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Comprehensive Clinical Insights into Managing Borderline Personality Disorder

Explores borderline personality disorder's diagnosis, etiology, stigma, clinical challenges, and treatment strategies, highlighting neurobiology and healthcare perceptions.

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THE CLINICAL CHALLENGE OF MANAGING BORDERLINE PSYCHOPATHOLOGY PRESENTERS- DR. SIMRANJIT SINGH, DR. CHIRAG SINGH COORDINATOR- DR. ADWITIYA RAY CHAIRPERSON- DR. PRITI SINGH
FLOW OF SEMINAR • Introduction • Comparative nosology • Etiology • Stigma and perception associated with the diagnosis of borderline personality disorder • Challenges in the clinical assessment • Challenges in treatment and clinical management • Challenges in managing suicidal crises • Conclusion
INTRODUCTION
PERSONALITY “Personality is the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought” [Allport; 1961]
PERSONALITY DISORDER A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and 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. [DSM-5-TR]
Borderline personality disorder (BPD) is a chronic psychiatric disorder characterized by pervasive patterns of affective instability, self-image disturbances, instability of interpersonal relationships, marked impulsivity, and suicidal behavior (suicidal ideation and attempt) causing significant impairment and distress in an individual’s life. [Kulacaoglu F.; 2018]
• Patients with BPD suffer considerable morbidity which complicates medical care compared to other individuals. • BPD has been identified as the most common personality disorder in clinical populations, and it is associated with significant individual and societal costs. • Since BPD is associated with receiving clinical attention and causes psychosocial impairments, it is more widely studied than other personality disorders. [Porter C. et al; 2020]
ORIGINS AND EVOLUTION OF THE BORDERLINE DIAGNOSIS • Stern (1938) introduced the term “Borderline” to describe what he understood as, “on the cusp” of both psychotic and neurotic. • The term “borderline” entered the psychological lexicon as a word that described a group of mental health out-patients who did not seem to fit comfortably with a diagnosis of psychotic or neurotic [Ahluwalia CA. et al; 2019]
• Kernberg (1967) made an effort to define their intrapsychic features. • Kernberg described borderline personality organization (BPO) as an intermediary level of internal personality organization, framed on one side by more severe psychotic personality organization and on the other by less severe neurotic organization.
• The BPO construct encompassed all serious forms of personality disorder and was characterized by three intrapsychic characteristics: 1) Identity diffusion; 2) Primitive defenses (e.g., splitting, denial, projection, action, and projective identification) 3) Reality testing that was generally intact, but vulnerable to alterations and failures. • BPO is not synonymous with BPD but formed the foundation for the integration of BPD into the DSM-III. [Skodol AE. et al; 2002]
PREVALANCE • BPD is relatively common in the general population, with a point prevalence of around 1%. • The prevalence of BPD is substantially higher in clinical settings, around 12% in the outpatient psychiatric population and 22% among inpatients. [Ellison WD. et al; 2018]
• The ratio of females to males with the disorder is also greater in the clinical population. • In contrast to the clinical setting ratio, in two epidemiologic surveys of United States general population, the lifetime prevalence of BPD was found to be similar in males and females. • This result can be interpreted as women with BPD are more likely to seek treatment than men. About 80% of patients who receive treatment for BPD were reported to be women. [Kulacaoglu F.; 2018]
COMPARATIVE NOSOLOGY
DSM-V TR ICD-10 ICD-11  The personality disorders are grouped into three clusters (A,B and C) based on descriptive similarities.  Borderline personality disorder is included under Cluster B personality disorders.  Personality disorders are subdivided according to clusters of traits that correspond to the most frequent or conspicuous behavioral manifestations.  Borderline type is a specifier under Emotionally unstable personality disorder.  Individual Personality disorder categories have been removed and replaced by a core diagnosis of PD which can be specified as mild, moderate or severe.  Trait domain specifiers: 6D11.0 Negative Affectivity 6D11.1 Detachment 6D11.2 Dissociality 6D11.3 Disinhibition 6D11.4 Anankastia 6D11.5 Borderline pattern
ETIOLOGY
1. Psychosocial factors: • Childhood physical, sexual, or emotional abuse or neglect. 2. Genetic factors: • Candidate gene study- Association between a haplotype containing the short allele in the serotonin transporter gene (the serotonin transporter-linked promoter region [5-HTTLPR] in SLC6A4) and the development of borderline personality disorder. [Leichsenring F. et al; 2011]
• Gene–gene interactions studies- An interaction between the Met allele of the catecholamine-O methyltransferase gene (COMT) and the short allele of 5-HTTLPR was reported in patients with borderline personality disorder. • Polymorphisms in 5-HTTLPR, tryptophan hydroxylase gene (TPH- 2), variable number tandem repeat of the high-activity monoamine oxidase A gene promoter allele.
