Borderline Personality Disorder

1. Borderline Personality Disorder How to Recognize, Empathize, and Assist people with Borderline Personality Disorder (BPD) Jamie Miller, MSW, LCSW-C @ JMiller@JHHC.com

2. Goals of the Training: How common is the diagnosis of BPD? How can you identify people struggling w/ BPD (without over-identifying it)? How can you empathize with someone who has BPD? What are the �Dos� and �Don�ts� of effective communication with someone who has BPD?

3. How Common is BPD? 2% of the general population 75% of all people w/ BPD are women 90% of people w/ BPD will attempt suicide 10% of people w/ BPD will commit suicide 20% of all IP Psych patients have BPD 10% of all OP psych patients have BPD The A.P.A. The World Health Organization 2% = approximately 6 million Americans 16% have MDD/O 3-4% have Bipolar D/O BPD is even more common in adolescents and young adults between the ages of 18 and 35 Because personality is formed by the end of the third year of life, if you have the disorder as an adult, you had it as a child and adolescent A common misperception is that BPD SI and gestures are manipulative and non-lethal. We�ll talk more, in just a few minutes, about the BPD motivation and intent but it is generally not malicious Gestures are sometimes miscalculated Some gestures are complicated with SA which messes with inhibitions, anger levels, and lethality of gesture Acutely stressed and hopeless, a BPD will have every intent on dying.2% = approximately 6 million Americans 16% have MDD/O 3-4% have Bipolar D/O BPD is even more common in adolescents and young adults between the ages of 18 and 35 Because personality is formed by the end of the third year of life, if you have the disorder as an adult, you had it as a child and adolescent A common misperception is that BPD SI and gestures are manipulative and non-lethal. We�ll talk more, in just a few minutes, about the BPD motivation and intent but it is generally not malicious Gestures are sometimes miscalculated Some gestures are complicated with SA which messes with inhibitions, anger levels, and lethality of gesture Acutely stressed and hopeless, a BPD will have every intent on dying.

4. How do you Identify someone w/ BPD? Frantic efforts to avoid abandonment A pattern of unstable/intense relationships w/ extremes in idealization and devaluation Marked/persistent unstable self-image Impulsive/self-damaging behavior Recurrent suicidal behavior Affective instability Chronic feelings of emptiness Inappropriate/intense anger Paranoid ideation or dissociative symptoms DSM-IV criteria for BPD = must meet 5 or more from the slide Impulsive and Self-Damaging = i.e. promiscuous sex, substance abuse, excessive spending, binge eating, etc Affect = Your affect is what other people can see about how you feel Dissociative: not Multiple Personality or Dissociative Identity D/O Some level of depersonalization / de-realization Origin of the name �BPD� An easy way to think of BPD = BPD is a disorder of emotion regulation BPD is characterized by a pervasive instability of: Mood Interpersonal Relationships Self-image Behavior That frequently disrupts: Family and work life Long-term planning The individual�s sense of self-identity What is not BPD: New/different presentation (not pervasive, predictable, long-term) Help-rejecting complainers Presentation only in the presence of acute depression, anxiety, psychosis, or mania Your hopelessness about their potential for improvement Your annoyance with them Inordinate amounts of time being spent in team discussions/supervision on themDSM-IV criteria for BPD = must meet 5 or more from the slide Impulsive and Self-Damaging = i.e. promiscuous sex, substance abuse, excessive spending, binge eating, etc Affect = Your affect is what other people can see about how you feel Dissociative: not Multiple Personality or Dissociative Identity D/O Some level of depersonalization / de-realization Origin of the name �BPD� An easy way to think of BPD = BPD is a disorder of emotion regulation BPD is characterized by a pervasive instability of: Mood Interpersonal Relationships Self-image Behavior That frequently disrupts: Family and work life Long-term planning The individual�s sense of self-identity What is not BPD: New/different presentation (not pervasive, predictable, long-term) Help-rejecting complainers Presentation only in the presence of acute depression, anxiety, psychosis, or mania Your hopelessness about their potential for improvement Your annoyance with them Inordinate amounts of time being spent in team discussions/supervision on them

