New perspectives in borderline personality disorder


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أ.د/ أماني هارون

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  • Als psychisch gesund mit positiver Persönlichkeitsentwicklung wäre eine Person zu bezeichnen, die sich – je nach Lebenskontext und Lebensanforderung – aller acht Bedürfnisaspekte bzw. Polaritäten situationsspezifisch und funktional bedienen wird. (131) Zwei Zielkonstrukte: a) sozialbezogene Autonomie b) erfahrungsoffene Selbstsicherheit Therapeutische Vorschläge (Millon 1996): 1. Bringe die extremen Pole ins Gleichgewicht 2. Wirke den wiederholten dysfunktionalen Mustern entgegen 3. Ergreife praktische Schritte (Tactical Modalities) Das Gute, das ich tun will, tue ich nicht Take-Home-Messages 1. in uns allen schlummern Regungen und unerfüllte Wünsche, die uns oft nicht so reagieren lassen, wie wir möchten (Römer 7) 2. Nicht nur auf die Schwächen schauen – auch die Stärken sehen. 3. Anreichern der Persönlichkeit mit anderen Anteilen – welche Anteile möchte ich bei mir verstärken? 4. Wir leben nicht allein – persönliche Nische (Willi) – Spannungsfeld Person – Ideal – Umgebung – Realität. 5. Lernen Spannungen auszuhalten und eine persönliche Mitte finden. – hier vielleicht geistliche Ansätze.
  • cognition - ways of perceiving and interpreting self, others and events affectivity - range, intensity, lability, appropriateness of emotional response
  • Dynamics are not pathology An obsessive man organises his life around thinking, achieving self-esteem in areas such as scholarship, logical analysis, planning, decision making. A pathologically obsessive man ruminates unproductively, accomplishing no objective, realising no ambition, hating himself for going in circles. You can change economics, but not dynamics.
  • Neurotic compulsive will be embarrassed to admit how often she washes the sheets. A borderline or psychotic woman will feel that anyone who washes them less often is unclean, or deficient in common sense or moral decency. Borderline - Primitive defenses, such as denial and splitting reduce reality testing in specific instances
  • New perspectives in borderline personality disorder

    1. 1. Borderline Personality Disorder Prof. Amany Haroun El Rasheed Ain Shams Univ., Cairo, Egypt M.N.P., D.P.P., M.D. Master in Mental Hygiene (Johns Hopkins Univ.)Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.) APA Membership ISAM Membership WPA Fellowship FRC Psych
    2. 2. What is a healthy personality? SHORT FORMULA: ability to enjoy, to relate and to work. Psychologically healthy with a positive development is a person who is able to utilize eight aspects or polarities – depending on life context or requirement – in a way that is situational or functional. (Fiedler)
    3. 3. Eight Modalities of Personal Functioning  Individuality, Independence.  Relationship, Attachment, Security.  Spontaneity, Desire for New Experiences.  Stability, Self control.  Wellbeing, Pleasure.  Allowing and accepting pain, Melancholy  Actively structuring life − Manipulation.  Passive Receiving, letting things happen.
    4. 4. Common Themes in Normality strength of character  ability to experience ability to learn from pleasure without experience conflict ability to work  flexibility/ability to ability to achieve adjust insight  ability to laugh absence of  ability to love another symptoms/conflict  degree of acculturation
    5. 5. Where is the line? It’s all a matter of degree and which traits:e.g. To be a successful pilot, a person must have a degree of narcissism (healthy sense of self-confidence) and obsessive compulsive (attention to detail, conscientious).
    6. 6. See the whole person Therefore,don’t rely on a single, “slice- in-time” conclusion when considering traits The most normal person can look pretty disordered at times when stressed
    7. 7. Characteristics of Personality Disorders An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.
