Chapter 14 Borderline Personality Disorder

BPD is typically

chronic, involves a high suicide rate, and is associated with significant distress

DSM5 Criteria

Five or more of the following symptoms are required for the diagnosis of BPD:

1. Profound fears of abandonment (real or imagined). The person makes frantic and sometimes extreme efforts to avoid abandonment by others.

2. Interpersonal relationships that are both intense and unstable and that alternate between feelings of idealization and devaluation of the other person.

3. Identity disturbance characterized by a highly unstable sense of self or markedly disturbed self‐image.

4. Impulsive behavior in at least two areas that have the potential to be self‐damaging or to have harmful consequences (such as substance abuse, reckless driving, binge eating, unsafe sexual behavior, excessive spending).

5. Recurrent self‐mutilating behavior or suicide threats, gestures, or suicidal behavior.

6. Highly reactive mood, leading to affective instability (e.g., intense negative affect such as depression, irritability, or anxiety that lasts a few hours or [rarely] a few days).

7. Persistent feelings of emptiness.

8. Intense or inappropriate anger that is difficult to control (e.g., constant feelings of anger, angry outbursts, or recurrent physical fights).

9. Brief periods of paranoid ideation or dissociative symptoms when under stress.

Zanarini and Frankenburg (1997) have noted, from the perspective of patients this pain is often perceived and described as being

“the worst pain anyone has felt since the history of the world began.” Other hallmarks of the disorder are instability and impulsivity

BPD may be best understood as a disorder of

“stable instability.” There is instability in mood. This is reflected in inappropriate, intense anger or in periods of rapidly changing negative emotions, often in response to interpersonal stress. There is also instability in self‐image

… further characterizes the BPD sufferer

Impulsivity

Adolf Stern (1938). Stern's use of the term

borderline was meant to reflect his view that the disorder did not fit well within the existing classification system, which was principally oriented around differentiating between neurosis and psychosis

Knight (1953) subsequently described

a group of patients with severely impaired ego functions and primary process thinking, which is a type of thinking that reflects unconscious wishes and urges; border not just of neurosis but of both neurosis and psychosis

Gunderson and Singer (1975).

This integrated the earlier descriptive efforts and attempted to provide diagnostic criteria for BPD

t before BPD was added to the DSM‐III, U.S. psychiatrists were polled about whether an alternative name for the disorder should be considered. More specifically, Spitzer, Endicott, and Gibbon (1979) proposed that the name

“unstable personality disorder” be substituted. However, a majority of clinicians felt inclined to retain the familiar term, borderline personality

prevalence in the general population of

1% to 2%

BPD is a clinically

heterogeneous disorder

BPD phenotype

varies widely across those diagnosed with the disorder. The heterogeneity in BPD has prompted research into the “core aspects” of the disorder and has led to debate about its most important features

Gunderson (1996)

takes a more interpersonal perspective and highlights fear and intolerance of aloneness as central to the disorder. According to this perspective, the extreme fear of abandonment and the accompanying “frantic” efforts to avoid it are at the core of BPD

Linehan (1993),

considers affective instability to be at the core of BPD. According to this view, it is the rapid mood changes, extreme reactivity to the environment, and dysthymic baseline mood that best characterize the disorder

Zanarini, Frankenburg, Hennen, and Silk (2003) have noted that,

even when other symptoms of the disorder remit, high levels of negative affectivity tend to remain in people with BPD. This suggests that a core aspect of the personality structure of those inclined to BPD may be an enduring dysphoria

A diagnosis of BPD was associated with higher rates

of concurrent major depression (61%), dysthymia (12%), bipolar disorder (20%), eating disorders (17%), PTSD (36%), and substance abuse problems (14%)

people with BPD meet criteria for a lifetime diagnosis of

mood disorder (83%), anxiety disorder (85%), or substance use disorder (78%)

