Borderline Personality DIsorder, DSM diagnostic Criteria, Dialectical Behavior Therapy (DBT), Medications and side effects

1. Borderline
Personality
Disorder
By:
Marlaina Maddux, Doyline Kreegel & Elizabeth Wolf

2. History of Diagnosis:
• Borderline Personality Disorder (BPD) was not an official
diagnosable disorder until 1980, when it was included in the
DSM-III for the first time.
• BPD affects moods, emotions, and relationships.
• Those with BPD often find themselves in crisis. Clients
present with a range of symptoms and behaviors, including
behavioral disturbance, self-harm, impulsive aggression, and
short-lived psychotic symptoms, as well as intense anxiety,
depression, and anger. As a result, they tend to be regular users
of psychiatric and acute hospital emergency services as well as
overusing medical services in general.

3. 1938 Adolph Stern lists most of the diagnostic criteria and calls the group of
affected people “the border line group.”
1941 Gregory Zilboorg describes the disorder as a mild version of schizophrenia
1942 Helene Deutsch defines a type of people dependent on others personalities as
having “as-if personality”
1940s Robert Knight introduces ego psychology and describes patients as being in
“borderline states.”
1967 Otto Kernberg defines boundaries between psychotic and neurotic, and he
places “borderline personality” in the middle.
1968 Roy Grinker does the first reearch on BPD
1975 John Gunderson publishes research to help diagnose BPD
1980 BPD is included in the DSM-III
1993 Marsha Linehan introduces dialectal behavior therapy (DBT) as an effective
treatment.
1994 DSM-IV is published, defining further symptoms of BPD required for
diagnosis

4. Current Prevalence
• Prevalence
• The median population prevalence of borderline personality
disorder is estimated to be 1.6%, but may be as high as
5.9%. The prevalence of BPD is about 6% in primary care
settings, about 10% among individuals seen in outpatient
mental health clinics, and about 20% among psychiatric
inpatients. The prevalence may decrease in older groups.

5. Current Prevalence
• Development and Course
• The most common pattern of development is one of chronic
instability in early adulthood, with episodes of serious
affective and impulse dysregulation and high levels of use
of health and mental health resources. Impairment and risk
of suicide are greatest in young adult years. During their 30s
and 40s, the majority of individuals with this disorder attain
greater stability in their relationships and vocational
functioning.

6. Current Prevalence
• Cultural-Related Diagnostic Issues
• BPD has been identified around the world. Adolescents and
young adults with identity problems may display behaviors
that misleadingly give the impression of BPD. 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.

7. Current Prevalence
• Gender-Related Diagnostic Issues
• BPD is diagnosed predominantly (75%) in females.

8. Borderline Personality
Disorder: F60.3
Criteria A
A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked
impulsivity, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the
following:

9. Borderline Personality
Disorder: F60.3
Criteria A-1
Frantic efforts to avoid real or imagined abandonment.
(Note: Do not include suicidal or self-mutilating behavior
covered in Criterion 5.)

10. Borderline Personality
Disorder: F60.3
Criteria A-2
A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of
idealization and devaluation.

11. Borderline Personality
Disorder: F60.3
Criteria A-3
Identity disturbance: markedly and persistently unstable
self-image or sense of self.

12. Borderline Personality
Disorder: F60.3
Criteria A-4
Impulsivity in a least two areas that are potentially self-
damaging (e.g., spending, sex, substance abuse, reckless
driving, binge eating). (Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.)

13. Borderline Personality
Disorder: F60.3
Criteria A-5
Recurrent suicidal behavior, gestures, or threats, or self-
mutilating behavior.

14. Borderline Personality
Disorder: F60.3
Criteria A-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).

15. Borderline Personality
Disorder: F60.3
Criteria A-7
Chronic feelings of emptiness.

16. Borderline Personality
Disorder: F60.3
Criteria A-8
Inappropriate, intense anger or difficulty controlling anger
(e.g., frequent displays of temper, constant anger, recurrent
physical fights).

17. Borderline Personality
Disorder: F60.3
Criteria A-9
Transient, stress-related paranoid ideation or severe
dissociative symptoms.

18. Associated Features
Supporting Diagnosis:
• Pattern of undermining themselves at the moment a goal
is about to be realized.
• Some individuals develop psychotic-like symptoms
during times of stress.
• May feel more secure with transitional objects than in
interpersonal relationships.

