The Borderline Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for SOMC Medi

1. The Borderline PatientA Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA September 11, 2009 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.

2. 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 masteringthe 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?”

3. 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.

4. 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.

5. 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. 1Review a video on BPD in YouTube™.

6. 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.

7. 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 some unexpected things.

8. 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.

9. 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.

10. 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.

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

12. Where can you find evidence-based information about mental disorders?1 • Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm. • Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://www.medscape.com/psychiatry. • Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/. • Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/. • 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 at http://www.medicine.uiowa.edu/ICMH/evidence/. 1Please visit www.KendallLStewartMD.comto download related White Papers and presentations.

13. How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1Speaking and consultation fees benefit the SOMC Endowment Fund.

14. Are there other questions? www.somc.org SafetyQualityServiceRelationshipsPerformance 