Transcript General advice ain

Borderline Personality Disorder
Definition of Personality Disorders
• Personality disorders are “enduring patterns
of perceiving, relating to, and thinking about
the environment and oneself” that “are
exhibited in a wide range of important social
and personal contexts,” and “are inflexible
and maladaptive, and cause either significant
functional impairment or subjective distress”
(DSM-IV, p. 630)
The “Big 5” Personality Traits
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Openness to experience
(v. premature closures)
Conscientiousness
(v. irresponsibility)
Extraversion
(v. introversion)
Agreeableness
(v. uncooperativeness)
Neuroticism
(v. a healthy world view and positive adjustments)
 personality disorders represent extreme variations
of OCEAN
Main Features of PDs
• Extreme patterns of thinking, feeling, and behaving
that deviate from a person’s culture
• Listed on Axis II of the DSM-IV-TR
• Begin early in life and remain stable
- not contextual or transient
• Inflexible and maladaptive
• Cause significant functional impairment and
subjective distress
- ego-syntonic vs. ego-dystonic
Impulsive-Aggressive Spectrum
ADHD
Bipolar
Tourette’s/
Spectrum Spectrum
OCD
Cluster B
Personality Disorders
Borderline
Personality
Disorders
Impulsivity &
Aggression
Developmental
Disorders
Autism
Spectrum
Sexual
Impulse Disorders
CompulsionsSubstance
Control
PTSD Disorders
Use
Disorder
Personality Disorder
- Inflexible patterns of behavior (maladaptive)
- Begins early in adulthood (lifelong)
- Results in social, occupational problems or
distress (pervasive)
• 11% of Psychiatric Outpatients and 19% of
Psychiatric Inpatients
• Of all PD’s 33% of outpatients are BPD and 63% of
Inpatients are BPD
• Severe problems and marked misery, 70-75% have
engaged in self-destructive activities
• 74% of those diagnosed are female. Females are
more likely to engage in self harm.
• 75% of self harm behaviors occur between the ages
of 18 and 45.
• Characteristic Behaviors: Emotional Vulnerability,
Self Invalidation, Unrelenting Crises, Inhibited
Grieving, Active Passivity, Apparent Competence
Cluster A Personality Disorders
Paranoid, schizoid, and schizotypal personality
disorders
Marked by eccentricity, odd behavior, not
psychosis
Share a superficial similarity with schizophrenia
(as if a milder version)
Cluster B Personality Disorders
Antisocial, borderline, histrionic, and
narcissistic personality disorders
Being self-absorbed, prone to
exaggerate importance of events
Having difficulty maintaining close
relationships
Poor capacity to engage in ongoing
cooperative relationships
Cluster B: Dramatic, Emotional, or Erratic
• Antisocial PD – is a pattern of disregard for, and
violation of, the rights of others
• Borderline PD – is a pattern of instability in
interpersonal relationships, self-image, and affects,
and marked impulsivity
• Histrionic PD – is a pattern of excessive emotionality
and attention seeking
• Narcissistic PD – is a pattern of grandiosity, need for
admiration, and lack of empathy
Primary Cluster B
Personality Disorders
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Borderline
NOS
Narcissistic
Antisocial
Histrionic
56%
22%
14%
7%
1%
– “Borderline Personality Organization”
BORDERLINE PD
Unstable Relationships, Affect, SelfImage Plus Impulsiveness
5 + of :
Fears Abandonment
Unstable Relationships
Changing Self-Image
Impulsive Sex, Spending,
