ED 624: Abnormal Psychology11-20-10

Deb Carney

Borderline Personality Disorder

Patients with borderline personality disorder stand on the border between neurosis and psychosis.

Characterized by extraordinarily unstable affect, mood, behavior, object relations, and self-image.

Persons with borderline personality disorder almost always appear to be in a state of crisis. Mood swings are very common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings.

Borderline Personality Disorder

Factors that seem likely to play a role include: Genetics. Some studies of twins and families

suggest that personality disorders may be inherited.Environmental factors. Many people with

borderline personality disorder have a history of childhood abuse, neglect and separation from caregivers or loved ones.

Brain abnormalities. Some research has shown changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.

Most likely, a combination of these issues results in borderline personality disorder.

Etiology of Borderline Personality Disorder

Risk Factors for Borderline Personality Disorder

Personality is shaped by both inherited tendencies and

environmental factors, or your experiences during

childhood. Some factors related to personality

development can increase your risk of developing

borderline personality disorder. These include:

Hereditary predisposition. You may be at a higher risk if a

close family member — a mother, father or sibling — has the

disorder.

Childhood abuse. Many people with the disorder report

being sexually or physically abused during childhood.

Neglect. Some people with the disorder describe severe

deprivation, neglect and abandonment during childhood.

Also, borderline personality disorder is diagnosed more

often in women than in men.

Although the precise cause of personality disorders isn't known, certain factors seem to increase the risk of developing or triggering personality disorders, including:

A family history of personality disorders or other mental illness Low socioeconomic status Verbal, physical or sexual abuse during childhood Neglect during childhood An unstable or chaotic family life during childhood Being diagnosed with childhood conduct disorder Loss of parents through death or traumatic divorce during childhood Personality disorders often begin in childhood and last

through adulthood. There's reluctance to diagnose personality disorders in a child, though, because the patterns of behavior and thinking could simply reflect adolescent experimentation or temporary developmental phases.

Risk Factors of Personality Disorder Continued

Depression: Unstable mood

Anxiety

Eating disorders

Suicidal behavior

Self-injury: Cutting or burning

Reckless behavior: Impulsive

Risky sexual behavior

Alcohol or substance abuse

Aggression or violence: Intense and Inappropriate.

Incarceration

Relationship difficulties: Volatile relationships

Social isolation: Fear of being alone/Abandonment Issues

School and work problems

Possible Area’s of Impairment

Chronic feelings of emptiness and boredom Mood Swings are very

common;DepressionAngerComplaints of having

“no feelings”.Loss of peer group

relationships.Marked identity

disturbance.

Often feel tumultuous and hostile.

Often dependent on those that they are close to.

However when angry at the person they can express enormous anger at loved ones and friends.

Possible Social/Emotional Impairment Lack a sense of

identity: Identity Diffusion

Patients diagnosed with borderline personality disorder have a defense mechanism of projective identification. In this primitive defense mechanism, intolerable aspects of the self are projected onto another; the other person is induced to play the projected role, and the two persons act in unison.

Patients with personality disorder tend to distort their relationships by considering each person as either all good or all bad.

They see persons as either nurturing attachment figures or as hateful, sadistic figures who deprive them of security needs and threaten them with abandonment whenever they feel dependent.

Shifts of allegiance from one person or group to another are frequent.

Social/Emotional Impairments Cont.

Acts impulsively, example: Driving Recklessly Risky Sexual Behaviors/promiscuous Tendency towards violence Tendency towards isolation from others Alcohol or substance abuse problems Eating disorders/ Bulimia/Anorexia Frantic efforts to avoid real or imagined abandonment Tendency to become extremely angry if the person feels the

he/she is not getting the perceived attention they feel they should have.

Recurrent suicidal gestures, threats, or self-mutilating behavior.

Impulsive behaviors that are potentially self-damaging. Frequent eruptions of intense, inappropriate behavior.

Possible Behavioral Impairments

Difficulty in relationship building with co-workers due to untrusting tendencies as well as violent outbursts.

Unable to attend work/school because of depression and social isolation.

Risky behaviors which could lead to job termination.Frequent absences which could lead to job

termination.As a child the person could be diagnosed with ADHD.This would cause difficulty in paying attention.Difficulty in completing tasks.Avoiding tasks that would required sustained effort.Organization skill deficits.

Possible Academic/Vocational Impairments

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: frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

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 (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 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)

chronic feelings of emptiness inappropriate, intense anger or difficulty controlling anger (e.g., frequent

displays of temper, constant anger, recurrent physical fights) transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostic Criteria DSM-IV

Borderline Personality Disorder 301.83

The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

Individuals with Borderline Personality Disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician's announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.

Diagnostic Features of Borderline Personality Disorder

Individuals with Borderline Personality Disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not "there" enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will "be there" in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

Diagnostic Features of Borderline Personality Disorder Continued

There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations.

Diagnostic Features of Borderline Personality Disorder Continued

Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with Borderline Personality Disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Completed suicide occurs in 8%–10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual's sense of being evil.

Diagnostic Features of Borderline Personality Disorder Continued.

Individuals with Borderline Personality Disorder may display affective instability that is 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) (Criterion 6). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual's extreme reactivity to interpersonal stresses. Individuals with Borderline Personality Disorder may be troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver's nurturance may result in a remission of symptoms.

Features of Borderline Personality Disorder Continued

Therapy is not expected to be brief It can typically last at least a year for most.

