borderline personality disorder in individuals with...

2018Vol.4 No.2:6

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Review Article

Journal of Childhood & Developmental DisordersISSN 2472-1786

DOI: 10.4172/2472-1786.100069

Allison Cowan*

WrightStateUniversity,BoonshoftSchool of Medicine, 627 S. Edwin C. Moses Blvd, Dayton, Dayton, OH, United States

*Corresponding author: Allison Cowan

[email protected]

Assistant Professor, Psychiatry, Wright State University,BoonshoftSchoolofMedicine,Dayton, OH 45417, United States.

Citation: Cowan A (2018) Borderline Personality Disorder in Individuals with Intellectual Disability. J Child Dev Disord. Vol.4 No.2:6

IntroductionBorderline personality disorder (BPD) is described in the DSM-5 as “apervasivepatternofinstabilityof interpersonalrelationships,self-images,andaffects”[1].TheprevalenceofBPDisestimatedto be close to 6% in theUnited States [2], and the prevalenceof intellectualdisability isestimatedtobeabout1%worldwide[3,4]. The literature about the co-occurrence of these twodisorders is scarce.While not a representative sample, Lindsayetal.foundaprevalenceof39.9%ofanypersonalitydisorderinforensic intellectual disability services and Borderline Personality Disorderbeing10-13%[5].Thereremainssignificantvarianceinthe understood prevalence of the disorder due to diagnosis being controversialinregardtodiagnosticovershadowing[6].SymptomsofBPDinthiscasewouldbeattributedtotheindividual’sintellectualdisability rather than to a diagnosable disorder. Some authors advise cautiongiventhatpeoplewithIDalreadyhaveonedevalueddisorderandthattoaddanotherdevalueddisordercouldpotentiallybeevenmorestigmatizing[7].TheStandardizedAssessmentofPersonalityis a semi-structured diagnostic interview which relies on havinga collateral historianwhohas known thepatientwell for at leastfiveyears[8]. Ithasbeenshowntohavevalidityforthediagnosisof personality disorder in adults with learning disability and severe behavioral problems [9].However, therehas not been convincingresearch into the true prevalence of the co-occurrence of these two disorders.

Diagnosis of BPD in Individuals with IDIndividuals with ID are often brought to the attention of apsychiatrist for aggression or “challenging behavior.”This isnotunlikeBPDwithself-injury,parasuidicalbehavior,suicidalideation,and suicide attempts. Also, like individuals with ID, individualswith BPD also have neuropsychological deficits including lowerverbal, performance, and full-scale IQ scores compared to controls[10].Theywerealsofoundtohaveimpairedmotorskillsvisuomotor integrationandwithasusceptibility to interference[10]. Findingsofdeficits inmemory,executive functioning, andprocessingspeedbyUnokaandRichman[11]havebeenshowntobemediatedbyleveloneducation,whichsuggeststhatpeoplewithintellectualdisabilitiesandBPDwouldfareworse.Negativeaffects appear to interfere with cognitive processing in peoplewithBPDinawaythatisdifferentfromcontrols,anddecreasedactivation in the orbitofrontal cortex [12]. The implications ofthese deficits in BPD are not yet elucidated in individualswithco-occurring ID and BPD, but the overlap of these disorders could indicate a poorer prognosis.

DM-ID-2 describes the following limitations in diagnosingindividualswithintellectualdisabilitieswithpersonalitydisorders[13].Theseinclude

- Any diagnosis of personality disorder should take into accountpersonalcharacteristicsinthecontextofanormalcultural framework…

Borderline Personality Disorder in Individuals with Intellectual Disability

Abstract Both Intellectual Disability (ID) and Borderline Personality Disorder (BPD) can be associated with behavioral dysregulation including self-harm, impulsivity, andintenseanger.Whenthesetwoentitiesoverlap,cliniciansarefacedwithlimitedguidance.TheAmericanPsychiatricAssociationhasguidelines for thediagnosisand treatment of Borderline Personality Disorder as well as the diagnosis of Intellectual Disability. The NADD press has published an adaptation of thesediagnosticcriteriaforBorderlinePersonalityDisorderastheyapplytothosewithID, but there are not yet any guidelines for treatment in co-occurrence of these disorders. This paperwill review the literature on the co-occurrence disordersandproposetreatmentrecommendationsfollowingtheexistingliteratureandinadaptingcurrenttreatmentstrategiesforpeoplewithID.

