borderline personality disorder
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Borderline Personality Disorder. Dr. Matthew Sager Psychiatric Medical Director St. Mary’s Hospital, Madison, WI. Borderline Personality Disorder (BPD). What is it? Perceptions and current diagnosis History Causes Facts Co-occurring diagnoses and differential Treatment - PowerPoint PPT PresentationTRANSCRIPT
Borderline Personality DisorderDr. Matthew SagerPsychiatric Medical DirectorSt. Mary’s Hospital, Madison, WI
Borderline Personality Disorder (BPD)
What is it? Perceptions and current diagnosis
History
Causes
Facts
Co-occurring diagnoses and differential
Treatment
Evaluating safety concerns/suicidality
BPD
Initial impressions
Stigma
Better descriptive terms? Emotional Regulation Disorder
Current Diagnosis
DSM IV-need to have 5 of 9 criteria (pervasive)
Unstable relationships-splitting example
Impulsive behaviors
Mood swings
Intense anger
Feelings of emptiness
Fear of abandonment
Identity disturbance, ‘poor sense of self’
Suicidal behavior or self-injury
Transient paranoia/dissociative states
Diagnostic Issues
Problems with DSM IV 5 of 9-there are 256 different variations 4 of 9-no diagnosis, but would look very similar
clinically
DSM V Revisions to look at dimensional aspects of
personality BPD on same axis as depression, anxiety In end-too complex for clinical practice-yet
Diagnostic Issues cont.’
Issues that affect making diagnosis: Transient states Medical illnesses Situational stress Sex and cultural beliefs/biases Clinician feelings-anger, disappointment,
frustration
Diagnostic Issues cont.’
In the end-the diagnosis focuses on ways of thinking and feeling about oneself and others that ends up affecting a persons ability to function
BPD History
1930s Psychoanalysts (i.e. Sigmund Freud)
divided psychosis (delusions, hallucinations) from neurosis (anxiety/distress). The area between, the borderline was the difference that explained why some patients did not act one way or the other.
1960s Psychiatrist Otto Kernbergpersonality organization to syndrome to
disorder
BPD History cont.’
1980s and 90sIncreased research
From analytical to medicalization
DSM III (1980)
DSM IV (1994)
DSM V (2013)
BPD Causes
Genetics Twin studies show strong inheritance
Environmental Unstable family relationships
Social and cultural factors 1900s-less unstructured time with more
work/survival instincts i.e. Eating Disorders indifferent countries
BPD Causes
Abnormal Brain functioning Amygdala – center of emotion Prefrontal Cortex – complex problem solving
BPD
Whatever the cause, data shows the impact of this illness
BPD Facts
2% of US population have BPD
(equal to population of New York City)
Twice that of bipolar disorder or schizophrenia
10% of mental health outpatient clinics
20% of inpatient psychiatric hospital units
BPD facts
75-90% of those diagnosed are women Do women seek treatment more than men? Men with similar symptoms may end up in jail or with
another diagnosis.
10% complete suicide in their lifetime
Comorbidities are rampant-mood disorders (depression, bipolar) anxiety disorders (PTSD) and substance abuse disorders
Probably ‘burns out’ or dissipates over time
BPD Facts
Face Studies: people with BPD are inclined to see anger in neutral emotion faces
Word Studies: people with BPD are inclined to attach a stronger reaction to neutral words
Comorbidities and differential diagnoses
Mood Disorders (bipolar disorder I and II, major depression, dysthymia)
Anxiety disorders including PTSD
Eating Disorders
Substance Abuse Disorders
Other personality Disorders
Comorbidities and differential
Lots of overlap with impulsive behaviors and mood instability
Different diagnoses from different providers
Explaining diagnosis
John Gunderson MD quoteAs an example that focuses on jargon free explanation that patients can understand
BPD Treatment
BPD-High utilization of health care $ER visits, inpatient medical/psych care
Hallmark of good care-multiple modalities
Alliance building to foster improved mood, behavior, social functioning and relationships
Treatment Goals
Containment of any safety issues
Structure
Provide support
Involve patient in decision making
Validation
Treatment Levels
Hospital
‘Step Down or Up’ Partial hospital(PHP) or Intensive Outpatient Program(IOP)
Outpatient Therapy + Med Management
Sociotherapies (group, family)
Treatment Levels
Focus on the least restrictive means of effective treatment
BPD Treatment
Hospital care Often contraindicated and can worsen
behavioral issues Hospital provides external control which can
become habit forming and cause BPD patient to attempt to gain control in negative fashion
Should be used only for acute safety stabilization
BPD Psychotherapy
Mainstay of BPD treatment
Specific types may be more effective
BPD Psychotherapy
DBT (Dialectical Behavioral Therapy) Pioneered by Marsha Linehan PhD
Focuses on mindfulness, acceptance and awareness of situations and feelings
decreases intensity of emotions
BPD Psychotherapy
CBT(Cognitive Behavioral Therapy)
Focus: Changing thinking will change behavior
Skill building/practice
Relaxation
Exposure therapy
BPD Psychotherapy
Schema therapy
Reframing ways people view themselves
BPD Psychotherapy
Group Therapies
Interpersonal
Family
DBT
Others (problem focused)
BPD Medications
Role of meds: manage symptoms, though benefit is often uncertain due to ‘symptom chasing’
Goal is to treat comorbidities
Avoid dependence, abuse, risk of overdose
Classes: Antidepressants
Antipsychotics Mood stabilizers Anti-anxiety AODA meds-antabuse/naltrexone/methadone
BPD Medications
Treat comorbidities!
Treatment Plans
Contracts with patients Makes expectations explicit From Crisis Intervention, when to call providers,
when to go to hospital to roles of those involved i.e. family/friends
BPD Safety issues
Suicide and borderline personality
10% completed lifetime
Safety plans-limited pill supply, family support, crisis contact
Highest risk are those with depression and alcohol/drug problems
BPD safety issues
‘Feeling Unsafe’
Goal is for patient to recognize when they need more active help and trust they will get it
Typical Crisis-express concern, allow patient to ventilate, avoid taking actions but let patient be explicit about situation
Follow-up after crisis
BPD and suicidal acts
John Gunderson, MD
“Suicidal acts are a dangerous distraction from the patient working on attaining a better life”.
Dr Gunderson views suicidal statements/acts as affecting a patient’s dependence on others and an effort to be cared for.
BPD
References:
1. Gunderson, John G, M.D. ‘Borderline Personality Disorder A Clinician’s Guide’, 2001.
2. DSM IV, American Psychiatric Association, 2000.
3. Robert E. Hales, M.D., Yudofsky, Stuart, M.D., Gabbard, Glen, M.D., ‘Textbook of Psychiatry, 5th Edition, 2008.