1、Borderline Personality Disorder in Primary Care,Ashley Owen, Ph.D. Department of Family and Preventive Medicine,Borderline Personality Disorder (BPD),Learning Objectives: 1.To understand prevalence and related statistics of BPD that are important to primary care.2.To understand the diagnostic criter
2、ia and conceptualization of BPD.3. To discuss the use of structure, boundary-setting, and constructive responses to behavior in the context of primary care treatment.,BPD: A Little Self Reflection What Do You Know?, Whats an individual with BPD like? How do you feel when you hear that a patient has
3、BPD? How might you feel after seeing a patient with BPD?,BPD: Prevalence and Related Statistics,- Most people have never heard of BPD even though it accounts for 1/4 of all psychiatric hospital admissions.- Affects primarily women.- The prevalence rate for the diagnosis of Borderline has been found
4、to be 4 times higher in primary care (6.4%) than in the general population (1.6 %).,BPD: Prevalence and Related Statistics,Risky: - Suicidal ideation very high in primary care populations (21.4%)- Up to 10% complete suicide.Underidentified in Primary Care: About half of patients who have BPD were “r
5、ecognized by their PCPs as having an ongoing emotional or mental health problem or had received mental health treatment during the past year”.Gross et al. (2002),BPD Diagnosis: Controversial,CONS:May be overdiagnosed by clinicians who are frustrated by a “difficult patient“.Stigma does exist. The na
6、me Borderline Personality Disorder seems to suggest the condition is a personality flaw.,PROS:Appropriate referral for treatment can be extremely helpful.Recognizing BPD may enhance understanding patients with challenging behaviors.Physicians may develop rapport, feel less frustrated, and even have
7、a therapeutic effect by learning about BPD.,BPD: Diagnostic Criteria,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 a diagn
8、osis of BPD.,BPD: Diagnostic Criteria,Criteria reflect the individuals significant difficulty regulating1.) Emotions * Shifts in mood usually lasting only a few hours and rarely more than a few days,BPD: Diagnostic Criteria,1.) Emotions (contd.)* Anger that is inappropriate, intense or very difficul
9、t to control.,BPD: Diagnostic Criteria,2.) Impulsivity* Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once.,BPD: Diagnostic Criteria,Self-destructive Acts/Self HarmThose with BPD frequently feel overwhelmed or anxious and seek ways to reduce th
10、eir frustration, stress, or pain. Dont have an outlet, so self-injurious behaviors may be experienced as releasing pent-up emotions.,BPD: Diagnostic Criteria,2.) Impulsivity(contd.) * Two potentially self-damaging impulsive behavior patterns. These could include:alcohol and other drug abuse, compuls
11、ive spending,eating disorders, gambling, shoplifting, compulsive sexual behavior, reckless driving,BPD: Diagnostic Criteria,3.) Experience of self - not knowing who one is or changing what one wants to do on a daily basis* Marked, persistent identity disturbance shown by uncertainty in: self-image,
12、sexual orientation, career choice or other long-term goals, friendships, values.,BPD: Diagnostic Criteria,“I have a hard time figuring out my personality. I tend to be whomever Im with.“,BPD: Diagnostic Criteria,* Chronic feelings of emptiness or boredom. “I remember describing the feeling of having
13、 a deep hole in my stomach. An emptiness that I didnt know how to fill.”,BPD: Diagnostic Criteria (contd.),4.) Cognitive experiences * transient, stress-related paranoid ideation or severe dissociative symptoms(Experiencing things as unreal),BPD: Diagnostic Criteria (contd.),5.) Interpersonal relati
14、onships* frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior.,BPD: Diagnostic Criteria,* a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (chaotic-l
15、ove/hate),BPD: Diagnostic Criteria,Additional examples of dysregulation experiences in the area of relationships (Goodwin, 1999)- Alternating clinging and distancing behaviors (I Hate You, Dont Leave Me). - Great difficulty trusting people and themselves. - Sensitivity to criticism or rejection. - F
16、eeling of “needing“ someone else to survive. - Heavy need for affection and reassurance.- People with BPD tend to have an unusually high degree of interpersonal sensitivity, insight, and empathy.,Audio segment:Kathleen3:27-8:40,BPD: Conceptually Speaking,Characteristics stem from the intensity of em
17、otional instability: Intensity of emotions leads to a tendency to perceiveothers behavior as malevolent (related to inappropriate, angry outbursts) abandonment (even minor loss may be experienced as panic) extreme emotional responses to intimacy (manifested in splitting and idealization/devaluing) d
18、issociation (helps the patient separate from the intensity of his/her emotions),BPD: Conceptually Speaking,Intensity of emotions leads to:desperate, impulsive, often unhealthy attempts to make themselves feel better or essentially, manage their emotions. Whats seen as manipulative or impulsive behav
19、iors are desperate attempts to obtain a response from their environment.The outcome of these behaviors may be soothing and empowering initially, but behaviors are often self-damaging in the long run.,BPD: Conceptually Speaking,Difficult to have good relationships if you cant regulate emotions butwit
