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Borderline Personality Disorder

Towards Understanding and Compassionate Care

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

What is BPD?
Complex and Often Misunderstood a pervasive pattern of instability of interpersonal relationships, selfimage, and affects, and marked by impulsivity beginning by early adulthood and present in a variety of contexts Diagnostic Criterion (DSM-IV-TR)
Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation Identity disturbance: markedly and persistently unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging (i.e., spending, sex, substance abuse, reckless driving, binge eating), excluding suicidal or self-mutilating behavior Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; 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) Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights); and Transient, stress-related paranoid ideation or severe dissociative symptoms.

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Prevalence
In 2008, the first-ever large-scale, community study of personality disorders found a lifetime prevalence of 5.9 percent (18 million people) for BPD, with no significant difference in the rate of prevalence in men (5.6 percent) compared with women (6.2 percent). The authors concluded BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. 10-20% of clients
DSM:1-2%; 3:1 Women

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Statistics
Nine criteria, five required for a diagnosis
256 possible combinations that could lead to dx

Presents as early as tween years 40-70% report childhood sexual abuse High co-occurrence of Axis I d/o
MDD 41-83% Panic D/O 31-48% Eating D/O 29-53% Social Phobia 23-47% OCD 16-25% BD 10-20% Less than 10% PTSD

Axis II APD 43-47% DPD 16-51% PPD 14-30% 70% attempt suicide, 10% complete Other self harm 60-80%

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Challenges
Patients with borderline personality disorder (BPD) . can challenge even the most experienced therapists. The most frightening symptoms of BPD are chronic suicidal ideation, repeated suicide attempts, and self-mutilation. All too frequently, BPD is diagnosed as major depression or bipolar disorder Patients with BPD are often mistreated.
Receive prescriptions for multiple drugs that provide only marginal benefit. Clients do not always get the evidence-based psychotherapy they need

Symptoms contribute to unstable and stormy interpersonal relationships, ALSO to the therapeutic relationship

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Hope and Dismay


Up to three-quarters of individuals diagnosed with BPD will experience measurable improvement with treatment
Many of the most debilitating and high-risk symptoms abate significantly

Still face discrimination and bias


Labeled as difficult, emotionally draining Further rejected (even by professionals)

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Bipolar Disorder
Bipolar disorder causes dramatic mood swings, from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression. An episode lasts at least a week. A cycle is the period of time it takes for a person to go through one episode of mania and one of depression. The frequency and duration of these cycles vary from person to person, from once every five years to once every three months.
People with a subtype of bipolar (rapid-cycling bipolar) may cycle more quickly, but much less quickly than people with BPD (shifts can even last minutes/seconds).
Manic Episode (Mania) is a distinct period during which there is an abnormally and constantly elevated, expansive, or irritable mood, lasting at least 1 week. Hypomanic Episode (Hypomania) is a milder form of mania that lasts at least 4 days. Major Depressive Episode (Depression) is a period during which there is either depressed mood or the loss of interest or pleasure in nearly all activities, lasting for at least 2 weeks. Mixed Episode is a period of time during which a person experiences both manic and major depressive symptoms nearly every day for at least 1 week.

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Differentiating BPD from BD


People with BPD cycle much more quickly, often several times a day. The moods in people with BPD are more dependent, either positively or negatively, on what's going on in their life at the moment. Anything that might seem like abandonment (however far fetched) is a major trigger. Bipolar mood shifts occur independent of what is going on in the environment. In people with BPD, the mood swings are more distinct. While people with bipolar disorder swing between all-encompassing periods of mania and major depression, the mood swings typical in BPD are more specific. "You have fear going up and down, sadness going up and down, anger up and down, disgust up and down, and love up and down. Dichotomous thinking (splitting) is not a symptom of BD.
I feel like I have to walk on eggshells around him/her!
Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Clinical Measures for Diagnoses


Personality lnterview Questionnaire ll (PlQ ll) Personality lnterview Questionnaire ll (PlQ) Borderline Personality Disorder Scale (BPD Scale) Personality Diagnostic Questionnaire 4th Edition (PDO4) Million Clinical Multi-axial lnventory lll (MCMI-lll) Wisconsin Personality Disorders lnventory (WISPI) Schedule for Normal and Abnormal Personality (SNAP) Structured Clinical Interview for DSM-IV Axis ll Personality Disorders (SCID-ll) Diagnostic lnterview for Borderlines-Revised (DlB-R) International Personality Disorders Examination (IPDE)

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Ego Strength and Functioning


Ego strength refers to the degree of emotional durability and adaptability a person exhibits. Graded on four scales:
(T) Thought processes (R) Reality Testing (D) Defenses (C) Control of Emotions and Impulses

1
Psychotic
1-2 T: Delusions R: Confusion, hallucinations D: Marginal C: Marked emotional dyscontrol

3
Borderline

5
Neurotic

7
Healthy, Adaptive

2-4 T: Impulsive, Magical R: misreading social cues D: Splitting, acting out, impaired C: Out of control or fragile overcontrol; Suicidal, Homicidal, Selfmutilating behaviors

4-6 T: No critical thinking, dichotomous R: Impaired re: relationships or strong emotions D: Overly defensive C: Impaired, diminished coping

6-7 T: Logical, realistic thinking R: Intact reality testing D: Defenses employed only during times of intense stress C: Appropriate, health emotional expression

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

Emotional Tolerance and Mindstates

Emotion Mind

Wise Mind

Reason Mind

Dyscontrol

Emotional Tolerance

Overcontrol

Ken Murray, Department of Social Work, murrayk@apsu.edu, 931-980-9496

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