality Disorder. Such situations are characterized by emotional instability, anxiety-provoking choices, uncertainty, and dilemmas.

    Gender and Cultural Differences in Presentation

    • BPD is diagnosed most often in females (about 75%).
    • There have been some studies which suggest that women with BPD are more likely to have eating disorders, as well as histories involving sexual or physical abuse that qualify them for PTSD (Post-Traumatic Stress Disorder).
    • These studies also suggest that men are more likely to abuse substances, and have more defined antisocial personalities.
    • 1 out of every 4 people with BPD are male (Kreger, 2008)
    • We know very little about how BPD expresses itself in men or if treatment programs designed for women are as effective for men (Kreger, 2008)
    • Men won’t seek treatment. They see it as “unmanly” to acknowledge feelings, especially the vulnerability and abandonment fears associated with BPD (Kreger, 2008)
    Clinician Bias
    • Anger is interpreted differently depending upon whether it comes from a man or a woman
    • Harder for clinicians accurately diagnose the presence of BPD in males (Kreger, 2008)
    Cultural influences
    • Men are socialized not to expose their fear of abandonment or other emotional vulnerabilties
    • Men are permitted anger (Kreger, 2008).
    Borderline men and domestic violence
    • Some men use the same outlets as borderline women do, such as making suicide threats
    • A great many of them anexthetize themselves with alcohol and drugs such as cocaine or methamphetamine
    • A subset channel their feelings into their more socially acceptable cousins: rage and aggression
    • Both men and women can express their fear of abandonment as physical aggression
    • Men’s level of violence is often more lethal
    • This aggression often results in a misdiagnosis of Antisocial PD or a conduct disorder in adolescents
    • They are often incarcerated (Kreger, 2008)
    Sexual acting out
    • Men frequently engage in addictive, sexually compulsive behaviors, including:
      • hiring prostitutes
      • having serial affairs
      • going to strip clubs
      • obsessive viewing pornography
      • engaging in voyeurism or exhibitionism
      • compulsive masturbation
      • (Kreger, 2008)

    Epidemiology

    • Borderline Personality Disorder affects about 1 to 2 percent of the population
    • Recent research is showing that this number is much higher (Kreger, 2008)
    • It is much more highly represented in the clinical population
    • About 10 percent of outpatients and about 20 percent of inpatients in psychiatric settings are diagnosed with this disorder.
    • About 75 percent of those diagnosed with Borderline Personality Disorder are females.
    • Five times more common in first degree relatives of affected persons
    • The course is decidedly variable. The most common pattern is of chronic instability in early adulthood, with episodes of affective and impulsive dyscontrol and high levels of the use of health resources. Impairment and the risk of suicide are greatest in young adults and decrease with age. the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, though these areas improve with intervention within the first year. Greater stability is often attained during the 30s and 40s.

    Etiology

    • The actual cause or root of the disorder is not known.
    • It is commonly believed that because the symptoms are long-lasting, that the symptoms primarily manifest in early adolescence, and may not show negative consequences until early adulthood.
    • People with symptoms may have a history of unstable relationships and sexual/physical abuse or neglect.
    • It also appears that a serotonin deficiency may be involved in the development of Borderline Personality Disorder.
    • This could possibly explain why these individuals engage in self-mutilation and why these individuals are impulsive, especially when it comes to aggressive behavior.
    • Other research has implicated an irregularity of non adrenaline.
    • Research also indicates that dopamine has been implicated in the etiology of Borderline Personality Disorder, which can be related to the fact that some borderline individuals demonstrate psychotic symptoms that are temporary.
    • Research indicates that a complex interaction of environmental and genetic factors likely contributes to the presence of BPD. One environmental factor hypothesized to contribute to BPD has been pathological child experiences leading to trauma as indicated by a co-occurring diagnosis of PTSD.
    • Another suggestion is that BPD is a dysfunction in the emotional regulations system that results from a combination of biological predisposition and environmental factors.
    • There is also considerable research indicating that early childhood abuse such as emotional and verbal abuse maybe implicated in individuals with Borderline Personality Disorder, which account for 90% of individuals with Borderline Personality Disorder.
    Older people with BPD
    • Experts differ on whether people with BPD “grow out of BPD” when they get into their fifties and above
    • Popular thinking is that they do
    • More research needs to be done on this
    • (Kreger, 2008)