Keywords: Borderline personality disorder; Intellectual disability; Adapted treatment for co-occurring BPD and ID

Received: March19,2018; Accepted: April 05, 2018; Published: April 12, 2018

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- TheIDDitselfislikelytopresentsomefeaturesthatarethesame as those of personality disorder…

- TheIDDislikelytohavecontributedtodelayeddevelopmentand a degree of immaturity.

- Institutional experience is pervasive among this clientgroup,andadaptationto institutional lifeshouldbetakeninto account when considering a diagnosis.

- Many individuals with IDD have experienced a protectedupbringing,givingthemareducedaccesstoopportunitiesto learn social norms, community skills, and so on…

- Along with other authors, the current committeerecommends the use of behavioral observation andinformantinformation,collectedinastandardizedmanner,asaprimaryinformationsourceinmakingadiagnosis.

- DM-ID-2, 2016.

DiagnosisinindividualswithIDcanbedifficultingeneral.Verbalandnonverbalcommunicationcanbeimpacted.Inworkingwithpeople with ID, more information about specifics like times,dates,andpatternsofbehaviormightbegatheredfromcollateralsources such as caregivers and family since a person with ID might not know these types of information. When addressingthe diagnosis of BPD in individuals with IDD, individuals with ID are“generallymorereliantoncaregiversthanareothersectionsofthepopulation”[13].Forexample, ifthecriteriaforavoidingreal or imagined abandonment is to be met, care must be taken to remember that individuals with ID have real reason to fear if aprimary,relied-uponcaregiverisnotpresent.Thispersonmayberesponsiblefortransportationtowork,helpingwithADLs,orcookingmeals.Theabsenceofthispersonmayconstitutearealemergency,andnotsimplythethreatofemotionalabandonment.As noted by Alexander and Cooray [14], the diagnosis ofpersonality disorders often requires subtle and subjectiveinformation like thoughtsand feelingswhich canbedifficult toobtaininpeoplewithreceptiveandexpressivelanguagebarriersaswellascognitivelimitations.

Of the nine criteria for diagnosis of Borderline Personality, elicitingthecriteriaofidentitydisturbanceandchronicemptinesscan be thought of as one of the most challenging as the skills required for the understanding of these concepts are “fairlysophisticated”[13].Additionally,makingdiagnosismoredifficultis the interrogative suggestibility of those people with ID andthe increased susceptibility to leading questions [15]. This isoften called “yessing” the interviewer—the individual answersquestionswith yes instead of admitting ignorance or providingananswertheindividualpredictswillupsettheexaminer.Thereremainstheexhortationthatself-injuryandangerdysregulationare often found in people with intellectual disability and that other causes be discounted before making a diagnosis of BPD [13]. Otherwise, the DM-ID-2 leaves fairly unchanged the ninecriteria for the diagnosis of BPD in individuals with ID.

Treatment of BPD in Individuals with ID The American Psychiatric Association encourages a thoroughassessment of suicide risk factors and reminds clinicians that

the primary treatment for BPD is psychotherapy, complemented by symptom-targeted pharmacotherapy (APA, 2010). While professionalsevaluatethetreatmentofpatientswithpersonalitydisorder and mild ID will take longer and that longstanding reduction inbehavioral problems is less likely [16], it hasbeendemonstrated that psychotherapy adapted for individuals with ID iseffective[17,18].Additionally,thereisevidencethattreatmentcanbeeffectiveforco-occurringBPDandID[19-21].DialecticalBehavioralTherapy(DBT)hasevidenceofreducinglevelofrisksandimprovementinoverallfunctioninginindividualswithIDandBPD[20].fMRIhasshownthatDBTreducesamygdalarhyperactivityinindividualswithBPDalone[22].Roscoeetal.foundthatwhileparticipantsshowedvaryinglevelsofunderstandingofDBT,therewerethemesoffindingDBTashelpfulandbeneficial[23].LargereductionsinchallengingbehaviorsinindividualswithIDandBPDwereshowninafour-yearstudywithDBTandaSkillsSystem[24].

