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Borderline Personality
Disorder: Origins, Treatments, Coping
June 4, 2004
Mt. Sinai
Medical Center, New York, NY
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Conference Sponsors: |
National Education
Alliance for Borderline Personality Disorder
(NEA-BPD)
Mount Sinai Medical Center
The New York City Chapter of the National Alliance
for the Mentally Ill (NAMI-NYC Metro) |
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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. |
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Conference Program |
| Welcome |
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Perry D. Hoffman, PhD
President, NEA-BPD
Charlotte Fischman, Esq.
President, NAMI-NYC Board |
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Introduction of Conference and Greetings |
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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 |
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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. |
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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. |
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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. |
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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 |
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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.
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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. |
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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. |
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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.
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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. |
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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. |
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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. |
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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.
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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.
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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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