Contents

Search

borderline personality disorder

Etiology: 1) unknown 2) psychodynamic theories a) excessive aggression 1] unstable identity development 2] unstable development of affective tolerance b) maternal withdrawal 1] incomplete differentiation of child from mother 2] dual & inconsistent image of mother a] rewarding & gratifying in response to dependency b] punitive & withdrawing in response to autonomy 3] child rejects attention to reality to maintain relationship to mother c) introjective failure - child's failure to internalize sense of self 3) biogenetic theories a) affective dysregulation 1] inability to modulate emotional responses to environmental events a] easy to enrage b] quickly to sadness 2] secondary defect in brain catecholamine metabolism b) neurological dysfunction 1] genetic predisposition or early organic insult 2] low threshold for activation of limbic structures Epidemiology: - 6% of primary care patients Pathology: - disconnection of cortical inhibition of amygdala may correlate with impulsive aggression & emotional lability [2] Clinical manifestations: 1) features must be present since young adulthood to meet criteria for personality disorder [2] 2) emotional dysregulation - frantic efforts to avoid real or imagined abandonment 3) a pattern of unstable & intense interpersonal relationships characterized by alternations between extremes of idealization & devaluation 4) identity disturbance: persistent & markedly disturbed, distorted or unstable image or sense of self 5) impulsivity in at least 2 areas that are potentially self damaging; i.e financial affairs, sex, substance abuse, reckless driving, binge eating 6) feelings of depression: recurrent suicidal behaviors, gestures of threats or self-mutilating behavior (episodes may be short) 7) feelings of emptiness (episodes may be short) 8) affective instability due to a marked reactivity of mood (i.e. intense episodic dysphoria, irritability, or anxiety usually lasting only a few hours, rarely more than a few days) 9) inappropriate, intense anger or lack of control of anger; i.e. frequent displays of temper, constant anger, recurrent physical fights 10) transient, stress-related paranoid ideation or severe dissociative symptoms 11) no changes in sleep or appetite [4] 12) complaints about other health care providers, but you are different [3] Differential diagnosis: 1) may co-occur with mood disorder - distinguishing features of borderline personality disorder - volatile interpersonal relationships - episodes of intense anger [4] - attributes problems to others - complains about healthcare providers 2) histrionic personality disorder a) histrionic patients exhibit more pure attention-seeking behavior & more superficial behavior b) histrionic personality disorder not associated with difficulty in regulating anger c) borderline patients exhibit 1] self-destructiveness 2] angry disruptions in close relationships 3] chronic feelings of deep emptiness & loneliness 3) schizotypal personality disorder - common symptoms of paranoia & illusions are more transient, interpersonally reactive & responsive to external structuring in borderline personality disorder 4) paranoid personality disorder a) relative stability of self-image b) lack of self destructiveness c) lack of impulsivity d) lack of abandonment concerns 5) narcissistic personality disorder a) relative stability of self-image b) lack of self destructiveness c) lack of impulsivity d) lack of abandonment concerns 6) antisocial personality disorder - common symptom of manipulative behavior 1] antisocial behavior - more likely for material gratification, power or profit 2] borderline personality disorder - more likely to gain nurturance 7) episodic dyscontrol syndrome; intermittent explosive disorder - failure to control aggressive impulses [7] Management: 1) refer to psychiatrist [3] 2) psychodynamic psychotherapy a) establish secure attachment & trusting alliance with patient to establish sense of safety b) provide stable treatment framework with clear patient- physician boundaries, schedules, rules & fairness c) therapist must actively identify, confront, & direct the patient's behaviors & establish connection between actions & feeling d) set limits on behaviors that threaten safety of the patient or therapist or the continuation of therapy e) make self-destructive behaviors ungratifying 3) supportive psychotherapy a) improve patient's adaptation to life circumstances b) diminish self-destructive responses to interpersonal conflicts 4) cognitive therapy a) develop a collaborative relationship with specific goals b) select initial goals or target areas c) minimize non compliance through adherence to treatment framework d) make patient aware of dichotomous thinking 1] review experience along a continuum rather than right or wrong behavior 2] work to decrease dichotomous thinking e) increase control over emotions f) improve impulse control g) strengthen sense of identity h) develop alternate nondestructive strategies to treat sense of emptiness & abandonment 5) dialectical behavior therapy a) group focuses on behavioral coping skills b) individual focuses on 6 hierarchically set goals 1] suicidal behaviors 2] therapy-interfering behaviors 3] behaviors that interfere with quality of life 4] behavioral skill acquisition 5] post-traumatic stress behavior 6] self-respect behavior 6) group therapy a) peers confront maladaptive & impuse patterns without being perceived as controlling to the patient b) dependent of maladaptive gratifications are more easily made undesirable c) group demonstrates a number of different coping methods d) network of support 7) pharmacotherapy for mood & anxiety-related symptoms a) selective serotonin re-uptake inhibitors (SSRI) b) tricyclic antidepressants (TCA) c) monoamine oxidase (MAO) inhibitors d) lithium carbonate: control of angry impulses e) anticonvulsants: control of angry impulses f) neuroleptics (low dose) - effects in reducing depression, anxiety, hostility, psychotic-like symptoms (depersonalization, dereali- zation, illusions, ideas of reference) g) anxiolytics 7) follow-up a) sustained long-term psychotherapy for 3-5 years b) compliance c) monitor effectiveness & judge side effects of pharmacotherapy

General

cluster B personality disorder

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1101-1102
  2. New AS Amygdala-prefrontal disconnection in borderline personality disorder Neuropsychopharmacology 2007, 32:1629 PMID: 17203018
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17. American College of Physicians, Philadelphia 2006, 2012, 2015
  4. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  5. Gunderson JG. Clinical practice. Borderline personality disorder. N Engl J Med. 2011 May 26;364(21):2037-42. Review. PMID: 21612472
  6. Stevenson J, Meares R, Comerford A. Diminished impulsivity in older patients with borderline personality disorder. Am J Psychiatry. 2003 Jan;160(1):165-6. PMID: 12505816
  7. NEJM Knowledge+ Psychiatry
  8. Borderline Personality Disorder http://www.nimh.nih.gov/publicat/bpd.cfm