1. Borderline Personality Disorder
Etiology: Causes and Correlations

2. Goals and Objectives
To briefly identify the current research regarding the etiology of a personality disorder.
To identify the current genetic, biological and psychological research regarding the etiology of borderline personality disorder.

3. Quick Review

4. Personality Disorders
Enduring, pervasive and fixated patterns of
Perceiving
Relating to
Thinking About

5. Personality Development
In order to understand how one develops a personality disorder, it can be helpful to review the elements of general personality theory.

6. Personality Development
Involves two components:
Temperament
mostly the genetic/constitutional component

7. Character
largely the component resulting from the molding and shaping influences of life events and development

8. Static in it’s “Ingredients” Genetic contributions; psychopathological
The Friendship Bread Phenomenon: The Development of a Personality Disorder
“Starter Kit” Only can be received from a friend
Temperament
Static in it’s “Ingredients”
Genetic contributions; psychopathological

9. Ingredients from your own kitchen
Environmental Influences
Infinite combinations of experiences
Trauma, parental ignorance, safety disruptions in young children

10. The Friendship Bread Phenomenon
As you will see from the following slides, most research regarding the development of Borderline Personality Disorder suggests a combination of both genetic and or biological traits as well as environmental influences.

11. Note~
All personality disorders consist of traits that most people exhibit.
Remember the general definition of a personality disorder as you review the next slides.
Pay particular attention to the quantifiers and qualifiers the APA uses to help differentiate personality disorders from healthy personalities.

12. Common Cognitive Distortions of clients with BPD
I must be loved
No one will ever love me
I’ll be alone forever
The world is a dangerous place
I don’t know what I want
When people know me they will hate me

13. Timeline of Clinical Observations and Diagnostics
By briefly reviewing the history of diagnostics as they relate to the Borderline Personality Disorder, you will have a chance to understand how it is that the understanding of the etiology of this disorder is rather new.

14. Timeline of Clinical Observations and Diagnostics
Schmidelberg
First to call it a
Character Disorder
Grinker 1952
First empirical Investigation
DSM-I Emotionally Unstable Personality
Hoch and Polatin 1942
Pseudoneurotic
Schizophrenia
Hoch and Polatin created the term pseudoneurotic schizophrenia to describe a disorder characterized by panphobias, pananxiety, and pansexuality.
Now used in the ICD-10 classification of diseases

15. Timeline of Clinical Observations and Diagnostics
Deutsch 1942
as-if
personalities
Zilboorg
Mild Form
Schizophrenia
Stern 1938
Psychosis
Neurosis
Stern Saw it as if it were on a continuum from psychosis….he pointed out the characteristics of dissociation and anxiety
As if personalities:1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction. She created the term as-if personalities because the patients completely identified with those upon whom they were dependent1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction. She created the term as-if personalities because the patients completely identified with those upon whom they were dependent

16. Timeline of Clinical Observations and Diagnostics
DSM-IV, and 2013
Borderline
Personality Disorder
DSM-III-R
DSM-III

17. The Equifinality Model of Etiology of Borderline Behavior
The model's equifinality assumption states:
Either or all factors can produce BPD despite starting at different points and following different paths to that end.

18. Factor I Life Events Mainly Traumatic Stress Borderline
Central Nervous System Changes
Borderline
Personality Disorder

19. A number of authors. have suggested a role. for environmentally
A number of authors have suggested a role for environmentally mediated, aversive events in the development of BPD.

20. Perry et. al describes the effects psychotrauma can have on a child's brain as follows:

21. Perry et. al's Neurobiological Analysis of Early Trauma
Perry et al. (1996) have presented a neurobiological analysis of childhood trauma exposure. In it they outline the effect trauma has on the human "fight or flight" and "freeze or surrender" systems, and the implications that repeated psychotraumatization has for a developing child's brain systems.

22. The brain regions involved play a critical role in regulating
arousal
vigilance
affect
behavioral irritability
locomotion
attention

23. The brain regions involved play a critical role in regulating
the response to stress
sleep, and
the startle response

24. . . . Initially following the acute fear response, these systems in the brain will be reactivated when the child is exposed to a specific reminder of the traumatic event (e.g., gunshots, the presence of a past perpetrator).

25. Over time, these specific reminders may generalize
Gunshots to loud noises
A specific perpetrator to any stranger and at times to any intimate relationship
Despite being distanced from threat and the original trauma, the stress-response apparatus of the child's brain is activated again and again.

26. Furthermore, these parts of the brain my be reactivated when the child simply thinks about or dreams about the event.
Research is suggesting both anatomical as well as neurochemical changes in the brain’s of children who have been victimized.

27. Ages of Critical Influence
0-18 months
Children’s brains are most maleable and easy to influence during this time.
Traumatic events during the pre-verbal stage of development can be most damaging to individuals. Since language helps us to make meaning from our experience, the pre-verbal child is left with psychological and emotional pain he/she cannot describe.

28. 2-5 years old Trust vs. Distrust
Critical Phase of Development Separation- Individuation.
Children are learning the important differences between their ego boundaries… “Who am I” and others… “Who are they”
Trauma during this period can have devastating results in identity formation, and social relatedness.

29. Factor One

30. Factor I (and mixed): Accounts for 70-75% of BPD
Life Events Mainly Traumatic Stress
Central Nervous System Changes
Borderline
Personality Disorder

31. Some Alarming Statistics
Herman et al. (1989) found the following rates of psychotraumatization for BPD patients:
71% had been physically abused
67% sexually abused
62% had witnessed domestic violence.
Histories of early childhood psychotrauma (under age six) were almost always only found in BPD patients versus other personality disorder patients.

