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Borderline Personality Disorder

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Umamah W. Zia

on 16 December 2015

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Transcript of Borderline Personality Disorder

Borderline Personality Disorder
Amna Zain, Hasham Tahir, Noreena Akbar, Shakila Amin,
Umamah Wajid, Zarnosh Nawaz
Introduction
History
Initial recognition by Homer, Hippocrates & Aretaeus.
Revived by Swiss physician, Théopole Bonet in 1684.
C. Hughes in 1884 & J.C Rosse in 1890 -
"borderline insanity"
Adolf Stern in 1938 - use the term "borderline": mild form of schizophrenia
1960s & 1970s - shift from borderline schizophrenia to borderline affective disorder
Considered to be on the fringe of bipolar disorder, cyclothymia and dysthymia
What Does "Borderline" Mean?
An indefinite area intermediate between two qualities or conditions, verging on a given quality or condition.
Known as “Borderline Personality Disorder” because it was originally thought that people were on the 'border' of psychosis and neurosis.
BPD is also sometimes called “Emotionally Unstable Personality Disorder.”
DSM History
DSM II – Cyclothymic Personality (Affective Personality).
DSM III – Became a personality disorder distinguished from sub-syndromal schizophrenia.
DSM IV – APA decided on the name “Borderline Personality Disorder”.
DSM-5 – Still applies.
Debate over term “Borderline”.

Definition
“Borderline Personality Disorder is a personality disorder that is characterized by impulsivity and instability of behaviors, moods, interpersonal relationships and self-image."
Elements of BPD
People with BPD usually suffer from:
Problems regulating emotions and thoughts
Impulsive and reckless behavior
Unstable relationships with other people
Also often include symptoms such as suicidal behaviors, self-harm, intense fears of abandonment, extreme anger, irritability & idealization and devaluation of others.
Five Main Types of Borderline Personality Disorder
Affective Borderline
Impulsive Borderline
Aggressive Borderline
Dependent Borderline
Empty Borderline

Intense feelings of bitterness and self-hatred.
Attention-seeking behavior.
Generally high-strung and moody.
Self-destructive behavior ranges from reckless driving & substance abuse to eating disorders and risky sexual behavior.
Affective Borderline
Prone to erratic actions.
Energetic & Charismatic at times, Cold & Hostile at other times.
Easily bored.
Engage in reckless behavior and thrill-seeking activities.
Lack of impulse control, suicidal behavior.
Resistant to treatment.
Impulsive Borderline
Also referred to as the “Angry Subtype.”
Emotions ranging from low self-worth to explosive anger.
Fearful, anxious, possessive, controlling, jealous.
Fear rejection and abandonment.
Overprotective, irritable.
Substance abuse, eating disorders.
Aggressive Borderline
Also known as the “discouraged” type.
Clingy, passive and reliant on others.
Turn feelings of anger inward.
Self-mutilation and suicidal behavior.
Intolerance of being alone.
Dependent Borderline
Lack of stable sense of self.
Identity disturbance.
Reflects inconstant early parenting.
Chronic feelings of emptiness.
Empty Borderline
Symptoms and Diagnosis
Diagnosis
Self reported experiences of the client.
A comprehensive personal and family history.
A physical examination.
Blood test to exclude HIV and SYPHILIS.
EEG,CT scan to exclude epilepsy and brain lesions.
Mental state examination.

DSM III
In 1980-first time BPD was listed as a diagnosable illness.
Overlapping symptoms therefore “BORDERLINE”
Schizophrenia (psychotic) :periods of psychosis/ paranoia.
Bipolar (neurotic):affective instability and impulsivity.
Historically ,the three major symptoms were:
1-Problems regulating emotion and thoughts.
2-Impulsive /reckless behaviour.
3-Unstable relationships with people.

DSM IV
In 1994 classic 9 >5:
 To be diagnosed with BPD you must exhibit frequently at least five of these nine symptoms:
1.Extreme reactions
2.Pattern of intense ,stormy relations.
3.Distorted ,unstable self images.
4.Impulsive ,risky behaviours.
5.Recurring suicidal behaviours or threats or self harm.
6.Intense and highly changeable moods.
7.Chronic feelings of emptiness or boredom.
8.Inappropriate intense anger or issues controlling it.
9.Stress-related paranoia ,dissociative symptoms.

