Download Borderline Personality Disorder

Borderline Personality Disorder
9 June 2016
Diagnostic Criteria for Personality
Disorder.
• Markedly disharmonious attitudes and behavior, generally involving
several areas of functioning; e.g. affectivity, arousal, impulse
control, ways of perceiving and thinking, and style of relating to
others;
• The abnormal behavior pattern is enduring, of long standing, and
not limited to episodes of mental illness;
• The abnormal behavior pattern is pervasive and clearly maladaptive
to a broad range of personal and social situations;
• The above manifestations always appear during childhood or
adolescence and continue into adulthood;
• The disorder leads to considerable personal distress but this may
only become apparent late in its course;
• The disorder is usually, but not invariably, associated with significant
problems in occupational and social performance.
Epidemiology
• 5-10% of the adult population in the
community suffer from a personality disorder.
• More common in younger age groups
• Equal sex distribution (unequal for some
subtypes e.g. dissocial more common in
males)
Specific Personality Disorders
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(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
(F60.3) Emotionally unstable personality disorder
Impulsive/Borderline personality disorder
(F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders
(F60.9) Personality disorder not otherwise specified
Emotionally unstable personality
disorder
• Personality disorder in which there is a marked tendency to
act impulsively without consideration of the consequences,
together with affective instability. Two subtypes:
• Impulsive type: predominant characteristics are emotional
instability and lack of impulse control. Outbursts of violence
or threatening behaviour are common, particularly in
response to criticism by others.
• Borderline type: characterized in addition by disturbances
in self-image, aims, and internal preferences, by chronic
feelings of emptiness, by intense and unstable
interpersonal relationships, and by a tendency to selfdestructive behaviour, including suicide gestures and
attempts.
Prevalence of Borderline PD
• 0.5 -0.7% of subjects in household surveys
• In mental healthcare settings borderline
personality disorder is the most common type
of personality disorder. Although the sex
distribution is equal, women are more likely to
present for treatment.
• 10% of psychiatric out-patients
• 20% of psychiatric inpatients
Impact
• Studies of clinical populations have shown that people
with borderline personality disorder experience
significantly greater impairment in their work, social
relationships and leisure compared with those with
depression
• People with borderline personality disorder may
engage in a variety of destructive and impulsive
behaviours including self-harm, eating problems and
excessive use of alcohol and illicit substances.
• 65-80% engage in non-suicidal self-injury
• 60-70% attempting suicide at some point in their life
Aetiology
• Genetics: twin studies suggest that the heritability
factor for borderline personality disorder is 0.69
• Psychosocial factors: neglect and emotional underinvolvement and/or abuse by caregivers; mother
perceived as distant or overprotective, and their
relationship with her as conflictual, while the father is
perceived as less involved and more distant; insecure
attachments to care-givers; physical and sexual abuse
occurring in the context of an unstable, non-nurturing
family environment
Mechanism
• Neurotransmitters with serotonin mainly
implicated in the regulation of impulses,
aggression and affect
• Neurobiology: evidence of structural and
functional deficit in brain areas central to affect
regulation, attention and self-control, and
executive function have been described in
borderline personality disorder including the
amygdala, hippocampus and orbitofrontal
regions
Diagnosis
• Most frequently made following an unstructured
clinical assessment (often without obtaining a
collateral history from an informant). However
agreement among clinicians’ diagnoses of
personality disorder has been shown to be poor.
• Reliability of diagnosis improved by use of
standardised interview schedules . No single
schedule identified as the gold standard, only
moderate correlation between different
schedules, few clinicians are trained in the use of
such instruments; time consuming.
Course
• Symptoms develop in adolescence and persist
into adulthood
• Between 50-80% of patients will improve
sufficiently to no longer meet the criteria for
borderline personality disorder 10 years after first
diagnosis (evidence suggests that a significant
proportion of improvement is spontaneous and
accompanied by greater maturity and selfreflection rather than secondary to treatment).
• 10% commit suicide
Co-morbidity
• Considerable overlap with other personality
disorders (particularly Cluster B: histrionic,
narcissistic and antisocial)
• Lifetime prevalence of at least one comorbid
mental illness approaches 100% for this group
(particularly depression, anxiety (PTSD) and
substance misuse)
Pharmacological treatment
• Many of the symptoms of borderline personality disorder (including
affective instability, transient stress-related psychotic symptoms,
suicidal and self-harming behaviours, and impulsivity) are similar in
quality to those of many types of mental illness and could
intuitively be expected to respond to drug treatment
• No psychotropic drug is specifically licensed for the management of
borderline personality disorder.