    Portrayed in Popular Culture

    • Play Misty for Me (1971)
    • Fatal Attraction (1987)
    • Poison Ivy (1992)
    • The Crush (1993)
    • Girl, Interrupted (1999)
      • It is about a girl diagnosed with borderline personality disorder who is sent to a mental institution.
    • Allein (Germany, 2004)
    • Chloe (2009)
    • Eliane from Seinfeld
      • She has extreme “black and white” thinking. She also has instability in relationships, self-image, identity, and behavior
    • Anakin Skywalker from Star Wars
      • He shows signs of six out of nine criteria
      • He has unstable moods, interpersonal relationships, and behaviors
      • Infantile illusions of omnipotence and dysfunction experiences of self and others
      • Frantic efforts to avoid real or imagined abandonment
      • Shows impulsive behavior and has difficulty controlling his anger
      • Experiences two “dissociative episodes”
      • Exterminated the Tusken people after his mothers death
      • Killed all of the Jedi younglings
      • Has a disturbance in identity when he turns to the dark side and changes his name
      • (Landau, 2010)
    • Catwoman from Batman
      • She is a woman of many moods and traumas
      • Her alter-ego, Selina Kyle, is typical of the impulsivity characterized by Borderline Personalities
    • Moaning Myrtle from Harry Potter
      • Has expressed feelings of loneliness and abandonment mixed with the occasionally warm approach
      • Has very dramatic mood swings

    Diagnostic Tests

    Diagnostic Interview for Borderline Patients (DIB-R)

    The Diagnostic Interview for Borderline Patients (DIB-R) is the best-known “test” for diagnosing BPD. The DIB is a semi structured clinical interview that takes about 50-90 minutes to administer. The test, developed to be administered by skilled clinicians, consist of 132 questions and observation using 329 summary statements. The test looks at areas of functioning that are associated with borderline personality disorder. The four areas of functioning include Affect (chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, emptiness), Cognition (odd thinking, unusual perceptions, nondelusional paranoia, quasipsychosis), Impulse action patterns (substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors), and Interpersonal relationships (intolerance of aloneness, abandonment, engulfment, annihilation fears, counterdependency, stormy relationships, manipulativeness, dependency, devaluation, masochism/sadism, demandingness, entitlement). The test is available at no charge by contacting John Gunderson M.D. McLean Hospital in Belmont Massachusetts (617-855-2293).

    Structured Clinical Interview (SCID-II)

    The Structured Clinical Interview (now SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It closely follows the language of the DSM-IV Axis II Personality Disorders criteria. There are 12 groups of questions corresponding to the 12 personality disorders. The scoring is either the trait is absent, subthreshold, true, or there is “inadequate information to code”. SCID-II can be self administered or administered by third parties (a spouse, an informant, a colleague) and yield decent indications of the disorder. The questionnaire is available from the American Psychiatric Publishing for $60.00.

    Personality Disorder Beliefs Questionnaire (PDBQ)

    The Personality Disorder Beliefs Questionnaire (PDBQ) is a brief self administered test for Personality Disorder tendencies.