    8. 8. Personality Disorders: Facts and Statistics Prevalence of Personality Disorders  About 0.5% to 2.5% of the general population  Rates are higher in inpatient and outpatient settings Gender Distribution and Gender Bias in Diagnosis  Gender bias exists in the diagnosis of personality disorders  Such bias may be a result of criterion or assessment gender bias
    9. 9. Personality Disorders: Facts and Statistics Originsand Course of Personality Disorders  Thought to begin in childhood  Tend to run a chronic course if untreated Co-Morbidity Rates are High (depression, anxiety)
    10. 10. Personality Disorders: Facts and Statistics Rates of personality disorder in the general population (Coid et al 2006) - 4-5% Rates of personality disorder in young adults, 24-25 years old (Moran et al 2006) – 18.6% Rates of personality disorder among self- harm patients (Haw et al 2001) – 47%
    11. 11. What is Personality? Personality lies along a continuum from healthy to pathological Itis founded on particular adaptations or arrests at various stages along the developmental path
    12. 12. Character structures/personality traits Result in distinct clusters of defenses, character structures, or personality traits These persist over time, become internalised and repeat as scripts They serve to assist us in managing anxiety and self-esteem
    13. 13. Character structures/Personality TraitsEnduring patterns of: Perceiving Relating to Thinking about oneself and the environment In a wide range of social and personal contexts
    14. 14. Not accounted for by: Culture Religious beliefs Immigration Stressful events Axis I disorders Medical condition Communication, autistic or developmental disorder
    15. 15. EffectsTwo or more of the following: Cognition Affectivity Interpersonal functioning Impulse control
    16. 16. Functional Assessment Motivation - What is wished for, feared, valued? Cognitive functioning - functioning, style, coherence, belief systems Affective functioning - intensity, lability, experience of affect, capacity for ambivalence Affect regulation - coping strategies, defenses, repertoire
    17. 17. Functional Assessment Experience of self - continuity, coherence, agent, self-esteem, ideals, self presentation, identity Experience of others - wishes, fears, schemas Capacity for relatedness Management of aggression Emotional developmental history
    18. 18. When is personality pathological? Where defenses become so rigid and inflexible that they are not adaptive Reality is distorted Psychological growth is prevented NB These were adaptive in early life
    19. 19. Personality Disorder Clusters Personality disorders fall into three general clusters:  Persons in cluster A seem odd or eccentric  Paranoid, schizoid, schizotypal  Persons in cluster B seem dramatic, emotional or erratic  Antisocial, borderline, histrionic, narcissistic  Persons in cluster C appear as anxious or fearful  Avoidant, dependent, obsessive-compulsive
    20. 20. Dimensions Dsm-iv: Emotional Cluster A – Odd or eccentric cluster (e.g., Dramatic paranoid, schizoid) Cluster B – Dramatic, emotional, erratic cluster (e.g., antisocial, borderline) Cluster C – Fearful or anxious cluster (e.g., avoidant, obsessive-compulsive) oDD ExcEntric anxious FEarFul avoiDant
    21. 21. Three Major Brain Systems Influencing Stimulus – Response Characteristics Brain System Principal Relevant Stimuli Behavioral(Related Personality Monoamine Response Dimension) NeuromodulatorBehavioral Dopamine Novelty Exploratoryactivation pursuit(novelty seeking) Potential reward Appetitive approach Potential relief of Active avoidance, monotony or escape punishmentBehavioral inhibition Serotonin Conditioned signals Passive(harm avoidance) for punishment, avoidance, novelty, or extinction frustrative nonrewardBehavioral Norepinephrine Conditioned signals Resistance tomaintenance for reward or relief extinction(reward of punishmentdependence)
    22. 22. Cloninger’s Seven-Factor Model Temperament Domains (Moderately heritable, not greatly influenced by family environment) a. Novelty Seeking b. Harm Avoidance c. Reward Dependence d. Persistence2. Character Domains (Moderately influenced by family environment, only weakly heritable) a. Self-transcendence b. Cooperativeness c. Self-directedness
    23. 23. DSM-IV Definition of Personality Disorder An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:  Cognition (i.e., ways of perceiving and interpreting self, other people, and events)  Affectivity (i.e., the range, intensity, ability, appropriateness of emotional response)  Interpersonal functioning  Impulse control The Enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
    24. 24. DSM-IV Definition of Personality DisorderC. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
    25. 25. Impulsive DisordersAxis II Borderline Personality Disorder Antisocial Personality DisorderAxis I Psychoactive Substance Use Disorder Bulimia Paraphilias Impulsive Control Disorder NEC
    26. 26. Levels of personality functioning Neurotic - stable, continuous, integrated identity, with mature and flexible defenses, good reality testing Borderline - unstable, inconsistent, discontinuous identity, primitive defenses, adequate reality testing Psychotic - fragmented, confused, disorganised identity, primitive defenses, poor reality testing
    27. 27. Concepts of Borderline DisordersBorDErlinEschizophrEnia(KEty) aFFEctivE atypical(schizotypal schizophrEnia DisorDErs aFFEctivEpD - raDo, DisorDErsmEEhl) (D.KlEin) BorDErlinE BorDErlinE pErsonality pErsonality organization DisorDEr (KErnBErg) BorDErlinE synDromE (grinKEr) nEurosE s
    28. 28. Aspects of Levels of Personality Organization Borderline Neurotic Normal Organization Orgaization OrgaizationIdentity Incoherent sense Coherent sense Integrated sense of self and of self and of self and others; poor others; others; investment in investment in investment in work, leisure work, leisure work, leisureDefenses Use of primitive Use of more Use of more defenses advanced advanced defenses; rigidity defenses; flexibilityReality testing Variable empathy Accurate Accurate with social perception of perception of criteria of reality; self vs, non-self self vs, non-self lack of subtle internal vs internal vs tactfulness external; external; empathy with empathy with social criteria of social criteria of reality. reality.