Suicidal Behavior
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Mood Shifts
Feels Empty
Anger
Temporary Etc
Paranoia
Borderline and comorbidity
• High degree of overlap with both Axis I and
Axis II disorders
• 24%-74% also diagnosed with major
depression; 4% to 20% bipolar
• 25% of bulimics also diagnosed with BPD
• 67% also diagnosed with substance use
disorder
Borderline Personality Disorder
• marked instability of mood, relationships,
self-image
• intense, unstable relationships
• uncertainty about sexuality
• everything is “good” or “bad”
• chronic feeling of “emptiness”
• recurrent threats of self-harm/ “slashers”
John Gunderson, MD
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Psychotic Borderline
The Borderline Syndrome
The As – If Borderline
The Neurotic Borderline
Grinker, Werble and Drye, 1968
ANTISOCIAL PD (ASPD)
Disregard Rights of Others (and meet
Conduct Disorder)
3 + of :
Unlawful
Reckless
Deceitful
Irresponsible
Impulsive
Lack Remorse
Aggressive
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ASPD
“I’m the most cold-hearted son of a b---- you will ever
meet”
– Ted Bundy
Cluster C Personality Disorders
Avoidant, obsessive-compulsive, dependent
disorders
Individuals are often anxious, fearful, and
depressed
Cluster A
Cluster B
Cluster C
Odd, Eccentric
Angry
Anxious
Psychosis
R – Reality Testing
E – Empathic Dysfunction
M – Mechanisms of Defense (Primitive, Immature)
I – Impulsive
N – Narcissistically Focused (Pathologically)
D – Diffuse Ego Boundaries
E – Empathic Failure
R – Rational Thought Dysfunction
Hendrick, 2009
Neurosis
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Core Conflict
Paradoxical Behavior
Neural and Glial Cell Genesis
Synaptogenesis and Pruning
Neuritic Extensions
Long Term Potentiation (LTP)
Axonal Remodeling
Personality & Impulse Control
Disorders
General characteristics of PD’s
Cluster A Disorders
Paranoid, Schizoid, Schizotypal
Cluster B Disorders
Antisocial, Borderline, Histrionic, Narcissistic
Cluster C Disorders
Avoidant, Obsessive-Compulsive, Dependent
Impulse Control Disorders
Childhood Antecedents Of
Severe Impulsivity and
Subsequent Adult Violence
• Impulsive self-centered children with a low
tolerance of criticism who tend to project blame
on others are at risk of developing borderline or
antisocial personality disorders as adults and
have increased incidences of violence
• Reckless drivers often have little concern for
others or are immature as adolescents and do
not foresee or consider consequences well
• Adjudicated as juvenile delinquents or as
adolescent “adult offenders” increase risk in
adulthood
Facts About Personality Disorders
Onset usually late childhood, early adolescence
Causes others distress – dysfunctional theory of mind
Pathological uncooperativeness
Effects behavior in many situations
Poor insight
Little behavior change over time
Coded on Axis II
General Diagnostic Criteria for PD’s
Enduring pattern of inner experience or behavior that
deviates from expectations of culture, manifested in
two or more of the following:
- cognition (perception of self, others)
– affectivity (intensity, range of emotions)
– interpersonal functioning
– impulse control
• Enduring pattern is inflexible, pervasive in many
situations
• Chronic, debilitating
• High morbidity and mortality
• Several forms of psychotherapy for BPD
– Patients often refractory
(i.e., DBT)
Personality Disorders: Why Axis 2?
