أ.د/ أماني هارون

1. Borderline
Personality
Disorder
Prof. Amany Haroun El Rasheed
Ain Shams Univ., Cairo, Egypt
M.N.P., D.P.P., M.D.
Master in Mental Hygiene (Johns Hopkins Univ.)
Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.)
APA Membership
ISAM Membership
WPA Fellowship
FRC Psych

2. What is a healthy personality?
 SHORT FORMULA:
ability to enjoy, to relate and to work.
 Psychologically healthy with a positive
development is a person who is able
to utilize eight aspects or polarities –
depending on life context or
requirement – in a way that is
situational or functional. (Fiedler)

3. Eight Modalities of Personal Functioning
 Individuality, Independence.
 Relationship, Attachment, Security.
 Spontaneity, Desire for New Experiences.
 Stability, Self control.
 Wellbeing, Pleasure.
 Allowing and accepting pain, Melancholy
 Actively structuring life − Manipulation.
 Passive Receiving, letting things happen.

4. Common Themes in Normality
 strength of character  ability to experience
 ability to learn from pleasure without
experience conflict
 ability to work  flexibility/ability to
 ability to achieve adjust
insight  ability to laugh
 absence of  ability to love another
symptoms/conflict  degree of
acculturation

5. Where is the line?
 It’s all a matter of degree and which
traits:
e.g. To be a successful pilot, a person
must have a degree of narcissism
(healthy sense of self-confidence) and
obsessive compulsive (attention to
detail, conscientious).

6. See the whole person
 Therefore,don’t rely on a single, “slice-
in-time” conclusion when considering
traits
 The most normal person can
look pretty disordered at times when
stressed

7. Characteristics of Personality
Disorders
 An enduring pattern of inner experience
and behavior that deviates markedly from the
expectations of the individual’s culture,
 is pervasive and inflexible,
 has an onset in adolescence or early
adulthood,
 is stable over time,
 and leads to distress or impairment.

8. Personality Disorders: Facts and Statistics
 Prevalence of Personality Disorders
 About 0.5% to 2.5% of the general population
 Rates are higher in inpatient and outpatient settings
 Gender Distribution and Gender Bias in
Diagnosis
 Gender bias exists in the diagnosis of personality
disorders
 Such bias may be a result of criterion or
assessment gender bias

9. Personality Disorders:
Facts and Statistics
 Originsand Course of Personality
Disorders
 Thought to begin in childhood
 Tend to run a chronic course if untreated
 Co-Morbidity Rates are High
(depression, anxiety)

10. Personality Disorders: Facts and
Statistics
 Rates of personality disorder in the general
population (Coid et al 2006) - 4-5%
Rates of personality disorder in young adults,
24-25 years old (Moran et al 2006) – 18.6%
 Rates of personality disorder among self-
harm patients (Haw et al 2001) – 47%

11. What is Personality?
 Personality lies along a continuum from
healthy to pathological
 Itis founded on particular adaptations
or arrests at various stages along the
developmental path

12. Character structures/personality
traits
 Result in distinct clusters of defenses,
character structures, or personality traits
 These persist over time, become internalised
and repeat as scripts
 They serve to assist us in managing anxiety
and self-esteem

13. Character structures/Personality Traits
Enduring patterns of:
 Perceiving
 Relating to
 Thinking about oneself and the
environment
 In a wide range of social and personal
contexts

14. Not accounted for by:
 Culture
 Religious beliefs
 Immigration
 Stressful events
 Axis I disorders
 Medical condition
 Communication, autistic or developmental
disorder

15. Effects
Two or more of the following:
 Cognition
 Affectivity
 Interpersonal functioning
 Impulse control

16. Functional Assessment
 Motivation - What is wished for, feared,
valued?
 Cognitive functioning - functioning, style,
coherence, belief systems
 Affective functioning - intensity, lability,
experience of affect, capacity for ambivalence
 Affect regulation - coping strategies,
defenses, repertoire

