What is BPD? - Addictions and Mental Health Network of Champlain
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Transcript What is BPD? - Addictions and Mental Health Network of Champlain
Helen Gottfried –UnRuh
Senior Manager, Canadian Mental Health Association – Ottawa
Deanna Mercer MD FRCPC psychiatry
Associate Staff, Department of Psychiatry, TOH
Assistant Professor, Department of Psychiatry, University of Ottawa
BPD symptoms
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, as indicated by five (or more) of the following:
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal
or self-mutilating behavior covered in Criterion 5.
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.
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending,
sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a
few days).
7. chronic feelings of emptiness (or boredom)
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
“The pain of being borderline”
Newly admitted inpatients, 146 BPD, 34 Axis II controls
50 dysphoric feelings
BPD > other Axis II on all 50 dysphoric feelings
% of time spent feeling:
Overwhelmed 61.7%
Worthless 59.5%
Very angry 52.6%
Lonely 63.5%
Misunderstood 51.8%
Abandoned 44.6%
Betrayed 35.9%
Evil 23.5%
Out of control 33.5%
Like a small child 39.1%
Like hurting or killing themselves 44%
Zanarini et al 1998
Rare in non-BPD patients
Treatment Histories
2 year study of freshman with (169) and without (192) BPD features
BPD+ : more pharmacologic, psychological and medical treatment,
even after controlling for gender, Axis I, II pathology
Bagge et al 2005
MSAD: 290 BPD, 72 other axis II consecutive inpatients at McLean
hospital
patients with BPD 2- 4.5 times more likely to have received each of 12
types of treatment
Zanarini et al 2001,
CLPS study : treatment seeking patients 175 BPD, 426 other PD, 97
MDD only
BPD > MDD OR 2.14 – 6.19 – individual, group, family, day hospital,
inpatient, all classes of medication
BPD > OPD for all treatments except family/couples and self-help
Bender 2001
BPD prevalence
General population 1% M=F
Outpatients 10 – 20 %
Inpatients 20%
Lezenweger 2007, Coid 2006, Samuels 2002, Torgersen 2001, DSMIV 2005
Comorbidity
Overall
Inpatients (Zanarini 2004)
Depression
50%
86.6 %
Dysthymia
70%
44.8%
Bipolar II
11%
5.5%
Bipolar I
9%
0% (exclusion criteria)
ED (AN, BN)
25% (5%/20%)
53.8% (21.7%/24.1%)
PTSD
30%
58.3%
SUD
35%
62.1%
Alcohol only
25%
50.3%
Panic Disorder
45.2%
OCD
14.5%
Gunderson, Links 2008, Zanarini et al 2004
Influence of BPD on Axis I disorders
CLPS
BPD + MDD : MDD remission in 64%
Other PD +MDD: MDD remission in 89%
Gunderson et al 2004
MSAD
BPD remitted: significant decline in rates of axis I
disorders
BPD never remitted: Rates of axis I disorders (mood,
anxiety, SUD, ED) remained stable despite intensive
treatment
Zanarini et al 2004
Central Institute of Mental Health
Mannheim, Germany
Age as a predictor
of symptomatology,
co-occuring disorders,
and socioeconomic
characteristics in BPD
N. Kleindienst, M. Limberger,
J. Barth, M. Bohus
Methods
Sample of treatment-seeking BPD-patients (n=367)
• University of Freiburg, CIMH (Mannheim)
• female BPD (DSM-IV)
• Age: 18 to 65
Census data from the general population comprising
all women from the catchment area (n=2,383,000)
Bench mark (e.g., marital status)
data from the general population were matched
by nationality and age
Distribution of Age (n=367 fem. BPD-Patients)
30%
25%
20%
15%
10%
5%
0%
18-22 23-27 28-32 33-37 38-42 43-47 48-52 53-57 58-62
Crucial for - education
- vocational training
- employment
- starting a family
Education: Years of Schooling
100%
80%
60%
21%
39%
other / NA
20%
38%
40%
20%
38%
34%
0%
BPD
Gen. Pop.
matched by
age, nationality
9 years
10 years
12-13 years
(qualifying for
univ. admission)
χ2=0.16, df=2
p=0.92
Patients are on par with respect to schooling
Completed Vocational Training
100%
other / NA
80%
18%
13%
60%
40%
20%
No degree
Apprenticeship
47%
57%
22%
17%
0%
BPD
Gen. Pop.
matched by
age, nationality
University Deg.
