Borderline Personality Disorder

1. Borderline Personality Disorder -Presentation by: Cathy Rehfus-Wilsek Medical Student from All Saints University School of Medicine September 2011

2. Borderline Personality Disorder • Definition: • “Borderline personality disorder is a condition in which people have long-term patterns of unstable or turbulent emotions, such as feelings about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships.” • Source: National Center for Biotechnology Information, U.S. National Library of Medicine http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001931/

3. Borderline Personality Disorder Epidemiology: -Borderline personality disorder (BPD) has a higher prevalence than previously considered within the general population, approximately 6%. There seems to be an equal prevalence among women and men, where as before it was considered more prevalent among women. -Additionally, BPD is often seen with comorbidities most commonly: -Bipolar disorder -Narcissistic personality disorder -Schizotypal -Substance abuse (drugs and/or alcohol)

4. Borderline Personality Disorder • Pathogenesis: • -The actual mechanism of disease in borderline personality disorder is not fully • known or understood. However, there is a strong genetic and family • component as well as social factors or environmental causes. • -Risk factors include but are not limited to: • -Abandonment in childhood or adolescence • -Disrupted family life • -Poor communication in the family • -Sexual abuse

5. Borderline Personality Disorder Borderline Personality Disorder Diagnosis DSM-IV Diagnostic Criteria 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: (1) Frantic efforts to avoid real or imagined abandonment. (2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. (3) Identity disturbance: markedly and persistently unstable self-image or sense of self. (4) Impulsivity in at 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. (5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Borderline Personality Disorder Borderline Personality Disorder Diagnosis (Cont.) DSM-IV Diagnostic Criteria (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). (7) Chronic feelings of emptiness. (8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). (9) Transient, stress-related paranoid ideation or severe dissociative symptoms. John Gunderson, M.D., adds that borderline may be subdivided into these four phenotypes: (1) Interpersonal hypersensitivity (criteria 1, 2 and 7) (2) Affect (emotional) dysregulation (criteria 6, 8 and 7) (3) Behavioral dyscontrol (Impulsivity) (criteria 4 and 5) (4) Disturbed self (criteria 3 and 9)

7. Borderline Personality Disorder Treatment: -There are no specific medicinal treatments for BPD, however in cases of comorbidity, certain mood stabilizing drugs may be of significant aid to reduce or alleviate symptoms. -Most effective treatment options: -Dialectical behavioral therapy -Group therapy -Optional medications

8. Borderline Personality Disorder Treatment: (Cont.) -Dialectical behavioral therapy -A component of cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT) gives importance to the psychosocial aspects of treatment. -There is strong evidence that some BPD patients react in a more intense and ‘out-of- the-ordinary’ manner than the general population when placed in certain emotional circumstances, most commonly relating to family and friends, but especially in romantic partnerships situations. -DBT theory works to reduce BPD patient’s stimulation levels in these conditions, while assisting them in decreasing the time required for their return to a baseline arousal level.

9. Borderline Personality Disorder Treatment: (Cont.) -Group therapy -This form of treatment offers psychotherapy in a setting of one therapist and a certain number of patients with similar or related conditions. -Sometimes the group format is better suited for a BPD patient than individual therapy possibly due to the ability to understand they are not alone with their condition and may receive better insight from fellow suffers of the same disorder. -There has been evidence that receiving feedback from group members will help BPD patients deal in a more socially acceptable manner in these stressful situations. **The problem for many of these patients is that they tend not to seek psychotherapeutic help, either in individual or group settings. If they have, they dismiss the process with a splitting reactionary behavior mechanism i.e., ‘I had one bad experience therefore all therapist are bad, stupid, or unnecessary’**

