Borderline Personality Disorder: Origins, Treatments, Coping – June 4, 2004

Borderline Personality Disorder: Origins, Treatments, Coping

June 4, 2004
Mt. Sinai Medical Center, New York, NY


Conference Sponsors:National Education Alliance for Borderline Personality Disorder (NEABPD)
Mount Sinai Medical Center
The New York City Chapter of the National Alliance for the Mentally Ill (NAMI-NYC Metro)
Purpose of Conference:This one-day meeting will provide a forum for professionals, family members and consumers to better understand this complex disorder from various perspectives. Presentations by renowned professionals will give up-to-date information on key issues such as an overview on borderline personality disorder, neurobiology, treatment options, medication, and childhood antecedents. A family and consumer panel will share their firsthand experiences with and perspectives on the disorder

Conference Program

Welcome

Perry D. Hoffman, PhD
President, NEABPD
Charlotte Fischman, Esq.
President, NAMI-NYC Board

Introduction of Conference and Greetings

Jack D. Gorman, MD
Professor and Chair – Department of Psychiatry at the Mount Sinai School of Medicine

Sharon E. Carpinello, RN, PhD
Commissioner, New York State Office of Mental Health

Borderline Personality Disorder: An Overview

Borderline personality disorder is a serious psychiatric condition with considerable prevalence and well documented morbidity and mortality. The syndrome has been noted to have a variety of clinical presentations, with the possibility of many different symptom constellations meeting DSM IV criteria for the disorder. The etiology of the disorder in not clear; as with many psychiatric illnesses, a consensus has evolved regarding a likely biologic predisposition in combination with environmental stressors as a working model for the illness. Multiple treatment interventions are now employed with considerable data regarding efficacy; these treatments include individual psychotherapies, group therapies including dialectical behavior therapy and other cognitive-behaviorally informed treatments, and pharmacotherapy.

Richard G. Hersh, M.D.
Richard Hersh is an Assistant Clinical Professor of Psychiatry at the Columbia University College of Physicians and Surgeons and the Assistant Director of the Intensive Outpatient Program at Columbia Presbyterian Medical Center. He is a graduate of Stanford University and received his M.D. degree from George Washington University. He completed an internship and residency in psychiatry at Northwestern University and served as an instructor in psychiatry at Harvard Medical School and as an attending psychiatrist at McLean and Massachusetts General Hospitals.

Neurobiological Findings in BPD

Borderline personality disorder is a diagnosis characterized by emotional instability, impulsivity, anger and aggression. There is evidence that it runs in families and is at least partially inherited. I will present data from neuroimaging studies using positron emission tomography showing that the brain regions, the orbital frontal cortex and anterior cingulate gyrus may inhibit aggression, and that serotonergic activation of these regions is less in borderline patients with aggression compared to controls. I will also show data that there is a difference in the way anger is controlled in the brains of men and of women and that physical aggression is seen when there is a more widespread deficit in frontal activation. In addition, relative metabolic brain activity in the orbital frontal cortex can be enhanced with fluoxetine, the same region that is underactive in borderline patients with poor impulse control.

Antonia S. New, MD

1995-present Assistant Professor of Psychiatry, Mount Sinai School of Medicine and Bronx VAMC New York, NY
1995-1997 Director of Research Fellowship Training, Dept. of Psychiatry, Mount Sinai School of Medicine, New York, NY
1995-present Research Director, Outpatient Services, Bronx VA Medical Center, Bronx, NY
1998-present Medical Director, Outpatient Services, Bronx VA Medical Center, Bronx, NY

A Continuing Debate: Is Borderline Personality Disorder a Trauma-Spectrum Disorder? a review of recent literature

This presentation will focus on the controversial question of whether Borderline Personality Disorder is part of a trauma-spectrum disorder. Data from the literature looking at prevalence of various childhood traumas in personality disorder, parameters of childhood sexual abuse in BPD and more recent studies in outpatient samples will be reviewed. An animal model of the neurobiological effects of childhood stress and subsequent human adult pathways of potential psychiatric illness will be described. Lastly the conceptualization of personality development as the interaction between biological temperament and environment will be exemplified by data from Caspi et al (2002) gene-environment interaction study on antisocial personality disorder.

