Borderline Personality Disorder/
Impulse Control Disorders

From 9th Annual Psychiatry Review: Pleasure and Motivation: Addiction, Impulsivity, and Compulsivity,
presented by the University of Minnesota Medical School

Educational Objectives

The goals of this program are to update information on the Systems Training for Emotional Predictability and Prob­lem Solving (STEPPS) program for persons with borderline personality disorder, and to improve the recognition of impulse control disorders in Parkinson’s disease. After hearing and assimilating this program, the clinician will be better able to:

Identify borderline personality disorder (BPD).

Discuss traditional treatment for BPD.

Consider integrating the STEPPS program as an adjunct to traditional treatment for BPD.

Recognize impulse control disorders (ICDs) that occur as side effects of treatment in patients with Parkinson’s disease (PD).

Compare and contrast dopamine dysregulation syndrome with ICDs in patients with PD.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Black is a consultant for and receives honoraria from Forest Laboratories and Jazz Pharmaceuticals, and receives grant/research support from Forest Laboratories. Dr. Weintraub is a consultant for, receives grant/re­search support from, and receives honoraria from Boehringer Ingelheim. The planning committee reported nothing to disclose.

Acknowledgements

Drs. Black and Weintraub were recorded at 9th Annual Psychiatry Review: Pleasure and Motivation: Addiction, Impulsivity, and Compulsivity, held September 18-19, 2008, in Minneapolis, MN, and sponsored by the University of Minnesota Medical School, Department of Psychiatry. The Audio-Digest Foundation thanks the speakers and UMMS for their cooperation in the production of this program.

The Systems Training for Emotional Predictability and Problem Solving (STEPPS) Program for Persons with Borderline Personality Disorder

Donald W. Black, MD, Professor, Department of Psychiatry, the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City

Personality disorder: defined by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as “an enduring pattern of inner experience and behavior that deviates markedly from an individual’s culture, is per­vasive and inflexible, has an onset in adolescence or early childhood, is stable over time, and leads to impairment or distress”; borderline personality disorder (BPD) requires that patient meet ³5 of 9 criteria; affective criteria  —  inappropriate anger; feelings of emptiness; mood instability over short periods (minutes to hours); cognitive criteria  —  stress-related paranoia and dissociation; identity disturbance; behavioral criteria  —  recurrent suicidal behavior; self-harm; interpersonal criteria  —  fear of abandonment; unstable relationships

Epidemiology: occurs in 1% to 2% of population; onset between 18 and 25 yr of age; 70% women, 30% men; affects all income groups; found worldwide; accounts for 20% of inpatient psychiatric hospitalizations and 11% of outpa­tients; patients tend to have high numbers of emergency department (ED) visits and to be high users of clinician’s time and energy

Comorbidity rule, not exception: major depression most common comorbidity, followed by substance misuse, post­traumatic stress disorder (PTSD), dysthymic disorders, and bipolar disorder (although speaker questions validity of reports of bipolar disorder type 2); comorbid Axis II disorders also common

Traditional treatment: 97% receive outpatient care; 95% in individual therapy, 56% in group therapy; 72% have had ³1 psychiatric hospitalization; other treatments include family/couples therapy, day treatment, and halfway houses

Medications: £86% receive psychotropic medications, with polypharmacy as norm, although no empiric support for combined therapy; antidepressants most commonly prescribed medications, followed by antipsychotics, mood stabilizers, sedatives/hypnotics, and psychostimulants; small study showed that patients who took one medication did as well as those who took ³3; BPD treatment “is generally viewed as disappointing and unsatis­factory; with medication, patients show mild degrees of improvement with many drugs, but fail to respond posi­tively to any”; speaker concludes  —  no standard treatment; mood stabilizers, antidepressants, and antipsychotics seem to have modest benefits; choice of drug depends on target symptoms

Psychologic treatment: several evidence-based group treatment programs have been developed, including dialecti­cal behavior therapy, mentalization program, and schema-focused therapy; main problems length of programs (1-3 yr), lack of trained therapists, and expense of training and therapy

Systems Training for Emotional Predictability and Problem Solving (STEPPS): “home grown” in Iowa to meet needs specific to Iowa, but found to be applicable to other areas as well, including Holland; short duration (20 wk); manual based; easily learned and delivered; cost-effective; compatible with current therapies

Description: group treatment for outpatients with BPD; combines skills training with cognitive-behavioral ele­ments; includes systems component for family, friends, and significant others; not comprehensive, but adjunctive (ie, supplements but does not replace patient’s current therapeutic regimen); encourages compliance with medi­cation; encourages attendance at individual psychotherapy sessions; validated by randomized controlled trials (RCTs) in Iowa and Holland

Recommended format: 20 weekly 2-hr sessions; 2 facilitators (preferably of opposite sex) for 6 to 10 patients; sys­tems component for treatment providers, family, and friends; focuses on awareness of BPD (including DSM-IV definition and criteria), skills training for emotion management, and training in behavior management

Reframing the picture: patients dislike term “borderline personality disorder,” and speaker prefers to use “disorder of emotional instability” or “emotional intensity disorder (EID)”

