Lecture 1 - Introduction, Personality Disorders, BPD
Personality = pattern of perceiving, relating to and thinking about the environment and oneself that are exhibited in a
wide range of social and personal contexts; enduring
Personality disorder = deviates from the expectations of an individual’s culture, pervasive and inflexible, has onset in
adolescence and early adulthood, stable over time, leads to clinically significant distress or impairment in social,
occupational, or other areas of functioning - Pervasive, Persistent, Pathological
- Exclusion Criteria: Not a manifestation of another mental disorder, nor attributable to physiological effects of a
substance or another medical condition
- Handbook published just before DSM5, PDs from 4 were retained; the alternative model was not published in
the DSM5, but included in the appendix; dimensional model is still relevant
DSM decision making:
- Empirical evidence
- Validity and clinical utility of diagnosis
- Is the syndrome separate from other syndromes and normality?
, - Conceptual evidence- clinical descr, demographic characteristics
- Antecedental evidence - precipitate PD
- Concurrent evidence (tests
- Predictive evidence
- Neuroscientific evidence
PD criteria DSM5
- Diagnostic features
- Associated features supporting diagnosis
- Prevalence
- Development and course
- Risk and prognostic factors
- Culture related diagnostic issues
- Differential diagnosis
dSm 4 to 5
- Deletion of multi axial system
- Minor textual changes of criteria
- Proposed changes
- (did not follow through, part of alternative model
- Deletion of diagnoses - histrionic, narcissistic, dependent, paranoid and schizoid PD
- To reduce the high level of PD co occurrence and proposed, relative lack of evidence (not
because underlying traits dont exist
- Reformulating PDs as early onset Axis1 disorders where possible, removal of others
- Partly due to stigma of being untreatable for PDs
Chapter 20: Borderline Personality Disorder
- Cluster B
- Little understood
Clinical Aspects
- Historical Origins
- Borderline 70 years ago = hypersensitive, problems with reality testing, negative reactions to therapy -
borderline = between psychoses (loss of touch with reality) and neuroses (chronic distress) (stern 1938)
, - “Pseudoneurotic schizophrenia” = problems with psychoanalytically defined ego functions, primitive
thought processes Kernberg smth smth fill this out
- 60s: more research on Borderline - GUnderson and Singer (1975) identified: intense affect, impulsivity,
relationship problems, brief psychotic experiences ⇒ differentiated from schizotypal personality disorder
→ included in DSM3;
- Now it is well researched but name still provides no important info, strongly associated with
psychoanalysis → “emotionally unstable disorder”
- Clinical Description
- 9 symptoms:
- 1. Frantic efforts to avoid abandonment
- 2. Unstable and intense relationships - swinging between idealization and devaluation
- 3. Identity disturbance - persistently unstable sense of self
- 4. Impulsivity in at least 2 areas that are self damaging
- 5. Recurrent suicidal behavior
- 6. Affective instability due to a marker reactivity of mood
- 7. Chronic emptiness
- 8. Inappropriate or intense anger
- 9. Transient paranoid ideation or dissociation (potentially stress related)
- 5 required for diagnosis → very heterogenous disorder (many combinations)
- “Stbaly unstable”- instability manifested in emotion, self concept, relationships and behavior - rapidly
changing emotions that are intense and unpredictable , difficult to control, creates tense relationships
- Negative affect due to negative interpersonal events, sensitive to the behavior of others, lack of stable
representations of other people
- Afraid of both abandonment and too much attachment → sabotaging relationships to test their
strength, any contradiction proves that the relationship is not safe enough
- Struggle with sense of self - don’t know who they really are
- Behavior: angry outbursts, impulsive, self damaging - drugs, spending sprees, driving recklessly, risky
sexual behavior , gambling, eating binges, suicidality, self harm
- “transient, stress-related paranoid ideation or severe dissociative symptoms”
- More stress overall, high stress → dissociation or stress related psychosis, more stress reactive and
more psychotiv in reaction to stress
- Comorbidity
- Super high rates - more often have Axis 1 pathology than normal controls; most often, MDD, then PTSD,
BD, ED
- But people recruited from clinical settings with BPD have more severe and deadly BPD symptoms and
more severe comorbid disorders
- High functioning BPD prevalent in community samples - less likely to suffer from comorbid Axis 1
disorders → people with high comorbidity and BPD more likely to search help because of debilitating
Axis 1 conditions
- Distinct Diagnosis?
