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BORDERLINE BORDERLINE PERSONALITY PERSONALITY ::DISORDDISORD

ERERWhat’s newWhat’s new??

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بمستشفى النفسي الطب بمستشفى استشاري النفسي الطب استشاريالنفسية النفسية الصحة الصحة

بالعبـــــــــــاسيةبالعبـــــــــــاسية

::Let’s rememberLet’s rememberDSM-IV-TR diagnostic criteria for DSM-IV-TR diagnostic criteria for

borderline personality disorderborderline personality disorderA pervasive pattern of A pervasive pattern of instabilityinstability of interpersonal of interpersonal relationships, self-image, and affects:relationships, self-image, and affects:

(1) frantic efforts to avoid real or imagined (1) frantic efforts to avoid real or imagined abandonment. abandonment.

(2) a pattern of unstable and intense interpersonal (2) a pattern of unstable and intense interpersonal relationships characterized by alternating relationships characterized by alternating between extremes of idealization and devaluationbetween extremes of idealization and devaluation

(3)markedly and persistently unstable self-image or (3)markedly and persistently unstable self-image or sense of selfsense of self

Diagnostic criteriaDiagnostic criteria::(4) impulsivity (e.g., spending, sex, substance (4) impulsivity (e.g., spending, sex, substance

abuse, reckless driving, binge eating). abuse, reckless driving, binge eating).

(5) recurrent suicidal behavior, gestures, or threats, (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavioror self-mutilating behavior

(6) affective instability due to a marked reactivity of (6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, mood (e.g., intense episodic dysphoria, irritability, or anxiety)or anxiety)

(7) chronic feelings of emptiness(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty (8) inappropriate, intense anger or difficulty controlling anger controlling anger

(9) transient, stress-related paranoid ideation or (9) transient, stress-related paranoid ideation or severe dissociative symptomssevere dissociative symptoms

Treatment of borderline Treatment of borderline personality disorderpersonality disorder

Psychodynamic individual psychotherapy. Psychodynamic individual psychotherapy. Supportive individual psychotherapy.Supportive individual psychotherapy. Cognitive-behavioral or schema-focused psychotherapy Cognitive-behavioral or schema-focused psychotherapy Dialectical behavior therapy. Dialectical behavior therapy. Interpersonal psychotherapy.Interpersonal psychotherapy. Family psychoeducation. Family psychoeducation. Antidepressant medications SSRIs (for affective Antidepressant medications SSRIs (for affective

dysregulation & impulsivity)dysregulation & impulsivity) Atypical antipsychotic medications (psychotic-Atypical antipsychotic medications (psychotic-

like features) like features) Anticonvulsant medicationsAnticonvulsant medications

((APA Textbook of Psychiatry, 5th ed., 2008APA Textbook of Psychiatry, 5th ed., 2008))

Borderline Personality Borderline Personality Disorder: Ontogeny Disorder: Ontogeny of a of a

Diagnosis (Diagnosis (Gunderson, 2009Gunderson, 2009))1)1) Before 1970Before 1970: psychoanalytic colloquialism : psychoanalytic colloquialism

for untreatable neurotics.for untreatable neurotics.2)2) 1970–19801970–1980: From Personality : From Personality

Organization to Syndrome: “An Adjective Organization to Syndrome: “An Adjective in Search of a Noun”in Search of a Noun”

3)3) 1980–19901980–1990:From Syndrome to :From Syndrome to Personality Disorder: “Wisdom Is Never Personality Disorder: “Wisdom Is Never Calling a Patient Borderline”Calling a Patient Borderline”

4)4) 1990–20001990–2000: From Unwanted Personality : From Unwanted Personality Disorder to Disorder-Specific Treatability: Disorder to Disorder-Specific Treatability: “Would the Patient Be Borderline If She “Would the Patient Be Borderline If She Remitted From a Medication?”Remitted From a Medication?”

5)5) 2000–20092000–2009: Borderline Personality : Borderline Personality Disorder: “A Good-Prognosis Brain Disorder: “A Good-Prognosis Brain Disease”?Disease”?

ConclusionsConclusions Bo. Per. D is a valid diagnosis with Bo. Per. D is a valid diagnosis with

significant heritability and with significant heritability and with specific and effective specific and effective psychotherapeutic treatments.psychotherapeutic treatments.

Increased awareness involving much Increased awareness involving much more education and research is still more education and research is still needed. needed.

Psychiatric institutions, professional Psychiatric institutions, professional organizations, public policies, and organizations, public policies, and reimbursement agencies need to reimbursement agencies need to prioritize this need.prioritize this need.