3. Neurobiology: Anatomical MRI findings • Reduced volume in the amygdala. • Reduction in grey matter volume in the anterior cingulate gyrus, posterior cingulate gyrus, or hippocampus, and a reduced size of the right parietal cortex. • Reduced grey matter volumes in the dorsolateral cortex and in the left orbitofrontal cortex were reported in an early stage of borderline personality disorder. [Ding JB.; 2021]
PET Findings • Fronto-limbic dysfunction: Changes in frontal glucose metabolism (a hypometabolism was more often reported than a hypermetabolism). • Abnormality in prefrontal brain regions associated with emotional control function in borderline personality disorder. • More activation of the orbital cortex. [Karas KH. et al; 2021]
FUNCTIONAL MRI FINDINGS • The fMRI analysis showed significant reduced functional connectivity in the BPD group compared to healthy controls between the amygdala (right and left) and the frontal pole. • Decreased connectivity was also found between amygdala (left) and precuneus and between amygdala (left) and temporal pole. [Mitolo M. et al; 2024]
• Increased amygdala activation compared with control individuals when viewing aversive emotion-inducing slides or when viewing pictures of human emotional facial expressions. • Activation of the prefrontal cortex was reported for patients with borderline personality disorder after inducing negative emotions, possibly indicating an attempt to control intensive emotions. [Wrege JS. et al; 2021]
• When asked to use a cognitive strategy to control their responses to unpleasant pictures by distancing themselves from the image, those with borderline personality disorder had less blood-oxygen-level dependent (BOLD) signal changes in the anterior cingulate and had greater activation in the superior temporal sulcus and superior frontal gyrus than did controls. • Thus, patients with borderline personality disorder do not seem to engage the cognitive control regions to the extent that healthy individuals do, which might contribute to the affective instability of this disorder.
• These reports lend support to the assumption of a dysfunctional fronto-limbic network in borderline personality disorder. • This network seems to involve the anterior cingular cortex, the orbitofrontal cortex, the dorsolateral prefrontal cortex, the hippocampus, and the amygdala.
STIGMA AND PERCEPTIONS ASSOCIATED WITH THE DIAGNOSIS OF BPD
• The phenomenon of stigma and negative attitudes surrounding the diagnosis of BPD has been widely researched. • Attitudes held by health professionals including emergency staff, mental health nurse, and the multidisciplinary team have been explored extensively and indicate that long-standing stigma remains attached to this disorder. [Aguirre B.; 2016]
• Further, many health professionals do not consider BPD to be a genuine diagnosis and believe the diagnosis to be self-induced or chosen. • Subsequently, it has been found that people with BPD either are not informed about their condition or are told they have a differing diagnosis, such as bipolar affective disorder, compromising the principle of veracity.
HEALTH PROFESSIONALS’ PERCEPTIONS OF INDIVIDUALS WITH BORDERLINE PERSONALITY DISORDER • A considerable body of research has explored health professionals’ attitudes and approaches towards people with BPD, highlighting the stigma associated with the diagnosis. • Findings indicated that health professionals were less validating of the subjective experiences of individuals with BPD in comparison to those who have other mental health diagnoses. [Lester R. et al; 2020]
• These perceptions appeared to elicit more negative attitudes and significantly less empathetic responses towards these individuals. • The characteristic ways that individuals with BPD may behave during interpersonal transactions with healthcare professionals have been described as –  Emotionally blackmailing.  Threatening.  Rule-breaking.  Evoking heightened emotional reactions.
