Handbook of Borderline Personality Disorder in Children and Adolescents

484 Pages·2014·6.33 MB·English

by  Carla Sharp

Carla Sharp 
Jennifer L. Tackett
Editors
Handbook of
Borderline
Personality Disorder
in Children and
Adolescents
Foreword by John M. Oldham
Handbook of Borderline Personality
Disorder in Children and Adolescents
.
Carla Sharp (cid:129) Jennifer L. Tackett
Editors
Handbook of Borderline
Personality Disorder
in Children and
Adolescents
Foreword by John M. Oldham
Editors
CarlaSharp JenniferL.Tackett
DepartmentPsychology DepartmentPsychology
UniversityofHouston UniversityofHouston
Houston,TX Houston,TX
USA USA
ISBN978-1-4939-0590-4 ISBN978-1-4939-0591-1(eBook)
DOI10.1007/978-1-4939-0591-1
SpringerNewYorkHeidelbergDordrechtLondon
LibraryofCongressControlNumber:2014932673
#SpringerScience+BusinessMediaNewYork2014
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Carla Sharp: For Milla and Christian—for
yourlove,patience,andsupport.
Jennifer Tackett: For my brother, Josh, who
gavemeinfinity.
.
Foreword
Greatprogresshasbeenmadeinourunderstandingofborderlinepersonality
disorder (BPD), a prevalent condition in clinical treatment settings that is
characterized by significant impairment in functioning and by disabling,
high-riskpatternsofbehavior.Persuasivedataare emerging thatclarify the
moderate heritability of BPD, the nature of its most relevant heritable
endophenotypes (e.g., emotion dysregulation and impulsivity), and the
importance of epigenetics and the principle of bidirectional gene/environ-
mentinteraction,allofwhichhelpusknowsomeofthethingstolookforas
wetrytounderstandagivenpatientwithBPD.Studiesutilizingsophisticated
brain imaging technologies are revealing patterns of neuropathology and
pathophysiology in patients with BPD that may, at least in part, explain
specificbehaviors.Forexample,volumeabnormalitiesinthelimbicsystem
and deficient connectivity between the limbic system and the prefrontal
cortex have been observed in patients with BPD, which could correlate
with emotional hyper-reactivity and impaired ability to down-regulate
emotions. These findings and many others, such as altered pain processing,
neuropeptide abnormalities, and abnormal immune responses, are being
steadily reported in patients with BPD, and there is a growing recognition
thatBPDisfundamentallyabraindisorder,conceptuallysimilartowhatuntil
recentlywerereferredtoas“AxisI”disorders.
Althoughthepersonalitydisorders(PDs)havebeenineveryeditionofthe
DiagnosticandStatisticalManualofMentalDisorders(DSM)oftheAmeri-
can Psychiatric Association (APA), the terms used to classify them have
changed through the years. In 1980, a multiaxial system was introduced in
DSM-III,inwhichthepersonalitydisorders(PDs)wereclassifiedonAxisII,
alongwithonlyoneothercategory,“SpecificDevelopmentalDisorders,”and
the rationale for placing these categories on a separate axis was to insure
“that consideration is given to the possible presence of disorders that are
frequentlyoverlooked...”(APA,1980,p.23).Intentionallyornot,Ibelieve
that the decision to locate the PDs on a separate axis from the “Clinical
Syndromes”onAxis I,such asaffective disorders, schizophrenicdisorders,
andanxietydisorders,reflectedacommonviewthatmanyAxisIconditions
were “biogenic,” i.e., heritableepisodicconditions,whereasthe personality
disorders were “psychogenic,” largely the result of early developmental
misfortune,andtheywerenotthoughtlikelytohavefavorableresponsesto
treatment.Nonetheless,evenifatleastpartiallysomotivated,thedecisionto
vii
viii Foreword
place the PDs on Axis II did have the intended result, launching a ground-
swellofresearchthathasledtoimportantadvancesinourunderstandingof
theseconditions,particularlyBPD.
Therehasbeenaparallelexplosionofprogressonthetreatmentfrontier.
I had the good fortune to chair the APA Work Group to develop a Practice
GuidelinefortheTreatmentofPatientswithBorderlinePersonalityDisorder,
whichwaspublishedin2001(APA,2001).Theprimary,orcore,evidence-
based treatmentrecommended for BPD was psychotherapy, combined with
symptom-targetedadjunctivepharmacotherapy,asneeded.Thetwospecific
typesofpsychotherapythathadthenbeenreportedtobeeffectiveinpatients
with BPD, based on randomized controlled trials (RCTs), were dialectical
behavior therapy (DBT) (Linehan, 1987) and mentalization-based therapy
(MBT)(Bateman&Fonagy,1999).Inmorethanadecadesincethen,RCTs
havedemonstratedtheeffectivenessofothertypesofpsychotherapy,includ-
ing transference-focused psychotherapy (TFP) (Clarkin et al., 2007),
schema-basedtherapy(SBT)(Young&Klosko,2005),cognitivebehavioral
therapy(CBT)(Davidson,2006),systemstrainingforemotionalpredictabil-
ity and problem solving (STEPPS) (Blum et al., 2008), and a number of
others.Furthermore,evidence-basedpracticeguidelinesforthetreatmentof
patients with BPD have now been published in The Netherlands (Trimbos
Instituut, 2008), the United Kingdom (Kendall et al., 2009), and Australia
(NHMRC, 2012), and a large Cochrane review has been published as well
