BPD youth Flashcards
Diagnostic criteria : DSM 5
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, as indicated by 5 or more of 9 criteria
(Syndrome not a disease - man made construct
where symptoms co occur in a cluster. BPD is 1 of 10 identified PDs.)
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation
- Identity disturbance: marked & persistently unstable self-image and sense of self
- Impulsivity in at least 2 areas that are potentially self damaging (eg: spending, sex, substance abuse, reckless driving, binge eating)
- RECURRENT suicidal behaviour, gestures, or threats, or self-mutilating behaviour
- Affective instability due to a marked reactivity of mood (eg: intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness (Emptiness, can be expressed as a sense of boredom - Just not experiencing fulfillment. Kind of lack of purpose. Relates to identity disturbance. If they talk about feeling bored all the time, could be emptiness.)
- Inappropriate, intense anger or difficulty controlling anger (eg: frequent displays of temper, constant anger, recurrent physical fights) (Anger usually because they can’t express themselves in relationships. Often explosive anger because they hold it in all the time.)
- Transient, stress-related paranoid ideation or severe
dissociative symptoms (however, not the same as other psychotic disorders, more trauma related. May be a lot of derogatory hallucinations which you can connect to low self worth.)
Self harm
A means of coping with life:
- to minimize harm (from suicide) & make it possible to keep going
- to concretise pain
- to communicate distress
- to self-punish
- to provide escape - have 10 benzodiazopines to go to sleep for a day or two. Or to be admitted to hospital. Provides relief.
- to ‘ground’ and provide a sense of existing
In BPD people over 30% will have three or more attempts of suicide in their life and 10-12% suicide completion rate.
Self injury is about coping with life. Whereas for someone
with depression, they usually do want to end their life.
BPD self harm might be harm minimisation, stop themselves engaging in suicide.
Causes of BPD
Interaction between: • BIOLOGICAL COMPONENTS -Born with emotional sensitivity • ENVIRONMENTAL INFLUENCES -Consistently inattentive care-givers -Neglect -Trauma / abuse / marginalization •Zanarini’s Tripartite model
- Biological / genetic predisposition
- Childhood adversity
- Kindling event - when symptoms commence - Kindling event is there are two predisposing factors, then something happens that causes symptoms to commence. Precipitating event.
We know it’s an interaction between being born with emotional sensitivity (even as a baby) then environmental influenses interact with that. Behaviourally, problem behaviours are reinforced. Psychodynamically, might focus on attachment. Zanarini, genetic emotion dysregulation. Then childhood adversity might be the mother had post natal dep, then child missed out.
Or abuse, possibly outside the family not the caregiver.
Early predictors
Geselowitz et al (2021)
- Longitudinal study with 170 children assessed at 3, 6, 14 & 19 years of age
- BPD psychopathology in adolescence predicted by
- Adverse childhood experiences
- Preschool and school age externalizing symptoms (aggression)
- Preschool internalizing symptoms (depression)
- Low maternal support
- Preschool and school age suicidality
Stigma
- Self-harming patients are stigmatised
- Interpersonal issues create anger & defensiveness in professionals & others
- Clinicians can experience strong negative emotions
- The community finds it hard to understand
- Stigma negatively impacts the patient’s ability to recover -exclusion from services
People don’t understand self harm. They just don’t
get it. There are cases of BPD self harm clients getting tx for self harm in ED, then nurses don’t give anaesthetic as
punishment
Video analysis of BPD - suicidality
Just because someone isn’t presenting with
intent to die, doesn’t mean they won’t engage in
behaviour that could result in death. Have to work on self-worth and what precedes the beginning of the slide into drinking and drug use etc. What puts you in that situation and what makes you vulnerable
Being in relationship
- Professionals describe BPD as one of the most difficult mental disorder to work with
- Interpersonal symptoms:
• Over-value / de-value
• “Splitting”
• Act on fears of abandonment
• Anger
• Distrust
• Strong transference & counter-transference - Chronic risk is hard to manage
- Systemic dynamics & DIALECTICS
Professional therapeutic relationship, strongest transference of all disorders. Acute - legally they are incompetent. We step in and take responsibility for their safety. Chronic risk - stepping in makes the risk issue worse. Splitting makes it hard because if the tx team can’t agree, it will be harder to treat person.
