Transcript Treating the Difficult Patient

Borderline Personality Disorder
Curley Bonds, MD
Presentation by Amber Kondor, MD
Telemental Health and Psychiatric Consultation
Los Angeles County DMH
 Special Thanks –
Ricardo Mendoza, MD
Chief Mental Health PsychiatristTelemental Health and
Psychiatric ConsultationLos Angeles Co. Dept. of
Mental Health
 Understand the Prevalence and Relevance of
Borderline Personality Disorder in Primary Care
 Be better able to identify, diagnose, and understand a
patient with BPD
 Define Countertransference and understand its
relevance
 Learn strategies to effectively communicate and care
for patients with BPD
• Prevalence ~2-6% of gen pop, ~10% of outpatient
psych patients; 30-60% of personality disorders
(Common in primary care!)
• Women:men = 4:1
• The apple doesn’t fall far from the tree – 5x more
common in family members of probands
• A large proportion have a history of sexual abuse,
unstable and traumatic childhood, early sexual
activity, drug use, and pregnancies
• More than half of adults with BPD self-mutilate
 Up to 10% of adults with BPD commit suicide – 400X
more likely than the general population – but this is
largely a “parasuicidal” population
 BPD is associated with considerable mental and
physical disability
 90% have 1 or more psych diagnoses
 Major Depression – 60% of patients with BPD
 Anxiety Disorders – 30% have panic disorder with
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agorophobia
Alcohol and other Substance Use Disorders – 12%
Bipolar Disorder – 10%
PTSD
Dissociative Identity Disorder (AKA Multiple Personality
Disorder)
Eating Disorders (especially Bulimia) – vomiting as
presentation in primary care
ADHD
Antisocial Personality Disorder
Other Personality Disorders (Cluster B traits)
 Borderline between neurosis and psychosis – a historic
way of looking at the disorder
• Unstable mood, affect, behavior, relationships, and
self-image
• Marked by impulsivity, suicidal acts, self-mutilation,
identity problems, and feelings of emptiness or
boredom
• ICD-10 uses the name “emotionally unstable
personality disorder”
A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood and present in
a variety of contexts.
Five (or more) criteria must be met for diagnosis of BPD.
(1) Frantic efforts to avoid real or imagined
abandonment (not including self-mutilating behavior)
“I’ve damaged so many relationships
through the need for control and the fear of
being left, and for a long time I thought that
fear was justified” – anonymous blogger
Patients with BPD will often stay in
physically and emotionally abusive
relationships, just so they won’t be alone.
(2) A pattern of unstable and intense
interpersonal relationships characterized by
alternating between extremes of idealization
and devaluation
(3) Identity disturbance:
markedly and persistently
unstable self-image or sense of
self
Uncertainty of self-image,
sexual orientation, career
choice or other long term
goals, friendships, values
“Sometimes I feel as though I’m two
different people, ripping at each
other” – anonymous blogger with
BPD
(4) Impulsivity in at least 2 areas that are potentially
self-damaging (spending, sex, drugs, recklessness, binge
eating)
(5) Recurrent suicidal behavior, gestures, or threats, or
self –mutilating behavior
(6) Affective Instability due to a marked reactivity of
mood (intense episodic dysphoria, irritability, or anxiety
– for hours to days at a time)
(7) Chronic feelings of
emptiness
“Constantly being terrified of abandonment
and confused over everything you are isn’t a
walk in the park; it’s a depressing, stressful,
soul-destroying way to exist.” – anonymous
blogger with BPD
(8) Inappropriate, intense anger or difficulty controlling
anger
WHAT DO YOU MEAN I CAN’T HAVE MORE XANAX???
(9) Transient, stress-related paranoid ideation or severe
dissociative symptoms
 Low K
 EKG changes in a young person; arrhythmias
 Enlarged Parotids, dental changes, gum irritation
 Self mutilation – cuts, burns, etc
 Childhood trauma, esp. sexual abuse
 Early history of drug use, pregnancies, high risk
behaviors
 Multiple somatic complaints, multiple former PCPs
 Difficult doctor-patient relationship
What are you likely to encounter in your office?
 Splitting your office staff, previous doctors – examples
to follow
 Splitting – the inability to feel two opposing emotions
simultaneously, or to integrate the good with the bad
 Requests for urgent appointments after hours,
multiple phone calls, often desperate. Extending
appointment times, repeated crisis or emergency
appearances at the office
 Sudden hostility at not meeting their immediate
demands (prescribing benzos, etc)
 STRUCTURE
 Set boundaries together, and stick to them
 Actively structure encounters
 Brief frequent visits, with verbal plan for future visits
 Be “Radically Genuine”
 Honest and straightforward
LaForge, E. (2007)
 Stay calm and empathic to diffuse hostility
 Emotional Outbursts: recognize feelings but request
appropriate behavior
“I see that you’re angry, and we can continue talking about this
if you will lower your voice.”
