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Review:
Sim Centre experience
 Borderline
Personality
Disorder
Hiba Zafran, PhD
March 18th, 2019 / OCC-443
Learning objectives
• Debate what a ‘personality’ is
• Describe an overview of personality
disorder diagnoses
• Define previous and current understandings
of borderline personality disorder
• Critique the BPD diagnosis from a social
(gendered) perspective
• Consider the occupational and therapeutic
challenges of individuals with BPD
What is a personality?
Depends on your theories
• Psychology
– Categories and traits
– Temperament and childhood experience
• Sociology
– Class, opportunity, access, gaze
• Cultural understandings of personhood
• Neurobiology of the brain
• Religion and the ‘soul’
So…then what is a disordered personality?
• Life-long pattern of relational mal-adaptation
• Emerges no later than adolescence
• No periods of remission ~ stable and persistent
in character
• Personality traits are only considered clinical
or diagnosable if they become prominent and
rigid enough to cause dysfunction (Bonder, 2004)
• Inconsistent diagnosability by self, others or co-
morbidity
• 10-20% of the general population
ICD-10
• Deviation of inner experience:
– Cognition ~ misinterpretation of other s behaviors and
situation, forming pervasively negative or maladaptive
attitudes about self and others.
– Affect ~ range is too broad or restricted, inappropriate
intensity of emotional response and emotional arousal (in
either direction)
– Self-control ~ of impulses and gratification of needs
– Interpersonal ~ manner of relating to others and handling
social situations
• Dysfunction across a broad range of personal and social
situations
• Distress and/or impact on social environment
An OT definition (Nott, 2005)
Personality refers to the characteristics and
behavior that make up an individual s adjustment
to life and includes major traits, interests, values,
self-concept, abilities, drives and emotional
patterns

Less impaired clinically but functionally more

disabled
Even though they may appear more stable with
good jobs
 • Personality: A person s characteristic
totality of emotional and behavioral
traits that is stable and predictable
(Kaplan & Sadock, 1998, p.775)
• Personality Disorder: Enduring
subjective experiences and behavior
that deviate from cultural standards,
are rigidly pervasive, have an onset in
adolescence or early adulthood, are
stable through time, and lead to
Before DSM5 unhappiness and impairment (DSM-
IV)
• People with an Axis II diagnosis find
it hard to distinguish that what their
experience of normal is, others find
painful.
The differences between….
Axis I Axis II

• Episodic • Enduring pattern

• Neuro-chemical • Deeply rooted cognitive-
dysregulation emotional dysfunction
• Symptoms are responsive • Medications do not
to medications remove the personality
style
 ( DSM- IV c r i te r i a )
The Axis II Clusters
• Cluster A
• Misinterpretations focus on the avoidance of intimacy
and the creation of relationships. Odd and eccentric,
sensitive and suspicious personalities
• Cluster B
• Affective life is tumultuous leading to a range of
acting out behaviors to seek attention in relationships,
or to react to social norms. Emotional and dramatic,
impulsive and erratic
• Cluster C
• Fragility of self and perception of the environment is
such that there is a need to rigidly control situations,
or heavily rely on others. Anxious and fearful, worry,
low self-esteem and poor confidence
 r sona l i t y Di sor d e r s
Cl ust e r A Pe
lin ic ally u n lesith comorbidity
s w
Rarely seen c
• Paranoid
– Overly suspicious, interprets situations as hostile or contemptuous,
bears grudges, doesn t forgive, combative with a tenacious sense of
personal rights. Will not trust others. .Inability to take responsibility
for own feelings, jealousy, micro-psychosis
• Schizoid
– Limited ability to express warmth or anger towards others; appears
cold, detached , indifferent. Prefers solitary activities which may not
even provide pleasure. No close relationships. Disregards social
norms unintentionally.
• Schizotypal
– Discomfort with close relationships, cognitive and perceptual
distortions are present, for e.g.: ideas of reference, odd beliefs and
magical thinking, bodily illusions, odd thinking and speech (vague,
metaphorical, circumstantial, over elaborate), appearance that is odd
or eccentric, and social anxiety that is associated to paranoid fears
rather than negative judgments about self.
 B P er sonality D iso r de r s
Cluster / R s a n d ja il s
y se rv e d b y E
Population significantl
• Antisocial ~ disregard for, and violation of, the rights and
safeties of others. Deceit, illegal acts, impulsivity, irritable
and aggressive, lack of remorse.
• Borderline
• Histrionic ~ Excessive emotionality and attention-seeking.
Sexual and provocative behaviors, uses physical appearance
to draw attention to self. Rapidly shifting and shallow
expression of emotions. Dramatic style of speech with little
detail. Is suggestible and easily influenced by others or
circumstances. Considers relationships to be more intimate
than they actually are.
• Narcissistic ~ Grandiosity in fantasy or behavior that
shows self-importance and the need for admiration. Lack of
empathy. Thoughts of unlimited success, power, brilliance,
beauty, ideal love. Believes self is special and unique and
should only be around other such people of status. Sense of
unreasonable entitlement. Is interpersonally exploitative.
Is often envious of others and believe they are envious of
him/her. Demonstrates arrogant, haughty behavior and
attitudes.
 pe r sona li ty d isor d e r s…
Former
Depressive personality disorder - is a pervasive pattern
of depressive cognitions and behaviors beginning by
early adulthood. Now reframed as Dysthymia
Passive-aggressive personality disorder: (negativistic
personality disorder) - is a pattern of negative attitudes
and passive resistance in interpersonal situations
Sadistic personality disorder: A pervasive pattern of
cruel, demeaning and aggressive behavior.
Self-defeating personality disorder: (masochistic
personality disorder) - is characterized by behavior
consequently undermining the person's pleasure and
goals
 a l i ty d i sor d e r s
Current person

