Borderline Personality

DisorderSubmitted by,

MaNaSa GS MSc Applied

Psychology

Description Of The Disorder

• Adolf stern in 1938 used the term borderline.• It described a group of patients who were on

a border between neurosis and psychosis. He thought this as a mild form of schizophrenia.

• Current trend is to call it “Emotional Intensity Disorder”

• In 1980, DSM-III listed BPD as a diagnosable illness for the first time.

• Mental illness marked by unstable moods, behavior, and relationships.

• Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.

• The DSM IV describes BPD as “ a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of context”.

• According to DSM-IV-TR, to be diagnosed with BPD, a person must show an enduring pattern of behavior that includes at least 5 of the following symptoms:Frantic attempts to avoid real or imagined

abandonment.Unstable and intense relationships alternating

between idealization (extreme closeness and love) and devaluation (to extreme dislike or anger )

Markedly unstable self image or sense of self.Potentially self damaging impulsive behavior in

at least 2 areas, such as unsafe sex, substance abuse, reckless driving, and binge eating

Suicidal or parasuicidal behavior. Intense and highly changeable moods, with each

episode lasting from a few hours to a few daysChronic feelings of emptiness.Inappropriate and uncontrollable anger.Having stress-related paranoid thoughts or

severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

• Linehan reorganized DSM-IV diagnostic criteria into five spheres of dysregulation.1. Emotion Dysregulation2. Behavioral Dysregulation3. Interpersonal Dysregulation4. Cognitive Dysregulation and5. Self Dysregulation

Causes

• Genetic and environmental factors– Studies on twins with BPD suggest that the

illness is strongly inherited.– Another study shows that a person can inherit

his or her temperament and specific personality traits, particularly impulsiveness and aggression.

– Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.

• Social or cultural factors– Unstable family relationships may increase a

person's risk for the disorder. – Impulsiveness, poor judgment in lifestyle choices,

and other consequences of BPD may lead individuals to risky situations.

– Adults with BPD are considerably more likely to be the victim of violence, including rape and other crimes.

Epidemiology

– 1 to 2 percent in general population.– About 10% in psychiatric outpatient

populations& 20% inpatient population.– 50% of personality-disordered inpatients are

diagnosed with BPD.– Nearly 75% of individuals diagnosed with BPD

are women– Age is negatively associated with grater

prevalence and severity of BPD.

– Comorbidity of Axis I disorders with BPD is high, like major depressive disorder, bipolar disorder, and anxiety disorders.

– Paranoid, avoidant, and dependent personality disorders are high among BPD.

Assessment

• BPD is often under diagnosed or misdiagnosed• can detect BPD based on a thorough interview and

a discussion about symptoms.• A careful and thorough medical exam can help rule

out other possible causes of symptoms.• The diagnostic assessment of BPD is complicated.• High rates of comorbidity complicate the diagnostic

picture.

• Snapshot observation and self-report information are primarily used for diagnosis. But this data may not be characteristic of the individual’s behavior and affect. Self report data may be unreliable. Diagnosis must be based on longitudinal observation.

• The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses.

• This information can help the mental health professional decide on the best treatment

• Women with BPD are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders.

• In men, BPD is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder.

• Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis.

• These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat BPD and other mental disorders.

Course And Prognosis• Course is variable.• Most commonly follows a pattern of chronic instability

in early adulthood with episodes of serious affective and impulsive dyscontrol.

• The impairment and the risk of suicide are the greatest at the young adult years and gradually wane with advancing age.

• In the 4th and 5th decades of life, these individuals tend to attain greater stability in their relationship and functioning.

• Emerges in the late teens and early 20s.• Chronic disorder , presenting symptoms for many years.

Recommended Data-based Treatments

BRIEF DESCRIPTION TREATMENT STAGES MULTIMODAL TREATMENT WORKPLACE ACCOMMODATIONS MAINTENANCE OF GAINS/RELAPSE

PREVENTION WORKPLACE STRATEGIES

BRIEF DESCRIPTION– Developed by Dr. Marsha Linehan and her

colleagues, DBT is an empirically validated cognitive-behavioral treatment for BPD.

– Dialectical behavior therapy (DBT) focuses on the concept of mindfulness, or being aware of and attentive to the current situation.

– DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships.

– In DBT problems are defined, analyzed and solved in a collaborative fashion.

• Cause is hypothesized according to operant, respondent, and observational learning models.

• Solutions fall into one of four categories: skills training, cognitive restructuring, exposure techniques, or contingency management.

• In DBT, behavior therapy is balanced with acceptance therapy and housed in a framework that is dialectical in nature.

• The core acceptance strategy in DBT is validation

• Validation is used to – Provide a balance to the push for change– Reinforce clinical progress– Teach self-validation and – Strengthen therapeutic relationship

• Mindfulness is the core acceptance skill taught in DBT

TREATMENT STAGES

• DBT provides stage-based hierarchical structure:– Pretreatment stage:• Assessment, orientation to treatment, initial

commitment to participate in therapy– Stage 1 targets• suicidal and parasuicidal behaviors• Therapy- interfering behaviors• Behaviors that severely interfere with a

reasonable quality of life

– Stage 2 targets• reduction of posttraumatic stress

– Stage 3 targets• Increasing self-respect• Working on other problems and issues with

which the client may desire help

MULTIMODAL TREATMENT

• DBT clients participate two primary modes of therapyIndividual Therapy and Skills Training Group• Individual Therapy motivate the individual to

use skillful behavior• Emotional, cognitive, and environmental

obstacles for skillfulness are assessed and treated• Group skills training improves client’s

capabilities• Training occurs in four primary skill sets:

mindfulness , distress tolerance, emotion regulation, and interpersonal effectiveness

WORKPLACE ACCOMMODATIONS

• Allow self-initiated removal from stressful stimuli• Mindfulness skills are taught• Early release a few days a week in order to attend

therapy• Environments to be validating of the difficulties and

needs of BPD• Validate the realness of the individual’s problem

without invalidating his or her capabilities and strengths

• Approach of consulting with the client rather than intervening directly in his or her environment

MAINTENANCE OF GAINS/RELAPSE PREVENTION

• Thoughtful strategies for preserving clinical change• Continuing therapy• Termination of therapy after clients complete Stage

2.• Development of Social support in the client’s

natural environment• To further assist maintenance of client gains and

prevention of relapse, a self-management skills unit may be established

WORKPLACE STRATEGIES

• Supervisors should reinforce the change in behavior through acknowledgement or praise.

• Validate(acknowledge non judgmentally) the individuals report of emotion and the difficulty of change in behavior.

• BPD are encouraged to consider whether the work place is or is not validating.

• Supervisors should give support to the BPD when needed, give sufficient training to achieve new behavior.

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