Case 4: Fergie Greer - Personality Disorder (BPD)

Attachment Theory: Description

Early emotional bonds between infant + primary caregiver shape social, emotional, cognitive development

Attachment Types

Secure

Avoidant

Ambivalent/anxious

Disorganized

Secure Attachment

Child shows preference for caregiver over strangers

• Distressed by caregiver leaving

• Comforted by caregiver returning

Avoidant Attachment

Child shows no preference for caregiver over strangers

No reaction to caregiver leaving/returning

Ambivalent/Anxious Attachment

Child distressed by caregiver leaving

Child conflicted by caregiver returning

Disorganized Attachment

Child shows bizarre or stereotypical behaviour

Psychosocial Development Stages

1: Basic trust vs mistrust

2: Autonomy vs shame + doubt

3: Initiative vs guilt

4: Industry vs inferiority

5: Identity integration vs confusion

6: Intimacy vs isolation

7: Generatively vs stagnation

8: Integrity vs despair

Personality Disorders (PD): Description

Pervasive + maladaptive egosyntonic behavioural traits causing distress/functional impairment

PD: Clusters

A: Odd + eccentric

B: Labile affect, impulsivity, anger

C: Low self-esteem + fearful/anxious

PD Cluster A

Paranoid: Excessive suspicion/distrust of others

Schizoid: Social detachment + restricted emotions

Schizotypal: Social discomfort

PD Cluster B

Antisocial: Lack of respect for + transgressions against rights of others

Borderline: Impulsivity + unstable self-image, emotions, relationships

Histrionic: Attention-seeking + emotional behaviour

Narcissistic: Grandiosity + need for attention + low empathy

PD Cluster C

Avoidant: Social inhibition + sensitive to criticism

Dependent: Fear of separation and clingy + need for others’ support

Obsessive-Compulsive: Perfectionism (order) + control (low flexibility)

PD: Epidemiology

Antisocial + narcissistic: More common in males

Histrionic + boderline: More common in females

PD: Etiology

Genetics

• Personality disorders in family

• Temperament: Biologically determined characteristics

Psychosocial environmental factors

• ACEs

  • Neglect

  • Abuse

• Trauma

• Personality: Characteristics developed over time from…

  • Experiences

  • Environment

  • Socialization

• SUD

PD: Clinical Presentation

Pts consider symptoms normal

Thinking + behaviour differing from social norms

Borderline Personality Disorder (BPD): Description

Unstable emotional regulation, relationships, impulse control, and self-image

BPD: Epidemiology

Risk factors…

• Women

• Trauma/adverse events

  • Abuse

  • Bullying

• Low SES

• High ACEs

BPD: Etiology

Childhood trauma → Insecure attachment (fear of abandonment)

BPD: Pathophysiology

HPA axis dysfunction

Cortico-limbic disruption

BPD Pathophysiology: HPA Axis Dysfunction

1. Chronic stress = Increased basal cortisol secretion

2. Glucocorticoid resistance (downregulation + habituation) = Decreased cortisol response = Blunted response to stress

BPD Pathophysiology: Cortico-Limbic Disruption

1. Decreased brain glucose metabolism =

• Amygdala hyperactivity + decreased mass

• Decreased prefrontal cortex activity

2. Emotional dysregulation

BPD: Diagnostic Criteria

DSM-5

≥ 5 of: PRAAAIISE

• P: Paranoid ideation + dissociative episode

  • Suspicious of others’ thoughts

• R: Relationships = Unstable

  • Splitting: No self-other differentiation = All-good/bad people

    • Defense mechanism

• A: Abandonment (fear of)

• A: Anger

  • Intense

  • Difficult to control

• A: Affect

  • Unstable mood (hours to days)

• I: Impulsivity

  • Self-damaging acts

• S: Suicidal behaviour + self-harm

• E: Emptiness

BPD: Treatment/Management

Nonpharmacological

Pharmacological

BPD Management: Nonpharmacological

Dialectical behaviour therapy (DBT): First-line

• CBT + …

  • Mindfulness

  • Skills training (emotional regulation)

BPD Management: Pharmacological

Manage comorbidities

Depression: Antidepressants

• Sleep disturbances: Trazodone

• Psychosis: Antipsychotics

• Impulsivity + Anxiety: Mood stabilizers

BPD: Complications

SI
Poor boundaries = Idealized transferance

Other psychiatric conditions

• Mood disorders

• Anxiety disorders

• SUD

BPD vs Bipolar Disorder: Course

BPD: Stable

Bipolar: Episodic

BPD vs Bipolar Disorder: Impulsivity

BPD: Generalized

• Triggered by interpersonal stress

Bipolar: Episodic

• Triggered by mood state

BPD vs Bipolar Disorder: Ego-Syntonicity

BPD: Egosyntonic

• Pt considers symptoms normal

Bipolar: Egodystonic

• Pt considers symptoms abnormal

BPD vs Bipolar Disorder: Depression

BPD: Borderline depression

Bipolar: Major depression