Borderline Personality Disorder N.P. Costigan, MD Alberta Health Services Community Addiction & Mental Health Central Zone Personality Disorder An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individuals culture, is pervasive and inflexible, is an onset at adolescence or early adulthood, is stable over time and leads to distress or impairment. 2 1
Introductory Comments The terms borderline originally described a constellation of symptoms considered to be on the border of neurosis and psychosis. Prior to DSM-III (1980), patients with BPD were thought to have a mild or atypical form of Schizophrenia. BPD first included in the DSM-III in 1980. Prior to 1980, the word borderline had been used to refer to: A spectrum of disorders. Difficult patients. Diagnostic uncertainty. A type of personality organization. Pretty much a variety of actual personality disorders could develop. Borderline often used to refer to symptoms or a syndrome that borders on illness. 3 Although in the past BPD has been considered a sub-type of Schizophrenia and by others an atypical mood disorder (a variant of Bipolar Disorder), research supports the validity of BPD as an independent diagnostic entity. 4 2
Characteristics Central to BPDDiagnosis 1. Chaotic relationships. 2. Wide fluctuations in emotional state (labile affect). 3. Unstable self of self or self-image. Patients with BPD are stably unstable or predictably unpredictable. 5 ICD - 10 Emotionally Unstable Personality Disorder Probably a better phenomenologic term for Borderline Personality Disorder. 6 3
Borderline DSM-IV Diagnostic Criteria Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, 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. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance; marked and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures or threats or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irribility usually lasting a few hours and only rarely only a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger. 9. Transient, stress related paranoid ideation or severe dissociated symptoms. 7 Movie Example Fatal Attraction Glen Close and Michael Douglas Fatal Attraction Situation - Referring to a situation where a spurned lover seeks revenge. The character of Alex Forrest has been variously diagnosed as psychotic, psychopathic, sociopathic, delusional, obsessed, crazy, disturbed, troubled, irrational, sad, distraught, erotomanic, and a deranged stalker. 8 4
Diagnostic Features The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity that begins by early adulthood and is present in a variety of contexts: 1. Frantic efforts to avoid real or imagined abandonment. Perception of impending separation or rejection or the loss of external structure can lead to profound changes in self-image, affect, cognition and behavior. Experience intense abandonment fears and inappropriate anger even when faced with a realistic time limited separation or when there are unavoidable changes in plans (eg. cancelled appointments). May believe that abandonment implies they are bad. Abandonment fears are related to an intolerance of being alone. 9 2. Pattern of unstable and intense relationships. May idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together and share the most intimate details early in a relationship. May switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not there enough. BPD individuals can empathize with and nurture others, but only with the expectation that the other will be there in return to meet their own needs on demand. BPD are prone to sudden and dramatic shifts in their view of others 10 5
3. Identity disturbance characterized by markedly and persistently unstable selfimage or sense of self. Sudden and dramatic shifts in self-image, characterized by shift in goals, values and vocational aspirations. May be sudden changes in opinions and plans about career, sexual identity, values and types of friends. BPD individuals may suddenly change from a role of a needy supplicant for help to a righteous avenger of past mistreatment. Self-image is usually based on being bad or evil; however may at times may have feelings that they do not exist at all. 11 4. Impulsivity in at least two areas that are potentially self-damaging. They gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, drive recklessly. 12 6
5. Recurrent suicidal behavior or gestures or threats or self-mutilating behavior. Completed suicide occurs in 8-10% of BPD. Self-mutilating acts and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. Self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Self-mutilation may occur during dissociative episodes and often brings relief by reaffirming the ability to feel. Self-mutilation often described as changing a catastrophic sense of being overwhelmed to something more tangeable. 13 6. Affective instability due to a marked reactivity of mood. These episodes may reflect the individuals extreme reactivity to interpersonal stresses. 14 7
7. Chronic feelings of emptiness. Easily bored, they may constantly seek something to do. 15 8. Frequently express inappropriate intense anger or have difficulty controlling their anger. May display extreme sarcasm, enduring bitterness, have verbal outbursts. Anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring or abandoning. 16 8
