Lecture 8: Borderline PD & Histrionic PD Flashcards
What are the diagnostic criteria for BPD
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. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Explain whether there are gender differences in BPD and if so, what they look like
It is assumed that BPD is more common in females over males. We actually see equal prevalences in community samples, however in clinical samples we do see more females than males with BPD.
Two potential reasons for this are that females are generally more likely to seek help, and that the characteristics of this disorder are more stereotypically related to women
Which 2 traits can easily be changed with treatment (of BPD) and which 4 are resistant to treatment
Easily changed:
- general severity
- affective instability
Resistant to change:
- impulsivity
- suicidality
- anger
- dissociation
Explain the emotional cascade model (ECM)
Negative affect (anger and anxiety), associated with increased amygdala response, leads to negative cognition (rumination, devaluation and low self-worth), associated with decreased prefrontal cortex activity, which then leads to more negative affect (and so on and so on)
—> this leads to NSSIs = non-suicidal self-injury
What are the short-term and long-term effects of NSSI
Short-term; increase in positive affect and decrease in negative affect —> short-lived
Long-term; increased negative affect and decreased positive affect —> shame, guilt and negative body image
What are two reasons for the fact that the emotional cascade in the ECM is particularly strong in adolescence
- Prefrontal cortex is still maturing so there’s reduced impulse control
- High amygdala response to stress
Explain the different aspects of the spectrum of NSSI and what belongs to them
Individual-avoid/relief; ‘feeling too much’ = reality is too raw/overwhelming, psychic equivalence
- emotion regulation
- attempt to stop escalation
- resembling addictive cycle (bc of short term relief, build up to do it and feeling of isolation)
- cry for help/of pain
Individual-elicit; ‘not feeling enough’ = i feel nothing at all, i am empty/numb, i feel cut off from the outside world
- eliciting positive affect
- antidissociative function
- self-punishment
Social-avoid/relief; avoiding social responsibilities
Social-elicit;
- influence on/from friends
- gaining access to privileges
- manipulation
What is the strongest motive for NSSI
Tension relief
What are 2 reasons for the fact that you cannot force a patient to stop engaging in NSSI
- Ineffective = patients are in a different state of mind when they promise this compared to when they self-harm
- Iatrogenic effect = behaviors become more covert, symptom shifting takes place —> different symptoms come up to replace the NSSI that you are trying to suppress (eg. Suicidality)
Psychic equivalence
= the belief that the thought that you have is fully and completely true and there are no other alternatives
Explain the concepts of idealization and devaluation and how they are related
Idealization = attributing overly positive qualities to another person/thing
—> dealing with fear of abandonment; keeping the fantasy of perfection intact
Devaluation = attributing exaggerated negative qualities to another person/thing
—> (imagined) sense of ambivalence; leaving before they get left
These two concept combined are called splitting = the inability to hold opposing thought; positive or negative attributed of a person/events are not weighed/cohesive —> someone is either absolutely perfect or they are the worst person in the world after having disappointed you
- black or white/all or nothing
- affects fluctuates with splitting
- linked to complex childhood trauma
Explain the concept of paranoid ideation and how it differs from epistemic hypervigilance
Paranoid ideation = focuses on the belief that others have malicious intentions
—> it’s about the source or the interaction/relation with someone that is not being trusted;
epistemic hypervigilance it is specifically about a piece of information that is not being trusted –> focuses on the distrust of information and its sources rather than the intent behind it
What does splitting lead to
Intense anger; other person on pedestal makes slight misstep —> Didn’t think they were ever capable of doing that —> ‘I have been lied to, I have been fooled by all of you’ —> betrayal, intense anger
Explain the concept of SOD and a study that was done related to this concept
Self-other distinction = the ability to distinguish one’s own body, actions and mental states from those of others, which is essential to interacting with others while maintaining a stable sense of self
