1. Borderline Personality Disorder
Definition

2. Current trend is to call it “Emotional Intensity Disorder”
Better accepted by patients – more meaningful

3. Four Categories for Borderline Symptoms
Poorly regulated emotions
Mood swings and unstable emotions
Anxiety
Inappropriately intense anger
Difficulty controlling anger
Chronic feelings of emptiness
Impulsivity
Reckless behavior
Suicidal behavior and self harm
Munchausen’s Syndrome and by Proxy
Suicide

4. Impaired perception or reasoning
Paranoid thinking
Dissociative episodes
Depersonalization
Unstable self image or sense of self
Markedly disturbed relationships
Intense and unstable interpersonal relationships
Black and white thinking
Frantic efforts to avoid real or imagined abandonment

5. DSM-IV Diagnostic Criteria
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 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 Criterion 5.

6. 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. Can look like….. Schizophrenia Bipolar Affective Disorder
hallucinations, illusions, paranoia
Bipolar Affective Disorder
mood lability and anger
Major Depressive Disorder
suicidal, depressed
Antisocial Personality Disorder
legal problems

8. Epidemiology (The branch of medicine that deals with the study of the causes, distribution, and control of disease in populations.)
2 % of the general population
Females 4 times the rate of males
11 % of psychiatry outpatients
25 % of acute psychiatry inpatients
50 % of long term psychiatry inpatients
60 % with co-existing Major Depressive Disorder
7% complete suicide. ( 7 X General population)

9. Interface with Health Care System
Inpatient Psychiatric Units
Top diagnosis for re-admissions to psych hospitals
Emergency Rooms
Cutting, burning, suicidal threats
Intensive Care Units and medical inpatient units
Overdoses and other sequelae of suicidal or parasuicidal behavior
Outpatient primary care setting
Psychosomatic complaints
Doctor shopping

10. Borderline Personality Disorder
Etiology

11. Genetic and Biological Factors
Genetics a modest contributor of BPD Diagnosis but may be more salient for specific symptoms of BPD
Reduced serotenergic activity in 5-HT system inhibits ability to modulate or control impulsive and aggressive behavior
Differences b/w BPD and nonBPD patients in serotenergic functioning
Repeated exposure to stress may blunt serotenergic activity (frequent increases in cortisol)
Stress  frequent increases in cortisol  blunting of serotenergic activity  emotion dysregulation
Limitations
Lack of specificity for serotonin (i.e., MDD w/out impulsivity)
Pharmacology targeting serotonin has limited efficacy in treating BPD

12. Trauma Childhood Sexual Abuse (CSA) Limitations
Historically considered a significant risk factor for BPD
75% of patients with BPD have a hx of CSA but… only 90% of CSA victims have BPD
Limitations
Current evidence suggests that emotion dysregulation mediates the relationship between CSA and BPD
Role of physical and emotional abuse which co-occurs with CSA?

13. Family Interactions
Neglect
Emotional uninvolvement
Invalidation

14. Models Individual Difference Environmental
Biological or genetic explanations of problem behaviors
Lies within the individual
Temperament
Environmental
Stressful or traumatic event

15. Interactional Transactional Interaction of two orthogonal factors
Diathesis-stress model
Predisposing factor interacts with environmental stressor
Ex. Individual with low baseline levels of dopamine and lives in a neighborhood with violence and drug use
Transactional
Two or more factors influence each other reciprocally resulting in a specific outcome

16. Linehan Biosocial Theory
Emotion Vulnerability
Pervasive History of
Invalidating Responses
Heightened Emotional Arousal
Inaccurate Expression
(maladaptive behavioral responses)
Invalidating Responses
(Fruzzetti, Shenk, & Hoffman, 2005)

17. Emotion Regulation
“process by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions.”

18. Emotion Dysregulation
Vulnerability to negative emotion
High sensitivity, reactivity, and slow return to baseline
Influences emotional arousal
Poor coping skills
Inability to: manage social interactions, awareness of relevant stimuli, identify and label emotional experiences, manage arousal
Maladaptive responses to others expressions of emotion
Wants, thoughts, goals. Others responses often trigger emotional arousal

19. Emotion Vulnerability
Heightened emotional sensitivity
Emotion reactivity
Slow return to baseline

20. Invalidation Validation Invalidation
Convey legitimacy and acceptance of the other’s experience or behavior
Invalidation
Delegitimize valid experiences or fail to acknowledge their existence and/or legitimacy

21. Invalidating Family Environment
Invalidation of…
Emotions, thoughts, desires
Over public behavior
Difficult tasks, developmental milestones
Sense of self and self initiated behavior

22. Consequences of Invalidation
Heightened emotional arousal
Cognitive and attentional dysregulation
Emotion skill deficits
Secondary emotions
Emotion dysregulation
Passivity in problem solving
Self-invalidation
Social and interpersonal dysregulation

23. Risk factors for invalidation
Unexpected experience or behavior
Behavior creates unwanted demands
Caretaker has insufficient ability to help or understand

24. Neurobiology Risk factors:
Diminished serotonergic function in the prefrontal cortex
Potential biological risk factor for disinhibition, impulsivity, and affect dysregulation.
Dysfunction in the cortical-striatal-thalamic-frontal network
behavioral control

25. Frontolimbic Circuitry
Prefrontal and limbic systems mediate the processing of and responses to emotional stimuli