Personality Disorders
Deanna Mercer MD FRCPC
MSII Jan 2016
dmercer@toh.on.ca
Schedule
1. Describe personality disorders: criteria,
clusters and core symptoms
2. Understanding self injurious behaviour
3. Borderline Personality Disorder: diagnosis
and treatment
Objectives I
• 5296 Describe the general diagnostic criteria for a
PD.
• 5297 State the classification of PD in 3 clusters.
• 5298 Describe the main enduring pattern of each PD
type.
• 5300 Describe the mental disorders associated with
self‐injurious behaviours (SIB)
• 5301 List the biological, demographic, economic,
social and developmental factors associated with SIB.
Objectives II
• 5302 Describe the pertinent factors in the
recognition of the potential of SIB.
• 5303 List criteria for borderline personality disorder
(BPD).
• 5304 Describe common psychiatric comorbidities
associated with BPD.
• 5305 Describe a treatment approach to BPD
including use of hospitalization, outpatient care,
pharmacological treatment and psychotherapy
PERSONALITY?
Definition of Personality
• Personality represents a complex set of
attributes that mediate how each human
being experiences his or her self and
subsequently understands and interacts with
the external world, especially the social
world.
Oldham, Skodol, Bender 2014
Personality
NEO PI
Neuroticism
Extraversion
Openness
Agreeableness
Conscientiousness
NEO-PI
Anxiety, angry hostility, depression,
self consciousness, impulsiveness
• Neuroticism: how prone an individual is to experiencing
psychological distress
Warmth, Gregariousness,
Assertiveness, Activity, Excitement
Seeking, Positive Emotions
• Extraversion: quantity, intensity of energy directed into
the social world
Fantasy, Aesthetics, Feelings,
Actions, Ideas, Values
• Openness to Experience: active seeking and appreciation
of experiences for their own sake
Trust, straightforwardness, altruism,
• Agreeableness: the kinds of interactions an individual
compliance, modesty, tender
prefers from compassion to tough mindedness
mindedness
Competence, order, dutifulness,
• Conscientiousness: degree of organization, persistence,
achievement striving, self discipline,
control and motivation in goal directed behaviour
deliberation
5296 Describe the general
diagnostic criteria for a PD
Personality Disorder?
• Categorical
• Present or absent, like
pregnancy
• DSM IV, DSM5 Section II
• Dimensional
• PD exists at the extreme
of a dimension, ie
extreme extroversion
• Like height
• Trait models
• DSM5 Section III
Personality Disorder
DSM 5 Section II
DSM 5 Section III
A. Enduring pattern of inner experience A. Moderate greater impairment in
personality functioning (LPFS)
and behaviour that deviates
B. One or more pathological personality
markedly from the expectations of
traits
the individual’s culture. Manifested
• Antisocial
in two or more of the following:
• Borderline
cognition, affectivity, interpersonal
• Schizotypal
functioning, impulse control
•
•
•
•
•
Cluster A: Schizoid, Schizotypal, Paranoid
Cluster B: Histrionic, Narcissistic,
Borderline, Antisocial
Cluster C: Avoidant, Dependent,
Obsessive Compulsive
Personality change due to another
medical condition
Other/unspecified personality disorder
•
•
•
Avoidant
Obsessive Compulsive
Narcissistic
OR
PID5
•
•
•
•
•
Negative Affectivity
Detachment
Antagonism
Disinhibition
Psychoticism
DSM 5 Section II
• General Criteria and criteria for one of
#criteria required
10 PD’s
Paranoid
PPD
4/7
Schizoid
SPD
4/7
Schizotypal
STPD
5/9
Antisocial
ASPD
3/7
Borderline
BPD
5/9
Histrionic
HPD
5/8
Narcissistic
NPD
5/9
Avoidant
APD
4/7
Dependent
DPD
5/8
Obsessive compulsive
OCPD
4/8
Personality change due to another
medical condition
Other/Un specified Personality
Disorder
LPFS
• Moderate impairment in minimum of 2 of 4 areas
• Self
– Identity: sees self as unique; stability of self esteem, accuracy of self appraisal;
experience and regulate emotions
– Self direction: Ability to set and pursue goals; prosocial internal standards of
behaviours; can self reflect productively
• Interpersonal
– Empathy: understands others experiences and motivation; able to tolerate
differing perspectives; understands effect of own behaviour on others
– Intimacy: Depth, duration, connection with others; desire and has capacity for
closeness; behaviour reflects mutual regard in relationships
• American Psychiatric Association 2013
What is the impact of a personality disorder?
