1. A Case study of Borderline Personality Disorder complicated by Intellectual Disability and misdiagnosis

2. Rachael’s Story Lived with foster parents from 9 weeks
Mild Cerebral Palsy
Aggression from a young age
Numerous placements and respites
Numerous behavioural programs
Variety of medications
Diagnosed with Autism
DoCS to DADHC handover…

3. A Quick Overview Case study - Rachael DSM-IV-TR diagnostic criteria
Stop walking on Eggshells (Mason & Kreger, 1998)
Borderline Personality Disorder (BPD) and DSM-IV-TR, Axis 1 and 2
The Borderline Controversy
A Question of Attachment, Personality and Developmental Disability

4. Some statistics
BPD is less known but more common then bipolar disorder or schizophrenia
2% of the general population
10% of all mental health outpatients
20% of psychiatric inpatients
75% are women
54% have substance abuse problems
75% have been physically or sexually abused
14.9% of American adults have a personality disorder
Recent American study, NESARC, n=43,000 (cited in Wright, 2004)
the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with a sample size of approximately 43,000 people

5. Rachael’s Story Mood swings from charming to aggressive
Triggers to emotionally or physically aggressive outbursts hard to identify
Tall stories including ‘nightmares’, alleged sexual abuse and being too sick to go to school
Manipulating staff
Irrational or dissociated comments
Strategies included
Car with a safety shield
Safety room for staff
Reactive and proactive strategies and OHS procedures

6. Diagnostic criteria for 301.83 Borderline Personality Disorder
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.  Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
(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 Criterion5 
(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 
(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

7. Remembered by the mnemonic
P - Paranoid ideas
R - Relationship instability
A - Angry outbursts, affective instability, abandonment fears
I - Impulsive behaviour, identity disturbance
S - Suicidal behaviour
E - Emptiness

8. Stop Walking on Eggshells Additional Criteria
Pervasive Shame (often related to sexual or physical abuse)
Undefined Boundaries
Control issues
Lack of object constancy
Interpersonal Sensitivity (BPD ‘psychic abilities’)
Situational Competence
Narcissistic demands (ego-centred also an infantile stage of personality)
Manipulation or Desperation?
High Functioning, Low Functioning
Acting In, Acting Out (Abuse and accusation vs. self-mutilation and suicide)

9. Rachael’s Story
Health professionals reluctant to confirm diagnosis of Borderline
Antidepressant helpful but didn’t solve everything
Rachael moved to a new group home
Weekly counselling including relaxation, social skills worksheets and interpersonal and psychodynamic work
Did not confront negative behaviour until stronger rapport was built

10. DSM-IV-TR Axis I and II
Most diagnostic criteria in the DSM includes the warnings
‘Not if better accounted for by…’
‘Does not occur exclusively during the course of …’
‘Criteria are not met for …’
Both personality disorders and intellectual disability listed on Axis II
Diagnostic Overshadowing? (Reiss, 2000; Reiss, Levitan & McNally, 1982)
A question of co-morbidity and jargon

11. The Borderline Controversy
The borderline myths within psychology and psychiatry
Labelling, stigma and reluctance
On the borderline between psychosis and neurosis?
Emotional dysregulation disorder? Reactive Attachment Disorder?
DSM V due in 2011
Some literature suggesting that personality disorders only occur in mildly intellectually disabled people (Masi, 1998)
Personality disorders within Developmental Disability - A minority within a minority group or an undiagnosed population?
To me this would suggest that people with a moderate disability don’t have a personality

12. Attachment, personality and developmental disability
Literature saying that relationships difficulties and insecure attachment more common in this population. Many factors including residential services that militated against emotional development. (Clegg & Lansdall-Welfare, 1995)
“Attention Seeking” – we ALL need attention
There is a link between attachment and challenging behaviour that needs more research. (Clegg & Sheard, 2002)
There is a link between attachment and personality disorder. (Agrawal, Gunderson, Holmes & Lyons-Ruth, 2004)

13. A Question of attachment, personality and developmental disability
Question – what defines the continuum from a healthy personality to a disordered person? And from early attachment to adult intimate relationships?
When does a label help?
If I tried to answer this question I think it would be good to keep in mind:
14.9 percent of Americans 18 years or older…
Health is a bio-psycho-social phenomena.
Regardless of age or ability, no person is independent, we all have a Self and persona which must exist within many interdependent relationships.
Nelson Mandela, Gandhi, some of my clients, sports heroes and hardened criminals all challenge society.

14. Rachael’s Story Frequency of aggression greatly reduced
Attended a personal development / sex education course
Had her first kiss
Reconnected with family
Changing jobs we had to say goodbye

15. References and Resources
Agrawal, H., Gunderson, J., Holmes, B. & Lyons-Ruth, K. (2004). Attachment Studies with Borderline Patients: A Review. Harvard Review of Psychiatry, 12(2),
Clegg, J.A. & Lansdall-Welfare, R. (1995). Attachment and Learning Disability: a theoretical review informing three clinical interventions. Journal of Intellectual Disability Research, 39,
Clegg, J.A. & Sheard, C. (2002). Challenging Behaviour and Insecure Attachment. Journal of Intellectual Disability Research, 46(6),
Masi, G. (1998, Summer). Psychiatric illness in mentally retarded adolescents: clinical features. Adolescence.
Mason, P. T., Kreger, R. (1998). Stop Walking on Eggshells: Taking your life back when someone you care about has Borderline Personality Disorder. New Harbinger.
Reiss, S., Levitan, G. W., & McNally, R. J. (1982). Emotionally disturbed mentally retarded people: An underserved population. American Psychologist, 37,
Reiss, S. (2000, Spring). A Mindful Approach to Mental Retardation. Journal of Social Issues.
Wright, J. (2004, Oct 15). A survey of personality disorders. American Family Physician.

16. The I-CAN!
…Shameless plug…