Lecture 5: Borderline Personality Disorder
PERSONALITY DISORDERS
● Personality
○ Characteristics and behavior of a person in line with interests, drives, and values
○ Stable over time
○ Adjust to varying situations
● Psychopathology related to personality traits
● Describe it as part of the ‘self’, in contrary to syndrome disorders
● Emerges during the development over time (almost always start during adolescence)
● Dysfunctional
SYMPTOMS OF PERSONALITY DISORDERS
● In mulitple aspects of the daily functioning such as:
○ Cognition/thinking
○ Affect regulation
○ Interpersonal functioning
○ Impulse regulation
● Three P’s
○ Problematic – unusual and distress for self or others
○ Pervasive – starting in adolescence and continues in adulthood
○ Persistent – affecting different areas of functioning
TYPES OF PERSONALITY DISORDERS
CLUSTER A: Odd/ eccentric CLUSTER B: Dramatic/emotional/impulsive CLUSTER C: Anxious/ inhibited (more prevalent)
Paranoid personality disorder Antisocial personality disorder Avoidant personality disorder
Schizoid personality disorder Histronic personality disorder Obsessive compulsive personality disorder
Schizotypcal personality disorder Narcissistic personality disorder Dependent personality disorder
Emotionally unstable personality disorder
Borderline personality disorder is present
(but is related to others in this cluster)
BORDERLINE PERSONALITY DISORDER
● Prevalence general population 1-4%
● Prevalence mental health inpatients 15-25%
● Low quality of life
● High societal costs
● High suicide rates
● Comorbidity (anxiety, depression, trauma), substance abuse, criminality
● Intergenerational transmission (often a parent may have BPD)
BPD SYMPTOMS
● A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by
early adulthood and present in a variety of contexts, as indicated by five (or more) of these symptoms
○ Abandoment reaction
○ Idealization and Devaluation
○ Unstable self-image
○ Impulsiity (self-damaging)
○ Recurrent suicidal behavior/ self harm
○ Emotional instability
○ Chronic feelings of emptiness
○ Inapproprite anger
○ Paranoia and dissociation
,ETIOLOGY
● Genetics - vulnerability
● Neurobiological
○ Neurotransmitter serotonin
○ Brain development
● Environmental factors
○ Physical, sexual or emotional (!) abuse
○ Trauma
○ Emotional abandonment
○ Psychopathology in the family
STIGMA
● Social rejection resulting from negatively perceived characteristics
● Three different forms:
○ 1. Public or societal stigma
○ 2. Associative stigma
○ 3. Self-stigma
STIGMATIZATION AND BPD
● BPD is associated with heavy stigma
● Attitudes and behaviours towards BPD tend to be more negative than other disorders.
● Health professionals view patients with BPD as manipulative, faking symptoms and distress, disorganizing emergency and
psychiatric units and putting in danger the team's cohesion.
● Negative reactions to BPD can lead to:
○ Premature termination of treatment
○ Rationalization of treatment failures
○ Lower likelihood of forming an effective treatment alliance with patients
○ Emotional and social distancing Lack of belief in recovery
● Even though BPD can be reliably diagnosed, many clinicians do not make the diagnosis of BPD in adolescents
STIGMA IN BPD
● “They cause trauma and pain in their loved ones’ lives”
● “They’re miserable people who just want to make everyone around them miserable”
● “You feel like you’re walking on eggshells around them”
● “They’re the worst patients, noncompliant and draining”
WHY SHOULD CLINICIANS DIAGNOSE BPD IN ADOLESCENTS?
Pros of diagnosis BPD
● It is better for prevention and early intervention
● Features of BPD are robust markers for severity
● Features of BPD are robust markers for future problems
● Adolescence is a critical period for early intervention
● It improves treatment and might reduce drop-out
● Inappropriate or ineffective treatment might cause harm
● It might actually help to reduce stigmatization
WHY SHOULD CLINICIANS BE CAUTIOUS WITH DIAGNOSING BPD IN ADOLESCENTS?