χ2=7.59, df=2
p=0.02
Differences were minor…
… similar level with respect to vocational training
Employment Status
Employed
Unemployed
Other
χ2=387.03,
df=2, p<0.001
Premature Pension: 7%
(Re-)Education / Secondary Labor Market 21%
Homemaker: 7%
other: 18%
Very large differences in employment status
Marital Status
BPD
Married
Gen. Population
BPD
Unmarried
General Population
Widowed,
Divorced
BPD 15%
χ2=123.23,
df=2, p=0.007
Substantial differences in marital status
BPD vs depression and other PD
CLPS: 668 pts age 18-45 years
Severe impairment in month prior to admission %
Schizotypal
N=86
BPD
N=175
Avoidant
N=157
OCPD
N=153
MDD only
N= 97
employment
53.9
51.5
28.2
11.4
18.4
Global Social
adjustment
83.7
71.4
50.3
36
42.3
GAF< 50
40.7
47.4
21.0
13.1
18.6
Skodal et al 2002
BPD and suicide
Mortality data
Psychological autopsy studies
12% adults with psychiatric illness who suicided
Kullgren et al 1986
33% of adolescent suicides
Runeson and Beskow 1991
Lifetime risk of suicide in BPD: 3-10%
Early all cause mortality 18.2% at mean age 50 yrs
(expected in general pop 4.5% women 7.5% men)
Paris and Zweig-Frank 2001
BPD mothers and their infants
•
59 mother-infant dyads
Mom’s average age 30, infants 12-18 months
Strange situation procedure
Compared to moms with MDD(15) and moms with no mental
disorder (31), BPD moms (13) are:
prone to relate to their infants with intense, inconsistent and often
self- oriented styles of engagement
more likely to exhibit fear/disorientation in response to their
infant’s attachment bids
Disrupted affective communication:
BPD moms 85%
MDD moms 47%
No dx moms 42%
Hobson et al 2009
BPD mothers and their children
BPD moms(16), No disorder moms (116) , MDD moms(36)
Cluster C moms (28)
Compared with children of moms with MDD, cluster C or
no disorder, children (ages 11-18) of BPD moms exhibited:
Higher harm avoidance
Perceived their mother as being overly protective (mother gets
overinvolved, mother induces feeling of shame and guilt, mother acts very anxious,
mother dictated what clothes should be worn)
Lower levels of self esteem
Compared with children of moms with no disorder
attention problems, behavioural problems (delinquency and
aggression)
Death wishes and suicidal ideas/plans
Barnow et al 2006
BPD: effect on families
Families with parental BPD
more unstable than families with other PD
children more frequently exposed to parental substance
abuse, neglect and suicide attempts
Feldman et al 1995
Families with parental BPD report interactional styles with
more conflict, less expression and less cohesion
Moos and Moos 1986
BPD patients entering treatment
perceived family relationships as extremely difficult,
overall scores for quality of relationships with partner,
children and family were much worse than with MDD.
Gerull et al 2008
BPD: burden on families
16 patients with BPD or schizotypal PD
35 family members
Burden on Family Unit (0-5)
34% moderate
31% high
15% extreme
Higher than having family member with DM, CVD, cancer
Family member with scz: 70% extreme burden
Most troublesome sx: anger, impulsivity, financial burden
Schulz et al 1985
Gunderson and Hoffman 2005:
3 main problem areas:
communication, anger and suicidality
NICE 2009
1.3.4.3 When providing psychological treatment for people
with BPD, especially those with multiple co-morbidities
and/or severe impairment the following service
characteristics should be in place:
Explicit and integrated theoretical approach
Structured care
Provision for therapist supervision
Twice weekly sessions may be considered
1.3.4.4 Do not use brief psychotherapeutic interventions (
of less than 3 months duration) specifically for BPD or for
the individual symptoms of the disorder
Cochrane 2012
indications of beneficial effects comprehensive
and non-comprehensive therapies for core and
associated psychopathology
*DBT, MBT, TFP, SFT, STEPPS most data
None of the treatments have a robust evidence
base
Findings support a substantial role in treatment
of people with BPD
Meds for BPD?
• NICE 2009 1.3.5.1 Drug treatment should
not be used specifically for borderline
personality disorder or for the individual
symptoms or behaviour associated with
the disorder
• Cochrane 2010:
• Findings suggestive in supporting use of
second generation antipsychotics, mood
stabilizers and omega 3 fatty acids…
• Total BPD severity was not significantly
influenced by any drug.”