- Large overlap with mood disorders - is it just very bad depression? Not rlly
- Diff pattern of neural activity from dysthymia, so not just a chronic mood disorder
- It s not PTSD variant either
- In DSM 5
- Was to be diagnosed by matching patients to narrative prototypes, but that was discarded as it wouldve
discontinued the definition of BPD on which research is based
- New criterion: impairments in self and interpersonal relatedness + 7 traits (emo lability, anxiousness,
separation insecurity, depressivity, impulsivity, risk taking, hostility)
- No evidence for categorical entity - better as dimensional concept, advised to move to Axis 1 from Axis 2
- Epidemiology
- 10-15% prevalence in outpatient samples, but data from clinical samples cannot be used to estimate
actual prevalence
, - Prevalence assessment done by lay people - over or under estimation possible
- Reasonably, in general population 1-2%
- 6% lifetime prevalence
- Men-women 50/50, but not in psychiatric samples (1:3)
- Higher in younger individuals
- Small associations to living status
- Highly relate to poor functioning & QoL, and attendance psychiatric facilities
- Sex Differences
- Women more likely to seek treatment - ovrestimation, no actual sex differences
- Less prevalent in older age due to successful suicide rate (and treatment and such)
- Suicide
- BPD = major risk factor
- More suicide attempts on avg than in normal population, high risk of death from suicide, before 40 yo
- Identifying who is most at risk - difficult
- Affective instability + intensity of negative mood + poor psychosocial adjustment
- Abuse history, depressed mood, hopelessness, impulsivity and aggression not correlated with
suicide
- ⅓ BPD pateints attempt sicide, 10% mortality before 40
- Self injuring alleviates overwhelming negative emotions
- Self injure as a form of self directed anger or self punishment
- Also maybe to influence others or produce a physical sign of emotional distress, avoid others or die
- Categorical vs dimensional model
- Presence or absence - categorical (DSM)
- Dimensional - rank or continuous quantitative dimensions
- Big 5 and BPD
- High N (all facets) , Low A (trust, compliance and morality
- High on fantasy (O), low on liberalism (O/C)
- Comorbidity especially high in clinical BPD patients
- Mood disorders, eating disorders, substance abuse, other PDs
- Course and prognosis
- BPD = high consumer of psychiatric services, but maintaining clinical relationship is difficult, common to
terminate treatment prematurely
- But if they keep up treatment, high changes of reduction of symptoms and clinical remission for a few
years - young age, lack of childhood sexual abuse and lack of family substance abuse history helps
- Good recent work history, agreeable temperament, low neuroticism and lack of anxious personality also
helps
- But.
- Recurrence os symptoms common within 10 years
- Clinical remission does not mean no psychosocial problems
- 4.4% suicide death rate
- Only 50% recovered from diagnosis and had good social and vocational functioning
- Family environment: Expressed emotion (EE) linked to relapse and poor clinical outcomes, but not in
BPD; Emotional OverInvolvement associated with better outcomes (concern, anxiety, self-sacrificing and
overprotective attitudes and behaviors toward the patient)
- EOI is beneficial because BPD has higher left PF cortex when hearing EOI comments → positive
experiences and approach motivation (even though reported experience of EOI is negative
- Etiology and Risk Factors
- Genes and environment are intertwined; the clinical diagnosis of BPD reflects a broad range of
phenotypes that are the end products of unique influences and developmental trajectories
- Genetic Aspects
- BPD runs in families, but family studies pose a lot of methodological problems - more likely to
have BPD if a relative has it
Personality = pattern of perceiving, relating to and thinking about the environment and oneself that are exhibited in a
wide range of social and personal contexts; enduring
Personality disorder = deviates from the expectations of an individual’s culture, pervasive and inflexible, has onset in
adolescence and early adulthood, stable over time, leads to clinically significant distress or impairment in social,
occupational, or other areas of functioning - Pervasive, Persistent, Pathological
- Exclusion Criteria: Not a manifestation of another mental disorder, nor attributable to physiological effects of a
substance or another medical condition
- Handbook published just before DSM5, PDs from 4 were retained; the alternative model was not published in
the DSM5, but included in the appendix; dimensional model is still relevant
DSM decision making:
- Empirical evidence
- Validity and clinical utility of diagnosis
- Is the syndrome separate from other syndromes and normality?
