Borderline Personality Disorder

Borderline Personality Disorder Matthew Gaskell Leeds Addiction Unit

Agenda • Personality • Personality Disorder • Borderline Personality Disorder • Management of BPD • LAU PD Care Programme

What do we mean by personality?

Personality • Enduring features that determine how we respond to life events & experiences; also provide convenient means by which others can label and react to us • Describes how we cope with & adapt and respond to life events: challenges, frustrations, successes & failures

Personality • While it is enduring in its core features we: • Evolve through experience • Learn new & effective ways of responding • Allows us to adapt with increasing success to life’s demands

What is a personality disorder?

Personality Disorder • Variations or exaggerations of normal personality attributes

Common Features of Personality Disorder • Start in childhood and adolescence • Pervasive through many situations • Not secondary to mental illness • Personal distress or adverse impact on others • Deviation from the cultural norm in cognition, affectivity, control of impulses, ways of relating to others

Personality disorder • Rarely learn to adapt their responses or learn new ones • Fixed and unchanging in dealing with life events • Despite negative consequences • Often unable to associate problems with their own inflexible ways of thinking/behaving

Specific Personality Disorder – Cluster A (odd) Paranoid sensitive, suspicious, combative about F60.0 about personal rights, bearing grudges, self important Schizoid emotionally cold, poor expression of F60.1 feelings towards others, fantasies and introspection, indifferent to praise or criticism

Specific Personality Disorder – Cluster B (dramatic) Antisocial irresponsible disregard for social norms, F60.2 intolerant, blame others, no guilt, aggressive Emotionally unstable – lack of impulse control, poor self Unstable image, emotional crises, extreme behaviour F60.3 such as self harm in response to crises Histrionics dramatisation, suggestibility, shallow and F60.4 labile emotions, seeking attention, seductiveness, easily hurt

Specific Personality Disorder – Cluster C (anxious) Anakastic self doubt, caution, preoccupied with detail F60.5 and rules, perfectionist, rigid, excessively conscientious, intrusive thoughts Anxious feelings of tension and anxiety, feel socially F60.6 inept, preoccupied with being criticised or rejected, need for physical security Dependent others make decisions, own need secondary F60.7 to others, unwilling to make demands on others, helpless when alone, need reassurance

Drug Services n=216 Alcohol Services n=62 3.7% 2.7% 0.9% 6.5% 4.8% 3.2% 30.1% 10.2% 15.8% 7.7% 3.6% 24.2% 11.3% 3.2% 9.7% 3.2% t 13.0% 0.9% 5.0% 8.1% 35.5% 3.2% 27.4% 16.1% Personality Disorder in last 12 months Cluster A Disorders Paranoid Schizoid Cluster B Disorders Antisocial Impulsive Borderline Histrionic Cluster C Disorders Anankastic Anxious Dependent Source: Bowden-Jones et al. (2004)

What is Borderline Personality? Read Claire’s story & see how many features you can identify

Criteria for BPD (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, as indicated by five or more of the following:

Criteria for BPD (DSM-IV) • Frantic efforts to avoid real or imagined abandonment; • A pattern of unstable and intense interpersonal relationships characterised by alternation between extremes of idealisation and devaluation;

Criteria for BPD (DSM-IV) • Identity disturbance: markedly and persistently unstable self-image or sense of self; • Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating);

Criteria for BPD (DSM-IV) • Recurrent suicidal behaviour, gestures or threats, or self-mutilation; • Affective instability due to a marked reactivity of mood (e.g. intense episodes of depression, irritability or anxiety that lasts only for a few hours or a few days); • Chronic feelings of emptiness;

Criteria for BPD (DSM-IV) • Inappropriate, intense anger or difficulty controlling anger (e.g. fraudulent displays of anger, constant anger, recurrent physical fights); • Transient, stress-related paranoid ideation or severe dissociative symptoms

So people with BPD: • Fall into close & conflict-ridden relationships even after a single meeting with someone; • Are just as likely to fall out with that person if they interpret the person’s behaviour as uncaring or not attentive enough • Are riddled with fear about being rejected and losing that relationship

So people with BPD: • Leads to rapid, ill-tempered mood changes if they feel things ‘are not going their way’; • Leads to: Regular & unpredictable shifts in self-image characterised by changing personal goals, values & career aspirations; prolonged bouts of depression, deliberate self-harm, suicidal ideation & actual suicide attempts and impulsive behaviour such as drug abuse, physical violence & inappropriate promiscuity

A challenge for practitioners • People with a diagnosis of BPD regularly access services in crisis and often self harm. They make intense demands on health professionals and will regularly repeat these demands, e.g. threatening suicide or self harm • These factors combined with drug or alcohol use make this group particularly challenging to work with

Diagnosis • Controversy exists about the label & how useful it is • Stigmatising • Stereotyping of women

Prevalence • 1-2% of general population • At least 3:1 ratio of women to men diagnosed (up to 75% are women) • 20% psychiatric admissions • Up to 10% suicide rate

Problems of diagnosis…BPD also meet diagnosis for: • A mood disorder – dep, bipolar (96.3%) • Anxiety disorder (88.4%) (panic = 47.8%; social phobia = 45.9%) • Substance abuse disorders (64.1%) • Eating disorders (53%) • PTSD (55.9%) – some clinicians see BPD as a form of PTSD • Zanarini et al. (1998)

