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Borderline Personality Disorder Borderline Personality Disorder Presentation Transcript

  • BORDERLINE PERSONALITY DISORDER Presented by Dr Ashraf Amin
  • BORDERLINE PERSONALITY DISORDER
    • PATIENT IDENTIFICATION/CHIEF COMPLAINT:
    • 17 y/o HF undomiciled transferred to MHC Psych ED from LICH due to self injurious behavior (cutting/burning herself), and depression.
    • HISTORY OF PRESENT ILLNESS:
    • 17 y/o HF presented to MHC psych ED with self injurious behavior (cutting/burning herself). Patient started cutting herself 4 years ago “by accident” as per patient and continued to injure herself thereafter in order to control her anger. Patient reports mood swings for the past 4 years. Patient reports feeling of emptiness. Patient reports insomnia for the past couple of months. Patient states that she feels better after she cuts/burns herself and it is her only way of controlling her anger. Patient reports several stressors in her life (she constantly fights with her mother; patient has been living in shelter for the past 2 years). Patient denies SI/HI. Patient is afraid that she may hurt someone if she can’t control her anger. Patient reports having a physical fight with her mother and stated in the past that she wants to beat her mother up. Patient denies A/V/T/O hallucination. Patient denies any delusions. Patient denies any abuse h/o.
  • BORDERLINE PERSONALITY DISORDER
    • MENTAL STATUS EXAM UPON ADMISSION:
    • Patient appears stated age. Patient has multiple ear and nose piercing. Patient is cooperative, with normal eye contact, and normal psychomotor activity. Her speech is normal. Her thought process is goal directed. Her thought content appears normal. Her mood is irritable and affect is labile. Patient denies SI/HI. Her impulse control is unpredictable. Pt denies A/V/T/O hallucination. Her insight and judgment are impaired.
    • PAST PSYCHIATRIC HISTORY: Patient denies past psychiatric hospitalization. Patient admits to h/o of BPD and therapy for 4 years. Pt denies any past suicide attempts.
    • PAST PSYCHIATRIC MEDICATIONS: Patient denies.
    • FAMILY PSYCHIATRIC HISTORY:
    • Mother has borderline personality disorder, mood disorder, two suicide attempts (hospitalized), alcoholic, and history of colon cancer.
    • SUBSTANCE USE HISTORY: Patient denies.
    • PAST MEDICAL HISTORY: Herniated disc, migraine.
    • ALLERGIES: No known drug allergies. No other allergies are reported.
    • PSYCHOSOCIAL HISTORY: Patient has been living in a family shelter for the past 2 years with her mother.
    • DEVELOPMENTAL HISTORY: Normal, doing well at school. Patient completed up to 11th grade.
  • BORDERLINE PERSONALITY DISORDER
    • HOSPITAL COURSE:
    • Upon admission treatment plan was discussed with the patient and her mother. Patient and mother refused any pharmacological intervention for BPD. Patient was placed on Trazodone 50 mg po bedtime for her insomnia. Patient had participated in Unit activities and group meetings. No further self-mutilating behavior was noted while in the Unit. Patient was sociable with peer’s interaction. Her mood and affect had improved.
    • CURRENT MENTAL STATUS EXAM:
    • Patient appears stated age. Patient has multiple ear and nose piercing. Patient is cooperative, with normal eye contact, and normal psychomotor activity. Her speech is normal. Her thought process is goal directed. Her thought content appears normal. Patient denies SI/HI. Her mood and affect have improved. Pt denies A/V/T/O hallucination. Her insight and judgment have improved.
    • DIAGNOSIS:
    • Axis 1- Mood disorder NOS
    • Axis 2- Borderline personality disorder
    • Axis 3- Herniated disc, migraine
    • Axis 4- Psychosocial
    • Axis 5- 75
    • CURRENT MEDICATIONS:
    • Trazodone 50 mg po bedtime
  • BORDERLINE PERSONALITY DISORDER
    • Definition:
    • Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.