• Level of self and interpersonal functioning

• Typology/Cluster Diagnosis
– Antisocial/Psychopathic Type
– Avoidant Type
– Borderline Type
– Obsessive-Compulsive Type
– Schizotypal Type
• Trait domains and facets

www.dsm5.org
Level of self and interpersonal functioning
Adaptive failure :
Impaired sense of self-identity
i. Identity integration
ii. Integrity of self-concept
iii. Self-directedness
Failure to develop effective interpersonal functioning
i. Empathy and reflection
ii. Intimacy
iii. Cooperativeness
iv. Complexity and integration of representations of others.
 Overall - Difficulties include
— Struggles to cope with stressful situations
— Lonely and isolated
— Fluctuating labile mood
— Poor self-concept and low self-esteem
— Unable to cope with responsibility and decision-
making
— Feels inadequate
— Reduced social skills esp. assertiveness
— Struggles to form mature relationships i.e. Roles
 na l i t y Di sor d e r
Borderline Perso
— Instability in relationships, affect and self-image.
— Fear of abandonment, frantic behavior to avoid this
— Cycles of idealization and devaluing significant others
— Impulsive self-destructive behavior (spending, sex, drugs,
driving, binge eating)
— Recurrent (para)suicidality: thoughts, attempts, gestures,
threats, self-mutilation
— Marked reactivity of mood: intense periods of dysphoria,
irritability, anxiety that last a few hours to a maximum of
a few days
— Chronic feelings of emptiness
— Inappropriate, intense anger or difficulty controlling anger
— Stress-related micropsychotic symptoms: Transient
paranoid ideation or dissociative symptoms
• History of unhealthy Definition of self
relationships • Individuation
• Negative / lack of • Identity as adult
occupational woman
experiences • Knowing about BPD
• Lack of constructive and self
routines and habits • Finding interests
Challenges to/for the BPD
diagnosis
• Why is it 80-90% women?
• Classic vs quiet borderline (A.Asphodel, youtube)
• Significant variations in prevalence across
(micro)cultures
– Antisocial is survival in war torn country
– BPD is ‘the norm’ in post-war and post cancer
diagnosis
– Culture itself cultivates different character
traits e.g. cohesion/dependency vs. narcissism
Sansone, R.A. & Sansone, L.A. (2011). Personality disorders. A nation-based
perspective on prevalence. Innovations in Clinical Neuroscience, 8(4), 13-18
Challenges for clients with BPD
• Stigma within the health care profession
• Their recovery process is different from
other individuals with mental illness –
emerging research
• Causality is variable
• The key to their recovery is social
connectedness, and yet….
What might you conclude
about occupational challenges
and therapeutic challenges if
you were working with
“Borderline Bill”?
• https://www.youtube.com/watch?v=BF
op1UxiDdY