Borderline Personality Disorder In Adolescents

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  • Borderline Personality Disorder In Adolescents

    1. 1. Borderline Personality Disorder in Adolescents<br />Jackie Henry<br />
    2. 2. Outline<br />Description of BPD<br />Differences in BPD Presentation<br />Theories of Origin<br />Treatment Options<br />Counseling Implications<br />Suggestions for Future Research<br />
    3. 3. DSM IV Criteria (Axis II Cluster B)<br />A pervasive pattern of instability of interpersonal relationships, self-image and affects<br />Impulsivity: Five (or more) of the following: <br />Frantic efforts to avoid abandonment <br />Unstable and intense interpersonal relationships<br />Unstable self-image or sense of self<br />Impulsivity in at least two areas that are potentially self-damaging <br />(e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving. <br />
    4. 4. DSM IV Criteria con’t<br />Recurrent suicidal behavior, gestures, threats or self-injuring behavior<br />Cutting or picking at oneself<br />Afffectinstability due to a marked reactivity of mood <br />(e.g., intense irritability or anxiety usually lasting a few hours and only rarely more than a few days)<br />Chronic feelings of emptiness<br />Inappropriate anger or difficulty controlling anger <br />Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms<br />
    5. 5. Common Comorbidities<br />Major Depressive Disorder    60%<br />Dysthymia  70%      <br />Eating Disorders  25%   <br />Substance Abuse  35%<br />Bipolar Disorder  15%<br />Antisocial Personality Disorder   25%<br />Narcissistic Personality Disorder  25%<br />(www.nami.org)<br />
    6. 6. BPD in Children and Adolescents<br />Referring to teacher as “best” friend<br />Reckless driving, substance abuse<br />I hate you! Don’t leave me!<br />Fleeting persecutory delusions<br />Easily provoked into an argument or fight<br />Self mutilation behavior<br />Cross dressing, running for class president but has few friends<br />Chronic complaints of boredom, doesn’t invest in any activities<br />Occasional almost phobic fear of abandonment, being alone<br />
    7. 7. BPD vs. Normal Teen Behavior<br />BPD symptoms of affective instability, uncontrolled anger, impulsivity, and identity disturbance are common in adolescents<br />How to differentiate?<br />Paris (2005) “One sometimes hears that all adolescents may be ‘a little borderline.’ No one denies that moodiness and some degree of impulsive behavior are common in this age group. But most adolescents are not seriously troubled or rebellious” (p. 240). <br />Severity of the behavior and impact on functioning can assist clinicians in differentiating<br />
    8. 8. BPD in Girls vs. Boys<br />Bradley, Conklin, & Westen (2005)<br />294 randomly selected doctoral-level clinicians described adolescent patients using Axis II rating scales and the Shedler–WestenAssessment Procedure-200 for Adolescents (SWAP-200-A)<br />Results: <br />BPD in adolescent girls looks more like BPD in adults<br />BPD in the sample was clearly gendered <br />Female patients<br />More internalizing and emotionally dramatic<br />Male patients<br />More behaviorally disinhibited, externalizing, and angry<br />
    9. 9. BPD in Children and Adolescents vs. Adults<br />• Similarities<br />Comorbidities<br />Environmental risk factors<br />Deficits in executive functioning<br />• Differences<br /> Prevalence rates higher for juveniles<br />Less female gender predominance<br />
    10. 10. Controversies<br />Distinguishing from normal adolescent behavior<br />Origins<br />Biological? Social? Psychological?<br />Diagnosis prior to adulthood<br />DSM requires 1 year of key symptoms for adolescent diagnosis<br />Terminology<br />emotional regulation disorder,emotional dysregulation disorder, impulse disorder, interpersonal regulatory disorder<br />
    11. 11. What Causes BPD?<br />Marsha Linehan: Biosocial Theory<br />BPD is caused by the interaction of biology and environment<br />Innate tendency to be hyper-reactive to stimuli<br />Coupled with invalidation or abuse during childhood<br />Dialectical Behavior Therapy<br />
    12. 12. What Causes BPD?<br />Brunner et al. (2010) <br />60 females (14–18 years), 20 with a DSM-IV diagnosis of BPD, 20 patients with a DSM-IV defined current psychiatric disorder and 20 healthy control subjects<br />Changes in Prefrontal Cortices<br />Adolescent with BPD had decreased gray matter volume compared with healthy subjects<br />Changes in limbic brain volumes and white matter structures might occur over the course of the illness<br />Biological predisposition: Other disorders related to PFC<br />
    13. 13. Risk Factors for Early BPD Development<br />Harsh maternal punishment<br />Inconsistent maternal enforcement of rules<br />Low expression of maternal affection<br />Low maternal educational aspirations<br />Low maternal and paternal time spend with child<br />Maternal use of guilt to control child’s behavior<br />Poor maternal and paternal supervision of child<br />Poor maternal communication with child<br />Poor paternal communication with child<br />
    14. 14. Treatment Options<br />Psychotherapy<br />DBT<br />Medications<br />
    15. 15. Dialectical Behavior Therapy<br />DBT is “the necessity of accepting patients just as they are within a context of trying to teach them to change” (Linehan, 1993, p. 19).<br />Blends CBT w/ Eastern philosophy influences<br />Meditation, mindfulness, etc.<br />Non-critical stance<br />Empathy and acceptance<br />Can be used with family therapy<br />4 Stages:<br />Orientation and Commitment<br />Attaining Basic Capacities (minimize suicidality)<br />Reducing Posttraumatic Stress<br />Increasing Self-Respect and Achieving Individual Goals<br />
