12- BPD and ASPD Flashcards
Origins of BPD
Origins in the psychoanalytic tradition
- Hypersensitive, rigid, feelings of inferiority, deep insecurity, use of projection mechanisms, difficulty with reality testing, experienced negative reactions in therapy
- Between the border of the psychoses (out of touch with reality) and neuroses (emotional) => view continued for decades (“pseudo-neurotic schizophrenia”)
- Typically referred to patients who were challenging to treat
Kernberg (1976) described the “borderline personality organization” => Reliance on primitive defense mechanisms ex: “splitting” (all good vs. all bad)
=> BPD introduced to DSM-III in 1980 with specific criteria developed:
- Intense affect
- Impulsivity
- Relationship problems
- Psychotic experiences
“Borderline” => Provides no descriptive info about the dx (Name still strongly linked to psychoanalytic tradition)
=> WHO’s International Classification of Diseases (ICD-10) uses the term “Emotionally Unstable Disorder” *Much more accurate description
BPD DSM-5 Criteria
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
Need FIVE or more of nine sx:
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships
- Identity disturbance
- Impulsivity in at least two areas that are potentially self-damaging
- Recurrent suicidal beh, gestures, or threats, or self-mutilating beh
- Affective instability due to a marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger, or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative sx
Core clinical Features: Instability with Emotions
Emotions change rapidly and repeatedly (“mood swings”) => Felt VERY intensely
- Often prolonged duration
- Slow return to baseline
- Heightened sensitivity and reactivity to
env stressors (little things) - Experience range of negative emotions (ex: Anger, sadness, shame, fear, disgust)
“Emotional Switching” => Switching between negative states ex: Anxiety to anger/Sadness to anxiety
=> From positive to negative state, or vice versa: Frequency vs. magnitude* which reflects dichotomous thinking / splitting (good vs. bad) *Not necessarily specific to BPD though (ex: BN, PTSD)
Core clinical Features: Instability with Relationships
Emotional instability is often triggered by loss, rejection, disappointment => Trigger is interpersonal (bcz of fear of abandonment)
- Volatile relationships, lots of conflict
- Unstable representations of others => “Splitting”: Idealized view vs. anger (pedestal to completely bad)
- Afraid of being dependent (in case they are abandoned)
- “Testing” significant others => leads to disappointment
Interpersonal Regulation Strategies => Interaction with another person serves an emotion regulation function
Two relevant strategies:
- Reassurance seeking (neg reinforcement)
- Venting
=> Useful in short-term but consequences in long-term:
- Interpersonal (relationship difficulty)
- Intrapersonal (more distress)
Core Clinical Features: Instability with Sense of self
Shift between no sense of self vs. many conflicting selves => Fragile and negative self-concept
- Persistent sense of “emptiness” (diff being alone)
- “Self-fragmentation” => No continuous sense of self across time
- Lack clear boundary between self and other (ppl pleasing = diff beh)
- Relationships are a high priority => Threat to relationships = threat to sense of self
Core clinical Features: Instability with Beh
Very impulsive => Typically driven by emotion (positive and negative)
Range of impulsive beh:
- High rates of alcohol, substance abuse
- Spending sprees
- Risky sexual behaviors
- Gambling
- Binge eating
- Non-suicidal self-injury
- Suicide risk
NSSI, Suicide and BPD
Non-Suicidal Self-Injury (NSSI) => Dx criteria for BPD (Used to be thought of as an indicator of BPD but Now recognize it is not necessary nor sufficient for BPD)
- VERY common in BPD => Variable prevalence rates (65-90%)
- Mistakenly viewed as attention-seeking beh => Lay people and clinical contexts have negative attitudes toward NSSI
- Key function of NSSI = Emotion regulation
Suicidality
- Suicidal ideation VERY common – almost all will report
- Suicide attempts: Estimates as high as 70% => Often multiple attempts (average 3 attempts), Ambivalent? (don’t know how serious it is)
- 8-10% die by suicide
- Whereas threats and ideation peak in early course of dx, the mean age of death by suicide is age 37 so Suicide doesn’t occur when therapist is most alarmed
- VERY hard to predict who is at high risk of going from ideation to attempt
Suicidal Threats => Verbal statement or beh act that may indicate serious intent to kill oneself (Interpersonal component)
- Common in BPD populations
- Presents a challenge for clinicians to determine actual risk
- Most often triggered by interpersonal relationships (ex: feeling abandoned) => Attempt to pull in another person in whatever way they can to alleviate distress
- Viewed by others as demanding and manipulative But, likely serves an emotion regulation function
*Caution: Link between suicidal threats and attempts
How to handle chronic suicidality?