Study; they had people look at the face and simultaneously look at another person’s face while stroking both with a small brush (synchronous stroking), they then showed the patient’s face slowly morphing into the other person’s face and asked them to identify when the face starts looking like not your own
—> healthy controls indicated this was about halfway through the process but BPD patients really struggled to indicate this
What are two systems related to SOD and what happens in BPD patients
- Frontoparietal MNS = shared representational (SR) system; experiencing mental states ourselves and observing others experiencing the same mental states —> working adequately (or even better) in BPD patients
- MSA system = develops with increasing healthy interpersonal experience; more cognitive and controlled reflection on mental state; centrally involved in SOD —> underdeveloped/impaired in BPD patients
What are the diagnostic criteria for HPD
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
Explain specifically criterion 4, 6 and 5/8 of HPD and what they entail
4: appearance fills identity void; time/energy/money spent on clothes/grooming, fishing for compliments
6: excessive public display of emotion; towards high-status figures, shallow and rapidly shifting affect
5/8: consider relations more intimate than they are; impressionistic speeds but lacking in detail (eg. saying someone is amazing but not being able to explain why)
How is HPD related to BPD, NPD and Bipolar/Mania and what differentiates them
HPD-Bipolar/Mania
Common:
- grandiosity
- excessive talking
Different (bipolar/mania):
- longer-term mood
- polarization
HPD-BPD
Common:
- attention seeking
- manipulative
- shifting affect
Different (BPD):
- self-harm
- anger
- chronic emptiness
- identity issues
HPD-NPD
Common:
- attention seeking
Different (NPD):
- reaffirming own grandiosity (vs. willing to look weak/like a victim for attention in HPD)
What are 7 common co-occurring disorders with BPD
- MDD, most common, more likely to attempt suicide, associated with longer depressive episodes and sharter time in between episodes
- Bipolar disorder; similarities have led to suggestion that BPD should belong to bipolar spectrum —> evidence does not support this (BD does not occur more than other psychiatric disorders); leads to more suicide attempts and prolonged unemployement
- Anxiety disorders, suggests that BPD may have shared underlying trait anxiety
- PTSD, many similarities leg irritability, dissociation, inability to tolerate emotional extremes —> difficult to differentiate, mutual influence of childhood trauma
- ADHD, overlapping features such as impulsivity and emotion dysregulation
- Substance use; impulsivity and emotion regulation play a role in the development of both disorders
- Eating disorders, comorbidity with PDs is associated with poorer treatment outcomes
What are 6 biological and neural underpinnings of BPD
- reduced gray matter (in frontolimbic circuits)
- hyperactivity of the left amygdala
- impaired amygdala habituation after negative affect inducing images
- processing social cues as negatively biased leading to inability to appraise trustworthiness —> less frontal activity and impaired top-down control
- oxytocin may play a role in rejection sensitivity and attachment difficulties
- early life stress may affect maturation of hypothalamic-pituitary-adrenal axis
What 3 aspects of life of a BPD patient should a therapist ask about
- Love and sexual relations
- Work, career and vocation
- Creative pursuits and leisure activity
what are 6 facets of personality functioning that can greatly aid assessment and treatment planning
- Assessment of identity = the coherence and continuity of one’s self-concept and understanding of others and investment in goals
- Quality of object relations = the maturity of internalized mental representations of significant others and capacity for intimacy
- Defensive operations = the adaptability versus rigidity/maladaptiveness of psychological defenses in the face of internal and external stressors
- Moral functioning = the capacity for an ethical and consistent set of values that one lives by
- Aggression = the capacity to adaptively tolerate and express anger, hostility, and aggressive behavior versus inhibiting and “acting out” impulsively with aggressive impulses
- Reality testing = the capacity to differentiate shared perceptions of social reality from perceptual distortions unique to the patient
What are 4 typical transferences in patients with BPD and 5 typical countertransferences to BPD patients
Transferences:
- paranoid transference; fear that if they’re open about problems the clinician will reject tem
- narcissistic transference; express depreciation and entitlement /inflated self-worth in relation to therapist
- erotic transference; express sexual interest/desire towards therapist
- depressive transference; may emerge when working through loss of “idealized” image of others
Countertransferences:
- overwhelmed/disorganized; feeling dread towards a threatened by a patient
- special/overinvolved; feeling that a patient is special/their favorite
- sexualized;experiencing erobic feelings/desires towards the client
- criticized/mistreated; feeling undervalued, helpless, criticized, inadequate and incompetent
- parental; taking on a maternal paternal nurturing role
What are 7 evidence-based treatments for BPD
-
Dialectical Behavior Therapy (DBT) = balances acceptance change strategies to help with emotion regulation capacities, individual therapy and
weekly group-skills training - Cognitive-Behavioral Therapy (CBT) = focus on altering care dysfunctional beliefs
- Schema Therapy (ST) = help become less influenced by pervasive schemas of thinking, feeling and behaving
- Mentalization-Based Treatment (MBT) = based on psychodynamic attachment theories, increasing rentalization
-
Transference-Focused Psychotherapy (TFP) = psychoanalytic treatment rooted in object relations theory, aims to reduce suicidality, increase
coherence of identity and improve vocational, social functioning - Dynamic Supportive Psychotherapy (DSP) = provides emotional support/advice on daily problems of living, bolster healthy caping strategies defenses
-
Good Psychiatric Management (GPM) = provides concrete support and problem-solving assistance for present challenges in patient’s life
–> use of medication as first-line I solo treatment is not supported
What are the 6 subtypes of HPB according to Millon
- Appeasing: Attention-seeking behavior coupled with a desperate need for friendship and acceptance driven by fear and anxiety; may engage in abusive or predatory partnerships with codependent traits.
- Vivacious: Charming, seductive, but emotionally empty; at times, effervescent to the verge of hypomania; struggles with complex emotional attachment, so relationships’ are short-lived and shallow, with a lack of empathy consistent with narcissistic behavior.
- Tempestuous: Emotionally labile, quick to anger, will engage in conflict if it serves perceived attention needs. Shares several traits with borderline personality disorder and/or bipolar 2 because of excessive mood lability and irritability.
- Disingenuous: Attention-seeking behavior is grounded in a desire to manipulate or control others for the patient’s personal amusement, particularly in the naive or unsuspecting; possesses many narcissistic qualities.
- Theatrical: Self-promoting and seeks praise and adulation for superficial features such as clothing or appearance. The need for external admiration may exceed the need to maintain strong friendships.
- Infantile Subtype: Shares features of its tempestuous counterpart, but behaviors don’t match her developmental age. Behaviors may arrange themselves in a borderline fashion; may pout and cry for attention, or present as volatile and respond inappropriately to perceived “injustices”-cancellation of plans due to work commitments, etc
What is the main goal of treatment for HPD
Improving meaningful interpersonal dynamics
Explain supportive psychotherapy and psychodynamic psychotherapy for HPD
Supportive psychotherapy = aims to reduce the use of maladaptive defenses, provide insight into the origin of maladaptive attention-seeking, help patients to identify high-risk situations and steer them towards more positive choices, point out to patient that they may have low self-esteem/feel dependent on other for care
Psychodynamic psychotherapy = revealing unconscious thought and explore how they’re affecting the patient’s life and focus on need for love and approval, how sexuality was viewed/experienced and used to create attachments, emphasis on transferences and bringing the patient back to what they’re thinking/feeling/how they’re behaving
What are 2 kinds of unconscious defense mechanisms
- Borderline personality organization (BPO) = splitting and dissociative defenses, sexualization, regression (= helpless/childlike behavior), acting out as a way to handle conflicts
- Neurotic personality organization (NPO) = use repression-based defenses, sexualization and repression
how do HPD patients differ from extroverts
they are either unaware of choose to ignore social boundaries, because the drive for attention is too great