17. Functional Assessment
 Experience of self - continuity, coherence,
agent, self-esteem, ideals, self presentation,
identity
 Experience of others - wishes, fears,
schemas
 Capacity for relatedness
 Management of aggression
 Emotional developmental history

18. When is personality pathological?
 Where defenses become so rigid and
inflexible that they are not adaptive
 Reality is distorted
 Psychological growth is prevented
 NB These were adaptive in early life

19. Personality Disorder Clusters
 Personality disorders fall into three
general clusters:
 Persons in cluster A seem odd or
eccentric
 Paranoid, schizoid, schizotypal
 Persons in cluster B seem dramatic,
emotional or erratic
 Antisocial, borderline, histrionic, narcissistic
 Persons in cluster C appear as anxious or
fearful
 Avoidant, dependent, obsessive-compulsive

20. Dimensions
Dsm-iv:
Emotional Cluster A – Odd or eccentric cluster (e.g.,
Dramatic paranoid, schizoid)
Cluster B – Dramatic, emotional, erratic
cluster (e.g., antisocial, borderline)
Cluster C – Fearful or anxious cluster (e.g.,
avoidant, obsessive-compulsive)
oDD
ExcEntric
anxious
FEarFul
avoiDant

21. Three Major Brain Systems Influencing
Stimulus – Response Characteristics
Brain System Principal Relevant Stimuli Behavioral
(Related Personality Monoamine Response
Dimension) Neuromodulator
Behavioral Dopamine Novelty Exploratory
activation pursuit
(novelty seeking) Potential reward Appetitive
approach
Potential relief of Active avoidance,
monotony or escape
punishment
Behavioral inhibition Serotonin Conditioned signals Passive
(harm avoidance) for punishment, avoidance,
novelty, or extinction
frustrative
nonreward
Behavioral Norepinephrine Conditioned signals Resistance to
maintenance for reward or relief extinction
(reward of punishment
dependence)

22. Cloninger’s Seven-Factor Model
 Temperament Domains (Moderately heritable,
not greatly influenced by family environment)
a. Novelty Seeking
b. Harm Avoidance
c. Reward Dependence
d. Persistence
2. Character Domains (Moderately influenced
by family environment, only weakly heritable)
a. Self-transcendence
b. Cooperativeness
c. Self-directedness

23. DSM-IV Definition of Personality
Disorder
 An enduring pattern of inner experience and
behavior that deviates markedly from the expectations
of the individual’s culture. This pattern is manifested in
two (or more) of the following areas:
 Cognition (i.e., ways of perceiving and
interpreting self, other people, and events)
 Affectivity (i.e., the range, intensity, ability,
appropriateness of emotional response)
 Interpersonal functioning
 Impulse control
 The Enduring pattern is inflexible and pervasive
across a broad range of personal and social situations.

24. DSM-IV Definition of Personality Disorder
C. The enduring pattern leads to clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
 The pattern is stable and of long duration and its
onset can be traced back at least to adolescence or
early adulthood.
 The enduring pattern is not better accounted for as
a manifestation or consequence of another mental
disorder.
 The enduring pattern is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition
(e.g., head trauma).

25. Impulsive Disorders
Axis II
 Borderline Personality Disorder
 Antisocial Personality Disorder
Axis I
 Psychoactive Substance Use Disorder
 Bulimia
 Paraphilias
 Impulsive Control Disorder NEC

26. Levels of personality functioning
 Neurotic - stable, continuous, integrated
identity, with mature and flexible defenses,
good reality testing
 Borderline - unstable, inconsistent,
discontinuous identity, primitive defenses,
adequate reality testing
 Psychotic - fragmented, confused,
disorganised identity, primitive defenses, poor
reality testing

27. Concepts of Borderline Disorders
BorDErlinE
schizophrEnia
(KEty) aFFEctivE
atypical
(schizotypal schizophrEnia DisorDErs
aFFEctivE
pD - raDo,
DisorDErs
mEEhl)
(D.KlEin)
BorDErlinE BorDErlinE
pErsonality pErsonality
organization DisorDEr
(KErnBErg)
BorDErlinE
synDromE
(grinKEr)
nEurosE
s

