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Borderline Personality Disorder

I. Borderline Personality Disorder

A. Clinical Description: DSMIV Diagnostic Criteria

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or serf-mutilating behavior covered in Criterion 5.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of anger, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms, border line personality

B. Etiology: Developmental Theories

1. Most theories postulate disturbed early parent-child relationships.

2. Proposed theories are not mutually exclusive.

3. Etiology is probably multi-determined.

4. Recent data on relationship of Borderline Personality Disorder to Post-traumatic Stress Disorder (PTSD). The timing of abuse may be later than previously suspected (eg, sexual and/or physical abuse in latency and/or adolescence).

5. Theory that Borderline Personality is PTSD incorporated into personality structure.

6. Biological

a. Temperamental/constitutional factor

i. Excessive aggression

ii. Low anxiety tolerance

b. Limbic instability: low threshold for excitability of limbic system

c. Possible relationship with Attention Deficit Hyperactivity Disorder (ADHD) and learning disorders

d. Possible deficient central serotonin metabolism associated with impulsive and hostile behavior. This might explain the association between Borderline Personality Disorder, mood and conduct disorders.

e. Self-mutilation and borderline personality may be response to early physical trauma and separation. ? endorphins or other biological changes results in dissociative or analgesic states.

7. Familial

a. Cluster of personality disorders: Antisocial, Narcissistic, Histrionic, and Borderline

b. Increased frequency of early parental losses and/or traumatic separations

c. Increased frequency of familial violence, incest and alcoholism

d. Parental psychopathology: mother often erratic, depressed; father often absent or character disordered

e. Hostile and conflictual parental relationship

f. History of physical and sexual abuse

g. Family/systems process: The role of projective identification - why one child becomes Borderline versus another. Also, given vulnerable temperamental features, environmental stressors may account for a Borderline child. (The nature versus nuture controversy may be an artificial construct.)

8. Interpersonal (reliance on Winnicott, object relations theory and self-psychology)

a. Deficits in normal separation-individuation

i. Role of the child: 

-Cognitive advances: 1+ 1 = 1

-Tolerance of ambivalence + primitive guilt

-Use of transitional objects and evocative memory 

-Developing capacity for concern and ability to take responsibility for impulses, actions, and instinctual drives 

-Problems with excessive aggression or other biological factors

ii. Role of the parent:

- "Holding environment:" allows separation, remains attuned and available, survives rage, receives reparation, does not retaliate, does not deal with separation as a betrayal nor with engulfment

- "Good enough mother:" mistakes are' inevitable, necessity of failures, mending empathic failures

- Process: new found ability to see that all people have limitations, imperfections, and yield disappointments, yet this can be managed. All this faith in others, tendency to self-blame.

iii. Developmental failures result in:

- Interpersonal distrust

- Inability to view others as whole objects (good and bad)

- Intense anxiety and primitive guilt - use of denial and splitting to preserve and protect the "good" object

- Deficient evocative memory and resultant inability to soothe self when alone

- Impaired empathy and capacity for concern

- Low self-esteem

- Pathological defenses: splitting, idealization, devaluation, denial, projection, projective identification - inability to take responsibility for one's feelings, thoughts, and actions

b. Deficits in parental function in self-formation

i. Deficient attention, admiration, validation

ii. Devaluation, abuse, neglect

c. Problems in goodness of fit: parent-child problem (chick and the egg problem)

d. Parental psychopathology

i. Poor role models

ii. Marital conflict

iii. Abuse and neglect

C. psychodynamics

1. Fears of abandonment and feelings of aloneness

2. Search for all-nurturing and protecting object

3. Chronic failure/disappointment in relationships resulting in regression

4. Regressions: dissolution of evocative memory, transient psychotic thinking, primitive defenses, feelings of rage, guilt, worthlessness, envy, feelings of aloneness, abandonment

5. Infantile entitlement, feeling victimized by dangerous/hostile world. Rage, resulting in overwhelming affect and acting out.

6. Ego strengths (when not regressed): social adaptability, intact reality testing, some higher neurotic defenses

7. Importance of realizing there is an adaptive reserve during emergency intervention.

II. Common Emergency Presentations

A. Crisis of Aloneness

B. Common Precipitants

1. Changes in psychotherapy, eg, vacations, changes in time, fees, medications

2. Interpersonal turmoil

3. Major life events

C. Attitude Toward Hospital Staff

1. Idealization

2. Devaluation

D. Diagnostic Dilemmas: The Great Imitator

III. Roll of Emergency Department Service Environment

A. Organization: Rapid Assessment and Management

B. Problems for Psychiatric Assessment

1. Impact of setting in assessment

2. Charged atmosphere

3. Public history taking, high technology, proximity to serious injury and death, impersonal atmosphere, long waits

4. Inadequate facilities

5. Negative attitudes of staff towards psychiatrists and psychiatric patients

6. Danger of acting out negative feelings on patients

C. Problems for the Borderline Patients

1. Frustration in search for "total" care

2. Action oriented EW fantasy (and dread) or really being taken care of (and possibly engulfed)

3. Minor delays and routine questions = staff's indifference and hostility feelings of victimization and regression/retaliation

4. Staff's insistence that the psychiatrist "take responsibility for the patient" regression and helplessness acting out, restraints, need for medicating, etc.

