New Research on Borderline
Personality Disorder
Blaise Aguirre, MD
Medical Director , 3East Residential
Assistant Professor of Psychiatry
Harvard Medical School
Belmont, MA
Alec L. Miller, PsyD
Co-Founder, Cognitive & Behavioral Consultants of Westchester, LLP
White Plains, NY
Professor of Clinical Psychiatry and Behavioral Sciences
Montefiore Medical Center/Albert Einstein College of Medicine
Bronx, NY
NAMI 9/5/14
Outline
• BPD diagnosis, prevalence, and self-harm
– The 5 problem areas
• Existing evidence-based BPD treatments
• DBT research
•
•
•
•
– First adolescent RCT
Early Intervention
Prevention
BPD and Trauma research
Future Directions
Borderline Personality Disorder
(Re-organized in DBT)
Emotion Dysregulation
Affective lability
Problems with anger
Interpersonal Dysregulation
Chaotic relationships
Fears of abandonment
Self Dysregulation
Identity disturbance/
difficulties with sense of self
Sense of emptiness
Behavioral Dysregulation
Parasuicidal behavior
Impulsive behavior
Cognitive Dysregulation
Dissociative responses/ paranoid ideation
BPD in ADULTS
DSM-IV and epi studies find BPD in:
1.8% of the general population,
8 to 11% of psychiatric outpatients,
and 14 to 20% of inpatients.
**NIAAA Study of 34,653 adults found:
Prevalence of lifetime BPD was 5.9%,
with no significant difference between
gender (J of Clin Psychiatry, 2008)
4
BPD is
associated with
fatal and non-fatal
suicidal behaviors as well
as nonsuicidal selfinjurious behaviors
6
BPD Can Be Fatal
• Among SUICIDES,
–40-65% have PD
• Among PDs,
–BPD is most associated with suicidal
behavior
• Among BPD,
–8-10% commit suicide
–up to 75% attempt suicide
–69-80% self-mutilate
7
ESTs for BPD:
Mentalization (Bateman & Fonagy)
•AJP, 1999; 2013
•JAACAP, 2012 (Roussow & Fonagy) -ADOLESCENTS
Transference-focused (Kernberg, Clarking, Levy et al)
•JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010
Schema-focused (Young et al.)
•Archives, 2006; 2009
STEPPS (Blum et al.)
•
2008; 2010
Cognitive Analytic Therapy (Chanen et al.)
•
BJP, 2008; 2012
DBT (Linehan et al.)
•Archives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTs
•JAACAP, in press (Mehlum et al.)-ADOLESCENTS
8
9
18 Randomized Clinical Trials
DBT Superior to Comparison
Treatments
Reducing:
•
•
•
•
•
•
Suicide attempts and self-injury
Premature drop-out
Inpatient/ER admissions and days
Drug abuse
Depression, hopelessness, anger
Impulsiveness
Increasing:
• Global adjustment
• Social adjustment
See Lieb, K., Zanarini, M., Linehan, M.,
& Bohus, M., 2004. 9
10
to severe and chronic multi-diagnostic,
difficult-to-treat patient
with both Axis I
and Axis II disorders
10
11
The Problem
FOCUS ON
CHANGE
!!AROUSAL!!
SENSE OF
INVALIDATION
OUT-OF-CONTROL
OF
SELF-CONSTRUCTS
Impaired Cognitive Processing
+
Intense Effort to Control
No New Learning – No Collaboration
11
12
The Problem
Further
FOCUS ON
ACCEPTANCE
!!AROUSAL!!
SENSE OF
INVALIDATION
OF
SUFFERING
OUT-OF-CONTROL
No New Learning – No
Collaboration
12
13
Solution Was to Apply
A
Approach Balancing
Change
Strategies
Acceptance
Strategies
Dialectics
13
Problem Areas
Skills
1. Confusion about Self
1. Mindfulness
2. Impulsivity
2. Distress Tolerance
3. Emotional Instability
3. Emotion Regulation
4. Interpersonal Problems 4. Interpersonal
Effectiveness
5. Adolescent - Family
Dilemmas
5. Walking the Middle
Path
Adolescent Outpatient DBT Modes
•
•
•
•
•
•
•
•
•
Phase I: 4-6 months
Multi-family skills training group
Individual psychotherapy
Telephone consultation (w/ teen & parent)
Family therapy
Therapist consultation meeting
Phase II: 16 weeks & recommit
Graduate group
Individual psychotherapy (phase out)
Telephone consultation
Family therapy, PRN
*All patients are eligible for pharmacotherapy
Dialectical Behavior Therapy for
Adolescents with Recent and Repeated
Suicidal and Self harm Behavior - a
Randomized Controlled Trial