28. Aspects of Levels of Personality Organization
Borderline Neurotic Normal
Organization Orgaization Orgaization
Identity Incoherent sense Coherent sense Integrated sense
of self and of self and of self and
others; poor others; others;
investment in investment in investment in
work, leisure work, leisure work, leisure
Defenses Use of primitive Use of more Use of more
defenses advanced advanced
defenses; rigidity defenses;
flexibility
Reality testing Variable empathy Accurate Accurate
with social perception of perception of
criteria of reality; self vs, non-self self vs, non-self
lack of subtle internal vs internal vs
tactfulness external; external;
empathy with empathy with
social criteria of social criteria of
reality. reality.

29. Aspects of Levels of Personality Organization
Borderline Neurotic Normal
Organization Orgaization Orgaization
Aggression Self-directed Inhibited Anger
aggression; aggression; modulated;
some with angry appropriate
aggression outbursts self-assertion
toward others; followed by
hatred in guilt
severe cases
Internalized Contradictory Excessive Stable,
values value system; guilt feelings; independent,
incapacity to some individualized.
live up to own inflexibility in
values, dealing with
significant self
absence of
certain values

30. Aspects of Levels of Personality Organization
Borderline Neurotic Normal
Organization Orgaization Orgaization
Object Troubled Some degree Lasting and
relations interpersonal; of sexual deep relations
absence of or inhibition, or with others;
chaotic sexual difficulties in sexual
relationships; integrating sex intimacy
confused with love; deep combined
internal working relations with with
models of other, with tenderness;
relationships; specific coherent
severe focused working
interference with conflicts with models of
love relations selected others relationskips

31. stpD
mDD
Bip-ii
ptsD
sEvErity spD
oF social
aspD
DysFunction BpD
avpD npD
hpD

32. Basic Beliefs and Strategies Associated with
Traditional Personality Disorders
Personality Basic Strategy (overt
Disorder Beliefs/Attitudes behavior)
Dependent “I am helpless” Attachment
Avoidant “I may get hurt” Avoidance
Passive- “I could be controlled” Resistance
Aggressive
Paranoid “People are dangerous” Wariness
Narcissistic “I am special” Self-aggrandizement
Histrionic “I need to impress” Dramatics
Obsessive- “I must not err” Perfectionism
Compulsive
Antisocial “Others are to be Attack
Schizoid taken” a plenty of
“I need Isolation
space”

33. Typical Overdeveloped and Underdeveloped Strategies
Personality Overdeveloped Underdeveloped
Disorder
Obsessive- Control- responsibility- Spontaneity- playfulness
compulsive systematization
Dependent Help-seeking – clinging Self-sufficiency
Passive- Autonomy- resistance- Intimacy- assertiveness-
aggressive passivity- sabotage activity- cooperativeness
Paranoid Vigilance- mistrust- Serenity- trust- acceptance
suspiciousness
Narcissistic Self-aggrandizement- Sharing- group identification
competitiveness
Antisocial Combativeness- Empathy- reciprocity- social
exploitativeness- predation sensitivity
Schizoid Autonomy- isolation Intimacy- reciprocity
Avoidant Social vulnerability- avoidance- Self-assertion
inhibition
Histrionic Exhibitionism- expressiveness- Reflectionism- control-
impressionism systematization

34. Borderline Personality Disorder

35. Epidemiology
 2 % of the general population
 Females 4 times the rate of males
 11 % of psychiatry outpatients
 25 % of acute psychiatry inpatients
 50 % of long term psychiatry inpatients
 60 % with co-existing Major Depressive
Disorder
 7% complete suicide. ( 7 X General population)
 up to 75% attempt suicide
 69-80% self-mutilate

