Symptoms of BPD-
-Frantic efforts to avoid real or imagined abandonment
-Patterns of intense, unstable interpersonal relationships characterized by alternating between extreme variances of idealization and devaluation
-Identity disturbance, markedly and persistent unstable self-image or sense of self
-Impulsivity in at least two areas that are potentially self-damaging (i.e. overspending, promiscuous sex, substance abuse, reckless driving, binge eating)
-Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
-Affective instability due to a marked reactivity of mood (i.e. intense episodic dysphoria, irritability, or anxiety)
-Chronic feelings of emptiness
-Inappropriate, intense anger or difficulty controlling anger
-Transient, stress-related paranoid ideation or severe dissociative symptoms
Associated Features of BPD-
-one of the most prominent features is instability in interpersonal relationships, self-image, and affects
-severe instability can be seen in their fluctuating view of him or herself, they often feel really good about themselves and their progress and then a seemingly minor experience turns their world upside down
-marked impulsivity
-people with BPD will often give up on something just before the goal is attained
-often difficult to maintain relationships, a job, or educational goals, since their basic instability extends to work and school
-psychotic-like symptoms may occur when they are under stress, including hallucinations, body-image distortions, ideas of reference, and hypagogic phenomena
-they don’t do well in personal relationships, if they do have relationships, they are unstable
-risk of suicidal, self-mutilating, or brief psychotic states increases when they are experiencing an emotional state they cannot handle
-also exhibit symptoms of depressive mood disorders, addictions to various things, and anti-social behavior, other comorbid disorders include mood, substance related, eating, ptsd, attention defecit, and other personality disorders
To the sufferer, BPD is about deep feelings, such as-
-if others get to know me, they will find me rejectable and will not love me and will leave me
-I need to have complete control of my feelings otherwise things will go wrong
-I am an evil person and deserve to be punished
-other people are evil and abuse you
-if someone fails to keep a promise, they can no longer be trusted
-if I trust someone I run a great risk of getting hurt or disappointed
-if you refuse someone’s request, you run the risk of losing them
-I will always be alone
-I can’t manage by myself, I need someone to hold back on
-there is no one who really cares about me
-I don’t really know what I want
-I will never get what I want
-I’m powerless and vulnerable
-I have no control of myself
-I can’t discipline myself
-my feelings and opinions are unfounded
BPD traits, organized by thoughts, feelings, and actions-
-Thinking-impaired perception and reasoning
-DSM traits-splitting, brief moments of stress-related paranoia or severe dissociative symptoms
-Feeling-poorly regulated, highly changeable emotions
-DSM traits-intense, unstable moods, strong reactions to shifts in the environment, irritability or anxiety, feelings of acute hopelessness, despair, and unhappiness, frantic efforts to avoid real or imagined abandonment, feelings of emptiness and lack of identity
Acting-impulsive behaviors
-DSM traits-innappropriate, intense anger, pain management behaviors such as overspending, suicide, self-harm, substance abuse, etc.