  • Diagnostic criteria for Borderline Personality Disorder
    • Five or more of the followings:
    • Frantic efforts to avoid real or imagined abandonment.
    • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (splitting).
    • Identity disturbance: markedly and persistently unstable self-image or sense of self.
    • Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
    • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
    • 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).
    • Chronic feelings of emptiness.
    • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
    • Transient, stress-related paranoid ideation or severe dissociative symptoms.
  • Associated Features and Disorders
    • Individuals with Borderline Personality Disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last).
    • Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring Mood Disorders or Substance-Related Disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts.
    • Recurrent job losses, interrupted education, and broken marriages are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with Borderline Personality Disorder.
    • Common co-occurring Axis I disorders include Mood Disorders, Substance-Related Disorders, Eating Disorders (notably Bulimia), Posttraumatic Stress Disorder, and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also frequently co-occurs with the other Personality Disorders.
  • Specific Culture, Age, and Gender Features
    • The pattern of behavior seen in Borderline Personality Disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of Borderline Personality Disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers. Borderline Personality Disorder is diagnosed predominantly (about 75%) in females.
  • Prevalence and familial pattern
    • The prevalence of Borderline Personality Disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. It ranges from 30% to 60% among clinical populations with Personality Disorders.
    • Borderline Personality Disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders, Antisocial Personality Disorder, and Mood Disorders .
  • Etiology
    • Psychoanalytic theories have emphasized the importance of early parent–child relationships in the etiology of BPD. These theories have emphasized 1) maternal mismanagement of the 2- to 3-year-old child's efforts to become autonomous, 2) exaggerated maternal frustration that aggravates the child's anger, or 3) inattention to the child's emotions and attitudes. A considerable body of empirical research has embellished these theories by documenting a high frequency of traumatic early abandonment, physical abuse, and sexual abuse
    • There is evidence of serotonergic dysfunction in the borderline trait of impulsivity. Structural and functional neuroimaging studies have shown reductions in frontal and orbitofrontal lobe volumes, altered metabolism in prefrontal brain regions, and failure of activation of these brain regions under stress. Because these brain regions are important in serotonergic function and mediate affective control, the observed deficits may be the source of the disinhibited impulses and affects characteristic of patients with BPD. Other studies have shown hyperactivity of the amygdala, which also plays a central role in emotion regulation. Patients with BPD perform poorly in multiple neurocognitive domains, particularly on functions lateralized to the right hemisphere. It is unknown, however, whether neurobiological dysfunctions are due to genetics, pre- or postnatal factors, or adverse events during childhood or are the consequences of the disorder. Thus, although the etiology of BPD has yet to be determined, it is undoubtedly complex and multifactorial.
  • Borderline Personality Disorder: Brain Differences Related to Disruptions in Cooperation in Relationships
    • Different patterns of brain activity in people with BPD were associated with disruptions in the ability to recognize social norms or modify behaviors that likely result in distrust and broken relationships, according to an NIMH-funded study published online in the August 8, 2008 issue of Science .
    • Left: In healthy participants, brain imaging scans show activity in the bilateral anterior insula in response to the amount of offers in an investment-style game. The graph shows an inverse relationship between insula activity and investment amount—high levels of activity in response to low offers, perceived by this brain region as unfair; decreasing response as the investment offer increases.
    • Right: In participants with BPD, activity in the bilateral anterior insula does not have a direct relationship with investment amounts. The findings suggest that either people with BPD are not persuaded by rewards of money in the same ways as healthy people, or that they do not regard low investment offers as a violation of social norms.
  • Course
    • There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age.
    • Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning.
    • Follow-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behavior that meets full criteria for Borderline Personality Disorder.
  • DD OF BPD
    • 1. Histrionic Personality Disorder is not characterized by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness.