19. Associated Features
Supporting Diagnosis
Continued:
• Premature death from suicide may occur in individuals
with this disorder, especially in those with co-occurring
depressive disorders or substance use disorders
• Physical handicaps may result from self-inflicted abuse
behaviors or failed suicide attempts.

20. Associated Features
Supporting Diagnosis
Continued:
• Recurrent job losses, interrupted education, and
separation or divorce are common.
• Physical and sexual abuse, neglect, hostile conflict and
early parental loss are more common in the childhood
histories.

21. Associated Features
Supporting Diagnosis
Continued:
• Common co-occurring disorders include include
depressive and bipolar disorders, substance use disorders,
eating disorders (notably bulimia nervosa), posttraumatic
stress disorder, and attention-deficit/hyperactivity
disorder.
• Borderline personality disorder also frequently co-occurs
with the other personality disorders.

22. 3 Classifications of Drugs
that treat BPD
Antidepressants are used in the treatment of various forms of
endogenous depression. Also can treat anxiety, enuresis, chronic pain
syndromes, smoking cessation, bulimia, obcessive compulsive disorder,
and social anxiety disorder.
Mood Stabilizers and Anticonvulsants(Anti-seizure)
Mood stabilizers have the ability to moderate extreme shifts in emotion
and relieve symptoms of mania and depression during acute episodes.
Anticonvulsants are used to decrease the incidence and severity of
seizures due to various etiologies. Also used to treat neuropathic pain.
Antipsychotics are used to treat acute and chronic psychosis
particularly when accompanied by increased psychomotor activity.

23. Antidepressants:
Tricyclic antidepressant (TCA)
amitriptyline (Elavil)-severe toxicity in overdose
SSRI ?-Traditionally considered first line therapy for years.
fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram
(Celexa)
MAOI ?
phenelzine (Nardil)
Atypical Antidepressants ?
bupropion (Wellbutrin), duloxetine (Cymbalta), venlafaxine (Effexor)
Elavil is only antidepressant medication shown to have a positive effect
on BPD symptoms outside episodes of major depression.

24. Mood Stabilizers and
Anticonvulsants(Anti-seizure):
Anticonvulsant and Mood Stabilizer
topiramate (Topamax) gabapentin (Neurontin)?
carbamazepine (Tegretol) ?
Anticonvulsant
lamotrigine (Lamictal)-delayed time to recurrence of mood episodes
phenytoin (Dilantin)? divalproex sodium (Depakote ER), valproate sodium
(Depacon), and valproic acid (Depakene)
Mood Stabilizer
lithium (Carbolith)?
Mood stabilizers effective in decreasing suicidal behaviors. Effective in
treating core symptoms of affective instability and impulsivity. Topamax
and Lamictal effective in treating aggression. Topamax also treats anxiety.

25. Antipsychotics:
Atypical Antipsychotics (less severe side effects)
olanzapine (Zyprexa) clozapine (clozaril)?
ziprasidone (Geodon)?
aripiprazole (Abilify) quetiapine (Seroquel)?
Conventional Antipsychotics
Haloperiodol (Haldol)
Chlorpromazine (Thorazine) ?
Effective in improving impulsivity, aggression, and anxiety, and
psychotic symptoms. Zyprexa reduces impulsivity, hostility, affective
instability and psychotic symptoms. Abilify and Haldol treat symptoms
of anger.
Antipsychotic medications are helpful in the treatment of psychotic
decompensation

26. Side Effects of Specific
Antidepressants
Tricyclic antidepressant (TCA)
amitriptyline (Elavil) – suicidal thoughts, arrhythmias, lethargy, sedation, blurred
vision, dry eyes, dry mouth, hypotension, constipation
SSRI
sertraline (Zoloft)-neuroleptic malignant syndrome, suicidal thoughts, dizziness,
drowsiness, fatigue, headache, insomnia, diarrhea, dry mouth, nausea, sexual
dysfunction, increased sweating, tremor
MAOI
phenelzine (Nardil)- seizures, hypertensive crisis, dizziness, headache, arrhythmias,
diarrhea, weight gain Must avoid foods containing tyramine (aged cheese, beer, red
wine, sardines, liver, raisins, avocado, chocolate, meat tenderizer, and yogurt)
Atypical Antidepressants
bupropion (Wellbutrin) also a smoking deterrent- seizures, suicidal
thoughts/behaviors, agitation, headache, dry mouth, nausea, vomiting, tremor

