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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
--------------------------------------------------------------------------------------------------------------------------------------------------------------------
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
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