Download Borderline Personality Disorder

Borderline Personality Disorder
Milton Brown
Behavioral Research & Therapy Clinics
University of Washington
Borderline Personality Disorder
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What is BPD?
How to assess BPD
How does BPD develop?
BPD in adolescence
Intervention options
How to respond to challenging BPD clients
What is a Personality Disorder?
DSM-IV diagnostic criteria
A.
An enduring pattern of inner experience and behavior
that deviates markedly from the expectations of the
individual’s culture. This pattern is manifested in two (or
more) of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting
self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and
appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control
What is a Personality Disorder?
DSM-IV diagnostic criteria
B. The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations
C. The enduring pattern leads to clinically significant distress
or impairment in social, occupational, or other important
areas of functioning
D. The pattern is stable and of long duration, and its onset can
be traced back at least to adolescence or early adulthood
E. The enduring pattern is not better accounted for as a
manifestation or consequence of another mental disorder
F. The enduring pattern is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition (e.g., head trauma).
Borderline Personality Disorder
DSM-IV diagnostic criteria
1. Frantic efforts to avoid real or imagined
abandonment. Note: Do not include suicidal or self-mutilation
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 selfmutilation behavior covered in Criterion 5
Borderline Personality Disorder
DSM-IV diagnostic criteria
5. Recurrent suicidal behavior, gestures, or threats,
or self-mutilation
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
BPD is Prevalent and Chronic
Prevalence
• 16% of adolescents
• 10% of adults
Stability
• 25% of adolescents still have BPD after 2 years
– 53% of severe BPD cases
• 60% of adults still have BPD after 6 years
• 35% of adults still have BPD after 15 years
What is BPD
• The multidiagnostic, difficult-to-treat patient
• Chronic suicidality and self-harm
• A diverse patient population
Parasuicidal Behaviors in BPD
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75% have a history of parasuicide
10% lifetime suicide rate*
more repeated suicide attempts than other disorders
more likely to have persistent and intense suicide
ideation between parasuicide episodes, whereas…
• individuals with only depression are more likely to
have long periods of normal mood and episodic suicide
ideation/behavior.
• nonsuicidal self-injury is common in BPD, and rare in
most other disorders (except mental retardation).
Diagnoses for Parauicide Study
Diagnosis
Lifetime Current
Depressive disorder*
Substance abuse/depend.
PTSD
Social phobia
Panic disorder
Eating disorder
Antisocial PD
Avoidant
97%
60%*
57%
22%
52%
41%
-
89%
31%
51%
16%
40%
24%
11%
21%
Diagnoses for Substance Abuse Study
Diagnosis
Current
Depressive disorder
Any anxiety disorder
Eating disorder
Antisocial PD
39%
52%
18%
44%
Diagnoses for Anger Study
Diagnosis
Current
Depressive disorder
Any anxiety disorder
Eating disorder
Antisocial PD
Substance use disorder
63%
83%
13%
17%
4%
The Core of BPD
• Emotion dsyregulation
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High sensitivity
High intensity
Slow return to baseline
Pervasiveness
Chronicity
• Impulsive behaviors
– Because emotions are “out of control”
– Because the behaviors regulate emotions
• Pervasive experiential avoidance
Borderline Personality Disorder
EMOTION
DYSREGULATION
Self
Dysregulation
Cognitive
Dysregulation
Action
Dysregulation
Suicidal
Action
Interpersonal
Dysregulation
-Death
-Distraction
-Sleep
-Biochemical
-Cue Removal
Cue
The Client’s View
Emotion Dysregulation
= Problem Behavior
Dysfunctional Behavior
= Problem Solution
Consequences
Cue
Basic Paradigm
Emotion
Dysregulation
Problem
Behavior
Consequences
Cues
For Example
Prescription picked up earlier that day,
in room alone, ruminating about criticism
roommate made of her earlier in the day
Emotion
Dysregulation
of shame
Problem Behavior
overdose
Consequences
sleep, stop ruminating, wake reduced shame
Methods of Experiential Avoidance
Denial of problems (rather than problem-solving)
Dissociation and emotional numbing
Isolation
Drug and alcohol abuse
Suicide attempts (and suicide)
Nonsuicidal self-injury
Self-punishment, self-criticism
Secondary emotions to avoid primary emotions
Hospitalization to escape stressful circumstances
Reasons for Parasuicide
Emotion Relief (92%, at least one)
• To stop bad feelings
• To stop feeling angry or frustrated or enraged
• To relieve anxiety or terror
• To relieve feelings of aloneness, emptiness or
isolation
• To stop feeling self-hatred, shame
• To obtain relief from a terrible state of mind
To punish yourself (63% of nonsuicidal self-injury)
Development of BPD
BPD becomes noticeable in early
adolescence, but begins long before that.
