Download Child and Adolescent Psychopathology

Chapter 14:
Borderline Personality
Disorder (BPD)
Jill M. Hooley
Sarah A. St. Germain
Diagnosis: Personality Overview
 Lack of stable self-image, goals, relationships,
and mood
 Impulsive, erratic, risk seeking, and
antagonistic
 Trouble with understanding the emotions and
desires of others, especially when threatened
 Mistrustful, demanding, and fear of
abandonment
 Frequently sad, hopeless, pessimistic, and
ashamed
Diagnosis: Symptom Criteria
 Pervasive and present since adolescence
 Five or more of the following (no change in DSM-5)
 Frequent feelings of emptiness
 Desperate attempts to avoid abandonment (real or otherwise)
 Unstable and intense relationships with periods of idealization and
deprecation
 Potentially self-harming impulsive behavior in at least two areas
 Recurring suicidal threats, gestures, or behavior, or self-mutilation
 Unstable mood, (especially frequent marked sadness, irritability, and
anxiety) that resolves in hours or a few days
 Disproportionate, intense anger, or difficulty suppressing anger
 Notable and sustained lack of stable self-image or sense of self
 Short, stress-induced paranoid thought or significant dissociative
symptoms
Diagnosis: Comorbidity and
Heterogeneity
 Significant comorbidity
 Major depressive disorder (~61%)
 Dysthymia (~12%)
 Bipolar disorder (~20%)
 Eating disorders (~17%)
 PTSD (~36%)
 Substance abuse (~14%)
 9 possible symptoms x 5 required symptoms = 126
possible symptom combinations will all get the
diagnosis
Symptoms: Psychosis Like
Experiences
 ~75% of patients report paranoid ideas and/or dissociative
episodes
 Stress-related psychotic episodes
 BPD hallucinations and delusions differ from those
in psychotic disorders
 Usually more insight than psychotic patients
 Paranoid ideas typically not so firmly held that they reach
delusional levels
 Dissociation episodes relatively brief and stress-related
Symptoms: Self-Harm
 In some cases, suicidal and self-injurious
behaviors are used as strategies to regulate strong
negative emotions
 Self-harm behaviors are most often
 Cutting
 Burning
Prognosis
 Utilize significant treatment resources
 10% will successfully commit suicide
 After 2 years 30% will achieve lasting remission,
80% after 16 years
 However, rate of lasting recovery (e.g., symptom
remission + good functioning) after 16 years is 40%
 Positive indicators: Youth, no history of childhood sexual
abuse, no family history of substance abuse, good recent
work history, agreeable temperament, low neuroticism,
and low anxiety
Epidemiology
 Prevalence in the general population: 1% to 2%
 Prevalence in outpatient samples: 10% to 15%
 Long-held belief that BPD is more common in
women than in men, that is approximately 75% of
cases
 However, population-based studies report no gender
differences in the prevalence of BPD
 May be due to the fact that women are more likely to
seek treatment
Etiology: “Core Features of BPD”
 Linehan
 Affective instability
 Bateman and Fonagy
 Instability in the self-structure
 Gunderson
 Fear and intolerance of aloneness
 Neurobiological Framework
 Disinhibition and general negative affectivity
 Zanarini, Frankenburg, Hennen, and Silk
 Negative affectivity/dysphoria
 Even though BPD is common, it is far from being
clearly conceptualized and is likely multi-\dimensional
Etiology: Constitutional
Aggression and Family
 Interferes with integration of different perspectives
(positive and negative) of the self and others.
 Good representations are threatened by strong
negative feelings such as rage or hostility
 Borderline patients lack the ability to call upon
memories of “good objects” (e.g., nurturing and
empathic caretakers) to provide self-soothing in
times of distress
Etiology: Linehan’s BiosocialDevelopmental Model
 Biological or temperamental vulnerabilities interact
with failures in the child’s social environment to
create or exacerbate problems with emotion
regulation
 Key environmental factor is an invalidating family
environment
 Child’s communications of actual internal experiences are
met by parental responses that are inappropriate, erratic,
or out of touch with what is happening to the child
• Child: “I’m hungry.”
Parent: “No you aren’t. You don’t want to eat that.”
Etiology: Trauma
 Often high levels of early life trauma and adversity.