Etiology
• Biology and Learning
• Genetic heritability of Personality Disorders
similar to heritability of personality 0.3 – 0.5
• Environment?
Adverse Childhood Events Study
http://www.huffingtonpost.com/jane-ellen-stevens/the-adversechildhood-exp_7_b_1944199.html
What is an Adverse Childhood
Experience / ACE?
Growing up experiencing any of the following conditions in the household
prior to age 18:
1.
Recurrent physical abuse
2.
Recurrent emotional abuse
3.
Contact sexual abuse
4.
An alcohol and/or drug abuser in the household
5.
An incarcerated household member
6.
Family member who is chronically depressed, mentally ill,
institutionalized, or suicidal
7.
Mother is treated violently
8.
One or no parents
9.
Physical neglect
10.
Emotional neglect
ACEShealth problems in
adults
• The young brain is especially vulnerable to stress.
• prolonged stress in infancy and childhood causes
increased release of the stress hormone cortisol
• stress hormones compromise normal brain
development and the immature immune and
nervous systems.
• Results in profound, lifelong impacts on the brain
and body
ACES impacts in adults
•
•
•
•
•
•
•
•
•
•
•
•
•
Cardiovascular disease
Cancer
Heart attacks
High blood pressure
Stroke
Diabetes
Weight gain(especially abdominal fat)
Exhaustion
Reduced Growth Hormone Levels
Compromised immune function
Bone loss
depression
alcohol and substance abuse
Epidemiology
 DSM 5
– Any PD 9 – 15%
– Individual PD’s 1-6 %
– Gender:
– ASPD more common in men
– Schizoid, schizotypal, narcissistic, obsessive compulsive
diagnosed more commonly in men
– BPD, dependent diagnosed more commonly in women
 In clinical populations 50 -80%
PROGNOSIS
Personality Disorder
DSM 5 Section II
•
•
•
•
•
Enduring pattern of inner experience and
behaviour that deviates markedly from
the expectations of the individual’s
culture. Manifested in two or more of the
following: cognition, affectivity,
interpersonal functioning, impulse control
Enduring pattern that is inflexible,
pervasive across a broad range of
personal and social situations
Leads to clinically significant distress or
impairment in social, occupational or
other important areas of functioning
Is stable and of long duration, can be
traced back to adolescence or early
adulthood
Not better explained by another mental
disorder, substance or another medical
condition
DSM 5 Section III
•
•
•
•
Moderate greater impairment in
personality functioning
One or more pathological personality
traits
Impairments are relatively inflexible
and pervasive across a broad range of
personal and social situations
Impairments are relatively stable over
time, can be traced back to at least to
adolescence or early adulthood
–
–
–
Not better explained by another mental
disorder
Not solely attributable to substance use or
another medical condition
Not better understood as normal for
developmental stage or sociocultural
environment
Impact of PD’s
• Functional Impairment
• more likely to be separated, divorced, never married than
people with depression or no PD
• More unemployment, frequent job changes, on disability
• Borderline, schizotypal, avoidant most impaired
• Histrionic, Narcissistic, Obsessive Compulsive least or no
functional impairment
• Increased treatment utilization
• Quality of Life
• PD more strongly related (negatively) to quality of life than
other mental disorder, physical illness health, any other socioeconomic, demographic or life situation variable
Impact of Personality Disorder
• Prognosis
– gradual improvement over time, symptoms more than function
– BPD at 10 yr F/U: 85% remitted, 50% recovered
• Reduced life expectancy (early all cause mortality) 15-20 years
• Suicide: increased for all personality disorders
– PD plus one psychiatric admission
– SMR (standardized mortality ratio) 32.8 women, 16.7 men
• Other mental disorders with PD
– More impaired, more chronicity
– Overall poorer response to treatment requiring more intensive and
prolonged care
– Depression, anxiety, schizophrenia, alcohol and substance use
disorders more frequent in people with PD
• Certain PD’s (BPD, ASPD, Schizotypal PD) have specific treatments
or are contraindications for certain treatments
5297 State the classification of
PD in three clusters.