Cons of diagnosis BPD
● The nature and transitional period of puberty and adolescents
● Specifically, the personality is still developing
● Stigma around BPD
● Adolescents that have BPD traits do not fulfil criteria all the time
● The conventional classification tools in diagnosing BPD are not tailored/ adequate for adolescents
● Lack of standardisation due to personalised circumstance of adolescents
● Diagnosing in general: How about the underlying mechanisms? (e.g. family problems)
,FINAL REMARKS
● Pros of diagnosing seem to outweigh the cons
● Diagnosing reduces potential harm in patients
● By diagnosing and addressing BPD properly we contribute to the patient's short and long-term prognosis => but this needs to
be done professionally in the right setting!
● We need to work toward a system without stigma
● Always be aware of underlying mechanisms en not only the classification
, Literature
The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence.
Hutsebaut, J., Clarke, S. L., & Chanen, A. M. (2023).
AIM: Provide 7 arguments in support that it is ethically right to diagnose and treat personality disorders when they occur in adolescent
● We argue that intervention during adolescence and young adulthood is humane & critical for efforts to avert the longstanding
psychosocial and health problems that seem refractory to treatment in adults with personality disorder
SEVEN ARGUMENTS WHY EARLY DIAGNOSIS AND TREATMENT OF PD IS JUST AND ETHICAL
1) Prevention and early intervention are common strategies in healthcare
2) Features of borderline PD are robust markers of the severity of present psychopathology
● Detecting BPD in its early stages might only be useful when these features refer to manifestations of severe psychopathology.
● PD criteria in adolescents predict a broad array of associated problems in mental, social, and academic functioning
○ Increased suicidality, school dropout, risk of substance abuse, increased use of healthcare services, problems at school
and fewer friends, more behavioral problems and difficulties at school, more alcohol abuse, drug use, and nicotine
dependence, more sexual partners, unsafe sexual behavior, riskier attitudes and norms toward sexual behavior, and
more crisis admissions and medication use
○ Burden of disease and health costs exceed those of adults with PD
○ Families and carers of young people with BPD experience higher levels of negative experiences related to their role
● Age of onset of BPD symptoms predicts developmental outcomes
○ Earlier age of self-harm onset and longer duration self-harm were both associated with increased frequency of
subsequent periods of self-harm and risk of the first suicide attempt (associated with more repeated suicide attempts)
● Features of BPD are robust markers of present problems and identify a group of young people at high risk for a broad range of
adverse immediate outcomes
3) Borderline PD features are robust markers for future problems
● Poor outcomes in (young) adulthood include academic failure, poor vocational outcomes, poor physical health, excess mortality
from medical conditions, increased suicide risk and long-term mental health problems and the need for treatment
● The key preventive aim for early detection and treatment of PD in young people is the prevention of severe impairments in
health, social, and vocational outcomes
4) Adolescence (and young adulthood) is a sensitive period for the development of chronic psychosocial disability
● BPD during the transition to adulthood interferes extensively with the development of adult role functioning
● Early detection and intervention of personality pathology appears to be time-sensitive, defining an ‘enriched’ risk group and
offering an opportunity to prevent long-term psychosocial disability and potentially irreversible psychosocial disadvantage
5) Regular treatment is often inaccessible or less effective for young persons with BPD
● Young people with PD usually do not enter services equipped to address their personality impairments, are often refused
access to psychotherapy programs, and respond less well than those without PD to existing treatments.
● Young people with (B)PD appear to respond less well to conventional treatments used in primary care.
● Main reason adolescents discontinue treatment: breakdowns in the therapeutic relationship
○ Ruptures that remain unaddressed, and for which the young person is held responsible, preceding drop-out. Young
people with BPD are highly sensitive interpersonally and are susceptible to what happens in the therapeutic
relationship.
○ This can occur especially when the practitioners are too rigid in their adherence to treatment protocols
6) Inappropriate or ineffective treatment might cause iatrogenic harm
● Professionals often follow a stepped-care logic and then only scale up to more intensive, complex, and/or specialized
treatments when these first-line treatments fail => Harmful
○ It is better to see if the condition can be treated with a mild intervention and only scale up if it is insufficient. However,
the requirement to ‘fail’ a particular step, is to progress to the next step that was needed when the person first
presented risks prolonging the period of untreated illness, potentially leading to worse outcomes.
● Too brief interventions for serious disorders have aversive effect
○ 40% of young people with BPD features showed no progress at all after six sessions, while another 40% deteriorated