Mehlum, L, Tormoen, A, Ramberg, M, Haga, E, Diep, L, Laberg, S,
Larsson, B, Stanley, B, Miller, AL, Sund, A, Groholt, B. (In press,
Journal of the American Academy of Child and Adolescent
Psychiatry).
L.Mehlum 2012
Overall aim
To determine the efficacy of DBT-A compared to
enhanced usual care in adolescents with recent and
repetitive self harm and with three or more borderline
personality disorder criteria.
L.Mehlum 2012
Design
• Randomized Controlled Trial with independent and
blinded pre-, post and follow-up evaluations
• Measurements at:
–
–
–
–
–
–
Baseline (interview, self-report and testing)
6 weeks (self-report)
12 weeks (self-report)
16 weeks - End of treatment (interview, self-report and testing)
1 year posttreatment follow-up (interview, self-report and testing)
2 years posttreatment follow-up (interview, self-report and testing)
• Ten year follow-up planned
L.Mehlum 2012
Treatment methods
1. DBT – Adapted for adolescents – 16 weeks
2. Enhanced Usual Care (EUC) – 16 weeks
Psychodynamic or CBT oriented therapy (non-DBT)
Treatments were delivered at five Child and Adolescent
Outpatient Clinics in Oslo, Norway
L.Mehlum 2012
Adolescent Outpatient DBT Modes
Phase I: 4 months (RESEARCH STUDY)
• Multi-family skills training group
• Individual psychotherapy
• Telephone consultation (w/ teen & parent)
• Family therapy
• Therapist consultation meeting
Phase II: 16 weeks & recommit (NOT RESEARCH)
• Graduate group
• Individual psychotherapy (phase out)
• Telephone consultation
• Family therapy, PRN
*All patients are eligible for pharmacotherapy
DBT therapists
• Recruited from five Child & Adolescent outpatient psychiatric
clinics at the Oslo University Hospital
• MDs and Psychologists
• All therapists were new to DBT and trained for the purpose of
the trial and hired if/when reaching a consistently high adherence
level (score >= 4.0 on Linehan adherence coding instrument)
• Trained for the purpose of the trial in suicide risk assessment and
management
• All treaments were conducted at and paid for by the Oslo
University Hospital
Coding of 166 individual
therapy sessions
Mean score = 4.11 SD = 0.14
L.Mehlum 2012
Participants
• Patient inclusion: March 2008 thru March 2012
• Altogether 77 patients were included and randomly
allocated to receive:
– DBT-A (n=39)
– or
– EUC (n=38)
• Stratified by gender, presence of major depression and
suicide intent at most severe self-harm episode last 4
months before enrollment.
L.Mehlum 2012
RCT of DBT-A vs EUC for self-harming and suicidal
adolescents with emotion dysregulation (N=77)
Patient characteristics - baseline
Dialectical Behaviour
Therapy
N=39
Enhanced Usual
Care
N=38
N
%
N
%
Girls (%)
34
87.2
34
89.5
Completed high school
13
41.9
7
25.0
Parents currently married
17
43.6
17
44.7
Mean
SD
Mean
SD
Age (yrs)
15.9
1.4
15.3
1.6
C-GAS
55.3
8.0
57.9
10.1
No significant differences between groups
L.Mehlum 2012
RCT of DBT-A vs EUC for self-harming and suicidal
adolescents with emotion dysregulation (N=77)
Patient characteristics – baseline cont.
Dialectical Behaviour
Therapy
N=39
Enhanced Usual
Care
N=38
N
%
N
%
Psychiatric treatment (past)
28
73.7
23
62.2
Pharmacotherapy (past)
2
5.4
6
17.1
Child protection (past)
10
26.3
11
28.9
Child protection (current)
6
15.4
7
18.4
Mean
SD/SE
Mean
SD/SE
CBCL (total no of problems)
69.6
11.0
68.4
8.6
Lifetime NSSH episodes (mean/rate)
29.8
2.8
25.9
3.0
Lifetime suicide attempts (mean/rate)
3.2
0.6
3.1
0.6
No significant differences between groups
L.Mehlum 2012
So what about the outcomes?
L.Mehlum 2012
Conclusions
• Patients receiving DBT-A experienced significant
reductions in all 3 primary outcome measures, in contrast
to patients receiving EUC where only self-reported
depression was significantly reduced
• Patients who received DBT-A had a significantly
–
–
–
–
–
Stronger reduction in the number of self-harm episodes
