Borderline Personality Disorder
Matthew Gaskell
Leeds Addiction Unit
Agenda
• Personality
• Personality Disorder
• Borderline Personality Disorder
• Management of BPD
• LAU PD Care Programme
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What do we mean by
personality?
Personality
•Enduring features that determine how
we respond to life events &
experiences; also provide convenient
means by which others can label and
react to us
•Describes how we cope with & adapt
and respond to life events: challenges,
frustrations, successes & failures
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Personality
•While it is enduring in its core features
we:
•Evolve through experience
•Learn new & effective ways of
responding
•Allows us to adapt with increasing
success to life’s demands
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What is a personality
disorder?
Personality Disorder
•Variations or exaggerations of normal
personality attributes
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Common Features of Personality Disorder
• Start in childhood and adolescence
• Pervasive through many situations
• Not secondary to mental illness
• Personal distress or adverse impact on others
• Deviation from the cultural norm in cognition,
affectivity, control of impulses, ways of relating to
others
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Personality disorder
•Rarely learn to adapt their responses or
learn new ones
•Fixed and unchanging in dealing with
life events
•Despite negative consequences
•Often unable to associate problems with
their own inflexible ways of
thinking/behaving
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Specific Personality Disorder – Cluster A (odd)
Paranoid
F60.0
sensitive, suspicious, combative about
about personal rights, bearing grudges, self
important
Schizoid
F60.1
emotionally cold, poor expression of
feelings towards others, fantasies and
introspection, indifferent to praise or
criticism
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Specific Personality Disorder – Cluster B
(dramatic)
Antisocial
F60.2
irresponsible disregard for social norms,
intolerant, blame others, no guilt, aggressive
Emotionally unstable – lack of impulse control, poor self
Unstable
image, emotional crises, extreme behaviour
F60.3
such as self harm in response to crises
Histrionics
F60.4
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dramatisation, suggestibility, shallow and
labile emotions, seeking attention,
seductiveness, easily hurt
Specific Personality Disorder – Cluster C
(anxious)
Anakastic
F60.5
self doubt, caution, preoccupied with detail
and rules, perfectionist, rigid, excessively
conscientious, intrusive thoughts
Anxious
F60.6
feelings of tension and anxiety, feel socially
inept, preoccupied with being criticised or
rejected, need for physical security
Dependent
F60.7
others make decisions, own need secondary
to others, unwilling to make demands on
others, helpless when alone, need
reassurance
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Personality Disorder in last 12 months
Drug Services
n=216
Alcohol Services
n=62
Cluster A Disorders
3.7%
6.5%
Paranoid
Schizoid
2.7%
0.9%
4.8%
3.2%
Cluster B Disorders
30.1%
24.2%
Antisocial
Impulsive
Borderline
Histrionic
10.2%
15.8%
7.7%
3.6%
11.3%
3.2%
9.7%
3.2%
13.0%
35.5%
0.9%
5.0%
8.1%
3.2%
27.4%
16.1%
Cluster C Disorders
t
Anankastic
Anxious
Dependent
Source: Bowden-Jones et al. (2004)
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What is Borderline
Personality?
Read Claire’s story & see how
many features you can identify
Criteria for BPD (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:
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Criteria for BPD (DSM-IV)
•Frantic efforts to avoid real or imagined
abandonment;
•A pattern of unstable and intense
interpersonal relationships
characterised by alternation between
extremes of idealisation and
devaluation;
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Criteria for BPD (DSM-IV)
•Identity disturbance: markedly and
persistently unstable self-image or
sense of self;
•Impulsivity in at least two areas that are
potentially self-damaging (e.g.