    • 2. Paranoid ideation or illusions in Schizotypal Personality Disorder is characterized by paranoid ideation that is less interpersonally reactive and less amenable to the provision of external structure and support.
    • 3. Paranoid ideation or angry reactions to minor stimuli in Paranoid Personality Disorder and Narcissistic Personality Disorder is characterized by relative stability of self-image and relative lack of self-destructiveness, impulsivity, and abandonment concerns.
    • 4. Manipulative behavior in Antisocial Personality Disorder is characterized by manipulative behavior motivated by a desire for power, profit, or material gain rather than a desire for nurturance.
    • 5. Abandonment concerns in Dependent Personality Disorder is characterized by a reaction to the threat of abandonment with increasing appeasement and submission and attempts to seek a replacement relationship to provide caregiving and support.
    • 6. Personality Change Due to a General Medical Condition, Labile Type is characterized by a change in personality related to the direct effects of a general medical condition.
    • 7. Identity problem is characterized by identity concerns that are related to a developmental phase and that are less severe
  • Treatment
    • Borderline patients are high utilizers of psychiatric outpatient, inpatient, and psychopharmacological treatment. The extensive literature on the treatment of BPD universally notes the extreme difficulties that clinicians encounter with these patients. These problems derive from the patients' appeal to their treaters' nurturing qualities and their rageful accusations in response to their treaters' perceived failures. Often therapists develop intense countertransference reactions that lead them to attempt to re-parent or, conversely, to reject borderline patients. As a consequence, regardless of the treatment approach used, personal maturity and considerable clinical experience are important assets.
    • Much of the early treatment literature focused on the value of intensive exploratory psychotherapies directed at modifying borderline patients' basic character structure. However, this literature has increasingly suggested that improvement may be related not to the acquisition of insight but to the corrective experience of developing a stable, trusting relationship with a therapist who fails to retaliate in response to these patients' angry and disruptive behaviors. Paralleling this development has been the suggestion that supportive psychotherapies or group therapies may bring about similar changes. Evidence has provided support for the effectiveness of an 18-month psychoanalytic treatment called " mentalization-based treatment " that took place in a partial hospital setting. In addition, a long-term phased model of psychodynamic therapy that combined hospital-based and community-based strategies was reported to be more effective than hospital-based treatment alone.
  • Treatment
    • At present, treatment of borderline patients typically includes cognitive-behavioral and pharmacological interventions. Studies have shown that behavioral treatment consisting of a once-weekly individual and twice-weekly group regimen can effectively diminish the self-destructive behaviors and hospitalizations of borderline patients. The success and cost benefits of this treatment, called dialectical behavior therapy , have led to its widespread adoption and to modifications that can be used in a variety of settings. Schema-focused therapy is a newer cognitive therapy that has also been shown to be efficacious..
    • Although no one medication has been found to have dramatic or predictable effects, studies indicate that many medications may diminish specific problems such as impulsivity, affective lability, or intermittent cognitive and perceptual disturbances, as well as irritability and aggressive behavior. Most recently, studies have shown efficacy for atypical antipsychotics for dysphoria and aggression and anticonvulsants for anger and aggression. In general, the profusion of treatment modalities and the introduction of empiricism point toward the increasing use of more focused treatment strategies.
  • Psychotherapies
    • General principles that should guide all treatments:
    • Instability of feelings, behaviors, and relationships is the hallmark of borderline psychopathology. Regularity, consistency, and reliability need to be the hallmarks of its treatment.
    • Structure is necessary, and interventions should be explicit and clear. Simple aspects of structure include clarifying and sustaining a treatment frame in which what is expected by the patient and clinician is spelled out and adhered to.
    • Borderline patients need stable relationships to assure themselves of being worthwhile. Helping patients attain stable, supportive involvements is a major goal.
    • Self-destructiveness and suicidality always require attention.
    • "It takes a team." Most treatments are better able to meet patients' needs, decrease countertransference reactions, and diminish therapists' burden when provided by multiple treaters. Such teams communicate, share responsibilities, and cover for each other.
