the development of borderline personality and self inflicted injury
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The Development of Borderline Personality and Self-Inflicted Injury. Chapter 18 Sheila E. Crowell, Erin A. Kaufman, and Mark F. Lenzenweger. HISTORICAL CONTEXT. Self-Inflicted Injury

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the development of borderline personality and self inflicted injury
The Development of Borderline Personality and Self-Inflicted Injury

Chapter 18

Sheila E. Crowell, Erin A. Kaufman, and Mark F. Lenzenweger

historical context
HISTORICAL CONTEXT
  • Self-Inflicted Injury
    • Most studies of SII have been conducted by suicide researchers, and important distinctions between suicidal and nonsuicidal self-injury have only been acknowledged recently (Linehan, 1997; Muehlenkamp & Gurierrez, 2004).
    • Offer and Barglow (1960) identified a relatively large subgroup of hospitalized youth who harmed themselves without suicidal intent.
    • Current research on adolescent suicide and nonsuicidal SII is focused on:
      • Understanding the etiology of SII
      • Placing adolescent SII within a theoretical context
      • Determining how to represent SII within the DSM
      • Developing a standard of care for adolescents who engage in SII
historical context1
HISTORICAL CONTEXT
  • Borderline Personality Disorder
    • Historically, the term borderline resulted from difficulties diagnosing those who did not fit into the psychiatric nomenclature of the early to mid 20th century.
    • Kernberg (1967) was among the first to identify borderline personality organization as a specific and stable personality pattern.
    • DSM-III (APA, 1980) established diagnostic criteria for BPD.
    • Current research focuses on the dysfunctional psychosocial and biological underpinnings of BPD.
historical context2
HISTORICAL CONTEXT
  • Borderline Pathology in Childhood
    • Although research on childhood borderline pathology (BP) evolved in parallel with the adult literature, existing research with youth remains extremely limited in scope.
    • Researchers studying the development of BPD generally describe a developmental pathway characterized by:
      • Sequential comorbidity
      • Heterotypic continuity
diagnostic terminological and conceptual issues
DIAGNOSTIC, TERMINOLOGICAL, AND CONCEPTUAL ISSUES
  • DSM-IV-TR (2000)
    • Self-inflicted injury is included in the criterion lists of major depression and BPD.
    • Because BPD is a controversial diagnosis for adolescents many clinicians assign one or more Axis I disorders to self-injuring youth, especially major depression.
    • Ongoing efforts to list SII within the DSM as a stand-alone diagnosis.
  • Debate around BPD diagnosis, especially for adolescents.
  • There is increasing evidence that precursors to BPD appear well before age 18 (Bradley, Zittel Conklin, & Westen, 2005).
etiological formulations
ETIOLOGICAL FORMULATIONS
  • Biosocial developmental model of borderline personality development (Crowell, et al., 2009)
    • Trait impulsivity and emotional sensitivity are early-emerging biological vulnerabilities that confer risk for SII, BPD, and other disorders characterized by poor behavioral control.
    • Extreme emotional lability is shaped and maintained within high-risk developmental contexts, which are characterized by intermittent reinforcement of aversive behaviors paired with chronic invalidation of intense expressions of emotion.
    • Over time, biological vulnerabilities interact with environmental risks to potentiate more extreme behavioral and emotion dysregulation.
etiological formulations1
ETIOLOGICAL FORMULATIONS
  • By adolescence, these Biology × Environment interactions promote a constellation of identifiable problems and maladaptive coping strategies such as SII, which indicates heightened risk for BPD.
  • Early features of borderline pathology may further exacerbate risk for BPD by negatively affecting one’s abilities to navigate stage-salient developmental tasks, form appropriate interpersonal relationships, and develop healthy strategies for coping with distress.
familiality and heritability
FAMILIALITY AND HERITABILITY
  • There are strong biological underpinnings for both BPD and SII.
  • SII also aggregates in families and includes a clinical phenotype characterized by both suicide and suicide attempts (Brent & Mann, 2005).
  • Family studies of those with BPD reveal significant familial aggregation of mood and impulse control disorders (White et al., 2003).
  • BPD co-aggregates with mood and anxiety disorders, alcohol and drug abuse/dependence, pain disorder, and several personality disorders.
genetics and neurotransmitter dysfunction
GENETICS AND NEUROTRANSMITTER DYSFUNCTION
  • Dopamine
    • There is consensus that DA dysfunction contributes to some of the behavioral traits seen in BPD, including SII (Osuch & Payne, 2009; Sher & Stanley, 2009).
  • Serotonin
    • Deficits in central 5HT have been associated consistently with mood disorders, suicidal behaviors, and aggression (Kamali, Oquendo, & Mann, 2002).
  • Other Biological Vulnerabilities
    • Chronic stress leads to elevated LHPA axis responses that are involved in suicidal behavior.
    • Oxytocin dysregulation may contribute to the difficulty those with BPD experience in relationships (Stanley & Siever, 2010).
    • Deficits within the prefrontal cortex may contribute to suicidal and other impulsive behaviors through a diminished capacity to inhibit strong impulses.
contextual and family risk factors
CONTEXTUAL AND FAMILY RISK FACTORS
  • Family processes that shape emotion dysregulation have been well delineated in such samples and may translate well to youth at risk for BPD (Beauchaine et al., 2009).
  • Invalidating caregiving environment.
  • Emotional lability is shaped within families via operant conditioning.
  • Mixed results on child abuse research highlights the importance of the interplay between biological and psychosocial risks.
theoretical synthesis and future directions
THEORETICAL SYNTHESIS AND FUTURE DIRECTIONS
  • BPD and SII likely emerge due to repeated, complex interactions between biological vulnerabilities and contextual stressors.
  • By adolescence, there are a constellation of identifiable problems and maladaptive coping strategies, such as SII, that indicate heightened risk for BPD.
  • BP features may further exacerbate risk for BPD by affecting a person’s ability to navigate stage salient developmental tasks, form appropriate interpersonal relationships, and develop healthy strategies for coping with distress.
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