Helen Gottfried –UnRuh
Senior Manager, Canadian Mental Health Association – Ottawa
Deanna Mercer MD FRCPC psychiatry
Associate Staff, Department of Psychiatry, TOH
Assistant Professor, Department of Psychiatry, University of Ottawa
BPD symptoms
 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:
 1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal
or self-mutilating behavior covered in Criterion 5.
 2. a pattern of unstable and intense interpersonal relationships characterized
by alternating between extremes of idealization and devaluation.
 3. identity disturbance: markedly and persistently unstable self-image or sense of self.
 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending,
sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.
 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
 6. affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a
few days).
 7. chronic feelings of emptiness (or boredom)
 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights)
 9. transient, stress-related paranoid ideation or severe dissociative symptoms
“The pain of being borderline”
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Newly admitted inpatients, 146 BPD, 34 Axis II controls
50 dysphoric feelings
BPD > other Axis II on all 50 dysphoric feelings
% of time spent feeling:
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
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
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
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Overwhelmed 61.7%
Worthless 59.5%
Very angry 52.6%
Lonely 63.5%
Misunderstood 51.8%
Abandoned 44.6%
Betrayed 35.9%
Evil 23.5%
Out of control 33.5%
Like a small child 39.1%
Like hurting or killing themselves 44%
Zanarini et al 1998
Rare in non-BPD patients
Treatment Histories
 2 year study of freshman with (169) and without (192) BPD features
 BPD+ : more pharmacologic, psychological and medical treatment,
even after controlling for gender, Axis I, II pathology

Bagge et al 2005
 MSAD: 290 BPD, 72 other axis II consecutive inpatients at McLean
hospital
 patients with BPD 2- 4.5 times more likely to have received each of 12
types of treatment

Zanarini et al 2001,
 CLPS study : treatment seeking patients 175 BPD, 426 other PD, 97
MDD only
 BPD > MDD OR 2.14 – 6.19 – individual, group, family, day hospital,
inpatient, all classes of medication
 BPD > OPD for all treatments except family/couples and self-help

Bender 2001
BPD prevalence
 General population 1% M=F
 Outpatients 10 – 20 %
 Inpatients 20%
Lezenweger 2007, Coid 2006, Samuels 2002, Torgersen 2001, DSMIV 2005
Comorbidity
Overall
Inpatients (Zanarini 2004)
Depression
50%
86.6 %
Dysthymia
70%
44.8%
Bipolar II
11%
5.5%
Bipolar I
9%
0% (exclusion criteria)
ED (AN, BN)
25% (5%/20%)
53.8% (21.7%/24.1%)
PTSD
30%
58.3%
SUD
35%
62.1%
Alcohol only
25%
50.3%
Panic Disorder
45.2%
OCD
14.5%
Gunderson, Links 2008, Zanarini et al 2004
Influence of BPD on Axis I disorders
 CLPS
 BPD + MDD : MDD remission in 64%
 Other PD +MDD: MDD remission in 89%

Gunderson et al 2004
 MSAD
 BPD remitted: significant decline in rates of axis I
disorders
 BPD never remitted: Rates of axis I disorders (mood,
anxiety, SUD, ED) remained stable despite intensive
treatment

Zanarini et al 2004
Central Institute of Mental Health
Mannheim, Germany
Age as a predictor
of symptomatology,
co-occuring disorders,
and socioeconomic
characteristics in BPD
N. Kleindienst, M. Limberger,
J. Barth, M. Bohus
Methods
Sample of treatment-seeking BPD-patients (n=367)
• University of Freiburg, CIMH (Mannheim)
• female BPD (DSM-IV)
• Age: 18 to 65
Census data from the general population comprising
all women from the catchment area (n=2,383,000)
 Bench mark (e.g., marital status)
 data from the general population were matched
by nationality and age
Distribution of Age (n=367 fem. BPD-Patients)
30%
25%
20%
15%
10%
5%
0%
18-22 23-27 28-32 33-37 38-42 43-47 48-52 53-57 58-62
Crucial for - education
- vocational training
- employment
- starting a family
Education: Years of Schooling
100%
80%
60%
21%
39%
other / NA
20%
38%
40%
20%
38%
34%
0%
BPD
Gen. Pop.
matched by
age, nationality
9 years
10 years
12-13 years
(qualifying for
univ. admission)
χ2=0.16, df=2
p=0.92
 Patients are on par with respect to schooling
Completed Vocational Training
100%
other / NA
80%
18%
13%
60%
40%
20%
No degree
Apprenticeship
47%
57%
22%
17%
0%
BPD
Gen. Pop.
matched by
age, nationality
University Deg.
χ2=7.59, df=2
p=0.02
 Differences were minor…
… similar level with respect to vocational training
Employment Status
Employed
Unemployed
Other
χ2=387.03,
df=2, p<0.001
 Premature Pension: 7%
(Re-)Education / Secondary Labor Market 21%
 Homemaker: 7%
 other: 18%
 Very large differences in employment status
Marital Status
BPD
Married
Gen. Population
BPD
Unmarried
General Population
Widowed,
Divorced
BPD 15%
χ2=123.23,
df=2, p=0.007
 Substantial differences in marital status
BPD vs depression and other PD
 CLPS: 668 pts age 18-45 years
 Severe impairment in month prior to admission %
Schizotypal
N=86
BPD
N=175
Avoidant
N=157
OCPD
N=153
MDD only
N= 97
employment
53.9
51.5
28.2
11.4
18.4
Global Social
adjustment
83.7
71.4
50.3
36
42.3
GAF< 50
40.7
47.4
21.0
13.1
18.6

