Transcript Borderline Personality Disorder

Borderline Personality
Disorder
Dr. Matthew Sager
Psychiatric Medical Director
St. Mary’s Hospital, Madison, WI
Borderline Personality
Disorder (BPD)
 What is it? Perceptions and current diagnosis
 History
 Causes
 Facts
 Co-occurring diagnoses and differential
 Treatment
 Evaluating safety concerns/suicidality
BPD
 Initial impressions
 Stigma
 Better descriptive terms?
Emotional Regulation Disorder
Current Diagnosis
 DSM IV-need to have 5 of 9 criteria (pervasive)
Unstable relationships-splitting example
Impulsive behaviors
Mood swings
Intense anger
Feelings of emptiness
Fear of abandonment
Identity disturbance, ‘poor sense of self’
Suicidal behavior or self-injury
Transient paranoia/dissociative states
Diagnostic Issues
 Problems with DSM IV
 5 of 9-there are 256 different variations
 4 of 9-no diagnosis, but would look very similar
clinically
DSM V
 Revisions to look at dimensional aspects of
personality
 BPD on same axis as depression, anxiety
 In end-too complex for clinical practice-yet
Diagnostic Issues cont.’
 Issues that affect making diagnosis:
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Transient states
Medical illnesses
Situational stress
Sex and cultural beliefs/biases
Clinician feelings-anger, disappointment, frustration
Diagnostic Issues cont.’
 In the end-the diagnosis focuses on ways of
thinking and feeling about oneself and others that
ends up affecting a persons ability to function
BPD History
 1930s Psychoanalysts (i.e. Sigmund Freud)
divided psychosis (delusions, hallucinations)
from neurosis (anxiety/distress). The area
between, the borderline was the difference that
explained why some patients did not act one
way or the other.
 1960s Psychiatrist Otto Kernberg
personality organization to syndrome to disorder
BPD History cont.’
 1980s and 90s
Increased research
From analytical to medicalization
DSM III (1980)
DSM IV (1994)
DSM V (2013)
BPD Causes
Genetics
 Twin studies show strong inheritance
Environmental
 Unstable family relationships
Social and cultural factors
 1900s-less unstructured time with more work/survival
instincts
 i.e. Eating Disorders indifferent countries
BPD Causes
 Abnormal Brain functioning
 Amygdala – center of emotion
 Prefrontal Cortex – complex problem solving
BPD
 Whatever the cause, data
shows the impact of this illness
BPD Facts
 2% of US population have BPD
(equal to population of New York City)
 Twice that of bipolar disorder or schizophrenia
 10% of mental health outpatient clinics
 20% of inpatient psychiatric hospital units
BPD facts
 75-90% of those diagnosed are women
 Do women seek treatment more than men?
 Men with similar symptoms may end up in jail or with
another diagnosis.
 10% complete suicide in their lifetime
 Comorbidities are rampant-mood disorders (depression,
bipolar) anxiety disorders (PTSD) and substance abuse
disorders
 Probably ‘burns out’ or dissipates over time
BPD Facts
 Face Studies: people with BPD are inclined to see
anger in neutral emotion faces
 Word Studies: people with BPD are inclined to
attach a stronger reaction to neutral words
Comorbidities and
differential diagnoses
 Mood Disorders (bipolar disorder I and II, major
depression, dysthymia)
 Anxiety disorders including PTSD
 Eating Disorders
 Substance Abuse Disorders
 Other personality Disorders
Comorbidities and
differential
 Lots of overlap with impulsive behaviors and mood
instability
 Different diagnoses from different providers
Explaining diagnosis
 John Gunderson MD quote
As an example that focuses on jargon free explanation that
patients can understand
BPD Treatment
 BPD-High utilization of health care $
ER visits, inpatient medical/psych care
 Hallmark of good care-multiple modalities
 Alliance building to foster improved mood,
behavior, social functioning and relationships
Treatment Goals
 Containment of any safety issues
 Structure
 Provide support
 Involve patient in decision making
 Validation
Treatment Levels
Hospital
‘Step Down or Up’ Partial hospital(PHP) or Intensive
Outpatient Program(IOP)
Outpatient Therapy + Med Management
Sociotherapies (group, family)
Treatment Levels
 Focus on the least restrictive
means of effective treatment
BPD Treatment
 Hospital care
 Often contraindicated and can worsen behavioral
issues
 Hospital provides external control which can become
habit forming and cause BPD patient to attempt to
gain control in negative fashion
 Should be used only for acute safety stabilization
BPD Psychotherapy
 Mainstay of BPD treatment
 Specific types may be more effective
BPD Psychotherapy
 DBT (Dialectical Behavioral Therapy)
 Pioneered by Marsha Linehan PhD
 Focuses on mindfulness, acceptance and awareness
of situations and feelings
 decreases intensity of emotions
BPD Psychotherapy
 CBT(Cognitive Behavioral Therapy)
 Focus: Changing thinking will change behavior
 Skill building/practice
 Relaxation
 Exposure therapy
BPD Psychotherapy
 Schema therapy
Reframing ways people view themselves
BPD Psychotherapy
 Group Therapies
Interpersonal
Family
DBT
Others (problem focused)
BPD Medications
 Role of meds: manage symptoms, though benefit is
often uncertain due to ‘symptom chasing’
 Goal is to treat comorbidities
 Avoid dependence, abuse, risk of overdose
 Classes:
Antidepressants
Antipsychotics
Mood stabilizers
Anti-anxiety
AODA meds-antabuse/naltrexone/methadone
BPD Medications
Treat comorbidities!
Treatment Plans
 Contracts with patients
 Makes expectations explicit
 From Crisis Intervention, when to call providers,
when to go to hospital to roles of those involved
i.e. family/friends
BPD Safety issues
 Suicide and borderline personality
 10% completed lifetime
 Safety plans-limited pill supply, family support,
crisis contact
 Highest risk are those with depression and
alcohol/drug problems
BPD safety issues
‘Feeling Unsafe’
Goal is for patient to recognize when they need more
active help and trust they will get it
Typical Crisis-express concern, allow patient to ventilate,
avoid taking actions but let patient be explicit about
situation
Follow-up after crisis
BPD and suicidal acts
 John Gunderson, MD
 “Suicidal acts are a dangerous distraction from the
patient working on attaining a better life”.
Dr Gunderson views suicidal statements/acts as
affecting a patient’s dependence on others and an effort
to be cared for.
BPD
References:
1. Gunderson, John G, M.D. ‘Borderline Personality
Disorder A Clinician’s Guide’, 2001.
2. DSM IV, American Psychiatric Association, 2000.
3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D.,
Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th
Edition, 2008.