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Chapter 12 Borderline Personality Disorder Kim L. Gratz, Ph.D. Director, Personality Disorders Division

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Chapter 12 Borderline Personality Disorder Kim L. Gratz, Ph.D. Director, Personality Disorders Division Center for Addictions, Personality, and Emotion Research University of Maryland. Borderline Personality Disorder: Diagnostic Criteria

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Chapter 12

Borderline Personality Disorder

Kim L. Gratz, Ph.D.

Director, Personality Disorders Division

Center for Addictions, Personality, and Emotion Research

University of Maryland

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Borderline Personality Disorder: Diagnostic Criteria

  • Frantic efforts to avoid real or imagined abandonment
  • A pattern of unstable and/or intense interpersonal relationships
  • Persistent and markedly unstable self-image or sense of self
  • Impulsivity in at least two potentially self-damaging areas (e.g. substance abuse, binge eating, sex)
  • Recurrent suicidal behavior, gestures, or threats, and/or self-injury
  • Intense, usually brief, mood swings
  • Chronic feelings of emptiness
  • Inappropriate, intense anger
  • Transient, stress-related paranoid ideation or severe dissociation
  • [To meet criteria for BPD, must meet 5+ criteria]
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BPD: Differential Diagnosis

  • Depression
    • Chronic vs. acute mood symptoms
    • Persistent behavioral and interpersonal dysfunction not specific to depressed mood
    • Depression resolves after BPD remits
  • Psychosis
    • Quasi-psychotic symptoms vs. psychotic symptoms
        • level of disconnection from reality
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BPD: Differential Diagnosis

  • PTSD
    • Criterion A event vs. less acute/severe stressor
    • Onset and duration of symptoms
    • Pre-trauma vs. post-trauma functioning
    • Presence of re-experiencing symptoms
    • Nature of interpersonal difficulties (trauma-related vs. not)
    • Emotional triggers (trauma-related vs. interpersonal)
  • ASPD
    • Impulsive behaviors within relationships more likely to be driven by fears of abandonment
    • Excessive guilt and shame about impulsive acts
    • Harm more likely to be directed inward, rather than outward
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Borderline Personality Disorder

  • Elevated risk for self-destructive behaviors
    • 10% commit suicide
    • 80% self-injure
    • Risky sexual behaviors, disordered eating, substance abuse
  • Associated with many other psychiatric disorders
    • Mood disorders ( > 80%)
    • Anxiety disorders (> 80%), including PTSD (> 50%)
    • Substance use disorders (> 50%)
    • Other personality disorders, esp. anxious cluster (> 50%)
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Borderline Personality Disorder

  • Course
    • Developmental origins in early childhood
        • Many patients with BPD report having experienced BPD-related symptoms (e.g., self-injury, emotional lability, fears of abandonment)years before diagnosed
    • Usually diagnosed in late adolescence/early adulthood
    • Historically considered to be “life-sentence,” but research suggests a more hopeful, positive prognosis
        • ~75% of BPD inpatients remit within 6 years
        • Low rates of recurrence (< 6%)
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Borderline Personality Disorder

  • Course: Predictors of failure to remit
    • Anxiety cluster personality disorder (e.g., avoidant)
        • May reflect underlying anxious-inhibited temperament
    • Substance use disorders
    • PTSD
    • Mood or anxiety disorder
    • Eating disorder
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Borderline Personality Disorder

  • Risk factors
    • BPD results from combination of biologically-based vulnerabilities and childhood environmental stressors
    • Biologically-based vulnerabilities
        • Affective dysfunction
        • Impulsivity
        • Insecure attachment
    • Environmental stressors
        • Childhood abuse
        • Emotional/physical neglect, emotional invalidation
        • Early prolonged parental separation and/or loss (e.g., absence of parent, parental illness, parental death)
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Treatments for BPD

  • Dialectical Behavior Therapy
    • Empirically-supported cognitive-behavioral therapy composed of both individual and group treatments
    • Associated with reduced self-injurious/suicidal behaviors, substance abuse, and anger, fewer hospitalizations, higher global functioning
    • Treatment targets four different areas
        • Emotion Regulation
        • Distress Tolerance
        • Interpersonal Effectiveness
        • Mindfulness
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Treatments for BPD

  • Dialectical Behavior Therapy: Treatment Domains
    • Emotion Regulation
        • Increasing emotional awareness and clarity
        • Decreasing emotional vulnerability
        • Learning adaptive strategies for modulating emotions
    • Distress Tolerance
        • Distraction
        • Self-soothing
        • Acceptance/willingness
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Treatments for BPD

  • Dialectical Behavior Therapy: Treatment Domains
    • Interpersonal Effectiveness
        • Getting your objectives met
        • Maintaining relationships
        • Maintaining self-respect
    • Mindfulness
        • “What” skills: Observing, describing, participating
        • “How” skills: Non-judgmentally, one-mindfully, effectively
        • Skills promote present moment focus, non-judgmental awareness, and attentional flexibility
        • Goal is to develop a lifestyle of participating with awareness
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