    29. 29. Aspects of Levels of Personality Organization Borderline Neurotic Normal Organization Orgaization OrgaizationAggression Self-directed Inhibited Anger aggression; aggression; modulated; some with angry appropriate aggression outbursts self-assertion toward others; followed by hatred in guilt severe casesInternalized Contradictory Excessive Stable,values value system; guilt feelings; independent, incapacity to some individualized. live up to own inflexibility in values, dealing with significant self absence of certain values
    30. 30. Aspects of Levels of Personality Organization Borderline Neurotic Normal Organization Orgaization OrgaizationObject Troubled Some degree Lasting andrelations interpersonal; of sexual deep relations absence of or inhibition, or with others; chaotic sexual difficulties in sexual relationships; integrating sex intimacy confused with love; deep combined internal working relations with with models of other, with tenderness; relationships; specific coherent severe focused working interference with conflicts with models of love relations selected others relationskips
    31. 31. stpD mDD Bip-ii ptsD sEvErity spD oF social aspDDysFunction BpD avpD npD hpD
    32. 32. Basic Beliefs and Strategies Associated with Traditional Personality DisordersPersonality Basic Strategy (overtDisorder Beliefs/Attitudes behavior)Dependent “I am helpless” AttachmentAvoidant “I may get hurt” AvoidancePassive- “I could be controlled” ResistanceAggressiveParanoid “People are dangerous” WarinessNarcissistic “I am special” Self-aggrandizementHistrionic “I need to impress” DramaticsObsessive- “I must not err” PerfectionismCompulsiveAntisocial “Others are to be AttackSchizoid taken” a plenty of “I need Isolation space”
    33. 33. Typical Overdeveloped and Underdeveloped StrategiesPersonality Overdeveloped UnderdevelopedDisorderObsessive- Control- responsibility- Spontaneity- playfulnesscompulsive systematizationDependent Help-seeking – clinging Self-sufficiencyPassive- Autonomy- resistance- Intimacy- assertiveness-aggressive passivity- sabotage activity- cooperativenessParanoid Vigilance- mistrust- Serenity- trust- acceptance suspiciousnessNarcissistic Self-aggrandizement- Sharing- group identification competitivenessAntisocial Combativeness- Empathy- reciprocity- social exploitativeness- predation sensitivitySchizoid Autonomy- isolation Intimacy- reciprocityAvoidant Social vulnerability- avoidance- Self-assertion inhibitionHistrionic Exhibitionism- expressiveness- Reflectionism- control- impressionism systematization
    34. 34. Borderline Personality Disorder
    35. 35. Epidemiology 2 % of the general population Females 4 times the rate of males 11 % of psychiatry outpatients 25 % of acute psychiatry inpatients 50 % of long term psychiatry inpatients 60 % with co-existing Major Depressive Disorder 7% complete suicide. ( 7 X General population) up to 75% attempt suicide 69-80% self-mutilate
    36. 36. Interface with Health Care System Inpatient Psychiatric Units  Top diagnosis for re-admissions to psych hospitals Emergency Rooms  Cutting, burning, suicidal threats Intensive Care Units and medical inpatient units  Overdoses and other sequelae of suicidal or parasuicidal behavior Outpatient primary care setting  Psychosomatic complaints  Doctor shopping
    37. 37. Borderline: On the “borderline” between“neurosis” and “psychosis”Not an accurate term though – and not relevantto current nosologyCurrent trend is to call it “Emotional IntensityDisorder”Better accepted by patients – more meaningful
