BPD subtypes

[DrGachet]

What do you think of borderline personality disorder subtypes? Do the following make sense, based on your clinical/research experience?

There are a few different ones in literature, like "withdrawn–internalizing", "severely disturbed–internalizing", and "anxious–externalizing" in a recent study by Digre and Reece. Or "internalizing-dysregulated", "externalizing-dysregulated", and "histrionic-impulsive" (Bradley, Conklin, & Westen).

Millon talked about four subtypes: "discouraged" (with avoidant, dependent, or depressive features), "petulant (negativistic), "self destructive" (masochistic/depressive), and "impulsive" (histrionic/antisocial).

I've also heard of less academic distinctions, like narcissistic/externalizing/blaming type, versus internalizing/"don't-leave-me-or-I'll-cut-myself" type.

Personally I see BPD as histrionic traits atop a borderline personality organization, and think that the different subtypes are merely BPD combined with other personality traits.

Digre, E., & Reece, J.E. (2009). Treatment response in subtypes of borderline personality disorder. Personality and Mental Health, 3, 56 – 67.

Bradley R, Conklin CZ, Westen D (2005) The borderline personality diagnosis
in adolescents: gender differences and subtypes. J Child Psychol
Psychiatry. 46:1006 –1019.

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[HollyHobby]

What do you think of borderline personality disorder subtypes? Do the following make sense, based on your clinical/research experience?

There are a few different ones in literature, like "withdrawn–internalizing", "severely disturbed–internalizing", and "anxious–externalizing" in a recent study by Digre and Reece. Or "internalizing-dysregulated", "externalizing-dysregulated", and "histrionic-impulsive" (Bradley, Conklin, & Westen).

Millon talked about four subtypes: "discouraged" (with avoidant, dependent, or depressive features), "petulant (negativistic), "self destructive" (masochistic/depressive), and "impulsive" (histrionic/antisocial).

I've also heard of less academic distinctions, like narcissistic/externalizing/blaming type, versus internalizing/"don't-leave-me-or-I'll-cut-myself" type.

Personally I see BPD as histrionic traits atop a borderline personality organization, and think that the different subtypes are merely BPD combined with other personality traits.

Digre, E., & Reece, J.E. (2009). Treatment response in subtypes of borderline personality disorder. Personality and Mental Health, 3, 56 – 67.

Bradley R, Conklin CZ, Westen D (2005) The borderline personality diagnosis
in adolescents: gender differences and subtypes. J Child Psychol
Psychiatry. 46:1006 –1019.

I think this is a fantastic question!

I'm in my second year of an undergraduate psychology degree, so my clinical experience is zero - but this is a very specific interest of mine.

Atop of the subtypes you've mentioned there's quite a bit of talk about the "Quiet" borderline - someone with BPD who doesn't have difficulty controlling their temper or raging at others (arguably they internalize their anger so may be more likely to self-harm),
I'm unsure where this term stems from but as far as I'm aware their doesn't seem to be any clinical research on it.
Is it unusual for someone with BPD to not meet the criteria 'inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)'?

It's interesting that you see 'BPD as histrionic traits atop a borderline personality organization, and think that the different subtypes are merely BPD combined with other personality traits.'
I personally think there are definitely distinct subtypes(I'm just not sure of the how and why of them yet) - I've thought that possibly they're to do with sub-clinical(or undiagnosed co-morbid??) levels of other personality disorders, or perhaps just the way that meeting different criteria drastically effects the 'type' of person with BPD (eg. 1, 2, 5, 6 + 9 vs. 1, 3, 6, 7 + 9)

Do you find patients with BPD to be any more diverse then other populations?

Forgive me if I seem a little ignorant, or am asking too many questions, as I don't have much experience and my access to the literature can be frustratingly limited - I was happy to just lurk and read other responses but there's been nothing yet so I'm hoping to push the conversation along!

Also, going slightly off-topic, I read somewhere(my apologies if it was this forum) that if someone 'recovers' from BPD they usually develop NPD - do you think there's any truth in that?

 

[DrGachet]

Is it unusual for someone with BPD to not meet the criteria 'inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)'?

Well, emotional dysregulation is a core part of BPD, so if strong emotions are not expressed verbally, the person may resort to cutting and that sort of thing, more somatic or symbolic ways of expressing the pain.

Do you find patients with BPD to be any more diverse then other populations?

Ah, I have very little experience with that, but I don't think so. If you use the notion of borderline personality organization, however, there may be more diversity as all personality disorders may be present at borderline level of organization. In other words, you could have a person with narcissistic personality at borderline level or a person with paranoia at the borderline level, etc.