- Hospitalization? => But, no clear tx are actually provided (“Suicide watch”, “Safety management”) => useful for psychotic breaks
- Consider function of suicide for BPD: Escape from distress, Interpersonal communication of distress
- Joel Paris: Hospital setting might inadvertently positively reinforce suicidality => Leads to “psychiatrization”, rather than learning life skills
- Recommendation to manage suicide an outpatient basis
Epidemio
Prevalence: 1-2% => Higher in clinical settings (10-20%)
- Higher rates among women => But biases in gender expectations may account for a lot of this
=> Diagnosis in adolescence?
- Cons: personality still developing, stigma
- Pros: interventions in adolescence are beneficial
=> Course:
- BPD thought to be chronic (stable PD)
- But many improve with appropriate tx
- Often more severe in younger pop
Comorbidity
- Very high (rarely ever dx alone)
- Comorbid with other PDs: Schizotypal, narcissistic, and dependent PD especially
- Comorbid with both internalizing and externalizing dx: MDD, PTSD, anxiety, substance use, eating disorder (ex: bulimia), bipolar
A variant of depression? Chronic form?
A variant of PTSD? Due to role of trauma?
Dissociation
Up to 75% report “psychotic-like symptoms” ex: Hallucinations, paranoid ideas, dissociation
- But, not the same as in psychotic dx =>Typically more insight (not delusional)
- Theorized to occur in response to
stress *Indicated in DSM criteria
2 types:
- Depersonalization (separate from your body)
- Derealization (detached from the external world/ppl/objects)
Study: with BPD, clinical controls (CC), and healthy
control (HC) doing an ecological momentary assessment (EMA) => Provide hourly ratings of stress and dissociation for 48 hours
- All groups showed association between stress and dissociation
- But, effect strongest for BPD
- BPD have more dissociative experiences
(frequency and intensity) => Also present under relatively low levels of stress
Negative Early Life Experiences and Attachment
Childhood trauma, abuse, and neglect play a large role => BPD tend to report more trauma compared to controls
Studies:
- Female patients in ER who were sexually abuse during childhood were 5x more likely to have BPD dx
- Only 6.1% of BPD had NO history of childhood trauma => Whereas 61.5% of controls had NO such history
- Caution warranted with retrospective recall => But similar findings with prospective reports
- BUT, trauma is not a dx-specific risk factor => Trauma increases risk for most forms of psychopathology
Insecure Attachment => Develop internal models of self and others through attachment with primary caregiver
- Self: acceptable, lovable, worthy
- Others: responsive, available, supportive
=> Consistently find relationship between BPD and insecure attachment styles = Can explain many features of clinical presentation: ex: clinginess, proximity checking, intolerance of being alone
*Oscillation between Preocuppied and Fearful-Avoidant
Mentalization
Process by which we understand ourselves and others in terms of mental states => Acquire this capacity through attachment with caregiver
- BPD = failure of mentalization
- Mediates link between attachment and emotion dysregulation outcomes
Non-Mentalization Modes:
- Teleological: Inferring another person’s state of mind
based on their actions (don’t call so don’t love me) - Psychic Equivalence: Equating internal states with reality (i think she rejected me so she for sure did)
- Pretend Mode: Mental world is decoupled from reality (disconnect from own mental states)
Biosocial Theory
Had BPD herself and developed theory and therapy (DBT) to help others with similar difficulties
- Core problem in BPD: emotion dysregulation => Arises from combination of vulnerable biology and invalidating social env
Vulnerable Biology:
- High sensitivity
- High reactivity
- Slow return to baseline
=> Assumption is that emotional vulnerability is biological (people are born like this) and Also refers to biological basis of impulsivity
Invalidating Social Env
- Problems arise when caregivers consistently and persistently fail to validate their child’s emotional exp => Results in failure to learn how to identify, label, and regulate own emotions
- Transactions between personal vulnerability and env
=> Etiologically heterogeneity
- High biological + Low invalidation
- Low biological + High invalidation
ASPD Historical Perspect and DSM-5 Criteria
Historical Perspectives
- Cleckley: comprehensive description of psychopathy in 1940s => Beh features: impulsivity, antisocial beh, sexual deviancy, and irresponsibility + affective and interpersonal traits: egocentricity, superficial charm, lack of empathy
