1. Chapter 14: Borderline Personality Disorder (BPD) Jill M. Hooley Sarah A. St. Germain

2. Diagnosis: Personality Overview Lack of stable self-image, goals, relationships, and mood Impulsive, erratic, risk seeking, and antagonistic Trouble with understanding the emotions and desires of others, especially when threatened Mistrustful, demanding, and fear of abandonment Frequently sad, hopeless, pessimistic, and ashamed

3. Diagnosis: Symptom Criteria Pervasive and present since adolescence Five or more of the following (no change in DSM-5) Frequent feelings of emptiness Desperate attempts to avoid abandonment (real or otherwise) Unstable and intense relationships with periods of idealization and deprecation Potentially self-harming impulsive behavior in at least two areas Recurring suicidal threats, gestures, or behavior, or self-mutilation Unstable mood, (especially frequent marked sadness, irritability, and anxiety) that resolves in hours or a few days Disproportionate, intense anger, or difficulty suppressing anger Notable and sustained lack of stable self-image or sense of self Short, stress-induced paranoid thought or significant dissociative symptoms

4. Diagnosis: Comorbidity and Heterogeneity Significant comorbidity Major depressive disorder (~61%) Dysthymia (~12%) Bipolar disorder (~20%) Eating disorders (~17%) PTSD (~36%) Substance abuse (~14%) 9 possible symptoms x 5 required symptoms = 126 possible symptom combinations will all get the diagnosis

5. Symptoms: Psychosis Like Experiences ~75% of patients report paranoid ideas and/or dissociative episodes Stress-related psychotic episodes BPD hallucinations and delusions differ from those in psychotic disorders Usually more insight than psychotic patients Paranoid ideas typically not so firmly held that they reach delusional levels Dissociation episodes relatively brief and stress-related

6. Symptoms: Self-Harm In some cases, suicidal and self-injurious behaviors are used as strategies to regulate strong negative emotions Self-harm behaviors are most often Cutting Burning

7. Prognosis Utilize significant treatment resources 10% will successfully commit suicide After 2 years 30% will achieve lasting remission, 80% after 16 years However, rate of lasting recovery (e.g., symptom remission + good functioning) after 16 years is 40% Positive indicators: Youth, no history of childhood sexual abuse, no family history of substance abuse, good recent work history, agreeable temperament, low neuroticism, and low anxiety

8. Epidemiology Prevalence in the general population: 1% to 2% Prevalence in outpatient samples: 10% to 15% Long-held belief that BPD is more common in women than in men, that is approximately 75% of cases However, population-based studies report no gender differences in the prevalence of BPD May be due to the fact that women are more likely to seek treatment

9. Etiology: “Core Features of BPD” Linehan Affective instability Bateman and Fonagy Instability in the self-structure Gunderson Fear and intolerance of aloneness Neurobiological Framework Disinhibition and general negative affectivity Zanarini, Frankenburg, Hennen, and Silk Negative affectivity/dysphoria Even though BPD is common, it is far from being clearly conceptualized and is likely multi-\dimensional

10. Etiology: Constitutional Aggression and Family Interferes with integration of different perspectives (positive and negative) of the self and others. Good representations are threatened by strong negative feelings such as rage or hostility Borderline patients lack the ability to call upon memories of “good objects” (e.g., nurturing and empathic caretakers) to provide self-soothing in times of distress

11. Etiology: Linehan’s Biosocial- Developmental Model Biological or temperamental vulnerabilities interact with failures in the child’s social environment to create or exacerbate problems with emotion regulation Key environmental factor is an invalidating family environment Child’s communications of actual internal experiences are met by parental responses that are inappropriate, erratic, or out of touch with what is happening to the child Child: “I’m hungry.” Parent: “No you aren’t. You don’t want to eat that.”