Borderline Evaluation of Severity over Time (BEST): new scale for rating BPD symptoms and measuring change over time; self-rated; 15 items rated on 5-point scale; scores range from 12 to 72; 3 subscales; found to be reliable and valid

Data supportive of STEPPS: 3 uncontrolled studies and 2 RCTs; speaker’s study showed that patients seemed to get better from eighth week; those who attended <15 sessions improved, but not as much as those who attended ³15; findings  —  reduced impulsivity and negative affectivity; improved social adjustment; suicide attempts and self-harm behaviors not reduced (but trend seen towards fewer suicide attempts); hospital days not reduced (but trend seen towards less utilization); findings not confounded by medication or attendance at individual psychotherapy sessions; 1-yr follow-up — gains maintained but not enhanced; suicide attempts, self-harm behaviors, and hospi­tal days not reduced; ED visits reduced; limitations — drop-out rate high (27%); clinician ratings not blind; treat­ment as usual not active comparator; few men and minorities participated

Conclusions: BPD common and problematic; treatment of BPD challenging and results modest; 3 uncontrolled stud­ies and 2 RCTs supportive of STEPPS; STEPPS reduces global severity, BPD symptoms, depression, and ED vis­its; gains maintained over 1 yr; STEPPS now joins other evidence-based treatments for BPD

Impulse Control Disorders in Parkinson’s Disease

Daniel Weintraub, MD, Assistant Professor, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia

Introduction: “impulse control disorders” (ICDs) increasingly accepted as term to describe major disorders in Par­kinson’s disease (PD); behaviors atypical for that individual, who has no control over them and often does not perceive them as pleasurable; behaviors distress patient, may cause impairment, and are difficult to manage clin­ically

How do ICDs differ from dopamine dysregulation syndrome (DDS)? DDS more akin to substance abuse disorders and involves medication misuse; DDS more commonly occurs with short-acting agents (eg, levodopa, subcutane­ous apomorphine) than with dopamine agonists; ICDs, as identified in DSM-IV, include pathologic gambling, compulsive buying, compulsive sexual behavior, and, to some extent, compulsive eating

Continuum of behaviors: within ICDs—behaviors not always harmful, do not rise to threshold of disorder, and po­tentially beneficial; between ICDs—less problematic disorders include hobbyism (unfinished projects), punding (purposeless manipulation of objects), and walkabout (aimless wandering)

ICDs in PD: first reports (2003) coincided with introduction of pramipexole and ropinirole (dopamine agonists) for treatment of PD symptoms; speaker’s recent survey of 3090 patients with PD showed that approximately two-thirds took dopamine agonist, mainly pramipexole and ropinirole, and “overwhelming majority” took levodopa; ³1 ICD found in »14%, and of those, »36% had >1 ICD; factors associated with occurrence of ICDs include younger age, being unmarried, higher total levodopa-equivalent daily dosage (LEDD; calculated from dosages of levodopa and dopamine agonist), and family history of gambling problem (associated with any ICD)

Primary outcome measures: likelihood of having ICD significantly higher for subjects who took dopamine agonist vs those who did not; no statistically significant difference between pramipexole and ropinirole, suggesting effect due to drug class (as opposed to specific medication); levodopa also associated with ICDs, but odds ratio not as high

Clinical management: do nothing (assess clinical significance of symptoms; some patients unable or reluctant to risk return of motor symptoms by adjusting dosages of PD medications); adjust dosages of PD medications; con­sider deep brain stimulation; psychopharmacology; psychosocial treatments; little known about optimal manage­ment strategies for, or long-term outcomes of, ICDs in PD; reports of improvement or resolution of ICD symptoms with changes in dopamine agonist therapy (including discontinuation, lowering dosage, or switching to different dopamine agonist); unclear what role levodopa or other PD treatments play

Long-term follow-up of ICDs: 15 subjects from previous study completed telephone interview; mean follow-up time, 29 mo after identification of ICD; modified Minnesota Impulsive Disorders Interview (MIDI) administered; 80% of subjects had discontinued or significantly decreased (>30%) use of dopamine agonists, and 83.3% no lon­ger met diagnostic criteria for ICD; however, 26.7% of subjects overall still met criteria for ICD, including 50% of those who continued dopamine agonist; as dopamine agonist-equivalent dosage decreased, levodopa-equivalent dosage increased (as result, LEDD did not change)

Deep brain stimulation: 7 patients with pathologic gambling underwent deep brain stimulation; preoperative LEDD 1390 mg/day; 74% decrease postoperatively; pathologic gambling decreased in all patients over mean of 18 mo; improvement paralleled time course and degree of LEDD reduction; study authors concluded “dopaminergic dys­regulation commonly attributed to pulsatile overstimulation of the limbic dopaminergic system may be subject to desensitization on chronic subthalamic stimulation, which has a relative motor selectivity and allows for decrease in dopaminergic treatment”; however, numerous case reports of ICDs starting after deep brain stimulation

Psychopharmacology: antidepressants, atypical antipsychotics, and mood stabilizers used clinically with no empiric evidence to support their use; case reports for use of atypical antipsychotics in treatment of ICDs in PD; medica­tions needed that will allow patients to stay on PD medications and not worsen parkinsonism; possibilities include specific D₃-receptor antagonists (several in development), partial dopamine agonists, and 5HT_1A agonists (one in development)