Stronger decline in suicidal ideation
Stronger reduction in interviewer rated depressive symptoms
Stronger reduction in hopelessness feelings
Stronger reduction in borderline symptoms
L.Mehlum 2012
Next steps in Norway
• 1 year posttreatment follow-up (interview,
self-report and testing) - ongoing
• 2 years posttreatment follow-up (interview,
self-report and testing) – ongoing
• 10 year posttreatment follow-up – planned
• Evaluate effectiveness of Adolescent DBT
Graduate Group as a maintenance,
continuation phase of treatment
L.Mehlum 2012
Prevention & Early Intervention
DBT in School Settings
• Secondary and Tertiary Prevention:
– Middle and HS
– Elementary schools
• Primary Prevention Interventions
– Elementary schools
30
•
DBT in Schools
School Interventions
– Ulster County HS Health Class Curriculum (1999)
– Far Rockaway HS
• Salley et al, (2002)
– New Haven Elementary School/Yale University
• Perepletchikova et al, (2010)
– PS 8 Bronx, NY/Albert Einstein College of Medicine
• Lander, Miller, Edwards, et al, (2009-2012)
– Ardsley School District, NY (2008-present)
• School-based Mental Health Teams in MS and HS and
• Now teaching in Health Class
• Presented data at conferences (Catucci et al.; Mason et al)
– Pleasantville, NY School District (2009-present)
• School-based Mental Health Teams in MS and HS
– Mamaroneck, NY School District (2010-present)
– Rockland County BOCES HS (2012-present)
– New Rochelle and Florida, NY School Districts (2012-present)
– University of Washington, MS & HS Education
• Mazza & Mazza (2010-)
Do not reproduce or distribute without written permission from CBC. © CBC 2012
Dialectical Behavior Therapy in
Public Schools
STEPS-A (Emotional Problem Solving for Adolescents;
Mazza et al, in preparation) is a Universal program –
Teacher administered 42-minute/class DBT curriculum
5-10%
Using an RTI model
10-15%
80-85%
Tier III
Indicated
Using Mental Health model
Tier II
Selected Population
Tier I
Universal Population
(Mazza, 2012)
Why DBT in Schools?
• Mounting pressure to keep ED
(emotionally disabled) students within
District
– Costs District @ 100K/per student per year
when sent out of District for specialized
programs.
Do not reproduce or distribute without written permission from CBC. © CBC 2012
32
Why DBT in Schools?
• Schools often urge staff to send students
to ER when suicidal thinking or self-harm
is reported.
• ERs are flooded with visits from students
who do not necessarily need
hospitalization.
• Sending students to ER may reinforce
problem (escape/avoidance) behaviors.
Do not reproduce or distribute without written permission from CBC. © CBC 2012
33
Data from Schools
• Preliminary results from an open trial
at Ardsley High School (Mason,
Catucci, Lusk, and Johnson, 2011)
– Reduced referrals to assistant principal
– Reduced cutting class
– Reduced detentions and suspensions
– Anecdotal reduction in depression,
anxiety, NSSI
– Requires change of culture re: how
schools manage problem behavior
Do not reproduce or distribute without written permission from CBC. © CBC 2013
34
Why DBT in schools?
• It may be more cost-effective
• It may reduces problem behaviors that
often result in suspensions, ER visits, etc
• DBT is skills based, can be taught in
groups/classes
• It can be applied transdiagnostically
• DBT has observable and measurable
outcomes
• It may PREVENT BPD symptoms?
Do not reproduce or distribute without written permission from CBC. © CBC 2013
35
DBT in Schools
Reference :
Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller,
AL, & Rathus, JH (In preparation). Skills
Training for Emotional Problem Solving for
Adolescents (STEPS-A): Implementing DBT
skills training in schools . Guilford Press.
Do not reproduce or distribute without written permission from CBC. © CBC 2012
Dalai Lama
Early Intervention in BPD