Lower functioning vs. high functioning
lower functioning-
-conventional BPs, acting in mostly self-destructive acts such as self-harm, BPD and associated symptoms make it difficult to live independently, hold a job, manage finances, families often step in to help, self-harm and suicidal tendencies, high interest in therapy
high functioning-
-invisible BPs, acting out in uncontrolled and impulsive rages, criticism, and blame, lack of interpersonal skills, appear normal, even charismatic, but exhibit BPD traits behind closed doors, has a career and may be successful, state of denial, disavow responsibility for relationship difficulties, refuses treatment, may see a therapy but it rarely lasts, concurrent illness, commonly substance abuse disorders or narcissist personality disorder
Substance use among people with BPD-
-often skilled in seeking multiple sources of medications they prefer, such as benzos
-associate drugs with social interactions
-often use substances in a chaotic and unpredictable pattern
-poly drug use is common
-usually have big appetites, often experience powerful emotion-driven needs for something outside of themselves
-when they stop using drugs, they are extraordinarily vulnerable to meeting their needs through compulsive behaviors, such as-
-compulsive sexual behavior
-compulsive gambling
-compulsive spending
Child vs adult presentation
-the DSM is not currently modified to diagnose patients under 18 years old
Gender and cultural differences in presentation-
-BPD is diagnosed mainly in females
-women with BPD are most likely to also have eating disorders
-men with BPD are most likely to also abuse substances
-1 out of every 4 people diagnosed with BPD is male
-men tend not to seek treatment
-BPD affects 1 to 2 percent of the world’s population, but new estimates see the number much larger than that
-about 10% of BPD diagnoses are made in outpatient settings, about 20% of BPD diagnoses are made in inpatient settings
-BPD is five times more commonly diagnosed in first degree relatives of affected persons
-the actual cause of the disorder is unknown
-it is commonly believed that the symptoms are long-lasting
-people with symptoms have a history of unstable relationships, and sexual abuse, physical abuse, or neglect
-serotonin deficiency may be involved in the development of BPD
-or an irregularity of non-adrenaline
-or dopamine, which has also been implicated
-experts differ on whether people with BPD “grow out of it” when they get into their 50s and above
-more research needs to be done on this
Diagnostic Tests for BPD
-the Diagnostic Interview for Borderline Patients (DIB) is the best known “test” for BPD
-the DIB is a semi-structured clinical interview that takes 50 to 90 minutes to administer
-the four areas of functioning that the test includes are-
-affect-chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, and emptiness
-cognition-odd thinking, unusual perceptions, non-delusional paranoia, quasi-psychosis
-impulse action patterns-substance abuse/dependence, sexual deviance, manipulative, suicidal gestures
-interpersonal relationships-intolerance of aloneness, devaluation, masochism/sadism, demandingness, entitlement
-The Structured Clinical Interview (SCID-II)
-12 groups of questions, relating to the 12 personality disorders
-The Personality Disorders Belief Questionnaire (PDBQ)
-Zanarini Rating Scale for BPD (ZAN-BPD)
-McLean Screening Instrument for BPD (MSI-BPD)
Emprically Supported Treatments
-the best treatment is DBT, designed by Marsha Linehan
-first, life threatening or harmful situations are dealt with
-then they are pushed to experience emotions that are painful to them
-part three addresses living problems
-four, helps the patient feel complete as a person
-Other types of therapies include-
-CBT
-group therapy
-family therapy
-individual therapy
Key Issues and Concerns in the Treatment of BPD-
-slow progress in therapy
-suicidal behavior
-self-injury
-client contracting
-transference and counter-transference
-clear boundaries
-resistance
-subacute withdrawal
-symptom substitution
-somatic complaints
-therapist well-being
Types of Psychotherapy used-
-CBT-cognitive bahvioral therapy
-TFP-transference-focused therapy
-DBT-dialectical behavior therapy
-SFT-schema-focused therapy
-MBT-mentalization-based therapy
Prognosis-
-disorder peaks in young adulthood and frequently stabilizes after age 30
-75% to 80% of BPD patients threaten suicide, between 8 and 10% are successful
-BPD decreases significantly over time, especially for remitted BPD patients
-the most co-occuring personality disorders declined significantly over time, except avoidant, dependent, and self-defeating PDs
Prevention-
-prevention recommendations are scarce
-the disorder may be genetic and not preventable
Medications-
-medication is not recommended as a first-line treatment
-may be useful in treating some symptoms
-naltrexone may be good for relieving physical discomfort of dissociative episodes
neuroleptics-navane, haldol, stelazine, flupenthixol
atypical-zyprexa, abilify, risperdal, clozaril, seroquel
SSRIs-prozac, luvox, zoloft, effexor
mood stabilizers-depakote, lamictal, topamax, tegretol, lithium
Economic Impacts-
-up to 40% of high users of mental health services have BPD
-more than 50% of people with BPD are severly impaired in emloyability, with a resulting burden on SSI, SSD, and medicaid and medicare
-12% of men and 28% of women in prison have BPD
The BPD Group 