Personality Disorders: Clusters
• Cluster A: odd
Schizoid, schizotypal, paranoid
• Cluster B: dramatic
Borderline, histrionic, narcissistic, antisocial
• Cluster C: anxious
Obsessive compulsive, dependent, avoidant
5298 Describe the main enduring
pattern of each PD type.
Cluster A PD
• Schizoid
• Schizotypal
• Paranoid
Cluster A PD
• All have genetic link to schizophrenia,
schizotypal has strongest relationship.
• All have risk of brief psychotic episodes under
stress
• Few relationships
• Schizoid, schizotypal: no close relationships except
first degree relatives
• Paranoid PD: tends to associate with people who
share similar beleifs
Pictures of famous People with
Schizoid Personality Disorder
Pervasive pattern of:
•Detachment from
social relationships
•Restricted range of
expression of emotions
in interpersonal
settings
beginning in early
adulthood and present in a
variety of contexts
Schizoid PD
• Detachment from social relationships
–
–
–
–
Prefer solitary pursuits
Little interest in sexual experiences, rarely marry
Observers, not participants
“asocial, not antisocial”
• Restricted range of expression of emotions in
interpersonal settings
– Bland, distant, lack social graces
• Symptoms resemble negative symptoms of schizophrenia, but
psychotic symptoms not present or very brief (minutes to
hours) psychotic symptoms under stress
– Negative symptoms schizophrenia 4 A’s:
• Flat Affect, Anhedonia – lack of pleasure, Amotivation- lack of
ability to begin, sustain activities, Alogia – speaks little
Schizotypal Personality Disorder
Pervasive pattern of social
and interpersonal deficits
marked by:
• acute discomfort with, and
reduced capacity for, close
relationships
• cognitive or perceptual
distortions
• eccentricities of behavior
Schizotypal PD; clinical features
• acute discomfort with, and reduced capacity for, close
relationships
– Excessive social anxiety that does not improve with familiarity. Due
to paranoid fears/mistrust rather than negative judgments about
self
• cognitive or perceptual distortions
– Odd beliefs: superstitious, clairvoyance, 6th sense
– Unusual perceptions - bodily illusions “”my skin feels waxy and old”
– Suspiciousness, paranoid ideation
• eccentricities of behavior
– Speech: vague, circumstantial
– Behaviour: odd dress and appearance
• Looks like positive symptoms of schizophrenia, but psychosis, if
present, is brief
• 10 – 20% go on to have schizophrenia, less likely after age 30
• Treatment: some evidence for low dose atypical antipsychotics
Olanzapine 10 mg, Risperidone 2 mg
Paranoid Personality
Disorder
Pervasive pattern of:
•distrust and
suspiciousness of
others
•Other’s motives are
interpreted as
malevolent
Paranoid PD : Clinical features
•distrust and suspiciousness of others
•other’s motives are interpreted as malevolent
•
•
•
•
•
Suspects others are exploiting him
Unjustified doubts re: loyalty/trustworthiness of friends/associates
Reads hidden meanings into benign remarks
pathological jealousy
Perceives attacks that are not apparent to others, quick to
counterattack
•Looks like delusional disorder, paranoid type, but not psychotic
(except briefly under stress)
•Inpatients 10-30% Outpatients 2-10%
•Increased in hearing impaired, new immigrants, minority groups
CHALLENGE YOUR KNOWLEDGE
Ms A
• Ms A is a 20 year woman referred for possible psychosis. She
lives with her mother and has no friends. She reports that she
has been feeling “more paranoid” lately – and describes that
she gets very restless around people and always has to be on
her guard – “in case anyone takes advantage of me”.
• Ms A has a number of unusual beliefs- including a belief in the
occult, beliefs about the powers of various crystals – which
she prefers to medications, and ESP.
• Ms A was somewhat unkempt and dressed in bright clothing
with heavy makeup. She keeps repeating that her fate lays
with the stars and excusing herself to leave because “you
won’t understand me”.
Ms A
1. What is your preferred diagnosis?
2. What types of psychotic disorder is Ms A at
risk for?
