Posted by Phillipa on June 6, 2011, at 21:25:57
Treatment and criteria for borderline personality discussed. Phillipa
From Medscape Medical News
Management of Borderline Personality Disorder Reviewed
Laurie Barclay, MDAuthors and Disclosures
June 6, 2011 The response of borderline personality disorder (BPD) to psychotherapy is usually favorable, but the benefits of pharmacotherapy are usually only modest, and adverse effects may be considerable, according to a clinical review reported in the May 26 issue of the New England Journal of Medicine.
"...BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics," writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. "Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder."
Criteria for BPD Diagnosis
For a diagnosis of BPD, at least 5 of the following criteria must be met:
Interpersonal hypersensitivity:
◦Frantic efforts to avoid real or imagined abandonment;
◦Fluctuating between extremes of idealization and devaluation, resulting in a pattern of unstable and intense interpersonal relationships;
Affective dysregulation:
◦Marked mood reactivity, such as intense episodic dysphoria, irritability, or anxiety, usually lasting for a few hours and rarely more than a few days, causing affective instability;
◦Inappropriate, intense anger or problems with anger management, resulting in frequent displays of temper, constant anger, and/or recurrent physical fights;
◦Chronic feelings of emptiness;
Impulsivity:
◦Impulsive, potentially self-damaging behavior in 2 or more of the following areas: excessive spending, inappropriate sexual behavior, substance abuse, reckless driving, binge eating;
◦Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior;
Other criteria:
◦Disturbed sense of identity with markedly, persistently unstable self-image or sense of self;
◦Transient, stress-related paranoid ideation or severe dissociative symptoms.
BPD TreatmentsFour evidence-based treatments for BPD are dialectical behavior therapy, mentalization-based therapy, transference-focused psychotherapy, and general psychiatric management. Dialectical behavior therapy involves individual as well as group behavioral therapy, with didactics and homework on mood monitoring and stress management. This therapy is the best validated and easiest to learn of the psychotherapies. The therapist acts as a coach with extensive availability to instruct the patient in how to regulate feelings and behaviors.
Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a "not-knowing" stance, the therapist insists that the patient "mentalize," or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.
Transference-focused psychotherapy, which is developed from psychoanalysis, is an individual psychotherapy with twice-weekly sessions. It highlights interpretation of motives or feelings unknown to the patient and focuses on the patient's misunderstanding of others, particularly of the therapist in the form of transference. This form of therapy is the least supportive and the most difficult to learn.
General psychiatric management, which is conducted once weekly, is a form of psychodynamic therapy developed from the American Psychiatric Association guidelines and the basic BPD treatment textbook. Although the main focus is on the patient's interpersonal relationships, this therapy may sometimes involve family interventions and pharmacologic treatment. General psychiatric management is the least theory bound and easiest to learn of the therapies, but it is also the least well evaluated.
"Selective serotonin-reuptake inhibitors and other antidepressants are frequently prescribed to patients with BPD, but in randomized trials such drugs have had little if any benefit over placebo," Dr. Gunderson writes.
"Data from randomized trials support the benefits of atypical antipsychotic agents (e.g., olanzapine) and mood stabilizers (e.g., lamotrigine), particularly for reducing impulsivity and aggression, in patients with BPD. However, these effects are typically modest, and side effects are common (e.g., obesity and associated hypertension and diabetes with atypical antipsychotic agents or sedation and possibly toxic effects to kidneys and during pregnancy with mood stabilizers)."
Regardless of which therapy is chosen to treat the patient with BPD, there are shared basic principles of treatment. One primary clinician needs to be designated to discuss the diagnosis with the patient, to evaluate progress, to monitor safety, and to oversee communications with other providers and with family members.
A therapeutic structure is essential, with the clinician establishing and maintaining goals and roles. This especially applies to the therapist identifying the limits of his or her availability and creating a management plan to address the patient's future suicidal impulses or other emergencies. Another basic therapeutic need is for the clinician's support of the patient, validating his or her extreme distress and desperation, and providing encouragement about the patient's potential to change.
Also basic to any treatment of BPD is the need for the patient's involvement in the therapeutic process as well as for the clinician's intervention. Both should acknowledge that progress depends on the patient's active efforts to assume control for his or her feelings and behavior, and that the clinician should play an active role. This includes interrupting silences and tangential discussions, focusing on immediate situations such as angry or dismissive responses, and helping the patient connect his or her feelings to rejections, loss of supportive relationships or situations, and other past events.
When treating the patient with BPD, the clinician should express concern about and listen patiently to the patient's threats of suicide or other self-harming acts but should respond judiciously. It may not always be necessary to recommend hospitalization.
Finally, treatment of the BPD poses a special challenge in that the patient's interpersonal style involves alternating between idealization or devaluation. Accordingly, the clinician needs to be self-aware of countertransference, or the predictable inclination to rescue or punish the patient. Because countertransference can disrupt treatment, the clinician should be ready to consult with colleagues and/or to seek outside consultation for the patient if it develops.
"Once the diagnosis is made, clinicians should educate the patient about genetic and environmental contributors and the likelihood of a favorable response to psychotherapy," Dr. Gunderson concludes. "If the patient has relied on medications for treatment, [he or] she should have them reevaluated, and a referral should be made for psychotherapy with a clinician who is experienced in BPD. A thoughtful evaluation of the patients self-harming behaviors can avert unnecessary hospitalization."
Dr. Gunderson has disclosed no relevant financial relationships.
N Engl J Med. 2011;364:2037-2042
poster:Phillipa
thread:987313
URL: http://www.dr-bob.org/babble/20110529/msgs/987313.html