Prospective Predictors of Suicidal Prospective Predictors of Suicidal Behavior in Borderline Personality Behavior in Borderline Personality

Disorder at 6-Year F-UDisorder at 6-Year F-U((Soloff & Chiappetta, 2012Soloff & Chiappetta, 2012).).

Most patients achieve remission Most patients achieve remission of suicidal behavior over time, as of suicidal behavior over time, as

many as 10% die by suicide, many as 10% die by suicide, raising the question of whether raising the question of whether

there is a high-risk suicidal there is a high-risk suicidal subtype??subtype??


Disorder at 6-Year F-UDisorder at 6-Year F-U((Soloff & Chiappetta, 2012Soloff & Chiappetta, 2012).).

Results:Results: Among 90 participants, 25 (27.8%) made at least Among 90 participants, 25 (27.8%) made at least

one suicide attempt in the interval, and most one suicide attempt in the interval, and most attempts occurred in the first 2 years. The risk of attempts occurred in the first 2 years. The risk of suicide attempt was increased by: suicide attempt was increased by:

1.1. low socioeconomic status, low socioeconomic status,

2.2. poor psychosocial adjustment, poor psychosocial adjustment,

3.3. family history of suicide, family history of suicide,

4.4. previous psychiatric hospitalization. previous psychiatric hospitalization.


Disorder at 6-Year F/UDisorder at 6-Year F/U((Soloff & Chiappetta, 2012Soloff & Chiappetta, 2012).).

Conclusions:Conclusions: Risk factors predictive of suicide attempt change Risk factors predictive of suicide attempt change

over time. over time. Acute stressors such as major depressive disorder Acute stressors such as major depressive disorder

were predictive only in the short term (12 were predictive only in the short term (12 months). months).

Poor psychosocial functioning had persistent and Poor psychosocial functioning had persistent and long-term effects on suicide risk. long-term effects on suicide risk.

Half of borderline patients have poor psychosocial Half of borderline patients have poor psychosocial outcomes despite symptomatic improvement. outcomes despite symptomatic improvement.

A social and vocational rehabilitation model of A social and vocational rehabilitation model of treatment is needed to decrease suicide risk and treatment is needed to decrease suicide risk and optimize long-term outcomes.optimize long-term outcomes.

Attainment and Stability of Sustained Attainment and Stability of Sustained Symptomatic Remission and Recovery Symptomatic Remission and Recovery

Among Patients With Borderline Among Patients With Borderline Personality Disorder and Axis II Personality Disorder and Axis II Comparison Subjects: A 16-Year Comparison Subjects: A 16-Year

Prospective Follow-Up Study (Prospective Follow-Up Study (Zanarini Zanarini et al, 2012et al, 2012)) OBJECTIVE: OBJECTIVE:

To determine time to attainment of To determine time to attainment of symptom remission and to recovery symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and with borderline personality disorder and comparison subjects with other comparison subjects with other personality disorders and to determine personality disorders and to determine the stability of these outcomes.the stability of these outcomes.

Attainment and Stability of Sustained Attainment and Stability of Sustained Symptomatic Remission and Recovery Symptomatic Remission and Recovery

Among Patients With Borderline Among Patients With Borderline Personality Disorder and Axis II Personality Disorder and Axis II

Comparison SubjectsComparison Subjects METHOD: METHOD: A total of 290 inpatients with borderline A total of 290 inpatients with borderline

personality disorder and 72 comparison personality disorder and 72 comparison subjects with other axis II disorders were subjects with other axis II disorders were assessed during their index admission using a assessed during their index admission using a series of semi-structured interviews, which series of semi-structured interviews, which were administered again at eight successive 2-were administered again at eight successive 2-year follow-up sessions. year follow-up sessions.

ConclusionConclusion:: Borderline patients were significantly slower to Borderline patients were significantly slower to

achieve remission or recovery (which involved achieve remission or recovery (which involved good social and vocational functioning as well as good social and vocational functioning as well as symptomatic remission) than axis II comparison symptomatic remission) than axis II comparison subjects. subjects.

Sustained symptomatic remission is substantially Sustained symptomatic remission is substantially more common than sustained recovery from more common than sustained recovery from borderline personality disorder and that borderline personality disorder and that sustained remissions and recoveries are sustained remissions and recoveries are substantially more difficult for individuals with substantially more difficult for individuals with borderline personality disorder to attain and borderline personality disorder to attain and maintain than for individuals with other forms of maintain than for individuals with other forms of personality disorder.personality disorder.

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