Download - Descriptors
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Descriptors
• “frequent flyers”
• “help-rejecting complainers”
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Descriptors
• “frequent flyers”• “help-rejecting complainers”
• emotional hypochondriacs (secondary gain)
• egocentric • irresponsible, fickle • “love intoxicated”
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Sources of Stigma
• Reaction to anger, neediness (countertransference)
• The perception of willful treatment resistance (“help rejecting complainers”)
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“Negative Therapeutic Reactions”
a) Unconscious guilt
b) Unconscious envy – need to destroy
therapists offerings
c) Unconscious identification with a
sadistic object
Kernberg, OF 1977
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Sources of Stigma
• BPDs self concept: “bad”, “evil”, “damaged”, “small child” (Zanarini et al. 2001)
• Reaction to anger, neediness (countertransference)
• The perception of willful treatment resistance (“help rejecting complainers”)
• Cross-sectional exposure (“frequent flyers”)
• Misinformation about heritability and prognosis
• Unrealistic expectations of competence
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Consequences of Stigma
• avoidance and misinformation by professionals
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“Despite its prevalence, enormous public health costs, and the devastating toll it takes on individuals, families, and communities, [borderline personality disorder] only recently has begun to command the attention it requires”.
House Resolution 1005, April 1, 2008
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Consequences of Stigma
• an “unwanted diagnosis” by patients confirming their worst fears about themselves
• avoidance and misinformation by professionals
• under-utilization of the diagnosis (~ 2-6% in one OPC)• failure to provide adequate didactic training or capable clinical supervision
• lack of parity; fair reimbursement
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“I dread being diagnosed as borderline. It conveys that I’m malicious and manipulative.”
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REPONSES TO DIAGNOSIS OF BPD(N = 30)
WORSE BETTER
Shame
Likability
Hope
Overall
Rubovszky et al.
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Psychoeducation for BPD
- 30 with workshop about BPD vs. 20 wait listed- PE decreases impulsivity and unstable relations over next 12 weeks- “a useful and cost efficient form of pre-treatment”
Zanarini & Frankenburg, JPD 2008
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Minimal BPD Didactic Training Objectives(? 6 Hours)
i) Knowledge of the DSM diagnostic criteria and their meaningii) Awareness of its prognosis and heritabilityiii) How to assess and manage deliberate self- harm and suicidal threatsiv) The role and liabilities of medicationv) The role and outcomes from BPD-specific therapies
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Four Models About the Interface between MDD & BPD And their Implications about Course
BPD is Primary: BPD can cause 2 signs and symptoms of MDD; its improvements will be followed by a decrease in MDD
MDD is Primary: MDD can cause 2 BPD Phenomenology; its improvements will be followed by a decrease in BPD
BPD & MDD are Unrelated: Changes in the course in either disorder will not effect the other
Overlapping Etiology: Changes in either disorder will effect the course of the other disorder; but will do so weakly or inconsistently
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AD COOCCURRENCE IN BPD
No. BPD % with AD % GeneralType AD No. Studies Subjects All (CLPS****) Population*
MDD** 7 1122 44-53 (50%) 17%
Bipolar I*** 8 1006 9 (12%) 1.6%
Bipolar II*** 6 436 11 (8%) 2-3%
Cyclothymic*** 2 404 4% 1%
* Kessler et al., 1994 ** Koenigsberg et al. 1999; Gunderson et al. 2001 *** Paris et al. 2005* *** McGlashan et al. 2000
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BPD COOCCURRENCE IN AD
No. AD Type AD No. Studies Subjects % with BPD
MDD* 6 1005 10-15%
Bipolar I** 12 830 11%
Bipolar II** 3 137 16%
* Koenigsberg et al. 1999; Gunderson et al. 2001** Paris et al., 2005
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FAMILY STUDIES
Increased Prevalence in RelativesProbands MDD Bipolar I Bipolar II BPD
MDD YES* Yes* ? ?
Bipolar I Yes* YES* Yes* No
Bipolar II Yes Yes* YES ?
BPD ? No ? YES
*Replicated Family Study data
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Cross-lagged Panel Analysis Relating Borderline and Depressive Psychopathology over 3 Years (N =
570)
BOR_B
DEP_B
BOR_6
DEP_6
BOR_12
DEP_12
BOR_24
DEP_24
BOR_36
DEP_36
.75*** .78*** .68*** .81***
-.08 .38*** .38*** .33***
.20*** .09* .17*** .11*
.01 .06 .04 .04
Note: BPD = Borderline features, assessed at Baseline (B) and 6, 12, 24 and 36 month follow- alongs; DEP = Depression diagnostic status assessed at these intervals. ***p <.001, **p <.01, *p <.05.
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INTERACTIONS OF AXIS I WITH BPD
Effect Co-Occurring Axis I Disorder
↓ BPD Course
↓ Axis I Course
↑ Med Use
Subst Ab
NO
YES
?