If someone 'recovers' from BPD they usually develop NPD - do you think there's any truth in that?

I don't know. I do know that is comorbidity with other Cluster B disorders...I think as many as 50% of those with BPD may have NPD. I'll see if I can find the source....

 

[kugel]

from MDConsult news:

Trend emerging toward treating syndromes in borderline personality disorder


March 21, 2011

BY SHERRY BOSCHERT
SAN FRANCISCO (EGMN) – Trials of drug therapy for borderline personality disorder have produced conflicting results and controversy, but a new trend is emerging: targeting medications to syndromes within the diagnosis.

Two or three recent meta-analyses of studies provide some support for this strategy, Dr. S. Charles Schulz said at the annual meeting of the American College of Psychiatrists, where he led an interest group discussion on drug therapy for borderline personality disorder.

“For the impulsive-aggressive borderline patients, the mood-stabilizing anticonvulsants have a very significant effect. For anger and cognitive or perceptual disturbance, the atypical antipsychotics are pretty good. For some depressed patients” with borderline personality disorder, the selective serotonin reuptake inhibitors (SSRIs) “can be useful,” though they have a small effect in these patients, said Dr. Schulz, chair of psychiatry at the University of Minnesota, Minneapolis.

As a result, in the last 4 years or so, clinicians are thinking more in terms of targeting medications to subsets of patients rather than drug therapy for borderline personality disorder as a whole, he said. “That’s emerging” and is a strategy worth testing in prospective trials, Dr. Schulz said. The scant data in the meta-analyses are “nowhere near enough to fully support what these meta-analyses” suggest, he added.

No medications have been approved by the Food and Drug Administration to treat borderline personality disorder.

Research also is needed to build on preliminary studies of combining drug therapy with psychosocial therapy for borderline personality disorder, he said. One preliminary study found that people with borderline personality disorder who were randomized to dialectical behavior therapy (DBT) plus the atypical antipsychotic olanzapine showed significantly more improvement than did patients who got DBT plus placebo. “The strongest impact was on decreased danger,” he said.

Studies of combining medications and psychosocial therapies are much more common for other psychiatric diagnoses than for borderline personality disorder, Dr. Schulz noted. “I would really like for us to step it up and mirror some of the other studies done for schizophrenia and bipolar disorder,” he said.

He believes the National Institute of Mental Health should better fund large studies of drug therapy for borderline personality disorder, as it has for other diagnoses.

“I feel pretty passionately about this,” Dr. Schulz said in an interview after the group discussion. “I’m pleased with the investment in the larger studies for bipolar disorder and schizophrenia. Borderline personality disorder is common, severe, and functionally impairing, and I believe we really need to understand it from a neurobiologic and psychologic vantage point.”

Another problem is researchers’ preference in the past decade for enrolling “symptomatic volunteers” in studies of treatment for borderline personality disorder instead of enrolling diagnosed patients, he added. Soliciting symptomatic volunteers from newspaper advertisements or other methods can make a trial easier for researchers because they don’t have to withdraw patients from medications in order to participate, but it’s unclear whether results from such trials can be generalized to treatment of patients in clinics and hospitals.

“We have to look at some new methodology” to have confidence in results, he said.

Initial trials of drug therapy for borderline personality disorder in the 1980s suggested that some low-dose neuroleptic medications helped, the tricyclic antidepressant amitriptyline made approximately a quarter of patients worse, and the benzodiazepine alprazolam proved to be dangerously disinhibiting, he said. When SSRIs were introduced, a double-blind, placebo-controlled trial found that fluoxetine was helpful for impulsive and aggressive patients with borderline personality disorder.

Various studies of atypical antipsychotic medications since the 1990s produced conflicting results, claiming they do or do not help patients with borderline personality disorder when compared with placebo. Several placebo-controlled trials report that anticonvulsant mood-stabilizing drugs can be helpful, particularly for patients with borderline personality disorder and impulsive-aggressive behavior, he said.

With any medication, he advised physicians to titrate the dose slowly. “Start low, go slow, and be very careful of the exquisite sensitivity that some borderlines have to some medications, which in my opinion cannot be detected in a clinical interview,” he said. At his institution, weekly case consultations bring psychiatrists and psychologists together to discuss the potential ramifications of drug therapy in a patient with borderline personality disorder.

Dr. Schulz has been an adviser to Biovail, Bristol-Myers Squibb, and Eli Lilly and has received grant support from AstraZeneca.

 

[DrGachet]

Interesting, thanks.