    Other

    Other commonly used assessment tests are rating tests such as the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). In addition there are some free, informal tests available. (Facing the Facts, 2010)

    Empirically Supported Treatments

    • Borderline individuals remain some of the most difficult to treat effectively in therapeutic situations, whether they are outpatient or inpatient. Personality traits are not left at entrance, so they are quite visible during treatment.
    • The best treatment for BPD is Dialectical behavior therapy, credited to Marsha Linehan, a professor at University of Washington.
    • This treatment, established in 1993, focuses on helping the patient not only survive but to build a life that is meaningful to them by helping the patient to balance change and acceptance of the situations in their life.
    • First, life-threatening or harmful situations are dealt with.
    • Then they are gently pushed to experience emotions that are painful to them.
    • Part three addresses living problems.
    • The procedure is to help the patient feel complete as a person.
    • Trust is a critical concern; it is difficult to create and difficult to maintain when created. The therapeutic relationship is a teeter totter tilting back and forth the good and bad aspects of the therapist proclaimed by the patient. There is risk for suicide but the cries for help are difficult to separate out a true cry from a gesture that is not an emergency.
    • Other types of therapies may be used also, including cognitive-behavioral therapy, group therapy, and family therapy, along with individual therapy. Therapy sessions should have specific, special strategies, and the therapists should set boundaries for the client. Therapists should be aware that clients with BPD can be difficult to manage even for experienced mental health professionals.
    • A person with Borderline PD who seeks a mental health treatment is acutely emotionally distraught, and needs some relief from how she or he feels. Those that seek substance abuse treatment are probably only seeking treatment for the substance use disorder, and not the personality disorder (SAMHSA, 2009).
    • An overwhelming number of clinicians do not have the training or experience to effectively treat those with the disorder (Kreger, 2008).
    • Research-based therapies for BPD are not widely available and are only appropriate for a subsection of those with the disorder (Kreger, 2008).
    • 80 percent of psychiatric nurses believe that people with BPD receive inadequate care (Kreger, 2008)
    • A 30 year old woman with BPD typically has the medical profile of a woman in her 60s (Kreger, 2008)
    • Counseling a Client with Borderline Personality Disorder
    • Anticipate that client progress will be slow and uneven
    • Assess the risk of self-harm by asking about what is wrong, why now, whether the client has specific plans for suicide, past attempts, current feelings, and protective factors.
    • Maintain a positive but neutral professional relationship, avoid over-involvement in the client’s perceptions, and monitor the counseling process frequently with supervisors and colleagues.
    • Set clear boundaries and expectations regarding limits and requirements in roles and behavior.
    • Assist the client in developing skills (e.g. deep breathing, meditation, cognitive restructuring) to manage negative memories and emotions.
    • (SAMHSA, 2009)
    • Key Issues and Concerns in the Treatment of Borderline Personality Disorders
    • slow progress in therapy
    • suicidal behavior
    • self-injury or harming behavior
    • client contracting
    • transference and counter transference
    • clear boundaries
    • resistance
    • subacute withdrawal
    • symptom substitution
    • somatic complaints
    • therapist well-being
    • (SAMHSA, 2009)
    • Types of Psychotherapy Used:
    • The psychotherapies that have been proved successful for BPD all strive to address underlying deficits in the ability of patients to relate to others, manage emotions, and confront longstanding problems that are typically rooted in childhood experience.
    • Cognitive-behavioral therapy (CBT):
    • This therapy approach allows the patient to learn how to recognize and change their maladaptive thought patterns. The main focus is on restructuring the dysfunctional cognitions through a process of identifying, challenging, and reshaping the thoughts. The other focus is on changing the process to prevent, alter, or replace unhealthy behavior with a healthier, and more effective, behavior.
    • Transference-focused therapy (TFP)
    • TFP is a psychodynamic treatment that was designed especially for patients with BPD.
    • It is a type of psychoanalysis that focuses on correcting the distortions in a patients perceptions of significant others and the therapist.
    • TFP places importance on the assessment and on the treatment contract between the client and therapist.
    • The treatment contract has parameters that are established in order to deal with the most likely threats to the treatment and the patients well-being that may or many not occur during the treatment.
    • Dialectical-behavioral therapy (DBT)
    • DBT targets suicidal and other dangerous, severe, or destabilizing behaviors. DBt strives to increase behavioral capabilities, improve motivation for skillful behavior through management of issues and problems as they come up in day-to-day life, reduce interfering emotions and cognitions, and to structure the treatment environment in a way that reinforces functional rather than dysfunctional behaviors.
    • DBT skills for emotion regulation include
    • identifying and labeling emotions
    • identifying obstacles to changing emotions
    • reducing vulnerability to emotion mind
    • increasing positive emotional events
    • increasing mindfulness to current emotions
    • taking opposite action
    • applying distress tolerance techniques
    • Schema-focused therapy (SFT)
    • builds on CBT and is also known as CBT with a psychodynamic component
    • It is an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, which are called schemas.
    • Schema therapists use an inventory to assess the schemas that cause persistent problems in a patients life.
    • To change the schemas, they use a range of techniques that include:
    • congitive restructuring
    • limited re-parenting
    • changing schemas as they arise in the therapy relationship
    • intensive imagery work to access and change the source of schemas
    • creating dialogues between the schema side of the patients and the healthy side
    • Mentalization-based therapy (MBT)
    • Mentalization is the capacity to understand behavior and feelings, and how they are associated with specific mental states.
    • One of the many theories about Borderline Personality Disorders is that those who are diagnosed with BPD have a decreased capacity for mentalization.
    • The therapy itself seeks to help increase the capacity for mentalization, or the ability to perceive the mind of others as distinct from one’s own.
    • Mentalization is a component in most of the traditional types of psychotherapy, but is usually not the main focus.
    • (Facing the Facts, 2010)

