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Flashcards in BPD Deck (34)
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Pervasive instability of relationships, self-image, emotion and impulsivity


DSM-5 Criteria for BPD

At least 5+ of the below:
- Frantic efforts to avoid abandonment
- Unstable/intense relationships
- Unstable sense of self
- Impulsivity in 2+ self-damaging areas
- Recurrent self-harm
- Intense, brief emotional shifts
- Chronic feelings of emptiness
- Inappropriate anger
- Transient, stress-related paranoid ideation/dissociation (out of body experience)


Areas of dysregulation in BPD

- Emotional
- Behavioural
- Interpersonal
- Identity/self
- Cognitive


Emotional dysregulation

- Unstable emotions/mood
- Intense anger/difficulty controlling anger


Behavioural dysregulation

- Impulsive/self-destructive behaviours
- Suicide/self-harm


Interpersonal dysregulation

- Unstable/intense relationships
- Frantic efforts to avoid abandonment


Identity/self dysregulation

- Unstable sense of self/identity
- Feelings of emptiness


Cognitive dysregulation

- Stress related paranoid thoughts
- Dissociation


Prevalence of BPD

- ~6% of population
- Ratio of women to men who have it used to be thought of as 3:1 but now it's looking about equal according to recent studies


Course of BPD

- 85% remit in 10-15 years (not lifelong disorder)
- 75% self harm
- 10% die by suicide (mental illness with second highest rate of suicide)


Issues in diagnosing BPD

- Underdiagnosis and misdiagnosis
- Gender bias in diagnosis
- Heterogeneity in population


Differential diagnosis (BPD vs. bipolar)

- Commonly confused
- Differences include:
1) Speedy and frequency of mood shifts
2) Baseline mood
3) Context of impulsive behaviours


Environmental risk factors

- 75% report abuse histories
- Most report invalidating environment (parents who criticize or discount emotional responses; parents who punish individuation and separation)


Biological risk factors

- Closer relatives have higher rates (9-25%; MZ = 35-42%)
- Heritability = 0.46
- Impulsivity/emotionality may be underlying heritable traits


Linehan's Biosocial Model of BPD Diagram

See notes


Biosocial Model - Emotional Vulnerability

- Emotional sensitivity: More easily triggered emotions (thinner emotional skin; respond to things that wouldn't trigger the same response in others)
- Emotional reactivity: More intense emotions (increased emotional baseline)
- Slower return to baseline: Emotions stick around longer


Biosocial model - Invalidation

- Emotional fit
- Reciprocal effects
- Absence/abuse/neglect
- Denial/suppression of emotions


Emotional fit

Clashes occur if your emotions are intense and you have very rational parents; they just won't get it


Reciprocal effects

More intense emotions -> more invalidation ("What's wrong with you, why are you acting like that?")


Denial/suppression of emotions

You're told not to express certain emotions (e.g. "Don't cry")


BPD Treatments

- Dialectal behavioural therapy
- Mentalization-based therapy
- Schema-focused therapy
- Transference-focused therapy


Development of DBT

- Developed by Dr. Linehan at U of Washington b/c CBT was not working for clients with chronic suicidality and BPD
- Solution: Dialectics, Validation, multi-modal treatment and treatment hierarchy


Why was CBT not working for clients with BPD?

- Change focus was invalidating
- BUT you also can't validate everything they say or else they won't get better, so you have to strike a balance in treatment that CBT can't accomplish
- Unrelenting crisis interfered with treatment/skills acquisition



Thesis = my emotions make sense
Anti-thesis = my emotions aren't helping
Synthesis = my emotions make sense BUT they aren't helping me in this situation


Multi-modal treatment

Many different components
Individual therapy - to help with crises and keep the individual going
Group skills - teach them coping skills
Phone calls - coach them on what skills they can apply in different situations
Therapist consultation team - therapists get burned out pretty easily, so no one does DBT by themselves; so therapists meet once a week and help each other (therapy for therapists)


DBT goals and skills

- Cognitive dysregulation -> mindfulness (mindfulness helps people understand what's going on (e.g. people with BPD often forget why they were so upset))
- Impulsivity -> distress tolerance
- Labile emotions (rapid changes in mood and very strong emotions) -> emotional regulation
- Interpersonal chaos -> interpersonal effectiveness


Stage 1 of DBT: Stabilization

- Focus: Mainly trying to keep people alive (hell -> misery)
- Goal: Move from behavioural dyscontrol to control to achieve a normal life expectancy


Treatment hierarchy in stabilization stage

- Reduced life threatening behaviours: Suicide, NSSI
- Reduce therapy-interfering behaviours: e.g. missing sessions, not completing homework, behaviors that interfere with therapists' motivation to treat client
- Reduce quality-of-life-interfering behaviour: e.g. substance use, eating disorder behaviours, inability to keep employment, educational issues
- Increase skills that replace ineffective coping: replace dysfunctional behaviours


Stage II of DBT: Suffering in Silence

Begin to build life up


Focus of Stage II

- Address inhibited emotional experiencing
- Reduce PTSD symptoms