36. Interface with Health Care System
 Inpatient Psychiatric Units
 Top diagnosis for re-admissions to psych hospitals
 Emergency Rooms
 Cutting, burning, suicidal threats
 Intensive Care Units and medical inpatient units
 Overdoses and other sequelae of suicidal or parasuicidal
behavior
 Outpatient primary care setting
 Psychosomatic complaints
 Doctor shopping

37. Borderline: On the “borderline” between
“neurosis” and “psychosis”
Not an accurate term though – and not relevant
to current nosology
Current trend is to call it “Emotional Intensity
Disorder”
Better accepted by patients – more meaningful

38. Four Categories for Borderline
Symptoms
 Poorly regulated emotions
 Mood swings and unstable emotions
 Anxiety
 Inappropriately intense anger
 Difficulty controlling anger
 Chronic feelings of emptiness
 Impulsivity
 Reckless behavior
 Suicidal behavior and self harm
 Munchausen’s Syndrome and by Proxy
 Suicide

39. Four Categories for Borderline
Symptoms
 Impaired perception or reasoning
 Paranoid thinking
 Dissociative episodes
 Depersonalization
 Unstable self image or sense of self
 Markedly disturbed relationships
 Intense and unstable interpersonal relationships
 Black and white thinking
 Frantic efforts to avoid real or imagined
abandonment

40. Can look like…..
 Schizophrenia
 hallucinations, illusions, paranoia
 Bipolar Affective Disorder
 mood lability and anger
 Major Depressive Disorder
 suicidal, depressed
 Antisocial Personality Disorder
 legal problems

41. Constituent Elements of Borderline
Personality Organization (BPO)
 Patients with BPO are characterized by diffuse
identity, the use of primitive defenses, generally
intact yet fragile reality testing, impairments in
affect regulation and in sexual and aggressive
expression, inconsistent internalized values, and
poor quality of relation with others.
 Clinically, the lack of integration of these internal
representations of self and others becomes evident
in the patient’s non-reflective, contradictory, or chaotic
descriptions of self and others and in the inability to
integrate or even to become aware of these
contradictions.
 This lack of integration has a fundamental impact on
the individual’s experience in the world.

42. Cluster B Personality Disorders and Development
Development of
Typical Development of Borderline/ Antisocial/Narcissistic
Development Histrionic Personality Personality Disorders
Disorders
self self self
world and
world and world and
others
others others

43. Cluster B Personality Disorders and
Development
Development of Development of
Borderline/Histrionic Antisocial/Narcissistic
Personality Disorders Personality Disorders
self self
world and world and
others others

44. Constituent Elements of Borderline
Personality Organization (BPO)
 Behavioral correlates of this borderline
psychic structure include emotional lability,
anger, interpersonal chaos, impulsive self-
destructive behaviors, and proneness to
lapses in reality testing.
 A typical specific manifestation in this diffuse
and fragmented identity is the oscillation
between helplessness and a rageful,
tyrannical aggression directed toward oneself
or others.

45. Constituent Elements of Borderline
Personality Organization (BPO)
 Primitive defenses are organized around
splitting, the radical separation of good and
bad affects and of good and bad objects.
 These defense mechanisms represent
attempts to protect an idealized segment of
the individual psyche, or internal world, from
an aggressive segment.
 This separation is maintained at the
expense of integration of the images in the
psyche.

46. Constituent Elements of Borderline
Personality Organization (BPO)
S+S-
S+S-
O+O-
O+O- O+O-
O+O- S+S- S+S-
NORMAL ORGANIZATION
Consciousness of integration/complexity

47. Constituent Elements of Borderline
Personality Organization (BPO)
S- S-
S+ S+
O-
O+ O-
O+
SPLIT ORGANIZATION
Consciousness of all-good or all-bad

48. Constituent Elements of Borderline
Personality Organization (BPO)
Reality Testing
 Individuals with BPO may lack subtle
tactfulness in social interactions,
particularly under stress.
 For example, under stress, those with
BPO more easily regress to paranoid
thinking.