DSM-III (1980) first includes Antisocial Personality Dx
- Strong emphasis on objectively measured beh criteria
- Affective/interpersonal traits not included in criteria
- Goal: improve diagnostic reliability
Criteria
A pervasive pattern of disregard for and violation of the rights of others, occurring since age of 15, as indicated by 3+ sx:
- Failure to conform to social norms with respect to lawful beh
- Deceitfulness
- Impulsivity or failure to plan ahead
- Irritability and aggressiveness
- Reckless disregard for safety of self or others
- Consistent irresponsibility
- Lack of remorse
Plus:
- Individual is at least 18 years of age
- Evidence of conduct dx with onset before age 15
- Sx bring them into conflict with society (ex: incarcerated)
Very beh definition => DSM doesn’t tell us about underlying personality features + Also results in very heterogeneous clinical presentation
Conduct Dx
4 Core Cat
- Aggression to people and animals => often bullies, has used a weapon to intimidate others, has been physically cruel to animals
- Destruction of property => deliberately engaged in fire setting, deliberately destroyed property
- Deceitfulness or theft => stealing non-trivial items, lies to obtain things
- Serious violation of rules => ignores curfew, often truant from school (before age 13)
Specifiers
- Childhood-onset type (prior to age 10)
- Adolescent-onset type (no sx prior to age 10)
Other specifiers: With limited prosocial emotions
- Lack of remorse or guilt
- Callous, lack of empathy
- Unconcerned about performance
- Shallow or deficient affect
=> Boys 4X more likely to be dx & Girls dx at a later age
Gender differences in aggression
- Men: Physical
- Women: Relational
=> Assortative mating: Associated with more severe negative beh, conflict, poor parenting, Kids have high genetic vulnerability + chaotic environment
Psychopathy
Cleckley advanced view that psychopath appears normal on the surface => But under the mask is a very fundamental, severe deficit
- More psychologically-than beh- focused
- Criminal behavior is only one potential piece
- Can be successful, law-abiding citizen
=> Out of 16 criterias: Absence of nervousness or psychoneurotic manifestations + general poverty in major affective reactions
Psychopathy Checklist (PCL): 20-item checklist that’s rated via interview and any available records (school, police, prison)
- Hare also emphasizes that not all psychopaths are criminal => Best career path: Business
- PCL widely used in North America ex: Parole decisions often rely on PCL scores But criticized for not assessing lack of anxiety/fear
*Factor Structure of PCL:
- Factor 1: Interpersonal/Affective (map + to psychopathy)
- Factor 2: Social deviance (map + to ASPD)
Features Associated with Psychopathy and ASPD vs Psychopathy
- More violence and aggression, severe crimes => But often get reduced sentences and likely to get released but High reoffending rates
- But also noncriminal psychopaths => Higher rates in corporate samples
- Ability to detect vulnerable people they can manipulate
ASPD vs. Psychopathy
- ASPD focuses on observable beh
- Psychopathy includes reference to emotional and interpersonal factors => Factor 1 of PCL distinguishes
- Only small portion of individuals dx with
ASPD are psychopathic - BUT, most people who are psychopathic would qualify for ASPD diagnosis
=> Psychopathy as more extreme form of ASPD? ASPD misses non-criminal psychopathy
Epidemio
ASPD
- 2-3% lifetime prevalence in general pop
- 3-5x more common in men *recall dx bias
- Higher rates in criminal settings
- Higher rates also in hospital settings
Psychopathy
- No epidemiological studies estimating prevalence
- Hare estimates about 1% in North America
- Over-represented in prison settings => Especially maximum-security
Etiology: Prenantal & Birth Factors & Genes
Pregnancy and birth factors
- Low birth weight
- Malnutrition (possible protein deficiency) during pregnancy
- Lead poisoning
- Mother’s use of nicotine, marijuana, alcohol, other subs during pregnancy
=> No direct causal link between these factors and conduct problems has been established
- Many possible paths linking smoking to conduct problem
- Smoking might alter neurotransmitter systems
- Smoking affects birth weight, and birth weight affects conduct problems
Genes
- Family studies reveal aggregation of externalizing disorders ex: ADHD, SUD, ASPD
- Data from adoption and twin studies suggest at least moderate genetic contribution
What is inherited?