Good Psychiatric Management of Borderline Personality Disorder is described as once weekly individual therapy (if useful), case management,andprudentmedicationmanagementifnecessary[25].GPMhasbeenshowntobeaseffectiveasDBTforindividualswithout IDacrossabroad rangeofoutcomemeasures [26,27].ThemethodproposedhereistoadaptthecoretenetsofGPMtotreatmentofindividualswithco-occurringIDandBPD.Thebasicprinciples of GPM are

- Offerpsychoeducation

- Beactive,notreactive

- Bethoughtful

- Therelationshipisrealaswellasprofessional

- Conveythatchangeisexpected

- Fosteraccountability

- Maintain a focus on life outside of treatment

- Beflexible,pragmatic,andeclectic

- Good Psychiatric Management for BPD, 2014

Thepsychoeducationprovidedin GPM is that the majority of people diagnosed with BPD will no longer meet criteria for BPD at ten years [28,29].Anotheraspectofpsychoeducation is thatgenetic factorshaveasignificantrelationshipindevelopingthedisorderassupportedbyfamilyandtwinstudies[30,31].ThisisinoppositiontopreviousstancethatpatientswithBPDare“untreatable”andthatthefailuresin treatment “were explained solely by the borderline patient’sperniciousmotivations”[32].GPMalsocallsforthefrankdiagnosisof BPD, walking through the criteria with patients. In individualswithIDandBPD,theseconversationsoftenprovideprofoundrelief.Knowledgeof an illness and treatment results in reduced anxiety[33].Familiesandcaregiversarecomfortedtohaveadiagnosisthatfitswith their lovedone’s symptoms. This can function to reduceshame and to increase acceptance and support and reinforcing thatthesymptomsthattheillnessisnotthefaultofthepatientorthe familyoforigin.Theadaptationofpsychoeducationwouldbeexplainingterminologyinclearterminology.

Thetenetsof“beactive,notreactive”;“bethoughtful”;and“beflexible, pragmatic, and eclectic” are a function of therapeutic

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stance[25].Ratherthanthecaricature of a silent psychoanalyst, clinicians working with individuals with BPD are encouraged to bewarm,empathic,andcuriousaswellasusingtechniquesthatcan be more supportive or more interpretative. This naturallyleadstotheprinciplethattherelationshipisarealrelationship—the clinician should “acknowledge…mistakes” and “acceptidealization,butdonotencourageunrealisticexpectations”[25].TheseshouldalsoallholdtrueforworkingwithindividualswithID. Clinicians may have an easier time forming a therapeuticalliance with the caregiver who brings the patient, but theprimaryrelationshipshouldbewiththeindividualbeingtreated.

The remaining principles focus on life outside the treatmentoffice. “Change is expected,” “accountability,” and “focus onlife outside treatment” all stress the importance of makingimprovementswithintherapyandthattheindividualparticipatein social rehabilitation. The reliance of individual with BPD onromanticrelationshipsfor feelingsofconnectednessandworthcan be problematic, butGPMencourages patients to focus onwork-eithervolunteerworkorpaidwork.TheseGPMprinciplesare easily translated to work with people with ID and BPD. TherearemanyservicestoencourageindividualswithIDtofindsupported or individual employment, either through sheltered workshops or through boards or departments of developmental disabilities. Interestingly, attending a training for GPM has theadditionaleffectofdecreasingdislikeofpatientswithBPDanddecreasingthebeliefthatBPD’sprognosisishopelessaswellasincreasing the belief that effective psychotherapies exist [34].Conveying that change is likely andexpectedfitswellwith theevidence of likely remission for a significant portion of peoplewith BPD. However, there remains a need for long-term follow-up studies for people with co-occurring ID and BPD.

Particular attention should be paid to interpersonalhypersensitivity—the reaction to a real or perceived slight orinsultwithemotional instability [35].Caregiverscanpresent topsychiatricofficeswithreportsof“he/she justgotenragedoutofnowhere.”When lookingat thespecificsof theevent,oftena perceived loss or slight can be determined as the incitingevent. Educating the interdisciplinary teamabout theseeventsprecipitating a response seemingly out of proportion can behelpful in understanding the individual with ID and BPD as well as generatingincreasedempathy.