5. Case Example: Jackie: Please take up to five (5) minutes to read the case example of Jackie Much of the rest of the presentation will refer back to this case example (see handout) As an infant and child, Jackie was emotionally neglected by her parents. In attempts to help her feel like her needs were being met, Jackie developed very primitive skills to bring others close enough to her to help her feel connected. However, she�s always felt insecure and like her needs have never been met. Now that she is 32, Jackie is often initially seen as a bright, witty, and funny woman who can be the life of the party. She has always been able to build relationships easily. Her relationships start out intense, consuming, and she can�t say enough positive things about the person. However, she has always had a hard time maintaining these relationships. When a slight separation or conflict occurs, she angrily accuses the other person of not caring for her. Even with family members, she is highly sensitive to rejection and reacts with anger and distress to things like people taking a vacation or sudden changes in plans. Eventually, her relationships combust and disintegrate into nothing. In the end, she can only remember the relationship as having always been disappointing and lacking. Jackie has a pervasive fear of abandonment that stems from her difficulty feeling emotionally connected to important people when they�re not there. In fact, she�s always had a problem when an important person leaves (even temporarily). When they leave, she has difficulty remembering the feelings of security she had when they were present. She�s always had difficulty tolerating being alone, even for short periods of time. When alone, Jackie frequently feels lost, empty, and worthless. Jackie frequently adopts the interests and views of the people around her. She can, at times, adopt these interests and views so quickly that there can be very little evidence of her persona, prior to the relationship. Her intimate relationships frequently end in hateful exchanges that leave her feeling devastated and angry. Jackie fears the breakup of these relationships, almost from the start. Jackie has had a long history of job changes. She has never known what she wants to do with her life but she continues to feel compelled to define herself with a career; she just doesn�t know what she wants that career to be. Because of this, she continues to get jobs that she, initially, finds very fulfilling. For the first few weeks, she can�t say enough about her boss and coworkers. She talks up the company and shares her dreams about moving into roles with more and more responsibility. However, in time, Jackie perceives each direction given to her by her supervisor as an unfair criticism. She quickly begins to feel that her supervisor is out to "get her". She also becomes frustrated with her coworkers because she sees them as making lackluster efforts. To Jackie, it is clear that they just don�t like her and are picking on her. She eventually has conflict with her supervisor and peers. Sometimes she quits; disillusioned with the job and angry at, or disappointed with, others. Other times, she is fired. On one occasion, she believed that people at the office were trying to find a reason to fire her. This led her to react with rage. She yelled and swore at her boss; loudly and inappropriately complaining about how unfair the situation was. On another occasion, Jackie developed an intimate relationship with a coworker. In her fear that the coworker would end up abandoning her, Jackie started to follow and spy on him. In the end, she dramatically threatened to kill herself if he stopped seeing her. In both situations, Jackie was let go. Jackie has lived most of her adult life in widespread pain in her muscles, ligaments, and tendons. She has had chronic, intermittent fatigue for years. It took years of complaints and tests before her primary care physician gave her the diagnosis of Fibromyalgia. The current Fibromyalgia, her history of unexplained fainting spells, and her history of pseudo seizures have been concerns and annoyances for both her and her treatment team. She began drinking in her teens. Now that she is older and the chaos in her life has grown, she drinks more. She has been prescribed and has a history of busing narcotic pain medication. She sometimes drinks and abuse her medications to self-medicate her chronic pain. Other times, to dull the feelings and fears that have always plagued her. When Jackie is under the influence of drugs or alcohol, she dislikes herself less and her anger at others grows. In both her sober and intoxicated states, her anger has blown up in violent rages. Her frequent self-loathing has driven her to periodic self-mutilation, multiple suicidal gestures, and three serious