Borderline Personality Disorder Definition

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

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

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

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 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 Criterion 5.

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

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

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)

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

Borderline Personality Disorder Etiology

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

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?

Family Interactions Neglect Emotional uninvolvement Invalidation

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

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

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

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

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

Emotion Vulnerability Heightened emotional sensitivity Emotion reactivity Slow return to baseline

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

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

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

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

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

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