    16. 16. Benefits and Limitations of DBT for Adolescents<br />Benefits<br />Can reduce both therapist and client anxiety through structured sessions<br />Client-centered<br />Focuses on keeping adolescent engaged in treatment through collaboration<br />More likely to engage in treatment if they feel a sense of control<br />Areas addressed are consistent with the developmental tasks of adolescence<br />Limitations<br />Resource intensive: group/individual/family therapy<br />Difficulty in access to treatment<br />Short-term treatment for adolescents (12 weeks)<br />
    17. 17. Medication<br />Antidepressants (affective instability, impulsivity)<br />Mood Stabilizers (affective instability, anger)<br />Antipsychotics (impulsivity,<br />interpersonal skills, cognitive<br />symptoms, global function)<br />
    18. 18. Counseling Implications<br />Aviram (2006): BPD, Stigma and Treatment Implicatons<br />May affect how practitioners tolerate the actions, thoughts, and emotional reactions of these individuals<br />The very behaviors that make it difficult to work with these individuals contribute to the stigma of BPD<br />Minimizing symptoms and overlooking strengths<br />Blaming the patient<br />Less empathy<br />Clinicians may emotionally distance themselves<br />Exacerbate negative symptoms<br />Clinicians' reactivity may be self-protective(distancing)<br />Individual comes to be seen as the problem, not the behaviors<br />Self-fulfilling prophecy and a cycle of stigmatization (both patient and therapist contribute)<br />
    19. 19. Suggestions for Future Research<br />More!<br />Long term prognosis not known for adolescents diagnosed with BPD<br />Origins<br />Dealing with stigma<br />Different types of treatment<br />
    20. 20. References<br />Al-Alem, L., & Omar, H. A. (2008). Borderline personality disorder: An overview of history, diagnosis and treatment in adolescents. International Journal of Adolescent Medicine and Health, 20(4), 395-404. Retrieved from www.csa.com<br />Bradley, R., Conklin, C. Z., & Westen, D. (2005). The borderline personality diagnosis in adolescents: Gender differences and subtypes. Journal of Child Psychology and Psychiatry, 46(9), 1006-1019. <br />Brunner, R., Henze, R., Parzer, P., Kramer, J., Feigl, N., Lutz, K., Essig, M., Resch, F., & Stieltjes, B. (2010). Reduced prefrontal and orbitofrontal gray matter in female adolescents with borderline personality disorder: Is it disorder specific?NeuroImage, 49(1), 114-120. <br />Crawford, T. N., Cohen, P. R., Chen, H., Anglin, D. M., & Ehrensaft, M. (2009). Early maternal separation and the trajectory of borderline personality disorder symptoms. Development and Psychopathology, 21(3), 1013-1030. <br />American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision).Washington, D.C.: Author.<br />Aviram, R. (2006). Borderline Personality Disorder, Stigma, and Treatment. Harvard Review of Psychiatry. 14, 5, 249-256 , DOI 10.1080/10673220600975121 <br />Guthrie, D. (2006). Adolescent Borderline Personality Disorder and Dialectical Behavior Therapy. Praxis, 6, 35-42.<br />Hopwood, C. J., & Grilo, C. M. (2010). Internalizing and externalizing personality dimensions and clinical problems in adolescents. Child Psychiatry and Human Development, 41(4), 398-408. <br />Kobak, R., Zajac, K., & Smith, C. (2009). Adolescent attachment and trajectories of hostile-impulsive behavior: Implications for the development of personality disorders. Development and Psychopathology, 21(3), 839-851.<br />Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.<br />Macfie, J. (2009). Development in children and adolescents whose mothers have borderline personality disorder. Child Development Perspectives, 3(1), 66-71. <br />Takahashi, T., Chanen, A. M., Wood, S. J., Walterfang, M., Harding, I. H., Yücel, M., Nakamura, K., McGorry, P. D., Suzuki, M., <br />Miller, A. L., Muehlenkamp, J. J., & Jacobson, C. M. (2008). Fact or fiction: Diagnosing borderline personality disorder in adolescents. Clinical Psychology Review, 28(6), 969-981. <br />Paris, J. (2005). Diagnosing borderline personality disorder in adolescence. Adolescent Psychiatry, 29, 237–247.<br />Rajpal, V. (2006). Impact of family risk factors and psychopathology on suicidal behavior in adolescents with borderline personality disorder. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 67(4-B), 2239-2239. (Electronic; Print)<br />Santisteban, D. A., Muir, J. A., Mena, M. P., & Mitrani, V. B. (2003). Integrative borderline adolescent family therapy: Meeting the challenges of treating adolescents with borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training, 40(4), 251-264.<br />Velakoulis, D., & Pantelis, C. (2009). Midline brain structures in teenagers with first-presentation borderline personality disorder. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(5), 842-846. <br />Woodberry, K. A., Roy, R., & Indik, J. (2008). Dialectical behavior therapy for adolescents with borderline features. In L. A. Greco, & S. C. Hayes (Eds.), Acceptance and mindfulness treatments for children and adolescents: A practitioner's guide. (pp. 115-138). Oakland, CA, US: New Harbinger Publications. <br />

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