32. Famularo et. al. (1991) reported that 79% of nineteen children ages seven to fourteen who had been recently diagnosed as having BPD by DSM III-R criteria reported significant traumatic experiences.
Goldman et al. (1992) found in a sample of 44 children diagnosed with BPD versus 100 comparison children that BPD children had significantly higher rates of physical and physical/sexual abuse rates than the comparison group.
They concluded that the hypothesis that a history of trauma is associated with the disorder is supported.

33. Factor II

34. Factor II: accounts for 25 to 30% is Factor II BPD.
Genetics
Uneducated and/or
Inappropriate
Parental Response
Personality Disorder

35. Genetic Contributions
Genetically Based Temperament Characteristics
Borderline Personality Disorder
Mood
Affective Lability
Regularity, also known as Rhythmicity
Difficulty in Regulating Schedules of feeding, sleeping, transitioning
Persistence & Attention Span
~Attention Problems~
Sensory Threshold or threshold of responsiveness
Low Threshold for responsiveness
Intensity
Regularity, also known as Rhythmicity refers to the level of predictability in a child’s biological functions such as waking, becoming tired, hunger and bowel movements.
Persistence & Attention Span refers to the child’s ability to stay with a task through frustrations and length of time on the task.
Sensitivity refers to how easily a child is disturbed by changes in their environment. It is also referred to as Sensory Threshold or threshold of responsiveness. Does the child get bothered by external stimuli in their environment such as noises, textures, lights, etc. or do they just seem not to be bothered by them at all and simply ignore them?

36. Endophenotypes (Siever et al., 2002)
thought to reflect underlying genetic vulnerabilities
impulsive aggression
impulse/action patterns
affective instability
cognitive organization
and anxiety/inhibition.

37. Biology

39. Ekman Faces

40. Neutral, Happy, Sad, and Fearful
more likely to attribute more negative qualities to the neutral face.
BPD fMRI studies were done to identify what was happening in the Amygdala
Looking at any face increases limbic, specifically amygdala’s response
Plus impaired inhibition in the prefrontal cortex

41.
In response to fearful faces, the amygdala, the fear hub, showed exaggerated activity in the BPD patients, while the ACC was relatively underactive. Since ACC activity would normally increase to dampen an overactive amygdala, this suggested weak regulation of emotion in the circuit.
Suspecting that this functional impairment mirrors structural differences — as has been found in depression — the researchers next used anatomical MRI to compare grey matter in the same patients and healthy controls.

42. Consistent with the fMRI results and the earlier findings, grey matter density was increased in parts of the amygdala and decreased in parts of the ACC, in BPD patients relative to controls.
This suggested an abnormality in the number or architecture of neurons in these key components of the emotion-regulating circuit, which other evidence links to impaired functioning of the serotonin chemical messenger system.

43. ACC=
anterior cingulate cortex (ACC), hinted that this might affect the way the brain works in BPD.

44. Biological Vulnerabilities
Impairs Child’s ability to develop age appropriate behavioral self-control in the areas of:
impulse control
mood stability
aggression modulation

45. untreated attention deficit disorder
At present there does not appear to be a consensus BV candidate, The possibilities include
untreated attention deficit disorder
untreated childhood bipolar disorder
EEG abnormalities
genetic transmission
familial affective/impulse control dysfunction

46. Biological Factors impulsive aggression affective instability
Reduced serotonergic activity in the brain
affective instability
increased responsivity of cholinergic systems.

47. Biological Factors Reduced hippocampal regions
Low Threshold for Limbic System arousal

48. Normal Psychological Development and Subsequent Maturity
Appropriate, Timely Maternal/Caregiver Response
Infant’s Expression of Physical and Psychological Needs: Arousal

49. Internalized Idealization of Self and Others
Sense of Trust of Self
Sense of Trust in Relationships
My Feelings Are True
I have the right to hurt
It won’t last forever
I am the center of the universe
Others are trustworthy
Others will always take care of me when I need them
Others are wonderful

50. Normal Psychological Development and Subsequent Maturity
Infant’s Expression of Physical and Psychological Needs: Arousal
Mother/Caregiver is late or is setting boundaries

51. Internalization of Devaluation of Self and Others
Sense of Insecurity in Self
Others are not trustworthy
Others will never take care of me when I need them
Others are bad
Sense of Insecurity in Relationships
My Feelings don’t matter
I must tolerate my solitude/arousal state
I can’t wait
I am not the center of the universe

52. Healthy Sense of Self and Others
I am sufficient but not egocentric
Others are
To be trusted and watched
Healthy Personality

53. Disruptions in early attachments
Trauma/
Abuse Neglect
(Biogenetic Impairments)

54. Borderline “Splitting”
I am the center of the universe and I am no-one
Others can never be trusted and I need to be loved and taken care of

55. Sociological Factors BPD has been identified all over the world
There does not seem to be any socioeconomic, race or other cultural characteristics (alone) that increase the likelihood of developing this personality disorder

56. Familial Studies
BPD is found more frequently in BPD families than in the families of schizophrenia, bipolar, schizotypal, antisocial or dysthymic clients
There is no increase in the prevalence of schizophrenia in the families of BPD
Alcoholism and substance abuse are frequently found in families of BPD

57. Mixed Factors Factor I (and mixed): Accounts for 70-75% of BPD
Genetic Influence
Traumatic Life Events
Borderline
Personality Disorder