Current evidence supports:

the development of indicated prevention and early
intervention programs for the emerging BPD
phenotype

(Chanen et al. 2007, 2008)



Benefits of Early Intervention are likely to outweigh risks, such as stigmatizing attitudes
from clinicians.

(Chanen et al. 2007, 2008)

Potential opportunities for Early Intervention is frequently missed

Identification of outpatient youth with DSM-IV BPD is feasible through screening

(Chanen et al. 2008)
The Evidence



15-18 yo (41 to CAT vs. 37 to GCC vs. 32 TAU)
≥ 2 DSM-IV BPD criteria
one or more childhood risk factors for young adult
generic PD
 childhood PD symptoms
 disruptive behavior disorder symptoms
 low socio-economic status
 depressive symptoms
 history of childhood abuse or neglect
Assessments





Baseline (n=78)
6-months (n=70)
12-months (n=70)
24-months (n=68)
At least three time points in 92% of sample
Outcome Variables




Total BPD score (SCID-II)
Youth self-report (YSR; Achenbach, 1991)
 Internalizing
 Externalizing
Social and occupational functioning (SOFAS)
Parasuicidal behaviors
 suicide attempts and non-suicidal self-injury
 semi-structured interview
 coded as: none, monthly, weekly and daily
Main Results








At 24-month follow-up:
CAT and GCC was more effective than TAU
CAT yielded the greatest median improvement on the
four continuous measures
CAT had lower levels of and a faster rate of
improvement in externalizing, compared to GCC*
CAT had lower levels of and a significantly faster rate of
improvement in both internalising and externalising,
compared to TAU
GCC had lower levels of internalising and a faster rate of
improvement in SOFAS, compared to TAU
All treatment groups demonstrated significant and
clinically substantial improvement.
Conclusions




Early intervention for BPD is possible
Patients 13-15 years younger than in recent
RCTs
GCC not ineffective perhaps easier to teach
Need longer-term follow-up
gains sustained?
 divert patients from unhelpful engagement with
adult treatment settings?

Childhood Trauma and Adolescent Borderline
Personality Disorder Co-morbidity: Clinical and
Treatment Implications
Blaise Aguirre, MD
Medical Director
3East Residential
Assistant Professor of Psychiatry
Harvard Medical School
BPD, PTSD and Childhood Maltreatment

Prevalence of borderline personality disorder (BPD) comparable or slightly higher in
adolescents vs. adults

2+% adulthood (APA, 2000)

3%-6% in adolescence (Zanarini, 2003; Chabrol et al., 2004)

In the Adult BPD Population

Childhood maltreatment/trauma – as high as 85% (Venta et. al., 2012)

Prevalence of PTSD-33%-58% (Harned & Linehan, 2008)

Trauma and PTSD increases the likelihood of remission from BPD (Zanarini et. al.,
2005)

In the Adolescent BPD Population

Only a few studies have explored the link between BPD and trauma in adolescents

Childhood sexual abuse successfully discriminated between patients with BPD and
MDD
Co-occurrence of Borderline Personality Disorder (BPD),Trauma and
Post-Traumatic Stress Disorder (PTSD)

BPD inpatients have rates of PTSD from 56-58%; BPD outpatients have
rates of PTSD from 36-50%1

Epidemiologic research has indicated that 30.2% of individuals with BPD
have PTSD, whereas 24.2% of individuals with PTSD have BPD2