(note the recognition of the emotion, and clear request for
appropriate behavior)
If the patient doesn’t respond – leave the room, indicating that
when their behavior is appropriate, the conversation can
resume.
LaForge, 2007
 Beware of splitting: don’t devalue or over
defend
 “the woman you have working at the front desk is
completely useless. If you weren’t so good at
treating your patients, no one would come to this
clinic.”
 “I’m so lucky I found you – I think my last doctor
was trying to kill me with his incompetence.
 Reacting may reinforce the behavior
 Splitting is often an unconscious process in
BPD patients – remain as neutral as possible,
and talk about your feelings with a colleague
LaForge, 2007
 Watch for Countertransference
 What is countertransference?
 The emotions that the patient encounter/relationship
stirs up in you
 Positive countertransference: Clinician unconsciously
responds to idealization to stay in the patient’s favor
 Negative Countertransference: Unconsciously
responding to devaluing by ignoring, avoiding or
devaluing the patient’s complaints, even feeling
tempted to punish the patient
LaForge, 2007
 Strive for conservative medical management – but
provide an appropriate thorough, routine medical
evaluation
 Overuse of diagnostic resources promotes a “sick” role
for the patient
 Patients with BPD do appear to display a high degree
of somatization
 Address their concerns, but also teach about stress and
its effects on health – it’s generally a bad idea to tell
them, “It’s all in your head.”
LaForge, 2007
 Open honest discussion of the role of emotions/life
stressors in medical concerns – and even aspects of
BPD, if appropriate
 They might begin to understand the connection
 Your stable doctor-patient relationship may be their
first stable relationship!
 Your influence may help them get the appropriate
mental health treatment
 The patient needs to know that you are not abandoning
them – you are still their PCP, but they will be forming
an additional relationship
LaForge, 2007
 Bring a chaperone for physical exams –
 patients with BPD misinterpret reality and have poor
boundaries. They may mistake elements of a physical
exam as indicative of a personal relationship.
 Patients with BPD constitute a majority of patients
who falsely accuse their therapists of sexual
involvement – it’s wise to have a third party as a buffer.
LaForge, 2007
 Suicide and self-harm will be issues
 The patient will likely acknowledge this
 Take the behaviors seriously
 REFER for psychiatric treatment, involuntary hospitalization if
necessary:
 It is appropriate to refer when patients engage in repeated
self-injurious or life-endangering behaviors, or when their
needs for reassurance or safety monitoring involve many
interappointment contacts
1. A 44-Year-Old Woman With Borderline Personality Disorder; JAMA, February 27, 2002—Vol 287, No. 8 1035
2. LaForge, E. (2007). The Patient with Borderline Personality Disorder. Journal of the American Academy of Physician
Assistants. 20,46-50.
 Low-Serotonin Trait Vulnerability in BPD- Manifests
as significant impulsivity
 SSRIs
 Benzos for co-occurring anxiety? Use sparingly and
monitor usage
 Affective instability may be treated with mood
stabilizers
 Meds are effective at target symptoms, but not curative
 Treat co-morbid Axis I disorders – takes higher doses
and longer to take effect
 Dialectical Behavior Therapy – developed by Marsha
Linehan – is the mainstay
 Requires a significant commitment from the patient
 Prognosis is not bad- over many years of therapy, the
majority will improve.
 The PCP is likely to have the essential role in initiating
psychotherapy treatment (adjunct, not replacement
for primary care)
 In treating BPD patients in the medical setting, set
clear boundaries, be honest and clear in
communications, validate their feelings and reassure,
but don’t get too close! Monitor your own countertransference (and talk with colleagues to help with
this).
 Long term attachment and stable support systems are
the essence of what is needed in people with BPD.
 Once you build rapport, talk to your patient about
DBT – they can get better!
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition. Washington: American Psychiatric Association.
Davison, SE. (2002). Principles of managing patients with Personality Disorder. Advances in
Psychiatric Treatment. 2002, 8:1-9.
Gross, R, et al. Borderline Personality Disorder in Primary Care. Archives of Internal
Medicine, 2002; 162(1):53-60.
LaForge, E. (2007). The Patient with Borderline Personality Disorder. Journal of the
American Academy of Physician Assistants. 20,46-50.
Ward, R.,(2004). Assessment and Management of Personality Disorders. American Family
Physician. 2004 Oct 15;70(8):1505-1512.
Literature to consider: Sansone, R. and Sansone, L. Borderline Personality Disorder in the
Medical Setting: Unmasking and Managing the Difficult Patient.