Transcript Understanding Borderline Personality Disorder Series

Treatment Approaches to Help Them Heal
Janice R. Morabeto M.Ed. L.S.W. C.H.T.
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Review the particular therapeutic challenges with which
these individuals present.
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Discuss the APA guidelines for effective treatment
management for individuals suffering from BPD.
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Discuss the treatment approaches which show promise
in helping individuals who suffer from BPD as well as
their family members.
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The Challenge of BPD: A brief review
APA Guidelines For Effective Treatment
Pharmacological Interventions
Dialectical Behavior Therapy
◦ Philosophy
◦ Principles and Practices
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Psychodynamic and Pscyhoanalytic Modalities
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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).
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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
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Research suggests that 1 out of 10
individuals with BPD complete suicide
Chronic Suicidality Among Patients With Borderline Personality Disorder
Joel Paris, M.D.
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8-10%
Does not reflect those in the treatment
groups
Abandonment
Impulse
Dyscontrol
Emotional
Dysregulation
Relationship
Polarities
Suicidality
Substance
Abuse/Prom
iscuity
Crisis and
Crazy
Making
Suicidality
Attempted Suicide
Suicide Crisis
Threats
Impulsivity
Substance
Use/Abuse/Dependency
Self Harm
Recklessness
Affective
Instability
Anger
Dysphoria
Anxiety
American Psychiatric Association
PRACTICE GUIDELINE FOR THE
Treatment of Patients With
Borderline Personality
Disorder
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
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
• 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:
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Hospitalization
Wrap around services
Increasing outpatient visits plus family
watches until the suicide crisis is over
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.
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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.
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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 and
document coverage.
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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-thanusual appointments, doing special favors for the
patient.
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Always avoid boundary violations, such as the
development of a personal friendship outside
of the professional situation or a sexual
relationship with the patient.
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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.
“What the caterpillar calls the end of the world,
the master calls a butterfly”
Richard Bach, Illusions: The adventures of a reluctant Messiah
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Psychotropic Medications
Dialectical Behavior Therapy
 DBT
Transference Focused Psychotherapy
◦ TFP
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Affective Dyscontrol Symptoms
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Impulsive-Behavioral Dyscontrol Symptoms
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Cognitive-Perceptual Symptoms
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Serotonin Selective Reuptake Inhibitors
◦ Fluoxetine
◦ Sertraline
◦ Venlafaxine
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Prozac
Zoloft
Effexor
Affective dysregulation,
Impulsive-behavioral dyscontrol
Cognitive-perceptual difficulties
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Aggression,
Irritability,
Depressed mood,
Self-mutilation
Some somatic complaints (headaches/PMS)
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Amitriptyline
Imipramine
Desipramine
Elavil, Endep
Norpramin, Pertofrane
Janimine, Tofranil
Decreased depressive symptoms and indirect
hostility
Enhanced attitudes about self-control
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Effective for the “associated” symptoms
Depersonalization,
Paranoid symptoms,
Obsessive-compulsive symptoms
Helplessness
Hopelessness
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Lithium
Mood-stabilizing
Anti-aggressive effects
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Divalproex
Carbamazepine
Depakote, Epival
Tegretol, Epitol
May be useful in treating behavioral
dyscontrol and affective dysregulation in
some patients with borderline personality
disorder, although further studies
are needed
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Haloperidol
Perphenazine
Thiothixene
Haldol
Etrafon, Trilafon
Navane
Improvement in impulsive-behavioral
symptoms, global symptom severity, and
overall borderline psychopathology. Similar
efficacy found in the adolescent population
Marsha Linehan (1993)
Suicidal
Behaviors
Behaviors
interfering
with therapy
Behaviors
interfering with
quality of life
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Enhance and maintain the client’s
motivation to change
Enhance the client’s capabilities
Ensure that the client’s new capabilities are
generalized to all relevant environments
Enhance the therapist’s motivation to treat
clients while also enhancing the therapist’s
capabilities
Structure the environment so that treatment
can take place.
Interpersonal Dysregulation
Self Dysregulation
Emotional
Dysregulation
Cognitive Dysregulation
Behavioral Dysregulation
Synthesis
Thesis
Antithesis
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Radical Acceptance
◦ Of the Client
◦ Teach to the Client
 Self
 Environment
 Others
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Giving Self Up to the moment
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Focused Consciousness
Breathing
Thought Stopping
Radical Acceptance
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Radical Acceptance of Others’ Point of View
Listening Skills
◦ Repeating back
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Self-Assertion
◦ Making a Request
◦ Saying No
◦ Expressing Self, Using I statements
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Conflict Resolution Skills
 Teach and Use Socratic
◦ Identifying Differences between
 Thoughts
 Evaluations
 Behavioral/Emotional Reactions
 ABC’s
of CBT
Discussion
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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.
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It views the individual as holding
unreconciled and contradictory internalized
representations of self and significant others
that are affectively charged.
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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
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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.
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Clarkin, JF, Yeomans, FE, & Kernberg, OF (1999).
Psychotherapy for Borderline Personality. New York: J.
Wiley and Sons.
Kernberg, OF, Selzer, MA, Koenigsberg, HA, Carr, AC, &
Appelbaum, AH. (1989). Psychodynamic Psychotherapy
of Borderline Patients. New York: Basic Books.
Koenigsberg, HW, Kernberg, OF, Stone, MH, Appelbaum,
AH, Yeomans, FE, & Diamond, DD. (2000). Borderline
Patients: Extending the Limits of Treatability. New York:
Basic Books.
Yeomans, FE, Clarkin JF, & Kernberg, OF (2002). A Primer
of Transference-Focused Psychotherapy for the
Borderline Patient. Northvale, NJ: Jason Aronson.
Yeomans, FE, Selzer, MA, & Clarkin, JF. (1992). Treating
the Borderline Patient : A Contract-based Approach. New
York: Basic Books
Borderline personality disorder: The treatment dilemma.
Author(s): Oldham, J.M.
Published: 1997
Source: Journal of the California Alliance for the Mentally Ill
Number 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: 1987
Source: Bulletin of the Menninger Clinic
Volume: 51
Number 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.