Axis II disorders:
long-lasting,chronic patterns of interactions
not discreet episodes
begin by adolescence
frequently co-occur with Axis I diagnoses
complete recovery not possible
Enduring pattern leads to distress, impairment in important
areas of functioning
Pattern is stable and of long duration, generally can be traced
back to childhood
Pattern not better explained by another disorder
Pattern not due to substance abuse or medical condition
Two Basic Affects
-Anger and Fear• These are the most likely emotional antecedents of
violence
• If associated with paranoid delusions the magnitude of
harm also is increased
• Systematized paranoid ideation – as opposed to a
monosymptomatic delusional idea – also increases the
risk of violence
• A specific delusion of being poisoned is related to a
high incidence of violence
• In summary, risk is greater for delusions than for
hallucinations combined with delusions and both are
greater than for hallucinations by themselves
Early Environment Alters
Neurochemistry
Control
Subjugated
50
40
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20
5-HT Immunoreactivity
Vasopressin (pg/punch)
60
0
Vasopressin
Delville et al, J Neurosci 1998;18(7):2667-2672
*
40
30
20
10
0
Serotonin
Parental or Adult Brutality
• “Today’s catcher is tomorrow’s pitcher” – Prison saying
• Brutalized or molested boys tend to repeat the cycle,
especially by aggressing on the vulnerable
• Similarly victimized girls tend to repeat the victimization
• Girls who have been molested are twice as likely to be rape
victims as those who have not had a similar history
• Girls and women arrested for prostitution – as opposed to
all other crimes – are 23 X more likely to have been
molested
• Victims of childhood abuse have a 6 X greater incidence of
Borderline Personality Disorder and 20 X greater incidence
of psychopathology
Diagnostic Criteria for 301.83 BPD
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Fears of abandonment
Unstable intense interpersonal relationships
Identity disturbances
Self-damaging impulsivity (e.g., spending, sex)
Recurrent suicidal or self-mutilating behavior
Affective instability
Feelings of emptiness
Inappropriate intense anger
Transient paranoia or dissociation
DSM-IV, 1994
Preparation for Therapy
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Assessment
Data Collection on Current Behaviors
Precise Operational Definitions of Treatment Targets
A collaborative working relationship between
patient and therapist
Orientation to the therapy and a commitment to
mutually defined treatment goals
Use of cognitive, behavioral, metaphorical and
paradoxical technique
Reframing and acceptance of the here and now
Tolerance of affects and recognition of their impact
Treatment of Personality Disorders
• Psychotherapy
– people who complain about lack of confidence and have difficulties in
making relationships are usually motivated for psychotherapy
– in emotionally unstable and dyssocial personalities disorders the patient
should recognize the situations which provoke his/her pathological
reactions and should work tomanage them
– psychotherapy of personality disorders is a very difficult task and to reach a
partial effect requires a patient’s thorough motivation
• Pharmacotherapy
helpful in emotional disorders
– anxiolytics and SSRI antidepressants suppress anxiety and depressive
symptoms
– lithium and other thymoleptics (carbamazepine, valproic acid) reduces
mood fluctuation and aggressive tendencies
Dialectical Behavior Therapy
• Mindfulness
• Marsha Linehan, PhD
Commitments in dialectical behavior therapy
• Patient agreements
• Stay in therapy for the specified time period
• Attend scheduled therapy sessions
• Work toward reducing suicidal behaviors as a goal of therapy
• Work on problems that arise that interfere with the progress of therapy
• Participate in skills training for the specified period
• Therapist agreements
• Make every reasonable effort to conduct competent and effective therapy
• Obey standard ethical and professional guidelines
• Be available to the patient for weekly therapy sessions and provide needed
therapy back-up
• Maintain confidentiality
• Obtain consent when needed
Core Treatment Procedures
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Problem Solving
Exposure Techniques
Skill Training
Contingency Management
Cognitive Modification
Neurotransmitters associated with prosocial
attitudes and behaviors
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Dopamine
Serotonin
Vasopressin
Oxytocin
Medications Which Have Been Used
Off Label in Borderline
Personality Disorder
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SSRIs
5-HT1A agonists, 5-HT2 antagonists
Lithium
Anticonvulsants
Atypical and typical neuroleptics
Beta blockers
Alpha antagonists (e.g., clonidine, guanfacine)
Opiate antagonists (e.g., naltrexone)
Dopamine agonists (e.g., stimulants, bupropion)
* All off-label uses
Divalproex Treatment in BPD
Randomization
Clinical
Assessment
