Child and Adolescent Psychopathology
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Transcript 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