Childhood abuse in BPD pop. found to be from 61% to 76%3

BPD clients experience adult traumas at a higher rate than non-BPD
peers with rates as high as 90%4

Co-occurring PTSD is associated with greater impairment in individuals
with BPD and lower likelihood of long-term remittance of BPD5

BPD clients with PTSD engage in more frequent NSSI than those without
PTSD6
1 Zanarini
4Zanarini
2Pagura
5Harnad
et. al., 1998, 2004;Linehan et. al., 2006
et. al., 2010
3Zanarini et. al., 1997, 2006
et. al., 2005
et. al., 2010; Zanarini et. al., 2006
6 (Rusch et al., 2007)
Our Research Data

Female adolescents (n = 157)
 Ages 13-20 (Mean age = 17.21; SD= 2.39)
 Short-Term Residential Program
 Length of Stay (Mean = 72days)

Pre- and Post-Treatment Assessments
 BPD Criterion and Symptoms
 PTSD Symptoms
 Depressive Symptoms
 Childhood Maltreatment
 Risky Behavior Engagement
Results
Relationship of Trauma to Initial BPD
Criterion Behaviors

Adolescents with moderate-severe trauma report higher
initial levels of borderline psychopathology (t=-2.47,
p=.02)

Robust association between childhood emotional/sexual
trauma and severity of borderline psychopathology as
measured by ZAN-B (r=.18, p=.05) and MSI (r=.28,
p=.002)

Adolescents with trauma history also report greater risky
behavior engagement as measured by Total RBQ
scores which were highly correlated with both physical
(r=.23, p=.01) and sexual abuse (r=.19, p=.03)
Impact of Trauma in Adolescence




Childhood Sexual Abuse (CSA) is a strong predictor of
substance abuse, conduct disorder and depression1
Up to 20% of all adolescent suicide attempts are
attributable to CSA; CSA victims are 8X more likely than
non-abused counterparts to attempt suicide repeatedly in
adolescence2
Adolescents with sexual-abuse-related PTSD also have
more high-risk sexual behaviors as adolescents3
Trauma survivors with PTSD are more likely to report
health problems than those without PTSD4 (Schnurr &
Green 2004) making it a public health problem.
1
2
3 Stiffman,
Diamond et. al., 2001
Brown et. al, 1999
4
Schnurr & Green 2004
1992
Initial Level of Borderline Symptoms as a Function of
Trauma
Risky Behavior by Trauma History
With Standard (DBT)

Although showing decreases in PTSD over time, a significant
proportion (56.7%) of patients with histories of childhood abuse still
met clinical criteria for PTSD on the CPSS at the time of program
discharge

Patients with a history of childhood abuse/maltreatment showed
relatively less change in PTSD scores then their non-abused
counterparts

Many of our patients with trauma histories reported using BPD
criterion behaviors as way to manage their PTSD symptoms and
traumatic memories

Overall this data suggests that childhood trauma may play a pivotal
role in the genesis of BPD and increase the intractability of PTSD
Effectiveness of Standard DBT for
BPD+PTSD



1
DBT is the most empirically supported treatment
available for SI and NSSI, particularly among
individuals with BPD1,2
In recent study of DBT for suicidal BPD women,
however, only 13% of clients with co-occurring PTSD
achieved full remission after one year3
DBT alone has not been shown to help achieve
remission of PTSD as an Axis-I diagnosis, either with or
without SI/SB/NSSI4,5
Harnad, Comtois and Linehan, 2010
2 Harned & Linehan, 2008
3 Harned et. al., 2008
4,
(Feigenbam et. al.,
Chapter, in preparation)
5Harnad-Invited
Suicide and Self-Injury in BPD

Among inpatients with BPD, 70% have multiple episodes of NSSI
and 60% report multiple suicide attempts1

BPD clients with PTSD engage in more NSSI than those without
PTSD2

The rate of completed suicide among individuals with BPD is
estimated to be 8-10%3

Clients with BPD+PTSD are more likely than those with BPD alone
to report a variety of trauma-related cues for self-injury4

