The Borderline The Borderline PatientPatient

A Patient-Centered, Evidence-Based Diagnostic A Patient-Centered, Evidence-Based Diagnostic and Treatment Process and Treatment Process

A Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPAFebruary 18, 2011February 18, 2011

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.3These are complicated and exasperating patients; your gut instincts will not serve you well.

Why is this important?

• 10 to13-percent of the population will meet the criteria for one or more of the personality disorders during their lifetimes.

• These people often seek medical care.

• They are some of the most difficult patients you will ever attempt to serve.

• Patients with Borderline Personality Disorder (BPD) are especially challenging.1,2

• Recognizing their underlying disorders and managing these patients appropriately won’t entirely eliminate the challenges these patients pose, but it will make your professional life easier.

• After mastering the information in this presentation, you will be able to identify– The general diagnostic

criteria for a personality disorder,

– The three “clusters” of personality disorders and the characteristics of each cluster.

– The specific diagnoses contained in each cluster,

– The diagnostic criteria for Borderline Personality Disorder (BPD),

– Some of the associated features of BPD,

– A differential diagnosis,– A typical treatment plan,

and – Some expected treatment

challenges.1When a primary care physician calls you in the afternoon, you know it’s important.2 “A patient just told me that she loves me. What do I do now?”

What are the general diagnostic criteria for a personality disorder?

• An enduring pattern of inner experience and behavior that differs from the expectations of the culture. This pattern is evident in– Ways of perceiving and interpreting

things– Emotional responses– Interpersonal functioning– Impulse control

• Pattern is inflexible and pervasive• Pattern leads to distress or

impairment1,2,3

• Pattern is stable and of long duration• Not due to another mental disorder• Not due to substance use

1We all have personality quirks. This is much more than that.2To make the diagnosis, you must uncover evidence of social or occupational impairment or distress.3The people in their lives finally wash their hands of them in hopeless frustration.

What specific diagnoses are included here?1,2,3

• The odd or eccentric cluster of Personality Disorders– Paranoid (suspicious)– Schizoid (withdrawn)– Schizotypal (withdrawn and weird)

• The dramatic or erratic cluster– Antisocial (disregard for rights of others)– Borderline (unstable and impulsive)– Histrionic (attention-seeking)– Narcissistic (self-centered)

• The anxious or fearful cluster– Avoidant (social discomfort)– Dependent (needy)– Obsessive-Compulsive (perfectionist)

1These diagnoses frequently coexist and overlap.2It usually takes more than one interview to make the diagnosis.3Always ask screening questions.

How might a patient with BPD present?

• This is a 25-year-old single graduate student.

• “I’ve been thinking of killing myself.”

• “My boyfriend went alone on a vacation to Europe.”

• “I told him we needed some time apart.”

• “We were like Siamese twins and I couldn’t stand it.”

• “But I can’t believe he would leave me like this.”

• “I feel abandoned and empty.”

• “I am angry that he would make me feel like this.”

• “He should have known it was only a test.”

• “Sometimes I cut myself because that is the only way to let the pain out.”1

• “I can’t stand to be with someone and I can’t stand to be without someone.”

• “I’ve been in several different graduate programs, but the faculty members never turned out to be as nurturing as they claimed.”

• “My parents divorced when I was nine, and we’ve not been close.”

• “Nothing I do will ever please my mother, and I hate her.”

• “I couldn’t get by without the money she gives me though.”

• When talking about her relationship with her boyfriend, she alternated between distraught sobbing and barely-contained rage.

• Listen to a patient here.

What are the diagnostic criteria for BPD?

• A pervasive pattern of instability of interpersonal relationships, self-image and affects

• Marked impulsivity beginning by early adulthood and present in a variety of contexts

• Five or more of the following:– Frantic efforts to avoid real or imagined

abandonment– Pattern of unstable and intense relationships1

– Unstable self image– Impulsivity– Recurrent suicidal behavior or

self-mutilating behavior– Mood instability– Chronic feelings of emptiness– Intense anger– Stress-related suspicion or dissociation

1I’ve been stalked at home, church and on vacation by these patients.

What associated features might you see?

• These people tend to undermine themselves and rarely achieve the level of accomplishment they might otherwise reach.

• Transient psychotic symptoms are common.1,2

• Suicide is a constant risk.• Substance abuse is common.• Physical disability from failed suicide

attempts and self mutilation is common.• Physical and sexual abuse along with

conflict and neglect are often found in their early histories.

• They often also suffer from concomitant mental disorders.

1These patients can be downright spooky.2These patients do dramatic and unexpected things.

What other diagnoses might your include in the differential diagnosis?

• Mood disorders1

• Other personality disorders– Dependent– Histrionic– Narcissistic

• Personality change due to a general medical condition

• Personality changes associated with chronic substance use

• The underlying personality diagnosis often only becomes clear over time.

1Episodic Axis I disorders often obscure underlying personality disorders.

What might a typical treatment plan look like?• Counseling

– Long-term treatment is generally required.

– The setting and acceptance of limits is necessary.

– A recognition of pathologic patterns of impulsive behavior is essential.

– Patience is demanded.

– Boundaries must be set and respected.

– Discharge from treatment is sometimes the most helpful therapy.1,2

• Medication– All medications are

double-edged swords.

– Avoid sedatives altogether.

– Antidepressants may be necessary at times.

– Atypical antipsychotics in low dosages have been helpful in some cases.

– Lithium may help to prevent suicide—or it may be the instrument of the patient’s demise.

1You will not be able to help everyone.2Transfer them if you can’t trust them or can’t stand them.

What are some of the treatment challenges you can expect?

• Noncompliance is the rule.• These patients will demand a special

relationship with you and special treatment from you, and they will never be satisfied.

• These patients will be exceptionally demanding.1

• You will likely feel very frustrated, helpless, resentful and angry. (And that is only the beginning.)

• They will draw you in with their need, lead you to believe no one else can help them and then devastate you with their enraged contempt.

• If you fail to set limits, they will terrorize you with their demands.

• If you fail to respect professional boundaries, they will ruin your personal and professional lives.

• But these people really need help.• If you are not up to it, find them the help

they need.1A patient once told me that it was my job to accept whatever she said and never confront her.

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking

some routine demographic questions.

• Ask me to list all of problems and concerns.

• Using my problem list as a guide, ask me clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.

• Ask about my family and social histories.

• Clarify my pertinent medical history.

• Perform an appropriate mental status examination.

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.

• Reassure me.• Outline your recommended

treatment plan while making sure that I understand.

• Repeatedly invite my clarifying questions.

• Be patient with me.• Provide me with the

appropriate educational resources.

• Invite me to call you with any additional questions I may have.

• Make a follow up appointment.• Communicate with my other

physicians.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007

• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008

• Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

1,2Please note that you must master all of the information in a basic neurology textbook and a basic psychiatrytextbook to do well on the comprehensive, standardized final examination.

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

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