Symptoms
BDP is a complex disorder and those suffering from it often show symptoms of other mental illnesses such as anxiety disorders, depression, eating disorders and drug and substance abuse.
The symptoms of BDP include:

Intense feelings of insecurity
Idealising or devaluing other people
Excessive reassurance seeking behaviour
Difficulty compromising
Feelings of abandonment and loss
Self-harm
Impulsive and potentially harmful behaviour such as excessive spending, unsafe sex or substance abuse
Intense outbursts of anger
Anxiety and depression.

Etiology of BPD
Biological Factors
Developmental Factors
Social Factors
Psychological Factors
Biological Factors
Highly inheritable approx 45%
May play a role in impulsivity and emotional dysreguation


Hippocampus:
The hippocampus tends to be smaller in people with BPD
Amygdala:
The amygdala are smaller and more active in people with BPD
Prefrontal cortex:
The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment
Neurotransmitter:
Hyperactivity in serotonin level

Genetics:
Brain Abnormalities:
Developmental Factors
Biosocial Developmental Diathesis Stress Model
Psychoanalytic Theory of Object Relation
Linehan's Diathesis Stress Theory
Marsha Linehan provided the theory in 1993.
Individual with BPD have difficulty controlling their emotions
-possible biological diathesis
Family invalidates or discounts emotional Experience and expression
Interaction between extreme emotional reactivity and invalidating family BPD
Linehan's Diathesis Stress Model
Kernberg's theories on Borderline Personality disorder:
Occurs during the third stage of development(the differentiation of self from object relations).
Kern berg postulated a theory based on a phenomenon he describes as splitting.
Splitting occurs when development is disrupted in the third stage. The child responds by splitting
The aggressive self-objects away from the good self objects
This results in unrealistic views of others, as they are seen only in black and white…good or bad.

Social Factors
Family environment:
An unstable family environment predicts the development of the disorder, while a stable family environment predicts a lower risk
Childhood trauma:
Strong correlation between child abuse and development of BPD
Early maternal separation
Psychological Factors
Personality:
Traits that include impulsiveness and aggression may play a role in the development of borderline personality disorder. E.g Type A personality

Emotionally vulnerable people

Negative thoughts
Co-Morbidities
Borderline personality disorder often occurs with other illnesses. These include:

Major Depressive Disorder
Dysthymia
Substance Abuse
Eating Disorders
Bipolar Disorder
Antisocial Personality Disorder
Narcissistic Personality Disorder
Self-Injury
Treatment
Dialectical Behavior Therapy
A type of talking therapy.
A modification of Cognitive Behavioral Therapy.
Developed by Marsha Linehan
Based on the concept that the symptoms of borderline disorder are the result of inherent biological impairments in those brain mechanisms that regulate emotional responses.

Decreasing suicidal behaviors
Decreasing those behaviors that interfere with therapy and the quality of life
Increasing behavioral skills
Primary Behavioral Targets of DBT:
Skills taught in DBT
Mindfulness: the practice of being fully aware and present in this one moment
Distress Tolerance: how to tolerate pain in difficult situations, not change it
Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
Emotion Regulation: how to change emotions that you want to change
DBT consists of
Once a week individual psychotherapy
A two and one-half hour DBT skills training session conducted in a group setting
And substantial home work assignments.
In DBT, you are usually discouraged from using the hospital as a means of controlling emotional tension, as
The goal of treatment is to learn to manage the current emotional crisis in more effective ways.

Mentalization Based Therapy
Psychodynamically-oriented psychotherapy
Focus is helping people to differentiate and separate out their own thoughts and feelings from those around them.
In (MBT), the concept of mentalization is emphasized, reinforced and practiced within a safe and supportive psychotherapy setting.
The therapist focuses exclusively on the patient’s current thoughts, feelings, wishes and desires.
The therapist avoids discussions that are not linked to subjectively felt reality, thus emphasizing more on conscious information (the aim of therapy is not insight but increased mentalization)
Transference-Focused Psychotherapy
Focus of treatment is on a deep psychological make-up – a mind structured around a fundamental split that determines the patient’s way of experiencing self and others and the environment.
Initially focuses on your establishing with the therapist a behavioral agreement that deals with the likely threats that may occur in the course of the treatment, both to the treatment and to your well-being.
Therapy then moves on to modify primary psychological disturbances and reduce symptoms, mainly by examining, understanding and improving your interactions with your therapist.