(Lieb, Vollm, Rucker, Timmer, & Stoffers, 2010), all of which present
similar recommendations that psychotherapy is the primary treatment for
BPD.Theseworldwideanalysesofclinical studiesoftreatmentofBPDare
enormously encouraging, endorsing hope, and signaling that patients with
BPD can benefit from treatment and need not fear that a diagnosis of BPD
representsthepronouncementofa“lifesentence.”
Most of the work summarized above, however, has been carried out in
adultpatientswithBPD.Interestingly,DSM-IIIstatedthatPDs“bydefinition
begininchildhoodoradolescenceandarecharacteristicofmostofadultlife”
(APA, 1980, p. 306). In 1994, DSM-IV stated that “Personality Disorder
categories may be applied to children or adolescents in those relatively
unusualinstancesinwhichtheindividual’sparticularmaladaptivepersonality
traits appear to be pervasive, persistent, and unlikely to be limited to a
particulardevelopmentalstageoranepisodeofanAxisIdisorder.Itshould
berecognizedthatthetraitsofaPersonalityDisorderthatappearinchildhood
will often not persist unchanged into adult life. To diagnose a Personality
Disorder in an individual under age 18 years, the features must have been
presentforatleast1year”(APA,1994,p.631),andthislanguageisessen-
tiallyunchangedinDSM-5(APA,2013,p.647).Asaresult,therehasbeena
general assumption, even though it is incorrect, that clinicians were not to
diagnose PDs in anyone under the age of 18, which may have contributed,
untilrecently,totheslowpaceofresearchonPDsinadolescents.
Fortunately,thecriticalimportanceofprevention,earlyidentification,and
early intervention has gained traction for all forms of illness, and mental
disorders in particular have been referred to as the chronic diseases of the
young. Brain development during childhood and adolescence is complex
Foreword ix
under normal circumstances, as the pre-programmed process of change
transforms early high levels of neuroplasticity and cellular redundancy into
maturing states of greater efficiency, resulting in the emergence of abstract
thinking, executive function, cognitive control, and emotion regulation.
Successfulnavigationoftheseneurodevelopmentalwatersisenhancedbya
stable psychosocial environment and relies especially on the presence of
caring and available attachment figures. If a child has a moderate level of
heritable risk to develop an illness such as BPD, the presence of stable,
caring, and predictable caretaking figures may offset that risk and the PD
maynotdevelop.Conversely,however,evenalowerlevelofriskmaysetthe
stageforthedevelopmentofBPDinthecontextofcaretakerinconsistency,
neglect,orevenfrankabuse.
Asourunderstandingofearlydevelopmenthasevolved,abroadconsen-
sushasemergedthatdisruptionsinattachmentandexperiencesofearlylife
stresscanderailthesecomplexanddelicatematurationalprocessesinways
thatcanbedisablingandpersistent.Adolescenceisacriticaldevelopmental
window when pathological patterns of identity formation and behavior can
begintoappearasharbingersoffuturepersonalitydisorders,andrecognition
ofthesepatternsisthekeytoprotectiveearlyintervention.
Agreatdealofprogresshasbeenmadeinourunderstandingofemerging
patternsofBPDduringadolescence.Thisvolume,theHandbookofBorder-
line Personality Disorder in Children and Adolescents, is an invaluably
important compendium, contributing a wealth of new information. Carla
Sharp and Jennifer Tackett have assembled a remarkable cast of authors
(they among them) to cover with breadth and depth the latest conceptual
thinking,clinicalwork,andresearchfindings,richlyfillinginwhathavebeen
large gaps inourknowledge about the biopsychosocial scaffolding thatcan
lead to the emergence of BPD. A comprehensive resource, the Handbook,
presents sophisticated analyses of trait models of borderline pathology;
reviews of neurobiological, genetic, and social-cognitive (e.g., “hypermen-
talizing”) factors in borderline patients; descriptions of the early develop-
mental course of emerging BPD; and evidence-based treatment
recommendations.
ThefinalsectionoftheHandbookincludesadescriptionoftheAlternative
Model for the Personality Disorders, published in Section III (“Emerging
Measures and Methods”) of DSM-5. As a member of the Work Group on
Personality and Personality Disorders for DSM-5, I was involved in the
developmentofthisAlternativeModel(AM),whichre-framesthepersonal-
itydisorders,includingBPD,asmoderateorgreaterimpairmentinpersonal-
ity functioning (defined as impairment in a sense of self [identity and self-
direction] and impairment in interpersonal relationships [empathy and
intimacy]),alongwiththepresenceofpathologicalpersonalitytraits.Inthe
case of BPD, there is no stipulation regarding age of onset at age 18. In
addition to the presence of moderate or greater impairment in personality
functioning, BPD is defined by the presence of four or more of seven
pathological personality traits. Four of these are in the trait domain of
Negative Affectivity(emotionallability,anxiousness, separationinsecurity,
and depressivity), two are in the trait domain of Disinhibition (impulsivity