- Antisocial traits
- Aggressiveness
- Impulsivity
- Callous and unemotional tendencies
MAOA Gene => Degrades neurotransmitters (ex: Dopamine, Norepinephrine, Serotonin)
- More MAOA = more degradation = lower levels of NTs (associated with depression)
- Less MAOA = less degradation = higher
levels of NTs (associated with impulsivity and aggression)
Childhood maltreatment is a robust risk factor for conduct problems => But, most children who are maltreated do not go on to engage in significant criminal beh in adulthood
=> Different susceptibility to the experience of maltreatment with gene-env interaction
Low MAOA* + childhood maltreatment (none/probable/severe*) most likely to develop ASPD
Etiology: Env and Sociocultural
Both retrospective and prospective reports associate negative upbringing (ex: abuse) with antisocial and psychopathic traits => BUT hard to separate genetics from parenting
Passive rGE:
- Parent give antisocial genes and also give more chaotic environment (ex: maltreatment, neglect)
Evocative rGE:
- Parents often lack psychological/physical resources to deal with difficult children
- Results in more inconsistent discipline
Active rGE:
- Antisocial individuals prefer to associate with similar others – miss opportunities to learn prosocial beh
- Early criminality / drug use can eliminate future opportunities
Sociocultural Influences
- Poverty and neighborhood crime are related to delinquency
Possible mechanisms?
- Social cause: living in poverty increases rates of delinquency
- Social selection hypothesis: people with psychopathology drift down to poverty
- Work with children indicates causal association between poverty and disruptive beh, with parent supervision as mediator
=> Some evidence that collectivistic cultures have lower rates than individualistic cultures (Antisocial beh associated with minority status in North America, but this is likely due to low SES)
Fearlessness Hypothesis
ASPD and psychopaths thought to be “fearless” => Higher threshold for feeling fear + Don’t show usual fear conditioning response
Is this specific to physical punishments?
Also find they are indifferent to social punishments
Evidence from startle reflex:
- Defensive response
- Magnitude is increased when person is fearful
- Present people startle probe (ex: noise or image) and measure eye blink response
Study:
Presented neutral (ex: lamp), positive (ex: babies), and negative (ex: gun pointed at you) images
- Groups did not differ in self-report of emotional response to images
- Psychopaths did not display the typical potentiation of startle to the negative image (don’t blink)
Tx
Treatment is a challenge => Without distress, little
motivation to change
- ASPD or psychopathy results in poorer tx outcomes for substance use
- Some weak evidence that SSRIs reduce aggressive beh and increase interpersonal skills
Building a better psychopath?
- Some tx are effective at reducing rates of reoffending among criminal offenders
- However, these treatments can actually cause rates of reoffending to increase for psychopaths
- Treatments that emphasize training in social skills may actually be useful in helping psychopaths become better at charming or conning future victims
- CBT interventions recognized as most effective (ex: increase self-control, anger management) But often fails to generalize outside of tx context