9. During periods of extreme stress, transient paranoid ideation or dissociative symptoms may occur. These episodes occur frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. 17 Associated Features Repeated crisis, often resulting in ER visits. Marked devaluation of past relationships, therapists and other efforts to help the patient. Considerable diagnostic versatility; may have several different diagnoses given over time. Appear to be unable to solve basic problems for themselves. May have a pattern of undermining themselves at the moment the goal is about to be realized (dropping out of school just before graduation; severe regression after how well therapy is going; destroying a good relationship just when it is clear the relationship could last). May feel more secure with transitional objects (pets or inanimate possessions) than interpersonal relationships. Recurrent job losses, interrupted education, broken marriages are common. Physical and sexual abuse, neglect, hostile conflict and early parental loss or separation are common themes. 18 9
Comorbidities Commonly co-occurring AXIS I disorders include: Mood Disorders Substance-related Disorders Eating Disorders (notably bulimia) Post-Traumatic Stress Disorder Attention Deficit Hyperactivity Disorder BPD also frequently co-occurs with other personality disorders. Over 90% of patients have two diagnoses, and over 40% have three or more diagnoses. 19 Course of BPD Considerable variability. Most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive discontrol with high levels of use of health and mental health resources. Impairment and risk of suicide are greatest in the young adult years and gradually wane with advancing age. Individuals who engage in therapeutic intervention often show improvement during the first year. During their 30 s and 40 s, most individuals with BPD attain greater stability. Follow-up studies identified through outpatient Mental Health Clinics indicate that after 10 years, as many as half the individuals no longer meet the criteria. 20 10
Genetics BPD is 5 times more common among first degree biological relatives of those with the disorder than in the general population. Also an increased familial risk for substance related disorders, anti-social personality disorder and mood disorders. 21 BPD in it s more florid forms is not difficult to diagnose. Patients frequently present to Differential Diagnosis ER in a state of turmoil. Often a psychosocial crisis that threatens a relationship causes the upheaval. Patients become overwhelmed and seek admission by making suicidal gestures or attempts. As outpatients, they remain stably unstable. In less obvious forms, BPD can present a diagnostic challenge. Mood Disorders affective/mood instability. Psychotic Disorders micro/brief psychotic episodes. Substance Use Disorders impulsivity. Dissociative Disorders dissociates in response to stress. Sexual Identity Disorders sexual and identity diffusion. Anxiety Disorders obsessions, phobias, irritability. Eating Disorders impulsivity with food. Impulse Control Disorders inability to restrain impulses. 22 11
Differential Diagnosis Mood Disorders 90% of BPD have two diagnoses. 40% of BPD have three or more diagnoses. 23 Differential Diagnosis Depression Considerable symptomatic overlap between depression and BPD. The mood disorder with greatest overlap is dysthymic disorder. BPD patients are chronically empty, bored and lonely, and have a pervasively negative affect. In BPD vegetative signs are usually absent anorexia, insomnia, fatigue, and impaired concentration. There is a reactivity of mood symptoms to social situations. 24 12
Differential Diagnosis Bipolar Disorder Resemblance between BPD and Cyclothymia or ultra rapid cycling Bipolar Disorder Amplitude of mood change is dramatic enough to be included in the cyclothymic spectrum. BPD rarely encompasses the required number of criteria for hypomania. Elevated mood states are short-lived do not meet required duration for hypomanic nor manic criteria. 25 Etiology/Presumed Etiology 1. Biological/Genetic Factors A significant genetic contribution exists. BPD is five times more common in a first degree relatives. The extended families of borderline patients have increased rates of Substance Use Disorders, Cluster B Personality Disorders (particularly ASPD), Conduct Disorder, Learning Disabilities, and Mood Disorders. 26 13
2. Neurochemical Factors As children, borderline patients commonly found have had neuopsychological difficulties. Neurological soft signs are often found eg. impaired coordination, balance, motor performance and gait abnormalities. Learning disabilities, ADHD and EEG abnormalities often found. These findings point to pathology in the pre-frontal cortex, causing impairment in executive functioning and leading to the marked impulsivity seen in BPD. It is postulated that dysregulation of serotonin and/or dopamine systems may exist in BPD. 27 3. Psychosocial Contributions The psychosocial contributions to BPD become particularly apparent when carbon copies can seemingly be made of many patients personal histories. The following historical adversities are the most common: Sexual abuse Physical abuse Extreme neglect 28 14
Epidemiology Prevalence estimated to be approximately 3%. By far the most common personality disorder diagnosis made in clinical settings. Prevalence can be as high as 10% on inpatient units and 20% in outpatient clinics. Women are diagnosed at least three times as often as men. 29 Inpatient Management Hospitalization for patients with BPD is controversial. Patients may be admitted in order to avoid possible medical/legal repercussions. There is little, if any, evidence to indicate that hospitalization results in any enduring effectiveness. Admitting patients may reinforce that they are unable to take control of their own lives. Institutions may function as containers for borderline impulses. Patients arrive in a state of crisis and the inpatient unit becomes a holding tank in which patients may regress, as their needs are largely cared for by others. Short admissions, adherence towards routines as a condition of admission, and setting firm limits on behavior may help limit regression. 30 15
