L9: BPD & HISTRIONIC PD Flashcards
What is the prevalence of BPD?
- general pop 3%
- primary care 6%
- outpatient 11%
- inpatient 21%
more women diagnosed in clinics, but in general equal prevalence!
What are BPD symptoms?
pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity, beginning by early adulthood & present in ++ contexts, as shown by min 5:
1. frantic efforts to avoid real / imagined abandonment
2. unstable & intense relationships (idealization, devaluation, splitting)
3. identity disturbance
4. impulsivity
5. self injury
6. affective instability
7. emptiness
8. anger
9. paranoid ideation
What are BPD treatments?
- Dialectical Behaviour Therapy
- Schema Therapy
- CBT
- Transference focused psychotherapy
- Dynamic Supportive Psychotherapy
- Mentalization based therapy
- Good psychiatric managment
- meds is not supported
How effective is BPD treatment?
what improves: general severity & affective instability
what is more resistant to treatment: impulsivity, suicideality & NSSI (most commonly met diagnostic criterion for BPD in adolescence), anger, dissociation
What is the psychobio mechanism behind self injury (or NSSI: non suicidal self injury) ?
emotional cascade model leads to such intense psych distress that NSSI is used to numb this distress & elicit more positive affect
Why does NSSI not work on the long term?
short term it decreases psych distress & increases positive affect
but long term it increases negative affect & cognitions due to:
- shame
- guilt
- lower body image
- low self worth (can be related to scars as well)
-> so self harm becomes part of the emotional cascade!
What is the Emotional Cascade Model?
negative affect (anger, anxiety (like abandonment anxiety) -> negative cognition (rumination, devaluation, low self worth)
AKA the worse you feel, the worse your thoughts are
but this becomes a self perpetuating negative cycle: the negative thoughts make the mood worse
-> especially strong in adolescents
Why is the emotional cascade model especially strong in adolescents? How does this relate to NSSI?
strong because
- PFC not fully matured yet, so lower PFC functioning -> lower positive cognition
- Heightened amygdala response -> higher/more intense negative affect
so very strong emotional cascade
-> NSSI is a very effective & easily usable way of disrupting or short circuiting this intense emotional cascade! it decreases the negative affect & psych distress
What is the functionality of self injury?
4 factor model: individual - social goal; suppressing something - eliciting something
individual + suprressing = feeling too much (so as emotion regulation: attempt to stop escalation, resembles addictive cycle, cry of pain, psychic equivalence) MOST COMMON
individual + eliciting: not feeling enough (to elicit positive affect, antidissociative function, self punishment)
social + suppress: avoid social responsibilities (rarely reported by clients)
social + elicit: influence on/from friends, gaining access to privilges, manipulation, get attention
+ to gain control!
How is NSSi used to gain control?
having full control over physical pain can soothe a fragile sense of self
“to feel alive/real” “feel where my body ends & outside world starts” “only control in an unpredictable world”
Why can’t you force your patient to stop engaging in NSSI?
cause then they lose that sense of control they gained by doing it, so might do something else
-> IATROGENIC EFFECT: behaviours become more (symptom shifting) ie suicidality
How does NSSI resemble addiction?
- short term relief but long term increased need to engage in the behaviour
- often need higher dose so more severe/frequent NSSI to get same amount of relief
- preoccupation w the behaviour
- isolation
What is psychic equivalence?
there is no other truth than my thoughts
what i think is true
seen in NSSI
What is idealization?
attributing overly positive qualities to another person/thing
- stems from fear of abandonment: keeps fantasy of perfection intact which keeps fear at bay (ambivalence is intolerable for them)
What is devaluation?
attributing exaggerated negative qualities to another person/thing
- stems from (imagined) sense of ambivalence so they leave before they get left (cause abandonment is too scary)
What is paranoid ideation?
stress related paranoia (that person probably hates me!)