    38. 38. Four Categories for Borderline Symptoms Poorly regulated emotions  Mood swings and unstable emotions  Anxiety  Inappropriately intense anger  Difficulty controlling anger  Chronic feelings of emptiness Impulsivity  Reckless behavior  Suicidal behavior and self harm  Munchausen’s Syndrome and by Proxy  Suicide
    39. 39. Four Categories for Borderline Symptoms Impaired perception or reasoning  Paranoid thinking  Dissociative episodes  Depersonalization  Unstable self image or sense of self Markedly disturbed relationships  Intense and unstable interpersonal relationships  Black and white thinking  Frantic efforts to avoid real or imagined abandonment
    40. 40. Can look like….. Schizophrenia  hallucinations, illusions, paranoia Bipolar Affective Disorder  mood lability and anger Major Depressive Disorder  suicidal, depressed Antisocial Personality Disorder  legal problems
    41. 41. Constituent Elements of Borderline Personality Organization (BPO) Patients with BPO are characterized by diffuse identity, the use of primitive defenses, generally intact yet fragile reality testing, impairments in affect regulation and in sexual and aggressive expression, inconsistent internalized values, and poor quality of relation with others. Clinically, the lack of integration of these internal representations of self and others becomes evident in the patient’s non-reflective, contradictory, or chaotic descriptions of self and others and in the inability to integrate or even to become aware of these contradictions. This lack of integration has a fundamental impact on the individual’s experience in the world.
    42. 42. Cluster B Personality Disorders and Development Development of Typical Development of Borderline/ Antisocial/NarcissisticDevelopment Histrionic Personality Personality Disorders Disorders self self self world and world and world and others others others
    43. 43. Cluster B Personality Disorders and Development Development of Development ofBorderline/Histrionic Antisocial/NarcissisticPersonality Disorders Personality Disorders self self world and world and others others
    44. 44. Constituent Elements of Borderline Personality Organization (BPO) Behavioral correlates of this borderline psychic structure include emotional lability, anger, interpersonal chaos, impulsive self- destructive behaviors, and proneness to lapses in reality testing. A typical specific manifestation in this diffuse and fragmented identity is the oscillation between helplessness and a rageful, tyrannical aggression directed toward oneself or others.
    45. 45. Constituent Elements of Borderline Personality Organization (BPO) Primitive defenses are organized around splitting, the radical separation of good and bad affects and of good and bad objects. These defense mechanisms represent attempts to protect an idealized segment of the individual psyche, or internal world, from an aggressive segment. This separation is maintained at the expense of integration of the images in the psyche.
    46. 46. Constituent Elements of Borderline Personality Organization (BPO) S+S- S+S- O+O- O+O- O+O- O+O- S+S- S+S-NORMAL ORGANIZATIONConsciousness of integration/complexity
    47. 47. Constituent Elements of Borderline Personality Organization (BPO) S- S- S+ S+ O- O+ O- O+SPLIT ORGANIZATIONConsciousness of all-good or all-bad
    48. 48. Constituent Elements of Borderline Personality Organization (BPO)Reality Testing Individuals with BPO may lack subtle tactfulness in social interactions, particularly under stress. For example, under stress, those with BPO more easily regress to paranoid thinking.