49. Borderline Personality Disorder
Etiology

50. Etiology
Multiple risk factors:
 Biological
 Temperament abnormalities (heritable)
 Decreased serotonin activity
 Psychological
 Trauma
 Emotional neglect
 Social
 Lack of support/emotional security
 Linehan’s theory – emotional invalidation
 Invalidating environment

51. Etiology of BPD
Type 1: Affective (Akiskal, Klein)
 **A moderately heritable “subaffective”
vulnerability, precipitated by environmental
stress
Prototypic Criteria:
 #6: affective instability due to marked
reactivity of mood (dysphoria or anxiety);
 #5: recurrent suicidal behavior, gestures or
threats, or self-mutilating behavior

52. Etiology of BPD
Type 2: Impulsive (Zanarini, Hollander,
Siever)
 **A moderately heritable impulse spectrum
disorder, precipitated by environmental stress
Prototypic Criteria:
 #4: impulsivity in at least two areas that are
potentially self-damaging;
 #5: recurrent suicidal behavior, gestures or
threats, or self-mutilating behavior

53. Etiology of BPD
Type 3: Aggressive (Kernberg)
 **A primary moderately heritable aggressive
temperament, or a secondary reaction to
early trauma and/or abuse
Prototypic Criteria:
 #8: inappropriate, intense anger or difficulty
controlling anger;
 #6: affective instability due to marked
reactivity of mood (irritability)

54. Etiology of BPD
Type 4: Dependent (Masterson and Rinsley;
Gunderson)
 **intolerance of aloneness, and impaired
autonomy, possibly secondary to parental
separation-resistance
Prototypic Criteria:
 #1: frantic efforts to avoid real or imagined
abandonment;
 #6: affective instability due to marked
reactivity of mood (anxiety)

55. Etiology of BPD
Type 5: Empty (Mahler; Adler and Buie)
 **failure to develop an evocative memory
secondary to lack of empathy and
inconsistency in early parenting
Prototypic Criteria:
 #7: chronic feelings of emptiness;
 #3: identity disturbance: markedly and
persistently unstable self-image or sense of
self

56. Genetic and Biological Factors
 Genetics a modest contributor of BPD Diagnosis but
may be more salient for specific symptoms of BPD
 Reduced serotenergic activity in 5-HT system inhibits
ability to modulate or control impulsive and aggressive
behavior
 Differences b/w BPD and nonBPD patients in
serotenergic functioning
 Repeated exposure to stress may blunt serotenergic
activity (frequent increases in cortisol)
 Stress  frequent increases in cortisol  blunting of
serotenergic activity  emotion dysregulation
 Limitations
 Lack of specificity for serotonin (i.e., MDD w/out
impulsivity)
 Pharmacology targeting serotonin has limited
efficacy in treating BPD

57. Neurobiology
Risk factors:
 Diminished serotonergic function in the
prefrontal cortex
 Potential biological risk factor for
disinhibition, impulsivity, and affect
dysregulation.
 Dysfunction in the cortical-striatal-
thalamic-frontal network
 behavioral control

58. Frontolimbic Circuitry
 Prefrontal
and limbic systems mediate
the processing of and responses to
emotional stimuli

59. Trauma
 Childhood Sexual Abuse (CSA)
 Historically considered a significant risk factor for
BPD
 75% of patients with BPD have a hx of CSA but…
only 90% of CSA victims have BPD
 Limitations
 Current evidence suggests that emotion
dysregulation mediates the relationship between
CSA and BPD
 Role of physical and emotional abuse which co-
occurs with CSA?

