BPD Flashcards
BPD
Pervasive instability of relationships, self-image, emotion and impulsivity
DSM-5 Criteria for BPD
At least 5+ of the below:
- Frantic efforts to avoid abandonment
- Unstable/intense relationships
- Unstable sense of self
- Impulsivity in 2+ self-damaging areas
- Recurrent self-harm
- Intense, brief emotional shifts
- Chronic feelings of emptiness
- Inappropriate anger
- Transient, stress-related paranoid ideation/dissociation (out of body experience)
Areas of dysregulation in BPD
- Emotional
- Behavioural
- Interpersonal
- Identity/self
- Cognitive
Emotional dysregulation
- Unstable emotions/mood
- Intense anger/difficulty controlling anger
Behavioural dysregulation
- Impulsive/self-destructive behaviours
- Suicide/self-harm
Interpersonal dysregulation
- Unstable/intense relationships
- Frantic efforts to avoid abandonment
Identity/self dysregulation
- Unstable sense of self/identity
- Feelings of emptiness
Cognitive dysregulation
- Stress related paranoid thoughts
- Dissociation
Prevalence of BPD
- ~6% of population
- Ratio of women to men who have it used to be thought of as 3:1 but now it’s looking about equal according to recent studies
Course of BPD
- 85% remit in 10-15 years (not lifelong disorder)
- 75% self harm
- 10% die by suicide (mental illness with second highest rate of suicide)
Issues in diagnosing BPD
- Underdiagnosis and misdiagnosis
- Gender bias in diagnosis
- Heterogeneity in population
Differential diagnosis (BPD vs. bipolar)
- Commonly confused
- Differences include:
1) Speedy and frequency of mood shifts
2) Baseline mood
3) Context of impulsive behaviours
Environmental risk factors
- 75% report abuse histories
- Most report invalidating environment (parents who criticize or discount emotional responses; parents who punish individuation and separation)
Biological risk factors
- Closer relatives have higher rates (9-25%; MZ = 35-42%)
- Heritability = 0.46
- Impulsivity/emotionality may be underlying heritable traits
Linehan’s Biosocial Model of BPD Diagram
See notes
Biosocial Model - Emotional Vulnerability
- Emotional sensitivity: More easily triggered emotions (thinner emotional skin; respond to things that wouldn’t trigger the same response in others)
- Emotional reactivity: More intense emotions (increased emotional baseline)
- Slower return to baseline: Emotions stick around longer
Biosocial model - Invalidation
- Emotional fit
- Reciprocal effects
- Absence/abuse/neglect
- Denial/suppression of emotions
Emotional fit
Clashes occur if your emotions are intense and you have very rational parents; they just won’t get it
Reciprocal effects
More intense emotions -> more invalidation (“What’s wrong with you, why are you acting like that?”)
Denial/suppression of emotions
You’re told not to express certain emotions (e.g. “Don’t cry”)
BPD Treatments
- Dialectal behavioural therapy
- Mentalization-based therapy
- Schema-focused therapy
- Transference-focused therapy
Development of DBT
- Developed by Dr. Linehan at U of Washington b/c CBT was not working for clients with chronic suicidality and BPD
- Solution: Dialectics, Validation, multi-modal treatment and treatment hierarchy
Why was CBT not working for clients with BPD?
- Change focus was invalidating
- BUT you also can’t validate everything they say or else they won’t get better, so you have to strike a balance in treatment that CBT can’t accomplish
- Unrelenting crisis interfered with treatment/skills acquisition
Dialectics
Thesis = my emotions make sense Anti-thesis = my emotions aren't helping Synthesis = my emotions make sense BUT they aren't helping me in this situation
Multi-modal treatment
Many different components
Individual therapy - to help with crises and keep the individual going
Group skills - teach them coping skills
Phone calls - coach them on what skills they can apply in different situations
Therapist consultation team - therapists get burned out pretty easily, so no one does DBT by themselves; so therapists meet once a week and help each other (therapy for therapists)
DBT goals and skills
- Cognitive dysregulation -> mindfulness (mindfulness helps people understand what’s going on (e.g. people with BPD often forget why they were so upset))
- Impulsivity -> distress tolerance
- Labile emotions (rapid changes in mood and very strong emotions) -> emotional regulation
- Interpersonal chaos -> interpersonal effectiveness
Stage 1 of DBT: Stabilization
- Focus: Mainly trying to keep people alive (hell -> misery)
- Goal: Move from behavioural dyscontrol to control to achieve a normal life expectancy
Treatment hierarchy in stabilization stage
- Reduced life threatening behaviours: Suicide, NSSI
- Reduce therapy-interfering behaviours: e.g. missing sessions, not completing homework, behaviors that interfere with therapists’ motivation to treat client
- Reduce quality-of-life-interfering behaviour: e.g. substance use, eating disorder behaviours, inability to keep employment, educational issues
- Increase skills that replace ineffective coping: replace dysfunctional behaviours
Stage II of DBT: Suffering in Silence
Begin to build life up
Focus of Stage II
- Address inhibited emotional experiencing
- Reduce PTSD symptoms
Goal of Stage II
Move from quiet desperation to full emotional experiencing
Stage III of DBT: Build a life worth living
- Focus: Problems in living
- Goal: Life of ordinary happiness and unhappiness
Stage IV of DBT: Address issues of meaning (Optional)
- Focus: Spiritual fulfillment and connectedness to greater whole
- Goal: Move from incompleteness to ongoing capacity for experiences of joy and freedom
Research shows improvement in:
- Suicidal behaviour
- NSSI
- Depression
- Anger control
- Emotional dysregulation
- Anxiety
- Emotional regulation
- Experiential avoidance
- Assertive anger
- Hospitalizations
