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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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