1. Borderline Personality Disorder
Dr. Matthew Sager
Psychiatric Medical Director
St. Mary’s Hospital, Madison, WI

2. Borderline Personality Disorder (BPD)
What is it? Perceptions and current diagnosis
History
Causes
Facts
Co-occurring diagnoses and differential
Treatment
Evaluating safety concerns/suicidality

3. BPD Initial impressions Stigma Better descriptive terms?
Emotional Regulation Disorder

4. Current Diagnosis DSM IV-need to have 5 of 9 criteria (pervasive)
Unstable relationships-splitting example
Impulsive behaviors
Mood swings
Intense anger
Feelings of emptiness
Fear of abandonment
Identity disturbance, ‘poor sense of self’
Suicidal behavior or self-injury
Transient paranoia/dissociative states

5. Diagnostic Issues Problems with DSM IV
5 of 9-there are 256 different variations
4 of 9-no diagnosis, but would look very similar clinically
DSM V
Revisions to look at dimensional aspects of personality
BPD on same axis as depression, anxiety
In end-too complex for clinical practice-yet

6. Diagnostic Issues cont.’
Issues that affect making diagnosis:
Transient states
Medical illnesses
Situational stress
Sex and cultural beliefs/biases
Clinician feelings-anger, disappointment, frustration

7. Diagnostic Issues cont.’
In the end-the diagnosis focuses on ways of thinking and feeling about oneself and others that ends up affecting a persons ability to function

8. BPD History 1930s Psychoanalysts (i.e. Sigmund Freud)
divided psychosis (delusions, hallucinations) from neurosis (anxiety/distress). The area between, the borderline was the difference that explained why some patients did not act one way or the other.
1960s Psychiatrist Otto Kernberg
personality organization to syndrome to disorder

9. BPD History cont.’ 1980s and 90s Increased research
From analytical to medicalization
DSM III (1980)
DSM IV (1994)
DSM V (2013)

10. BPD Causes Genetics Environmental Social and cultural factors
Twin studies show strong inheritance
Environmental
Unstable family relationships
Social and cultural factors
1900s-less unstructured time with more work/survival instincts
i.e. Eating Disorders indifferent countries

11. BPD Causes Abnormal Brain functioning Amygdala – center of emotion
Prefrontal Cortex – complex problem solving

12. BPD
Whatever the cause, data shows the impact of this illness

13. BPD Facts 2% of US population have BPD
(equal to population of New York City)
Twice that of bipolar disorder or schizophrenia
10% of mental health outpatient clinics
20% of inpatient psychiatric hospital units

14. BPD facts 75-90% of those diagnosed are women
Do women seek treatment more than men?
Men with similar symptoms may end up in jail or with another diagnosis.
10% complete suicide in their lifetime
Comorbidities are rampant-mood disorders (depression, bipolar) anxiety disorders (PTSD) and substance abuse disorders
Probably ‘burns out’ or dissipates over time

15. BPD Facts
Face Studies: people with BPD are inclined to see anger in neutral emotion faces
Word Studies: people with BPD are inclined to attach a stronger reaction to neutral words

16. Comorbidities and differential diagnoses
Mood Disorders (bipolar disorder I and II, major depression, dysthymia)
Anxiety disorders including PTSD
Eating Disorders
Substance Abuse Disorders
Other personality Disorders

17. Comorbidities and differential
Lots of overlap with impulsive behaviors and mood instability
Different diagnoses from different providers

18. Explaining diagnosis John Gunderson MD quote
As an example that focuses on jargon free explanation that patients can understand

19. BPD Treatment BPD-High utilization of health care $
ER visits, inpatient medical/psych care
Hallmark of good care-multiple modalities
Alliance building to foster improved mood, behavior, social functioning and relationships

20. Treatment Goals Containment of any safety issues Structure
Provide support
Involve patient in decision making
Validation

21. Treatment Levels
Hospital ‘Step Down or Up’ Partial hospital(PHP) or Intensive Outpatient Program(IOP) Outpatient Therapy + Med Management Sociotherapies (group, family)

22. Treatment Levels
Focus on the least restrictive means of effective treatment

23. BPD Treatment Hospital care
Often contraindicated and can worsen behavioral issues
Hospital provides external control which can become habit forming and cause BPD patient to attempt to gain control in negative fashion
Should be used only for acute safety stabilization

24. BPD Psychotherapy Mainstay of BPD treatment
Specific types may be more effective

25. BPD Psychotherapy DBT (Dialectical Behavioral Therapy)
Pioneered by Marsha Linehan PhD
Focuses on mindfulness, acceptance and awareness of situations and feelings
decreases intensity of emotions

26. BPD Psychotherapy CBT(Cognitive Behavioral Therapy)
Focus: Changing thinking will change behavior
Skill building/practice
Relaxation
Exposure therapy

27. BPD Psychotherapy
Schema therapy
Reframing ways people view themselves

28. BPD Psychotherapy Group Therapies Interpersonal Family DBT
Others (problem focused)

29. BPD Medications
Role of meds: manage symptoms, though benefit is often uncertain due to ‘symptom chasing’
Goal is to treat comorbidities
Avoid dependence, abuse, risk of overdose
Classes: Antidepressants
Antipsychotics
Mood stabilizers
Anti-anxiety
AODA meds-antabuse/naltrexone/methadone

30. BPD Medications
Treat comorbidities!

31. Treatment Plans Contracts with patients Makes expectations explicit
From Crisis Intervention, when to call providers, when to go to hospital to roles of those involved
i.e. family/friends

32. BPD Safety issues Suicide and borderline personality
10% completed lifetime
Safety plans-limited pill supply, family support, crisis contact
Highest risk are those with depression and alcohol/drug problems

33. BPD safety issues ‘Feeling Unsafe’
Goal is for patient to recognize when they need more active help and trust they will get it
Typical Crisis-express concern, allow patient to ventilate, avoid taking actions but let patient be explicit about situation
Follow-up after crisis

34. BPD and suicidal acts John Gunderson, MD
“Suicidal acts are a dangerous distraction from the patient working on attaining a better life”.
Dr Gunderson views suicidal statements/acts as affecting a patient’s dependence on others and an effort to be cared for.

35. BPD
References: 1. Gunderson, John G, M.D. ‘Borderline Personality Disorder A Clinician’s Guide’, DSM IV, American Psychiatric Association, Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.