A look at Borderline Personality Disorder (BPD): diagnostic criteria, co-occurring disorders, causes/development and treatment of.

1. Borderline
Personality Disorder
Andy Novinska, MS, LCPC, CADC

2. Personality Disorders
• Personality disorders are associated with ways of thinking and
feeling about oneself and others that significantly and
adversely affect how an individual functions in many aspects
of life.
• During the development process of the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-
5), several proposed revisions were drafted that would have
significantly changed the method by which individuals with
these disorders are diagnosed.
• Based on feedback from a multilevel review of proposed
revisions, the American Psychiatric Association Board of
Trustees ultimately decided to retain the DSM-IV categorical
approach with the same 10 personality disorders.
http://www.dsm5.org/Documents/Personality%20Disorders%20Fact%20Sheet.pdf

3. Diagnostic & Statistical Manual (DSM)
• DSM-I, 1952
106 disorders, 130 pages
• DSM-II, 1968
182 disorders,134 pages
• DSM-III, 1980
265 disorders, 494 pages
• DSM-IV, 1994
297 disorders, 886 pages
• DSM-5, 2013
300 disorders, 947 pages

4. BorderlinePersonalityDisorder(BPD)
Part of the “Cluster B” – Dramatic, Emotional or Erratic
• Antisocial - Disregard for the rights of others that begins in
childhood/early adolescence and continues into adulthood. Criminal
activities common.
• Narcissistic - Grandiosity with a need for admiration coupled with a
lack of empathy for others. Preoccupied with competence, power
and prestige. Closely linked to self-centeredness.
• Histrionic - Excessive need for approval. Are often animated,
dramatic, enthusiastic, seductive or flirtatious.
• Borderline - Poor self-image/identity with an abnormal level of
mood swings. Chaotic and unbalanced in their interpersonal
relationships.

5. DSM-5
Borderline Personality Disorder (BPD) 301.83
(Emotionally unstable personality disorder, emotional intensity disorder, borderline type in the ICD-10)
Diagnostic criteria require at least 5 of the following features:
 Frantic efforts to avoid real or imagined abandonment. (Note: Do not include
suicidal or self-mutilating behavior from criterion 5.)
 A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
 Identity disturbance: markedly and persistently unstable self-image or sense of
self.
 Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending,
sex, substance abuse, reckless driving, binge eating). (Note: Do not include
suicidal or self mutilating behavior covered in criterion 5.)
 Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
 Affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely
more than a few days).
 Chronic feelings of emptiness.
 Inappropriate, intense anger or difficulty controlling anger (e.g. frequent
displays of temper, constant anger, recurrent physical fights).
 Transient stress –related paranoid ideation or severe dissociative symptoms.

6. Common Co-Occurring Disorders
• Depressive Disorders
• Bipolar Disorder
• Substance Use Disorders
• Eating Disorders (especially bulimia)
• Posttraumatic Stress Disorder
• Attention Deficit/Hyperactivity Disorder
• Other Personality Disorders (especially other cluster B)

7. Causes & Development of BPD
Nurture
• Childhood abuse (especially sexual abuse)
• Loss of primary caregivers
• Neglect
• Hostile conflicts with caregivers or within environment
Nature
• Chromosomal and neurological abnormalities
• Brain region (occipital lobe & amygdala) functioning
• 5x’s as likely in first degree biological relatives
Temperament, Culture & Development
• Diagnosed 75% of the time in females
• Adolescents may display transient “symptoms”
• Temperament (mood, intensity, adaptability) may mimic traits

8. Considerations
Is Borderline Personality Disorder a “disorder”
• Symptom or reaction to trauma, loss, neglect?
• A gender stereotype that is expressed in “feminine” terms?
Over Diagnosed?
• Estimated at 1.6% of the population (might be as high as 5.9%)
but can be a dumping ground (“they are acting just like a
borderline”) or a dismissive disorder (“oh, they are just a
borderline”).
Not “Personality”
• Symptoms tend to diminish with age.
• A lack of emotional development due to drug and alcohol use,
abuse, neglect, etc.

9. Treatment Modalities
Individual Therapy (long-term)
Dialectic Behavior Therapy (DBT)
• Mindfulness
• Interpersonal Effectiveness
• Emotional Regulation
• Distress Tolerance
Schema Therapy
• Cognitive, behavioral and emotion-focused (including some
limited re-parenting)
Transference Focused Therapy
• Addressing distortions in perceptions

10. Therapeutic Alliance & Interactions
Set Limits
• Idealization & devaluation will occur, be consistent.
• Splitting in a practice, office, team will occur. Utilize team
staffings and stay unified.
Validate
• Empathize experiences without getting pulled in (or under!).
Avoid Hospitalization
• Have client partake in the world as much as possible (tricky as
you must attend to suicidality and the co-occurring disorders,
like depression, that can accompany suicidal thinking and
behaviors).

11. Thank You
Andy Novinska, MS, LCPC, CADC
http://www.linkedin.com/in/apnovin