BORDER LINE PERSONALITY BY EMADULLAH SHAFIRAK MEDICAL AND HEALTH SCIENCES UNIVERSITY, UAE
A CASE OF BPDSusan, 28 yrs old female, She experienced a troubled childhood,including her father dying when she was 4 and her mother marryinga man who sexually abused SusanShe went to school, did well. Once out of school she ran into manyproblems. Colleagues and employers did not like her moodiness,she was inappropriately seductive at timesHer greatest difficulty occurred in her relationships. Fairlyattractive, she never had any trouble attracting men. However, herrelationships became stormy and self destructive
She would rapidly get very angry when her BF wasn’t available toher. When her most recent boyfriend went to visit his parents shebecame so angry that she found a man at a bar and spent theweekend with him.The first night she met a man, she would idealize him, share everybit of her history. And after somedays she would hate himAt times this woman would feel she did not exist and would cut herarms in dissociative episodes. She could never tolerate beingalone, she would feel bored, empty and desperately throw herselfinto some risky activitySince finishing college she has chosen various paths. Went to lawschool, dropped out. Worked for a magazine and she quit.Sometimes she feels rage at her mother for not protecting her andat times she idealizes her
WHY THE TERM “BORDERLINE”• Adolf stern in 1938 used the term “borderline”. It described a group of patients who were on a borderline between neurosis and psychosis. He thought this as a mild form of schizophrenia• Current trend is to call it “Emotional Intensity Disorder”• Better accepted by patients – more meaningful
EPIDEMIOLOGY• 1 to 2 percent in General population• Three times more often in women then men• A study done on 35,000 subjects in 2008 stated lifetime risk of BPD as 5.9%• 20 % of the inpatients and 10 % of the outpatients in Psychiatry
ETIOLOGY• Reduced serotenergic activity in 5-HT system inhibits ability to modulate or control impulsive and aggressive behavior • Differences b/w BPD and non BPD 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
TRAUMA• Childhood Sexual Abuse (CSA) • Historically considered a significant risk factor for BPD • 75% of patients with BPD have a hx of CSA
FAMILY INTERACTIONS• Neglect• Emotional uninvolvement
CO MORBIDITY• These patients are at increased risk for major depression, substance abuse or dependence, eating disorder (notably bulimia), posttraumatic stress disorder (PTSD)• Borderline personality disorder cooccurs with most other personality disorders.
FEATURES OF BPD• Splitting – Patient divides people into two categories, those who hate him and those who like him. These feelings are changeable• Projective identification – the patient attributes a positive or negative attitude towards a person and seeks to engage this person in various interactions that will confirm a person’s belief• Patient has intense aggressive need• Patient has a marked fear of abandonment• Turning against self is prominent• Identity disturbance
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
• 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
CAN LOOK LIKE…..• Schizophrenia • hallucinations, illusions, paranoia• Bipolar Affective Disorder • mood lability and anger• Major Depressive Disorder • suicidal, depressed• Antisocial Personality Disorder • legal problems
DIFFERENTIALS OF BPD• Psychotic disorder – impaired reality testing persists• Mood disorder – the mood disturbance is non reactive. Can be difficult to differentiate from Major depressive disorder with atypical features• Personality change secondary to a GMC – results of medical tests are positive• Schizotypal personality disorder – affective features are less severe
DIFFERENTIALS OF BPD CONTD.• Antisocial personality disorder – attachment ability is more severe• Histrionic personality disorder – suicide and self-mutilation is less common. Also these patients tend to have more stable interpersonal relationships
DSM-IV DIAGNOSTIC CRITERIAA pervasive pattern of instability of interpersonal relationships, self-image, and affects,and marked impulsivity beginning by early adulthood and present in a variety ofcontexts, as indicated by five (or more) of the following:1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidalor self-mutilating behavior covered in Criterion 5.2. A pattern of unstable and intense interpersonal relationships characterized byalternating between extremes of idealization and devaluation3. Identity disturbance: markedly and persistently unstable self-image or sense of self4. 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 orself-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilatingbehavior6. Affective instability due to a marked reactivity of mood (e.g.,intense episodic dysphoria, irritability, or anxiety usually lasting a fewhours and only rarely more than a few days)7. Chronic feelings of emptiness8. 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 dissociativesymptoms
PHARMACOTHERAPY• In controlling anger, psychotic episodes – Anti psychotics• For depressed mood and anxiety– Antidepressants particularly Alprazolam(Xanax) but some patients show disinhibition with these drugs• MAOI – in modulating impulsive behavior• To improve global functioning – Carbamazepine(tegritol)• Fluoxetine have proved to be useful
PSYCHOTHERAPY – TREATMENT OF CHOICE• Difficult for the therapist and the patient• More difficult for the therapist Patient’s impulsive behavior Projective identification • Social skills training is very important in improving the patient’s interpersonal relationships
COGNITIVE BEHAVIORAL THERAPY• Cognitive therapy refers to an approach that focuses on a person’s cognitions i.e their thoughts, assumptions, and beliefs.• The patient learns to recognize and change faulty or maladaptive thought patterns• Behavioral therapy focus on changing a person’s unhealthy and problematic behaviors, actions, and responses• Focus is not on “WHY” something happens, but changing the process to prevent, alter, or replace it with a healthier more effective behavior
DIALECTICAL-BEHAVIORAL THERAPY• Targets suicidal and parasuicidal behaviors and thoughts• Focused on improving motivation for skillful behavior through management of issues and problems as they come up in day to day life• Recent studies have shown subjects receiving DBT were half as likely to make a suicide attempt, required fewer hospitalizations for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined.
• Transference-focused Psychotherapy - aims to correct distortions in the patients perception of others• Mentalization therapy - focuses the ability to perceive the mind of others as distinct from ones own and hence to reconsider and reassess ones own perceptions of reality• Schema therapy - the newest of the psychotherapies for BPD. Schema therapy integrates elements of cognitive therapy, behavior therapy, into one unified, systematic approach to treatment.
COURSE AND PROGNOSIS• Course is variable. Most commonly follows a pattern of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol.• The impairment and the risk of suicide are the greatest at the young adult years and gradually wane with advancing age.• In the fourth and fifth decades of life, these individuals tend to attain greater stability in their relationships and functioning• A study published 2010 on hundreds of patients and followed for several years. Half recovered, meaning they no longer met the criteria of BPD, and half of the patients had reduction in symptoms