suicide attempts when she became acutely angry at perceived abandonments and disappointments. As an infant and child, Jackie was emotionally neglected by her parents. In attempts to help her feel like her needs were being met, Jackie developed very primitive skills to bring others close enough to her to help her feel connected. However, she�s always felt insecure and like her needs have never been met. Now that she is 32, Jackie is often initially seen as a bright, witty, and funny woman who can be the life of the party. She has always been able to build relationships easily. Her relationships start out intense, consuming, and she can�t say enough positive things about the person. However, she has always had a hard time maintaining these relationships. When a slight separation or conflict occurs, she angrily accuses the other person of not caring for her. Even with family members, she is highly sensitive to rejection and reacts with anger and distress to things like people taking a vacation or sudden changes in plans. Eventually, her relationships combust and disintegrate into nothing. In the end, she can only remember the relationship as having always been disappointing and lacking. Jackie has a pervasive fear of abandonment that stems from her difficulty feeling emotionally connected to important people when they�re not there. In fact, she�s always had a problem when an important person leaves (even temporarily). When they leave, she has difficulty remembering the feelings of security she had when they were present. She�s always had difficulty tolerating being alone, even for short periods of time. When alone, Jackie frequently feels lost, empty, and worthless. Jackie frequently adopts the interests and views of the people around her. She can, at times, adopt these interests and views so quickly that there can be very little evidence of her persona, prior to the relationship. Her intimate relationships frequently end in hateful exchanges that leave her feeling devastated and angry. Jackie fears the breakup of these relationships, almost from the start. Jackie has had a long history of job changes. She has never known what she wants to do with her life but she continues to feel compelled to define herself with a career; she just doesn�t know what she wants that career to be. Because of this, she continues to get jobs that she, initially, finds very fulfilling. For the first few weeks, she can�t say enough about her boss and coworkers. She talks up the company and shares her dreams about moving into roles with more and more responsibility. However, in time, Jackie perceives each direction given to her by her supervisor as an unfair criticism. She quickly begins to feel that her supervisor is out to "get her". She also becomes frustrated with her coworkers because she sees them as making lackluster efforts. To Jackie, it is clear that they just don�t like her and are picking on her. She eventually has conflict with her supervisor and peers. Sometimes she quits; disillusioned with the job and angry at, or disappointed with, others. Other times, she is fired. On one occasion, she believed that people at the office were trying to find a reason to fire her. This led her to react with rage. She yelled and swore at her boss; loudly and inappropriately complaining about how unfair the situation was. On another occasion, Jackie developed an intimate relationship with a coworker. In her fear that the coworker would end up abandoning her, Jackie started to follow and spy on him. In the end, she dramatically threatened to kill herself if he stopped seeing her. In both situations, Jackie was let go. Jackie has lived most of her adult life in widespread pain in her muscles, ligaments, and tendons. She has had chronic, intermittent fatigue for years. It took years of complaints and tests before her primary care physician gave her the diagnosis of Fibromyalgia. The current Fibromyalgia, her history of unexplained fainting spells, and her history of pseudo seizures have been concerns and annoyances for both her and her treatment team. She began drinking in her teens. Now that she is older and the chaos in her life has grown, she drinks more. She has been prescribed and has a history of busing narcotic pain medication. She sometimes drinks and abuse her medications to self-medicate her chronic pain. Other times, to dull the feelings and fears that have always plagued her. When Jackie is under the influence of drugs or alcohol, she dislikes herself less and her anger at others grows. In both her sober and intoxicated states, her anger has blown up in violent rages. Her frequent self-loathing has driven her to periodic self-mutilation, multiple suicidal gestures, and three serious suicide attempts when she became acutely angry at perceived abandonments and disappointments.