Neurobiology: ICDs generally do not occur in patients with PD who are not exposed to dopamine agonists, levodopa, or deep brain stimulation; in addition, even among patients exposed to these treatments, majority do not develop ICDs; little known about premorbid risk factors (ie, risk factors that existed before onset of PD); some studies show higher occurrence in patients with history or family history of substance abuse disorders; novelty-seeking traits may be associated with occurrence of ICDs; possible genetic contribution; other possible factors include impairment of executive function, mild cognitive impairment, dementia, and degeneration of substantia nigra projecting to dorsal striatum

Overdose hypothesis of ventral striatum: speaker hypothesizes that dorsal striatum affected early in course of PD, ventral striatum only later; preliminary results of Balloon Analogue Risk Task (BART) study seem to support this hypothesis

Assessment: speaker found lack of 1) good screening instruments developed or used to assess ICDs in PD, 2) estab­lished, formal diagnostic criteria for some ICDs seen in PD, and 3) rating scales that have been tested in PD to determine changes in severity of ICDs over time

Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease (QUIP): developed by speaker’s group; meant to be self-administered screening instrument, not diagnostic interview; covers pathologic gambling and compulsive sexual behavior, buying/shopping, and eating disorders, as well as hobbyism, punding, walkabout, and compulsive medication use; found that 2 questions per disorder had good sensitivity and specificity (ie, hav­ing ³1 endorsement of any of 4 disorders good way to screen for these patients); positive results indicate need for clinical interview to eliminate false-positive results

Conclusions: ICDs relatively common in PD, although no good studies comparing rates to general population; ICDs in PD often comorbid; appear to be associated with use of dopamine agonists and, to lesser extent, use of levodopa; ICDs appear to be dosage-related; ICDs have other clinical and demographic risk factors that need to be teased out; neurobiology likely related to dopamine system; currently, lack of validated assessment instruments for range of ICDs and other compulsive disorders that occur in PD; manipulation of PD pharmacotherapy area of treatment with most compelling evidence; ultimately, though, treatments needed that will allow patients to maintain PD pharmaco­therapy and not worsen symptoms of PD

Suggested Reading

American Psychiatric Association: American Psychiatric Association Practice Guidelines. Practice guideline for the treat­ment of patients with borderline personality disorder. Am J Psychiatry 158(suppl 1):1, 2001; Black DW et al: Borderline personality disorder in male and female offenders newly committed to prison. Compr Psychiatry 48:400, 2007; Black DW et al: Predictors of response to Systems Training for Emotional Predictability and Problem Solving (STEPPS) for border­line personality disorder: an exploratory study. Acta Psychiatr Scand Jan 9, 2009 [Epub ahead of print]; Black DW et al: The STEPPS group treatment program for outpatients with borderline personality disorder. J Contemp Psychotherapy 34:193, 2004; Blum N et al: STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with border­line personality disorder - a preliminary report. Compr Psychiatry 43:301, 2002; Blum N et al: Systems Training for Emo­tional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry 165:468, 2008; Evans AH et al: Compulsive drug use linked to sen­sitized ventral striatal dopamine transmission. Ann Neurol 59:852, 2006; Farrell JM et al: A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. J Behav Ther Exp Psychiatry Jan 14, 2009 [Epub ahead of print]; Ferrara JM, Stacy M: Impulse-control disorders in Parkinson’s disease. CNS Spectr 13:690, 2008; Frank MJ et al: Hold your horses: impulsivity, deep brain stimulation, and medication in par­kinsonism. Science 318:1309, 2007; Kondo T: Dopamine dysregulation syndrome. Hypothetical application of reward sys­tem stimulation for the treatment of anhedonia in Parkinson’s disease patients. J Neurol 255(Suppl 4):14, 2008; Lim SY et al: Impulse control and related disorders in Parkinson’s disease: review. Ann N Y Acad Sci 1142:85, 2008; Mamikonyan E et al: Long-term follow-up of impulse control disorders in Parkinson’s disease. Mov Disord 23:75, 2008; Potenza MN et al: Drug Insight: impulse control disorders and dopamine therapies in Parkinson’s disease. Nat Clin Pract Neurol 3:664, 2007; Soler J et al: Dialectical behaviour therapy skills training compared to standard group therapy in borderline person­ality disorder: A 3-month randomised controlled clinical trial. Behav Res Ther Jan 29, 2009 [Epub ahead of print]; Van Wel B et al: STEPPS group treatment for borderline personality disorder in The Netherlands. Ann Clin Psychiatry 18:63, 2006; Weintraub D et al: Association of dopamine agonist use with impulse control disorders in Parkinson’s disease. Arch Neu­rol 63:969, 2006; Weintraub D: Dopamine and impulse control disorders in Parkinson’s disease. Ann Neurol 64(Suppl 2):S93, 2008; Wolters ECh et al: Parkinson’s disease-related disorders in the impulsive-compulsive spectrum. J Neurol 255(Suppl 5):48, 2008.