Marianne S. Goodman, MD
Marianne Goodman is an Assistant Professor of Psychiatry at the Mount Sinai School of Medicine, and Bronx VA Medical Center. She is the director of the Dialectical Behavioral Therapy (DBT) Program at the Bronx VA Medical Center and member of the Mount Sinai Mood and Personality Disorder research group headed by Dr. Larry Siever. Her research interests are the interface of childhood trauma and BPD and neurobiological underpinnings of DBT.

Impulsivity and Aggression: Borderline Personality Disorder

Research suggests that impulsive aggression is a primary component of many psychiatric disorders, manifesting in a spectrum of behaviors from impulsive acting out behaviors to violent outbursts. Although there are no DSM-IV criteria for an impulsive aggression diagnosis, we are working to delineate the role of specific medications in the treatment of borderline personality disorder and autism based on prominent symptom components. Current studies have focused on the role of SSRIs, MAOIs, atypical neuroleptics, and mood stabilizers in the treatment of these patients. Data suggest that divalproex sodium, lithium and carbamazepine, either alone or used concomitantly with other medications provide mood-stabilizing and anti-impulsive effects in impulsive aggressive patients. Large-scale double-blind studies are needed to provide direction in the optimal care of these hard-to-treat patients. Data from double-blind, placebo-controlled studies in borderline personality disorder and autistic patients will be highlighted, and future directions discussed for the treatment of impulsive aggressive symptoms in these disabling disorders.

Eric Hollander, MD
Dr. Hollander is Professor of Psychiatry and Director of Clinical Psychopharmacology at the Mount Sinai School of Medicine in New York City. He is also Director of the Compulsive, Impulsive, and Anxiety Disorders Program and Director of the Seaver and Greater New York Autism Center of Excellence, also at the Mount Sinai School of Medicine. Dr. Hollander is the principal investigator for eight current federal grants, including the NIH Greater New York Autism Center of Excellence and the NIMH Research Training Grant in Psychopharmacology and Outcomes Research. Dr. Hollander is also the principal investigator for 11 current foundation and investigator-initiated industry grants. He is involved in research on the neuropharmacology, neuropsychiatry, functional imaging, and treatment of obsessive-compulsive disorder, impulsive/aggressive personality disorders, obsessive-compulsive-related disorders-such as body dysmorphic disorder and pathological gambling-and autism. Dr. Hollander has received a Research Scientist Development Award from the National Institute of Mental health to investigate the psychobiology of obsessive-compulsive and related disorders. He has received orphan drug grants from the Food and Drug Administration to study new treatments for body dysmorphic disorder, child/adolescent autism, and adult autism, and a grant from the National Institute of Drug Abuse for a study on the neurobiology of pathological gambling. He has received grants from the National Institute of Mental Health to develop treatments for borderline personality disorder, adolescent body dysmorphic disorder, and autism. Dr. Hollander has received two national research awards from the American Psychiatric Association and a Distinguished Investigator Award from the National Alliance for Research in Schizophrenia and Depression.

Biology of BPD: Towards a Rational Use of Medication and Psychotherapy

While the diagnosis of borderline personality disorder (BPD) was originally formulated by clinicians with a psychoanalytic background, new evidence suggests that disordered brain function underlies the impulsivity and emotional instability that are the cornerstones of this disorder. Both genetic factors, suggested by twin and family studies, and environmental factors contribute to the turbulent relationships, emotional storms, and poor impulse control associated with this disorder. Reduced activity of a brain chemical, serotonin, that regulates activity of the front part of the brain (prefrontal cortex) that inhibits or puts the “brakes” on the emergence of aggression may increase the likelihood of impulsive aggressive behavior. Genetic studies, medication trials, and brain imaging studies support such a model of reduced serotonergic activity. Deeper, more primitive regions (limbic regions) of the brain may drive the emotional instability of the disorder. Newer studies aim to characterize the specific brain circuitry involved in the intense negative emotions and low threshold for aggression implicated in borderline personality disorder using objective laboratory tests that are associated with aggression and emotional reactivity before and after medication or cognitive/behavioral therapy. Medications may help by enhancing the prefrontal “brakes” system by augmenting for example, serotonergic activity regulating this system or by reducing the “drive” from limbic system. Medications that block inactivation of serotonin (Prozac, Zoloft, Celexa, Paxil, Lexapro) work by the first mechanism and anticonvulsants (Depakote, Topamax, Lamictal, Tegretol) and lithium by the second mechanism. Psychosocial interventions may help to shift the maladaptive coping strategies acquired in the context of intense, shifting affects as well as impulsive acting out patterns by cognitive behavioral or psychodynamic methods.