    DSM-V Changes

    • Reformulated as Borderline Type
    • Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness. As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships.
    • Self-appraisal is often associated with self-loathing, rage, and despondency.
    • Individuals with this disorder experience rapidly changing, intense, unpredictable, and reactive emotions and can become extremely anxious or depressed. They may also become angry or hostile, and feel misunderstood, mistreated, or victimized.
    • They may engage in verbal or physical acts of aggression when angry.
    • Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment.
    • Relationships are based on the fantasy of the need for others for survival, excessive dependency, and a fear of rejection and/or abandonment.
    • Dependency involves both insecure attachment, expressed as difficulty tolerating aloneness; intense fear of loss, abandonment, or rejection by significant others; and urgent need for contact with significant others when stressed or distressed, accompanied sometimes by highly submissive, subservient behavior.
    • At the same time, intense, intimate involvement with another person often leads to a fear of loss of an identity as an individual. Thus, interpersonal relationships are highly unstable and alternate between excessive dependency and flight from involvement.
    • Empathy for others is severely impaired.
    • Core emotional traits and interpersonal behaviors may be associated with cognitive dysregulation, i.e., cognitive functions may become impaired at times of interpersonal stress leading to information processing in a concrete, black-and white, all-or-nothing manner.
    • Quasi-psychotic reactions, including paranoia and dissociation, may progress to transient psychosis. Individuals with this type are characteristically impulsive, acting on the spur of the moment, and frequently engage in activities with potentially negative consequences.
    • Deliberate acts of self-harm (e.g., cutting, burning), suicidal ideation, and suicide attempts typically occur in the context of intense distress and dysphoria, particularly in the context of feelings of abandonment when an important relationship is disrupted.
    • Intense distress may also lead to other risky behaviors, including substance misuse, reckless driving, binge eating, or promiscuous sex. (APA, 2010)

    Prognosis

    • The disorder usually peaks in young adulthood and frequently stabilizes after age 30.
    • Approximately 75–80% of borderline patients attempt or threaten suicide , and between 8–10% are successful.
    • If the borderline patient suffers from depressive disorder, the risk of suicide is much higher. For this reason, swift diagnosis and appropriate interventions are critical.
    • Remitted borderline patients were significantly less likely than non-remitted borderline patients to meet criteria for a number of other personality disorders, mostly anxious cluster disorders
    • BPD decreases significantly over time, especially for remitted borderline patients
    • (Zanarini, Frankenburg, Vujanovic, Hennen, Reich, & Silk, 2004)
    • The most co-occurring personality disorders declined significantly over time
    • Three exceptions were avoidant, dependent, and self-defeating PDs
    • Anxious cluster of disorders are the Axis II disorders that are most strongly associated with BPD failing to remit (Zanarini et al., 2004)
    • There may be subtypes of BPD patients and some of these subtypes are most likely to remit in the short- to mid-term, making them less temperamentally impaired than those whose borderline pathology remains relatively constant
    • Treatment aimed at these subtypes needs to be developed (Zanarini et al., 2004)