One unusual feature of BPD is that it

tends to be comorbid with both internalizing and externalizing disorders

Current Theoretical Perspectives / models

1. Kernberg (1975)

2. tradition of self‐psychology psychoanalytic theory

3. Adler and Buie

4. Linehan's biosocial theory

Kernberg (1975)

presented one of the earliest theories of the pathogenesis of BPD. a high level of constitutional aggression in the child is regarded as a predisposing factor. This temperamental factor interferes with normal developmental processes such as the integration of different perspectives of the self and others. Accordingly, memories of experiences with significant others are stored separately from each other as either good or bad

tradition of self‐psychology psychoanalytic theory

emphasizes the importance of the caretaker's attunement to the needs of the child. Key components here are empathic responses that mirror the child's strengths and efforts to explore the world and that validate the child's sense of mastery

Adler and Buie

have theorized that borderline patients lack the ability to call on memories of “good objects” (internal representations or images of nurturing and empathic caretakers) to provide self‐soothing in times of distress. The absence of these images for people with BPD thus becomes an important factor in their inability to regulate their own emotions

Linehan's biosocial theory,

BPD results when biological or temperamental vulnerabilities interact with failures in the child's social environment, such that problems with emotion regulation are either created or exacerbated (Linehan, 1993). More specifically, problems such as a high level of sensitivity to negative emotions, high emotional reactivity, and a slow return to baseline after becoming emotionally aroused are thought to be precursors of the chronic problems with emotional regulation that are so characteristic of BPD; key environmental factor is an invalidating family environmen

Biological Factors

1. Genetics

2. neurotransmitters

3. Hormonal Systems

4. Oxytocin

5. Structural Appraoches

6. White Matter Abnormalities

Psychosocial Factors

1. Childhood Maltreatment

2. Attachment

   1. attachment theory

Cognitive Factors

1. Executive Neurocognition

2. Memory Systems

   1. autobiographical memory

3. Social Cognition

   1. trait appraisal

   2. Implicit trait appraisal is a primary shortcut allowing us to make quick, complex judgments about the traits or personality of others

Diagnosis and Assessment

1. diagnostic Interviews

   1. Structured Clinical Interview for DSM‐IV Personality Disorders (SCID‐II)

   2. Diagnostic Interview for Borderlines–Revised (DIB‐R)

   3. Personality Disorder Interview (PDI‐IV)

   4. Diagnostic Interview for Personality Disorders (DIPD‐IV)

2. Self-Report Questionnaires

   1. Personality Disorders Questionnaire (PDQ‐4)

3. Measuring Change in BPD

   1. Zanarini Rating Scale for Borderline Personality Disorder (ZAN‐BPD)

4. Psychometric assessment approaches to BPD

   1. Personality Assessment Inventory (PAI)

   2. e Schedule for Nonadaptive and Adaptive Personality–Second Edition (SNAP‐2)

   3. Revised NEO Personality Inventory (NEO PI‐R)

Gunderson and colleagues (2011) reported a

BPD prevalence of 14.1% in the relatives of individuals with BPD

using a twin sample, Torgersen and colleagues (2000) reported

a concordance rate for BPD of 35% in monozygotic (MZ) twins compared with a concordance rate of 7% for dizygotic (DZ) twins

much more likely that individuals

inherit genetic propensities to exhibit traits that underlie the behavioral manifestations of BPD but that are also transdiagnostic

Joyce and his colleagues (Joyce et al., 2009, Joyce, Stephenson, Kennedy, Mulder, & McHugh, 2014) have now

replicated their earlier finding that the 9‐repeat allele of the DAT1 gene is more likely to be found in depressed patients with BPD than in depressed patients who do not have BPD. This finding suggests that this polymorphism may be a risk factor for BPD.

With regard to the prediction of borderline pathology, the interaction between

genes regulating oxytocin and environmental factors may also be moderated by gender. Cicchetti, Rogosch, Hecht, Crick, and Hetzel (2014) argue that a plasticity framework, in which genes influence the susceptibility of an individual to given environments (for better or worse), best explains the role of OXTR in predicting borderline pathology in boys; This means that OXTR polymorphisms predict the effects of both positive (protective) and negative (risk‐ conferring) environmental factors on boys

Disturbances in … functioning have been implicated in BPD. There is also evidence of abnormalities in the…

serotonin, norepinephrine, and dopamine, hypothalamic‐pituitary‐adrenal (HPA) axis

serotonin hypothesis, Rinne, Westenberg, den Boer, and van den Brink (2000) administered a neuroendocrine challenge test to 12 women with BPD and 9 healthy control subjects.

results suggest that traumatic stress in childhood (which is reported by 20% to 75% of BPD patients; ) may alter aspects of the serotonin system, perhaps at the level of the serotonin receptors.