• A literature review of mental health nurses’ attitudes towards BPD individuals in acute mental health settings identified that mental health nurses tended to distance themselves from individuals with BPD, again contributing to the stigma surrounding the diagnosis. • A recent study suggested that differing staff perceptions of recovery in BPD can pose risks for consistent teamwork due to the relational difficulties associated with the diagnosis. [Lester R. et al; 2020]
CARERS AND FAMILIES’ PERCEPTIONS AND LIVED EXPERIENCES OF INDIVIDUALS WITH BORDERLINE PERSONALITY DISORDER • Some studies highlighted that carers can experience feelings of being overwhelmed and powerless to help the person because of their repeated self-harm or suicide attempts. • Bailey and Grenyer found that burden and grief were significantly higher for carers of individuals diagnosed with BPD than reported by carers of those with other mental health diagnoses. [Lester R. et al; 2020]
• Similar findings were noted by Kirtley et al. who reported higher levels of carer burden, stigma, expressed emotion, emotional overinvolvement, criticism, and perceived threat of strong emotions in carers of individuals with BPD compared to carers of individuals with other types of mental health difficulty. • Giffin discovered that the broader family, as reported by parents of individuals with BPD, tended to have less tolerance for behaviors associated with the diagnosis and seemed readier to express their expectations that they should take more responsibility for their actions.
CHALLENGES IN THE CLINICAL ASSESSMENT
• Impulsivity • Psychiatric comorbidity
IMPULSIVITY • It is seen in behaviors such as substance misuse, unsafe sexual activity, disordered eating, and impulsive self-harm. • It is generally assumed that impulsive behaviors are the product of being an impulsive individual. High-trait impulsivity is frequently found in BPD patients and has been defined as a tendency for rapid and unplanned behaviors. • There is a tendency to act on urges without regard for the possible consequences. [Barker V.; 2015]
• In the study of Brodsky et al. impulsivity was the only characteristic of BPD found to be associated with a higher number of suicide attempts controlling for diagnoses such as depression and substance abuse. • Self-destructive impulsivity probably represents the clinically most challenging part of the borderline syndrome and, as suggested by Brodsky et al., monitoring impulsivity in patients in the course of treatment might be a useful guide to therapeutic response.
PSYCHIATRIC COMORBIDITY • Other mental disorders are common in patients with BPD, as evidenced by the high comorbidity rates reported in numerous cross-sectional and longitudinal studies. • The findings of an epidemiological study in the USA suggested that BPD is rarely diagnosed alone, with high lifetime prevalence rates in these patients for anxiety disorders (84.8%), mood disorders (82.7%), substance use disorders (78.2%), and eating disorders (33.7%). [Pascual JC.; 2023]
• Similarly, several other mental disorders also present high rates of comorbidity with BPD, including posttraumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), and bipolar disorder. • However, it is important to consider that the symptoms of BPD frequently overlap with several disorders that share the same features. For example, while impulsivity with drug abuse or binge eating is a key marker of BPD, it is also a common symptom in other disorders.
• Patients with BPD, and co-occurring psychiatric disorders are often chronic, and may be associated with severely impaired social and occupational functioning that requires social support; moreover, they are often difficult to treat. 1. Comorbid Mood Disorders:  Mood disorders are one of the most common disorders in individuals with BPD.  Up to 80% of patients with BPD present one or more episodes of major depressive disorder (MDD) in their lifetime and 10–30% of patients with MDD have co-occurring BPD. [Pascual JC.; 2023]
2. Comorbid Anxiety Disorders  Lifetime comorbidity between BPD and anxiety disorders is high (84.8%) and patients with BPD are 14 times more likely to present an anxiety disorder (especially panic disorder with agoraphobia, generalized anxiety disorder, and PTSD). 3. Comorbid Eating Disorders  Eating disorders also present high rates of comorbidity with BPD.  In a meta-analysis that examined the prevalence of personality disorders among individuals with eating disorders, BPD was present in 28% of patients with bulimia nervosa (BN), 25% of those with anorexia nervosa.
4. Comorbid Substance Use Disorders  BPD is generally characterized by greater impulsivity and a preference for short-term rewards.  This inability to focus on the long term predisposes patients to develop SUD. The overall lifetime prevalence of SUD in patients with BPD is approximately 78%.
• The prevalence of these comorbid disorders tends to decrease gradually over time in parallel with the clinical improvement of the typical symptoms that characterize BPD. • No drugs have yet been approved specifically for the treatment of BPD.
