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A Case study of Borderline Personality Disorder complicated by Intellectual Disability and misdiagnosis Rachael’s Story • • • • • • • • Lived with foster parents from 9 weeks Mild Cerebral Palsy Aggression from a young age Numerous placements and respites Numerous behavioural programs Variety of medications Diagnosed with Autism DoCS to DADHC handover… A Quick Overview • Case study - Rachael • DSM-IV-TR diagnostic criteria • Stop walking on Eggshells (Mason & Kreger, 1998) • Borderline Personality Disorder (BPD) and DSM-IV-TR, Axis 1 and 2 • The Borderline Controversy • A Question of Attachment, Personality and Developmental Disability Some statistics • BPD is less known but more common then bipolar disorder or schizophrenia • 2% of the general population • 10% of all mental health outpatients • 20% of psychiatric inpatients • 75% are women • 54% have substance abuse problems • 75% have been physically or sexually abused • 14.9% of American adults have a personality disorder – Recent American study, NESARC, n=43,000 (cited in Wright, 2004) Rachael’s Story • Mood swings from charming to aggressive • Triggers to emotionally or physically aggressive outbursts hard to identify • Tall stories including ‘nightmares’, alleged sexual abuse and being too sick to go to school • Manipulating staff • Irrational or dissociated comments • Strategies included – Car with a safety shield – Safety room for staff – Reactive and proactive strategies and OHS procedures Diagnostic criteria for 301.83 Borderline Personality Disorder 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 Criterion5 (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 Remembered by the mnemonic P - Paranoid ideas R - Relationship instability A - Angry outbursts, affective instability, abandonment fears I - Impulsive behaviour, identity disturbance S - Suicidal behaviour E - Emptiness Stop Walking on Eggshells Additional Criteria • • • • • • • Pervasive Shame (often related to sexual or physical abuse) Undefined Boundaries Control issues Lack of object constancy Interpersonal Sensitivity (BPD ‘psychic abilities’) Situational Competence Narcissistic demands (ego-centred also an infantile stage of personality) • Manipulation or Desperation? • High Functioning, Low Functioning • Acting In, Acting Out (Abuse and accusation vs. selfmutilation and suicide) Rachael’s Story • Health professionals reluctant to confirm diagnosis of Borderline • Antidepressant helpful but didn’t solve everything • Rachael moved to a new group home • Weekly counselling including relaxation, social skills worksheets and interpersonal and psychodynamic work – Did not confront negative behaviour until stronger rapport was built DSM-IV-TR Axis I and II • Most diagnostic criteria in the DSM includes the warnings – ‘Not if better accounted for by…’ – ‘Does not occur exclusively during the course of …’ – ‘Criteria are not met for …’ • Both personality disorders and intellectual disability listed on Axis II • Diagnostic Overshadowing? (Reiss, 2000; Reiss, Levitan & McNally, 1982) • A question of co-morbidity and jargon The Borderline Controversy • The borderline myths within psychology and psychiatry • Labelling, stigma and reluctance • On the borderline between psychosis and neurosis? • Emotional dysregulation disorder? Reactive Attachment Disorder? • DSM V due in 2011 • Some literature suggesting that personality disorders only occur in mildly intellectually disabled people (Masi, 1998) • Personality disorders within Developmental Disability - A minority within a minority group or an undiagnosed population? Attachment, personality and developmental disability • Literature saying that relationships difficulties and insecure attachment more common in this population. Many factors including residential services that militated against emotional development. (Clegg & Lansdall-Welfare, 1995) • “Attention Seeking” – we ALL need attention • There is a link between attachment and challenging behaviour that needs more research. (Clegg & Sheard, 2002) • There is a link between attachment and personality disorder. (Agrawal, Gunderson, Holmes & Lyons-Ruth, 2004) A Question of attachment, personality and developmental disability Question – what defines the continuum from a healthy personality to a disordered person? And from early attachment to adult intimate relationships? When does a label help? If I tried to answer this question I think it would be good to keep in mind: • 14.9 percent of Americans 18 years or older… • Health is a bio-psycho-social phenomena. • Regardless of age or ability, no person is independent, we all have a Self and persona which must exist within many interdependent relationships. • Nelson Mandela, Gandhi, some of my clients, sports heroes and hardened criminals all challenge society. Rachael’s Story • Frequency of aggression greatly reduced • Attended a personal development / sex education course • Had her first kiss • Reconnected with family • Changing jobs we had to say goodbye References and Resources www.BPDcentral.com Agrawal, H., Gunderson, J., Holmes, B. & Lyons-Ruth, K. (2004). Attachment Studies with Borderline Patients: A Review. Harvard Review of Psychiatry, 12(2), 94-104. Clegg, J.A. & Lansdall-Welfare, R. (1995). Attachment and Learning Disability: a theoretical review informing three clinical interventions. Journal of Intellectual Disability Research, 39, 295-305. Clegg, J.A. & Sheard, C. (2002). Challenging Behaviour and Insecure Attachment. Journal of Intellectual Disability Research, 46(6), 503-506. Masi, G. (1998, Summer). Psychiatric illness in mentally retarded adolescents: clinical features. Adolescence. Mason, P. T., Kreger, R. (1998). Stop Walking on Eggshells: Taking your life back when someone you care about has Borderline Personality Disorder. New Harbinger. Reiss, S., Levitan, G. W., & McNally, R. J. (1982). Emotionally disturbed mentally retarded people: An underserved population. American Psychologist, 37, 361-367 Reiss, S. (2000, Spring). A Mindful Approach to Mental Retardation. Journal of Social Issues. Wright, J. (2004, Oct 15). A survey of personality disorders. American Family Physician. The I-CAN! …Shameless plug…