A strong helping relationship develops between client and counselor.

Clear roles and responsibilities are established between client and counselor.

Counselor is active and directive not passive.Client and therapist develop a hierarchy of priorities..Counselor conveys empathic validation plus the need for the

client to control his/her behavior.Flexibility is needed as new stressors develop.Limit setting preferably mutually agreed upon.Concomitant individual and group approaches are used.

Psychopharmacology strongly recommended.\

Common Treatment Measures Recommended

Treatment for Borderline Personality Disorder is long term. It is often on going.

Psychotherapy for this disorder is an area on intensive investigation and has been the treatment of choice. For best results, pharmacology has been added to this treatment regime.

A particular form of therapy called DBT has proven to be very helpful in the treatment of the maladaptive behaviors that the client with borderline personality disorder can exhibit.

Treatment Efficacy

Pharmacotherapy is useful to deal with specific personality features that interfere with patients’ overall functioning. Antipsychotics have been used to control anger, hostility, and brief psychotic episodes. Antidepressants improve the depressed mood common in clients with borderline personality disorder. The MAO inhibitors (MAOIs) have successfully modulated impulsive behavior in some patients. Benzodiazepines, particularly alprazoloam,(Xanax), help anxiety and depression, but some clients, show a disinhibition with a this class of drugs. Anticonvulsants, such as casrbamazepine, may improve global functioning for some patients. Serotonergic agents such as seretonin reuptake inhibitors (SSRI’s)have been helpful in some cases.

Pharmacotherapy

Medication alone is insufficient because the client is not taught how to manage their lives and the array of maladaptive feelings and actions that they project onto themselves as well as others.

The following interventions are suggested along with medication:

Social skill groups: Dialectical Behavior Therapy(DBT) Research conducted on this treatment have shown it to be more effective than most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder.

learn new coping skills emotion regulation social learning theory and conflict resolution.

Psychosocial Interventions

What is Dialectical Behavior Therapy

Research conducted on this treatment have shown it to be more effective than

most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder. It seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self-knowledge,

emotion regulation, and cognitive restructuring. It is a comprehensive

approach that is most often conducted within a group setting. Because the skill set learned is new and complex, it is not

an appropriate therapy for those who may have difficulty learning new concepts.

Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

What is Dialectical Behavior Therapy Continued. . .

Characteristics of DBT

Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life. Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion. Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.

Generally, dialectical behavior therapy (DBT) may be seen as having two main components:

1. Individual weekly psychotherapy sessions that emphasize problem-solving behavior for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviors take first priority, followed by behaviors that may interfere with the therapy process. Quality of life issues and working toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post traumatic stress responses (from previous trauma in the person’s life) and helping enhance their own self-respect and self-image.Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.

During individual therapy sessions, the therapist and client work toward learning and improving

many basic social skills.

2. Weekly group therapy sessions, generally 2 1/2 hours a session and led by a trained DBT therapist, where people learn skills from one of four different

modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion

regulation, and mindfulness skills are taught.

Generally, dialectical behavior therapy (DBT) may be seen as having two main

components:

Domain: Social/EmotionalLong Term Goal

Develop and demonstrate coping skills to deal with

mood swings.

Short Term Goal: Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk.

Strategy: Assign the client homework exercises in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure.

Domain: Social/EmotionalLong Term Goal

Cooperate with an evaluation by a physician

for psychotropic medication and take

medication, if prescribed.

Short term Goal: Assess the client’s need for medication (e.g., selective serotonin reuptake inhibitors) and arrange for prescription if appropriate.

Strategy: Monitor and evaluate the client’s psychotropic medication prescription compliance and the effectiveness of the medication on his/her level of functioning.

Domain: BehavioralLong Term

Goal:

Terminate self-damaging

behaviors (such as substance abuse, reckless driving, sexual acting out, binge eating, or

suicidal behaviors).

Short Term Goal: Reduce the frequency of

maladaptive behaviors, thoughts, and feelings that interfere with attaining a reasonable quality of life.

Strategy: use validation, dialectical strategies and problem-solving strategies(e.g., behavioral and solution analysis, cognitive restructuring skills training, exposure) to help the client manage behaviors(e.g.. Angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending),thoughts(e.g., all-or-nothing thinking, catastrophizing, personalizing), feelings of hopelessness, and abandonment

Domain: BehavioralLong Term Goal:

Develop and demonstrate anger management skills.

Short term goal: Participate in a group

(preferably) or individual personal skills development course.

Strategy: Conduct group or individualized training tailored to the client’s identified problem behavioral patterns (e.g., assertiveness for abusive relationships, cognitive strategies for identifying and controlling financial, sexual, and other impulsivity.

Domain: Academic/Vocational

Long Term Goal:

Learn and practice

interpersonal relationship

skills.

Short Term Goal: Verbalize a sense of self-

respect that is not dependent on others’ opinions.

Strategy: Help the client to value, believe, and trust in his/her evaluations of himself/herself, others, and situations and to examine them nondefensively and independent of others’ opinions in a ;manner that builds self-reliance but does not isolate the client from others.

Diagnostic and statistical manual of mental disorders. (2000). Arlington Virginia: American Psychiatric Association

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Sadock, m.d. (2007). Synopsis of psychiatry. Philadelphia Pennsylvania: Lippincott Williams & Wolters

Kluwer Business.

The Complete Adult Psychotherapy Treatment Planner. (2006). Hoboken New Jersey: John Wiley and Sons.

References