Borderline Personality Borderline Personality DisorderDisorder

Irving Kuo, M.D.Irving Kuo, M.D.

Central Arkansas Veterans Central Arkansas Veterans Healthcare SystemHealthcare System

Case StudyCase Study

A 24 year old separated white female A 24 year old separated white female presents to court attempting to obtain presents to court attempting to obtain custody of her 4 year old child. She has custody of her 4 year old child. She has been married for 3 years to a gentleman been married for 3 years to a gentleman who she has accused of physically who she has accused of physically assaulting her throughout their relationship. assaulting her throughout their relationship. They have been separated on numerous They have been separated on numerous occasions, during which times she would cut occasions, during which times she would cut her arms and thighs with a razor blade and her arms and thighs with a razor blade and she has overdosed on psychotropic she has overdosed on psychotropic medications on 3 occasions.medications on 3 occasions.

She has a history of alcohol, cannabis and She has a history of alcohol, cannabis and cocaine use. She has had multiple sexual cocaine use. She has had multiple sexual partners since the age of 13 was sexually partners since the age of 13 was sexually abused by her 2abused by her 2ndnd and 4 and 4thth step-fathers step-fathers between the ages of 4-12. She has had 5 between the ages of 4-12. She has had 5 psychiatric admissions over the past 5 years psychiatric admissions over the past 5 years for suicide/self-harm behaviors. She has for suicide/self-harm behaviors. She has multiple tattoos, including over both wrists multiple tattoos, including over both wrists covering self-inflicted scars.covering self-inflicted scars.

Personality DisorderPersonality Disorder

Axis II in DSMAxis II in DSM

Onset in adolescence or young adulthoodOnset in adolescence or young adulthood

Stable in appearanceStable in appearance

Pervasive in effectsPervasive in effects

Impacts functioning in a clinically Impacts functioning in a clinically significant mannersignificant manner

Borderline Personality Disorder Borderline Personality Disorder Diagnosis – DSM-IVDiagnosis – DSM-IV

A pervasive pattern of interpersonal A pervasive pattern of interpersonal relationships, self-image and affects, and relationships, self-image and affects, and marked impulsivity, beginning by early marked impulsivity, beginning by early adulthood.adulthood.

Includes at least 5 of the following Includes at least 5 of the following diagnostic criteria:diagnostic criteria:

Borderline Personality Disorder Borderline Personality Disorder Diagnosis – DSM-IVDiagnosis – DSM-IV

A pattern of intense and unstable interpersonal A pattern of intense and unstable interpersonal relationshipsrelationships

Frantic efforts to avoid real or imagined Frantic efforts to avoid real or imagined abandonmentabandonment

Identity disturbanceIdentity disturbance

Impulsivity that is potentially self-damagingImpulsivity that is potentially self-damaging

Recurrent suicidaal or parasuicidal behaviorRecurrent suicidaal or parasuicidal behavior

Affective instability with marked mood reactivityAffective instability with marked mood reactivity

Borderline Personality Disorder Borderline Personality Disorder Diagnosis – DSM-IVDiagnosis – DSM-IV

Chronic feelings of emptinessChronic feelings of emptiness

Inappropriate, intense anger or lack of Inappropriate, intense anger or lack of control of angercontrol of anger

Transient, stress-related severe Transient, stress-related severe dissociative symptoms or paranoid dissociative symptoms or paranoid ideationideation

Borderline Personality Disorder Borderline Personality Disorder ReorganizedReorganized

Emotional dysregulationEmotional dysregulation - affective instability- affective instability - problems with anger- problems with anger

Interpersonal dysregulationInterpersonal dysregulation - chaotic relationships- chaotic relationships - fears of abandonment- fears of abandonment

Self dysregulationSelf dysregulation - identity disturbance/difficulties- identity disturbance/difficulties - sense of emptiness- sense of emptiness

Borderline Personality Disorder Borderline Personality Disorder ReorganizedReorganized

Behavioral dysregulationBehavioral dysregulation

- parasuicidal behavior- parasuicidal behavior

- impulsivity- impulsivity

Cognitive dysregulationCognitive dysregulation

- dissociative responses- dissociative responses

- paranoid ideation- paranoid ideation

Borderline Personality Borderline Personality DisorderDisorder

11% of psychiatric outpatients and 19% of 11% of psychiatric outpatients and 19% of psychiatric inpatients meet BPD criteriapsychiatric inpatients meet BPD criteria

BPD is the personality disorder most associated BPD is the personality disorder most associated with suicidal behaviorswith suicidal behaviors