    • Clinicians should identify, confront, and give priority to treatment of a comorbid substance abuse disorder. F/U studies suggest that resolution of a comorbid substance abuse disorder may greatly improve the course of BPD.
  • 1. Individual Psychotherapy
    • Individual psychotherapy is the cornerstone of most treatments for BPD. Studies showed that borderline patients require longer-term therapy to achieve benefits than do other types of patients. Studies found that those who remained in stable psychotherapy for 2 or more years showed more improvement than those who used therapy more intermittently. Despite these observations and regardless of the therapeutic approach or the therapist's level of experience, most individual psychotherapies end with the borderline patient's dropping out. This is usually a result of the patient's sense of being misunderstood or mistreated but can also be caused by antagonism toward therapy on the part of the patient's significant others.
  • Individual Psychotherapy
    • Based on the literature and our clinical experience, the following five simple principles are useful:
    • Provide a stable treatment framework. This starts by establishing agreed-upon roles and goals. The therapist should stress that psychotherapy is a collaborative enterprise.
    • Identify adverse effects of self-destructive behaviors. Although it should be established from the outset that safety is an important issue, it must be made clear to the patient that the therapist is neither omnipotent nor omniscient.
    • Be highly active and involved. Such a stance is essential to elicit a sense of agency and alliance.
    • Establish a connection between actions and feelings using detailed chain analyses.
    • Manage and pay careful attention to the countertransference, a major component of therapeutic intervention in individual psychotherapies. Ongoing discussion of the therapy with colleagues is valuable even for experienced therapists. This concept is built into those therapies that have been empirically validated (e.g., dialectical behavior therapy [DBT] and mentalization-based treatment [MBT], discussed later). Such discussions enhance the therapist's ability to contain and clarify the borderline patients' projections and contain countertransference anger and resentment, which can in turn safeguard against suicidality. In the absence of ongoing discussions with other clinicians, therapists should set a low threshold for seeking consultation.
  • 2. Supportive Psychotherapy
    • Intensive psychotherapies constitute only a small fraction of the treatments actually given to borderline patients. Most borderline patients are seen in supportive psychotherapies, usually once a week or less, in which the primary focus is on the reality problems of daily life, and the patient and therapist have relatively little opportunity to examine and work through developmental issues or transferences. Nevertheless, within this less intensive form of psychotherapy, the same demands for saving interventions and the same accusations of cruel withholding are predictable strains on therapists. Supportive psychotherapy was found to be as effective for a predominantly borderline patient group as a more exploratory interpretive approach. Several studies have made it clear that supportive relationship-building interventions are a usual and probably necessary part of what dynamic therapies include.
    • Supportive therapy is usually expected to last for a long time, sometimes serving maintenance functions punctuated by intermittent phone calls and emergency sessions. The goals of this form of psychotherapy are directed at improving the patient's adaptation to his or her life circumstances and diminishing the likelihood of self-destructive responses to expectable interpersonal frustrations. Usually such therapies taper off into an as-needed schedule.
  • 3. Psychodynamic Psychotherapy
    • The capacity of borderline patients to regress in unstructured therapies explains why formal psychoanalysis is contraindicated for most of these patients. The reason for this relative contraindication is the proclivity for psychotic or regressive transferences and uncontrolled acting-out in an unstructured treatment such as psychoanalysis.
    • Now, however, two forms of psychodynamic therapies (Mentalization-Bas4ed Treatment [MBT] and Transference-Focused Psychotherapy [TFP]) have now received empirical validations in randomized, controlled trials. It is notable that in both instances, there were significantly fewer dropouts (less than 20%) than in usual individual therapies.
  • a. Mentalization-Based Treatment
    • Studies have shown that children fail to develop a coherent or realistic sense of self without sensitive, timely, and accurate responses from their caretakers. Such caretaker responses provide a child with a language to identify feelings, an awareness of his or her effect on others, and a sense that actions (his/her own or others') are motivated. These capacities comprise mentalization.
