8. DSM III
• 1980 – first time BPD was listed as a diagnosable illness
• Overlapping symptoms therefore “Borderline”
• Schizophrenia (psychotic): periods of pscyhoses/paranoia
• Bipolar (neurotic): affective instability and impulsivity
• Historically, the three major symptoms were:
1. Problems regulating emotions and thoughts
2. Impulsive/reckless behaviour
3. Unstable relationships with people
9. DSM-IV
• 1994 Classic 9 symptoms ≥5:
1. Extreme reactions 6. Intense and highly changeable moods
2. Pattern of intense, stormy 7. Chronic feelings of
relationships emptiness/boredom
3. Distorted, unstable self image 8. Inappropriate intense anger, or issues
4. Impulsive, risky behaviours controlling it
5. Recurring suicidal behaviours or 9. Stress-related paranoia, dissociative
threats or self-harm symptoms
10. • A DSM Dx requires min 5/9
• = 256 different combinations
• Extremely heterogeneous!
17. Developmental theories
• Traumatic childhood events:
• Sexual, physical, psychological abuse/neglect
• Styles of communication/treatments:
• Failure to acknowledge significance of emotions, thoughts, ideas
• Not conducive to development of healthy identity
• No causality has officially been determined
19. Co-occurrance with other illnesses
• Women more likely to co-occur with:
• Major depression
• Anxiety disorders
• Eating disorders
• Men more likely to co-occur with:
• Substance abuse
• Antisocial Personality Disorder (ASPD)
22. Prevalence
• Data validity:
• Underreporting false negatives
• Adolescents not included in DSM false positives
Source Prevalence Gender Clinical Populations
Grant et al 0.5-5.9% 5.9% m 6.2% f 10% outpatients
2008. 15-25% inpatients
Johnson et al 0.4-1.8% 75-90% females 10-25% among clinical
2003 samples
Grant et al. (2008) Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related
Conditions. Journal of Clinical Psychiatry. 69 (4):533-45
Johnson DM. Et al. (2003). Gender Differences in Borderline Personality Disorder: Findings From the Collaborative Longitudinal Personality Disorders Study
Comprehensive Psychiatry. 44(4):284-292
23. Suicidality
• 10% people with BPD commit suicide.
• 33% of youth who commit suicide have features, or traits, of BPD.
• 400 times higher than the general population
• Young women with BPD: 800 times higher than the general population.
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. The Lancet, 364(9432), 453-461.
25. • Against Diagnosing early:
• Personality Evolving in age group
• Low predictive validity into adulthood instability
• For Diagnosing early:
• Prevent “Crystallization” of maladaptive behaviours
• Treat significant distress and dysfunctioning
• Benefits > costs!!
26. Shift to Axis I?
• Case: Some doubt of BPD altogether
• Shifting to Axis I serious disorder
1. Change terminology:
• “borderline” no longer reflects original meaning
2. Treat as a disorder:
• ‘phenotypic expression of symptoms and behaviours that emerge in the context of past
and present stressors’
New, A. S., Triebwasser, J., & Charney, D. S. (2008). The case for shifting borderline personality disorder to Axis I. Biological Psychiatry, 64(8), 653-659.
28. • BPD is common and extremely complex
• Debilitating to patients, family/partners, and mental health system
• 10-25% clinical pop
• Successful Prevention and treatment available
• Greater awareness
• De-stigmatize!
30. References
• New, A. S., Triebwasser, J., & Charney, D. S. (2008). The case for shifting borderline
personality disorder to Axis I. Biological Psychiatry, 64(8), 653-659.
• Grant et al. (2008) Prevalence, correlates, disability, and comorbidity of DSM-IV
borderline personality disorder: results from the Wave 2 National Epidemiologic Survey
on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 69 (4):533-45
• Johnson DM. Et al. (2003). Gender Differences in Borderline Personality Disorder:
Findings From the Collaborative Longitudinal Personality Disorders Study
Comprehensive Psychiatry. 44(4):284-292
Editor's Notes
BPD is characterised by frantic efforts to avoid perceived abandonment, long standing problems with relationships, identity of sense of self, the control of emotions and behaviour and a mortality rate by suicide of almost 10%. People with BPD often have other personality disorders and mental illnesses as well as related alcohol and drug misuse
Often presents with brief psychotic episodes; originally considered a borderline version of other mental disorders, such as bipolar or schizophrenia
Classic 9 symptoms, require minimum combination of 5, over a significant period of time:Extreme reactions – panic, depressions, rage, frantic actionsPattern of intense, stormy relationships; veering from extreme idealization to devaluationDistorted, unstable (negative) self imageImpulsive, risky behaviours: unsafe sex, substance abuse, binge eatingRecurring suicidal behaviours or threats or self-harm; cuttingIntense and highly changeable moods; each episode few hours-few daysChronic feelings of emptiness/boredomInappropriate intense anger, or issues controlling angerStress-related paranoia, severe dissociative symptoms (lose touch with self/reality)NEGATIVE AFFECTIVITY: Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger, etc.), and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations.1. Emotional lability2. Anxiousness3. Separation insecurity4. Submissiveness 5. Hostility6. Perseveration7. Depressivity8. Suspiciousness9. Restricted affectivityDISINHIBITIONDisinhibition (vs. conscientiousness)Orientation towards immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences; the opposite pole of this domain reflects excessive constraint of impulses, risk avoidance, hyperresponsibility, hyperperfectionism, and rigid, rule governed behavior.1. Irresponsibility2. Impulsivity3. Distractibility4. Risk taking5. (lack of) Rigid perfectionism
SFT: CBT + Psychotherapy: Based on theory of BPD in which dysfunctions originate from negative self image brought on by childhood experiencesFocus on the mindfulness of situations in which they would normally react irrationally. Balance between acceptance of behaviours and changing them
increased risk for MDD, affective instability & impulsivity, and more common than Axis IIsuggesting a strong genetic effect in the development of the disorder
Upper and lower percentilesSubstance misuse, PTSD, panic disorder, dependant and avoidant personality disorder
Higher than 1% schiz/bipolar
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. The Lancet, 364(9432), 453-461.
Suicidality, Self-cutting, Identity disturbance, academic failure, social dysfunction, and substance abusethe adolescent BPD criteria manifest less construct validity than the adult diagnosis in that its criteria did not uniformly predict the overall diagnosis, and showed more criterion overlap with other personality disorders and a broader pattern of axis II comorbidity. Further diminishing its construct validity, factor analysis suggested that adolescent BPD was not a single entity, and its low predictive validity was demonstrated by little diagnostic stability through adolescence into adulthood.
Some doubt regarding the validity of BPD and existence altogether still exist; shifting the classification of the disease to Axis I for clinicians and researchers to take more seriouslyMajor misconceptions:“Borderline”: between two states (neurotic vs psychotic) – a view no longer acceptedBPD a direct consequence of childhood, rather than phenotypic expression of symptoms and behaviours that emerge in the context of past and present stressors
the adolescent BPD criteria manifest less construct validity than the adult diagnosis in that its criteria did not uniformly predict the overall diagnosis, and showed more criterion overlap with other personality disorders and a broader pattern of axis II comorbidity. Further diminishing its construct validity, factor analysis suggested that adolescent BPD was not a single entity, and its low predictive validity was demonstrated by little diagnostic stability through adolescence into adulthood.
