Understanding Borderline Personality Disorder

SeriesTreatment Approaches to Help Them Heal

Janice R. Morabeto M.Ed. L.S.W. C.H.T.

Review the particular therapeutic challenges with which these individuals present.

Discuss the APA guidelines for effective treatment

management for individuals suffering from BPD.

Discuss the treatment approaches which show promise in helping individuals who suffer from BPD as well as their family members.

Goals and Objectives:

The Challenge of BPD: A brief review APA Guidelines For Effective Treatment Pharmacological Interventions Dialectical Behavior Therapy

◦ Philosophy◦ Principles and Practices

Psychodynamic and Pscyhoanalytic Modalities

Agenda

Most common personality disorder in clinical settings.◦ 10% of individuals seen in outpatient mental health clinics,

15%–20% of psychiatric inpatients◦ 30%–60% of clinical populations with a personality disorder. ◦ It occurs in an estimated 2% of the general population (1,

136). Borderline personality disorder is diagnosed

predominantly in women, with an estimated gender ratio of 3:1. The disorder is present in cultures around the world.

Five times more common among first-degree biological relatives

Epidemiology

Research suggests that 1 out of 10 individuals with BPD complete suicide

Chronic Suicidality Among Patients With Borderline Personality Disorder

Joel Paris, M.D.

8-10%

Does not reflect those in the treatment groups

Suicide Rates among BPD

Particular Therapeutic Challenges

Abandonment

Emotional Dysregulat

ion

Impulse Dyscontr

ol

Relationship

Polarities

Suicidality

Substance

Abuse/Promiscuit

y

Crisis and

Crazy Making

Core of BPD Suffering

Suicidality

Attempted Suicide

Suicide Crisis

Threats

Impulsivity

Substance Use/Abuse/Dependency

Self Harm

Recklessness

Affective Instability

Anger Dysphoria Anxiety

Defense Mechanisms

•Projection•Transference•Reaction Formation•Countertransference

Common Denominators of

Effective Treatment Programs and

ProvidersAmerican Psychiatric Association

PRACTICE GUIDELINE FOR THETreatment of Patients With

Borderline PersonalityDisorder

Originally published in October 2001.

Monitor patients carefully for suicide risk and document this

assessment; be aware that feelings of rejection, fears of

abandonment, or a change in the treatment may precipitate

suicidal ideation or attempts.

Take suicide threats seriously and address them with the patient.

Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated

for acute suicide risk

Suicide Precautions

• to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide by:

Chronic suicidality without acute risk

needs to be addressed in therapy (e.g.,

focusing on the interpersonal context of the

suicidal feelings and addressing the need for the patient

Suicide Precautions

Hospitalization Wrap around services Increasing outpatient visits plus family

watches until the suicide crisis is over

Suicide Precautions

Involve the family (if otherwise

clinically appropriate and with adequate

attention to confidentiality issues) when patients are

chronically suicidal.

For acute suicidality,

involve the family or significant others if their

involvement will potentially protect the

patient from harm.

Suicide Precautions

A promise to keep oneself safe (e.g., a “suicide contract”) should not be used as a substitute for a careful and thorough clinical evaluation of the patient’s suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient’s responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.

Monitor the patient carefully for impulsive or violent behavior, which is difficult to predict and can occur even with appropriate treatment.

Address abandonment/rejection issues of anger, and impulsivity in the treatment.

Arrange for adequate coverage when away; carefully communicate this to the patient anddocument coverage.

Impulsivity

The following are risk management considerations for boundary issues with patients with borderline personality disorder:

Monitor carefully and explore countertransference feelings toward the patient.

Be alert to deviations from the usual way of practicing, which may be signs of countertransference problems—e.g., appointments at unusual hours, longer-than-usual appointments, doing special favors for the patient.

BOUNDARY VIOLATIONS

Always avoid boundary violations, such as the development of a personal friendship outside of the professional situation or a sexual relationship with the patient.

If the patient makes threats toward others (including the clinician) or exhibits threatening behavior, the clinician may need to take action to protect self or others.

Get a consultation if there are striking deviations from the usual manner of practice.

The Full Report can be found at:

Effective Treatment Modalities

“What the caterpillar calls the end of the world, the master calls a butterfly”

Richard Bach, Illusions: The adventures of a reluctant Messiah

Psychotropic Medications

Dialectical Behavior Therapy DBT

Transference Focused Psychotherapy◦TFP

Affective Dyscontrol Symptoms

Impulsive-Behavioral Dyscontrol Symptoms

Cognitive-Perceptual Symptoms

Pharmacological Interventions

Serotonin Selective Reuptake Inhibitors◦ Fluoxetine Prozac◦ Sertraline Zoloft◦ Venlafaxine Effexor

Affective dysregulation, Impulsive-behavioral dyscontrol Cognitive-perceptual difficulties

Medication Regimes (APA guidelines)

Aggression, Irritability, Depressed mood, Self-mutilation Some somatic complaints (headaches/PMS)

Amitriptyline Elavil, Endep Imipramine Norpramin, Pertofrane Desipramine Janimine, Tofranil