    49. 49. Borderline Personality Disorder Etiology
    50. 50. EtiologyMultiple risk factors: Biological  Temperament abnormalities (heritable)  Decreased serotonin activity Psychological  Trauma  Emotional neglect Social  Lack of support/emotional security Linehan’s theory – emotional invalidation  Invalidating environment
    51. 51. Etiology of BPDType 1: Affective (Akiskal, Klein) **A moderately heritable “subaffective” vulnerability, precipitated by environmental stressPrototypic Criteria: #6: affective instability due to marked reactivity of mood (dysphoria or anxiety); #5: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
    52. 52. Etiology of BPDType 2: Impulsive (Zanarini, Hollander, Siever) **A moderately heritable impulse spectrum disorder, precipitated by environmental stressPrototypic Criteria: #4: impulsivity in at least two areas that are potentially self-damaging; #5: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
    53. 53. Etiology of BPDType 3: Aggressive (Kernberg) **A primary moderately heritable aggressive temperament, or a secondary reaction to early trauma and/or abusePrototypic Criteria: #8: inappropriate, intense anger or difficulty controlling anger; #6: affective instability due to marked reactivity of mood (irritability)
    54. 54. Etiology of BPDType 4: Dependent (Masterson and Rinsley; Gunderson) **intolerance of aloneness, and impaired autonomy, possibly secondary to parental separation-resistancePrototypic Criteria: #1: frantic efforts to avoid real or imagined abandonment; #6: affective instability due to marked reactivity of mood (anxiety)
    55. 55. Etiology of BPDType 5: Empty (Mahler; Adler and Buie) **failure to develop an evocative memory secondary to lack of empathy and inconsistency in early parentingPrototypic Criteria: #7: chronic feelings of emptiness; #3: identity disturbance: markedly and persistently unstable self-image or sense of self
    56. 56. Genetic and Biological Factors Genetics a modest contributor of BPD Diagnosis but may be more salient for specific symptoms of BPD Reduced serotenergic activity in 5-HT system inhibits ability to modulate or control impulsive and aggressive behavior  Differences b/w BPD and nonBPD patients in serotenergic functioning  Repeated exposure to stress may blunt serotenergic activity (frequent increases in cortisol)  Stress  frequent increases in cortisol  blunting of serotenergic activity  emotion dysregulation  Limitations  Lack of specificity for serotonin (i.e., MDD w/out impulsivity)  Pharmacology targeting serotonin has limited efficacy in treating BPD
    57. 57. NeurobiologyRisk factors: Diminished serotonergic function in the prefrontal cortex  Potential biological risk factor for disinhibition, impulsivity, and affect dysregulation. Dysfunction in the cortical-striatal- thalamic-frontal network  behavioral control
    58. 58. Frontolimbic Circuitry Prefrontal and limbic systems mediate the processing of and responses to emotional stimuli
    59. 59. Trauma Childhood Sexual Abuse (CSA)  Historically considered a significant risk factor for BPD  75% of patients with BPD have a hx of CSA but… only 90% of CSA victims have BPD Limitations  Current evidence suggests that emotion dysregulation mediates the relationship between CSA and BPD  Role of physical and emotional abuse which co- occurs with CSA?
    60. 60. Link with Childhood Trauma Many people with personality disorder report a history of childhood abuse or neglect Children who are physically abused, sexually abused, or neglected are significantly more likely to develop a PD as a young person Sexual abuse [usually with emotional abuse and neglect] is most strongly associated with BPD in particular In BPD, childhood trauma may still be affecting the individual as an adult, to an extent that impairs daily functioning Johnson JG et al. Arch General Psychiatry 1999
    61. 61. Family Interactions Neglect Emotional uninvolvement Invalidation
    62. 62. Emotion Regulation “processby which individuals influence which emotions they have, when they have them, and how they experience and express these emotions.”
    63. 63. Emotion Dysregulation Vulnerability to negative emotion  High sensitivity, reactivity, and slow return to baseline  Influences emotional arousal Poor coping skills  Inability to: manage social interactions, awareness of relevant stimuli, identify and label emotional experiences, manage arousal Maladaptive responses to others expressions of emotion  Wants, thoughts, goals. Others responses often trigger emotional arousal
    64. 64. Emotion Vulnerability Heightened emotional sensitivity Emotion reactivity Slow return to baseline
    65. 65. Invalidation Validation  Convey legitimacy and acceptance of the other’s experience or behavior Invalidation  Delegitimize valid experiences or fail to acknowledge their existence and/or legitimacy
    66. 66. Invalidating environmentPervasively negates or dismissesbehavior independent of the actual validity of the behavior
    67. 67. Invalidating Family Environment Invalidation of…  Emotions, thoughts, desires  Over public behavior  Difficult tasks, developmental milestones  Sense of self and self initiated behavior
    68. 68. Risk Factors for Invalidation Unexpected experience or behavior Behavior creates unwanted demands Caretaker has insufficient ability to help or understand
    69. 69. Invalidating responses - examples- rejects self-description as inaccurate- rejects response to events as incorrect or ineffective- dismiss or disregard- directly criticize or punish- neglect- pathologize normal responses- reject response as attributable to sociallyunacceptable characteristic
    70. 70. Linehan Biosocial TheoryEmotion Vulnerability Pervasive History of Invalidating Responses Heightened Emotional Arousal Inaccurate Expression (maladaptive behavioral responses) Invalidating Responses (Fruzzetti, Shenk, & Hoffman, 2005)
    71. 71. Linehan’s Diathesis-Stress theory: Etiology of borderline personality disorder•Emotional dysregulation in child (diathesis) and a failure to validate the child’s feelings by the parents (stress) leads to a vicious cycle. –The emotional dysregulation may be inadvertently reinforced by parents if it becomes one of the only times the child receives parental attention.
