“I hate you….don’t leave me!”Managing and Responding to Borderline Personality Disorder :“I hate you….don’t leave me!”Managing and Responding to Borderline Personality Disorder Dr Angela Dixon NSW Institute of Psychiatry


: What are some of your experiences with people who may have “borderline traits”? What are some of the traits that might indicate a “borderline” presentation?


Overview :Overview What is it? How is it diagnosed? DSM-IV criteria What causes it? The course of BPD Responding to BPD Managing BPD Case examples


What is a Personality Disorder? :What is a Personality Disorder? Maladaptive personality characteristics that have a consistent and serious effect on work & interpersonal relationships Affect approx. 10% of population DSM-IV – 10 categories (Axis II)


Borderline Personality Disorder :Borderline Personality Disorder Central feature = instability Impulsive behaviours Emotionally unstable Brief psychotic episodes Suicide attempts Unstable interpersonal relationships Boundary problems Mood swings Identity disturbances (impaired ego integration)


How is it diagnosed? :How is it diagnosed? The Diagnostic Interview for Borderlines, Revised (Gunderson & Kolb, 1989) Affect (e.g., chronic depression, anger, loneliness, emptiness, guilt, anxiety) Cognition (e.g., odd thinking, nondelusional paranoia) Impulse action patterns (e.g., substance abuse, manipulative sexual gestures) Interpersonal relationships (e.g., intolerance of aloneness, counterdependency, demandingness)


DSM-IV Criteria :DSM-IV Criteria At least 5 of the following 9: Traits involving emotions: 1. shifts in mood lasting only a few hours 2. anger that is inappropriate, intense or uncontrollable “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement” (Linehan)


DSM-IV criteria :DSM-IV criteria Traits involving behaviour 3. Self-destructive acts 4. Two potentially self-damaging impulsive behaviours Traits involving identity 5. Marked, persistent identity disturbance 6. Chronic feelings of emptiness or boredom


DSM-IV Criteria :DSM-IV Criteria Traits involving relationships 7. Unstable, chaotic intense relationships characterized by splitting 8. Frantic efforts to avoid real or imagined abandonment alternating clinging & distancing behaviours (I hate you, don’t leave me) difficulty in trusting sensitivity to criticism or rejection need for affection & reassurance 9. Transient, stress-related paranoid ideation or severe dissociative symptoms


Miscellaneous attributes :Miscellaneous attributes Bright, funny, witty Problems with object constancy Difficulty in tolerating aloneness Chaotic lives Backgrounds of abuse


BPD in adolescents v. adults :BPD in adolescents v. adults Problems with diagnosing BPD in adolescents Perjorative label – stigmatizing May end up “growing out of it” Symptoms less stable in teens Can improve with treatment


Aetiology :Aetiology Multiple risk factors: Biological Temperament abnormalities (heritable) Decreased serotonin activity Psychological Trauma Emotional neglect Social Lack of support/emotional security Linehan’s theory – emotional invalidation Invalidating environment


Link with childhood trauma :Link with childhood trauma Many people with personality disorder report a history of childhood abuse or neglect Children who are physically abused, sexually abused, or neglected are significantly more likely to develop a PD as a young person Sexual abuse [usually with emotional abuse and neglect] is most strongly associated with BPD in particular In BPD, childhood trauma may still be affecting the individual as an adult, to an extent that impairs daily functioning Johnson JG et al. Arch General Psychiatry 1999


Linehan’s theory :Linehan’s theory Emotional invalidation: emotionally vulnerable individual + invalidating environment = BPD Limited opportunity to learn to label, understand or trust own feelings Looks to others for how to cope Oscillates between emotional inhibition to gain acceptance and emotional disinhibition to have feelings acknowledged Intermittent reinforcement = emotional dysregulation


A biopsychosocial model :A biopsychosocial model Disorganised attachment system Temperament traits Maltreatment Chronic stress Integrative processing problem Dissociation Emotional dysregulation Cognitive dysfunction Behavioural dysregulation Intense unstable relationships Identity diffusion Genetics Environment Adapted from Hoffman-Judd P & McGlashan TH, 2003


Contributing factors? :Contributing factors? Jessica was a made a ward of the state at age 10 and had been sexually and physically assaulted by her father. She reports that her mother was often hospitalised for recurrent episodes of depression. Jessica had numerous placements with foster families and at 15 and a half ran away. She has lived in refuges, squats and on the street since this time. By age 19, Jessica had been hospitalised on three occasions following episodes of self-harm and been diagnosed as having a Borderline Personality Disorder.


Contributing factors? :Contributing factors? Susan was from an upper-class family where success and money were highly valued. Her father was a stern man who expected his children to be neat and quiet. He angered easily and would threaten to send her away if she misbehaved. At age 5, her younger brother was born 3 months premature. Susan’s mother was in hospital for 2 months while her father continued with his busy executive life. A nanny was hired to look after Susan. Susan’s mother became depressed, barely interacting with Susan or the baby. Her father withdrew from family life and blamed Susan for her mother’s sad and tearful state, regularly threatening to send her to boarding school if she did not behave better. Susan had problems with attention and did poorly at school. This contributed to her father’s anger towards her. By this time, Susan’s mother was drinking heavily.