Longer Term Admissions The majority of patients can probably be managed with 24 to 72 hour admissions to help settle the crisis. Some common indications for longer term treatment are: Repeated failures of brief hospitalization and outpatient treatment. Associated Axis I conditions. Escalating violent or self-destructive behavior. Severe or psychotic symptoms. A chaotic environment that provides no social support. Diagnostic uncertainty. Substance withdrawal requiring medical management. Obvious losses that are beyond the typical range of psychosocial difficulties faced by the patient. 31 Cognitive Therapy Basic Cognitive Distortions Mistrust and Suspiciousness The world is against me Distorted Perceptions People are deceptive and manipulative Vulnerability I am powerless to control my life Worthlessness I am unlovable 32 16
Group A useful form Therapy of treatment of borderline patients either alone or combined with individual psychotherapy. A group setting may allow patients to explore new ways of dealing with people in a protective environment. Dialectical behavior therapy. Developed by Marsha Linehan from Cognitive Behavior Therapy. DBT assumptions Patients are doing the best that they can. Patients willing to improve. Patients need to do better, try harder and being more motivated to change. Patients may not have caused all of their own problems, but they have to solve them anyway. The lives of suicidal borderline individuals are unbearable. Patients must learn new behaviors. Patients cannot fail in therapy. Therapist treating borderline patients need support. 33 Components of DBT 1. Individual outpatient psychotherapy. 2. Skills training. 3. Supportive process group therapy. 4. Telephone consultation. 34 17
Suicidal Behavior in BPD Joel Paris (2002) reviewed 170 papers on BPD and suicide/suicidality with the following results: Several articles report 10% rate of completed suicide. Only a minority of suicidal threats and behaviors occurred during active treatment: the majority appeared to take place later on when patients do not recover and efforts to help them have been unsuccessful. Completed suicides appear to be more common in patients in their 30 s. Suicide is more likely when patients have comorbid depression and/or substance use disorders. 35 Considerations Regarding Hospitalization (J. Paris) Considerations regarding hospitalization (J. Paris). Can be ineffective and in fact counter productive neither medication nor short-term containment are likely to have lasting beneficial effects. Hospitalization may act as a reinforcer for behaviors. The warm welcoming atmosphere of an inpatient unit may become a substitute for such nurturance on a personal basis. 36 18
Things to Remember Mood symptoms are different from those with Mood Disorders and respond differently to antidepressant medication. Self-injury is behaviors that include mutilation, burning, biting, intentional sun burn, hair pulling, hitting, abuse of medication, substance misuse, promiscuity and accident pronness. 75% of habitual self-mutilators use multiple methods, which undergo substitution over time. 37 Pharmacotherapy SSRI s have been found to decrease impulsivity and the frequency of selfharm. The mood stabilizers have been used primarily for behavioral dyscontrol and reducing impulsivity. Anxiolytics frequently sought by BPD patients pose considerable addiction risks, as well as potentially worsening impulse control through disinhibition. Antipsychotics indicated for short-term control of psychosis and delusions. Sedated effects of novel antipsychotics might be beneficial. Novel antipsychotics may provide mood stabilization. 38 19
Cluster A Personality Disorders Paranoid Personality Disorder pattern of distrust and suspiciousness. Schizoid Personality Disorder - pattern of social detachment and restricted emotional expression. Schizotypical Personality Disorder - pattern of acute discomfort in relationships; cognitive or perceptual disturbances and eccentricities of behavior. 39 Cluster B Personality Disorders Antisocial Personality Disorder pattern of disregard and violation of the rights of others. Borderline Personality Disorder pattern of instability in relationships, selfimage and affects along with impulsivity. Histrionic Personality Disorder pattern of excessive emotionality and attention seeking. Narcissistic Personality Disorder pattern of grandiosity, need for admiration and lack of empathy. 40 20
Cluster C Personality Disorders Avoidant Personality Disorder pattern of social inhibition, feelings of inadequacy and hypersensitivity. Dependant Personality Disorder pattern of submissive and clinging behavior. Obsessive Compulsive Personality Disorder pattern of preoccupation with orderliness, perfectionism and control. 41 MNEMONIC (I raised a pain) Identity disturbance Relationships are unstable Abandonment is frantically avoided Impulsive Suicidal gestures Emptiness Dissociative symptoms. Affective instability. Paranoid ideation Anger, poorly controlled Idealization of others, devaluation Negativistic 42 21
The End 43 22