• A “difficult” temperament may be a sign of
vulnerability during infancy
• Suicidal ideation, threats, and behavior
during childhood and adolescence
• Conduct disorder, antisocial behavior, mood
disorders, anxiety disorders
• 16% of adolescents meet BPD criteria
Development of BPD
Environmental Factors
Pathological parenting is an important risk factor.
• emotional neglect
• parental over-involvement*
• inconsistent care by a primary caretaker*
• disrupted attachment patterns
• parental psychopathology
• physical and sexual abuse
• early separation and loss?
Development of BPD
Biological Correlates
Biological correlates of emotional instability and
impulsivity have been identified
• Patients with emotional instability may have higher
levels of noradrenaline activity
• Patients with impulsive disorders may have lower
levels of serotonin activity.
• Patients with major depressive disorder and BPD
both have shorter and more variable REM latencies.
• Some brain differences have been found in BPD.
• A twin study supports a psychosocial model more
than a genetic model of BPD transmission.
Development of BPD
Linehan’s Biosocial Theory (1993)
Biological and environmental factors account for BPD.
• BPD individuals are born with emotional vulnerability
– highly sensitive to emotional stimuli
– more intense in their emotional reactions
– slower to return to their emotional baseline
• BPD individuals grow up in invalidating environments
– childhood abuse
– poorness-of-fit between the child and the family
• Transactions between biological vulnerabilities and an
invalidating environment lead to a dysfunction in the
emotion regulation system.
Development of BPD
Linehan’s Biosocial Theory (1993)
The path to BPD is a process of reciprocal
influences.
• invalidating environments worsen
dysregulation of vulnerable children.
• emotionally intense children may exacerbate
the invalidating environment.
• mutual coercion can escalate emotion,
violence, and self-harm.
Does it make sense to diagnose
BPD in adolescence?
• BPD in adolescents accurately reflects current distress
and dysfunction
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Social impairment/isolation
School problems
Work problems
Comorbid axis I diagnosis
Contact with police for antisocial behavior
• As expected, BPD co-occurs with PTSD, conduct
disorder, depression (construct validity)
• Overall, BPD diagnosis is not stable
• 53% of moderate/severe cases of BPD persist
What to look for
• Caucasian female
• Severe BPD (predicts chronicity)
• Parasuicide, identity disturbance, intense
anger (predicts chronicity)
• Co-occurring mood and conduct disorder
• Bipolar II disorder
• History of childhood maltreatment
Disability in BPD
• What are the functional limitations?
• What are reasonable accommodations in
academic settings?