spending, sex, substance abuse,
reckless driving, binge eating);
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Criteria for BPD (DSM-IV)
•Recurrent suicidal behaviour, gestures
or threats, or self-mutilation;
•Affective instability due to a marked
reactivity of mood (e.g. intense
episodes of depression, irritability or
anxiety that lasts only for a few hours or
a few days);
•Chronic feelings of emptiness;
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Criteria for BPD (DSM-IV)
•Inappropriate, intense anger or difficulty
controlling anger (e.g. fraudulent
displays of anger, constant anger,
recurrent physical fights);
•Transient, stress-related paranoid
ideation or severe dissociative
symptoms
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So people with BPD:
• Fall into close & conflict-ridden relationships
even after a single meeting with someone;
• Are just as likely to fall out with that person if
they interpret the person’s behaviour as
uncaring or not attentive enough
• Are riddled with fear about being rejected and
losing that relationship
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So people with BPD:
• Leads to rapid, ill-tempered mood changes if
they feel things ‘are not going their way’;
• Leads to: Regular & unpredictable shifts in
self-image characterised by changing
personal goals, values & career aspirations;
prolonged bouts of depression, deliberate
self-harm, suicidal ideation & actual suicide
attempts and impulsive behaviour such as
drug abuse, physical violence & inappropriate
promiscuity
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A challenge for practitioners
•People with a diagnosis of BPD
regularly access services in crisis and
often self harm. They make intense
demands on health professionals and
will regularly repeat these demands,
e.g. threatening suicide or self harm
•These factors combined with drug or
alcohol use make this group particularly
challenging to work with
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Diagnosis
•Controversy exists about the label &
how useful it is
•Stigmatising
•Stereotyping of women
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Prevalence
•1-2% of general population
•At least 3:1 ratio of women to men
diagnosed (up to 75% are women)
•20% psychiatric admissions
•Up
to 10% suicide rate
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Problems of diagnosis…
BPD also meet diagnosis for:
•A mood disorder – dep, bipolar (96.3%)
•Anxiety disorder (88.4%)
(panic = 47.8%; social phobia = 45.9%)
•Substance abuse disorders (64.1%)
•Eating disorders (53%)
•PTSD (55.9%) – some clinicians see
BPD as a form of PTSD
• Zanarini et al. (1998)
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Why do they present for
treatment? Not for BPD…
•Relationship problems
•Depression (consistently experience
loss or failure)
•Anxiety (intense fears of rejection etc)
•Self-harm, drug abuse, suicidal
ideation/attempts – recurrent crises
•Educational/vocational
underachievement
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Risk factors for BPD
•Physical, sexual, verbal abuse &
neglect in childhood (60-90%) Gabbard, 1990.
•Sexual abuse (67-87%) Bryer, 1987.
•Physical abuse (71% v 38% psychiatry
patients) Herman et al., 1989.
•Environmental instability
•Parental substance abuse & promiscuity
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Risk factors
•Academic underachievement
•Low intelligence & artistic skills Helgeland &
Torgersen, 2004
•But……
20% of BPD patients never report
childhood abuse or neglect – therefore it is
not a necessary condition for developing BPD
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Theories
•Biological
• Seems to run in families
• Twin studies – concordance rates of 35% in
MZ twins & 7% of DZ twins (Torgerson et al.,
2000)
• Genetic analysis – traits of BPD (e.g. rapid
mood changes) have strong inherited
component
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Theories
•Biological
• Closely related to Bipolar Disorder Spectrum (44% of
BPD) - & we know there is a significant genetic
component to bipolar disorder
• Low levels of serotonin = associated with impulsivity
& may account for regular bouts of depression
• Some evidence for dysfunction in dopamine activity
(has role in emotion processing, impulse control &
cognition
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Theories
•Biological
• Neuroimaging: abnormalities in frontal lobe
functioning (impulsive behaviour) & limbic system,
including the hippocampus and amygdala (controls &
regulates emotions)
• Not known if these are a consequence or biological
cause of the disorder
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Theories
•Psychological
• Focuses on the ‘invalidating environment’ and
childhood trauma e.g. Object relations theory –
experiences lead to developing insecure ego, low
self-esteem, increased dependence & fear of
separation/rejection. Respond in ways they have
learned from important others. Engage in defence
mechanism ‘splitting’
• Doesn’t explain why early experiences turn to BPD
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Theories
•Psychological
Dysfunctional schemas (Young et al., 2003)
APD & BPD score similarly high on childhood
abuse & dysfunctional schemas = different
manifestations of single underlying disorder?