    Prevention

    • Prevention recommendations are scarce. The disorder may be genetic and not preventable. The only known prevention would be to ensure a safe and nurturing environment during childhood

    Medications

    • Medication is not considered a first-line treatment choice, but may be useful in treating some symptoms of the disorder and/or the mood disorders that have been diagnosed in conjunction with BPD. Recent clinical studies indicate that naltrexone may be helpful in relieving physical discomfort related to dissociative episodes
    • No FDA-approved medication exists for BPD (although many medications are used to treat the symptoms (Kreger, 2008)

    Medications Studied and Used in the Treatment of Borderline Disorder (Kreger, 2008)

    ANTIPSYCHOTICS
    Drug class Medications Symptoms Improved by One or More Medications in the Class
    Neuroleptics

    thiothixene (Navane)

    haloperidol (Haldol)

    trifluoperazine (Stelazine)

    flupenthixol

    anxiety, obsessive-compulsivity, depression, suicide attempts, hostility, impulsivity,

    self-injury/assaultive-ness, illusions, paranoid thinking, psychoticism, poor

    general functioning

    Atypical

    olanzapine (Zyprexa)

    aripiprazole (Abilify)

    risperidone (Risperdal)

    clozapine (Clozaril)

    quetiapine (Seroquel)

    anxiety, anger/hostility, paranoid thinking, self-injury, impulsive aggression,

    interpersonal sensitivity, low mood, aggressions

    ANTIDEPRESSANTS
    Drug Class Medications Symptoms Improved by One or More Medications in the Class

    SSRIs and

    related antidepressants

    fluoxetine (Prozac)

    fluvoxamine (Luvox)

    sertraline (Zoloft)

    venlafaxine (Effexor)

    anxiety, depression, mood swings, impulsivity, anger/hostility,

    self-injury, impulsive aggression, poor general functioning

    MAOIs phenelzine (Nardil)

    depression, anger/hostility, mood swings, rejection sensitivity,

    impulsivity

    Mood stabilizers

    divalproex (Depakote)

    lamotrigine (Lamictal)

    topiramate (Topamax)

    carbamazepine (Tegretol)

    lithium

    unstable mood, anxiety, depression, anger, irritability, impulsivity,

    aggression, suicidality, poor general functioning

    Economic Impact

    • Up to 40 percent of high users of mental health services have BPD
    • More than 50% of individuals with BPD are severely impaired in emplyability, with a resulting burden on Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Medicaid and Medicare
    • 12 percent of men and 28 percent of women in prison have BPD (Kreger, 2008)

    Information for the Family

    Facing the Facts when a loved one has Borderline Personality Disorder
    • To the family members, BPD behavior is frustrating, and can feel unfair. Some common thoughts are:
    • You have been viewed as overly good and then overly bad
    • You have been the focus of unprovoked anger or hurtful actions, alternating with periods when the family member acts perfectly normal and very loving
    • Things that you have said or done have been twisted and used against you
    • You are accused of things you never did or said
    • You often find yourself defending and justifying your intentions
    • you find yourself concealing what you think or feel because you are not heard
    • You feel manipulated, controlled, and sometimes lied to (Facing the Facts, 2010)

    For More Information, Please Read:

    • Linehan, M.M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
    • Kreger, R. (2008). The essential family guide to borderline personality disorder: New tools and techniques to stop walking on eggshells. Center City, Minnesota: Hazeldon Publishing.

    Links

    • APA: Borderline Personality Disorder Often Missed First Time Around
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