While psychotherapies are the preferred treatment in working withpeoplewithBPD,polypharmacyoccurswithmostpatientswith BPD [36-38]. Polypharmacy also occurs at higher rates inindividualswithIDthanthegeneralpopulation.A2016studybyDebetal.showedthat89%ofpatientswithchallengingbehaviorwerereceivingpsychotropicmedicationsand45%receivedmorethanonpsychotropicmedication.Onestudyfoundthatindividualswith ID were more likely to live at home, more likely to have been prescribedCNSmedicationsexcludingbenzodiazepinesandmoodstabilizersthatarealsoanticonvulsants,andmorelikelytohavehadpsychiatrichospitalization[39].ThereisnomedicationthathasreceivedtheFoodandDrugAdministrationindicationforthetreatment of BPD, but there is someevidencethatmedicationsmaybehelpfulwhentargetedtoaspecificsymptom[40].Thereis

insufficientevidence,however,tosupporttheuseofpsychotropicmedicationsforthechallengingbehaviorsdescribedinintellectualdisabilities[41]. Ifmedicationsareusedforpeoplewith IDandBPD, functional analyses can be used to measure the effectsof psychotropicmedications andmedication changes [42]. TheInternational guide to prescribing psychotropic medications toindividualswithIDrecommendsthelowestoptimaldose,regularfollow-upandconsiderationofdiscontinuationoftreatment[43].ThisisalsowhatisrecommendedinGPMinconsideringuseofpsychotropicmedicationstotreatsymptomsofBPD[25].

The recent focus on Trauma-Informed care in ID has had theimpact of educating direct care staff about the existence andsequelaeof trauma[44].RatesofmistreatmentofpeoplewithID have been found to be higher than that of control groups [45],and individualswithBPDreporthigher ratesofchildhoodmaltreatment[46].Takingthesefactorsintoconsiderationwouldbebeneficialforfamiliesandcaregivers.OthertreatmentssuchasEMDRandHorticulturalTherapyhavealsobeenshowntobehelpfulinindividualswithID[47,48].

Clinical VignetteMs. A is a 28-year-old woman with a diagnosis of Mild Intellectual Disability. She presents with her mother for anger outbursts resulting in property destruction and physical violence. Herworkshopstaffsendinwrittenincidentreportsthatstatetheseepisodes “come out of nowhere.” When discussing the latestevent in more detail with her therapist, Ms. A reported that her favoritestaffpersonwasgoingtogoonthescheduledoutingonanothervanandMs.Afeltleftout.Ms.Areported,“Shelikesthoseotherpeoplebetterthanshelikesme.”Whengatheringhistory,Ms.Aalsoendorseschaotic,intenserelationshipscharacterizedbydatingonepersonforaweek,typicallybecomingmadathim,breaking up and immediately starting to date someone else.She endorses affective instability in response to interpersonalhypersensitivity, e.g. is elated with positive feedback fromsupervisorbutenragedwhenroommatedidn’thearherrequestfrom the other room and assumed she was ignoring her. Ms. A alsoreportsbingeeatingandspendingherclothesandnecessitiesallowanceon items that shedoesnotneed, later regretting it.Whenupsetafterafightwithherroommate,Ms.Athreatenedtokill herself. When she was calmed, she reported that she did not meanit,butthatshewasonlyupset.Thisalsofollowsapatternthat when Ms. A is upset, she threatens suicide but is typically redirected.

Ms. A’s treatment team made the diagnosis of BorderlinePersonality Disorder. Her family reported that she had previously been diagnosed with Bipolar Disorder but that when described, those symptoms did not fit the BPD criteria did. Her motherreported,“It’s likethat listofborderlinesymptomswaswrittenabout her.” Ms. A’s team worked with her on connecting herfeelingsandreactionstoeventsofinterpersonalhypersensitivityandusingcopingskillsratherthanpropertydestruction.Shewasable to get a volunteering job working with animals at a shelter and reported that it made her feel good to help. Her psychiatrist was able to slowly reducesomeofthemedicationsthatshewastaking.Ms.Aisdoingbetterattwo-yearfollow-up.

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ConclusionWhile there remains lack of research about the diagnosis of BPD in individualswith ID, theadaptationofDSM-5criteriabyin the DM-ID-2 provides guidance about the potential pitfallsandintricaciesofworkingwithpeoplewithID.Thereareseveral

therapies that have evidence of being effective in treatingindividualswith ID includingDBTandCBT.Thisarticle suggestsadaptingGood PsychiatricManagement for BPD for treatmentof individuals with ID. There remains a great need for furtherresearchbothinthediagnosisandoptimaltreatmentofpeoplewith ID and BPD.

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