Placebo
N=21
10 Weeks
Referral
Divalproex sodium
Randomization
Methods
Outcome Measures
21 individuals
with BPD
Global Assessment Scale (GAS)
Initial dose 250
mg/d, titrated to
blood level of
80 g/mL
Aggression Questionnaire (AQ)
Clinical Global Impression Improvement Scale (CGI)
Overt Aggression Scale-Modified (OASM)
Beck Depression Inventory (BDI)
Hollander E et al, J Clin Psychiatry 2001
Divalproex Sodium/Placebo in Cluster
B Personality Disorders
Study Schematic
Screening
2 Weeks
Double-Blind
12 Weeks
Tapering
1 Week
Divalproex (N=47)
Taper off excluded
psychotropic meds
Placebo (N=49)
Randomized in 1:1 ratio within diagnostic groups
Hollander et al, 2002 (APA)
Double-Blind
Divalproex Sodium in BPD
Analysis of Completers
Baseline (SD) End Mean (SD)
P
CGI Improvement
4.0
2.2 (0.9)
0.006
GAS
52.2
66.7 (4.1)
0.003
Hollander et al, J Clin Psychiatry 2001
Fluoxetine in Borderline Personality Disorder
Mean (SEM) OAS-M
Aggression Score
100
Fluoxetine
Placebo
80
60
40
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20
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0
-2
p<0.05
0
2
4
6
8
10
12
End
Point
Week
Coccaro et al, Arch Gen Psychiatry 1997
Fluoxetine in Borderline Personality Disorder
Mean (SEM) OAS-M
Irritability Score
8
Fluoxetine
Placebo
7
6
5
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4
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3
2
1
0
-2
p<0.05
0
2
4
6
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10
12
End
Point
Week
Coccaro et al, Arch Gen Psychiatry 1997
Olanzapine in Borderline Personality Disorder
Measure
N
Mean
Base
GAF
11
53.0
SCL-90 global CSI
11
2.12
1.09
49
3.37
.007
BPRS global
10
43.10
30.80
29
5.79
.0005
SIB total
11
1.91
1.63
14
2.54
.029
Buss-Durkee total
11
16
2.13
.059
BIS11 total
11
15
2.50
.032
48.3
2.26
Mean
Last
%
Change
t
P
67.0
26
-3.86
.004
40.8
1.93
Schulz et al, Biol Psychiatry 1999
Psychotic and Pathological Defenses
The mechanisms on this level, when
predominating, almost always are severely
pathological. These defenses, in conjunction,
permit one to effectively rearrange external
experiences to eliminate the need to cope
with reality. The pathological users of these
mechanisms frequently appear crazy or insane
to others. These are the "psychotic" defenses,
common in overt psychosis. However, they are
found in dreams and throughout childhood as
well.
Immature Defenses
These mechanisms are often present in adults and
more commonly present in adolescents. These
mechanisms lessen distress and anxiety provoked
by threatening people or by uncomfortable
reality. People who excessively use such defenses
are seen as socially undesirable in that they are
immature, difficult to deal with and seriously out
of touch with reality. These are the so-called
"immature" defenses and overuse almost always
leads to serious problems in a person's ability to
cope effectively. These defenses are often seen in
severe depression and personality disorders. In
adolescence, the occurrence of all of these
defenses is normal.
Splitting
A primitive defense. Negative and positive
impulses are split off and unintegrated.
Fundamental example: An individual views
other people as either innately good or
innately evil, rather than as a whole
continuous person.
* Tellin’ a man to go to hell and makin’ him do it
are two entirely different propositions
Acting Out
Acting Out is performing an extreme behavior in
order to express thoughts or feelings the person
feels incapable of otherwise expressing. Instead
of saying, “I’m angry with you,” a person who acts
out may instead throw a book at the person, or
punch a hole through a wall. When a person acts
out, it can act as a pressure release, and often
helps the individual feel calmer and peaceful
once again. For instance, a child’s temper
tantrum is a form of acting out when he or she
doesn’t get his or her way with a parent. Selfinjury may also be a form of acting-out,
expressing in physical pain what one cannot stand
to feel emotionally.
Projection
Projection is the misattribution of a person’s
undesired thoughts, feelings or impulses onto
another person who does not have those
thoughts, feelings or impulses. Projection is used
especially when the thoughts are considered
unacceptable for the person to express, or they
feel completely ill at ease with having them. For
example, a spouse may be angry at their
significant other for not listening, when in fact it
is the angry spouse who does not listen.
Projection is often the result of a lack of insight
and acknowledgement of one’s own motivations
and feelings.
Projective Identification
Projective Identification is a term first introduced by Melanie Klein of
the object relations school of psychoanalytic thought in 1946. It
refers to a psychological process in which a person engages in the
ego defense mechanism projection in such a way that their
behavior towards the object of projection invokes in that person
precisely the thoughts, feelings or behaviors projected.