Why do they present for treatment? Not for BPD… • Relationship problems • Depression (consistently experience loss or failure) • Anxiety (intense fears of rejection etc) • Self-harm, drug abuse, suicidal ideation/attempts – recurrent crises • Educational/vocational underachievement

Risk factors for BPD • Physical, sexual, verbal abuse & neglect in childhood (60-90%) Gabbard, 1990. • Sexual abuse (67-87%) Bryer, 1987. • Physical abuse (71% v 38% psychiatry patients) Herman et al., 1989. • Environmental instability • Parental substance abuse & promiscuity

Risk factors • Academic underachievement • Low intelligence & artistic skills Helgeland & Torgersen, 2004 • But…… 20% of BPD patients never report childhood abuse or neglect – therefore it is not a necessary condition for developing BPD

Theories • Biological • Seems to run in families • Twin studies – concordance rates of 35% in MZ twins & 7% of DZ twins (Torgerson et al., 2000) • Genetic analysis – traits of BPD (e.g. rapid mood changes) have strong inherited component

Theories • Biological • Closely related to Bipolar Disorder Spectrum (44% of BPD) - & we know there is a significant genetic component to bipolar disorder • Low levels of serotonin = associated with impulsivity & may account for regular bouts of depression • Some evidence for dysfunction in dopamine activity (has role in emotion processing, impulse control & cognition

Theories • Biological • Neuroimaging: abnormalities in frontal lobe functioning (impulsive behaviour) & limbic system, including the hippocampus and amygdala (controls & regulates emotions) • Not known if these are a consequence or biological cause of the disorder

Theories • Psychological • Focuses on the ‘invalidating environment’ and childhood trauma e.g. Object relations theory – experiences lead to developing insecure ego, low self-esteem, increased dependence & fear of separation/rejection. Respond in ways they have learned from important others. Engage in defence mechanism ‘splitting’ • Doesn’t explain why early experiences turn to BPD

Theories • Psychological Dysfunctional schemas (Young et al., 2003) APD & BPD score similarly high on childhood abuse & dysfunctional schemas = different manifestations of single underlying disorder? BPD = women; APD = men.

BPD & Substance Use What patterns of use do you see?

Patterns of use • Dependence • Episodic, impulsive use in response to experiencing intense emotions

Management of BPD Thoughts on how to manage them effectively?

Management & Treatment • Consistency – offer the stability to contrast the client’s lability of emotion & thinking • Try not to discharge or pass them around to other agencies or have multiple agencies involved • Proper and well defined boundaries carefully explained at onset

Management & Treatment • Long-term involvement (1 year+) • Reframing practitioner labels or beliefs “attention-seeker”; “manipulative”; “trouble-maker” • Practitioner resilience – tolerate repeated episodes of rage, distrust & fear – good at evoking anger in others/you • Therapeutic alliance – strong need to be accepted, understood, need safety

Management & Treatment • Offer united front to manage any splitting in your team/ward – don’t get hooked in & set firm limits/strict rules • Manage endings & transitions • Good crisis management planning

Management & Treatment • Pharmacotherapy (NICE) • Psychological – CBT/DBT (best evidence). BI not recommended. • Targets = engagement; cognitive restructuring; impulse control; emotion regulation; skills training; target reduction in self-destructive behaviour

NICE Guidelines for BPD

Key priorities for implementation Assessment & care planning • Community mental health services are responsible for routine assessment & treatment of BPD • Effective risk assessment and management • Co-ordinated care with specialists addictions • Treat addiction first or if BPD treatment started treat at same time (care co-ordinator) • Guidance regarding goal setting (ST/LT); crisis planning

Key priorities for implementation The role of psychological treatment • The service should use an explicit and integrated theoretical approach – shared with the service user • Provision for therapist supervision • Don’t use brief interventions specifically for the disorder or symptoms of it in services which fall outside the recommended spec

Key priorities for implementation The role of pharmacotherapy: • Drug treatment should not be used specifically for BPD or for the individual symptoms or behaviour associated with the disorder (e.g. repeated self-harm, marked emotional instability, transient psychotic symptoms) • Anti-psychotic drugs should not be used for medium or long term treatment of BPD • Review prescribed drugs with a view to reducing and stopping unnecessary drug treatment

Psychological therapies • Evidence base is relatively weak • Methodological problems – picture may improve with more effective studies • DBT and MBT are useful in reducing problems when combined with hospitalisation • Very brief interventions are not effective

Psychological therapies recommendations • Outpatient therapy should not be provided in isolation – needs to be part of structured programme with other support available and well trained staff • DBT recommended for recurrent self-harm in women

Pharmacotherapy • Methodological problems limits findings • Some evidence that some drugs can reduce symptoms such as anxiety, depression, anger, impulsivity • No evidence they alter the nature of the disorder in short or long term

Managing comorbidity • Community mental health services are responsible for routine assessment & treatment of BPD • Refer to appropriate service for major psychosis, dependence on alcohol or drugs, severe eating disorder • Treat depression, anxiety, PTSD within well-structured treatment for BPD

Outcomes • 50-75% in the long term no longer show enough symptoms to meet the diagnosis (with or without treatment)

Leeds Addiction Unit Personality Disorder Care Programme

Borderline Personality Disorder