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Helen Gottfried UnRuh Senior Manager, Canadian Mental Health Association Ottawa Deanna Mercer MD FRCPC psychiatry Associate Staff, Department of Psychiatry, TOH Assistant Professor, Department of Psychiatry, University of Ottawa

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BPD symptoms A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. identity disturbance: markedly and persistently unstable self-image or sense of self. 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. chronic feelings of emptiness (or boredom) 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociative symptoms

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The pain of being borderline Newly admitted inpatients, 146 BPD, 34 Axis II controls 50 dysphoric feelings BPD > other Axis II on all 50 dysphoric feelings % of time spent feeling: Overwhelmed 61.7% Worthless 59.5% Very angry 52.6% Lonely 63.5% Misunderstood 51.8% Abandoned 44.6% Betrayed 35.9% Rare in non-BPD patients Evil 23.5% Out of control 33.5% Like a small child 39.1% Like hurting or killing themselves 44% Zanarini et al 1998

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Treatment Histories 2 year study of freshman with (169) and without (192) BPD features BPD+ : more pharmacologic, psychological and medical treatment, even after controlling for gender, Axis I, II pathology Bagge et al 2005 MSAD: 290 BPD, 72 other axis II consecutive inpatients at McLean hospital patients with BPD 2- 4.5 times more likely to have received each of 12 types of treatment Zanarini et al 2001, CLPS study : treatment seeking patients 175 BPD, 426 other PD, 97 MDD only BPD > MDD OR 2.14 6.19 individual, group, family, day hospital, inpatient, all classes of medication BPD > OPD for all treatments except family/couples and self-help Bender 2001

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BPD prevalence General population 1% M=F Outpatients 10 20 % Inpatients 20% Lezenweger 2007, Coid 2006, Samuels 2002, Torgersen 2001, DSMIV 200 5

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Comorbidity OverallInpatients (Zanarini 2004) Depression50%86.6 % Dysthymia70%44.8% Bipolar II11%5.5% Bipolar I9%0% (exclusion criteria) ED (AN, BN)25% (5%/20%)53.8% (21.7%/24.1%) PTSD30%58.3% SUD35%62.1% Alcohol only25%50.3% Panic Disorder45.2% OCD14.5% Gunderson, Links 2008, Zanarini et al 2004

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Influence of BPD on Axis I disorders CLPS BPD + MDD : MDD remission in 64% Other PD +MDD: MDD remission in 89% Gunderson et al 2004 MSAD BPD remitted: significant decline in rates of axis I disorders BPD never remitted: Rates of axis I disorders (mood, anxiety, SUD, ED) remained stable despite intensive treatment Zanarini et al 2004

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Age as a predictor of symptomatology, co-occuring disorders, and socioeconomic characteristics in BPD N. Kleindienst, M. Limberger, J. Barth, M. Bohus Central Institute of Mental Health Mannheim, Germany

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Methods Sample of treatment-seeking BPD-patients (n=367) University of Freiburg, CIMH (Mannheim) female BPD (DSM-IV) Age: 18 to 65 Census data from the general population comprising all women from the catchment area (n=2,383,000) data from the general population were matched by nationality and age Bench mark (e.g., marital status)

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Distribution of Age (n=367 fem. BPD-Patients) Crucial for - education - vocational training - employment - starting a family

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Education: Years of Schooling 2 =0.16, df=2 p=0.92 Patients are on par with respect to schooling (qualifying for univ. admission)

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Completed Vocational Training 2 =7.59, df=2 p=0.02 Differences were minor similar level with respect to vocational training

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Employment Status Very large differences in employment status Premature Pension: 7% (Re-)Education / Secon- dary Labor Market 21% Homemaker: 7% other: 18% Employed Unemployed Other 2 =387.03, df=2, p

Cochrane 2012 meta 4 outcomes DBT vs TAU Anger- large Parasuicide, mental health status moderate Single studies estimates of effect (DBT vs TAU) DBT>TAU BPD core pathology and associated psychopathology

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DBT vs TAU studies: summary 6 DBT (Linehan 1991, 2006, Turner 2000, Koons 2001, Verhuel 2003, Clarkin 2007) 2 DBT-S (Linehan 1999, 2002) With TAU 1-3 : DBTTAU retention 2/5 studies DBT

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DBT vs Level 4 treatments Level 4 treatments Well defined theoretical basis Weekly supervision, support Once or twice weekly intervention Active therapists Here and now focus DBT=GPM significant reductions in: suicide attempts*, self harm episodes, ER visits, psych hospital days, # BPD symptoms, depression, anger, interpersonal function McMain et al 2009 DBT vs TFP DBT= TFP significant improvements SI/A, depression, anxiety, GAF, retention in treatment DBT