27. Side Effects of Specific Anticonvulsants
and Mood Stabilizers
Anticonvulsants and Mood Stabilizers
topiramate (Topamax)-increased seizures, suicidal thoughts, dizziness, drowsiness,
fatigue, impaired concentration/memory, nervousness, psychomotor slowing, speech
problems, sedation, abnormal vision, diplopia, nystagmus, nausea, weight loss,
ataxia, paresthesia
Anticonvulsants
lamotrigine (Lamictal)-suicidal thoughts , Stevens-Johnson Syndrome, ataxia,
dizziness, headache, nausea, vomiting, photosensitivity, rash
divalproex sodium (Depakote ER), valproate sodium (Depacon), and valproic acid
(Depakene)-suicidal thoughts, hepatotoxicity, pancreatitis, hyperammonemia,
hypothermia, agitation, dizziness, headache, insomnia, sedation, visual disturbances,
abdominal pain, anorexia, diarrhea, indigestion, nausea, vomiting, tremor
Mood Stabilizers
lithium (Carbolith)-seizures, arrhythmias, fatigue, headache, impaired memory, ECG
changes, abdominal pain, anorexia, bloating, diarrhea, nausea, polyuria, acneiform
eruption, folliculitis, hypothyroidism, leukocytosis, muscle weakness, tremors

28. Side Effects of Specific
Anticonvulsants
Atypical Antipsychotics
olanzapine (Zyprexa) also a therapeutic mood stabilizer-neuroleptic malignant syndrome,
seizures, suicidal thoughts, agranulocytosis, agitation, dizziness, headache, restlessness,
sedation, weakness, amblyopia, rhinitis, constipation, dry mouth, weight loss or gain, tremor
clozapine (clozaril)-neuroleptic malignant syndrome, seizures, myocarditis, agranulocytosis,
leukopenia, dizziness, sedation, hypotension, tachycardia, constipation
ziprasidone (Geodon)also a therapeutic mood stabilizer- neuroleptic malignant syndrome,
prolonged QT Interval, agranulocytosis, dizziness, drowsiness, restlessness, constipation,
diarrhea, nausea
Conventional Antipsychotics
Haloperiodol (Haldol)-seizures, agranulocytosis, neuroleptic malignant syndrome,
extrapyramidal reactions, blurred vision, dry eyes, constipation, dry mouth
Chlorpromazine (Thorazine) – neuroleptic malignant syndrome, agranulocytosis, sedation,
blurred vision, dry eyes, hypotension, constipation, dry mouth, photosensitivity

29. • http://fiu.kanopy.com/video/dsm-5-guided-collection-vol-
6

30. Marsha M. Linehan:
- Created Dialectical Behavior Therapy (DBT) in the early 1990’s.
- Linehan herself suffered from Borderline Personality Disorder.
- The first time she was treated for anything was when she was 17 at
the Institute of Living where she received treatment for extreme
social withdrawal. Then with a diagnosis of Schizophrenia and put
on a combination of psychotropic medications.
- Later on in life she was driven to help people who were chronically
suicidal, often as a result of Borderline Personality Disorder. She
didn't’t know it at the time but she was dealing with herself.
- - Years later she found answer of why she could now weather her
emotional storms without cutting or harming herself, it was that she
accepted herself. That’s where she came up with the idea of radical
acceptance and it has become increasingly important as she began
working with patients

31. Marsha M. Linehan:
https://www.youtube.com/watch?v=tAz_o8G-67E&t=68s

32. What is DBT? The Basics
• DBT stands for Dialectical Behavior Therapy
• DBT is one of the most effective treatments for Borderline
Personality Disorder
• DBT aims to change behavior and manage emotions and behaviors
through a synthesis of both acceptance and change.
• Dialectics is a term that means a synthesis or integration of opposites.
The primary dialectic within in DBT is between the seemly opposite
strategies of acceptance and change.
• It uses the principles of CBT combined with mindfulness,
acceptance and dialectics.
• DBT differs from CBT in that it places less emphasis on using
cognitive methods and instead focuses on the learning and practice of
new skills.
• Lastly, mindfulness is considered to be central to DBT in the form of
a practice as opposed to a philosophy.
(O’Connell, Dowling, 2013).