The Course of BPD :The Course of BPD Usually begins in adolescence 80% women Severe, chronic 1 in 10 suicide Impulsivity & emotional instability tend to decline over time


Living with BPD: personal accounts :Living with BPD: personal accounts 19


: What reactions/emotions do individuals with BPD elicit from you? How do you manage these reactions? What are some of the ways you deal with individuals with BPD?


Managing own reactions :Managing own reactions Be aware of feelings, thoughts & physical reactions Identify own, & colleagues, stereotypes around BPD Work through issues in supervision Have realistic expectations about your role Set appropriate boundaries & limits Be patient Help individual focus on developing skills to manage their distress


Be aware of… :Be aware of… ‘Burnout’, frustration Anger or dislike towards client Inappropriate gifts/acts Boundary issues Staff conflict


Treatment :Treatment Drugs? Psychotherapy Impulsivity – 2/3rds drop out Chaotic lives = difficult cases Relationship problems – apply in therapy Focus of therapy Therapeutic relationship  impulsivity  better judgment


Treatment :Treatment BPD/chronic PTSD Re-traumatising False memories Dialectical behaviour therapy Individual & group Emotional validation & teaching adaptive behaviours Interpersonal effectiveness Distress tolerance/reality acceptance Emotional regulation Mindfulness skills


Keep in mind…. :Keep in mind…. Structure Limits Consistency Predictability Psychological safety Reinforcing adaptive behaviours Communication between professionals


Treatment components :Treatment components Expect treatment to be long-term Create hierarchy of priorities Monitor self-destructive & suicidal behaviours Build strong therapeutic alliance (empathic validation) Help individual take responsibility Manage own intense feelings Promote reflection rather than impulsive action Diminish splitting Set limits on individual’s self-destructive behaviour and, if necessary, convey the limitations of the therapists capacities


Hierarchy of priorities :Hierarchy of priorities Decreasing high-risk suicidal behaviours Decreasing responses or behaviours that interfere with therapy Decreasing behaviours that interfere with quality of life Decreasing and dealing with post-traumatic stress responses Enhancing respect for self Acquisition of the behavioural skills taught in group


: Co-ordinate management across providers Establish clear roles, crisis management plans, regular communication


General tips for working with people with BPD :General tips for working with people with BPD Regularly discuss person with your colleagues and supervisor Support colleagues working with BPD clients Ensure the person gets a comprehensive assessment; identify and manage co-morbid problems (eg. depression) Suggest the person sees a GP regularly (in addition to a mental health worker)


General tips for working with people with BPD :General tips for working with people with BPD Focus on solving non-medical problems (eg. employment, budgeting, self care) Agree among colleagues on protocols for managing crises Become familiar with guidelines for managing anger or violent behaviour Recognise your own limits for personal involvement


Boundaries :Boundaries How do these individuals push the boundaries? How do you respond?


Splitting/boundaries :Splitting/boundaries Facilitate communication among providers Consider altering treatment (e.g., increasing support, seeking consultation) Be explicit in establishing “boundaries” Maintain consistency Case worker’s responsibility to monitor and sustain boundaries (monitor own feelings toward the student) Avoid boundary violations


Boundary crossings :Boundary crossings Explore the meaning of the boundary crossing Restate expectations about boundary and rationale Employ limit-setting Making exceptions to the usual boundaries may signal need for consultation or supervision


Case Studies – Leonie and Sonia :34 Case Studies – Leonie and Sonia In small groups, discuss the case study provided and respond to the focus questions. Choose a spokesperson to provide feedback for your group


Case Study 1 - Leonie :Case Study 1 - Leonie Leonie, plus two children aged three and 18 months History of domestic violence Feeling depressed Arguing with all the residents/service users Leonie yells and walks out. Disagreement within the team re how to manage the situation


Case Study 2 - Sonia :Case Study 2 - Sonia 38 year old woman with longstanding history of depression and substance misuse Diagnosis of borderline personality disorder Recent problems with neighbours Disagreement within the team re how to manage the situation


Slide 37:Video Working effectively with clients Dr Ros Montague


Explaining BPD to people :Explaining BPD to people People with borderline personality disorder: have usually experienced significant early abuse have grown up feeling unfairly treated and are angry about this look for someone to care for them properly, and have very high expectations for relationships can feel very angry when they feel someone has let them down can blame themselves for relationship problems and become suicidal or self-destructive often bring out feelings of guilt or protectiveness in others experience a destructive cycle of hopes and high expectations for relationships, followed by disappointment and a feeling of being rejected and abandoned. Adapted from Gunderson JG, 2003