    • The core psychopathology of BPD is hypothesized to be the inability to mentalize, and the core therapeutic need is to develop these patients' capacity to do so.
    • Studies have shown that patients who received MBT had better social functioning, fewer self-injurious behaviors, and less depression. Moreover, in follow-up after patients left the MBT, these gains continued to grow. At present, MBT is being tested as an outpatient package (without the milieu or expressive therapy components).
    • MBT is conceptually appealing. It bridges psychoanalytic and cognitive therapy approaches, and its effectiveness was established. Still, it remains unclear whether the treatment can be manualized, whether adherence can be measured, and whether its effectiveness is due to the mediating effects on mentalization.
  • b. Transference-Focused Psychotherapy
    • TFP has adopted several goals and recognizes the importance of feeling states (as in both DBT and MBT). Unlike either DBT or MBT, TFP has a much greater focus on identifying the distorted perceptions of relationships and of the therapist and how these perceptions relate to past experience. In this regard, TFP has a closer association with traditional psychoanalytic therapies than does MBT.
  • 4. Cognitive-Behavioral Therapies
    • Cognitive-behavioral therapies for patients with BPD are being developed. This approach postulates that borderline patients have disturbed cognitions ("core beliefs") that developed early in their lives, with maladaptive consequences that are self-perpetuating and are the targets for change. The usual strategies of cognitive or cognitive-behavioral therapy must be modified for borderline patients. Needed modifications include the use of greater flexibility in the therapy and greater attention to the creation and maintenance of an actively collaborative therapeutic relationship.
    • Dialectical Behavior Therapy:
    • DBT includes manualized group and individual therapy components; the group therapy focuses on teaching patients behavioral coping skills, whereas the individual therapy focuses on "coaching" patients to attain the following six goals for change that are arranged with priority:
    • Suicidal behaviors
    • Behaviors that interfere with therapy
    • Behaviors that interfere with quality of life
    • Behavioral skill acquisition
    • Posttraumatic stress behavior
    • Self-respect behaviors
  • Functions of Dialectical Behavior Therapy
    • There are five essential “functions” in treatment:
    • To enhance and expand the patient's repertoire of skillful behavioral patterns
    • To improve patient motivation to change by reducing reinforcement of maladaptive behavior, including dysfunctional cognition and emotion
    • To ensure that new behavioral patterns generalize from the therapeutic to the natural environment
    • To structure the environment so that effective behaviors, rather than dysfunctional behaviors, are reinforced
    • To enhance the motivation and capabilities of the therapist so that effective treatment is rendered.
  • Modes of treatment in DBT
    • 1. Group Skills Training
    • In group format, patients learn specific behavioral, emotional, cognitive, and interpersonal skills. Unlike traditional group therapy, observations about others in the group are discouraged. Rather, a didactic approach, using specific exercises taken from a skills training manual, is used, many of which are geared to control emotional dysregulation and impulsive behavior.
    • 2. Individual Therapy
    • Sessions in DBT are held weekly, generally for 50 to 60 minutes, in which skills learned during group training are reviewed and life events in the previous week examined. Particular attention is paid to episodes of pathological behavioral patterns that could have been corrected if learned skills had been put into effect. Patients are encouraged to record their thoughts, feelings, and behavior on diary cards which are analyzed in the session.
    • 3. Telephone Consultation
    • Therapists are available for phone consultation 24 hours per day. Patients are encouraged to call when they feel themselves heading toward some crisis that might lead to injurious behavior to themselves or others. Calls are intended to be brief and usually last about 10 minutes.
    • 4. Consultation Team
    • Therapists meet in weekly meetings to review their work with their patients. By doing so, they provide support for one another and maintain motivation in their work. The meetings enable them to compare techniques used and to validate those that are most effective.