Skodal et al 2002
BPD and suicide
Mortality data
 Psychological autopsy studies
 12% adults with psychiatric illness who suicided

Kullgren et al 1986
 33% of adolescent suicides
 Runeson and Beskow 1991
 Lifetime risk of suicide in BPD: 3-10%
 Early all cause mortality 18.2% at mean age 50 yrs
(expected in general pop 4.5% women 7.5% men)

Paris and Zweig-Frank 2001
BPD mothers and their infants
•
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59 mother-infant dyads
Mom’s average age 30, infants 12-18 months
Strange situation procedure
Compared to moms with MDD(15) and moms with no mental
disorder (31), BPD moms (13) are:
 prone to relate to their infants with intense, inconsistent and often
self- oriented styles of engagement
 more likely to exhibit fear/disorientation in response to their
infant’s attachment bids
 Disrupted affective communication:
 BPD moms 85%
 MDD moms 47%
 No dx moms 42%
 Hobson et al 2009
BPD mothers and their children
 BPD moms(16), No disorder moms (116) , MDD moms(36)
Cluster C moms (28)
 Compared with children of moms with MDD, cluster C or
no disorder, children (ages 11-18) of BPD moms exhibited:
 Higher harm avoidance
 Perceived their mother as being overly protective (mother gets
overinvolved, mother induces feeling of shame and guilt, mother acts very anxious,
mother dictated what clothes should be worn)
 Lower levels of self esteem
 Compared with children of moms with no disorder
 attention problems, behavioural problems (delinquency and
aggression)
 Death wishes and suicidal ideas/plans

Barnow et al 2006
BPD: effect on families
 Families with parental BPD
 more unstable than families with other PD
 children more frequently exposed to parental substance
abuse, neglect and suicide attempts

Feldman et al 1995
 Families with parental BPD report interactional styles with
more conflict, less expression and less cohesion

Moos and Moos 1986
 BPD patients entering treatment
 perceived family relationships as extremely difficult,
 overall scores for quality of relationships with partner,
children and family were much worse than with MDD.

Gerull et al 2008
BPD: burden on families
 16 patients with BPD or schizotypal PD
 35 family members
 Burden on Family Unit (0-5)
 34% moderate
 31% high
 15% extreme
 Higher than having family member with DM, CVD, cancer
 Family member with scz: 70% extreme burden
 Most troublesome sx: anger, impulsivity, financial burden

Schulz et al 1985
 Gunderson and Hoffman 2005:
 3 main problem areas:
 communication, anger and suicidality
NICE 2009
 1.3.4.3 When providing psychological treatment for people
with BPD, especially those with multiple co-morbidities
and/or severe impairment the following service
characteristics should be in place:
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Explicit and integrated theoretical approach
Structured care
Provision for therapist supervision
Twice weekly sessions may be considered
 1.3.4.4 Do not use brief psychotherapeutic interventions (
of less than 3 months duration) specifically for BPD or for
the individual symptoms of the disorder
Cochrane 2012
 indications of beneficial effects comprehensive
and non-comprehensive therapies for core and
associated psychopathology
 *DBT, MBT, TFP, SFT, STEPPS most data
 None of the treatments have a robust evidence
base
 Findings support a substantial role in treatment
of people with BPD
Meds for BPD?
• NICE 2009 1.3.5.1 Drug treatment should
not be used specifically for borderline
personality disorder or for the individual
symptoms or behaviour associated with
the disorder
• Cochrane 2010:
• Findings suggestive in supporting use of
second generation antipsychotics, mood
stabilizers and omega 3 fatty acids…
• Total BPD severity was not significantly
influenced by any drug.”
Dialectical Behaviour Therapy
 Developed in 1991
 8 RCT studies to date, 8 Naturalistic studies
 Manualized treatment
 4 components: individual therapy, group based skills
training, telephone coaching, therapist consultation
 Intensive treatment 1 year, approximately 50 % of
individuals participate in less intensive treatment after
1 year
Cochrane 2012
 meta 4 outcomes DBT vs TAU
 Anger- large
 Parasuicide, mental health status – moderate
 Single studies estimates of effect (DBT vs TAU)
 DBT>TAU BPD core pathology and associated
psychopathology
DBT vs TAU studies: summary
 6 DBT (Linehan 1991, 2006, Turner 2000, Koons 2001,
Verhuel 2003, Clarkin 2007)
 2 DBT-S (Linehan 1999, 2002)
 With TAU 1-3 :
 DBT<TAU Suicide attempts 4/5 studies
 DBT >TAU retention 2/5 studies
 DBT<TAU hospital days 2/4 studies
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TAU 1: individual session less than once per week (1)
TAU 2: individual session once per week (1)
TAU 3: individual session 1/wk and one of: group, a second
individual session/week, therapist supervision
DBT vs Level 4 treatments
 Level 4 treatments
 Well defined theoretical basis
 Weekly supervision, support
 Once or twice weekly intervention
 Active therapists
 Here and now focus
 DBT=GPM significant reductions in:
 suicide attempts*, self harm episodes, ER visits, psych hospital days, #
BPD symptoms, depression, anger , interpersonal function

