Transcript A Case Study of Borderline Personality

A Case study of Borderline Personality
Disorder complicated by Intellectual
Disability and misdiagnosis
Rachael’s Story
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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
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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!
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