, - Conceptual evidence- clinical descr, demographic characteristics
- Antecedental evidence - precipitate PD
- Concurrent evidence (tests
- Predictive evidence
- Neuroscientific evidence
PD criteria DSM5
- Diagnostic features
- Associated features supporting diagnosis
- Prevalence
- Development and course
- Risk and prognostic factors
- Culture related diagnostic issues
- Differential diagnosis
dSm 4 to 5
- Deletion of multi axial system
- Minor textual changes of criteria
- Proposed changes
- (did not follow through, part of alternative model
- Deletion of diagnoses - histrionic, narcissistic, dependent, paranoid and schizoid PD
- To reduce the high level of PD co occurrence and proposed, relative lack of evidence (not
because underlying traits dont exist
- Reformulating PDs as early onset Axis1 disorders where possible, removal of others
- Partly due to stigma of being untreatable for PDs
Chapter 20: Borderline Personality Disorder
- Cluster B
- Little understood
Clinical Aspects
- Historical Origins
- Borderline 70 years ago = hypersensitive, problems with reality testing, negative reactions to therapy -
borderline = between psychoses (loss of touch with reality) and neuroses (chronic distress) (stern 1938)
, - “Pseudoneurotic schizophrenia” = problems with psychoanalytically defined ego functions, primitive
thought processes Kernberg smth smth fill this out
- 60s: more research on Borderline - GUnderson and Singer (1975) identified: intense affect, impulsivity,
relationship problems, brief psychotic experiences ⇒ differentiated from schizotypal personality disorder
→ included in DSM3;
- Now it is well researched but name still provides no important info, strongly associated with
psychoanalysis → “emotionally unstable disorder”
- Clinical Description
- 9 symptoms:
- 1. Frantic efforts to avoid abandonment
- 2. Unstable and intense relationships - swinging between idealization and devaluation
- 3. Identity disturbance - persistently unstable sense of self
- 4. Impulsivity in at least 2 areas that are self damaging
- 5. Recurrent suicidal behavior
- 6. Affective instability due to a marker reactivity of mood
- 7. Chronic emptiness
- 8. Inappropriate or intense anger
- 9. Transient paranoid ideation or dissociation (potentially stress related)
- 5 required for diagnosis → very heterogenous disorder (many combinations)
- “Stbaly unstable”- instability manifested in emotion, self concept, relationships and behavior - rapidly
changing emotions that are intense and unpredictable , difficult to control, creates tense relationships
- Negative affect due to negative interpersonal events, sensitive to the behavior of others, lack of stable
representations of other people
- Afraid of both abandonment and too much attachment → sabotaging relationships to test their
strength, any contradiction proves that the relationship is not safe enough
- Struggle with sense of self - don’t know who they really are
- Behavior: angry outbursts, impulsive, self damaging - drugs, spending sprees, driving recklessly, risky
sexual behavior , gambling, eating binges, suicidality, self harm
- “transient, stress-related paranoid ideation or severe dissociative symptoms”
- More stress overall, high stress → dissociation or stress related psychosis, more stress reactive and
more psychotiv in reaction to stress
- Comorbidity
- Super high rates - more often have Axis 1 pathology than normal controls; most often, MDD, then PTSD,
BD, ED
- But people recruited from clinical settings with BPD have more severe and deadly BPD symptoms and
more severe comorbid disorders
- High functioning BPD prevalent in community samples - less likely to suffer from comorbid Axis 1
disorders → people with high comorbidity and BPD more likely to search help because of debilitating
Axis 1 conditions
- Distinct Diagnosis?
