Chapter 12 Borderline Personality Disorder Kim L. Gratz, Ph.D. Director, Personality Disorders Division

1. Chapter 12 Borderline Personality Disorder Kim L. Gratz, Ph.D. Director, Personality Disorders Division Center for Addictions, Personality, and Emotion Research University of Maryland

2. Borderline Personality Disorder: Diagnostic Criteria • Frantic efforts to avoid real or imagined abandonment • A pattern of unstable and/or intense interpersonal relationships • Persistent and markedly unstable self-image or sense of self • Impulsivity in at least two potentially self-damaging areas (e.g. substance abuse, binge eating, sex) • Recurrent suicidal behavior, gestures, or threats, and/or self-injury • Intense, usually brief, mood swings • Chronic feelings of emptiness • Inappropriate, intense anger • Transient, stress-related paranoid ideation or severe dissociation • [To meet criteria for BPD, must meet 5+ criteria]

3. BPD: Differential Diagnosis • Depression • Chronic vs. acute mood symptoms • Persistent behavioral and interpersonal dysfunction not specific to depressed mood • Depression resolves after BPD remits • Psychosis • Quasi-psychotic symptoms vs. psychotic symptoms • level of disconnection from reality

4. BPD: Differential Diagnosis • PTSD • Criterion A event vs. less acute/severe stressor • Onset and duration of symptoms • Pre-trauma vs. post-trauma functioning • Presence of re-experiencing symptoms • Nature of interpersonal difficulties (trauma-related vs. not) • Emotional triggers (trauma-related vs. interpersonal) • ASPD • Impulsive behaviors within relationships more likely to be driven by fears of abandonment • Excessive guilt and shame about impulsive acts • Harm more likely to be directed inward, rather than outward

5. Borderline Personality Disorder • Elevated risk for self-destructive behaviors • 10% commit suicide • 80% self-injure • Risky sexual behaviors, disordered eating, substance abuse • Associated with many other psychiatric disorders • Mood disorders ( > 80%) • Anxiety disorders (> 80%), including PTSD (> 50%) • Substance use disorders (> 50%) • Other personality disorders, esp. anxious cluster (> 50%)

6. Borderline Personality Disorder • Course • Developmental origins in early childhood • Many patients with BPD report having experienced BPD-related symptoms (e.g., self-injury, emotional lability, fears of abandonment)years before diagnosed • Usually diagnosed in late adolescence/early adulthood • Historically considered to be “life-sentence,” but research suggests a more hopeful, positive prognosis • ~75% of BPD inpatients remit within 6 years • Low rates of recurrence (< 6%)

7. Borderline Personality Disorder • Course: Predictors of failure to remit • Anxiety cluster personality disorder (e.g., avoidant) • May reflect underlying anxious-inhibited temperament • Substance use disorders • PTSD • Mood or anxiety disorder • Eating disorder

8. Borderline Personality Disorder • Risk factors • BPD results from combination of biologically-based vulnerabilities and childhood environmental stressors • Biologically-based vulnerabilities • Affective dysfunction • Impulsivity • Insecure attachment • Environmental stressors • Childhood abuse • Emotional/physical neglect, emotional invalidation • Early prolonged parental separation and/or loss (e.g., absence of parent, parental illness, parental death)

9. Treatments for BPD • Dialectical Behavior Therapy • Empirically-supported cognitive-behavioral therapy composed of both individual and group treatments • Associated with reduced self-injurious/suicidal behaviors, substance abuse, and anger, fewer hospitalizations, higher global functioning • Treatment targets four different areas • Emotion Regulation • Distress Tolerance • Interpersonal Effectiveness • Mindfulness

10. Treatments for BPD • Dialectical Behavior Therapy: Treatment Domains • Emotion Regulation • Increasing emotional awareness and clarity • Decreasing emotional vulnerability • Learning adaptive strategies for modulating emotions • Distress Tolerance • Distraction • Self-soothing • Acceptance/willingness

11. Treatments for BPD • Dialectical Behavior Therapy: Treatment Domains • Interpersonal Effectiveness • Getting your objectives met • Maintaining relationships • Maintaining self-respect • Mindfulness • “What” skills: Observing, describing, participating • “How” skills: Non-judgmentally, one-mindfully, effectively • Skills promote present moment focus, non-judgmental awareness, and attentional flexibility • Goal is to develop a lifestyle of participating with awareness