Borderline Personality Disorder

Curley Bonds, MD Presentation by Amber Kondor, MD

Telemental Health and Psychiatric ConsultationLos Angeles County DMH

Treating the Difficult Patient

Special Thanks –

Ricardo Mendoza, MDChief 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

Objectives:

• 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

Epidemiology of BPD

• 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

Epidemiology of BPD

Major Depression – 60% of patients with BPDAnxiety Disorders – 30% have panic disorder with

agorophobiaAlcohol and other Substance Use Disorders – 12%Bipolar Disorder – 10%PTSDDissociative Identity Disorder (AKA Multiple Personality

Disorder)Eating Disorders (especially Bulimia) – vomiting as

presentation in primary careADHDAntisocial Personality DisorderOther Personality Disorders (Cluster B traits)

BPD and other differential diagnostic consideratons, and comorbidities

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”

Borderline 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.

DSM-IV-TR Criteria for BPD

(1) Frantic efforts to avoid real or imagined abandonment (not including self-mutilating behavior)

BPD: Diagnostic Criteria

“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

BPD Diagnostic Criteria

(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

BPD Diagnostic Criteria

(4) Impulsivity in at least 2 areas that are potentially self-damaging (spending, sex, drugs, recklessness, binge eating)

BPD Diagnostic Criteria

(5) Recurrent suicidal behavior, gestures, or threats, or self –mutilating behavior

BPD Diagnostic Criteria

(6) Affective Instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety – for hours to days at a time)

BPD Diagnostic Criteria

(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

BPD Diagnostic Criteria

(8) Inappropriate, intense anger or difficulty controlling anger

WHAT DO YOU MEAN I CAN’T HAVE MORE XANAX???

BPD Diagnostic Criteria

(9) Transient, stress-related paranoid ideation or severe dissociative symptoms

BPD Diagnostic Criteria

Low KEKG changes in a young person; arrhythmiasEnlarged Parotids, dental changes, gum

irritationSelf mutilation – cuts, burns, etc Childhood trauma, esp. sexual abuseEarly history of drug use, pregnancies, high

risk behaviorsMultiple somatic complaints, multiple former

PCPsDifficult doctor-patient relationship

BPD in Primary Care: Red Flags in the Chart/Office

What are you likely to encounter in your office?Splitting your office staff, previous doctors –

examples to followSplitting – 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)

BPD in Primary Care Setting

STRUCTURESet 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)

BPD: Primary Care Setting

Stay calm and empathic to diffuse hostilityEmotional 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

BPD: Primary Care Setting

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 behaviorSplitting is often an unconscious process in

BPD patients – remain as neutral as possible, and talk about your feelings with a colleague

LaForge, 2007

BPD: Primary Care Setting

Watch for CountertransferenceWhat 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

BPD: Primary Care Setting

Strive for conservative medical management – but provide an appropriate thorough, routine medical evaluationOveruse of diagnostic resources promotes a

“sick” role for the patientPatients with BPD do appear to display a high

degree of somatizationAddress 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

BPD: Primary Care Setting

Open honest discussion of the role of emotions/life stressors in medical concerns – and even aspects of BPD, if appropriateThey 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 treatmentThe 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

BPD: Primary Care Setting

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

BPD: Primary Care Setting

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 10352. LaForge, E. (2007). The Patient with Borderline Personality Disorder. Journal of the American Academy of Physician Assistants. 20,46-50.

BPD: Primary Care Setting

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

Meds for BPD?

Dialectical Behavior Therapy – developed by Marsha Linehan – is the mainstayRequires a significant commitment from the

patientPrognosis 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)

Therapy

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 counter-transference (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!

Summary

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.

References