3. What is Ms A’s prognosis?
Mr H
• Mr H is a 40 yo man was referred for assessment of
depression. He recently lost his job with a local call
center. He was fired because he was not able to get
along with other employees. He reports that he
should have been promoted because everyone else
he worked with were crooks, and he was the only
one who was trustworthy . He said that he treated
everyone else decently – but added “why bother
since they all end up taking advantage of me”. He
would like to date, but has given up on this because
“women use me like a stepping stone”.
Mr H
• What is your preferred diagnosis
• How is the treatment of Mr H’s depression
likely to be impacted by this diagnosis?
• What challenges do you anticipate will occur
in the therapeutic relationship with Mr H?
Ms M
• Ms M is a 72 year old woman who is referred to psychiatry
by ER for assessment of capacity to make her own decisions
about where she will live
• Ms M has a pneumonia and has been prescribed
antibiotics. She plans to return to live on the street. The ER
doc wants her to go to a shelter. She insists that she can
handle herself and has lived on and off the streets her
whole life. It is September. She plans to make her way back
to Victoria once her pneumonia is better because the
winters are milder and she doesn’t mind the shelters in
Victoria.
• Ms M denies any problems with depression, psychosis. She
has family, but has not had contact with them, or anyone
else, in years. She is soft spoken, makes little eye contact
and seems unconcerned about her current situation.
Ms M
• What is your preferred diagnosis?
• What are the possible reasons that Ms M
avoids relationships with others?
• What are the likely causes of Ms M’s
personality disorder?
• What is unusual about Ms M’s presentation?
Cluster B
•
•
•
•
Histrionic PD
Antisocial PD
Narcissistic PD
Borderline PD
Histrionic
Personality
Disorder
Pervasive pattern of:
• excessive emotionality
• attention seeking
HPD: clinical features
• excessive emotionality
• attention seeking
• Uncomfortable in situations in which they are
not the centre of attention
• consistantly uses physical appearance to draw
attention to self. More evident in opposite sex
relationships
• Speech vague, lacking in detail
• “theatrical”: exaggerated, rapidly shifting,
shallow expressions of emotion
• One of the least impairing of the PD’s
Antisocial Personality
Disorder
Pervasive pattern of:
• disregard for, and
violation of, the rights of
others
• occurring since age 15
years (conduct disorder)
/ must be at least age
18 years
Antisocial PD
•
disregard for, and violation of, the rights of others
•
•
•
•
•
•
•
Repeated lawbreaking
Deceitfulness
Impulsivity
Irritability and aggressiveness
Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse
• occurring since age 15 years /at least age 18 years
• Conduct disorder: aggression towards people or animals,
destruction of property, deceitfulness/theft, serious rule violations
• 25% of girls, 40% of boys with CD ASPD. Increased risk with
early onset, more, severe behaviours and substance use disorder
in adolescence
ASPD: etiology
Genetic and Environmental
– Genetic – MAO-A low activity gene
– adult aggressive behaviour
• MAO-A high activity + childhood abuse OR 1.6
• MAO-A low activity +childhood abuse OR 9.8
•Congenital
– Smoking ½ ppd OR 4.4 conduct disorder
– Severe starvation, first, second trimester OR 2.5
•Poverty? Only for youth with aggressive behaviour
Treatment
• Primary prevention
– National programs aimed at stopping physical punishment
of children
– Early intervention programs for children of high risk moms
– Head Start.
• High risk moms – teens, single, poverty, addictions, mental health,
legal involvement
• Secondary Prevention
– Parenting education “Positive Parenting” for children who
have aggression
• Tertiary Prevention
– Treatment alcohol and substance use disorders
– Maybe CBT for ASPD, not psychopathy
Psychopathy
“Malignant” form of ASPD
2 factors
•“meanness”
• Grandiose, deceptive, dominant,
manipulative
• Shallow emotions, unable to form
strong emotional bonds, lack
empathy, guilt, remorse
•“socially deviant lifestyle”
• Irresponsible, impulsive, ignores
social conventions and rules
•Robust risk factor for
• Recidivism, violence, poor
treatment outcomes
http://www.youtube.com/w
atch?v=s5hEiANG4Uk
Narcissistic Personality Disorder
A pervasive pattern of:
• Grandiosity - fantasy or
behaviour
• need for admiration,
• lack of empathy
Narcissus
• Greek mythological figure from poem
Metamorphoses.