 Compared to patients with other Axis I and Axis II
disorders, patients with BPD are significantly more
likely to report physical abuse, sexual abuse, or
neglect during childhood
 Those who experienced early abuse or neglect more
than 7x more likely to be diagnosed with BPD later on
Etiology: Attachment
 Vast majority are insecurely attached; only minority
(6% to 8%) have secure attachment pattern
 Often emotionally attached to artificial safe and
stable attachment objects such as stuffed animals,
even in adulthood
 Patients with BPD struggle to sustain a mental
representation of their clinician as helpful and the
treatment relationship as caring and supportive
Etiology: Executive
Neurocognition (EN)
 Executive Neurocognition (EN): Family of
cognitive processes that delay or terminate a
response in order to achieve a less immediate
goal/reward
 Interference Control: Conscious attempt to control
attention and motor behavior
 Cognitive Inhibition: Suppress information from working
memory
 Behavioral Inhibition: Repressing frequent response
(e.g., hit spacebar for every letter except “Y”)
 Motivational or Affective Inhibition: Interruption of
tendency or behavior arising from an emotional state
Etiology: Executive
Neurocognition (EN)
 BPD patients show deficits on tasks tapping
EN processes
 Symptom severity correlated with deficit
 May be partially explained by depressive
symptoms
 Impairments in immediate and delayed
memory linked to increased impulsivity
Biological Etiology: Heritability
 Monozygotic twin concordance rate = 35%
 Dizygotic = 7%
 Prevalence rate for BPD in relatives is 3.4 % when
the relatives are assessed in person (15.1% when
patient report is used)
 BPD traits more common in relatives than diagnosis itself
• Neuroticism, cognitive dysregulation, anxiety, affective lability, and
impulsivity
 Relatives also show increased rate of mood and anxiety
disorders, impulse control disorders, and personality
disorders such as antisocial PD
Biological Etiology: Role of
Serotonin System
 Serotonin related genes associated with BPD type
behaviors, for example, suicide, impulsivity, and
emotional lability
 Physical and sexual abuse history in BPD women
associated with reduced response to serotonin agonist
challenge
 Suggests reduced receptor activity
 Low levels of 5-hydroxyindolacetic acid (5-HIAA;
metabolite of serotonin) associated with increased risk
of impulsive aggression and suicide (especially violent
forms of suicide)
Biological Etiology: Dopamine
and Novelty Seeking
 High novelty seeking (associated with BPD) is
related to altered dopaminergic function in the
brain.
 High levels of comorbidity between substance abuse
disorders and BPD
 9 repeat version of DAT1 gene is more likely to be found
in depressed patients with BPD then those without BPD
 Antipsychotic medications, which block dopamine
receptors, clinically benefit BPD patients
Biological Etiology:
Neuroanatomy
 Orbital frontal cortex (OFC): Plays a
role in emotion regulation, the stress
response, and impulse control
BPD is associated with lower
metabolic activity in the OFC
 Abnormalities in frontolimbic circuitry
may underlie many of the key clinical
features of BPD
Treatment
 Treating patients who suffer from BPD
is not easy
 Self-harming behaviors in 60% to 80% of
cases
 Mean number of lifetime suicide attempts
is 3.4
 Difficulty establishing trust and
therapeutic alliance
 Effective treatment may require long-term
and intensive treatment
Treatments: Medications
 SSRIs may help with mood stability; however,
benefits are usually modest
 Antipsychotic medications have beneficial effects
on impulsivity and aggression
 Significant side effects (weight gain, etc.) limit usefulness
 Mood stabilizers, for example divalproex sodium,
help with anger and mood instability
 Do not help impulsivity, aggression, or sociality
 Lithium not shown to be effective
Treatments: DBT
 Developed by Marsha Linehan
specifically to treat BPD
 Cognitive behavioral approach
 Weekly psychotherapy
 Weekly skills training in group format
 Therapist available 24 hours by phone
 Therapist attends weekly team
consultation meetings
Treatments: DBT Efficacy
 Improves mood and symptoms
 Reduces suicidal ideation and
increases will to live
 Reduces self-injurious behaviors
 Reduces suicide attempt rate when
compared with expert non-DBT
treatment (~23% vs. 46%)
 Less likely to drop out and less likely
to require hospitalization
Treatments: Psychodynamic
Approaches
 Mentalization Therapy
 Based on attachment theory
 Use therapeutic relationship to help patient develop skills to
understand emotions of themselves and others
 Efficacy shown in double-blind trials and maintained for years
afterward
 Transference Focused Psychotherapy (TFP)
 Use therapeutic relationship to understand and correct
distortions in perceptions of others
 Primary techniques: Clarification, confrontation, and
interpretation
 Improves depression, anxiety, anger social adjustment, overall
functioning, suicidality
Treatment: Schema Focused
Therapy (SFT)
 Uses CBT techniques to modify constellations
of underlying beliefs (i.e., schemas)
 Prevents maladaptive schemas from
distorting perceptions and causing
maladaptive behavior
 Decreases symptoms, improves quality of life,
and decreases dysfunctional behaviors
 May be more effective than transferencefocused psychotherapy: less dropout, greater
success rates