Borderline Personality Disorder and Addiction Erica Hoff, PhD Licensed Clinical Psychologist What s in a name? Term first appeared in early 20 th century Borderline between neurotic and psychotic symptoms Borderline does not refer to: Borderline intelligence Manipulative tendencies Suicide attempts DSM-IV TR Diagnostic Criteria 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. 1
DSM-IV TR Diagnostic Criteria 1. Frantic efforts to avoid real or imagined abandonment 2. Unstable, intense relationships characterized by alternating extremes of idealization and devaluation 3. Identity disturbance: unstable image of self 4. Impulsivity in at least two areas that are potentially self-damaging 5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior 6. Affective instability due to marked reactivity of mood 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger 9. Transient, stress-related paranoid ideation or severe dissociative symptoms BPD by the numbers 2% of the general population meet diagnostic criteria 11% in outpatient setting 19% in inpatient setting Approximately 10% die by suicide Criteria met in 30% of completed suicides A marginalized population: She s just borderline Research regarding attitudes toward individuals with BPD consistently demonstrate: Less empathy Greater blame, belief they deserve their misery Greater desire to distance self emotionally Blurred lines regarding nature of person vs. nature of behaviors Denial of services 2
A call for education and empathy Individuals with BPD are suffering intensely Burn victims of mental health They have a missing/shifting sense of self (feeling empty ), their behavior is a reflection of this Emotional vulnerability Self invalidation Unrelenting crises Active passivity Apparent competence Understanding the cause Linehan s Biosocial Model Biological vulnerability to emotionality (hypersensitivity of the limbic system) Slow return to baseline Invalidating childhood environment Child learns his/her emotional experience is not accurate He/she is not taught how to regulate emotions Extreme emotional reactions are necessary to get an environmental response Abuse: the ultimate invalidation Approximately 75% of those with BPD report childhood sexual abuse (base rate for inpatients is 35%) This feels bad but you say it s ok. Not believed by family members, blamed for the behavior, etc. Physical abuse prevalence estimates range from 60-71% (base rate for inpatients is 38%) 3
Addiction and BPD: commonly cooccurring disorders 63.5% of individuals with BPD have a current or past substance abuse problem Why? Genetics Invalidating environments Drugs/alcohol as a means of self-soothing Potential for diagnostic error Treatment of BPD: Is there reason to be hopeful? The myth that BPD is untreatable has stemmed from a lack of understanding Psychodynamic therapies Traditional CBT DBT Psychopharmacology Dialectical Behavior Therapy Building a life worth living Created by Marsha Linehan (1993) and is heavily informed by CBT Has been adapted for use in co-occurring disorders Is rooted in a dialectical viewpoint of the world I didn t ask for/cause this pain AND I am responsible for feeling better I quit using drugs AND I relapsed yesterday 4
Traditional DBT Components Comprised of 4 broad skill sets: 1. Core Mindfulness 2. Emotion Regulation 3. Distress Tolerance 4. Interpersonal Effectiveness Traditional DBT components cont. 1. Individual therapy with a trained DBT therapist 2. Skills group training 3. Phone consultation 4. Treatment team meetings Efficacy in randomized clinical trials: It works! TAU vs. DBT Decreased suicidal ideation and suicide attempts Decreased number of hospital admissions/er visits Decreased use of non-suicidal self-injury Decreased anger and impulsivity Decreased drop out rate in therapy Increased sobriety 5
Take home points Individuals with BPD are suffering from intense emotional pain. Substance abuse intensifies this pain. BPD, with or without co-occurring substance abuse, can be treated effectively These individuals present challenges in treatment, and it is our responsibility to be flexible and effective Be aware of your personal biases/attitude toward these individuals Recommended Reading Borderline Personality Disorder Demystified - Robert Friedel, MD Cognitive-Behavioral Treatment of Borderline Personality Disorder - Marsha Linehan, PhD Skills Training Manual for Treating Borderline Personality Disorder - Marsha Linehan, PhD Treating Self-Injury: A Practical Guide - Barent Walsh, PhD 6