1. Borderline Personality Disorder Milton Brown Behavioral Research & Therapy Clinics University of Washington

2. Borderline Personality Disorder What is BPD? How to assess BPD How does BPD develop? BPD in adolescence Intervention options How to respond to challenging BPD clients

3. What is a Personality Disorder? DSM-IV diagnostic criteria A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: (1)cognition (i.e., ways of perceiving and interpreting self, other people, and events) (2)affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3)interpersonal functioning (4)impulse control

4. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C.The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood E.The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder F.The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma). What is a Personality Disorder? DSM-IV diagnostic criteria

5. 1.Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilation 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- mutilation behavior covered in Criterion 5 Borderline Personality Disorder DSM-IV diagnostic criteria

6. 5.Recurrent suicidal behavior, gestures, or threats, or self-mutilation 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 Borderline Personality Disorder DSM-IV diagnostic criteria

7. BPD is Prevalent and Chronic Prevalence 16% of adolescents 10% of adults Stability 25% of adolescents still have BPD after 2 years –53% of severe BPD cases 60% of adults still have BPD after 6 years 35% of adults still have BPD after 15 years

8. What is BPD The multidiagnostic, difficult-to-treat patient Chronic suicidality and self-harm A diverse patient population

9. Parasuicidal Behaviors in BPD 75% have a history of parasuicide 10% lifetime suicide rate* more repeated suicide attempts than other disorders more likely to have persistent and intense suicide ideation between parasuicide episodes, whereas… individuals with only depression are more likely to have long periods of normal mood and episodic suicide ideation/behavior. nonsuicidal self-injury is common in BPD, and rare in most other disorders (except mental retardation).

10. Diagnosis LifetimeCurrent Depressive disorder*97%89% Substance abuse/depend.60%*31% PTSD57% 51% Social phobia22%16% Panic disorder52%40% Eating disorder41%24% Antisocial PD-11% Avoidant-21% Diagnoses for Parauicide Study

11. Diagnosis Current Depressive disorder39% Any anxiety disorder52% Eating disorder18% Antisocial PD44% Diagnoses for Substance Abuse Study

12. Diagnosis Current Depressive disorder63% Any anxiety disorder83% Eating disorder13% Antisocial PD17% Substance use disorder 4% Diagnoses for Anger Study

13. The Core of BPD Emotion dsyregulation –High sensitivity –High intensity –Slow return to baseline –Pervasiveness –Chronicity Impulsive behaviors –Because emotions are “out of control” –Because the behaviors regulate emotions Pervasive experiential avoidance

14. Borderline Personality Disorder EMOTION DYSREGULATION Cognitive Dysregulation Action Dysregulation Self Dysregulation Interpersonal Dysregulation Suicidal Action -Death -Distraction -Sleep -Biochemical -Cue Removal

15. The Client’s View Emotion Dysregulation = Problem Behavior Emotion Dysregulation = Problem Behavior Dysfunctional Behavior = Problem Solution Cue Consequences

16. Basic Paradigm Cue Consequences Emotion Dysregulation Problem Behavior

17. For Example Cues Prescription picked up earlier that day, in room alone, ruminating about criticism roommate made of her earlier in the day Consequences sleep, stop ruminating, wake reduced shame Problem Behavior overdose Emotion Dysregulation of shame

18. Methods of Experiential Avoidance Denial of problems (rather than problem-solving) Dissociation and emotional numbing Isolation Drug and alcohol abuse Suicide attempts (and suicide) Nonsuicidal self-injury Self-punishment, self-criticism Secondary emotions to avoid primary emotions Hospitalization to escape stressful circumstances

19. Reasons for Parasuicide Emotion Relief (92%, at least one) To stop bad feelings To stop feeling angry or frustrated or enraged To relieve anxiety or terror To relieve feelings of aloneness, emptiness or isolation To stop feeling self-hatred, shame To obtain relief from a terrible state of mind To punish yourself (63% of nonsuicidal self-injury)

20. Development of BPD BPD becomes noticeable in early adolescence, but begins long before that. A “difficult” temperament may be a sign of vulnerability during infancy Suicidal ideation, threats, and behavior during childhood and adolescence Conduct disorder, antisocial behavior, mood disorders, anxiety disorders 16% of adolescents meet BPD criteria

21. Development of BPD Environmental Factors Pathological parenting is an important risk factor. emotional neglect parental over-involvement* inconsistent care by a primary caretaker* disrupted attachment patterns parental psychopathology physical and sexual abuse early separation and loss?

22. Development of BPD Biological Correlates Biological correlates of emotional instability and impulsivity have been identified Patients with emotional instability may have higher levels of noradrenaline activity Patients with impulsive disorders may have lower levels of serotonin activity. Patients with major depressive disorder and BPD both have shorter and more variable REM latencies. Some brain differences have been found in BPD. A twin study supports a psychosocial model more than a genetic model of BPD transmission.

23. Development of BPD Linehan’s Biosocial Theory (1993) Biological and environmental factors account for BPD. BPD individuals are born with emotional vulnerability –highly sensitive to emotional stimuli –more intense in their emotional reactions –slower to return to their emotional baseline BPD individuals grow up in invalidating environments –childhood abuse –poorness-of-fit between the child and the family Transactions between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system.

