July 2008 Presented By: Breena Lehan Lindsey Schaumburg Kathleen Bies-Jaede

 The central feature of BPD is a pervasive pattern of instability, afflicting patients with mood swings, troubled relationships, frequent self harm, and a rollercoaster emotional life. The disorder begins by early adulthood. People with borderline personality disorder are unpredictable, impulsive, prone to mood swings and erratic, excessive behaviors such as gambling or sexual promiscuity without consideration of the consequences. They are prone to outbursts of emotion, and quarrelsome behavior especially when impulsive acts are thwarted or censored. They are also easily depressed and tend to class things in black and white terms.  Why the name borderline? The name borderline was coined by Adolph Stern in This name was used to describe patients who were on a ‘borderline’ between neurosis and psychosis. Throughout Europe, the same disorder has been given the more appropriate and less misleading title of ‘Emotionally Unstable Personality Disorder.’

 Borderline Personality Disorder is the most commonly diagnosed personality disorder and one of two personality disorders associated with self-harm behavior. One is BPD and the other is antisocial behavior disorder.  It is estimated that between 2 ‐ 3% of the general population are effected..  75% of people diagnosed with BPD are female and usually within childbearing age.  People diagnosed with BPD will often have other psychiatric conditions such as schizophrenia, or other affective disorders and epilepsy. At least 50% of BPD sufferers also suffer from a major depressive disorder, dysthymia, both, or identity and interpersonal issues. They are frequent users of mental health resources  Between 40 and 71% of BPD patients report having been sexually abused, usually by a non ‐ caregiver.

 One in ten people with BPD will commit suicide  70 to 80 % of patients meeting the diagnostic criteria for BPD self mutilate or self harm.  Very little research has been conducted to investigate BPD in men, however, men with BPD compared with men suffering from other personality disorders have shown more evidence of dissociation, image distortion, frequency of childhood sexual abuse experiences, longer experiences of physical abuse and experiences of loss at an early age. Research suggests that male BPD patients are more regularly diagnosed with substance abuse problems than female BPD patients are.  Clinicians are often wrongly educated or under educated about BPD and BPD treatments, believing it hopeless to treat. There is strong evidence from the McLean Study of Adult Development that 40% of patients with borderline personality disorder remit after 2 years, with 88% no longer meeting Diagnostic Interview for Borderlines

 There are many suggested causes of borderline personality disorder, but no definite answer.  Developmental  Often a history of childhood sexual abuse, physical abuse, witnessing violence in the home, emotional abuse and neglect. BPD patients often come from a background of dysfunctional family relationships. This suggests that trauma and suffering could be a key factor in why people may go on to develop BPD.  It has been suggested that BPD may be a form of, or similar to post traumatic stress disorder.

 Biological Genetic  Research evidence exists indicating that parents with BPD have an increased likelihood of having children who are prone to BPD and other mental disorders. Genetic factors may cause a slight susceptibility to a person developing BPD. This susceptibility may only result in a disorder when nurtured in a triggering environment (i.e. that of abuse or neglect.)

 Some medical professionals also believe that physical problems in the brain may be a contributing cause of BPD, (e.g., It has been suggested that brain damage caused to a baby in the womb or during or after birth). There is also some evidence of organic lesions in the brains of people with BPD.  It has been theorized that there may be a chemical dysfunction in the brains of BPD patients. Hormonal and chemical imbalances found in subjects may explain some of the symptoms,) e.g., imbalances of several chemicals including serotonin, dopamine, norepinephrine (noradrenaline) and acetylcholine monoamine oxidase).

Indicated by five (or more):  Frantic efforts to avoid real or imagined abandonment  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation  Identity disturbance: markedly and persistently unstable self-image or sense of self  Impulsivity in at least two areas that are potentially self-damaging

 Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior  Affective instability due to a marked reactivity of mood  Chronic feelings of emptiness  Inappropriate, intense anger or difficulty controlling anger  Transient, stress-related paranoid ideation or sever dissociative symptoms

 Borderline Personality Disorder Video Clip Borderline Personality Disorder Video Clip

 Difficult to treat  Goal: Independent functioning rather than restructuring  Long term (1 yr +), mostly outpatient, “talk therapy”, reduce the symptoms  Medication  Treatment usually requires a combination of therapy and medication. Confounds research study results.  Hospitalization: Suicidal behaviors, Self Mutilations (Cutting, burning, branding)  Expensive Especially ER visits  Rarely appropriate  3 – 4 week inpatient stay (insurance)  Day treatment is preferred  Self-Help

 Most Effective Psychotherapies  Psychotherapy is the most common treatment for BPD, but there are also some pharmaceutical approaches to control the symptoms, as well as the use of techniques developed for post Traumatic stress Disorder (PTSD).  Psychoanalytic Transference-Focused Psychotherapy (TFP) Uses the counselor/client relationship to reflect TFP may be at least the equal of DBT. TFP has been associated with improved impulsivity, irritability, verbal assault, and direct assault. (see case example in notes) Mentalization-Based Therapy (MBT) Realize mental states of emotions (see attached notes for case example)  Systems Training for Emotional Predictability & Problem Solving (STEPP). (see attached notes for case)

 Dialectical Behavior Therapy (Marsha Linehan)  DBT has shown the highest success rate but this is hardly surprising due to it being designed specifically for those with this diagnoses.  DBT Teaches control of lives, emotions, and themselves  Use of: self-knowledge, emotion regulation, and cognitive restructuring  Group Setting Focus  Not good for individuals that have a hard time learning new concepts

 Research shows that some medications reduce the symptoms  Should be used with some form of psychotherapy Antidepressants - (sadness, low mood, anxiety, emotional reactivity, Antipsychotics - (anger/hostility, impulsivity, paranoid thinking) Mood Stabilizers/Anticonvulsants - (impulsivity, rapid mood change) Anxiolytics (Anti-anxiety) - (Very little research to support use)  Concerns of overmedicating

 Books  Knowledge is power Recognize Symptoms Cognitive Thinking Behaviors  Resources  Crisis Hotlines  Coping and Control  Seek treatment

 High burn out rate working with Individuals diagnosed with BPD  A lot of crisis situations  Suicidal Concerns or Self Injurious Behavior  Push boundaries/limits Onset of therapy set boundaries  Inappropriate behavior at times

 American Psychiatric Association. (2000).Diagnostic and Statistical Manual of Mental Disorders IV-TR (4th ed. Text revision). Washington  Bateman, A. and Fonagy, P. (2008). 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual. Am J Psychiatry 165:5.  Blum, St. John, Pfohl, et al. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up. Am J Psychiatry 2008; 165:468–478.  Hoglend, P. et al. (2008). Transference Interpretations in Dynamic Psychotherapy: Do They Really Yield Sustained Effects? Am J Psychiatry 2008; 165:763–771   treat.htm  Silk, K. (2008). Augmenting Psychotherapy for Borderline Personality Disorder: The STEPPS Program, Am J Psychiatry 165:4  Yaeger, Joel (2007). How Do Psychotherapies for Borderline Personality Disorder Compare? Transference-focused psychotherapy, a psychodynamically based therapy, seems effective. Journal Watch Psychiatry, July 30.  