McMain et al 2009
 DBT vs TFP
 DBT= TFP significant improvements SI/A, depression, anxiety, GAF,
retention in treatment
 DBT<TFP anger, impulsivity

Clarkin et al 2007
DBT resources current
 Full DBT (individual, group, telephone coaching and
therapist consultation)
 CMHA- Ottawa
 Clients meeting criteria for case management
 Capacity – 2 groups, 16 clients
 Also CW training and support
 TOH –until March 2013
 High–utilizer – at least one hospital admission and one ER
visit in the past 12 months
 Capacity – 1 group, 8 patients
 Montfort
DBT resources in Ottawa
 DBT-lite:
 Skills training group 6 months,
 clients have not had suicide or self harm behaviours in
past 6 months
 clients have a therapist in the community who agrees to
support client weekly during the program
 TOH – 1 group, 8 clients
DBT resources in Ottawa
 DBT modifications
 CMHA DBT-S
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DBT skills training group
modified for clients with active substance abuse/dependence
24 weeks
8 clients
 TOH Working With Emotions
 12 week skills training group, based on DBT
 Open to all Urgent Consultation Clinic patients
 ~ 50% of attendees have BPD
 ROH WWE
 Women’s health and Addictions program
 1 group
DBT outreach
 Community based therapists
 initial training in 2005/6
 DBT-lite
 CMHA partnerships
 Family Services Ottawa
 Salus
 ROH
Case Study Ms A
• First presented to TOH at the age of 18.
• Axis I: dysthymia, major depressive disorder, social phobia, eating
disorder NOS, polysubstance dependence (ephedrine , THC)
• Axis II: borderline personality disorder, avoidant personality disorder
• Axis III: asthma, myofacial pain syndrome, environmental allergies
Community Consultation
 March 2 2011
 Attendees
 CMHA – Ottawa, Centretown CHC, Ottawa Academy of
Medicine- Family Practice, Ottawa Inner City Mental
Health
 Families- Ottawa Network for BPD
 Hospitals – TOH, Montfort, ROH – Addictions, Mood,
Youth, Women’s Program, Community Mental Health
 Department of Psychiatry University of Ottawa
Community Consultation
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Presentations by ON-BPD Family Connections and Dr
Paul Links, internationally recognized expert on BPD
Priority setting exercise
3 top priorities
1.
2.
3.
Improved access to services
Education
Coordination of services
HSIP
 Sept 2012 – TOH and CMHA meet to discuss next
steps
 Oct 2012- TOH, CMHA, ROH, FSO meet and agree to
develop HSIP proposal
 Proposal developed to address priority 1- improving
access to services
 Proposal includes request for funding to develop
coordinated, one point of access intake
CMHA and FSO Summary of Changes
Staffing – Current FTE
Staffing - Proposed FTE
Case worker
2 FTE
4 FTE
MD/psychiatrist
0.225 FTE
0.6 FTE
Current Capacity
Proposed Capacity (total)
DBT full (M)
2 groups/ 16 clients
4 groups/ 32 clients
DBT –S
1 group/ 8 clients
2 groups/ 16 clients
DBT-grad
1 group / 8 clients
2 groups / 16 clients
Individual therapy
7 clients
31 clients
Assessments Case Workers
36/yr
50/ year
Assessments MD
0
20/yr
TOH Summary of Changes
Staffing – Current FTE
Staffing – Proposed FTE
Psychiatry
0.6
0.8
Psychology
0.4
0.6
Social Work
0.2
0.6
Occupational Therapy
0
0.6
RN
0
0.6
Admin
0.1
0.4
Social Work On-Call
0
0.2
RN On- Call
0
0.2
Current Capacity
Proposed Capacity- FTE
DBT-full
1 group/ 8 clients
2 groups/ 16 clients
DBT- Lite
1 group/ 16 clients
1 group/ 16 clients
DBT – Grad group
1 group/ 8 clients
2 groups/ 16 clients
DBT- Grad follow up
0
16 clients
DBT- Individual therapy
7 clients
16 clients
MD Consults
30
90