Dialectical Behaviour Therapy
Developed in 1991
8 RCT studies to date, 8 Naturalistic studies
Manualized treatment
4 components: individual therapy, group based skills
training, telephone coaching, therapist consultation
Intensive treatment 1 year, approximately 50 % of
individuals participate in less intensive treatment after
1 year
Cochrane 2012
meta 4 outcomes DBT vs TAU
Anger- large
Parasuicide, mental health status – moderate
Single studies estimates of effect (DBT vs TAU)
DBT>TAU BPD core pathology and associated
psychopathology
DBT vs TAU studies: summary
6 DBT (Linehan 1991, 2006, Turner 2000, Koons 2001,
Verhuel 2003, Clarkin 2007)
2 DBT-S (Linehan 1999, 2002)
With TAU 1-3 :
DBT<TAU Suicide attempts 4/5 studies
DBT >TAU retention 2/5 studies
DBT<TAU hospital days 2/4 studies
TAU 1: individual session less than once per week (1)
TAU 2: individual session once per week (1)
TAU 3: individual session 1/wk and one of: group, a second
individual session/week, therapist supervision
DBT vs Level 4 treatments
Level 4 treatments
Well defined theoretical basis
Weekly supervision, support
Once or twice weekly intervention
Active therapists
Here and now focus
DBT=GPM significant reductions in:
suicide attempts*, self harm episodes, ER visits, psych hospital days, #
BPD symptoms, depression, anger , interpersonal function
McMain et al 2009
DBT vs TFP
DBT= TFP significant improvements SI/A, depression, anxiety, GAF,
retention in treatment
DBT<TFP anger, impulsivity
Clarkin et al 2007
DBT resources current
Full DBT (individual, group, telephone coaching and
therapist consultation)
CMHA- Ottawa
Clients meeting criteria for case management
Capacity – 2 groups, 16 clients
Also CW training and support
TOH –until March 2013
High–utilizer – at least one hospital admission and one ER
visit in the past 12 months
Capacity – 1 group, 8 patients
Montfort
DBT resources in Ottawa
DBT-lite:
Skills training group 6 months,
clients have not had suicide or self harm behaviours in
past 6 months
clients have a therapist in the community who agrees to
support client weekly during the program
TOH – 1 group, 8 clients
DBT resources in Ottawa
DBT modifications
CMHA DBT-S
DBT skills training group
modified for clients with active substance abuse/dependence
24 weeks
8 clients
TOH Working With Emotions
12 week skills training group, based on DBT
Open to all Urgent Consultation Clinic patients
~ 50% of attendees have BPD
ROH WWE
Women’s health and Addictions program
1 group
DBT outreach
Community based therapists
initial training in 2005/6
DBT-lite
CMHA partnerships
Family Services Ottawa
Salus
ROH
Case Study Ms A
• First presented to TOH at the age of 18.
• Axis I: dysthymia, major depressive disorder, social phobia, eating
disorder NOS, polysubstance dependence (ephedrine , THC)
• Axis II: borderline personality disorder, avoidant personality disorder
• Axis III: asthma, myofacial pain syndrome, environmental allergies
Community Consultation
March 2 2011
Attendees
CMHA – Ottawa, Centretown CHC, Ottawa Academy of
Medicine- Family Practice, Ottawa Inner City Mental
Health
Families- Ottawa Network for BPD
Hospitals – TOH, Montfort, ROH – Addictions, Mood,
Youth, Women’s Program, Community Mental Health
Department of Psychiatry University of Ottawa
Community Consultation
Presentations by ON-BPD Family Connections and Dr
Paul Links, internationally recognized expert on BPD
Priority setting exercise
3 top priorities
1.
2.
3.
Improved access to services
Education
Coordination of services
HSIP
Sept 2012 – TOH and CMHA meet to discuss next
steps
Oct 2012- TOH, CMHA, ROH, FSO meet and agree to
develop HSIP proposal
Proposal developed to address priority 1- improving
access to services
Proposal includes request for funding to develop
coordinated, one point of access intake
CMHA and FSO Summary of Changes
Staffing – Current FTE
Staffing - Proposed FTE
Case worker
2 FTE
4 FTE
MD/psychiatrist
0.225 FTE
0.6 FTE
Current Capacity
Proposed Capacity (total)
DBT full (M)
2 groups/ 16 clients
4 groups/ 32 clients
DBT –S
1 group/ 8 clients
2 groups/ 16 clients
DBT-grad
1 group / 8 clients
2 groups / 16 clients
Individual therapy
7 clients
31 clients
Assessments Case Workers
36/yr
50/ year
Assessments MD
0
20/yr
TOH Summary of Changes
Staffing – Current FTE
Staffing – Proposed FTE
Psychiatry
0.6
0.8
Psychology
0.4
0.6
Social Work
0.2
0.6
Occupational Therapy
0
0.6
RN
0
0.6
Admin
0.1
0.4
Social Work On-Call
0
0.2
RN On- Call
0
0.2
Current Capacity
Proposed Capacity- FTE
DBT-full
1 group/ 8 clients
2 groups/ 16 clients
DBT- Lite
1 group/ 16 clients
1 group/ 16 clients
DBT – Grad group
1 group/ 8 clients
2 groups/ 16 clients
DBT- Grad follow up
0
16 clients
DBT- Individual therapy
7 clients
16 clients
MD Consults
30
90