Borderline Personality Disorder

What does it mean that BPD has been referred to as a disorder of “stable instability”?

They are constantly unstable in many aspects of life

In what ways are individuals with BPD “unstable”?

There is instability in mood, which is reflected by inappropriate, intense anger or in periods of rapidly changing emotions, often in response to interpersonal stress. There is instability in self-image, as patients can have difficulty maintaining a sense of self (who they are and what they want from life), or in defining goals and values. They are very unstable in interpersonal relationships. They can idolize someone in the morning and hate them at night. They are very impulsive in a way that is potentially self-damaging and likely to create trouble (drugs, reckless driving, spend money that don’t have, risky sex, gamble, binge.

What are the clinical features of BPD as per Table 14.1?

Five or more of the following symptoms are required for the diagnosis of BPD: (1) profound fears of abandonment (real or imagined). (2) The person makes frantic and sometimes extreme efforts to avoid abandonment by others. Interpersonal relationships that are both intense and unstable and that alternate between feelings of idealization and devaluation of the other person. (3) Identify 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 (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 (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 (constant feelings of anger, angry outburst, or recurrent physical fights. (9) Brief periods of paranoid ideation or dissociative symptoms when under stress.

From where does the term borderline come? Be familiar with the types of patients that Stern (1938) and Knight (1953) were working with and how this informed their choice of the term.

Borderline comes from Stern’s view that the disorder did not fit well within the existing classification system, which was oriented around differentiating between neurosis and psychosis. Psychoanalyst Adolf Stern was working with borderline patients. Knight described a group of patients with severely impaired ego functions and primary process thinking (reflects unconscious wishes and urges) as borderline. Knight considered the disorder to be on the border of neurosis and psychosis. These groups had special needs and if they weren’t met, it created tension among staff members.

According to APA, approximately what percentage of patient with BPD are women?

75% of cases

What are some theories about why this might be (other than that a genuine difference exists across gender)?

Reported gender differences in the prevalence rates may be caused by samplings in clinical settings. If women are more likely to seek treatment, prevalence estimates will naturally be biased towards them.

What did Torgersen et al. (2001) and Lenzenweger et al. (2007) find?

They reported no gender differences in the prevalence of BPD.

What do the authors of the chapter ultimately conclude with respect to gender differences in BPD?

There is no evidence to support the once commonly held assumptions that there is a 3:1 female to male gender ratio.

What do Linehan (1993) and Gunderson (1996) consider to be the core features of BPD?

Linehan considered affective instability to be the core of BPD. The rapid mood changes, extreme reactivity to the environment, and dysthymic baseline mood best characterize disorder. Gunderson highlights fear and intolerance of aloneness as central to the disorder. The extreme fear of abandonment and the accompanying frantic efforts to avoid it are the core.

What are the main components of Linehan’s (1993) biosocial theory?

BPD results when biological temperamental vulnerabilities interact with failures in the child’s social environment, such that problems with emotion regulation are either created or exacerbated. Problems such as high level of sensitivity to negative emotions, high emotional reactivity, and a slow return to baseline after becoming emotionally aroused are precursors of the chronic problems with emotional regulation seen in BPD.

What does Linehan consider as the key environmental factor in the development of the disorder?

Invalidating family environment, as invalidation means that the child’s communications of his or her actual internal experiences are met by responses on the part of the parents that are inappropriate, erratic, or out of touch with what is truly happening to the child.

What types of negative life events characterize the youth of those later diagnosed with BPD?

High levels of trauma and adversity – several studies show that BPD are more likely to report physical abuse, sexual abuse, or neglect during childhood. They have significantly more maternal and paternal absences, more discord between the parents, more experiences being raised by other relatives or in a foster home, physical violence in the family.

What is the main problem with almost of the studies that examine the early life experiences of BPD patients and why is this a problem?

They rely on retrospective reporting, which may be unreliable due to problems with recall or reporting biases. However, a longitudinal study found that abuse/neglect was associated with higher levels of BPD.

What is attachment theory and how has it been used to understand BPD?