    Larry J. Siever, MD
Larry J. Siever is Professor of Psychiatry and Director of the Out-patient Psychiatry Division at Mount Sinai School of Medicine in New York, New York. He also serves as Executive Director of Mental Illness Research, Education and Clinical Center (MIRECC) at the Bronx VA Medical Center in Bronx, New York. Dr. Siever has published over 325 peer-reviewed articles. (He earned his Bachelor of Arts degree from Harvard College, Cambridge, Massachusetts, and his MD from Stanford University School of Medicine, Stanford, California). He directs the Mood and Personality Disorders program at Mount Sinai, a federally funded research program which investigates the neurobiology of the schizophrenic spectrum personality disorders such as schizotypal personality disorder and impulsive/affectively unstable personality disorders, such as borderline personality disorder (BPD). He is a member of the American College of Neuropsychopharmacology (ACNP) and Past President of the Society of Biologic Psychiatry, from which he received the A.E. Bennett Award for clinical research.

Treatment: Transference-Focused Psychotherapy (TFP)

TFP is based on psychodynamic concepts and designed specifically for borderline patients. This twice-per-week individual therapy is described in a treatment manual. TFP combines many of the elements in the Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association. For example, TFP places special emphasis on the assessment and on the treatment contract and frame. This part of the treatment has a behavioral quality in that parameters are established to deal with the likely threats that may occur both to the patient’s well-being and to the treatment. The patient is engaged as a collaborator in setting up these parameters. A feature of TFP is the belief in a deep psychological structure that underlies the specific symptoms of BPD. The focus of treatment is on a fundamental split in the patient’s mind that divides perceptions of self and others into extremes of bad and good. This internal split determines the patient’s way of experiencing self, others and the environment, and it leads to the specific symptoms of BPD, such as chaotic interpersonal relations and impulsive self-destructive behaviors. After the behaviors typical of borderline pathology are contained through structure and limit setting, this split psychological structure is observed and analyzed as it unfolds in the transference [the relation with the therapist as perceived by the patient]. This work leads to an integration of the split internal world that allows for more flexible, adaptive, and satisfying functioning.

Dr. Frank Yeomans
Dr. Frank Yeomans is Clinical Associate Professor of Psychiatry at the Weill Medical College of Cornell University and Director of Training at the Personality Disorders Institute of the New York Presbyterian Hospital. His was educated at Harvard and Yale, and trained in psychiatry at the Payne Whitney Clinic. He then joined the faculty of the New York Presbyterian Hospital, where he was Unit Chief of the Borderline Unit in Westchester.
Dr. Yeomans combines practice with research, supervision and teaching at the Personality Disorders Institute. He also consults at a number of other sites internationally. His writings include A Primer on Transference-Focused Psychotherapy for the Borderline Patient.

Treatment: A Brief Overview of Dialectical Behavior Therapy

This presentation will provide a brief overview of DBT with an emphasis on the clinical strategies of problem solving and validation. The frame of DBT treatment will also be described and clinical examples will be provided.

Christine Foertsch, Ph.D.
Christine Foertsch has been conducting and teaching Dialectical Behavior Therapy (DBT) for over a decade. She was intensively trained in 1993, became a trainer with Dr. Linehan’s training group shortly thereafter, and has taught and consulted throughout the country and internationally since 1995. She has developed the model in inpatient and day program settings and directed the St. Luke’s Roosevelt Hospital DBT day program from 1998-2003. She has been particularly dedicated to implementing this treatment in community settings and for mixed populations of patients. She lives with her husband and twin toddlers in Putnam County, NY and is currently in private practice.

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