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Personality = Temperament + Character

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Personality = Temperament + Character

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  1. Update on Personality Disorders with specific focus on Borderline Personality DisorderGrand RoundsDepartment of PsychiatryUniversity of MarylandSeptember 28, 2006John M. Oldham, M.D.Professor and ChairmanDepartment of Psychiatry and Behavioral SciencesMedical University of South Carolinaoldhamj@musc.edu

  2. Personality =Temperament + Character

  3. Outline • Brief review of borderline concept • Heterogeneity of DSM-IV BPD • Biological / environmental • Theories of etiology • Practice guideline • New developments

  4. Precursors of BPD Concept • Latent schizophrenia (E Bleuler, 1924) • The borderline group of neuroses (A Stern, 1938) • Ambulatory schizophrenia (G Zillborg, 1941) • “As if” personality (H Deutsch, 1942) • Pseudoneurotic schizophrenia (P Hoch, P Polatin, 1949) • Borderline states (R Knight, 1953) • Psychotic character (J Frosch, 1964) • The borderline syndrome (R Grinker, B Werble, R Drye, 1968)

  5. The Borderline Syndrome • Failures of self-identity • Anaclitic relationships • Depression based on loneliness • The predominance of expressed anger - Grinker et al., 1968

  6. Development of the Borderline Construct Construct BPD Validity Benjamin Clarkin Fonagy Gunderson Linehan Links Loranger Marziali McGlashan Paris Perry Silk Soloff Stone Torgerson Zanarini Phenomenology Cognition Spitzer Affect Klein Akiskal Family history Course Impulse Siever Cowdry Treatment response Development Trauma Herman - Gunderson, 2001

  7. Concepts of Borderline Disorders Affective Disorders Borderline Schizophrenia (Kety) (Schizotypal PD - Rado, Meehl) Atypical Affective Disorders (D.Klein) Schizophrenia Borderline Personality Organization (Kernberg) Borderline Personality Disorder Borderline Syndrome (Grinker) Neuroses

  8. Borderline Personality Organization Based on Kernberg

  9. Borderline Personality Disorder (DSM-IV) 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: 1. Frantic efforts to avoid real or imagined abandonment. Note: do not include suicidal or self-mutilating 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-mutilating behavior covered in Criterion 5.

  10. Borderline Personality Disorder (DSM-IV) 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: 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 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.

  11. Prevalence of PDs in a Community Sample(N=2053)Overall – 13.4%Torgersen, Kringlen, Cramer, 2001

  12. Prevalence of PDs in a Community Sample(N=2053) Personality DisorderPresent Prevalence Paranoid 2.4 Schizoid 1.7 Schizotypal 0.6 Antisocial 0.7 Borderline 0.7 Histrionic 2.0 Narcissistic 0.8 Avoidant 5.0 Dependent 1.5 Obsessive-Compulsive 2.0 Passive-Aggressive 1.7 Self-Defeating 0.8 Torgersen, Kringlen, Cramer; 2001

  13. PD Prevalence Studies Torgersen, 2005

  14. PD Prevalence Studies (n=5081) Torgersen, 2005

  15. Heterogeneity of BPD • DSM-IV - defined BPD is an extremely heterogeneous construct (Est. 256 varieties) • Mix of unstable, stress-induced symptoms and stable personality characteristics (i.e., dimensional traits)

  16. Levels of Functioning STPD Bip-II MDD PTSD BPD Severity of social dysfunction SPD ASPD NPD AVPD HPD Gunderson, 2001

  17. BPD as a Personality Disorder Emerging From the Interaction of Underlying Genetically-Based Traits Impulsive aggression and affective instability = heritable endophenotypes that would contribute significantly to development of BPD Siever et al., 2002

  18. Heritability of BPD • Twin study (Torgersen et al. 2000) • Novelty seeking (Cloninger, 2005) • Impulsivity (New and Siever, 2002)

  19. Neurocognitive Deficits in BPD BPD patients vs Controls delayed, maladaptive choices  impulsive, disinhibited responses  impairment in planning suggest complex impairments in cognitive processes involving frontal lobes Bazanis et al., 2002

  20. Attentional Mechanisms in BPD • 39 patients with BPD 22 temperamentally-matched controls 30 average controls • Attention Network Test (ANT) administered, to match for “negative affect” and “effortful control” • BPD patients showed specific abnormality (vs average controls) in - Conflict resolution (↓) - Cognitive control (↓) • ? Related to deficient development of the conflict network between ages 2-7, involving the anterior cingulate gyrus Posner M et al, PNAS 2002; 99:16366-16370