Risk management issues :Risk management issues General Collaborate & communicate with other providers Documentation Be alert for splitting, transference & counter-transference Consider consultation Assess suicide risk, angry/violent behaviour, boundary violations


Suicide :Suicide Monitor Treat co-morbid Axis I disorders Take suicide threats seriously Consider consultation/hospitalisation Address chronic suicidality in therapy (in absence of acute risk)


Responding to a crisis :Responding to a crisis During a crisis Express concern after the person alerts you to suicidality/other safety issues Allow person to ventilate to relieve tensions Avoid taking actions to prevent potential suicidal behaviours when possible Ask person to be explicit about wanting help, and what help they want After a crisis Help the person understand what provided relief (eg. the perception of being cared for) Help the person think of alternatives to deal with the crisis


Managing suicidality in a person with BPD :Managing suicidality in a person with BPD Never ignore hints of suicidality but don’t proactively look for it It is never safe to assume that the behaviour is merely ‘attention-seeking’ or ‘manipulative’ Explain that suicidal acts are dangerous distractions from what should be the person’s real goal: to try improve her/his life Gunderson JG, 2003


Managing suicidality in a person with BPD :Give the client information about the common motives for suicidal behaviour by people with BPD Do not automatically arrange hospital admission unless necessary Document all factors you considered in deciding how to react to client’s potentially suicidal behaviour Managing suicidality in a person with BPD


Responding to self-harm behaviour :Responding to self-harm behaviour Remain calm and show concern and sympathy − don’t show alarm or shock Don’t take over − avoid gratifying the person’s fantasy about being rescued Advise visit to emergency department for injuries if necessary, not admission to acute psychiatric ward Make arrangements for the person’s immediate safety overnight Consider risks vs benefits of medications (eg benzodiazepines) Assess and document suicide risk


Why I hurt myself :Why I hurt myself Reasons reported by patients include the following: To externalise or show mental pain in a physical way To feel physical pain to overcome psychological pain when in distress (to experience relief from intolerable emotional state) To punish self for being bad To control feelings To gain a sense of control To express anger To overcome feeling of numbness. Gunderson JG, 2003


Tips for managing repeated crisis or aggression :©PRA Tips for managing repeated crisis or aggression Plan for crisis – negotiate a plan for repeated behaviour All behaviour has a function – find the function of the behaviour Reinforce useful/helpful behaviours Don’t provide unsolicited advice- only provokes resistance Plan as a team Recognise your own feelings/responses (get good supervision) Establish a good relationship with the person – like each other


Tips for managing repeated crisis or aggression :Tips for managing repeated crisis or aggression Maintain respect, calm, patience Give the person a chance to talk freely about concerns, and acknowledge their point of view Show you are willing to help but be honest; don’t make promises you can’t keep Speak firmly, clearly, slowly − don’t raise your voice Don’t take abusive statements personally If aggression escalates, decrease eye contact Offer refreshments when appropriate WHO Collaborating Centre for Mental Health and Substance Abuse 1997 47


Tips for managing repeated crisis or aggression :Tips for managing repeated crisis or aggression Reduce frustration by informing people of expected delays Verbal abuse is usually a reaction to fear or frustration; responds best to empathy Verbal menacing usually directed towards a particular person or achieving a particular thing: Try to calm the person down enough to be able to explain why they feel wronged If a person will not calm down, ask them to leave (if not a danger to the community) or leave the room and call in support Ensure all staff are familiar with safety protocols for dealing with aggressive clients and protocol for community visits WHO Collaborating Centre for Mental Health and Substance Abuse 1997


Dealing with paranoia :Dealing with paranoia Don’t be too friendly or inquisitive; maintain a formal, respectful, professional attitude Don’t use humour Tolerate accusations of belittling remarks Give them adequate opportunity to air concerns Accept the person’s paranoid beliefs as real to him/herself. Neither agree nor argue against Meticulously document all interactions WHO Collaborating Centre for Mental Health and Substance Abuse 1997 49


Summary – General strategies :©PRA Summary – General strategies Listen Acknowledge One statement at a time Be assertive and confident Actively involve the person in problem solving (externalise the problem) Be aware of non verbal communication (your and theirs) Don’t judge or blame


Dealing with seductive behaviour :Dealing with seductive behaviour Ignore the behaviour if due to intoxication or mania, or if relatively non-threatening Leave the door open during interviews Examine your own behaviour to make sure you have not given the wrong impression (eg. clothing, physical body contact, questions about client’s sex-life, sharing personal anecdotes) Clarify the situation without accusing If a client makes obscene comments, state that this is inappropriate and unacceptable and that you will not see him or her if such behaviour occurs again WHO Collaborating Centre for Mental Health and Substance Abuse 1997


Dealing with reports of sexual abuse: adult clients :Dealing with reports of sexual abuse: adult clients Provide support and organise psychological intervention Current relationships may involve sexual abuse or violence Where appropriate, refer for specific counselling on safety, rights and abuse recovery