Issues concerning diagnosing BPD in youth
Controversial arguments around whether we should diagnose under 18s.
Many symptoms of BPD are seen in adolescents who don’t end up with BPD
- Is it inappropriate to diagnose BPD in a young person who’s brain is still developing?
- Why label early, especially with a diagnosis that has such stigma attached?
Arguments for early diagnosis
- NHMRC Guidelines (2012), DSM5 & ICD11 all recommend diagnosing adolescents
- The benefits of early intervention suggest a rationale for giving young people a provisional diagnosis of BPD
• Starting treatment early results in better outcomes - Also beneficial to provide BPD treatments to youth with
symptoms that don’t meet the criteria as well.
Diagnosis reliable and valid as in adults. Research shows we can make a competent diagnosis under 18. Allows tx to start early. Avoids people moving into the adult system. Can treat early features.
Family breakdown
- In Australia, adolescents with BPD experience higher rates of family breakdown
• By 16 years of age, 37% of people with BPD are not living with their biological parent
• This increases to 53% by 18 years of age (Chanen et al, 2004, cited in NMHRC Guidelines, 2013) - Poor family functioning is associated with self-injurious
behaviour in adolescents (Sitton et al., 2020).
We imagine the stats will get higher rather than lower.
Identifying BPD features in young people
Frequent = high risk of self injury if not suicide
- Symptoms of BPD typically emerge during adolescence and early adulthood
- A full assessment is recommended if:
- Frequent suicidal or self-harm behaviour
- Marked emotional instability
- Other psychiatric conditions
- High level impairment of psycho-social functioning, self-care, peer and family relationships
- Non-responsive to established treatments for current symptoms
Managing self-harm & suicidal behaviour
ASIST strategies are for acute suicidality. If you have chronic risk, the strategies don’t work well.
In BPD, suicidality is often chronic in nature
- Self harm is often part of this picture, especially in adolescents
- Adolescents can engage in more risky behaviours
- Control taking strategies are likely to increase risk with chronic suicidality and self-harm, rather than decrease it
- Risk tolerance is recommended in BPD, however adolescents may require more intervention because of impulsivity and more risky behaviours. In this instance, Risk tolerance = family taking a closer eye on maintaining safety than for an adult
- With young people, family dynamics can contribute to the expression of risk, and this needs to be worked with
- Supervision and support to the clinician is essential in order to make good decisions
Not understanding the permanence of death is a risk factor more common for younger adolescents.
Capacity to act on thoughts is age related, how closely
supervised they are.
Developmental issues regarding risk
- Level of understanding
HOWEVER a limited understanding of the permanence of
death or consequences of suicidal behaviours IS NOT a
protective factor. - Capacity to act on thoughts
- Capacity to engage coping skills or engage in risk management strategies
Capacity to help-seek should risk escalate
Emerging BPD often used to describe adolescents
Systemic issues regarding risk
- Parents, grandparents, foster-carers, school & teachers
- Is the system around the child or young person…
• Able to understand the distress of the child?
• Able to monitor changes to distress or risk?
• Responsive?
• Protective?
• Capable?
• Capacity?
Do the parents have the capacity to respond? Services like us will have to respond well. There are always groups around the young people that are either good or bad.
Diagnostic screening in young people
- PAI-A BOR Scale good diagnostic accuracy & psychometric properties****
Good adult assessments:
• Borderline Personality Questionnaire (BPQ)
Highest diagnostic accuracy & test-retest reliability in
adults
• Structured Clinical Interview for DSM (SCID-II)
• McLean Screening Instrument for BPD
(MSI-BPD)
• International Personality Disorder Examination Screening Questionnaire (IPDE)
Not a lot of other good adolescent diagnostic tools.
Diagnostic Interviews for Borderline Revised - DIB-R
Borderline Evaluation of symptoms test - good for
looking at changes in level of severity.
