correlates, stability and predictors of borderline personality disorder among previously suicidal...

Correlates, stability and predictors of borderline

personality disorder among previously suicidal youth

Brian Greenfield Amir RazMelissa Henry L. Eugene ArnoldEric Lis Londa DanielJosh Slatkoff Brian L. Mishara

Jean-Marc Guile Robert K. KoenekoopGeoffrey Dougherty Filipa de CastroXun Zhang

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Acknowledgments

Thanks to Hogg Family Foundation

Thanks to NHRDP

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Borderline Personality Disorder (BPD)

Somewhat recognized during adolescence : DSM-5 (< 18 years old) (Yen S, Gagnon K, Spirito A, 2013; Miller AL, Muehlenkamp JJ, Jacobson CM, 2008)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

How to distinguish adolescent BPD from Hall’s “storm and stress”

o Distresso Fleeting Identity Confusion

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

G. Stanley Hall 1846-1924

How to distinguish adolescent BPD from Hall’s “storm and stress”

When does “storm and stress” exceed a threshold into an enduring personality disorder?

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Gunderson et al. (2011)

Ten year follow-up adult BPD:o 85% remissiono 12% relapseo Severe persistent impairment(Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, Ansell E, Pinto A, Skodol AE, 2011)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Prevalence

o 5.9% non-clinical adult sampleso Community adolescents (15% male; 17.2% female)o 22% adolescent outpatients

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Measurement

o Adult-based criteriao Variable measureso Inclusions of “storm and stress”

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Distress

o Many BPD sufferers attempt suicide

o 10% commit suicide(Paris J, 2002)

o Attempt during adolescenceo Suicide > 30 years old

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

American/Canadian suicide rates (2009/2010) ages 15-19 years old:

7.5 / 1000 and 9.0 / 100, 000

(Statistics Canada, 2009; Centre for Disease Control and Prevention, 2012)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

What we did

o Large cohorto Vulnerable early adolescent

patientso Followed to late adolescenceo Correlates of BPDo Stability to late adolescenceo Predictors of outcome

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Goals

o Early identificationo Distinguish BPD from the

‘condition’

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Hypothesis I

Group differences are apparent between previously suicidal adolescents with and without BPD at ages 14 and 18 years with respect to clinical and demographic variables at baseline and follow-up

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Hypothesis II

o BPD among suicidal adolescents is heterogeneous• Persisting• Emerging• Remitting

o BPD demonstrates temporal stability

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Hypothesis III

Persisting BPD driven by:• Drug use• Prior hospitalization• Mood disorders

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Procedure

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Sample286 T1

263 (92%) T3 at 6 months

229 (80%) T4

219 (77%) Completed measure

204 (71%)Completed data (T1 &

T4)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

34 = n (12%) Attrition

Dropouts similar to participants

o Age (14.6 years)o Female (70.7%)o % BPDo ↓ Depression (34 vs. 53%)o ↓ ETOH (37 vs. 55%)o ↓ IFRo ↑ Suicide (2.7 vs. 2.25)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Measures

o DISC MOOD CD

o Spectrum of Suicide Behavioro CGASo Substance abuseo Coddingtomo IFRo Ab-DIB

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Results Hypothesis ISignificant Differences between BPD & Non BPD

Recruitmento Depression ↑o Conduct disorder ↑o CGAS ↓o Drug use ↑o Coddington ↑o IFR ↑o Prior hospitalizations ↑o Previous visits to ER ↑

Follow-Upo Depression ↑o Conduct disorder ↑o CGAS ↓o Suicide ↑

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Results Hypothesis II

T1 T4

YES

NO Emerging 3.4% (7/204)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Persisting 76% (155/204)

Never 7.4% (15/204)

Remitting 13.2%

(27/204)

Results Hypothesis III

BPD at follow-up predicted by:Older age at first presentationLower level of functioning

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Results

o 17 (7.8%) of 219 patients remained suicidal at T4, 16 (94.1%) meeting BPD criteria

o No sex differences with respect to BPD diagnosis

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Discussion

Suicidal adolescents with BPD:o Drug useo Stressful life eventso Family Dysfunctiono Major Depressiono CDo ↓ functioning

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

EASY TO IDENTIFY

CLINICALLY

Discussion

Like adults with BPD, adolescents CGAS=59 ( ↑ of 20 from T1 but impaired functioning)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Discussion

o BPD stable = 76% (155/204) of suicidal youth over 4 year follow-up

o Compatible with BPD traits in the community (46-73%)

(Wingrad G, Cohen P, Chen H, 2008; Bornovalova MA, Hicks BM, Lacono WG, McGue M, 2009)

o Higher than reports of BPD threshold (14-23%)

(Mattanah JJ, Becker DF, Levy KN, Edell WS, McGlashen TH, 1995; Meijer M, Goedhart AW, Treffers, 1998)

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Discussion

o BPD baseline, 8x > non-BPD baseline

→ BPD follow-upo BPD can be diagnosed by age 14o BPD persistent and BPD

emerging may → BPD adulthood

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Discussion

o 16.7% BPD only once = o Predictors may distinguish BPD

from conditiono ↓ Function + ↑ Age = Predictors

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

“storm and stress”

Discussion

No gender differences• Does bifurcation occur > 18

years?• Are measures not discerning

adult male BPD?

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Discussion

o Suicide occurs more commonly > 30 o Most adolescent suicidality

associated with BPD – persistingo Help adolescents with suicidality

may ↓ adult BPD suicidalityo Only 7.8% adolescent BPD remain

suicidal but 76% of our sample remain BPD hence, BPD not synonymous with suicide

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Limitations

o Only reporting on 71% of original cohort

o Subtract 29% from stability = 48% (still very stable)

o Our subjects did not suicide!o Excluded medically and

surgically unstable suicidal adolescents

o Evaluation = therapyo Used the Ab-DIB

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Take home points

o Adolescent BPD may likely be diagnosable by age 14

o Adolescent BPD is highly stableo Adolescents remaining suicidal

are likely to suffer from BPDo Persisting BPD can be predicted

by later age (>14) and by poorer functioning at the time of presentation to emergency

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Take home points

o Most suicidal adolescents are no longer suicidal 4 years later

o Adolescent BPD has no gender bias

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015