Borderline Personality DisorderDr. Matthew SagerPsychiatric Medical DirectorSt. Mary’s Hospital, Madison, WI

Borderline Personality Disorder (BPD)

What is it? Perceptions and current diagnosis

History

Causes

Facts

Co-occurring diagnoses and differential

Treatment

Evaluating safety concerns/suicidality

BPD

Initial impressions

Stigma

Better descriptive terms? Emotional Regulation Disorder

Current Diagnosis

DSM IV-need to have 5 of 9 criteria (pervasive)

Unstable relationships-splitting example

Impulsive behaviors

Mood swings

Intense anger

Feelings of emptiness

Fear of abandonment

Identity disturbance, ‘poor sense of self’

Suicidal behavior or self-injury

Transient paranoia/dissociative states

Diagnostic Issues

Problems with DSM IV 5 of 9-there are 256 different variations 4 of 9-no diagnosis, but would look very similar

clinically

DSM V Revisions to look at dimensional aspects of

personality BPD on same axis as depression, anxiety In end-too complex for clinical practice-yet

Diagnostic Issues cont.’

Issues that affect making diagnosis: Transient states Medical illnesses Situational stress Sex and cultural beliefs/biases Clinician feelings-anger, disappointment,

frustration

Diagnostic Issues cont.’

In the end-the diagnosis focuses on ways of thinking and feeling about oneself and others that ends up affecting a persons ability to function

BPD History

1930s Psychoanalysts (i.e. Sigmund Freud)

divided psychosis (delusions, hallucinations) from neurosis (anxiety/distress). The area between, the borderline was the difference that explained why some patients did not act one way or the other.

1960s Psychiatrist Otto Kernbergpersonality organization to syndrome to

disorder

BPD History cont.’

1980s and 90sIncreased research

From analytical to medicalization

DSM III (1980)

DSM IV (1994)

DSM V (2013)

BPD Causes

Genetics Twin studies show strong inheritance

Environmental Unstable family relationships

Social and cultural factors 1900s-less unstructured time with more

work/survival instincts i.e. Eating Disorders indifferent countries

BPD Causes

Abnormal Brain functioning Amygdala – center of emotion Prefrontal Cortex – complex problem solving

BPD

Whatever the cause, data shows the impact of this illness

BPD Facts

2% of US population have BPD

(equal to population of New York City)

Twice that of bipolar disorder or schizophrenia

10% of mental health outpatient clinics

20% of inpatient psychiatric hospital units

BPD facts

75-90% of those diagnosed are women Do women seek treatment more than men? Men with similar symptoms may end up in jail or with

another diagnosis.

10% complete suicide in their lifetime

Comorbidities are rampant-mood disorders (depression, bipolar) anxiety disorders (PTSD) and substance abuse disorders

Probably ‘burns out’ or dissipates over time

BPD Facts

Face Studies: people with BPD are inclined to see anger in neutral emotion faces

Word Studies: people with BPD are inclined to attach a stronger reaction to neutral words

Comorbidities and differential diagnoses

Mood Disorders (bipolar disorder I and II, major depression, dysthymia)

Anxiety disorders including PTSD

Eating Disorders

Substance Abuse Disorders

Other personality Disorders

Comorbidities and differential

Lots of overlap with impulsive behaviors and mood instability

Different diagnoses from different providers

Explaining diagnosis

John Gunderson MD quoteAs an example that focuses on jargon free explanation that patients can understand

BPD Treatment

BPD-High utilization of health care $ER visits, inpatient medical/psych care

Hallmark of good care-multiple modalities

Alliance building to foster improved mood, behavior, social functioning and relationships

Treatment Goals

Containment of any safety issues

Structure

Provide support

Involve patient in decision making

Validation

Treatment Levels

Hospital

‘Step Down or Up’ Partial hospital(PHP) or Intensive Outpatient Program(IOP)

Outpatient Therapy + Med Management

Sociotherapies (group, family)

Treatment Levels

Focus on the least restrictive means of effective treatment

BPD Treatment

Hospital care Often contraindicated and can worsen

behavioral issues Hospital provides external control which can

become habit forming and cause BPD patient to attempt to gain control in negative fashion

Should be used only for acute safety stabilization

BPD Psychotherapy

Mainstay of BPD treatment

Specific types may be more effective

BPD Psychotherapy

DBT (Dialectical Behavioral Therapy) Pioneered by Marsha Linehan PhD

Focuses on mindfulness, acceptance and awareness of situations and feelings

decreases intensity of emotions

BPD Psychotherapy

CBT(Cognitive Behavioral Therapy)

Focus: Changing thinking will change behavior

Skill building/practice

Relaxation

Exposure therapy

BPD Psychotherapy

Schema therapy

Reframing ways people view themselves

BPD Psychotherapy

Group Therapies

Interpersonal

Family

DBT

Others (problem focused)

BPD Medications

Role of meds: manage symptoms, though benefit is often uncertain due to ‘symptom chasing’

Goal is to treat comorbidities

Avoid dependence, abuse, risk of overdose

Classes: Antidepressants

Antipsychotics Mood stabilizers Anti-anxiety AODA meds-antabuse/naltrexone/methadone

BPD Medications

Treat comorbidities!

Treatment Plans

Contracts with patients Makes expectations explicit From Crisis Intervention, when to call providers,

when to go to hospital to roles of those involved i.e. family/friends

BPD Safety issues

Suicide and borderline personality

10% completed lifetime

Safety plans-limited pill supply, family support, crisis contact

Highest risk are those with depression and alcohol/drug problems

BPD safety issues

‘Feeling Unsafe’

Goal is for patient to recognize when they need more active help and trust they will get it

Typical Crisis-express concern, allow patient to ventilate, avoid taking actions but let patient be explicit about situation

Follow-up after crisis

BPD and suicidal acts

John Gunderson, MD

“Suicidal acts are a dangerous distraction from the patient working on attaining a better life”.

Dr Gunderson views suicidal statements/acts as affecting a patient’s dependence on others and an effort to be cared for.

BPD

References:

1. Gunderson, John G, M.D. ‘Borderline Personality Disorder A Clinician’s Guide’, 2001.

2. DSM IV, American Psychiatric Association, 2000.

3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.