10. Borderline Personality Disorder Treatment: (Cont.) -Optional medications -In recent years there have been studies showing the lack of response of BPD patients on SSRI therapy. Currently the medications of choice are the atypical antipsychotic (see list with MOA below) or even mood stabilizing drugs. -There are two points that should be noted: -BPD patients should NOT receive benzodiazepines as they have been shown to increase length and intensity of symptoms -Medication alone has been shown to be ineffective. Patients should also receive some form of DBT or CBT

11. Borderline Personality Disorder Treatment: (Cont.) -Optional medications list -Atypical Antipsychotic Medications with MOA (partial list): -Aripiprazole (Abilify)- partial agonist D2, 5-HT1A, 5-HT2C; antagonist D3, D4, 5-HT2A, 5-HT7 -Asenapine (Saphris)- antagonist ALL serotonin, dopamine, histamine, & alpha adrenergic receptors -Clozapine (Clozaril)- while a dibenzo, there is high affinity for serotonin and dopamine receptors -Iloperidone (Fanapt)- antagonist serotonin and dopamine receptors -Olanzapine (Zyprexa)- antagonist serotonin and dopamine receptors -Paliperdone (Invega)- antagonist serotonin and dopamine receptors -Quetiapine (Seroquel)- antagonist serotonin and dopamine receptors -Risperidone (Risperdal)- antagonist serotonin and dopamine receptors -Ziprasidone (Geodon)- antagonist serotonin and dopamine receptors

12. Borderline Personality Disorder Prognosis and Complications: -Unfortunately borderline personality disorder is not curable, though in many patients the symptoms are controllable, through dialectic and cognitive behavioral therapy as well as adjunct pharmacotherapy. As previously stated, sadly many BPD patients do not seek or do not continue with therapy. -BPD patients have a constellation of complications, however, the most significant and important one to monitor for is suicidal behavior. It is estimated that up-to 10% of BPD patients have a successful suicide attempt and nearly 75% of all BPD have suicidal (or even homicidal/suicidal sometimes called crimes of passion) ideation. While almost 100% have done acts of self-harm. -The good news is that with therapy the incidence of suicide attempts and intervals between attempts decreases (see figure below).

13. Borderline Personality Disorder • Source: Grohol, J. Another Treatment for Borderline Personality Disorder. Psych Central. Retrieved on September 19, 2011, from http://psychcentral.com/blog/archives/2009/09/17/another-treatment-for-borderline-personality-disorder/

14. Borderline Personality Disorder Conclusion: Borderline personality disorder is a lifelong diagnosis. Patients are volatile, impulsive, and self destructive. That said, all is not lost for these patients. Advances in drug therapy and psychotherapy offer these patients the chance to live normal even happy existences. Coexisting in peace in what would have otherwise been chaos for them and the ones around them. If more BPD patients would seek the help that is available to them, the incidence of self-harm, suicide and homicide in this population could drop drastically. If you know someone who is thinking about suicide please call the suicide prevention hotline @ 1-800-273-8255

15. Borderline Personality Disorder References: Borderline personality disorder. National Center for Biotechnology Information, U.S. National Library of Medicine. Retrieved on September 9, 2011, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001931 Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ. 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. 2008;69(4):533–545. Grohol, J. Another Treatment for Borderline Personality Disorder. Psych Central. Retrieved on September 9, 2011, from http://psychcentral.com/blog/archives/2009/09/17/another-treatment-for-borderline-personality-disorder/ Gunderson, J. G. (2011). A BPD Brief: An Introduction to Borderline Personality Disorder Diagnosis, Origins, Course, and Treatment. National Education Alliance for Borderline Personality Disorder.

16. Borderline Personality Disorder References: (Cont.) Herkov, M. (2006). About Group Therapy. Psych Central. Retrieved on September 19, 2011, from http://psychcentral.com/lib/2006/about-group-therapy/ Psych Central. (2007). An Overview of Dialectical Behavior Therapy. Psych Central. Retrieved on September 19, 2011, from http://psychcentral.com/lib/2007/an-overview-of-dialectical-behavior-therapy/