Schema Focused Therapy
Commonly referred to as a modified cognitive-behavioral treatment.
Has been described by its developer as “a truly integrative psychotherapy” (Kellogg & Young, 2006, p. 446).
Schema therapy emphasizes the internalization of early relationships into cognitive-affective representations.
BPD is characterized by a predominance of certain maladaptive representations, known as early maladaptive schemas
SFT seeks to modify these schemas through the explicit use of interventions from various therapy models, including CBT, Gestalt, and Emotion-Focused Therapies (Kellogg & Young, 2006).
Cognitive-behavioral interventions include the use of Socratic dialogue, homework exercises, and recommendations for modifying maladaptive behaviors.
Mechanisms involved in SFT
“Limited re-parenting” by the therapist

Emotion-focused work–especially imagery and dialogues

Cognitive restructuring and education

Systems Training for Emotional Predictability and Problem Solving (STEPPS)
In STEPPS, borderline disorder is viewed as being a disorder of emotional and behavioral regulation, including perceptual disturbances such as all-or-nothing thinking (splitting).
The Stated Goals of STEPPS
Be fully manualized
Be easily taught and implemented in a variety of settings
Provide specific content/method for each session
Utilize a support system already in place
Be ‘value-added’
Group Therapy
Group therapy is utilized in addition to individual therapy
Group therapy is not intended to replace individual therapy for patients with borderline disorder
However, group therapy can serve to complement and to speed up the learning process of individual therapy.
It is particularly reassuring for patients to meet other people with the disorder, to listen to their accounts of how the disorder has affected them, to share problems, and to attempt to help one another deal more effectively with these problems by recounting new strategies that have been attempted, and the results of these attempts.
Group therapy is especially suitable for those patients with borderline disorder who do not engage in serious destructive behaviors, who are able to tolerate the emotional content of the sessions, and who have difficulties with interpersonal relationships.

Antipsychotic Agents
If one or more cognitive-perceptual symptoms are present and respond well to an antipsychotic agent, but other symptoms such as impulsivity and poor emotional control persist, the addition of another medication from the class of mood stabilizers is indicated.
Mood Stabilizers
Another class of medications, referred to as mood stabilizers, has been shown to significantly reduce certain symptoms in patients with borderline disorder.
These symptoms include impulsivity, anger, anxiety, depressed mood, and general level of functioning.
The size of these therapeutic effects range from moderate to very large.

Mood stabilizers do not reduce suspiciousness, split-thinking, dissociative episodes and paranoia in borderline disorder. When these symptoms persist after others improve with mood stabilizers, the addition of an antipsychotic agent is indicated.

Topiramate (Topamax)
Lamotrigine (Lamictal).

Other Medication
MAOIs:
Another class of antidepressants, the monoamine oxidase inhibitors (MAOIs), may be useful in patients with borderline disorder who are resistant to antipsychotics and mood stabilizers.
Other Treatments
Family Educational Programs

Family Training Workshop
Omega-3 fatty acids
One study done on 30 women with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression and depression. The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects.
Conclusion
There are a number of different levels of care, medications, and individual and group therapy approaches that can be utilized to help you gain increasing control over your life. The treatment plan that works best for some patient may not be appropriate or work well for another. Therefore, it is very important that the patient work closely with his psychiatrist and other mental health professionals to formulate that treatment plan which will produce the best results under his or her specific circumstances
Epidemiology
Controversies
The credibility of individuals with personality disorders has been questioned at least since the 1960s. Two concerns are the incidence of dissociative episodes among people with BPD and the belief that lying is a key component of this condition.
Researchers disagree about whether dissociation, or a sense of detachment from emotions and physical experiences, impacts the ability of people with BPD to recall the specifics of past events.
Some theorists argue that patients with BPD often lie, However, others write that they have rarely seen lying among patients with BPD in clinical practice.Regardless, lying is not one of the diagnostic criteria for BPD.
Men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance abuse.
That is the reason for more cases of women being reported.
Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide
Controversies (Cont.)
Controversies (Cont.)
Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder.
The features of BPD include emotional instability; intense, unstable interpersonal relationships; a need for intimacy; and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them.
Because of the above concerns, and because of a move away from the original theoretical basis for the term, there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed, since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate.
Thank You!
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