  21. PET and BPD BPD patients vs Controls • frontal and prefrontal hypermetabolism • hippocampus and cuneus hypometabolism = limbic and prefrontal dysfunction, implicated in regulation of emotion Juengling et al., 2003

  22. MRI in Patients with BPD 16% reduction in volume of hippocampus 8% reduction in volume of amygdala in BPD patients vs. healthy controls Not clearly related to trauma (results only significant for total BPD group [with and without hx of trauma]) Driessen et al., 2000

  23. MRI in Patients with BPD ↓ Volume hippocampus and amygdala (Schmahl et al, 2003; Rusch et al., 2003)

  24. Implications of Imaging Studies in BPD • Abnormalities in prefrontal, corticostriatal, and limbic networks • Perhaps related to lowered serotonin neurotransmission and behavioral disinhibition. Johnson et al., 2003

  25. Maternal Absence and CSF F-HIAA Concentrations in Rhesus Monkey Infants • Early maternal deprivation reduces CNS serotonin turnover • Nursery-rearing conditions do not restore serotonin levels • CSF 5-HIAA concentrations are trait-like and stabilize in infancy Shannon et al., 2005

  26. Maternal Absence and CSF F-HIAA Concentrations in Rhesus Monkey Infants “…evolution has selected for mothers to provide emotional security and to punish inappropriate social impulses, perhaps providing the input needed to properly link the serotonin system to the frontal cortex region, which is of crucial importance in both emotional regulation and impulse control. Shannon et al., 2005

  27. Childhood Abuse and BPD • Severe childhood trauma  persistent serotonergic disturbance • Dose/response correlation (age of onset, frequency, seriousness) • Only males show  serotonin and  aggression or  impulsivity • Sustained childhood abuse  - Hyporesponsiveness of 5-HT system - Hyper-responsiveness of HPA system (correlated with sustained abuse, not BPD pathology) • To know what characterizes BPD, must correct for chronic childhood trauma • Possibly faulty attachment in genetically vulnerable children  selected by abusers  sustained abuse  HPA disturbances susceptibility to stress and stress-related disorders (e.g. BPD, MDD) Rinne, T, ISSPD, Florence, 2003

  28. Adverse Early Rearing in Primates Persistent Overactivity of CSF CRF- Containing Neurons • Related to unpredictability of foraging conditions imposed on maternal-infant dyad • Putative mechanism = inconsistent, erratic, and sometimes dismissive rearing behavior exhibited by mothers undergoing VFD Coplan et al., 1996

  29. Theories of Etiology of BPD • 1. Affective/impulsive dysregulation (Klein, Akiskal) • 2. Excessive aggression (Kernberg) • A. Primary (constitutional) • B. Secondary (reaction to frustration or trauma) • 3. Maternal withdrawal (Masterson, Rinsley) • 4. Introjective failure (Mahler, Kohut) • 5. Neurological dysfunction (Andrulonis) • Gunderson and Zanarini

  30. Etiology of BPD Type 1: Affective (Akiskal, Klein) • **A moderately heritable “subaffective” vulnerability, precipitated by environmental stress Prototypic Criteria: • #6: affective instability due to marked reactivity of mood (dysphoria or anxiety); • #5: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

  31. Etiology of BPD Type 2: Impulsive (Zanarini, Hollander, Siever) • **A moderately heritable impulse spectrum disorder, precipitated by environmental stress Prototypic Criteria: • #4: impulsivity in at least two areas that are potentially self-damaging; • #5: recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

  32. Etiology of BPD Type 3: Aggressive (Kernberg) • **A primary moderately heritable aggressive temperament, or a secondary reaction to early trauma and/or abuse Prototypic Criteria: • #8: inappropriate, intense anger or difficulty controlling anger; • #6: affective instability due to marked reactivity of mood (irritability)

  33. Etiology of BPD Type 4: Dependent (Masterson and Rinsley; Gunderson) • **intolerance of aloneness, and impaired autonomy, possibly secondary to parental separation-resistance Prototypic Criteria: • #1: frantic efforts to avoid real or imagined abandonment; • #6: affective instability due to marked reactivity of mood (anxiety)

