Also its worth mentioning that Borderline Personlity has other PD’s as its co-morbidities . This increases in prevalence with the intensity of Psychiatric care.
Aetiology of borderline personality disorder afsa , mohammed (1)
Aetiology of Borderline Personality DisorderDrs. Afsa Shafi and Mohammed Hakim
What is Personality DisorderICD – 10A severe disturbance in the characterological condition andbehavioural tendencies of the individual, usually involvingseveral areas of the personality, and nearly always associatedwith considerable personal and social disruption .DSM IVAn enduring pattern of inner experience and behaviour thatdeviates markedly from the expectations of the individual’sculture, is pervasive and inflexible, has an onset inadolescence or early adulthood, is stable over time, and leadsto distress or impairment.
Cluster A , B and C• Cluster A: Odd or Eccentric Behaviors• Schizoid PD• Paranoid PD• Schizotypal PD
Cluster A , B and C• Cluster B : Dramatic, Emotional, or Erratic Behavioureg : BPD, Histrionic PD Narcissistic PD Anti-social PD
Cluster A , B and C• Cluster C : Anxious, Fearful Behaviour• Eg : Avoidant PD• Dependent PD• Obsessive Compulsive PD
ICD - 10A . General Criteria for the Personality Disordermust be met.B. At least 3 from criteria B1. Disturbances in and uncertainty about self- image, aims and internal preferences ( including sexual)2. Liability to become involved in intense and unstable relationships often leading to emotional crisis
ICD -10• Excessive efforts to avoid abandonment• Recurrent threats of acts of self harm• Chronic feelings of emptiness
Epidemiology of Personality Disorders• Prevalence of 10‐13% of adult population• Commoner in younger age groups (25‐44)• Overall gender ratio 1:1 but varies with individual PD (eg. Antisocial more common in males and Borderline more common in females)• More common diagnosis in white than black people• Very common in prisons (up to 78%) particularly antisocial
Epidemiology of Personality Disorders• Prevalence in psychiatric hospital populations 36‐67%• Prevalence increases with intensity of psychiatric care• Cluster B (borderline, antisocial, narcissistic, histrionic) attract most attention -• PD prevalent in inpatients with drug, alcohol and eating disorders• Comorbid psychiatric illness common, especially depression, and comorbid PD can complicate recovery in severe mental illness• Borderline 0.2% to 1.8% of general population (Community 0.7%, Mental Health OPD 8‐11%, Mental Health Inpatient 14‐ 20%), commoner in women
Impact of PD• On patient (social and occupational functioning, parenting,• substance misuse, self‐harm and suicide attempts, criminality)• On family/carers• On society (cost of use of emergency services,• inpatient/residential/secure provision, incapacity and other benefits, criminality)• Suicide and premature death ( 5 % all PD’s )
What causes BPD• Exact cause for BPD is not yet understood• Seems to be a Bio- Psychosocial picture to it.• Let’s look at each in turn.
Biological• Three different theories – Limbic system: involved in many of our emotions and motivations, particularly those that are related to survival. Such emotions include fear, anger and pleasure – Frontal lobe (important in affective responsiveness, social and personality development and self awareness) • Orbital prefrontal cortex • Orbitofrontal cortex
Biological• Three different theories – Limbic system – Orbital prefrontal cortex – Orbitofrontal cortex
Biological• The Limbic system – Most primitive part of human brain – Controls emotions – Specially amygdala and hippocampus in charge of fear, rage and automatic reactions – Both significantly smaller than normal in BPD cases – ?explanation for: • Excess anger • Fear in relationships • Self mutilation
Biological• The orbital prefrontal cortex (OPFC) – Important role in inhibiting limbic regions involved in control of generating aggression) – Serotonin controls OPFC activity. If low, means increased limbic inhibition. – Also low glucose in this area leading to low serotonin proposed as a causing factor
Biological• Orbitofrontal cortex BPD Lesions in Lesions in PFC Normal OFC but not OFC adults• Performance and reactions compared with tests and questionnaires• First two groups most similar: most impulsive, more aggressive and less happy but not identical.• But BPD cases more neurotic, less extraverted and less conscientious than the rest.• Not all traits = same cause
Aeitiology - Biological• The prefrontal cortex (P.F.C.) is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.• This brain region has been implicated in planning complex cognitive behavior, personality expression, decision making and moderating social behavior. The basic activity of this brain region is considered to be orchestration of thoughts and actions in accordance with internal goals.• The most typical psychological term for functions carried out by the prefrontal cortex area is executive function. Executive function relates to abilities to differentiate among conflicting thoughts, determine good and bad, better and best, same and different, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions, and social "control" (the ability to suppress urges that, if not suppressed, could lead to socially unacceptable outcomes).
Aetiology- Psychosocial factors• 87% victim of childhood abuse – 40-71% sexual abuse – 25-70% physical abuse• Leads to confusion – What’s happening??? Affects thoughts and feelings – Affects future relationships as discussed earlier because doesn’t understand the feelings of others – Dissociated state: emotionless during time of painful experience of abuse and then causing self harm in later life.
Aetiology- Psychosocial factors• Theories:• Failures of early mothering, especially mirroring• Fear of abandonment• High rates of parental loss• Family history of mood disorders and substance use• Excessive early aggression (due to constitutional orenvironmental factors) leading to difficulty integrating positive and negative aspects of self and mother and associated affects
Aetiology -Psychosocial factors• Conflictual relationships with parents with hostility,devaluation or abuse – less caring and more controlling• Childhood trauma, particularly sexual abuse• Childhood trauma as risk factor for adverse brain development – maltreated children and adolescents havesmaller intracranial volumes, cerebral volumes and larger lateral ventricles.
Aetiology -Psychosocial factors• Importance of attachment difficulties where early experience with the caregiver serves to organize later attachment relationships – ‘attachment propels cognitive development’• BPD can be understood as impairment of capacity for emotion regulation, attentional control and mentalization.
Diathesis-stress model• Discussion: – What comes first????
Discussion• Open for your opinions• PS: check out www.fixthelikes.blogspot.com• The presentation is on there.