5. Patients may provoke staff negative countertransference response confirming sense of rejection and/or justified rage and primitive entitlement

D. Meaning of the Environment

1. Institutional transference

IV. Emergency Evaluation

A. Principles of Assessment

1. Need for complete but rapid assessment

2. Differential diagnosis

3. Level of ego functioning, object relations

4. Use of countertransference in diagnostic process

B. Technique and Data Collection

1. Minimize wasting time

2. Evaluate the setting

a. Safety

b. Out of "limelight"

c Comfort level of both patient and clinician

3. use therapeutic maneuvers throughout interview

4. Determine overt or covert request: "How would you hope I could help you?' vs. "Why did you come here?"

5. Elicit precipitating event: usually perceived interpersonal conflict

6. Medical history: illnesses, hospitalizations, use of drugs and alcohol

7. Past psychiatric history: suicide attempts (death rate by suicide is 8-10% of borderline patients), impulsive behavior, previous and current therapy (in detail)

8. family psychiatric history: psychosis, depression, suicide, alcoholism

9. Social history: current support systems (see ego functioning)

10. Mental status exam:

a. Appearance and behavior: highly variable

b. Mood and affect: labile, intense, ranging from depression to anger

c. Cognition: intact

d. Thought form: possible transient psychosis

e. Thought content: themes of abandonment, victimization, aloneness, worthlessness

C. Differential Diagnosis

1. Mood disorder: depression, mania, dysthymic, cyclothymic disorder

2. Substance use disorders

3. Comorbid personality disorders or traits, e.g., narcissistic,  antisocial

4. Schizophrenia

5. Anxiety/panic disorder

6. Temporal lobe epilepsy

7. Regression in higher level personality/other character disorder

8. Physical disorders: none specifically associated with borderline personality. But, consider unstable, regressive behavior in endocrine, metabolic, autoimmune, CNS disorders. Also effects on psychosocial development of chronic disabling conditions, eg, juvenile diabetes mellitus, asthma, etc.

D. Ego Functioning

1. Past and current interpersonal relationships, support systems

2. Work history

3. Ability to tolerate aloneness, anxiety, depression, disappointment

4. Self-destructive or impulsive behavior

E. Counter transference Responses

1. Hate (aversion and malice)

2. Rage

3. Repugnancy, disgust

4. Helplessness

5. Impulses to rescue

6. "Special" patient

7. Countertransference responses are useful diagnostic tools (responses to splitting, idealization, devaluation, projective identification) and help avoid intrusive uncovering interviewing techniques

V. Principles of Management

A. Psychotherapeutic Intervention

1. Absence of working alliance: error to use uncovering techniques. Distinction between psychotherapy and emergency evaluation and management

2. Support adaptive defenses

3. No interpretation

4. Provide emergency "holding environment"

5. Foster emergency collaboration

6. Focus on three areas: empathic reassurance, crisis-intervention, education

7. Successful outcome: not symptom removal or patient satisfaction, but transient psychic stabilization and arrangement for follow-up

B. Empathic Reassurance

1. Empathic comments addressing psychodynamic themes

2. Danger: fostering omnipotent/omniscient fantasies about clinician

3. Solution: emphasize real relationship and its limitations (ie reality test)

4. Be aware of countertransference responses

5. Empathic reassurance: in tune with patients affective predicament, need for assistance to control regression. Requires empathy, reality testing and collaborative problem solving.

C. Crisis Intervention

1. Goals: thwart regression; ally with adaptive ego functions

2. Finn limits (in order to feel safe):

a. Proscriptions against assaultive/self-destructive behavior

b. Prescription that understanding requires words

c. No immediate "cures." Acknowledge deserving immediate care but, while hopes are understandable, some demands cannot be met.

d. De-emphasize immediate symptom removal and provide hope for future improvement as an outpatient. Avoid false promises for radical changes in life regression and pessimism

3. Technique: principles

a. Ally with higher level defenses

b. observing ego capacities

c. Discuss reality of crisis and limitations of immediate resources

d. Do not tamper with defensive structure: although it is pathological, it has adaptive significance. Stripping it helplessness