Patients with BPDPatients with BPD

- 8-10% commit suicide- 8-10% commit suicide

- up to 75% attempt suicide- up to 75% attempt suicide

- 69-80% self-mutilate- 69-80% self-mutilate

DBT Research FindingsDBT Research Findings

Multiple studies comparing DBT with Multiple studies comparing DBT with treatment as usual for BPD treatment as usual for BPD

Reduced parasuicidal behaviors, less Reduced parasuicidal behaviors, less anger and better social adjustmentanger and better social adjustment

Fewer psychiatric inpatient daysFewer psychiatric inpatient days

Reduced 12 month healthcare costsReduced 12 month healthcare costs

Biosocial Theory of BPDBiosocial Theory of BPD

Biological dysfunction of the emotion Biological dysfunction of the emotion regulation systemregulation system

Invalidating environmentInvalidating environment

Pervasive emotion dysregulationPervasive emotion dysregulation

Invalidating environmentInvalidating environment

Pervasively negates or dismisses behavior Pervasively negates or dismisses behavior independent of the actual validity of the independent of the actual validity of the

behaviorbehavior

Invalidating responses - examplesInvalidating responses - examples

- rejects self-description as inaccurate- rejects self-description as inaccurate

- rejects response to events as incorrect or - rejects response to events as incorrect or ineffectiveineffective

- dismiss or disregard- dismiss or disregard

- directly criticize or punish- directly criticize or punish

- neglect- neglect

- pathologize normal responses- pathologize normal responses

- reject response as attributable to socially - reject response as attributable to socially unacceptable characteristic unacceptable characteristic

ParasuicideParasuicide

Intent to cause self-harmIntent to cause self-harm

Deliberate actionDeliberate action

Acute injuryAcute injury

- tissue damage- tissue damage

- ingestion of poisons or drugs over a - ingestion of poisons or drugs over a reasonable prescriptionreasonable prescription

- serious risk without outside intervention- serious risk without outside intervention

ParasuicideParasuicide

Non-deliberate self injuryNon-deliberate self injury Deliberate action with intent Deliberate action with intent injure injure

AccidentAccident Self Ambivalent Self Ambivalent SuicideSuicide

injury suicide injury suicide attemptattempt attempt attempt

PARASUICIDEPARASUICIDE

Problems Associated with Problems Associated with ParasuicideParasuicide

Negative emotional statesNegative emotional states

Interpersonal conflictInterpersonal conflict

Being aloneBeing alone

AbandonmentAbandonment

Life events and changesLife events and changes

Treatment Treatment

PsychotherapyPsychotherapy

- Dialectical Behavior Therapy- Dialectical Behavior Therapy

- Object relations partial hospitalization- Object relations partial hospitalization

PharmacotherapyPharmacotherapy

What is DBT?What is DBT?

Evidence supported treatment for Evidence supported treatment for borderline personality disorder and borderline personality disorder and reduction of parasuicidal behaviorreduction of parasuicidal behavior

Team-based approachTeam-based approach

Eclectic approach including mindfulness, Eclectic approach including mindfulness, CBT, skills training with both individual and CBT, skills training with both individual and group therapy modalitiesgroup therapy modalities

Why DBT?Why DBT?

Reduce suicidal and paracuicidal Reduce suicidal and paracuicidal behaviors in BPD patientsbehaviors in BPD patients

Cost reduction with reduced ER visits and Cost reduction with reduced ER visits and inpatient hospitalizationinpatient hospitalization

Reduce suffering and improve Reduce suffering and improve psychosocial functioning in BPD patientspsychosocial functioning in BPD patients

May extend to other diagnoses – PTSD, May extend to other diagnoses – PTSD, substance abuse/dependencesubstance abuse/dependence

DBT Research FindingsDBT Research Findings

Multiple studies comparing DBT with Multiple studies comparing DBT with treatment as usual for BPD treatment as usual for BPD

Reduced parasuicidal behaviors, less Reduced parasuicidal behaviors, less anger and better social adjustmentanger and better social adjustment

Fewer psychiatric inpatient daysFewer psychiatric inpatient days

Reduced 12 month healthcare costsReduced 12 month healthcare costs

The Dialectical World ViewThe Dialectical World View

Relationship between parts of the system Relationship between parts of the system and the whole – parts and wholes evolves and the whole – parts and wholes evolves in consequence of the system, and the in consequence of the system, and the relationship itself evolvesrelationship itself evolvesPrinciple of polarity – reality is comprised Principle of polarity – reality is comprised of internal opposing forcesof internal opposing forcesPrinciple of continuous change – tension Principle of continuous change – tension between opposing forces that produce between opposing forces that produce changechange

Dialectical SynthesisDialectical Synthesis

Truth is sought through efforts to discover Truth is sought through efforts to discover what is left out of current ways of ordering what is left out of current ways of ordering events – the truth is a synthesis of events – the truth is a synthesis of opposing positionsopposing positions