Relationship betweenCSA and NSSI may be mediated by the
PTSD symptom clusters of re-experiencing and
avoidance/numbing5
1
Zanarini et. al., 2008
2 Harned et. al., 2010
3 Linehan et. al., 2000
4
5
Harned, in press
Weierich & Nock, 2008
Treatment Dilemmas for the PTSD/BPD
Client with SI/NSSI/SA


Empirical support is robust for Cognitive Behavioral Therapy
(CBT) with Prolonged Exposure (PE) as treatment of choice for
both adults and adolescents with PTSD1
Pendulum of treatment swung in the late 90’s to exclusion of
individuals with SI, SB or NSSI from established PTSD
treatments involving activation of trauma memories2

Current practice guidelines stipulate, "if significant suicidality is
present it must be addressed before any other treatment is
initiated”1

Left unanswered how to treat adolescents with self-injury, SA,
Dissociation and PTSD that is moderate to severe and intractible to
other interventions.
1
Foa et. al., 2009
2008
2 Stirman,
Current Exclusion Criteria for
Prolonged Exposure (PE)Treatment *







Imminent threat of SB or Homicidal
Behaviors
Serious NSSI in past three months
Current psychosis
High risk of being assaulted from
environment
Lack of clear/sufficient memory of
trauma
Substance abuse
Severe Dissociation
*Foa et. al., 2009
Evidence for DBT as ‘Primer’ Treatment for
BPD+PTSD

DBT is efficacious in reducing suicidal/NSSI behaviors in
clients with BPD/PTSD1

Using this approach for clients with BPD/PTSD, both
imminent self-injury and imminent suicide risk decreased
over a one year period2

BPD+PTSD clients showed a significant decrease in severe
dissociation and substance dependence decreased from
pre-to-post treatment2

Among BPD+PTSD clients who became eligible for
exposure treatment, the majority (82%) still continued to
meet criteria for PTSD

Some BPD patients are unable to stop target behaviors until
their PTSD is resolved; challenge is to find ways to safely
make PTSD treatment available to these clients.
1
Harnad & Linehan, 2008
2
(Harnad et. al., 2010)
Integrated Treatment: DBT+DBT/PE Protocol

Provides integrated treatment for BPD and PTSD

Focus is specifically on BPD + self-injury

Uses standard DBT in combination with PE for PTSD

Recent evidence shows that treatment is feasible
with no worsening of target/safety behaviors or
increased drop-out from treatment.1

Remission rates comparable to those found in metaanalysis of exposure treatments to PTSD on singlediagnosis populations.
1 Harnad,
2011
An Integrated DBT /PE Treatment Approach:
Further Modifications for Adolescents with BPD+PTSD

Dialectical Behavior Therapy Prolonged Exposure Protocol
 Prolonged Exposure Protocol (Harned et. al., 2012))

Eligible patients completed 2-5 exposures per week
 Baseline PTSD symptoms
 Developed an exposure hierarchy focusing on imaginal
exposures

During exposures
 Pre and post-exposure SUDS were measured
 Pre-and-post ratings were done for the primary emotions, urges
for self-harm and Radical Acceptance

Aims:
 (a) changes in PTSD symptoms and
 (b) changes in levels of rated emotions, urges and cognitions
Importance of Parental Involvement





Parents are key sources of information about patient,
trauma history and family functioning
Parents/Family should receive education about PTSD
and be enlisted to support patient in recovery
Issue of patient’s confidentiality/privacy should be
directly addressed with both patient and family
Use joint meetings to develop contract for ongoing
family involvement including detailing specific role in
crisis management, homework/hierarchy completion and
treatment meetings.
Stress the Importance of joint exposure and
skill development in instances of family trauma/loss
Final Points




Trauma is present in many patients with
BPD
PTSD worsens the prognosis and
symptoms expression in BPD
PTSD does not remit in a non integrated
DBT+PE treatment
Data suggests that very suicidal BPD
patients with trauma can treated far sooner
than we ever imagined!
Future Directions for BPD
Research
•
•
•
•
•
Early identification
Prevention
Involving families (e.g,. Family Connections)
Treatment
NEABPD Think Tank 2014 and beyond