60. Link with Childhood Trauma
 Many people with personality disorder report a
history of childhood abuse or neglect
 Children who are physically abused, sexually
abused, or neglected are significantly more
likely to develop a PD as a young person
 Sexual abuse [usually with emotional
abuse and neglect] is most strongly
associated with BPD in particular
 In BPD, childhood trauma may still be affecting
the individual as an adult, to an extent that
impairs daily functioning
Johnson JG et al. Arch General Psychiatry 1999

61. Family Interactions
 Neglect
 Emotional uninvolvement
 Invalidation

62. Emotion Regulation
 “processby which individuals influence
which emotions they have, when they
have them, and how they experience
and express these emotions.”

63. Emotion Dysregulation
 Vulnerability to negative emotion
 High sensitivity, reactivity, and slow return to
baseline
 Influences emotional arousal
 Poor coping skills
 Inability to: manage social interactions, awareness
of relevant stimuli, identify and label emotional
experiences, manage arousal
 Maladaptive responses to others
expressions of emotion
 Wants, thoughts, goals. Others responses often
trigger emotional arousal

64. Emotion Vulnerability
 Heightened emotional sensitivity
 Emotion reactivity
 Slow return to baseline

65. Invalidation
 Validation
 Convey legitimacy and acceptance of the
other’s experience or behavior
 Invalidation
 Delegitimize
valid experiences or fail to
acknowledge their existence and/or
legitimacy

66. Invalidating environment
Pervasively negates or dismisses
behavior independent of the actual
validity of the behavior

67. Invalidating Family Environment
 Invalidation of…
 Emotions, thoughts, desires
 Over public behavior
 Difficult tasks, developmental milestones
 Sense of self and self initiated behavior

68. Risk Factors for Invalidation
 Unexpected experience or behavior
 Behavior creates unwanted demands
 Caretaker has insufficient ability to help
or understand

69. Invalidating responses -
examples
- rejects self-description as inaccurate
- rejects response to events as incorrect or
ineffective
- dismiss or disregard
- directly criticize or punish
- neglect
- pathologize normal responses
- reject response as attributable to socially
unacceptable characteristic

70. Linehan Biosocial Theory
Emotion Vulnerability Pervasive History of
Invalidating Responses
Heightened Emotional Arousal
Inaccurate Expression
(maladaptive behavioral responses)
Invalidating Responses
(Fruzzetti, Shenk, & Hoffman, 2005)

71. Linehan’s Diathesis-Stress theory: Etiology
of borderline personality disorder
•Emotional dysregulation in child (diathesis) and a failure to
validate the child’s feelings by the parents (stress) leads to a
vicious cycle.
–The emotional dysregulation may be inadvertently
reinforced by parents if it becomes one of the only times the
child receives parental attention.

72. Linehan’s Theory
 Emotional invalidation:
 Emotionally vulnerable individual +
invalidating environment = BPD
 Limited opportunity to learn to label,
understand or trust own feelings
 Looks to others for how to cope
 Oscillatesbetween emotional inhibition to
gain acceptance and emotional disinhibition
to have feelings acknowledged
 Intermittent reinforcement = emotional
dysregulation

73. Consequences of Invalidation
 Heightened emotional arousal
 Cognitive and attentional dysregulation
 Emotion skill deficits
 Secondary emotions
 Emotion dysregulation
 Passivity in problem solving
 Self-invalidation
 Social and interpersonal dysregulation

74. Borderline Personality
Disorder Diagnosis – DSM-IV
A pervasive pattern of interpersonal
relationships, self-image and affects,
and marked impulsivity, beginning by
early adulthood.
 Includesat least 5 of the following
diagnostic criteria:

75. DSM IV - What is Borderline
Personality Disorder ?
• 1. frantic efforts to avoid real or imagined
abandonment.
•

76. Abandonment Issues
 The perception of impending separation or
rejection, or the loss of external structure,
can lead to profound changes in self-
image, affect, cognition, and behavior.
These individuals are very sensitive to
environmental circumstances. They
experience intense abandonment fears
and inappropriate anger even when faced
with a realistic time-limited separation or
when there are unavoidable changes in
plans, These abandonment fears are
related to an intolerance of being alone
and a need to have other people with
them. Their frantic efforts to avoid
abandonment may include impulsive
actions such as self-mutilating or suicidal
behaviors