Decreased depressive symptoms and indirect hostility

Enhanced attitudes about self-control

Tricyclic and heterocyclic antidepressants

Effective for the “associated” symptoms

Depersonalization, Paranoid symptoms, Obsessive-compulsive symptoms Helplessness Hopelessness

Tricyclic and heterocyclic antidepressants

Lithium

Mood-stabilizing Anti-aggressive effects

Mood Stabilizers

Divalproex Depakote, Epival Carbamazepine Tegretol, Epitol

May be useful in treating behavioral dyscontrol and affective dysregulation in some patients with borderline personality disorder, although further studiesare needed

Haloperidol Haldol Perphenazine Etrafon, Trilafon Thiothixene Navane

Improvement in impulsive-behavioral symptoms, global symptom severity, and overall borderline psychopathology. Similar efficacy found in the adolescent population

Neuroleptics

Dialectical Behavior Therapy

Marsha Linehan (1993)

Suicidal

Behaviors

Behaviors

interfering

with therapy

Behaviors

interfering with

quality of life

Dialectical Behavior Therapy

1. Enhance and maintain the client’s motivation to change

2. Enhance the client’s capabilities 3. Ensure that the client’s new capabilities

are generalized to all relevant environments

4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities

5. Structure the environment so that treatment can take place.

Five Critical Functions

Self Dysregulation

Cognitive Dysregulation

Behavioral Dysregulation

EmotionalDysregulation

Core of BPD Suffering: DBT

Synthesis

Thesis Antithesis

Balancing Act of DBT: Remember Philosophy

Radical Acceptance◦ Of the Client◦ Teach to the Client

Self Environment Others

Major Strategies

Giving Self Up to the moment◦ Focused Consciousness◦ Breathing◦ Thought Stopping◦ Radical Acceptance

Mindfullness

Radical Acceptance of Others’ Point of View Listening Skills

◦ Repeating back Self-Assertion

◦ Making a Request◦ Saying No◦ Expressing Self, Using I statements

Conflict Resolution Skills

Interpersonal Relatedness

Teach and Use Socratic Discussion◦ Identifying Differences between

Thoughts Evaluations Behavioral/Emotional Reactions

ABC’s of CBT

Cognitive Skills

TFP is an intense form of psychodynamic psychotherapy designed particularly for patients with borderline personality organization (BPO)◦ a minimum of two and a maximum of three 45 or

50-minute sessions per week. It views the individual as holding

unreconciled and contradictory internalized representations of self and significant others that are affectively charged.

Transference Focused Psychotherapy Otto Kernberg

The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The consistent interpretation of these distorted perceptions is considered the mechanism of change.

Kernberg designed TFP especially for patients with BPO. According to him, these patients suffer from identity diffusion, primitive defense operations and unstable reality testing.

Suicidal or homicidal threats

Overt threats to treatment continuity

Dishonesty or deliberate withholding

Contract breaches

Acting out in sessions

Acting out between sessions

Nonaffective or trivial themes

TFP

Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 48, 1060-1064.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, 371-390.

Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.

Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182, 135-140.

References

1. Clarkin, JF, Yeomans, FE, & Kernberg, OF (1999). Psychotherapy for Borderline Personality. New York: J. Wiley and Sons.

2. Kernberg, OF, Selzer, MA, Koenigsberg, HA, Carr, AC, & Appelbaum, AH. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.

3. Koenigsberg, HW, Kernberg, OF, Stone, MH, Appelbaum, AH, Yeomans, FE, & Diamond, DD. (2000). Borderline Patients: Extending the Limits of Treatability. New York: Basic Books.

4. Yeomans, FE, Clarkin JF, & Kernberg, OF (2002). A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ: Jason Aronson.

5. Yeomans, FE, Selzer, MA, & Clarkin, JF. (1992). Treating the Borderline Patient : A Contract-based Approach. New York: Basic Books

References

Borderline personality disorder: The treatment dilemma. Author(s): Oldham, J.M.Published: 1997Source: Journal of the California Alliance for the Mentally IllNumber of Pages: 13-15

Cognitive-Behavioral Treatment of Borderline Personality Disorder Author(s): Linehan, M.Published: 1993

Cognitive-Behavioral Treatment of Borderline Personality Disorder Author(s): Linehan, M.Published: 1993

Dialectical behavior therapy for borderline personality disorder. Author(s): Linehan, M.M.Published: 1987Source: Bulletin of the Menninger ClinicVolume: 51Number of Pages: 261-276

PRACTICE GUIDELINE FOR THE

Treatment of Patients With

Borderline Personality

Disorder

WORK GROUP ON BORDERLINE PERSONALITY DISORDER

John M. Oldham, M.D., Chair

Glen O. Gabbard, M.D.

Marcia K. Goin, M.D., Ph.D.

John Gunderson, M.D.

Paul Soloff, M.D.

David Spiegel, M.D.

Michael Stone, M.D.

Katharine A. Phillips, M.D. (Consultant)

Originally published in October 2001. A guideline watch, summarizing

significant developments in the scientific literature since publication of this

guideline, may be available in the Psychiatric Practice section of the APA

web site at www.psych.org.