Treatment Options:
The Main Dialectic
Short-term
avoid stress
remove cues
isolation
distraction
hospitalization
Long-term
block avoidance
tolerate distress
challenge fears
build a structured life
problem-solving
focus on emotions
alternative coping
An Ideal Treatment for BPD
is one that balances…
Acceptance and Change
Soothing versus pushing the client
Validation versus demanding
Most Good Treatments
Don’t Work for BPD
BPD has been associated with worse outcomes
in treatments of Axis I disorders such as
• major depression
• anxiety disorders
• eating disorders
• substance abuse
because BPD patients have low tolerance for
change in the absence of validation
Treatment Goals
• Reduce out of control behavior
• Build a structured/productive life consistent
with values
• Change (increase tolerate for) emotions
• Treat Axis I disorders
• Treat effects of childhood trauma
• Personal goals
Treatment Objectives
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Enhance capabilities
Reduce emotion vulnerability
Activate non-mood-dependent behavior
Enhance motivation
Generalization
structuring of the environment
Enhance capability and motivation of therapists
Treatment Strategies
Intervene early before maladaptive patterns
become crystallized and refractory to treatment.
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Problem-solving
Skills-focus*
Exposure and opposite action
Reinforcement
Cognitive modification
Support/Validation/Acceptance
Keep lethal means out of reach (e.g., pills)
Treatment of BPD:
Commitment to not parasuicide
Verbal commitment
Commitment strengthening
Devil's advocate
Motivational interviewing
Pros and cons analysis
Provide help
Provide incentives for no parasuicide
Problem-Solving
1. Understand the problem
1. Identify the trigger (event)
2. Identify the key emotions and thoughts
3. What problem did the behavior solve?
2. Generate alternative solutions
3. Practice solutions
Treatment of BPD
Significant Outcomes from DBT Study:
DBT vs. TAU
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Parasuicide Episodes
Treatment Drop Out
Psychiatric Inpatient: Admissions/Days
Anger
Global Adjustment
Social Adjustment
Treatment of BPD
UW Replication Study
• Effects of DBT were similar to the previous study
despite
– rigorous control condition of expert therapists
– high allegiance to the alternative treatment
• DBT is effective in six randomized controlled trials
• DBT is particularly effective with suicidal behavior
• Expert therapists are better than treatment as usual
Ways to fail with a BPD client
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Insufficient validation
Judgmental attitude toward client
Burnout
Insight therapy
Back down too easily
Reinforce dysfunctional behavior
No learning in context
How should a provider interact
with a BPD client?
• Validate and acknowledge what is valid
• Adopt a compassionate and nonjudgmental
view of the patient
• Don’t ignore your personal or institutional
limits, but stay objective
• Believe in the patient
• Encourage mastery; provide practical help
• Get support and consultation
Levels of Validation
• Listen and pay attention
• Show you understand – paraphrase
• Communicate how their behavior/emotions
make sense
– given their past experiences
– given their thoughts/beliefs
• Communicate how their behavior/emotions
are normal or make sense now
• Don’t “fragilize” them or treat them like a
patient
When to Refer
• When the client’s problems exceed your skill
• When you are approaching burnout
• If you cannot control judgmental thinking
about the client
• If the client does not improve
Medications for BPD
• SSRIs improve mood and impulsivity
– May reduce nonsuicidal self-injury
– May increase suicide attempts*
• Olanzapine improves irritability/anger
• Anticonvulsants (Tegritol) decrease behavioral
dyscontrol
• Alprazolam (Xanax) increases behavioral
dyscontrol and suicidality ratings
• Opiate blockers
Medication Recommendations
• Combine pharmacotherapy with an active
psychosocial treatment
• Focus on safety and effectiveness
– Do not give lethal drugs to lethal people
– Avoid benzodiazepines
– Amitriptyline makes some subjects worse
• Attend to medication non-compliance
• Consult with the patient
Medications for BPD
Dimeff, L.A., McDavid, J., Linehan, M.M. (1999).
Pharmacotherapy for borderline personality disorder: A
review of the literature and recommendations for
treatment. Journal of Clinical Psychology in Medical
Settings, 6(1), 113-138.
Grossman, R. (2002). Psychopharmacologic treatment of
patients with borderline personality disorder. Psychiatric
Annals, 32(6), 357-370.
Healy, D. (2003). Lines of evidence on the risks of suicide
with selective serotonin reuptake inhibitors. Psychotherapy
and Psychosomatics, 72(2), 71-79.