• Extremely handsome young man who scorned the
love of others. A heartbroken young man/woman
had their prayer answered by Nemesis: “may he
who loves not others love himself”.
• While drinking water in a pond, Narcissus fell in
love with his reflection and drowned/withered
away
NPD: Clinical Features
• need for Admiration
– Sense of entitlement
– Belief that he/she is special, should associate with other special people
– Easily injured self esteem leads to anger and resentment
• Grandiose sense of self importance
– Exaggerate own accomplishments (lying), begrudge successes of
others, jealous/discredit those seen as competitors
– Preoccupied with fantasies of unlimited success, power, brilliance,
beauty, love
• lacks Empathy
– interpersonally exploitative
• Normal developmental stage in teens, most grow out of this
• Despite being difficult to treat due to countertransference this
PD is associated with minimal functional impairment
Borderline Personality
Disorder
A pervasive pattern of:
• instability of
• interpersonal
relationships,
• self-image
• affects,
• marked impulsivity
CHALLENGE YOUR KNOWLEDGE
Ms B
• Ms B is a 30 yo woman presents to ER following an overdose.
She is extremely distressed because her boyfriend of 4
months broke up with her. She says it is all her fault because
she kept fighting with him about his going out with his friends
but refusing to take her. She said she loves to go out and hates
being left behind.
• Ms B is fashionably made up and looks like she might be
heading out to a dance club rather than spending a night
alone at home. She explains she “never goes out without her
make-up” because “you never know who you will meet”.
• She reports her mood as “horribly depressed”. Her mood in
the interview varied between being animated and happy to
being tearful.
Ms B
• What is your preferred diagnosis?
• What is Ms B’s overall function level likely to
be?
• What challenges do you anticipate in the
clinical interview?
Mr P
• Mr P is a 25 year man who presents for assessment of depression on his
mother’s urging. Mr P spends his days hanging around the house playing
video games since he quit his job 3 weeks ago. He worked for a computer
store and reports he was “their best salesman”. He quit because he was
passed over for promotion to sales manager. He could not believe that an
older person who had worked for the company longer got the job when
“clearly I am the one that they should be investing in”.
• When asked if he had any other difficulties at work he admitted that he
couldn’t stand customers that asked “stupid questions” and had been
given several warnings about this behaviour by his boss.
• Mr P has no plans to look for work “just yet” – he is currently supported
by his mother who he admits is loaning him money that she does not have
He owes her 10,000 which he will pay back “sometime”.
Mr P
• What is your preferred PD diagnosis?
• What is your emotional response to Mr P?
• What strategies can you use to manage your
emotional response?
• What is Mr P’s likely outcome?
Mr D
• Mr D is a 30 year old man who presents because CAS will not allow him to
see his wife and son due to his frequent fights with his wife. He has never
hit his wife “I would never do that to a woman” and is distraught that he
can’t see his son because “I don’t want to abandon him like my dad did to
me”.
• Mr D reports that he was bullied until high school, but when he grew
bigger the ‘tables were turned” and “no-one messed with me.” He was
kicked out of high school for fighting and frequent absences. He was
involved in several break and enters in high school and also dealt THC.
• Mr D has had many jobs, but gets bored easily and quits. He is currently
unemployed. He reports he has had “a few” fights, usually at the bar,
when “someone else takes the first swing’ and has done things he could
be charged with “from time to time” but won’t tell you what he has done.
Mr D
• What is your preferred PD diagnosis?
• What is different about this diagnosis
compared with the other PD diagnosis? Why is
this criteria present?
• What is the likely outcome for Mr D?
• If Mr D was found to meet criteria for
psychopathy, what would be the relevance of
this information?
