Stepped Care for Borderline Personality Disorder

Making Treatment Brief, Effective, and Accessible

Joel Paris

• Publisher: Academic Press
• Year: 2017
• Print ISBN: 9780128114216
• eBook ISBN: 9780128114223
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Synthesizing the latest research and treatment developments, Stepped Care for Borderline Personality Disorder: Making Treatment Brief, Effective, and Accessible aims to make treatment for borderling personality disorder (BPD) more accessible by providing clinicians with innovative brief and targeted intervention methods. Focusing on integrative treatment models, it offers clinicians a vital guide to the management of patients who are difficult to treat.Acknowleding the early developmental roots of BPD, the book includes sections on BPD in adolescence, childhood precursors of the disorder, and a broad range of etiological factors. It looks at the pitfalls clinicians face when trying to treat BPD, and offers a roadmap to avoiding them.- Brief and targeted methods of integrative treatment for BPD patients- Makes treatment more accessible to a wider range of patients- Provides clinicians and researchers with a review of the current BPD literature- Offers solutions to the problem of treatment access for BPD patients- Addresses questions regarding the complex developmental trajectories of BPD- Presents a model of stepped care treatment of BPD and describes research on its effectiveness

Part I

Research on BPD

Outline

Chapter One Diagnosis

Chapter Two Etiology

Chapter Three Outcome

Chapter Four Treatment

Chapter One

Diagnosis

Abstract

This chapter examines the diagnostic validity of borderline personality disorder (BPD). After reviewing the history of the construct, it examines the background of the two systems now in DSM-5. It examines the potential gains and losses of a dimensional system of diagnosis. The role of temperament and traits in defining personality disorders is reviewed.

BPD typically begins on adolescence and can be diagnosed at that age. Recent research on childhood precursors of BPD suggests that disruptive behavior disorders may precede onset.

The most important comorbidities affecting plans for treatment are substance use and eating disorders. Differential diagnosis of BPD is most important in the distinction from bipolar disorder. The danger of missing a BPD diagnosis has important implications for therapy.

Keywords

Borderline personality disorder; DSM-5; childhood precursors; comorbidities; differential diagnosis; emotional regulation; impulsivity

Contents

History of the BPD Diagnosis 4

Temperament, Traits, and BPD 10

The Onset of BPD in Adolescence 11

Childhood Precursors 12

Comorbidity 13

Differential Diagnosis 15

Implications of Diagnosis for Treatment 17

A Tentative Conclusion 18

BPD As a Public Health Problem 19

The Variety of Clinical Presentations in BPD 20

Case 1: Prominent affective instability 20

Case 2: Prominent cognitive features 21

Case 3: Prominent impulsive features 21

Case 4: Prominent interpersonal features 22

References 22

Further Reading 26

History of the BPD Diagnosis

To treat borderline personality disorder (BPD), you first need to define it. That is not a simple matter. Like most categories in psychiatry, BPD is a syndrome that combines a range of clinical features. Although a typical case is unmistakable, the construct is fuzzy around the edges.

The first clinician to write about BPD was Stern (1938), a psychoanalyst who described a form of pathology lying on a “border” between neurosis and psychosis. Stern described the “psychic bleeding” that these patients endure and emphasized that they did not respond to the psychotherapies available at the time. In spite of his misleading choice of a name, Stern’s description of BPD patients remains surprisingly contemporary. The term “borderline” tells us little (much as “schizophrenia” does not describe a split mind). But up to now, BPD has been retained for lack of a good alternative. Although emotional dysregulation disorder would be more specific (Livesley, 2017), it does not describe all aspects of the disorder.

Very little was written about BPD for the next 30 years. A few psychoanalysts kept the idea alive. The most influential was Kernberg (1976), who introduced the concept of “borderline personality organization.” But this construct was based on arcane theories of intrapsychic structure, was broad in scope, difficult to operationalize, and was not well supported by empirical data. Thus, the BPD diagnosis was not widely accepted, and it was not in early editions of the Diagnostic and Statistical Manual for Mental Disorders (DSM) published by the American Psychiatric Association, or in various editions of the International Classification of Diseases (ICD), published by the World Health Organization.

How then did BPD become a major topic of interest? One reason is that over time, more patients began to present with this clinical picture (Millon, 1993). Mental symptoms can change over time and history and can be shaped by social forces. Some current diagnoses, such as bulimia nervosa, were not seen by clinicians in the past (it was unheard of when I was a resident 50 years ago). There is no historical evidence that patients meeting criteria for BPD, or that, recurrent self-harm and repetitive overdoses were common in the past (Paris, 2008). Instead, psychopathology seems to have presented in other ways (e.g., with somatic symptoms), drawing from what has been called a “symptom bank” created by society and culture (Shorter, 1992).

Research in diagnosis requires a valid instrument. The first empirical studies of BPD began when Gunderson and Singer (1975) published a paper describing a structured interview. This instrument, the Diagnostic Interview for Borderlines, revised (DIB-R, Zanarini et al., 1989), can be scored reliably, and differentiates BPD from other diagnoses. This is because the DIB-R defines a narrower and more homogeneous group than DSM, and the scoring gives extra weight to characteristic features (impulsivity and problematic interpersonal relationships).