CHALLENGES IN TREATMENT AND CLINICAL MANAGEMENT
• The therapeutic relationship • What treatment works for BPD patients? • To hospitalize or not to hospitalize • Suicidal crises
THE THERAPEUTIC RELATIONSHIP • An important aspect of BPD individuals’ problems is their difficulty with regulating their relation to other people and to maintain nurturing close interpersonal relations over time. • This extends to the clinical setting where BPD patients all too often very soon feel disappointed over, rejected or invalidated by their therapists. [Campbell K. et al; 2020]
• Many patients bring with them from their past experiences of abuse, trauma, neglect, and rejection from families, friends, and previous healthcare providers. • Building a trusting relationship with the patient can therefore prove quite a difficult challenge, but is nevertheless indispensable if we are going to succeed in the treatment.
• Despite the lack of empirical evidence, a strong therapeutic alliance is a good candidate among potential suicide preventive aspects of treatments. • One of the factors that seem to strengthen a therapeutic alliance is for the patient early in the treatment to notice progress and increased coping, however small this improvement may be. • However, setting too ambitious targets early in the treatment may work in the opposite direction.
WHAT TREATMENT WORKS FOR BPD PATIENTS? • About 40 randomized (RCT) and nonrandomized controlled studies on psychosocial treatments of BPD patients have been published covering dialectical behaviour therapy, various forms of cognitive behaviour therapy, problem solving therapy, psychodynamically oriented psychotherapy and combinations. [Unruh BT. et al; 2016]
• Nearly 30 RCTs on pharmacological treatments have been published. All of these studies have recently been reviewed by the NICE in UK. • According to recommendations from NICE, BPD patients should be offered psychosocial treatments in the form of a structured care based on an explicit and integrated theoretical approach used by both the treatment team and the therapist.
• Lengthy, intensive, and expensive treatment models may have their limitations in many settings and require high motivation, good funding, and long-term commitment in order to succeed. • To be realistic, we should admit that there is a need to develop shorter and less resource-demanding alternatives for those patients and those clinical settings who are unable or not motivated to embark on long-term treatment programs.
HOSPITALIZE OR NOT TO HOSPITALIZE • BPD patients are high users of inpatient treatment. There is, however, no evidence that long-term hospitalization is effective in the treatment of BPD. • Most experts suggest that if hospital admission is needed, it should be brief and focus on crisis management. • Clinicians often find the question of hospitalization one of the most problematic decisions to make in the management of suicidal crises in BPD patients. [Campbell K. et al; 2020]
• This decision carries risks in several ways. There is the real risk that the patient – if not protected by the hospital environment – may actually commit suicide. • If hospitalized, on the other hand, the problems may actually become worse, through negative interplay with staff or fellow patients – leading to escalating suicide threats, self-mutilating or suicidal behavior.
• This may lead to extended admissions or premature discharge. Some patients will rapidly adapt their problem-solving strategies, once hospital treatment has been introduced to them as an option. • Having experienced that the hospital staff in general will respond to their suicidal behavior with the provision of increased support and attention, there is a danger that they will become shaped to use suicidal behavior as a strategy for obtaining psychological support.
• Hence, there are reasons to seek to avoid hospital admission. • If the need for protection makes hospitalization unavoidable, this intervention should be brief and it is recommendable to set a fixed date of discharge (‘next morning’ or ‘over the weekend’) and clearly inform the patient and her family about this. [Campbell K. et al; 2020]
SUICIDE IN BORDERLINE PERSONALITY DISORDER • The incidence of completed suicide in borderline personality disorder (BPD) has been unknown until recently. • In two long-term follow-up studies of borderline patients treated in residential settings, McGlashan and Stone et al. found that 3% and 9%, respectively, of borderline go on to complete suicide. [Mehlum L.; 2009]
• Patients with BPD represent 9.33% of all suicides. Mehlum et al. pointed out that a lack of control of high intensity affects such as depression, anxiety or anger may increase the tendency towards suicidal behavior. Thus the notion of BPD as ‘‘the suicidal personality disorder’’ may be justified. • On the other hand, the self-destructive tendency in subjects with BPD may not primarily be due to the personality disorder (PD) syndrome itself but rather be caused by some secondary or coexisting mental disorder.