• Psychiatric medications commonly prescribed and often in
combination (75% of patients with borderline personality disorder
are prescribed combinations of drugs at some point)
• Such treatment is often initiated during periods of crisis and the
placebo response rate in this context is high (50%); the crisis is
usually time limited and can be expected to resolve itself
irrespective of drug treatment.
Evidence base for pharmacological
treatment
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……….is weak
Few studies.
Wide variations in populations studied
Large number of outcomes reported by each
individual study
• Lack of standard outcome rating scales within
the research field
Summary of evidence for
pharmacological treatments
• Some evidence (largely based on single studies)
that pharmacological treatments can help to
reduce specific symptoms including anger,
anxiety, depression symptoms, hostility and
impulsivity.
• It is far from clear if the above effects are the
consequence of treating comorbid disorders.
• There is no evidence that pharmacological
treatments alter the fundamental nature of the
disorder in either the short or longer term.
NICE guidance
• Drug treatment should not be used specifically for borderline
personality disorder or for the individual symptoms or behaviour
associated with the disorder (for example, repeated self-harm,
marked emotional instability, risk-taking behaviour and transient
psychotic symptoms).
• Antipsychotic drugs should not be used for the medium- and longterm treatment of borderline personality disorder.
• Drug treatment may be considered in the overall treatment of
comorbid conditions
• Review the treatment of people with borderline personality
disorder who do not have a diagnosed comorbid mental or physical
illness and who are currently being prescribed drugs, with the aim
of reducing and stopping unnecessary drug treatment.
NICE (pharmacological management of
crises)
• Ensure that there is consensus among prescribers and other involved
professionals about the drug used and that the primary prescriber is
identified
• Establish likely risks of prescribing
• Take account of the psychological role of prescribing (both for the
individual and for the prescriber) and the impact that prescribing
decisions may have on the therapeutic relationship and the overall care
plan, including long-term treatment strategies
• Ensure that a drug is not used in place of other more appropriate
interventions
• Use a single drug, avoid polypharmacy whenever possible.
• Short-term use of sedative medication may be considered cautiously as
part of the overall treatment plan for people with borderline personality
disorder in a crisis. The duration of treatment should be agreed with
them, but should be no longer than 1 week.
Psychological treatment
• Specific therapies for borderline personality
disorder developed through modification of
existing techniques (CBT, CAT, IPT). Dialectical
Behaviour Therapy (DBT) a specific intervention
for borderline personality disorder per se.
• Most psychological therapy offered to people
with borderline personality disorder in the NHS
are generic or eclectic and do not use a specific
method.
Evidence base for psychological
therapies
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…………..is relatively poor
few studies
low numbers of patients and therefore low power
multiple outcomes with few in common between
studies
• and a heterogeneous diagnostic system that
makes it hard to target a specific treatment on
patients with specific sets of symptoms because
the trials may be too ‘all inclusive’.
Summary of evidence for psychological
treatments
• The state of knowledge about the current
psychological treatments available is in a
development phase rather than one of
consolidation. Conclusions are, therefore,
provisional and more and better-designed studies
need to be undertaken before stronger
recommendations can be made.
• Some evidence that psychological therapy
programs, specifically DBT and MBT, are effective
in reducing suicide attempts and self-harm,
anger, aggression and depression.
NICE guidance
• When providing psychological treatment for people with borderline
personality disorder the following service characteristics should be in
place: an explicit and integrated theoretical approach used by both the
treatment team and the therapist, which is shared with the service user;
structured care in accordance with this guideline; provision for therapist
supervision.
• Do not use brief psychological interventions (of less than 3 months’
duration) specifically for borderline personality disorder or for the
individual symptoms of the disorder, outside a service that has the
characteristics outlined above.
• Although the frequency of psychotherapy sessions should be adapted to
the person’s needs and context of living, twice-weekly sessions may be
considered.
• For women with borderline personality disorder for whom reducing
recurrent self-harm is a priority, consider a comprehensive dialectical
behaviour therapy program.
Recommendations
• Recognise transference/countertransference. (Avoid playing the
role unconsciously given to us by the patient )
• Empathise (try to understand the crisis from the person’s point of
view; avoid minimising the person’s stated reasons for the crisis;
refrain from offering solutions before receiving full clarification of
the problems)
• Avoid focusing on symptom management and instead explore the
reasons for the person’s distress and help them reflect on possible
solutions.
• Avoid making the situation worse!
• Provide practical help/sign-posting
• Actively treat co-morbidities
• Educate the patient about mood instability
• Inform the patient about good long-term prognosis
Recommendations