4. Technique: practice

a. Structured, common sense dialogue 

b. Interviewer activity: avoid silences c. Elicit collaboration: patient assuming responsibility regression and infantile wishes

d. use transitional objects: contracts, appointment slips, etc.

e inquire about sexual and/or physical abuse, especially for adolescents

D. Education

1. Discuss risks and potential benefits of psychotherapy 

2. For patient in therapy: help appraise impasse/crisis 

3. Counter unwarranted emergency visits/calls

E. Pharmacologic

1. Relatively few studies: no established methods for emergency use

2. Rule: medications should be used in context of ongoing therapy, not in emergency situations

3. Emergency uses of medications: to control severe anxiety, psychosis, violent behavior

4. Beware of benzodiazepines for outpatient use: may be used with other drugs and/or alcohol in future suicidal gestures. May cause paradoxical excitement or disinhibition

5. Value of low-dose antipsychotics and/or benzodiazepines for acute agitation

6. Acute agitation

a. Lorazepam 1-2 mg. PO or IM initially, then 1 mg every 30-60 minutes until sedation is achieved

b. Second line: Haloperidol 2-5 my. IM. Can be repeated every 20-30 minutes, if needed.

7. Patients with episodic dyscontrol

a. Impending loss of control, rapidly absorbed benzodiazepine such as Diazepam or Lorazepam useful

b. If violence seems near, IM or IV Lorazepam is better choice.

c. If history of CNS depressant abuse or benzodiazepine-induced disinhibition, Haloperidol 5 rag. IM could be used.

d. Although recent literature (see below) suggests that Lithium, Carbamazepine, serotonergic antidepressants (eg, Fluoxetine) and beta-adrenergic blockers (eg Propranolol) may be effective long-term, they are not effective acutely.

8. Patients with affective lability, anger or psychotic symptoms without marked agitation

a. Low doses of high-potency neuroleptics, eg, Haloperidol 1-2 mg. PO or IM every hour, as needed up to 3 doses

9. Severe disruptive behavior: agitation with psychosis

a. Haloperidol 5 my. with Lorazepam 1 rag. every hour, as needed, is quite effective.

b. Avoid such combinations if patient is intoxicated with alcohol or a sedative-hypnotic. In such cases, a high-potency antipsychotic is sufficient.

10. Antidepressants: Do not prescribe in emergency setting.

11. Hazards:

a. Use as pan of negative countertransference response.

b. Special meaning of medications to patient

12. Recent Empirical Studies (Cowdry and Gamed

a. Tranylcypromine

i. Physician and patient ratings demonstrated improved mood, decreased anxiety, decreased rage, increased euphoria, and enhanced capacity for pleasure.

ii. Subjects did not have comorbid mood disorder.

b. Carbamazepine

i. No significant positive effects on mood

ii. Episodes of behavioral dyscontrol dramatically reduced in frequency and severity

c. Trifluoperazine

i. When trial was not discontinued, physician-rated anxiety and suicidality and patient-rated depression, anxiety, and sensitivity to rejection showed significant improvement.

d. Alprazolam

i. Associated with increased suicidality and episodes of serious dyscontrol

F. Physical Restraint

1. Rule: Only to protect patient and/or staff

2. Execution: Non-negotiable, swiftly employed, clearly explained, brief; allow ventilation of rage; time limit

3. Some patients test limits and precipitate confrontation restraints. Dynamics

G. Disposition

1. Most difficult task: due to power struggles and I resources.

2. Should be considered from the beginning.

3. Assess and involve current support systems.

4. Consider immediate and long-term resources.

5. Outpatient Psychotherapy:

a. Referring is almost always advisable

b. Problem: patient searching for new therapist. Beware of reinforcing splitting

i. Call current therapist (with permission).

ii. Suggest consultation.

iii. No immediate/impulsive changes

6. Hospitalization: Toxic and highly regressive, but may be life- saving.

a. Thwart regression before admission

i. Narrow goals of admission

ii. Patient responsibility

iii. Ward roles

iv. Concrete tasks

v. Describe what would result in discharge.

7. Criteria for hospitalization:

a. Severe ego disorganization and suicidal ideation resulting from recent loss.

b. Inability to contract to continue seeing outpatient therapist despite suicidal intent.

c. Suicidal with history of life-threatening suicide attempts.

d. Diagnostic uncertainty best evaluated in hospital.

e. Homicidal ideation with poor impulse control

f. Marked agitation or psychosis, unremitting after adequate trial of pharmacotherapy.

8. Documentation: Describe history, behavior, mental status, ego defenses, therapeutic techniques

a. Especially useful for repeaters

b. May need contracts or protocols.

9. Educating the hospital/clinic staff

a. Acting out negative countertransference responses

b. Quality of management by understanding psychopathology.

c. Special care to educate new non-mental health professionals, eg, physicians, nurses