6. Review of Case Example: Jackie has the following S/Sxs of BPD: Frantic efforts to avoid abandonment Unstable/intense relationships Unstable self-image Impulsive & self-damaging Recurrent suicidal behavior Affective instability Inappropriate/intense anger Stress related paranoid thinking suicidal ideation w/ co-worker boyfriend no long-term friends & idealization/devaluation w/ all adopts others� interests � sense of self is missing in the absence of others substance abuse (ETOH and Pain Meds) and self-mutilation suicidal gestures and suicide attempts family taking vacation rage episodes at work Boss and co-workers are out to get me fired suicidal ideation w/ co-worker boyfriend no long-term friends & idealization/devaluation w/ all adopts others� interests � sense of self is missing in the absence of others substance abuse (ETOH and Pain Meds) and self-mutilation suicidal gestures and suicide attempts family taking vacation rage episodes at work Boss and co-workers are out to get me fired

7. How do you Empathize with BPD? Jackie has an expectation that her needs are not going to be met in any relationship Her needs are primative, preverbal, and are basic to anyone�s feelings of safety & security She feels misunderstood, mistreated, bored, �empty�, rejected, worthless, & she fears for her safety/security when left alone All of her S/Sxs feel and look worse when she feels isolated or �abandoned� There is no maliciousness to her behavior; only fear & anger that she�ll never have her basic needs met by others Mother cup: Baby cries until held � able to go without holding for longer periods of time as it ages Child runs and plays with strangers for a little while � fills the cup � runs back - slowly drains Watch your perceptions: Needy Bottomless pit Annoying Difficult Manipulative Malicious Evil BPDs tend to be pretty smart (It takes a fair amount of intelligence to develop a personality D/O) Your perceptions will come out in what you say and doMother cup: Baby cries until held � able to go without holding for longer periods of time as it ages Child runs and plays with strangers for a little while � fills the cup � runs back - slowly drains Watch your perceptions: Needy Bottomless pit Annoying Difficult Manipulative Malicious Evil BPDs tend to be pretty smart (It takes a fair amount of intelligence to develop a personality D/O) Your perceptions will come out in what you say and do

8. How do you Assist someone w/ BPD? Be clear about & maintain your boundaries Know your role in the relationship Know your �buttons� and limits Know you are never the idealized or the devalued object Have insight to & empathy w/ the feelings & experiences of the person with BPD Practice active listening and be prepared to calmly repeat your message in several ways Encourage/motivate for active treatment Dialectical Behavioral Therapy (DBT) Anti-Depressant, Mood Stabilizing, and/or Anti-Psychotic medications are helpful First Because miscommunication w/ people w/ BPD is PERVASIVE, it is important to� Boundaries = This means �No Hugging� !! Buttons = Counter-transference Last Add a therapist to the treatment team Any psychodynamic and/or cognitive/behavioral therapy can help Get a psychiatric/medication evaluation with a psychiatrist These meds can improve emotional symptoms, decrease the intensity of mood swings, and can help with reality testingFirst Because miscommunication w/ people w/ BPD is PERVASIVE, it is important to� Boundaries = This means �No Hugging� !! Buttons = Counter-transference Last Add a therapist to the treatment team Any psychodynamic and/or cognitive/behavioral therapy can help Get a psychiatric/medication evaluation with a psychiatrist These meds can improve emotional symptoms, decrease the intensity of mood swings, and can help with reality testing

9. Assisting (slide #2): Own & acknowledge your mistakes Model appropriate emotional & behavioral control Validate the feelings/perceptions of BPD while introducing consensual perception (reality) Have a 24/7 safety plan in place Be sensitive to & predict situations that could be perceived as abandonment I.e. vacations, changes in appointments, etc Identify your �call to self-defense� as a clue there�s been a miscommunication

10. Assisting (slide #3): Remember: BPD behaviors are primitive/mal-adaptive ways of getting the security they need Not intended to be manipulative/malicious Violence can occur (to the self & others) when acutely stressed Be prepared, trust your gut, have a plan Give people with BPD a transitional object during separations A business card An appointment card Transitional Object = refer back to the mother cup constructTransitional Object = refer back to the mother cup construct

11. For More Information on BPD: Jerold J. Kreisman M.D., Hal Straus. I Hate You, Don't Leave Me: Understanding the Borderline Personality (Avon Books [Harper Collins Publishers], 1989) Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72. Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67. Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403. Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7. Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.

12. More Information (continued): Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4). Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104. Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101. Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89. Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation - a possible prelude to violence. Science, 2000; 289(5479): 591-4.www. Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press. nimh.nih.gov www.borderlinepersonalitytoday.com