Borderline Personality Disorder

1. Borderline Personality Disorder

2. Borderline Personality Disorder: As Defined by DSM-IV • “…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.” (p. 650). • Defining features: • efforts to avoid abandonment • unstable interpersonal relations • Unstable affect • Unstable identity • impulsive, self-damaging behavior • suicidal and/or parasuicidal behavior • problems with anger • paranoia or dissociation in response to major stressors

3. Borderline Personality Disorder: A Disorder ofDysregulation(Linehan, 1993) • Cognitive • Paranoia, suspiciousness, and dissociation when under stress • Interpersonal • Unstable interpersonal relations, fears of abandonment, frantic efforts to avoid abandonment.

4. Borderline Personality Disorder: A Disorder ofDysregulation • Emotional • Intense anger and difficulty controlling anger • Emotional instability/ mood reactivity • Behavioral • Self-destructive impulsive behavior • Suicidal and self-harm behavior

5. Borderline Personality Disorder: A Disorder ofDysregulation Why study BPD?

6. HIGH RISK BEHAVIOR AND HEALTH SERVICE UTILIZATION • Prevalence of BPD: 0.2% - 1.8% • Up to 20% of psychiatric inpatients • Up to 38% of successful suicides • Up to 10% of BPD individuals commit suicide • 80% of them self-harm. • 75% have attempted suicide. • When the parasuicide criterion is removed, most (86%) BPD individuals retain their diagnosis and still demonstrate more serious suicide attempts than depressed individuals (Friedman, Aronoff, Clarkin, Corn, & Hurt, 1983).

7. Research on the Course of BPD • Generally Shows Unstable Course for More Extreme Behaviors • Some studies have found that up to 75% of BPD individuals no longer meet criteria for the disorder after a 6-year period (i.e., Zanarini et al.) • Studies generally suggest that the features of interpersonalinstability and emotional vulnerability/instability are more stable across time. • Crisis behaviors, such as suicidal and self-harm behavior are more likely to “remit”. • Other forms of impulsivity, such as binge-eating, verbal outbursts, and spending sprees remained more consistent over time. • Onset of significant BPD features tends to be in mid to late childhood.

8. Linehan’s (1993a) Biosocial Theory of Borderline Personality Disorder (BPD) Emotion Vulnerability Environmental Invalidation Problems with Emot. Regulation

9. Emotional Vulnerability Heightened Sensitivity Heightened Reactivity Slow Return to Baseline Emotional Stimuli Emotion Dysregulation Impulsive & Risky Acts Distress Intolerance Attentional Dyscontrol

10. Research on BPD • Generally Supports Biosocial Model • Higher negative affect intensity (Levine et al., 1997) • More dysphoria (Zanarini et al., 1998) • Neuroticism & Anxiety (Farmer & Nelson-Gray) • High rates of mood disorders (Jonas & Pope, 1992). • Sensitivity to facial emotion expressions (Wagner & Linehan, 1999) • Difficulty forgetting emotional stimuli (Korfine & Hooley, 2000). • Compared to healthy controls, states of aversive tension occurred significantly more often in patients with BPD. The average levels of tension were significantly higher and the increase of tension was markedly more rapid. Stiglmayr et al. (2001)

11. Recent Psychophysiology and Neurobiology Studies • Mixed Support for Biosocial Model • PTSD people show reduced hippocampal volumes, whereas BPD individuals show reduced amygdala and hippocampal volumes. • Some studies have actually shown less emotional sensitivity among borderlines as compared with normal controls and persons with avoidant personality disorder. • In contrast, Stiglmayr et al. (2001) found that BPD patients had significantly greater heart rates in response to emotional stimuli under daily life conditions, compared to healthy controls. • Research from the lab of Dr. Martin Bohus has found that BPD patients displayed significantly higher salivary cortisol levels than healthy controls, as demonstrated by higher total cortisol in response to awakening and higher total daily cortisol levels.

12. EMOTION REGULATION “… the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions.” (Gross, 1998, p. 275)

13. Tasks in Emotion Regulation(Gottman & Katz, 1990) 1.Decrease (or increase) physiological arousal associated with emotion 2. Re-orient attention 3. Inhibit mood-dependent action 4. Organize behavior in the service of external, non-mood dependent goals

14. EXPERIENTIAL AVOIDANCE • Behavior that functions to avoid or escape from particular internal experiences or external conditions that elicit them. (Hayes et al., 1996)

15. Attempt to avoid or escape the dreaded emotion Avoidance Paradigm PAST HISTORY • SUICIDAL BEHAVIOR • SELF INJURY • DRUGS/ALCOHOL • BINGE/PURGE • RECKLESS BEHAVIOR • ISOLATION • OVER EATING EMOTIONAL DISTRESS DEPRESSION SADNESS FEAR ANXIETY ANGER SHAME GUILT EMPTINESS HELPLESSNESS CURRENT ENVIRONMENTAL TRIGGERS TEMPORARY RELIEF But…Rebound Effect (Wegner, 1994) Repeated avoidance or escape confirms that the emotion is Unbearable and allows no opportunity for new learning These attempts to avoid create a vicious circle. THE “SOLUTION” IS THE PROBLEM, NOT THE EMOTION ITSELF.

16. Evidence for Avoidance in Self-Harm • Research • Carr (1977) • Self-injury can be maintained through negative reinforcement • Reduced by extinction procedures • Haines et al. (1995) • Self-harming persons exposed to imagery related to most recent episode of self-harm • Reduction in phys arousal. • Non self-harmers showed increase in arousal to self-harm imagery • BPD, self-harm, and avoidance • BPD persons report self-harm often functions to reduce negative emotions: anxiety, anger, tension (Brown, Linehan, & Comtois). • BPD persons with disorders characterized by avoidance behaviors have higher rates of self-harm (i.e., bulimia, substance use).

17. BPD, Self-Harm, Avoidance • Due to poor emotion regulation skills, BPD individuals may rely on destructive avoidance coping strategies. • Self-harm and suicidal behavior have been proposed to fit within the response class of avoidance behavior (Hayes et al., 1996; Linehan, 1993). • The strength of the repertoire of avoidance behavior should predict self-harm.

18. Evidence for Psychological Distress in Suicidal Behavior • Hopelessness, Depression, and Current Stressors • Recent suicide attempters have lives characterized by an unusually high number of stressful events (Cochrane & Robertson, 1975; Power et al., 1985). • Imprisonment, recent admission to inpatient units, bereavement • 15% of fatalities in mood disorders are suicide. Depression is a strong risk factor. • Hopelessness is perhaps the most robust risk factor for suicidal behavior (Beck et al., 1993).