- feeling threatened, persecuted, or conspired against: others have malicious intentions
- transient, stress related paranoia
What is epistemic hypervigilance? how does it differ from paranoid ideation?
epistemic hypervigilance focuses on the distrust of info & its sources rather than the intent behind it (while paranoia is when u think ppl have malicious intents)
What is splitting?
going from devaluation to idealization very quickly
- central concept in object relation theory for BPD by Kernberg
- inability to hold opposing thoughts, positive or negative attributes of a person or event are not weighed/cohesive
- black or white / all or nothing
- when it comes to situations /oneself/others / clinicians
- affect fluctuates w splitting (see intense anger)
related to intense anger! when other person on pedestal makes slight mistep they feel very betrayed since they couldnt imagine them doing that
Where does splitting originate from?
complex childhood trauma/abuse/neglect (experienced by 90% of BPD patients)
- in childhood splitting is everywhere for everyone! mum loves me, i am safe, she feeds me: all good; i am alone, mum doesnt feed me: all bad
- as we grow older we reach healthy ambivalence: mum is one source of pleasure & frustration
- but when trauma/abuse is experienced, the all bad in childhood is really bad (mum is dangerous but at other times she loves me, good vs bad) so its very hard to reach healthy ambivalence
- nr of traumatic events matters
- makes self-other distinction hard
What is self-other distinction? How does it relate to splitting?
ability to distinguish one’s own body, actions, and mental states from those of others
- essential to interacting w others while maintaining stable sense of self
- imparied in BPD patients (often think other ppl should be able to read their mind), this results from complex trauma
How was Self other (body) distinction impairments studied in BPD?
BPd patients & controls were both presented with another person & themsleves being simultaneously stroked with a brush
then their own picture on a screen slowly morphed into the other persons picture, and they had to indicate when it wasnt their face anymore
-> results showed later intervention by BPD patients than controls: so even when picture looked more like other person, they still thought it looked like themselves
How was self other distinction of mental states impaired in BPD patients?
neurobio evidence: we have a shared representational (SR) system located in frontoparietal region
- this area is activated when you experience a certain mental state + you observe others experiencing the same mental state
pros when activated appropriately: empathy, connection, cooperation
when overactivated (in hypermentalization): conflated experience of self/others (unsure whether what youre experiencing is also what the other is experiencing & vice versa) ->
MSA (mental state attribution) system prevents this conflation & hyperactivation of SR system
- develops w increasing healthy interpersonal experience
= more cognitive & controlled reflection on mental state
= centrally involved in SOD
-> IN BPD, THE FRONTOPARIETAL SR SYSTEM IS NORMAL/OVERACTIVATED + MSA SYSTEM IS UNDERACTIVATE
What are HPD symptoms?
pervasive pattern of excessive emotionality & attention seeking, beginning by early adulthood & present in ++ contexts, as shown by min 5:
1. need to be at center of attention
2. provocative behaviour
3. shifting & shallow expression of emotions
4. uses appearance to get attention (appearance fills identity void)
5. impressionistic style of speech (lack of details)
6. theatricality (excessive public display of emotions)
7. is suggestible (easily influenced)
8. considers relationships to be more intimate than they actually are
What are common differential diagnoses in HPD?
BPD: cause overlap in attention seeking, manipulative, shifting affect but BPD different cause self harm, anger, emptiness, identity struggle
NPD: attention seeking overlap but NPD different cause reaffiraming own grandiosity while HPD are willing to look weak/victim for attention
BIPOLAR (MANIA): cause overlap in grandiosity & excessive talking but mania is longer term mood polairzation while HPD is very brief mood swings
What are common co-morbidities with BPD?
- MDD (worsens suicidality & general course)
- Bipolar (similarities in impulsivity & mood instability, worsens suicidality & general course)
- Anxiety disorders
- PTSD (similarities in irritabilty, dissocation, inability to tolerate emotional extremes; mutual influence of childhood trauma on both, leads to increased NNSI)
- ADHD (overlap in impuslivity & emotion dysregulation)
- SUD (overlap in impuslivity & emotion dysregulation)
- EDs (poorer outcomes)
- other PDs like schizotypal & narcissistic
- other health issues
- 50x more likely to die by suicide than general pop
- high levels of psychosocial impairment
What is the remission rate for BPD remit?
yes! studies show 80-99% remission rates in 10y
What are the rates of NSSI in BPD?