CHALLENGES IN MANAGING SUICIDAL CRISES • When managing suicidal crises clinicians are generally faced with three challenges:  To protect the patient against repetition of attempted suicide and suicide or irreversible injury.  To reduce the patient’s profound feeling of hopelessness.  To elevate the patient’s subjective experience of quality of life. [Mehlum L; 2009]
ADDITIONAL CHALLENGES IN MANAGING SUICIDAL CRISES WITH BPD PATIENTS • For clinicians facing this type of situation with BPD patients, there are additional challenges:  To help the patient as quickly as possible to return emotionally to a more acceptable level of arousal and mental functioning.  To manage the crisis in the short term perspective in a way that does not increase the risk of suicidal behaviors in the long term perspective. [Mehlum L.; 2009]
MANAGEMENT OF SUICIDAL CRISES • One key to this is to distinguish between suicide attempts on the one hand and non-suicidal intentional self-harm on the other, even though the line between these two cannot be sharply drawn. • Patients can learn how to monitor their urges to self-harm and suicidal behavior and to distinguish between these. • When crises emerge this may become very useful with respect to what intervention approach to adopt. [Mehlum L.; 2009]
• Another strategy that may facilitate crisis management is for the patient and therapist early in the treatment to work out a safety plan describing which high-risk situations or emotional states the patient needs to be aware of.
DISTINGUISHING SUICIDAL FROM NON- SUICIDAL DELIBERATE SELF-HARM EVENTS • Within BPD populations, DSH is a common, though maladaptive, and often dangerous coping strategy used by individuals who experience extreme distress and who have not been able to utilize a more constructive approach to managing their distress. [Maddock GR.; 2010]
• Changes in attitude toward DSH by clinicians may improve the treatment experience of those who self-harm and therefore make treatment compliance a more attractive option for the patient. • Patients with BPD and DSH may engage in both NS-DSH and S- DSH events at different times, are motivated by a range of reasons, may or may not seek treatment, and are also at increased risk of subsequent suicide.
• SPECIFIC COUNTERTRANSFERENCE REACTIONS  Guilt Feelings  Rescue Fantasies  Transgressions of Professional Boundaries  Rage and Hatred  Helplessness and Worthlessness  Anxiety and Terror • Countertransference in the psychotherapy of borderline patients must be viewed as a source of valuable diagnostic and therapeutic information and not simply as interference with the therapeutic process. [Gabbard GO.; 1997] OTHER CHALLENGE
THE ROLE OF PROJECTIVE IDENTIFICATION • Ogden has defined it as a three-step procedure in which the following events occur: 1 An aspect of the self is projectively disavowed by unconsciously placing it in someone else. 2. The projector exerts interpersonal pressure that coerces the other person to experience or unconsciously identify with what has been projected. 3. The recipient of the projection (in the therapeutic situation) processes and contains the projected contents leading to a reintrojection of them by the patient in modified form.
PHARMACOLOGICAL CHALLENGES • Comorbidity with other mental disorders is common in individuals with BPD. • The prevalence of these comorbid disorders tends to decrease gradually over time in parallel with the clinical improvement of the typical symptoms that characterize BPD. • No drugs have yet been approved specifically for the treatment of BPD. [Pascual JC. et al; 2023]
• Nonetheless, various medications are routinely prescribed of label for this condition despite the lack of agreement among clinical guidelines. • Comorbidity between BPD and other psychiatric disorders is considered to be the main factor associated with both pharmacological treatment and polypharmacy in these patients.
CONCLUSION
• In conclusion, managing Borderline Psychopathology presents unique clinical challenges due to the complex and often unpredictable nature of the disorder. • It requires a comprehensive and individualized approach that incorporates psychotherapy, medication management, and support from a multidisciplinary team. • Despite the difficulties, with proper treatment and support, individuals with Borderline Psychopathology can experience significant improvements in their symptoms and quality of life.
• Continued research and collaboration among mental health professionals are essential to further enhance our understanding and management of this challenging disorder. • It is crucial for clinicians to stay updated on the latest evidence- based practices and to adapt their treatment strategies to meet the specific needs of each patient. • By providing a holistic and personalized approach to care, we can help individuals with Borderline Psychopathology navigate their symptoms and work towards improved mental health and well- being.
THANK YOU