Attachment theory is that through the relationships and transactions that they have with their caregivers. Infants develop mental representations of themselves and others and develop internal working models about interpersonal relationships. When an infant is raised by an abusive, neglectful, or emotionally disengaged caretaker, they will develop expectations of lack of care, unreliability, and unresponsiveness. BPD show low rates of secure attachment, which may underlie many of the fundamental aspects of BPD. They may help to explain why BPD are often extremely emotionally attached to safe and stable attachment objects, such as stuffed animals, even in adulthood.

What specific styles of insecure attachment appear linked to BPD in empirical studies?

There are no clear specific styles of insecure attachment.

Be familiar with Bateman and Fonagay’s notions of what links attachment style and BPD?

They consider an inability to mentalize (understand and interpret one’s own mental state as well as those of others) to be fundamental to BPD and linked to failures in early attachment relationships.

Know the different forms of executive neurocognition.

Executive neurocognitive 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.

Interference control?

When we make a conscious and deliberate effort to control our attention or motor behavior

Cognitive inhibition?

The ability to suppress information from working memory.

Behavioral inhibition?

Requires the person to inhibit an expected motor behavior or cognitive response 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.

Know the associated findings that link deficits in these areas to BPD.

Inhibitory deficits are involved in inattention, impulsivity, and problems with affect regulation. People with BPD would show impairments on neurocognitive tasks requiring inhibition. The pattern of results in highly consistent with the idea that BPD is associated with deficits in executive cognition, often when engaged in inhibitory tasks.

What is borderline personality disorder characterized by?

Instability in emotion, cognition, behavior, sense of self, and interpersonal relationships. There are efforts to change the name to unstable personality disorder and describe it as an emotionally unstable disorder. There are profound fears of abandonment (real or imagined) and desperate bids to avoid abandonment.

What are the early learning factors of BPD?

Early lives also involve significantly more maternal and paternal absences, more discord between parents, more experiences of being raised by other relatives or in foster homes, and more physical violence in the family. A more tumultuous early home environment is associated with BPD. When children are unattended or don’t have stability within the family, the child is parentized early. When they have early experiences of abandonment, they believe that they may not be lovable enough to keep people around, so they look for explanations as to why a parent might neglect them -\> leads to self-blame. Early on, abandonment begins to link strongly to one’s sense of self

Is BPD linked to trauma?

BPD patients are at a higher likelihood of having experienced early trauma in the form of physical abuse, sexual abuse, or neglect. Children who are unattended or are seeking adult affection and attention can more easily become targets for physical/sexual abuse from strangers.

What is the link between BPD and attachment?

A common theme across theoretical models of BPD is an invalidating early attachment environment. Good enough mothering. Parental responses to the child’s inner experiences are met with inappropriate or erratic responses from parents or caregivers (Linehan, 1993). Marsha Linehan is a top name in the field of BPD. Her primary theory is that BPD patients feel invalidated. They feel like they’re unable to trust their own emotional responses because although their emotions are real and valid, the people around them are invalidating these feelings

Do BPD patients have a stable self-concept?

Children adapt to their environment, problems occur when their adaptations don’t generalize to the broader world (adulthood). When your world is chaotic and disorganized, it’s hard to be adaptive, so they can’t create a good adaptation. This leads to an unstable sense of self and unstable ways of reacting to the environment. They have good and bad relations, so unstable self-concepts. For example, with our parents, we like to think of them as all good, So children will internalize the idea that their parents, even if they’re acting bad or erratically, remind wholly good and they (the child) must be bad. This leads to very black-and-white thinking in BPD. They have a hard time with nuance in other people/understanding that things are not all good or all bad

What are the biological factors of BPD?

In a twin sample, they found a concordance rate of 35% in dizygotic twins compared to a concordance rate of 75% in monozygotic twins. The closer you are genetic, the higher the likelihood becomes. To date, no adoption studies have been conducted, which is hard to remove environmental factors. Adoption allows for different environments

What are you inheriting in BPD?

Much like other personality disorders, it is more likely that certain predisposing traits are inherited as opposed to symptoms of the disorder. For example, rates of anxiety and mood disorders, impulse control problems, ASPD, affective instability, and cognitive dysregulation were found in relatives of those with BPD