Projective identification differs from simple projection in that
projective identification is a self-fulfilling prophecy, whereby a
person, believing something false about another, relates to that
other person in such a way that the other person alters their
behavior to make the belief true. The second person is influenced
by the projection and begins to behave as though he or she is in
fact actually characterized by the projected thoughts or beliefs. This
is a process that generally happens outside the awareness of both
parties involved, though this has been debated.
* When you give a lesson in meanness to a critter or a person, don’t be
surprised if they learn their lesson.
•
This one deserves a couple of extra East
Tennessee insights:
Never drop your gun to hug a bear.
A man who wants to loan you a slicker when it
ain’t raining ain’t doing much for you
Wisdom
• Frontostriatal and frontolimbic circuits
involving very specific neurotransmitters may
be required.
• An optimal balance of phylogenetically older
(limbic) and the later developing prefrontal
cortex may be the key to understanding the
nature of wisdom.
Subcomponents of Wisdom
• Prosocial Attitudes and Behaviors
• Social Decision Making/Pragmatic Knowledge
of Life
• Emotional Homeostasis
• Reflection/ Self – Understanding
• Value Relativism/Tolerance
• Acknowledgment of and dealing effectively
with uncertainty
Prosocial Attitudes and Behaviors
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Achievment of social good
Wisdom serves the common good
Altruism is a dimension of wisdom
Affective wisdom is “positive emotion and
behavior towards others and the absence of
indifferent or negative emotions towards
others (Ardelt)
• An aspect of wisdom is warmth (Jason, et al)
Social Decision Making/
Pragmatic Knowledge of Life
• Rich Factual Knowledge regarding human nature and life
course
• Rich procedural knowledge regarding ways of dealing with
life’s problems (Baltes, et al)
• Knowing but also knowing when, where, why and how to
apply knowledge (Sternberg)
• Practical knowledge is a dimension of wisdom (Meachum)
• Practical wisdom is “good interpersonal skills and
understanding, expeditious use of information, and
expertise in advice giving” (Wink and Helson)
• 3 dimensions of wisdom include judgment, life knowledge
and Life skills (Brown and Greene)
Emotional Homeostasis
• Emotional stability despite uncertainty
(Brugman)
• Emotional Management (Brown and Greene)
Reflection/ Self – Understanding
• Reflective abilities
• Reflective judgment
• Interest in Self Understanding –
Transcendental Wisdom
• Self – Knowledge and Reflective Wisdom
Value Relativism/Tolerance
• Tolerance and value relativism
• Reflective wisdom “ability and willingness to
examine phenomenon from multiple
perspectives; absence of projections (Ardelt)
• Tolerant and Understanding (Practical Wisdom
Scale)
Acknowledgment of, and dealing effectively
with, uncertainty
• Handling of uncertainty, including limits of
knowledge
• Comprehension of and dealing with uncertainty
• Meta – Cognition: acknowledging uncertainty
and ability for dialectical thinking
• Personality/affect: emotional stability despite
uncertainty and openness to new experience
• Behavior: ability to act in the face of uncertainty
• Cognitive wisdom includes an awareness of life’s
inherent uncertainty yet having the ability to
make decisions in spite of this.
I hate to think what it says on the front
References
• Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA.
Personality and personality disorders. In: Stern TA,
Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds.
Massachusetts General Hospital Comprehensive Clinical
Psychiatry. 1st ed. Philadelphia, Pa: Mosby
Elsevier;2008:chap 39.
• Borderline Personality Disorder Demystified by Robert
O. Friedel, M.D., Marlowe & Co., 2004
• National Education Alliance for Borderline Personality
Disorder’s Teachers Manual for Family Connections,
2006
• A BPD Brief, An Introduction to Borderline Personality
Disorder by John G. Gunderson, M.D., 2006
• A REMINDER for assessing psychosis- John Hendrick,
MD- CURRENT PSYCHIATRY April 2010 Volume 9, No. 4