12. Etiology: Trauma Often high levels of early life trauma and adversity. Compared to patients with other Axis I and Axis II disorders, patients with BPD are significantly more likely to report physical abuse, sexual abuse, or neglect during childhood Those who experienced early abuse or neglect more than 7x more likely to be diagnosed with BPD later on

13. Etiology: Attachment Vast majority are insecurely attached; only minority (6% to 8%) have secure attachment pattern Often emotionally attached to artificial safe and stable attachment objects such as stuffed animals, even in adulthood Patients with BPD struggle to sustain a mental representation of their clinician as helpful and the treatment relationship as caring and supportive

14. Etiology: Executive Neurocognition (EN) Executive Neurocognition (EN): Family of cognitive processes that delay or terminate a response in order to achieve a less immediate goal/reward Interference Control: Conscious attempt to control attention and motor behavior Cognitive Inhibition: Suppress information from working memory Behavioral Inhibition: Repressing frequent response (e.g., hit spacebar for every letter except “Y”) Motivational or Affective Inhibition: Interruption of tendency or behavior arising from an emotional state

15. Etiology: Executive Neurocognition (EN) BPD patients show deficits on tasks tapping EN processes Symptom severity correlated with deficit May be partially explained by depressive symptoms Impairments in immediate and delayed memory linked to increased impulsivity

16. Biological Etiology: Heritability Monozygotic twin concordance rate = 35% Dizygotic = 7% Prevalence rate for BPD in relatives is 3.4 % when the relatives are assessed in person (15.1% when patient report is used) BPD traits more common in relatives than diagnosis itself Neuroticism, cognitive dysregulation, anxiety, affective lability, and impulsivity Relatives also show increased rate of mood and anxiety disorders, impulse control disorders, and personality disorders such as antisocial PD

17. Biological Etiology: Role of Serotonin System Serotonin related genes associated with BPD type behaviors, for example, suicide, impulsivity, and emotional lability Physical and sexual abuse history in BPD women associated with reduced response to serotonin agonist challenge Suggests reduced receptor activity Low levels of 5-hydroxyindolacetic acid (5-HIAA; metabolite of serotonin) associated with increased risk of impulsive aggression and suicide (especially violent forms of suicide)

18. Biological Etiology: Dopamine and Novelty Seeking High novelty seeking (associated with BPD) is related to altered dopaminergic function in the brain. High levels of comorbidity between substance abuse disorders and BPD 9 repeat version of DAT1 gene is more likely to be found in depressed patients with BPD then those without BPD Antipsychotic medications, which block dopamine receptors, clinically benefit BPD patients

19. Biological Etiology: Neuroanatomy Orbital frontal cortex (OFC): Plays a role in emotion regulation, the stress response, and impulse control BPD is associated with lower metabolic activity in the OFC Abnormalities in frontolimbic circuitry may underlie many of the key clinical features of BPD

20. Treatment Treating patients who suffer from BPD is not easy Self-harming behaviors in 60% to 80% of cases Mean number of lifetime suicide attempts is 3.4 Difficulty establishing trust and therapeutic alliance Effective treatment may require long-term and intensive treatment

21. Treatments: Medications SSRIs may help with mood stability; however, benefits are usually modest Antipsychotic medications have beneficial effects on impulsivity and aggression Significant side effects (weight gain, etc.) limit usefulness Mood stabilizers, for example divalproex sodium, help with anger and mood instability Do not help impulsivity, aggression, or sociality Lithium not shown to be effective

22. Treatments: DBT Developed by Marsha Linehan specifically to treat BPD Cognitive behavioral approach Weekly psychotherapy Weekly skills training in group format Therapist available 24 hours by phone Therapist attends weekly team consultation meetings

23. Treatments: DBT Efficacy Improves mood and symptoms Reduces suicidal ideation and increases will to live Reduces self-injurious behaviors Reduces suicide attempt rate when compared with expert non-DBT treatment (~23% vs. 46%) Less likely to drop out and less likely to require hospitalization

24. Treatments: Psychodynamic Approaches Mentalization Therapy Based on attachment theory Use therapeutic relationship to help patient develop skills to understand emotions of themselves and others Efficacy shown in double-blind trials and maintained for years afterward Transference Focused Psychotherapy (TFP) Use therapeutic relationship to understand and correct distortions in perceptions of others Primary techniques: Clarification, confrontation, and interpretation Improves depression, anxiety, anger social adjustment, overall functioning, suicidality

25. Treatment: Schema Focused Therapy (SFT) Uses CBT techniques to modify constellations of underlying beliefs (i.e., schemas) Prevents maladaptive schemas from distorting perceptions and causing maladaptive behavior Decreases symptoms, improves quality of life, and decreases dysfunctional behaviors May be more effective than transference- focused psychotherapy: less dropout, greater success rates