HPA axis, which is involved in stress regulation, has been widely studied in depression through the use of the

dexamethasone suppression test (DST). This test involves administering an oral dose of dexamethasone, a synthetic glucocorticoid that acts via a feedback mechanism to suppress cortisol production. ; Lieb and colleagues (2004) collected a total of 32 saliva samples from 23 women with BPD who were not taking any medications and 24 matched healthy controls.; One problem with the Lieb et al. (2004) study, as well as with many other studies of HPA axis function in patients with BPD

Structural imaging studies have shown

a 13% to 21% reduction in the volume of the hippocampus and an 8% to 25% reduction in the volume of the amygdala in patients with BPD; some regions of the prefrontal cortex (PFC), including the dorsolateral prefrontal cortex (DLPFC), orbitofrontal cortex (OFC), and anterior cingulate cortex (ACC), have also been found to be reduced in volume

Several research groups have now reported that

BPD is associated with lower metabolic activity in the OFC

finding that when people with BPD are treated with fluoxetine, a selective serotonin reuptake inhibitor (SSRI) that is helpful in the treatment of depression and BPD, there is a significant

increase in OFC metabolism at 12 weeks posttreatment

major problem in BPD may be that there is a

disconnection between activity in the prefrontal cortex and activity in the amygdala

many reasons to suspect that basic executive cognition and memory processes might be disrupted in BPD.

involves unstable and dysregulated inhibitory control. This is readily apparent in the behavior, emotions, and cognitions of the BPD patient. Moreover, individuals with BPD and family members of these individuals report subjective difficulties with attention and memory

Executive neurocognition involves

being able to delay or terminate a given response (cognitive or motor) for the purpose of achieving another goal or reward that is less immediate

cognitive inhibition.

This is the ability to suppress information from working memory

“directed forgetting” task (see Bjork, 1989). In this task,

subjects are presented with a list of words. After each word is presented, subjects see either an F (for forget) or an R (for remember). Subjects are instructed to remember words followed by an R and forget words followed by an F. at the end of the task, subjects are asked to recall all the words that were presented to them

behavioural inhibition

A third type of executive neurocognition requires the person to inhibit an expected motor behavior or cognitive response in order to follow a different direction

motivational or affective inhibition

requires the purposeful interruption of a tendency or a behavior that results from a particular motivational‐emotional state

Inhibitory deficits are involved in

inattention, impulsivity, and problems with affect regulation

Posner et al. (2002) compared 39 BPD patients without comorbid mood disorder to 30 healthy controls on the Attention Network Task (ANT)

This cognitive task, which measures interference control, taps three different aspects of attention. The first (alerting) is the ability to sustain an alert cognitive state, the second (orienting) is the ability to focus attention and select stimuli, and the third (conflict) is the capacity to decide among competing responses based on a predetermined organizing principle; showed impairments on conflict task

Korfine and Hooley (2000) administered a directed forgetting task to healthy controls, and people diagnosed with BPD

remains unclear whether findings such as these are driven by borderline pathology or by depression

Lenzenweger, Clarkin, Fertuck, and Kernberg (2004) have reported

that BPD patients (without concurrent mood disorders) exhibit deficits in cognitive planning and set‐shifting on the Wisconsin Card Sorting Test (WCST)

current DSM definition of BPD combines

theoretical perspectives that are often quite different. There are also no required symptoms that must be present for the diagnosis to be made. This means that all nine symptoms are assumed to be of equal importance in the diagnosis of BPD

. Zanarini, Frankenburg, Reich, and Fitzmaurice (2012) conducted a 16‐year follow‐up study of a carefully diagnosed group of 290 patients with BPD who had initially received inpatient treatmen

Importantly, the results showed that over the 16‐ year follow‐up almost all (99%) of the patients with BPD showed significant reductions in their symptoms and entered remission for at least a 2‐year period

There is also one characteristic of the family environment that warrants mention with regard to clinical outcome in BPD.

