Transcript Treating Borderline Personality Disorder in the Primary Care Setting

Treating Borderline Personality Disorder
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 02/11/2016
Disclosures and Learning Objectives
• Learning Objectives
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Be able to name three evidence-based
therapies for BPD
Be able to list the three basic tenets of
Relationship Management
Know 7 ways to improve outcomes in
Borderline Personality Disorders
Appreciate the role of hope in the
treatment of BPD
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Assessing Borderline Personality Disorder
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Review BPD
Review Pharmacotherapy
Review Psychotherapy
Review Relationship Management
Review Office Management
Review the UK approach
Next Week
Borderline Personality Disorder, DSM-IV TR
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 5 (or
more) of the following 9 criteria:
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Frantic efforts to avoid abandonment, imagined or real
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A pattern of unstable, intense relationships
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Identity disturbance; unstable self-image or sense of self
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Impulsivity in at least two potentially damaging areas
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Recurrent suicidal behaviors, gestures, threats, self harm
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Affective instability due to market reactivity of mood
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Chronic feelings of emptiness
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Inappropriate intense anger or difficulty controlling anger
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Transient paranoia or severe dissociative symptoms
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_per
sonalidad_psicosis/material/dsm.pdf
Borderline Personality Disorder
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1-4% of the general population
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6% of a primary care clinic population
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50% had no mental health treatment that year
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43% not recognized by PCP has having any
emotional or mental health problems.
http://archinte.jamanetwork.com/article.aspx?articleID=210746
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Higher rates of common health problems, perhaps
due to medication-induced obesity
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Diabetes, Hypertension
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Chronic Back Pain
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Arthritis, Fibromyalgia
http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Borderline Personality Disorder and Health
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Medically self-sabotaging behavior
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Increased perceptions of illness
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Pain syndromes (BPD in 50% of chronic pain patients)
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Prescription misuse and abuse
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HIV
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Skin picking or excoriation (1 in 4 have BPD)
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Factitious illness
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Plastic Surgery (more surgeries, less satisfaction)
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Rheumatoid Arthritis (40% have BPD?)
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Disability (3 times more likely)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012616/pdf/PE_1_2_19.pdf
Treating BPD - Pharmacology
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SSRIs are recommended by the APA
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Mood stabilizers
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Valproate may be helpful for rage
Lamotrigine and Topiramate may help
Omega-3 Fatty Acids (one small study)
Low-dose Antipsychotics
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Fluvoxamine, Sertraline, Fluoxetine
Aripiprazole, Olanzapine
Avoid benzodiazepines
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-guide.pdf
http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.160.1.167
http://emedicine.medscape.com/article/913575-medication; http://www.bpddemystified.com/treatments/medication/
Treating BPD - Pharmacology
General study limitations:
• Outpatients, not severely ill (excluded if expressing acute suicidality).
• Small sample sizes
• Short duration (≤ 3 months); longer trials had high drop-out rates
• RCTs prone to high placebo response rate
APA practice guideline recommendation: Symptomtargeted approach.
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Opens door for polypharmacy, but there is little evidence regarding its
effectiveness.
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Using as few medications as possible to target central areas of clinical
dysfunction, together with evidence-based psychotherapy, is usually the
optimal treatment strategy.
Treating BPD - Pharmacology
Antidepressants
• Disturbances of serotonin has been associated with BPD, impulsive
aggression, self-harm, and suicidality.
• Early research with TCAs
• Amitriptyline has been associated with paradoxical increases in
suicidality, paranoia, and behavioral dysregulation. Medications with
adverse cognitive effects, including anticholinergic side effects, may
contribute to worsening impulsivity. Added risk with overdose potential.
TCA are discouraged in BPD.
• MAOIs
• Older studies have demonstrated benefit with phenelzine in the
treatment of hostility, anxiety, and borderline symptoms. Many patients
will not be able to tolerate adverse effects and associated restrictions.
Risk for toxicity in overdose.
Treating BPD - Pharmacology
• SSRIs
• Fluoxetine has been shown to reduce anger in BPD independent of any
ATD effect. Also may improve verbal and impulsive aggression,
irritability and overall functioning. Limited added benefit when added to
DBT.
• Paroxetine has demonstrated efficacy in preventing recurrent suicidal
behavior but no significant effect on depression, hopelessness, or anger.
• Fluvoxamine decreased affective lability, but not impulsivity or
aggression
• Current evidence-based practice recommends use of SSRIs, due to
potential benefits on impulsive aggression that may outweigh associated
risks. There has been no evidence that ATDs alleviate the chronic
emptiness, shameful self-concept, and intra-psychic pain in BPD.
Treating BPD - Pharmacology
Antipsychotics
• First Generation Antipsychotics
• A Cochrane review suggests haloperidol is efficacious in reducing anger
in BPD. By contrast, evidence for efficacy of neuroleptics on affective
symptoms, psychosis, and anxiety remains inconsistent. The dosage of
antipsychotic medication for evidence-based treatment of BPD is usually
lower than schizophrenia. High drop-out rates are noted, and risk of
extrapyramidal symptoms may further limit their utility.
