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)