34. DBT: Four Modules
• 1.) Mindfulness: is one of the core ideas behind all elements
of DBT. It is considered a foundation for the other skills
taught in DBT. Within DBT it is the capacity to pay attention,
nonjudgmentally, to the present moment; about living in the
moment, experiencing ones emotions and senses fully, yet
with perspective. The practice of mindfulness can also be
intended to make people more aware of their environments
through their 5 senses: touch, smell, sight, taste and sound.

35. DBT: Four Modules
• 2.) Distress Tolerance: these skills constitute a natural
development from DBT mindfulness skills. Patients will have
the ability to accept, in a non-evaluative and nonjudgmental
stance.
• The goal is to become capable of calmly recognizing negative
situations and their impact, rather than becoming overwhelmed
or hiding from them.
• This allows individuals to make wise decisions about whether
and how to take action, rather than falling into the intense,
desperate, and often destructive emotional reactions that are a
part of Borderline Personality Disorder

36. DBT: Four Modules
• 3.) Emotion Regulation: emotion regulations aim is at
understanding ones own emotions, reducing emotional vulnerability
and decreasing emotional suffering.
• The module begins by teaching clients a model for understanding
emotions and using this as a guide for clients to understand their own
emotions, the relationship of emotions to each other and the
relationship of emotions to environmental events.
• DBT skills for emotion regulation include:
• Identify and label emotions
• Identify obstacles to changing emotions
• Reduce vulnerability to emotion mind
• Increase positive emotional events
• Increase mindfulness to current emotions
• Take opposite action
• Apply distress tolerance techniques

37. DBT: Four Modules
• 4.) Interpersonal Effectiveness: focuses on teaching clients
how to manage interpersonal relationships. The module
teaches clients to identify and prioritize three aspects of such
interpersonal situations; their objective, relationship issues and
self respect.
• It then teaches clients how to negotiate any interpersonal
interaction using different set of skills according to identified
priorities in that interaction
• The skills taught are intended to maximize the chances that a
persons goals in a specific situation will be met, while at the
same time not damaging either the relationship or the persons
self respect.

38. DBT: 4 Components
• Individual: the therapist and patient discuss issues that come
up during the week
• Group: meets weekly for two to two and half hours and learns
to use specific skills that are broken down into four modules
• Therapist Consultation Team: a therapist consultation team
includes all therapists providing DBT. The meeting occurs
weekly and serves to support the therapist in providing the
treatment
• Phone Coaching: is designed to help generalize skills into the
patients daily life. Phone coaching is brief and limited to a
focus on skills

39. DBT: Tools
Diary Cards:
• Specially formatted cards
for tracking interfering
behaviors that distract or
hinder a patients progress.
• Diary cards can be filled
out 2-3 times a day or
once per week
Chain Analysis:
• Chain analysis is a form
of functional analysis of
behavior but with
increased focus on
sequential events that
form the behavior chain.

40. Other Psychotherapies:
• Cognitive Therapy:
• Cognitive therapy defines personality in terms of patterns of
cognitive-affective, motivational and social processes. Thereby
underlying that cognitive therapy emphasizes cognitions only.
• The schema concept is the cornerstone of cognitive treatment of
BPD.
• Cognitive Therapy for personality disorders strongly focuses on the
therapeutic relationship, characterized by collaboration and guided
discovery, and allows for processing of transference reactions (ie.,
emotional reactions within the therapy process) vital to fully
understand the patients system of thoughts and beliefs.
• Treatment of one year or longer is effective in reducing problematic
behaviors, but many BPD patients need longer treatment for more
extensive remediation

41. Other Psychotherapies:
• Schema-Focused Therapy:
• Schema-focused therapy focuses primarily on the deepest level of
cognition, schemas.
• The SFT model defines schema as “stable and enduring themes that
develop during childhood and are elaborated throughout an
individuals lifetime and are dysfunctional to a significant degree”
• Interventions in SFT focus in particular on 3 core manifestations of
maladaptive schemas:
• 1.) problems in interpersonal relationships
• 2.) Self-functioning (diffusion of identity)
• 3.) Affect regulation
Treatment is explorative and insight-oriented and accentuates alliance as
an important tool for modification and restructuring of schemas

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