Borderline Personality Disorder

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 • 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’, 2001. 2. DSM IV, American Psychiatric Association, 2000. 3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.