• Second Generation (Atypical) Antipsychotics
• Olanzapine has demonstrated effectiveness in treatment of BPD
patients’ anxiety, anger, interpersonal sensitivity, and paranoia, but not
depression. No difference when compared to haloperidol. Adding
fluoxetine to olanzapine did not elicit further benefit. The addition to DBT
reduced depression, anxiety, and impulsive aggression, but magnitude
and timing of benefits related to DBT was difficult to determine.
Treating BPD - Pharmacology
• Second Generation (Atypical) Antipsychotics
• Aripiprazole effective in reducing aggression, anxiety, depression,
psychosis, interpersonal symptoms, self-injurious behavior and
subjective distress in non-suicidal BPD patients.
• Meta-analyses demonstrate that the class of antipsychotics have
moderate effect in treating aggression, but no significant effect on
depression. Best evidence may be with olanzapine and aripiprazole.
Treating BPD - Pharmacology
Mood Stabilizers
• Lithium
• Particularly beneficial in quieting affective instability
• Toxicity and/or adherence may be problematic
• Carbamazepine
• Has demonstrated reductions in behavioral dyscontrol, and
improvements in global functioning, anxiety, anger, euphoria, impulsivity,
and suicidality, but has been associated with worsening melancholic
depression.
• Depakote
• Has reduced aggression, irritability, and overall disease severity in
patients with Cluster B personality disorders and prominent impulsive
aggression
Treating BPD - Pharmacology
Mood Stabilizers
• Lamotrigine
• Has been shown to reduce anger, reduce affective lability and
impulsivity, but no change in other BPD symptoms. Dose should be
titrated carefully.
• Topiramate
• Has been shown to reduce anger in BPD patients. Other benefits may
include improvements in somatization, anxiety, health-related QOL,
overall stress, interpersonal sensitivity, and hostility. Need to balance
risk benefit of cognitive adverse effects.
• Overall
• May be effective in treating impulsivity and aggression, with moderate
effect on depression in BPD. Little evidence of any effect on
interpersonal dysfunction or disturbances of identity.
Treating BPD - Pharmacology
Other Medications
• Benzodiazepines
• Have been associated with disinhibition, worsening impulsivity, suicidal
ideation, and behavioral dyscontrol in BPD. May interfere with progress
in psychotherapy and adversely affect cognition.
• Omega-3 fatty acid (E-EPA)
• May decrease aggression and depression. May act by inhibiting protein
kinase C (perhaps similar to lithium and valproic acid).
• Clonidine
• Study has shown reduction in tension, dissociative symptoms, selfinjurious urges, and suicidal ideation.
Treating BPD - Psychotherapy
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Dialectic Behavioral Therapy
Mentalization-Based Therapy
Transference Focused Psychotherapy
Schema-Focused Therapy
General Psychiatric Management
Systems Training for Emotional
Predictability and Problem Solving
http://www.bpddemystified.com/treatments/psychotherapy/
BPD – Relationship Management
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Social Contract
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Patient is intelligent, responsible and in control
PCP does not make decisions or give advice
Relationship Management
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Do no harm
Reduce chaos and curtail the distorted
relationship between patient and health care
Consider therapy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
http://www.powells.com/biblio/62-9781138004993-1
Relationship Management, continued
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Interview techniques
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Slowing down the interview
Using fewer words
Increasing the use of silence
Responding with empathetic neutrality
Assuming a position contrary to assigned
attributes
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
BPD – Office Management
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Structure, Structure, Structure
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Remain calm and go for the emotion
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Watch for splitting
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Notice your own feelings
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Open, honest discussions about the role of
emotions and life stressors in medical concerns
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Partner up for physical exams
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Educate about BPD
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Know that Suicide and Self Harm will be issues
http://www.ncbi.nlm.nih.gov/pubmed/17484331
http://www.learningace.com/doc/1139736/439fcb618548f7a4d233ad1696bca6de/borderline-presentation-4-16-09-print-
BPD – The UK Approach
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People with BPD should not be excluded from
healthcare
Work in partnership to develop autonomy and
promote choice
Develop an optimistic and trusting relationship
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Many have experienced trauma
Recovery is possible
Be open, engaging, non-judgmental, reliable
Anticipate the end of relationships and support
transitions
http://www.nice.org.uk/guidance/cg78/resources/guidance-borderline-personality-disorder-pdf
Summary
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BPD can disrupt healthcare
BPD improves with time and hard work
Treatment of BPD includes
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Avoiding harm
Management of relationships
Therapy
Medications
The End!
Treating
Insomnia
02/18/16
http://proof.nationalgeographic.com/2015/10/02/photo-of-the-day-best-of-september/