Dialectical lifestyle is walking the middle Dialectical lifestyle is walking the middle path with balanced behavioral patternspath with balanced behavioral patterns

A Dialectic:A Dialectic:

Change vs. AcceptanceChange vs. Acceptance

Dialectical DilemmasDialectical Dilemmas

Emotional vulnerabilityEmotional vulnerability

UnrelentingUnrelenting ActiveActive

crisescrises passivitypassivity

biologicalbiological

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socialsocial

ApparentApparent InhibitedInhibited

competencecompetence experiencing experiencing

Self-invalidation Self-invalidation

DBT Treatment ModalitiesDBT Treatment Modalities

Individual therapy - weeklyIndividual therapy - weekly

Group therapy – skills training - weeklyGroup therapy – skills training - weekly

Telephone consultation - PRNTelephone consultation - PRN

Consultation team - weeklyConsultation team - weekly

Individual therapyIndividual therapy

Eliciting commitmentEliciting commitment

Diary card and review of target behaviorsDiary card and review of target behaviors

Chain analysisChain analysis

Contingency management and behavioralContingency management and behavioral

skills trainingskills training

Exposure therapy and cognitive Exposure therapy and cognitive modificationmodification

Diary CardsDiary Cards

Daily monitor of target symptoms and skills Daily monitor of target symptoms and skills usageusage

Target symptoms include:Target symptoms include:

- self harm urge and action- self harm urge and action

- substance use- substance use

- suicidal ideation- suicidal ideation

- level of misery- level of misery

Allows individual therapist to target most urgent Allows individual therapist to target most urgent target symptoms for a sessiontarget symptoms for a session

Chain AnalysisChain Analysis

VulnerabilityVulnerability Problem behaviorProblem behavior

Prompting eventPrompting event

LinksLinks

ConsequencesConsequences

Chain AnalysisChain Analysis

Analysis is of chain of events moment to Analysis is of chain of events moment to moment over timemoment over time

Examine vulnerabilities, antecedents and Examine vulnerabilities, antecedents and consequences of problem behaviorconsequences of problem behavior

Allow for determination of patterns of Allow for determination of patterns of behaviorsbehaviors

Examine options for getting on a different Examine options for getting on a different path away from problems behaviorspath away from problems behaviors

Skills Training ProceduresSkills Training Procedures

Skills acquisitionSkills acquisition

Skills strengtheningSkills strengthening

Skills generalizationSkills generalization

Teach Skillful Behavior to Replace Teach Skillful Behavior to Replace Problem BehaviorsProblem Behaviors

Core mindfulness – identity confusion and Core mindfulness – identity confusion and emptinessemptiness

Interpersonal effectiveness – interpersonal Interpersonal effectiveness – interpersonal chaos and fear of abandonmentchaos and fear of abandonment

Emotion regulation – affective lability and Emotion regulation – affective lability and inappropriate angerinappropriate anger

Distress tolerance – impulsivity, suicidal Distress tolerance – impulsivity, suicidal threats, parasuicidethreats, parasuicide

Importance of mindfulnessImportance of mindfulness

Central to the theory and execution of DBTCentral to the theory and execution of DBT

Ability to “be in the moment”Ability to “be in the moment”

Allow distance from emotions and Allow distance from emotions and situationssituations

Dialectical synthesis of emotional mind Dialectical synthesis of emotional mind and reasonable mindand reasonable mind

Skills trainingSkills training

Group therapy to learn, strengthen, and Group therapy to learn, strengthen, and help generalize/monitor skillshelp generalize/monitor skills

Individual therapy to model skills and help Individual therapy to model skills and help reinforce skillsreinforce skills

Telephone consultations to generalize skill Telephone consultations to generalize skill use into the communityuse into the community

Telephone consultationTelephone consultation

Availability of therapist via phoneAvailability of therapist via phone

Focus on skills generalizationFocus on skills generalization

Patients are expected to call before they Patients are expected to call before they engage in parasuicidal behavior – 24/7engage in parasuicidal behavior – 24/7

Providing feedback on callsProviding feedback on calls

Recognizing therapist limitsRecognizing therapist limits

Conference to the TherapistConference to the Therapist

Weekly team meetingWeekly team meeting

Confer on treatmentConfer on treatment

Cheerlead and support one anotherCheerlead and support one another

EducationEducation

Provide dialectical balanceProvide dialectical balance

PharmacotherapyPharmacotherapy

Depends on co-morbid Axis I diagnosisDepends on co-morbid Axis I diagnosis

Treat target symptomsTreat target symptoms

- depression- depression

- anxiety- anxiety

- brief psychotic symptoms- brief psychotic symptoms

Don’t medicate transient symptomsDon’t medicate transient symptoms