Cluster C” anxious”
• Obsessive Compulsive
• Avoidant
• Dependent
Obsessive Compulsive
Personality Disorder
A pervasive pattern of
preoccupation with:
• Orderliness, perfectionism
mental and interpersonal
control,
• at the expense of flexibility,
openness, and efficiency
OCPD clinical features
• Orderliness: preoccupied with organization, lists, details to
extent that point of the activity is lost
• perfectionism: to the degree that it interferes with task
completion, excessive devotion to work to the exclusion of
relationships
• Mental and interpersonal control
– overconscientous about morality, ethics, values, miserly
spending style
– rigidity, stubbornness, reluctance to delegate
• Adolescents with strong OCPD traits often grow out of this
• Minimal or no impairment of quality of life, but significantly
slower recovery from depression
• 30% also have OCD
Avoidant Personality
Disorder
Pervasive pattern of:
• social inhibition
• feelings of
inadequacy
• hypersensitivity to
negative evaluation,
Avoidant PD: clinical features
• social inhibition, feelings of inadequacy,
hypersensitivity to negative evaluation
•
•
•
•
•
•
unusually reluctant to take personal risks, engage in new activities
because they may prove embarrassing,
won’t get involved with others unless they are certain of being liked
avoids occupational activities that involve significant interpersonal
contact because fears criticism, disapproval, or rejection
Anxious attachment: wants to have close relationships and
feels very vulnerable to potential punishment and neglect of
others
Shares genetics with social phobia, but environment is
different
One of the most impairing PD’s
Dependent
Personality
Disorder
•
•
A pervasive and
excessive need to be
taken care of
that leads to
submissive and
clinging behaviour and
fears of separation
Dependent PD
“Dependent on relationships”
– Difficulty making everyday decisions without a lot
of advice, reassurance
– unable to disagree with others because fears loss
of support, will do things that are unpleasant,
degrading to maintain support
•
If person’s fear of retribution realistic (abusive
spouse) do not make diagnosis
– Urgently seeks another relationship (within days)
when a relationship ends
– Unable to do things on their own
– Chronic physical illness, separation anxiety
disorder in childhood risk for DPD
CHALLENGE YOUR KNOWLEDGE
Ms S
• Ms S is a 35 year old woman who presents with complaints
of anxiety and problems sleeping. She works at a small library
with people she has known for years. Her chronic difficulties
with anxiety increased when she heard the library might be
closed and her position moved to a larger library downtown
where she will have to work with people she doesn’t know.
• Ms S reports she has struggled all her life with fears of being
evaluated and judged by others. She did many of her high
school classes by correspondence because of this fear.
• Ms S has one friend and lives with her parents. She would like
to have more friends but is never sure whether people “really
like her” so is reluctant to try to make friends.
Ms S
• What is your preferred PD diagnosis?
• If Ms S only had anxiety in performance
situations, but felt comfortable with friends
and can make new friends if she is able to take
time to get to know them, would you still be
able to make this diagnosis? Justify your
answer.
• What is Ms S’s prognosis?
Mr L
• Mr L is a 50 year old man who is referred by ER following a
suicide attempt. He reports that he has struggled with
depression over the past year since his mother passed away.
His mother was “everything to me”. He lived at home with her
and never lived on his own because “I can’t really care for
myself”. He has had several girlfriends but “my mom takes
care of me best – my girlfriends wanted me to make too many
decisions”.
• Following the death of his mother, Mr L struggled to get in to
work and eventually lost his job. He made his suicide attempt
“as a cry for help” after his dad kicked him out of the house –
“dad said I needed to stand on my own two feet and I can’t.”
Mr L
• What is your preferred PD diagnosis?
• By what age does Mr L have to display
symptoms to meet the criteria for a
personality disorder diagnosis?
• What solution to his distress is Mr L likely pin
his hopes on?
Mr M
• Mr M is a 54 year old aeronautical engineer. He presents for
treatment of depression following being laid off from work
one year ago. He did receive a generous severance package,
but has not looked for work because he believes he is
unemployable.
• Mr M reports he was very good at his job “because I was a
detail person”. However he had difficulty delegating tasks
because he did not trust others to do the job properly – which
meant that he was chronically late for deadlines.
• Mr H was married, but his wife left because “I worked too
hard” and because “I was too hard to get along with”. He is
very lonely but won’t invite people over because they might
make a mess and it will take too long to clean up.
Mr M
• What is your preferred PD diagnosis?
• In general what is the level of functioning for
individuals with this diagnosis?
• What is the impact of this diagnosis on Mr M’s
depression?
• Would you be able to make this diagnosis if Mr
M’s symptoms were consistent with the
expectations of his culture or subculture – for
example if everyone in his office worked long
hours and neglected their families and partners?