MDD
?
YES
YES
Bipolar
NO
YES
YES
ED
NO
YES
?
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MDD and BPD overlap descriptively, but when co-occurring BPD is primary
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BPD & BIPOLAR DISORDERS
% BPD with Bipolar I & II 20%
% Bipolar I with BPD 11%
% Bipolar II with BPD 16%
% BPD who become bipolar 10%Gunderson et al. 2006
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FAMILY STUDIES
Increased Prevalence in RelativesProbands MDD Bipolar I Bipolar II BPD
MDD YES* Yes* ? ?
Bipolar I Yes* YES* Yes* No
Bipolar II Yes Yes* YES ?
BPD ? No ? YES
*Replicated Family Study data
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New Onsets of Bipolar I and II in Borderline and Other Personality Disorder Samples
BPD (N = 164) OPD (N = 401)
Bipolar I 7 (4.3%) 6 (1.8%)
Bipolar II 6 (3.7%) 6 (1.8%)
Bipolar I and II 13 (7.9%) 12 (3.1%)
* Two patients have onsets of both Bipolar I and II
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INTERACTIONS OF AXIS I WITH BPD
Effect Co-Occurring Axis I Disorder
↓ BPD Course
↓ Axis I Course
↑ Med Use
Subst Ab
NO
YES
?
MDD
?
YES
YES
Bipolar
NO
YES
YES
ED
NO
YES
?
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Bipolar D and BPD overlap descriptively, but not familiarly, and when co-occurring BPD is independent
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BPD & Bipolar Disorder Diagnoses∙ Bipolar disorder is frequently overutilized (only 57% were confirmed with SCID)∙ 26% of false + Bipolar patients have BPD∙ 40% of BPD patients had false + Bipolar dx∙ Overuse of Bipolar dx is 2° to expected response to meds and the extensive marketing of mood stabilizers∙ Underuse of BPD is 2° to it’s lack of a medication–based therapy and its need for psychosocial treatment
Zimmerman et al. J Clin Psychiatry Jan 2010
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Overview
• Treatment of BPD is not done
consistently or well• Most clinicians don’t like treating
BPD patients• There is a shortage of well-trained
BPD treaters
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TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER
• From Psychoanalytic Primacy to Multiple Modalities
(notably psychoeducation, cognitive/behavioral and psychopharmacological)
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TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER
• From Possible Improvement to Probable Remission
• From Psychoanalytic Primacy to Multiple Modalities
(notably psychoeducation, cognitive/behavioral and psychopharmacological)
• From Clinical Expertise to Evidence-based
• From Generic to Disorder-specific
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THE FRAMEWORK FOR EXPECTABLE CHANGES
Areas of Relevant ExpectableDisturbance Interventions Time for ChangeSubjective state • Concerned attention, Hrs./Weeks Dysphoric feelings validation
• Reality testing • Problem solving
• MedicationBehavior • Clarification (esp. in-Rx months
examples) of defense purpose and maladapttive consequences
Interpersonal Style • Confrontation 6-18 months• Pattern recognition• Here-and-now interactional analysis
Intrapsychic • Defense and transference analysis >2 years Organization • Corrective experiences, real
relationships
From Gunderson, 2001
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Behavioral PSA
DBT SFT MBT TFP
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DBT
• Most influential
• Most validated
• Most understandable/learned
• Most accessible
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DBT TFP MBT
Behavioral focus + - -
Cognitive focus - - +
Transference focus - + -
Interpretation - + -
Defense analyses - + +
Support + - +
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Effective Manualized BPDTreatments Show:
1. They are better than TAU. 2. BPD patients require specifiably different and disorder-specific interventions.3. PSA therapy can be manualized – standardized and replicated (up to a point)4. Adherence and competence can be measured and shown to correlate with effectiveness.
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Mentalization: a common theme of all therapies for BPD
• All psychotherapies develop an interactional matrix in which the mind becomes a focus
• Therapists consider the patient by communicating their representations to them
• experience of patient is of another human having their mind in mind Process more important than content
Adapted from Bateman, 2004
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Are EBT’s Worth Learning:
1. Will I do better by my next patient as a
result of the training?
2. Is the increment of increased
effectiveness worth the time and expense
of getting trained?
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FIVE SHARED CHARACTERISTICS OF EFFECTIVE THERAPIES (DBT, TFP, MBT,
SFT) FOR BPD
- Structure (goals, roles)- Coherent theory with trained practitioners (self- selected)- Active: support and challenge- Focus on feelings recognition sources (chain analyses) experiencing
- Countertransference: recognition & management
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WHY DO THIS WORK?
• Pride in skills (“If you can treat borderline patients, you can treat anyone”)• Personal growth• Having a highly personal, deeply appreciated, life-changing role