- Large overlap with mood disorders - is it just very bad depression? Not rlly
- Diff pattern of neural activity from dysthymia, so not just a chronic mood disorder
- It s not PTSD variant either
- In DSM 5
- Was to be diagnosed by matching patients to narrative prototypes, but that was discarded as it wouldve
discontinued the definition of BPD on which research is based
- New criterion: impairments in self and interpersonal relatedness + 7 traits (emo lability, anxiousness,
separation insecurity, depressivity, impulsivity, risk taking, hostility)
- No evidence for categorical entity - better as dimensional concept, advised to move to Axis 1 from Axis 2
- Epidemiology
- 10-15% prevalence in outpatient samples, but data from clinical samples cannot be used to estimate
actual prevalence
, - Prevalence assessment done by lay people - over or under estimation possible
- Reasonably, in general population 1-2%
- 6% lifetime prevalence
- Men-women 50/50, but not in psychiatric samples (1:3)
- Higher in younger individuals
- Small associations to living status
- Highly relate to poor functioning & QoL, and attendance psychiatric facilities
- Sex Differences
- Women more likely to seek treatment - ovrestimation, no actual sex differences
- Less prevalent in older age due to successful suicide rate (and treatment and such)
- Suicide
- BPD = major risk factor
- More suicide attempts on avg than in normal population, high risk of death from suicide, before 40 yo
- Identifying who is most at risk - difficult
- Affective instability + intensity of negative mood + poor psychosocial adjustment
- Abuse history, depressed mood, hopelessness, impulsivity and aggression not correlated with
suicide
- ⅓ BPD pateints attempt sicide, 10% mortality before 40
- Self injuring alleviates overwhelming negative emotions
- Self injure as a form of self directed anger or self punishment
- Also maybe to influence others or produce a physical sign of emotional distress, avoid others or die
- Categorical vs dimensional model
- Presence or absence - categorical (DSM)
- Dimensional - rank or continuous quantitative dimensions
- Big 5 and BPD
- High N (all facets) , Low A (trust, compliance and morality
- High on fantasy (O), low on liberalism (O/C)
- Comorbidity especially high in clinical BPD patients
- Mood disorders, eating disorders, substance abuse, other PDs
- Course and prognosis
- BPD = high consumer of psychiatric services, but maintaining clinical relationship is difficult, common to
terminate treatment prematurely
- But if they keep up treatment, high changes of reduction of symptoms and clinical remission for a few
years - young age, lack of childhood sexual abuse and lack of family substance abuse history helps
- Good recent work history, agreeable temperament, low neuroticism and lack of anxious personality also
helps
- But.
- Recurrence os symptoms common within 10 years
- Clinical remission does not mean no psychosocial problems
- 4.4% suicide death rate
- Only 50% recovered from diagnosis and had good social and vocational functioning
- Family environment: Expressed emotion (EE) linked to relapse and poor clinical outcomes, but not in
BPD; Emotional OverInvolvement associated with better outcomes (concern, anxiety, self-sacrificing and
overprotective attitudes and behaviors toward the patient)
- EOI is beneficial because BPD has higher left PF cortex when hearing EOI comments → positive
experiences and approach motivation (even though reported experience of EOI is negative
- Etiology and Risk Factors
- Genes and environment are intertwined; the clinical diagnosis of BPD reflects a broad range of
phenotypes that are the end products of unique influences and developmental trajectories
- Genetic Aspects
- BPD runs in families, but family studies pose a lot of methodological problems - more likely to
have BPD if a relative has it