77. Diagnostic Criteria - more
• 2. a pattern of unstable and intense
interpersonal relationships
characterized by alternating between
extremes of idealization and
devaluation

78. More……
3.. identity disturbance:
markedly and persistently
unstable self-image or sense of
self

79. Identity Disturbance?
iDEntity DisturBancE – oFtEn DEscriBED as
“splitting”
From the book I Hate You, Don't Leave Me by Jerry Kreisman, M.D.
The world of a BP, like that of a child, is split into heroes and
villains. A child emotionally, the BP cannot tolerate human
inconsistencies and ambiguities; he cannot reconcile another’s
good and bad qualities into a constant coherent understanding
of another person. At any particular moment, one is either
Good or EVIL. There is no in-between; no gray area....people
are idolized one day; totally devalued and dismissed the next.
….Splitting is intended to shield the BP from a barrage of
contradictory feelings and images and from the anxiety of
trying to reconcile those images. But splitting often achieves
the opposite effect. The sense of his own identity and the
identity of others shifts even more dramatically and frequently

80. More DSM IV Criteria:
 4. impulsivity in at least two areas
that are potentially self-damaging
(e.g., spending, sex, substance
abuse, reckless driving, binge
eating).


81. More DSM IV
5. recurrent suicidal behavior,
gestures, or threats, or self-
mutilating behavior

82. More…..
6. affective instability due to a marked
reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety
usually lasting a few hours and only
rarely more than a few days)

83. More DSM IV Criteria:
 7. chronic feelings of emptiness

84. More…..
 8. inappropriate, intense anger or
difficulty controlling anger (e.g.,
frequent displays of temper, constant
anger, recurrent physical fights)
 9. transient, stress-related paranoid
ideation or severe dissociative
symptoms

85. Miscellaneous attributes
 Bright, funny, witty
 Problems with object constancy
 Difficulty in tolerating aloneness
 Chaotic lives
 Backgrounds of abuse

86. CAUTION!
 Everyone has all these traits to a certain
extent. Especially teenagers. These traits
must be long-standing (lasting years) and
persistent. And they must be intense.
 Many people who have BPD also have other
concerns, such as depression, eating
disorders, substance abuse — even multiple
personality disorder or attention deficit
disorder. It can be difficult to isolate what is
BPD and what might be something else.

87. BPD in Adolescents vs Adults
 Problems with diagnosing BPD in
adolescents
 Pejorative
label – stigmatizing
 May end up “growing out of it”
 Symptoms less stable in teens
 Can improve with treatment

88. The Course of BPD
 Usually begins in adolescence
 80% women
 Severe, chronic
 1 in 10 suicide
 Impulsivity & emotional instability tend
to decline over time

89. Co-Morbid Disorders
 Post traumatic stress disorder
 Mood disorders
 Panic/anxiety disorders
 Substance abuse (54% of BPs have a problem
with substance abuse)
 Gender identity disorder
 Attention deficit disorder
 Eating disorders
 Multiple personality disorder
 Obsessive-compulsive disorder

90. Co-Morbid Disorders- continued
 Highest incidence of co-morbid disorders:
mood and anxiety disorders (including
PTSD) *Gunderson (2001) study
 And… problems in managing mood and
anxiety problems through dissociation,
substance abuse, eating disorders.
 90-97% of BPD met criteria for other Axis II
personality disorders (avoidant, paranoid
and dependent were highest).