Borderline
Personality
Disorder
BPD
• 5303 List criteria for borderline personality
disorder (BPD).
• 5304 Describe common psychiatric
comorbidities associated with BPD.
• 5305 Describe a treatment approach to BPD
including use of hospitalization, outpatient
care, pharmacological treatment and
psychotherapy
BPD DSM 5
• A pervasive pattern of instability of interpersonal
relationships, self-image and affects, and marked
impulsivity
• Affects
• emotional lability, problems with anger
• Behaviours
• suicide and self harm
• impulsive (sex, A&D, binge eating, driving fast,
promiscuity)
• Relationships
• chaotic, idealizing/devaluing, fears of abandonment “I
hate you, don’t leave me”
• Cognitive: emptiness, unstable sense of self, mild psychotic
symptoms under stress, dissociation
Etiology
Bio-Social Theory
Emotionally
Vulnerable
Individual
•
•
Invalidating
Environment
Intense
emotions
impulsive
Linehan 1993
BPD: Comorbidity
• Mood disorders: 90%
– depression, dysthymia, bipolar disorder
• Eating Disorders(AN, BN, obesity) : 50%
• Anxiety Disorders: 90%
• Substance Use Disorders: 60%
BPD Treatment
• Mainstay of treatment: outpatient care,
psychotherapy. Teaching patients how to
– recognize, tolerate and regulate their emotional
reactions,
– build healthy relationships.
• Hospitalization for crisis – short term
• Medications for other mental disorders
(depression and anxiety) and short term for
sleep.
BPD: prognosis
• With OPD treatment, psychotherapy 75%
remitted after 6 years
• 75% have history of suicide and self harm
attempts. 3 - 10% die by suicide
• Best prognostic factor: GAF at time of
diagnosis
BPD: Hospitalization
• Admission indicated:
– After a serious suicide attempt
– Psychosis/severe disorganization
• May be indicated
– loss of significant social support
– Worsening depression, substance abuse
• Caution when
– Hospital has not been helpful or has made person
worse
SIB
• 5302 Describe the pertinent factors in the
recognition of the potential of SIB.
• 5300 Describe the mental disorders associated
with self‐injurious behaviours (SIB)
• 5301 List the biological, demographic,
economic, social and developmental factors
associated with SIB.
Self Harm / SIB
• Behaviours that inflict harm to one’s body
without the obvious intention of committing
suicide
• Cutting, skin carving, burning, severe abrading,
punching, hitting
• 1-4 % general population, may be increasing
• chronic/severe SH 1%
• Teens ~15 %, college age 17- 35%
• Age of onset: 14 – 24
• Social: Low SES, adverse events during childhood
(abuse and trauma)
Clinical Features
• majority (75%) <10 times
• Increasing in teens
• 50-80% of people who self injure have made
at least 1 suicide attempt
• F=M
Associated Mental Illness
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Psychiatric Disorders (90%)
40 – 80% of adolescent psychiatric patients
Personality disorders (BPD -75%),
depression
pervasive developmental delay
dissociative identity disorder
eating disorders
Alcohol and substance abuse
SIB
• Situational Risk factors: recent negative life
events
• Reported reasons for SIB
– relief from intense painful emotions
– self punishment
– to get significant others to respond
Assessing for SIB
• Suspect and ask about self harm in teens and young
adults who are presenting with psychological distress
• Important to recognize that SIB is usually an attempt
to reduce emotional distress
• Best way to solve the problem is to look for a
solution to the event that caused the emotional
distress
SIB: intervention
• Start by validating that the prompting problem
and the distress are real and that it makes sense
to want to reduce emotional pain
• Highlight that while SH does reduce emotional
pain in the short term, it is not a great way to
solve the problem that got the distress going in
the long run
• Invite the person to look at other methods of
problem solving
Personality Disorders Summary
• Personality disorders
– are very common, 10% of general population and 50-80%
in mental health settings
– Etiology of PD: biology and learning
– influence how an individual sees himself and how he
interacts with his world
– result in substantial morbidity and mortality and makes
other mental health disorders more difficult to treat
– Are a combination of extremes of normal personality traits
and symptoms and improve gradually over time, similar to
the normal mellowing of personality traits
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