24. Development of BPD Linehan’s Biosocial Theory (1993) The path to BPD is a process of reciprocal influences. invalidating environments worsen dysregulation of vulnerable children. emotionally intense children may exacerbate the invalidating environment. mutual coercion can escalate emotion, violence, and self-harm.

25. Does it make sense to diagnose BPD in adolescence? BPD in adolescents accurately reflects current distress and dysfunction –Social impairment/isolation –School problems –Work problems –Comorbid axis I diagnosis –Contact with police for antisocial behavior As expected, BPD co-occurs with PTSD, conduct disorder, depression (construct validity) Overall, BPD diagnosis is not stable 53% of moderate/severe cases of BPD persist

26. What to look for Caucasian female Severe BPD (predicts chronicity) Parasuicide, identity disturbance, intense anger (predicts chronicity) Co-occurring mood and conduct disorder Bipolar II disorder History of childhood maltreatment

27. Disability in BPD What are the functional limitations? What are reasonable accommodations in academic settings?

28. Treatment Options: The Main Dialectic Short-termLong-term avoid stressblock avoidance tolerate distress remove cueschallenge fears isolationbuild a structured life distractionproblem-solving focus on emotions hospitalizationalternative coping

29. An Ideal Treatment for BPD is one that balances… Acceptance and Change Soothing versus pushing the client Validation versus demanding

30. Most Good Treatments Don’t Work for BPD BPD has been associated with worse outcomes in treatments of Axis I disorders such as major depression anxiety disorders eating disorders substance abuse because BPD patients have low tolerance for change in the absence of validation

31. Treatment Goals Reduce out of control behavior Build a structured/productive life consistent with values Change (increase tolerate for) emotions Treat Axis I disorders Treat effects of childhood trauma Personal goals

32. Treatment Objectives Enhance capabilities Reduce emotion vulnerability Activate non-mood-dependent behavior Enhance motivation Generalization structuring of the environment Enhance capability and motivation of therapists

33. Treatment Strategies Intervene early before maladaptive patterns become crystallized and refractory to treatment. –Problem-solving –Skills-focus* –Exposure and opposite action –Reinforcement –Cognitive modification –Support/Validation/Acceptance –Keep lethal means out of reach (e.g., pills)

34. Treatment of BPD: Commitment to not parasuicide Verbal commitment Commitment strengthening Devil's advocate Motivational interviewing Pros and cons analysis Provide help Provide incentives for no parasuicide

35. Problem-Solving 1.Understand the problem 1.Identify the trigger (event) 2.Identify the key emotions and thoughts 3.What problem did the behavior solve? 2.Generate alternative solutions 3.Practice solutions

36. Treatment of BPD Significant Outcomes from DBT Study: DBT vs. TAU 1.Parasuicide Episodes 2.Treatment Drop Out 3.Psychiatric Inpatient: Admissions/Days 4.Anger 5.Global Adjustment 6.Social Adjustment

37. Treatment of BPD Effects of DBT were similar to the previous study despite –rigorous control condition of expert therapists –high allegiance to the alternative treatment DBT is effective in six randomized controlled trials DBT is particularly effective with suicidal behavior Expert therapists are better than treatment as usual UW Replication Study

38. Ways to fail with a BPD client Insufficient validation Judgmental attitude toward client Burnout Insight therapy Back down too easily Reinforce dysfunctional behavior No learning in context

39. How should a provider interact with a BPD client? Validate and acknowledge what is valid Adopt a compassionate and nonjudgmental view of the patient Don’t ignore your personal or institutional limits, but stay objective Believe in the patient Encourage mastery; provide practical help Get support and consultation

40. Levels of Validation Listen and pay attention Show you understand – paraphrase Communicate how their behavior/emotions make sense –given their past experiences –given their thoughts/beliefs Communicate how their behavior/emotions are normal or make sense now Don’t “fragilize” them or treat them like a patient

41. When to Refer When the client’s problems exceed your skill When you are approaching burnout If you cannot control judgmental thinking about the client If the client does not improve

42. Medications for BPD SSRIs improve mood and impulsivity –May reduce nonsuicidal self-injury –May increase suicide attempts* Olanzapine improves irritability/anger Anticonvulsants (Tegritol) decrease behavioral dyscontrol Alprazolam (Xanax) increases behavioral dyscontrol and suicidality ratings Opiate blockers

43. Medication Recommendations Combine pharmacotherapy with an active psychosocial treatment Focus on safety and effectiveness –Do not give lethal drugs to lethal people –Avoid benzodiazepines –Amitriptyline makes some subjects worse Attend to medication non-compliance Consult with the patient

44. Medications for BPD Dimeff, L.A., McDavid, J., Linehan, M.M. (1999). Pharmacotherapy for borderline personality disorder: A review of the literature and recommendations for treatment. Journal of Clinical Psychology in Medical Settings, 6(1), 113-138. Grossman, R. (2002). Psychopharmacologic treatment of patients with borderline personality disorder. Psychiatric Annals, 32(6), 357-370. Healy, D. (2003). Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors. Psychotherapy and Psychosomatics, 72(2), 71-79.