91. Borderline Personality Disorder
Reorganized
 Emotional dysregulation
- affective instability
- problems with anger
 Interpersonal dysregulation
- chaotic relationships
- fears of abandonment
 Self dysregulation
- identity disturbance/difficulties
- sense of emptiness

92. Borderline Personality Disorder
Reorganized
 Behavioral dysregulation
- parasuicidal behavior
- impulsivity
 Cognitive dysregulation
- dissociative responses
- paranoid ideation

93. “Living on the Edge”
Borderline Personality Disorder
Dr. Bob Carey
Regional Support Associates

94. The Inside Perspective –
Living on the Edge as a Borderline Personality
Being a borderline feels like eternal hell. Nothing
less. Pain, anger, confusion, hurt, never knowing
how I'm gonna feel from one minute to the next.
Hurting because I hurt those who I love. Feeling
misunderstood. Analyzing everything. Nothing
gives me pleasure. Once in a great while I will get
"too happy" and then anxious because of that.
Then I self-medicate with alcohol. Then I
physically hurt myself. Then I feel guilty because
of that. Shame. Wanting to die but not being able
to kill myself because I'd feel too much guilt for
those I'd hurt, and then feeling angry about that
so I cut myself or O.D. to make all the feelings go
away.”

95. Borderline PD in the Media
 Princess Diana?

96. Pharmacotherapy
B Type 1 (Affective)
P Type 2 (Impulsive)
D
Type 3 (Aggressive)
T
y Type 4 (Dependent)
p
e Type 5 (Empty)
Psychotherapy
96

97. Common Features of Recommended
Psychotherapy for BPD
 Non-brief
 Strong therapeutic alliance
 Establishment of clear roles and
responsibilities of patient and therapist
 Active therapist
 Hierarchy of priorities

98. Common Features of Recommended
Psychotherapy for BPD
 Empathic validation + need for patient
to control behavior
 Flexibility
 Concomitant individual and group
approaches
 Boundary Setting

99. Common Features of Recommended
Psychotherapy for BPD
 Monitor self-destructive & suicidal behaviours
 Manage own intense feelings
 Promote reflection rather than impulsive
action
 Diminish splitting
 Set limits on individual’s self-destructive
behaviour and, if necessary, convey the
limitations of the therapists capacities

100. General tips for working with
people with BPD
 Regularly discuss person with your
colleagues and supervisor
 Support colleagues working with BPD
clients
 Ensure the person gets a
comprehensive assessment; identify
and manage co-morbid problems (eg.
depression)

101. General tips for working with
people with BPD
 Focus on solving non-medical problems
(eg. employment, budgeting, self care)
 Agree
among colleagues on protocols for
managing crises
 Become familiar with guidelines for
managing anger or violent behaviour
 Recognise your own limits for personal
involvement

102. Boundaries
 Howdo these individuals push the
boundaries?
 How do you respond?

103. Splitting/boundaries
 Facilitate communication among
providers
 Consider altering treatment (e.g.,
increasing support, seeking
consultation)
 Be explicit in establishing “boundaries”
 Maintain consistency
 Avoid boundary violations

104. Boundary Crossings
 Explore the meaning of the boundary
crossing
 Restate expectations about boundary
and rationale
 Employ limit-setting
 Making exceptions to the usual
boundaries may signal need for
consultation or supervision

105. The Effectiveness of Psychodynamic Therapy
and Cognitive Behavior Therapy in the
Treatment of Personality Disorders: A Meta-
Analysis
 Both psychodynamic therapy and cognitive
behavior therapy are effective treatments of
personality disorders
 For psychodynamic therapy, the effect sizes
indicate long-term rather than short-term
change in personality disorders (mean follow-
up period = 1.5 years [78 weeks] vs CBT
mean follow-up = 13 weeks)
lEichsEnring F, lEiBing E, am J
psychiatry 2003; 160:1223-1232

106. Hierarchy of Priorities in Therapeutic Sessions
Dialectical Behavior Therapy Psychoanalytic/Psychodynamic Therapies
(Linehan 1993) (Kernberg et al. 1989; Clarkin et al. 1999)
Suicide or homicide threats
Suicidal behaviors
Overt threats to treatment continuity
Therapy-interfering Dishonesty or deliberate withholding
behaviors
Contract breaches
Behaviors quality-of-life In-session acting out
interfering
Between-session acting out
Non-affective or trivial themes

107. thanK you