    72. 72. Linehan’s Theory Emotional invalidation:  Emotionally vulnerable individual + invalidating environment = BPD  Limited opportunity to learn to label, understand or trust own feelings  Looks to others for how to cope  Oscillatesbetween emotional inhibition to gain acceptance and emotional disinhibition to have feelings acknowledged  Intermittent reinforcement = emotional dysregulation
    73. 73. Consequences of Invalidation Heightened emotional arousal Cognitive and attentional dysregulation Emotion skill deficits Secondary emotions Emotion dysregulation Passivity in problem solving Self-invalidation Social and interpersonal dysregulation
    74. 74. Borderline Personality Disorder Diagnosis – DSM-IVA pervasive pattern of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood. Includesat least 5 of the following diagnostic criteria:
    75. 75. DSM IV - What is Borderline Personality Disorder ?• 1. frantic efforts to avoid real or imagined abandonment.•
    76. 76. Abandonment Issues The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self- image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans, These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors
    77. 77. Diagnostic Criteria - more• 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
    78. 78. More……3.. identity disturbance: markedly and persistently unstable self-image or sense of self
    79. 79. Identity Disturbance?iDEntity DisturBancE – oFtEn DEscriBED as“splitting”From the book I Hate You, Dont Leave Me by Jerry Kreisman, M.D.The world of a BP, like that of a child, is split into heroes andvillains. A child emotionally, the BP cannot tolerate humaninconsistencies and ambiguities; he cannot reconcile another’sgood and bad qualities into a constant coherent understandingof another person. At any particular moment, one is eitherGood or EVIL. There is no in-between; no gray area....peopleare idolized one day; totally devalued and dismissed the next.….Splitting is intended to shield the BP from a barrage ofcontradictory feelings and images and from the anxiety oftrying to reconcile those images. But splitting often achievesthe opposite effect. The sense of his own identity and theidentity of others shifts even more dramatically and frequently
    80. 80. More DSM IV Criteria: 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
    81. 81. More DSM IV5. recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior
    82. 82. More…..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)
    83. 83. More DSM IV Criteria: 7. chronic feelings of emptiness
    84. 84. More….. 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
    85. 85. Miscellaneous attributes Bright, funny, witty Problems with object constancy Difficulty in tolerating aloneness Chaotic lives Backgrounds of abuse
    86. 86. CAUTION! Everyone has all these traits to a certain extent. Especially teenagers. These traits must be long-standing (lasting years) and persistent. And they must be intense. Many people who have BPD also have other concerns, such as depression, eating disorders, substance abuse — even multiple personality disorder or attention deficit disorder. It can be difficult to isolate what is BPD and what might be something else.
    87. 87. BPD in Adolescents vs Adults Problems with diagnosing BPD in adolescents  Pejorative label – stigmatizing  May end up “growing out of it”  Symptoms less stable in teens  Can improve with treatment
    88. 88. The Course of BPD Usually begins in adolescence 80% women Severe, chronic 1 in 10 suicide Impulsivity & emotional instability tend to decline over time
    89. 89. Co-Morbid Disorders Post traumatic stress disorder Mood disorders Panic/anxiety disorders Substance abuse (54% of BPs have a problem with substance abuse) Gender identity disorder Attention deficit disorder Eating disorders Multiple personality disorder Obsessive-compulsive disorder
    90. 90. Co-Morbid Disorders- continued Highest incidence of co-morbid disorders: mood and anxiety disorders (including PTSD) *Gunderson (2001) study And… problems in managing mood and anxiety problems through dissociation, substance abuse, eating disorders. 90-97% of BPD met criteria for other Axis II personality disorders (avoidant, paranoid and dependent were highest).