  • 5. Family Therapy
    • A supportive and educational approach with family members often is needed to ease their wariness and begin the process of developing an alliance.
    • Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue through denial or anger at their parents. Whether denied or reviled, these dependency needs are often being unwittingly reinforced by the family. Such families benefit from active participation in treatment, and their borderline offspring may have a better prognosis.
    • Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing. These approaches use multiple family groups in ways that offer cross-family support and education and are very cost beneficial. Preliminary evidence indicates very positive responses from participants and both better communication and less alienation. These approaches are often very welcome to families, who feel supported and respected. Psychodynamic family therapies for individual families or couples that include the borderline member usually should be reserved for those families or couples that have learned skills of listening and communicating without excessive hostility and that evidence mutually gratifying projective identifications between members.
  • 6. Group Therapy
    • Group therapies are useful for most borderline patients despite their usual resistance to entering them and their frequent difficulties in remaining in them. The chances of doing so are enhanced if participation is strongly urged from the beginning by concurrent individual therapists. Concurrent group and individual therapies exemplify a split treatment, which creates a holding environment where a borderline patient can be angry (have a "bad object") without needing to leave treatment. The fact that both DBT and MBT comprise individual and group therapy components helps account for their effectiveness and low dropout rates.
    • The presence of peers in a therapy group has several benefits not available in individual therapy. Peers are more able than a therapist to confront maladaptive and impulsive patterns without being dismissed as trying to control the patient. Groups are also very effective in identifying dependent needs or manipulative behaviors and making them more syntonic and dystonic, respectively. At the same time, the group provides a set of peers with whom feelings and personal problems can be communicated without harmful repercussions. Groups provide a field to study others' methods of coping, and borderline patients often find that it is easier to identify a maladaptive pattern of coping in another person than in themselves. Groups also provide a social networking function that may extend to the development of new and better relationships outside of, as well as within, the therapy.
  • Pharmacotherapy
    • Evidence and opinion continue to support the recommendation of the 2001 APA practice guideline that psychotherapy represents the primary, or core, treatment for this disorder and that adjunctive, symptom-targeted pharmacotherapy can be helpful.
    • Three classes of medications emerge as the most useful in treating BPD: serotonin reuptake inhibitors (fluoxetine, fluvoxamine), mood stabilizers (depakote for impulsivity and hyperactivity) and atypical antipsychotics (olanzapine usually 7.5 mg po bedtime for impulsivity and aggression). Dosing guidelines are not entirely clear because most trials aim to minimize possible undertreatment and tend to use relatively high dosages. Therefore, selective serotonin reuptake inhibitors (SSRIs) may be efficacious at lower dosages than the 60 or 80 mg/day fluoxetine target dosages that have been studied. There are also no guidelines for targeted blood levels of valproate in treating BPD, although a recent large trial reported efficacy at a mean endpoint blood level of 66 g/mL. In clinical settings, it makes sense to start with lower doses because these are generally better tolerated and gradually increase the dosage while carefully monitoring response to increasing dose. Symptoms of the disorder are often chronic and by their nature considerably fluctuating; thus, the effect of each medication and dose can be more reliably assessed over longer rather than shorter durations.
  • References
    • The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., and Glen O. Gabbard, M.D.
    • Gabbard's Treatments of Psychiatric Disorders, 4th Edition Glen O. Gabbard, M.D., Editor-in-Chief
    • DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision
    • DSM-IV-TR® Handbook of Differential Diagnosis Michael B. First, M.D., Allen Frances, M.D., and Harold Alan Pincus, M.D.
    • APA practice guidelines: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder John M. Oldham, M.D., M.S.
    • Kaplan & sadock’s synopsis of psychiatry 10th edition
    • King-Casas B, Sharp C, Lomax-Bream L, Lohrenz T, Fonagy P, Montague PR. The Rupture and Repair of Cooperation in Borderline Personality Disorder . Science . 2008 Aug 8;321(5890):806-10.