Lecture 13 - Borderline personality disorder Flashcards
“Border” of what?
“Border” of what?
* Origins in the psychoanalytic tradition
* Stern (30s)
* Inordinately hypersensitive, problems
with reality testing, and experienced
negative reactions in therapy
* Between the psychoses and neuroses;
border line
* Continued for several decades
* “pseudo-neurotic schizophrenia”
* Typically referred to patients who were
extremely challenging to treat
* 1970s-1980 (DSM-III) specific criteria
finally developed
- Intense affect
- Impulsivity
- Relationship problems
- Brief psychotic experiences
*Now stuck with this name
*Provides no descriptive
information about the disorder
* “Border” remains confusing
*Name strongly linked to
psychoanalytic tradition
*WHO’s International
Classification of Diseases (ICD10) uses the term “Emotionally
Unstable Disorder”
-Much closer to describing core
features of the disorder
Diagnosis
*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 FIVE OR MORE of the
following:
* 1. Frantic efforts to avoid real or imagined
abandonment
* 2. A pattern of unstable and intense
interpersonal relationships
* 3. Identity disturbance
* 4. Impulsivity in at least two areas that are
potentially self-damaging
* 5. Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior
* 6. Affective instability due to a
marked reactivity of mood
* 7. Chronic feelings of emptiness
* 8. Inappropriate, intense anger,
or difficulty controlling anger
* 9. Transient, stress-related
paranoid ideation or severe
dissociative symptoms
Very heterogeneous disorder
Neuroschemistry of BPD
Study with faces
Below awareness (too short of time)
Happy and fear
-Increased activation in amygdala
Hypervigilance, hypersensitivity to micro expressions
Serotonin in mood regulation
5-HT = serotonin
DA= dopamine
*Some evidence for low 5-HT activity
in BPD
*BPD treated with SSRIs show
improvements in aggressive
impulsivity
*Not overall reduction in symptoms
*Some evidence for DA dysfunction
-Primarily b/c antipsychotic meds
moderately effective in treating BPD
-Also inferred through behaviors:
– Impulsivity, sensation-seeking, emotion
dysregulation
Instability
Instability: Emotional
*Emotions change rapidly and
repeatedly
* Intense and unpredictable
*Within the course of a single
day: sadness to anger to guilt to
fear to deep despair
*Emotions INTENSELY felt
* More difficult to control
* Angry outbursts often a part of
the clinical picture
* Family members often report
“walking on eggshells”
Instability: Relationships
*Emotional instability often
triggered by loss, rejection,
disappointment
-Perceived or experienced
*Unstable representations of others
-Switch from idealizing to anger and
wanting to punish
*Fear of rejection coupled with fear
of becoming too attached
-Leads to “testing” sig. others
- “If my therapist really cared about
me, she would not go on vacation and
leave me.”
BPD and spousal abuse
Don Dutton (UBC)
*Men who engage in spousal
abuse often high on BPD
characteristics
*About 40% meet criteria
*Dutton argues:
*Susceptible because:
*Set unreasonably high
standards
*Blame partner when things
go wrong
*Poor impulse control
Instability: Sense of Self
*Self-concept very fragile
-Typically very negative
*Persistent sense of
“emptiness”
-Hard to tolerate being alone
*Relationships are a high
priority
-Threat to relationships =
threat to sense of self
Instability: Behavior
*Very impulsive, often selfdamaging
-High rates of alcohol,
substance abuse
-Spending sprees
-Risky sexual behaviors
-Gambling
-Eating binges
-Non-Suicidal Self-Injury
-Suicide risk
NSSI and suicide and dissociation
*The intentional and direct injury of one’s body without suicidal intent
- E.g., cutting, burning, scratching, hitting
*Not for socially sanctioned purposes
- E.g. Tattoos, piercings
*Between 1 and 4 % of adults, 13-23% of adolescents report lifetime
history of NSSI
*VERY common in BPD, prevalence estimates vary
* “I have tried to hurt myself [a few] times. Two times that I remember
have been when very significant caregivers have moved on, and I took
it personally. I thought that it was because of me that they left.
Another was when my grandmother died– she was a very important
person in my life.” (from Oldham, 2002, p. 1030)
*Suicidal ideation very common– almost all will report
*Suicide attempts: As many as 70%
-With an average of 3-4 attempts
*As many as one in ten die by suicide
*Reasons for suicide attempts:
*To get away, or escape
*To punish self
*Revenge
*To make others better off
-To make others better off (to stop hurting other people) is the number one reason for suicide attempts in bpd
Dissociation
*Some 75% experience
intensely paranoid ideas
and/or episodes of
dissociation
*Stiglmayr and colleagues (2008)
* BPD, clinical control, and control
* Provide hourly ratings of stress,
dissociation for 48 hrs
* BPD > stress than CC or C
* BPD > dissociative experiences
(frequency and intensity)
* Dissociation linked to stress for all
groups
* Present in BPD even under relatively
low levels of stress
Prevalence and etiology
*Prevalence: 1-2%
* Higher in clinical settings (10-15%)
*Etiology
* BPD runs in families
- Also find higher rates of SUD, APD, externalizing, MDD
* Has a genetic component (twin studies; Torgerson et al.,
2000)
* Early trauma, abuse, and neglect play a large role
- Bandelow, et al., 2005
- 6.1% of BPD had NO history of childhood trauma
– extreme parental, parental absences– mother or father in jail or
hospital, physical violence, discord in the family, more sexual abuse.
– 61.5% of controls had NO such history
- Many disorders have a history of childhood trauma/ abuse
Comorbidity
* Very high
* About 60% comorbid MDD
* About 35% comorbid PTSD
* 20% bipolar
* 17% Eating disorders
A distinct diagnosis?
*A variant of depression?
- Chronic form
- Evidence for distinct neural
signatures
*A variant of PTSD?
- Can develop BPD without
experiencing trauma
- Trauma not unique to either PTSD
or BPD
BPD course
*Chronic (PD)
*BUT:
-Evidence that as many as 88% can
be successfully treated
-Often most severe in younger
pops
*With treatment:
-Suicidal and impulsive behaviors
decrease
-Mood reactivity often persists, but
patients will be better able to cope
*DBT = Dialectical behaviour therapy (Marsha Linehan)
-Both acceptance and change
Marsha Linehan: Biosocial Theory
*Biological predisposition
towards difficulty regulating
emotions
-Emotions more intense
- More sensitive to variations
in emotional stimuli
-Take longer to return to
baseline
* Invalidating family
environment
*Results in inability to
regulate strong emotional
responses