    91. 91. Borderline Personality Disorder Reorganized Emotional dysregulation - affective instability - problems with anger Interpersonal dysregulation - chaotic relationships - fears of abandonment Self dysregulation - identity disturbance/difficulties - sense of emptiness
    92. 92. Borderline Personality Disorder Reorganized Behavioral dysregulation - parasuicidal behavior - impulsivity Cognitive dysregulation - dissociative responses - paranoid ideation
    93. 93. “Living on the Edge”Borderline Personality Disorder Dr. Bob Carey Regional Support Associates
    94. 94. The Inside Perspective –Living on the Edge as a Borderline Personality Being a borderline feels like eternal hell. Nothing less. Pain, anger, confusion, hurt, never knowing how Im gonna feel from one minute to the next. Hurting because I hurt those who I love. Feeling misunderstood. Analyzing everything. Nothing gives me pleasure. Once in a great while I will get "too happy" and then anxious because of that. Then I self-medicate with alcohol. Then I physically hurt myself. Then I feel guilty because of that. Shame. Wanting to die but not being able to kill myself because Id feel too much guilt for those Id hurt, and then feeling angry about that so I cut myself or O.D. to make all the feelings go away.”
    95. 95. Borderline PD in the Media Princess Diana?
    96. 96. PharmacotherapyB Type 1 (Affective)P Type 2 (Impulsive)D Type 3 (Aggressive)Ty Type 4 (Dependent)pe Type 5 (Empty) Psychotherapy 96
    97. 97. Common Features of Recommended Psychotherapy for BPD Non-brief Strong therapeutic alliance Establishment of clear roles and responsibilities of patient and therapist Active therapist Hierarchy of priorities
    98. 98. Common Features of Recommended Psychotherapy for BPD Empathic validation + need for patient to control behavior Flexibility Concomitant individual and group approaches Boundary Setting
    99. 99. Common Features of Recommended Psychotherapy for BPD Monitor self-destructive & suicidal behaviours Manage own intense feelings Promote reflection rather than impulsive action Diminish splitting Set limits on individual’s self-destructive behaviour and, if necessary, convey the limitations of the therapists capacities
    100. 100. General tips for working withpeople with BPD Regularly discuss person with your colleagues and supervisor Support colleagues working with BPD clients Ensure the person gets a comprehensive assessment; identify and manage co-morbid problems (eg. depression)
    101. 101. General tips for working withpeople with BPD Focus on solving non-medical problems (eg. employment, budgeting, self care) Agree among colleagues on protocols for managing crises Become familiar with guidelines for managing anger or violent behaviour Recognise your own limits for personal involvement
    102. 102. Boundaries Howdo these individuals push the boundaries? How do you respond?
    103. 103. Splitting/boundaries Facilitate communication among providers Consider altering treatment (e.g., increasing support, seeking consultation) Be explicit in establishing “boundaries” Maintain consistency Avoid boundary violations
    104. 104. Boundary Crossings Explore the meaning of the boundary crossing Restate expectations about boundary and rationale Employ limit-setting Making exceptions to the usual boundaries may signal need for consultation or supervision
    105. 105. The Effectiveness of Psychodynamic Therapyand Cognitive Behavior Therapy in theTreatment of Personality Disorders: A Meta-Analysis Both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality disorders (mean follow- up period = 1.5 years [78 weeks] vs CBT mean follow-up = 13 weeks) lEichsEnring F, lEiBing E, am J psychiatry 2003; 160:1223-1232
    106. 106. Hierarchy of Priorities in Therapeutic SessionsDialectical Behavior Therapy Psychoanalytic/Psychodynamic Therapies (Linehan 1993) (Kernberg et al. 1989; Clarkin et al. 1999) Suicide or homicide threats Suicidal behaviors Overt threats to treatment continuity Therapy-interfering Dishonesty or deliberate withholding behaviors Contract breaches Behaviors quality-of-life In-session acting out interfering Between-session acting out Non-affective or trivial themes
    107. 107. thanK you