  34. Etiology of BPD Type 5: Empty (Mahler; Adler and Buie) • **failure to develop an evocative memory secondary to lack of empathy and inconsistency in early parenting Prototypic Criteria: • #7: chronic feelings of emptiness; • #3: identity disturbance: markedly and persistently unstable self-image or sense of self

  35. Treatment of BPD

  36. Practice Guideline for the Treatment of Patients with Borderline Personality Disorder American Journal of Psychiatry October, 2001

  37. APA Practice Guidelines Work Group on Borderline Personality Disorder John Oldham, M.D. (Chair) Glen Gabbard, M.D. Marcia Goin, M.D., Ph.D. John Gunderson, M.D. Paul Soloff, M.D. David Spiegel, M.D. Michael Stone, M.D. Katherine Phillips, M.D.

  38. Part A: Treatment Recommendations for Patients with Borderline Personality Disorder I. Executive Summary of Recommendations II. Formulation and Implementation of a Treatment Plan III. Special Features Influencing Treatment IV. Risk Management Issues in Treating Borderline Patients

  39. Part B: Background Information and Review of Available Evidence V. Disease Definition, Epidemiology and Natural History VI. Review and Synthesis of Available Evidence Part C: Future Needs VII. Psychotherapy VIII. Pharmacotherapy and Other Somatic Treatments

  40. Part A: Treatment Recommendations for Patients with Borderline Personality Disorder II. Formulation and Implementation of a Treatment Plan A. The Initial Assessment • Initial assessment and determination of the treatment setting • Comprehensive evaluation • Establishing the treatment framework

  41. Indications for partial hospitalization (or brief inpatient hospitalization if partial hospitalization is not available) include the following: • Dangerous impulsive behavior unable to be managed with outpatient treatment • Nonadherence with outpatient treatment with a deteriorating clinical picture • Complex comorbidity that requires more intensive clinical assessment of response to treatment • Symptoms of sufficient severity to interfere with functioning and work or family life and which are unresponsive to outpatient treatment

  42. Indications for brief inpatient hospitalization include the following: • Imminent danger to others • Loss of control of suicidal impulses or serious suicide attempt • Transient psychotic episode associated with loss of impulse control and/or impaired judgment • Symptoms of sufficient severity to interfere with functioning and work or family life and which are unresponsive to outpatient treatment and partial hospitalization

  43. Indications for extended inpatient hospitalization include: • Persistent, severe, suicidality, self-destructiveness, or nonadherence to outpatient treatment or partial hospital treatment • Comorbid refractory Axis I disorder (e.g., eating disorder, mood disorder) that presents a potential threat to life • Comorbid substance abuse or dependence that is severe and unresponsive to outpatient or partial hospital treatment • Continued risk of assaultive behavior toward others despite brief hospitalization • Symptoms of sufficient severity to interfere with functioning and work or family life and which are unresponsive to outpatient treatment, partial hospitalization and brief hospitalization

  44. Part A: Treatment Recommendations for Patients with Borderline Personality Disorder II. Formulation and Implementation of a Treatment Plan D. Specific Treatment Strategies for the Clinical Features of Borderline Personality Disorder • Psychotherapy • Pharmacotherapy and other somatic treatments

  45. Psychotherapy Recommendations for BPD • 1. Dialectical behavior therapy • RCT: Linehan et al., Archives Gen Psych, 1991 • AJP, 1994 • Am J Addictions, 1999 • Clinical consensus: Strong • 2. Psychoanalytic/psychodynamic therapy • RCT: Bateman & Fonagy, AJP, 1999 • Clinical consensus: Strong

  46. Dialectical Behavior Therapy ↓ Frequency and severity of parasuicidal episodes ↓ Therapy attrition ↓ Number of psychiatric inpatient days • Improved scores on measures of anger, interviewer- related global social adjustment, and Global Assessment Scale • Improved self-rating on overall social adjustment • One-year maintenance of treatment gains -Linehan et al, Arch Gen Psychiatry 1991 -Linehan et al, Arch Gen Psychiatry 1993 -Linehan et al, Am J Psychiatry 1994

  47. Partial Hospital Psychoanalytic Psychotherapy • BPD patients (n = 38) • Randomized controlled design: • Partial hospital vs. Standard treatment • 18 months, psychoanalytic individual & group therapy  suicidal acts  self-mutilatory acts  depressive symptoms  hospital patient days  social and interpersonal functioning • 36 month, maintained gains Bateman & Fonagy, AJP, 1999 Bateman & Fonagy, AJP, 2001

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