BPD was first included in DSM-III as a diagnostic category in 1980. It described 8 criteria, of which patients needed to have 5. The DSM-IV added a ninth criterion (paranoid ideation or dissociative symptoms). These criteria were not changed in DSM-5 (American Psychiatric Association, 2013). They can be grouped into affective features (instability and reactivity of mood, emptiness, and intense anger), impulsive features (self-damaging acts, chronic suicidality), interpersonal features (frantic efforts to avoid abandonment, unstable and intense relationships), as well as an unstable identity.

As with so many categories in DSM, diagnosis requires only five out of a list of nine criteria, a “polythetic” approach (jocularly called the “Chinese menu”). Thus, the DSM system inevitably makes clinical populations heterogeneous. It has never been shown that the DSM criteria have sufficient discriminant validity to separate BPD from other mental disorders or from other Personality Disorders (PDs).

Over time, the unsatisfactory state of PD diagnosis became an embarrassment to psychiatry. Research in trait psychology showed that there is no sharp cut-off between PD and normal variations in personality (Livesley et al., 1998). Many researchers (Costa & Widiger, 2013) came down on the side of replacing categories with dimensional scores that could be applied to both normal and clinical populations.

When it came time to prepare DSM-5, the leaders of the revision process (Kupfer & Regier, 2011) were interested in changing most categories to dimensions. One reason was that quantitative scores are closer to neurobiology. They saw PD as a “poster child” for this larger venture: to eliminate all categorical diagnoses and replace them with dimensional scores. Thus, instead of diagnosing PDs as discrete diseases like hepatitis, they would be described by a profile of scores on personality traits.

However, when it came time to publish DSM-5, the American Psychiatric Association did not consider psychiatry ready for a radical revision in which familiar categories would be jettisoned. The committee in charge of PD diagnosis created a “hybrid” system in which categories would remain, but be rooted in clinical ratings of trait profiles (Oldham, 2015).

In this system, one would first determine whether a patient had a personality disorder, defined by an impairment of functioning in domains of identity, self-direction, empathy, and intimacy that would be scored quantitatively. Then, personality traits would be characterized as pathological based on five domain scores derived from trait psychology: negative affectivity (vs emotional stability); detachment (vs extraversion); antagonism (vs agreeableness); disinhibition (vs conscientiousness); and psychoticism (vs lucidity). Finally, categorical diagnoses could be constructed from these profiles.

Applying this model to BPD, diagnosis would be based on poor identity, unstable self-direction, compromised empathy, and unstable intimacy and would require four out of seven pathological traits: emotional liability, anxiousness, separation insecurity, depressivity, impulsivity, risk taking, and hostility—and requiring at least one of the last three.

The hybrid model did not replace the DSM-IV categories, but became an “alternative model” in Section III of DSM-5, reserved for “emerging measures.” The alternative model is a complex procedure that requires training. But the main reason for which it was not accepted in 2013 was that its algorithms had not been thoroughly tested. Since then, much more research has been published on the model, most of which has been authored by members of the committee who developed it. Their publications like to refer to it as “the DSM-5 model,” as if it were the main option. But the older diagnostic system, with all its faults, is still used by the vast majority of clinicians.

A dimensional system may be a scientifically superior way to diagnose PDs, but clinical utility requires a model that is simple enough to be used in practice. The complexity of the alternative model is intimidating for the average clinician. We also do not know whether untrained clinicians can make reliable ratings. Finally, given that most practitioners already have difficulty making a PD diagnosis using the DSM-IV system, the alternative model could make the process even harder. This might have unfortunate consequences for patients, who so often fail to receive a PD diagnosis, and are therefore denied the best form of treatment for their problems.

Meanwhile, the World Health Organization’s ICD, 11th edition (ICD-11) is expected to be approved and published sometime over the next few years. Its current proposal for PD diagnosis removes all categories in favor of clinician-rated trait dimensions (Tyrer, Crawford, Mulder, & Blashdfield, 2011). Thus, ICD-11 would ask clinicians to rate personality dysfunction on a 5-point scale (none, difficulty only, mild, moderate, and severe), as well on a set of trait domains (negative emotional, dissocial, disinhibited, anankastic, and detached). This procedure is much simpler than the alternative DSM-5 model, as there are fewer decision points. Yet, research on the ICD-11 proposal remains preliminary. It also does not deal with a fundamental problem, which is that clinicians would have to be trained to make reliable ratings of the trait domains. No one looks forward to having three different systems, each inconsistent with each other. But that seems to be just what is about to happen.

We are also living through a time when a completely different system of classification for all mental disorders has gained attention. The aim of the Research Domain Criteria (RDoC; Cuthbert & Insel, 2013) is to eventually classify disorders on the basis of etiology, with an emphasis on identifying abnormal connections in the brain. However, RDoC puts all the emphasis on neurobiology rather than promoting a biopsychosocial approach. Moreover, we are nowhere near to understanding the causes of mental disorders (Paris & Kirmayer, 2016). As of now, the system is designed for research only—the National Institute of Mental Health requires grant to applicants to use it. As it is not clear how RDoC could describe PDs, its adoption could lead to a failure to fund research in this area.

Another option is to assess personality and PD the way trait psychologists do, by patient self-report. Doing so would have the advantage of replacing clinical ratings with questionnaires with well-developed psychometrics. The disadvantages lie in the time needed to s...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Foreword
• Acknowledgments
• Introduction
• Part I: Research on BPD
• Part II: Applying a Stepped Care Model
• Index