A Case study of Borderline Personality Disorder complicated by Intellectual Disability and misdiagnosis

Rachael’s Story

• Lived with foster parents from 9 weeks • Mild Cerebral Palsy • Aggression from a young age • Numerous placements and respites • Numerous behavioural programs • Variety of medications • Diagnosed with Autism • DoCS to DADHC handover…

A Quick Overview

• Case study - Rachael • DSM-IV-TR diagnostic criteria • Stop walking on Eggshells (Mason & Kreger, 1998) • Borderline Personality Disorder (BPD) and DSM-IV-TR, Axis 1 and 2 • The Borderline Controversy • A Question of Attachment, Personality and Developmental Disability

Some statistics

• BPD is less known but more common then bipolar disorder or schizophrenia • 2% of the general population • 10% of all mental health outpatients • 20% of psychiatric inpatients • 75% are women • 54% have substance abuse problems • 75% have been physically or sexually abused • 14.9% of American adults have a personality disorder – Recent American study, NESARC, n=43,000 (cited in Wright, 2004)

Rachael’s Story

• Mood swings from charming to aggressive • Triggers to emotionally or physically aggressive outbursts hard to identify • Tall stories including ‘nightmares’, alleged sexual abuse and being too sick to go to school • Manipulating staff • Irrational or dissociated comments • Strategies included – Car with a safety shield – Safety room for staff – Reactive and proactive strategies and OHS procedures

Diagnostic criteria for 301.83 Borderline Personality Disorder 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 Criterion5 (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 (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

Remembered by the mnemonic

P

- Paranoid ideas

R

- Relationship instability

A

- Angry outbursts, affective instability, abandonment fears

I

- Impulsive behaviour, identity disturbance

S

- Suicidal behaviour

E

- Emptiness

Stop Walking on Eggshells Additional Criteria

• Pervasive Shame (often related to sexual or physical abuse) • Undefined Boundaries • Control issues • Lack of object constancy • Interpersonal Sensitivity (BPD ‘psychic abilities’) • Situational Competence • Narcissistic demands (ego-centred also an infantile stage of personality) • Manipulation or Desperation?

• High Functioning, Low Functioning • Acting In, Acting Out (Abuse and accusation vs. self mutilation and suicide)

Rachael’s Story

• Health professionals reluctant to confirm diagnosis of Borderline • Antidepressant helpful but didn’t solve everything • Rachael moved to a new group home • Weekly counselling including relaxation, social skills worksheets and interpersonal and psychodynamic work – Did not confront negative behaviour until stronger rapport was built

DSM-IV-TR Axis I and II

• Most diagnostic criteria in the DSM includes the warnings – ‘Not if better accounted for by…’ – ‘Does not occur exclusively during the course of …’ – ‘Criteria are not met for …’ • Both personality disorders and intellectual disability listed on Axis II • Diagnostic Overshadowing? (Reiss, 2000; Reiss, Levitan & McNally, 1982) • A question of co-morbidity and jargon

The Borderline Controversy

• The borderline myths within psychology and psychiatry • Labelling, stigma and reluctance • On the borderline between psychosis and neurosis?

• Emotional dysregulation disorder? Reactive Attachment Disorder?

• DSM V due in 2011 • Some literature suggesting that personality disorders only occur in mildly intellectually disabled people (Masi, 1998) • Personality disorders within Developmental Disability - A minority within a minority group or an undiagnosed population?

Attachment, personality and developmental disability

• Literature saying that relationships difficulties and insecure attachment more common in this population. Many factors including residential services that militated against emotional development. disorder. ( (Clegg & Lansdall-Welfare, 1995) • “Attention Seeking” – we ALL need attention • There is a link between attachment and challenging behaviour that needs more research. (Clegg & Sheard, 2002) • There is a link between attachment and personality Agrawal, Gunderson, Holmes & Lyons-Ruth, 2004)

A Question of attachment, personality and developmental disability

Question – what defines the continuum from a healthy personality to a disordered person? And from early attachment to adult intimate relationships?

When does a label help?

If I tried to answer this question I think it would be good to keep in mind: • 14.9 percent of Americans 18 years or older… • Health is a bio-psycho-social phenomena.

• Regardless of age or ability, no person is independent, we all have a Self and persona which must exist within many interdependent relationships.

• Nelson Mandela, Gandhi, some of my clients, sports heroes and hardened criminals all challenge society.

Rachael’s Story

• Frequency of aggression greatly reduced • Attended a personal development / sex education course • Had her first kiss • Reconnected with family • Changing jobs we had to say goodbye

References and Resources

www.BPDcentral.com

Agrawal, H., Gunderson, J., Holmes, B. & Lyons-Ruth, K. (2004).

Attachment Studies with Borderline Patients: A Review.

Harvard Review of Psychiatry, 12(2), 94-104.

Clegg, J.A. & Lansdall-Welfare, R. (1995).

Attachment and Learning Disability: a theoretical review informing three clinical interventions.

Journal of Intellectual Disability Research, 39, 295-305.

Clegg, J.A. & Sheard, C. (2002).

Challenging Behaviour and Insecure Attachment.

Journal of Intellectual Disability Research, 46(6), 503-506.

Masi, G. (1998, Summer).

Psychiatric illness in mentally retarded adolescents: clinical features.

Adolescence.

Mason, P. T., Kreger, R. (1998).

Stop Walking on Eggshells: Taking your life back when someone you care about has Borderline Personality Disorder.

New Harbinger.

Reiss, S., Levitan, G. W., & McNally, R. J. (1982).

Emotionally disturbed mentally retarded people: An underserved population.

American Psychologist, 37, 361-367 Reiss, S. (2000, Spring).

A Mindful Approach to Mental Retardation.

Journal of Social Issues.

Wright, J. (2004, Oct 15).

A survey of personality disorders.

American Family Physician.

The I-CAN!

…Shameless plug…