90%
What are the genetic, biological, and neural factors implicated in BPD?
- heritability: 40% but more studies needed (2 genes identified)
- abnormalities in brain areas involved in socio emotional processing (amygdala & insula) & regulatory control (frontal brain regions)
- reduced gray matter volume (ie in frontolimbic circuit areas)
- hyperactivity of left amgydala (moderated by individuals medication status)
- impaired amygdala habituation when presented series of negative afffect induced images
- less frontal activation: negatively biased processing of social stimuli (like faces) -> impairmed appraisal of trustworthiness of others
- reduced oxycotin related to rejection sensitivity & attachment issues
- HPA axis dysregulation
What are the psycho-social- cultural risk factors in BPD?
- adverse childhood experiences
- low SES
- insecure & disorganized attachment styles
How is BPD assessed?
- gather identifying info
- clarify presenting problem(s), including chief complaint & initial mental status examination
- ascertain general life assessment inclulding functioning in a) love & sexual relations b) work, career, and vocation c) creative pursuits and leisure activity
- consult w former treaters & close family members
- suicidality (past & present) assessment
- background of problem (history)
- relevant dev & fam history
How do you diagnose BPD?
- do assessment
- do differential diagnosis & diagnosis
- do Personality Organisation Assessment (including assessment of identity (diffused in BPD), quality of object relations, defensive operations, moral functioning, aggression, and reality testing)
What is transference & counter transference like in BPD?
transference
- intense & polarized from negative (paranoid) to positive (idealizing)
countertransference:
- special
- overwhelmed
- criticized
What are negative treatment response predictors in BPD?
- high levels of antisocial features (dyshonesty, manipulation etc)
- active substance use
- investment in the sick role
- somatization
- history of severe suicide attempts
What are the strongest predictors of suicidality?
- identity disturbance
- frantic efforts to avoid abandonment
- chronic feelings of emptiness
What are the 6 subtypes of HPD?
- appeasing: attention seeking + need for friendship & acceptance driven by fear & anxiety
- vivacious: charming & seductive but emotionally empty (especially in relationships), some narcisstic traits
- tempestuous: emotionally labile, quick to anger, overlap w BPD & bipolar
- disingenuous: attention seeking grounded in desire to manipulate/control others for own amusement, narcissistic traits
- theatrical: seeks praise for superficial features. need for admiration may exceed need to maintain strong friendships
- infantile: shares features w tempestuous type, but behaviours dont match dev age (may pout & cry for attention)
What is the prevalence of HPD?
- overdiagnosed in women and queer men, underdiagnosed in hetero men
What is transference & counter transference like in HPD?
transference
- entertaing
- dramatic
- focus on seducing clinician rather than engaging in treatment
countertransference
- feel overinvolved, overwhelmed, sexualized etc
What are the treatments for HPD?
- Psychodynamic Psychotherapy
- CBT
- Supprtive therapy
- Psychopharmacology (mostly for comorbid disorders)
How does psychodynamic psychotherapy work for HPD?
focuses on interpretation of characteristic defenses, coping styles, emotionality, and behaviour dysregulation & impacts on relationships and life of this. goal: consolidate healthier identity, dev secure attachments, mature sex life, and generally improve relationships
What is the prevalence of HPD?
2-3%
What makes diagnosing HPD challenging?
individuals often seek treatment only when their behaviour becomes ego dystonic (distressing or inconsistent w their self image)
What are often co morbidites with HPD?
- disingenuous: NPD
- appeasing: DPD
- co occurs w BPD
- depression
- bipolar
What are psychosocial & cultural factors in HPD?
- some professions reward attention seeking behaviour (influencers, celebrities etc)
- emotional expressiveness varies per culture
How is supportive psychotherapy used to treat HPD?
- aim: reduce maladaptive defeneses, increase self esteem, improve coping skills
- explore fam