BPD = women; APD = men.
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BPD & Substance Use
What patterns of use do you see?
Patterns of use
•Dependence
•Episodic, impulsive use in response to
experiencing intense emotions
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Management of BPD
Thoughts on how to manage them
effectively?
Management & Treatment
•Consistency – offer the stability to
contrast the client’s lability of emotion &
thinking
•Try not to discharge or pass them
around to other agencies or have
multiple agencies involved
•Proper and well defined boundaries
carefully explained at onset
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Management & Treatment
• Long-term involvement (1 year+)
• Reframing practitioner labels or beliefs
“attention-seeker”; “manipulative”; “troublemaker”
• Practitioner resilience – tolerate repeated
episodes of rage, distrust & fear – good at
evoking anger in others/you
• Therapeutic alliance – strong need to be
accepted, understood, need safety
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Management & Treatment
•Offer united front to manage any
splitting in your team/ward – don’t get
hooked in & set firm limits/strict rules
•Manage endings & transitions
•Good crisis management planning
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Management & Treatment
•Pharmacotherapy (NICE)
•Psychological – CBT/DBT (best
evidence). BI not recommended.
• Targets = engagement; cognitive restructuring;
impulse control; emotion regulation; skills training;
target reduction in self-destructive behaviour
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NICE Guidelines for BPD
Key priorities for implementation
Assessment & care planning
• Community mental health services are
responsible for routine assessment &
treatment of BPD
• Effective risk assessment and management
• Co-ordinated care with specialists addictions
• Treat addiction first or if BPD treatment
started treat at same time (care co-ordinator)
• Guidance regarding goal setting (ST/LT);
crisis planning
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Key priorities for implementation
The role of psychological treatment
• The service should use an explicit and
integrated theoretical approach – shared with
the service user
• Provision for therapist supervision
• Don’t use brief interventions specifically for
the disorder or symptoms of it in services
which fall outside the recommended spec
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Key priorities for implementation
The role of pharmacotherapy:
• Drug treatment should not be used specifically for
BPD or for the individual symptoms or behaviour
associated with the disorder (e.g. repeated self-harm,
marked emotional instability, transient psychotic
symptoms)
• Anti-psychotic drugs should not be used for medium
or long term treatment of BPD
• Review prescribed drugs with a view to reducing and
stopping unnecessary drug treatment
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Psychological therapies
•Evidence base is relatively weak
•Methodological problems – picture may
improve with more effective studies
•DBT and MBT are useful in reducing
problems when combined with
hospitalisation
•Very brief interventions are not effective
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Psychological therapies
recommendations
•Outpatient therapy should not be
provided in isolation – needs to be part
of structured programme with other
support available and well trained staff
•DBT recommended for recurrent selfharm in women
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Pharmacotherapy
•Methodological problems limits findings
•Some evidence that some drugs can
reduce symptoms such as anxiety,
depression, anger, impulsivity
•No evidence they alter the nature of the
disorder in short or long term
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Managing comorbidity
•Community mental health services are
responsible for routine assessment &
treatment of BPD
•Refer to appropriate service for major
psychosis, dependence on alcohol or
drugs, severe eating disorder
•Treat depression, anxiety, PTSD within
well-structured treatment for BPD
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Outcomes
•50-75% in the long term no longer show
enough symptoms to meet the
diagnosis (with or without treatment)
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Leeds Addiction Unit
Personality Disorder
Care Programme
Care Programme
• The care programme will last for a twelve month
period and will start with building a relationship
and stabilising substance use, followed by six
months participation within a group, and ending
with 3 months of SBNT.
• Weekly group- To be made up of abstinent
members
• Content of group work will be managing and
coping with intense emotions
• 1:1 appointments to complement group work
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Borderline Personality Disorder