Expressed emotion (EE) is a measure of the family environment that has been reliably linked to higher rates of relapse and poor clinical outcome

more unexpected was the finding that patients with BPD fared better when their family members showed high levels of

emotional overinvolvement (EOI), a component of EE that reflects high levels of overprotective attitudes, emotional concern, and anxiety, as well as self‐sacrificing behavior on the part of family members.

Hooley and Hoffman (1999) hypothesized that,

because of their fears of abandonment, people with BPD might process emotional overinvolvement in a different way, interpreting it as a positive rather than a negative stimulus. In a specific test of this hypothesis, Hooley et al. (2010) subsequently used fMRI to examine brain activation in participants with BPD, participants with dysthymia, and healthy controls during exposure to comments reflecting high levels of EOI; BPD showed elevated left prefrontal activation to EOI relative to the controls and to the dysthymic participants.

Treatment

1. pharmacological approaches

   1. 70% were treated with antipsychotics and/or antidepressants,

   2. 33% were treated with anticonvulsants,

   3. 30% with benzodiazepines

   4. 4% with lithium

   5. Selective serotonin reuptake inhibitors (SSRIs)

   6. atypical antipsychotics such as olanzapine, clozapine, and risperidone

   7. antiepileptic drugs

2. psychological approaches

   1. dialectical behavior therapy (DBT)- no lomger empirically validated psychological approach

   2. psychodynamic perspective, Bateman and Fonagy (2010) developed a new therapeutic approach called mentalization‐based therapy (MBT)

   3. transference‐focused psychotherapy, or TFP

   4. schema‐focused therapy (SFT)

   5. general psychiatric management (GPM)

   6. Systems Training for Emotional Predictability and Problem Solving (STEPPS)

DBT

Developed by Marsha Linehan, this cognitive‐behavioral approach involves weekly individual psychotherapy sessions as well as weekly skills training administered in a group format

MBT

Based on attachment theory, mentalization uses the therapeutic relationship to help patients develop the skills they need to accurately understand their own feelings and emotions, as well as the feelings and emotions of others

transference‐focused psychotherapy, or TFP

Developed by Kernberg and his colleagues, this treatment approach uses the therapeutic relationship to help the patient understand and correct the distortions that occur in his or her perceptions of other people. Clarification, confrontation, and interpretation are key techniques here, with the transference relationship between the patient and the therapist being a central focus of interest

schema‐focused therapy (SFT)

uses cognitive, behavioral, and also experiential techniques to explore and modify four schema modes (organized sets of schemas, or constellations, of underlying beliefs) that are thought to occur in BPD.; detached protector, punitive parent, abandoned/abused child, and angry/impulsive child modes. Patient and therapist work together in an effort to stop these dysfunctional schemas from controlling the patient's life

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

STEPPS incorporates skills training (like DBT) and cognitive‐ behavioral therapy, as well as a systems approach. Although not designed to be used as a stand‐alone treatment, STEPPS has been shown to provide incremental benefits when added to regular care

GPM

relies on six general principles (e.g., an active and nonreactive clinician style, support and validation, case management, and a collaborative agreement to monitor change and effectiveness of treatment) and can be learned fairly easily by individuals who are already clinically trained

many people who suffer from BPD do

not have childhood histories of maltreatment.

some cases, it may simply be

that genetic factors render patients especially sensitive to other, less malevolent (and common) forms of parental failure, such as invalidation or lack of empathic attunement

Animal research

has made it clear that adverse circumstances occurring during early development can have a permanent effect on the HPA axis, neurotransmitter systems, and cognitive functioning, as well as on attachment relationships and social adjustment (Fish et al., 2004; Oitzl, Workel, Fluttert, Frosch, & de Kloet, 2000)

Studying endophenotypes may be

especially valuable in this endeavor. An endophenotype is a variable that can be measured or indexed and that is thought to lie along the pathway between the genotype and the disease (see Gottesman & Gould, 2003; Lenzenweger & Cicchetti, 2005). This could be a neurobiological, endocrinological, neuroanatomical, neuropsychological, or cognitive process. The rationale for studying endophenotypes (e.g., people who show problems with inhibitory processes on neuropsychological tests or people who have chronic high negative affect) rather than people with the disorder itself is that the endophenotype (because it is a simpler clue) may lead researchers closer to the genetic underpinnings of the disorder