20、hout good relationships its also difficult to regulate emotions because much more emotionally vulnerable. Cyclic problem,BPD: Conceptually Speaking,Linehan Individuals with BPD are born with aninnate biological tendency to react more intensely to lower levels of stress than others and to take longer
21、 to recover.,BPD: Office Management,1.) Structure, structure, structure Actively structure the interviewRespond to repeated office calls by voicing commitment to the relationship within the context of negotiated boundary setting.Schedule brief, frequent visits and give verbal outline of the territor
22、y to be addressed in future visits, when a long list of issues or new last-second issues are brought up.LaForge, E. (2007),BPD: Office Management,2.) Remain calm and empathetic to diffuse hostility.Respond to emotional outbursts by:recognizing feelings while requesting appropriate behavior. “I can s
23、ee how you might be angry about this, and Id like to talk with you about it if you can lower your voice”.If the patient does not respond:voice awareness of the heightened emotion at present and the need for a break until this is reduced, when the conversation will resume. LaForge, E. (2007),BPD: Off
24、ice Management,3.) Beware of SplittingBeware that agreeing with an a devalued view of another treater, may be a form of splitting, unhelpful to the patients treatment. or thatBeing overly protective of another treaters goodness, may invalidate the perceptions of the individual with BPD.LaForge, E. (
25、2007),BPD: Office Management,4.) Look out for counter-transferencePositive counter-transference: Clinician unconsciously responds to idealization in a manner so as to continue extracting accolades from the patient.Ex. “giving in” to excessive special requests, responding to requests for medications
26、that are not medically warranted.Negative counter-transference: Clinician unconsciously responds to devaluation by ignoring, avoiding, or devaluing complaints.LaForge, E. (2007),BPD: Office Management,5.) Open honest discussion of the role of emotions/life stressors in medical concerns.Chronic rotat
27、ing physical complaints: attempt to focus on a specific complaint with brief discussion of patients psychosocial concerns. LaForge, E. (2007),BPD: Office Management,6.) Partner-up for physical examinations.LaForge, E. (2007),BPD: Office Management,7.) Educate about BPD if appropriate Reviewing the d
28、iagnostic criteria for BPD with the patient may lead the patient to feel more understood by theprovider. This may help the patient accept treatment efforts in general. LaForge, E. (2007),BPD: Office Management,8.) Know that suicide and self-harm will be issues. Patients with BPD are likely to acknow
29、ledge suicidal thoughts very commonly.Take these behaviors seriously, assess and document consistently, consider options if needed, but also know that suicidal ideation and self harm are ways in which patients with BPD cope with their disorder.If you are too uncomfortable with this, refer to someone
30、 else. LaForge, E. (2007),Office Management/Conceptualization: Marshas advice to youThe “manipulative” patient“One wants to conceptualize the behavior in a way that will keep you liking the patient” (Goodwin,1999),Office Management/Conceptualization: Marshas advice to you (contd.)Definition of manip
31、ulative: Skillful/artful handling of a situation with planning.“Borderline patients would do better if they would get skillful and artful.” ,Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. - Mood-stabilizing drugs that are known to enhance the activity of GABA, the
32、 brains major inhibitory neurotransmitter.Psychopharmacological treatment of BPD is complex. Pharmacotherapy not expected to solve the problem.,Meds for Borderline?,Therapy is the primary mode for treating BPD, so always consider this option as a primary step.Dialectical Behavior Therapy - Atlanta J
33、ohn S. Carton, Ph.D. (404) 364-8381 Katrina Davino, PhD, (404)668-9893 Minal Shah, MS, NCC, LPC (770)-833-0227 Robin Day, LPC (404) 636 7435,Therapy for Borderline,Marshas advice to you (contd.)Some medications appear to be effective for treating various aspects or symptoms of the disorder, but phar
34、macotherapy not expected to solve the problem. Psychopharmacological treatment of BPD is complex. Either keep up with the research literature so you know which medications to give, or refer to someone who does.But know that therapy is the primary mode for treating BPD, so always consider this option
35、 as a primary step.,The primary care clinician is likely to have the essential role in initiating psychotherapy treatment. (Presented as an adjunct, not a replacement for primary care) abandonment sensitivityIf the patient hasnt considered therapy, or has previously resisted, the PCP is well-positio
36、ned to create a functional and stable working relationship, that can facilitate the referral and embracing of therapy, possibly initiating a lifetime of change. (LaForge, 2007),ReferencesFusco, G. (2004). Borderline personality disorder: A patients guideto taking control. New York, W.W. Norton & Company. Goodwin, F. (Host.) (11-17-1999). Borderline personality disorder. The infinite mind. Podcast retrieved fromhttp:/ LaForge, E. (2007). The patient with borderline personality disorder. Journal of the American Academy of Physician Assistants. 20, 46-50.,
