What should we do and not do in treatment of borderline personality disorder?

1. What should we do and not do in treatment of borderline personality disorder? Prof Anthony W Bateman Glasgow 2006

2. Acknowledgments • St Ann’s Hospital, London • Catherine Freeman • Rory Bolton • Countless other clinicians • University College, London • Prof Peter Fonagy • Dr Mary Target • Dr Liz Allison • Menninger/Baylor Department of Psychiatry • Dr Efrain Bleiberg, • Dr Jon Allen

3. Therapies for BPD • Supportive Psychotherapy • Behavioural • Dialectical Behaviour Therapy (DBT) • Cognitive • Manual Assisted Cognitive Therapy (MACT) • Schema Focused Psychotherapy (SFP) • Psychoanalytic • Transference Focused Psychotherapy (TFP) • Mentalization Based Treatment (MBT)

4. Outcomes (selected) at baseline &12 months in MACT and TAU groupsTyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality Disorders, 18, 102-116.

5. Summary of clinical findingsTyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality Disorders, 18, 102-116. Neither self-harm episodes, nor other psychometric assessment outcomes, showed any convincing differences between MACT and TAU, either at 6 or 12 months. Possible that a longer period of treatment or greater engagement in face-to-face treatment, were this achievable in routine health care settings, would show more favourable results. BPD showed an increase in costs in health service usage with MACT Manual-assisted cognitive therapy slightly increases the likelihood of self harm relative to treatment as usual with PD patients

6. Dialectical Behaviour Therapy • Initial improvement • Disappointing in follow-up • Replication in inner city London delivered poor results • High drop out • Worse on a number of measures • Level of training required unknown but considered extensive • Better for self-harm than suicide • Effect on personality function unclear • Poor social-emotional function probably continues • Variable change on depression and hopelessness

7. Figure 2.Frequency of self-mutilating behaviors in the past 3 months at week 22 and week 52 since the start of treatment by treatment condition. DBT indicates Dialectical Behavior Therapy; TAU indicates treatment-as-usual. Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003) Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry, 182, 135-140.

8. Figure 4.Frequency of self-mutilating behaviors in the past 3 months at week 22 and week 52 since the start of treatment by treatment condition and baseline severity group. Membership of severity groups is determined by median split on the lifetime number of self-mutilating acts (i.e., <14 versus  14). DBT indicates Dialectical Behavior Therapy; TAU indicates treatment-as-usual. Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003) Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry, 182, 135-140.

10. Change in Reflective Function as a Function of Time and Treatment

11. Trial I: RCT of Psychoanalytic Partial Hospital Treatment (18 months)(Bateman & Fonagy, 1999, 2001, 2003) Attempted Suicide: NNT (18 months)= 2.1 NNT (36 months)= 1.9 Self-Mutilating: NNT (18 months)= 2.1 NNT (36 months)= 2.0 Inpatient Episodes: ES(18m)= 1.4 ES(36m)= 1.1 Depression: NNT(36m)= 2.1

12. Limitations • Small sample size • Control treatments undefined • Multi-component treatment • No replication sites yet (no longer true) • Costly, relative to an outpatient treatment (at least relative to little service) • Only for most chaotic and severe • Length of treatment unclear

13. Dutch Cohort Study Effect size: SCL-90: 1.1 BDI: 2.2 IIP: 2.2 OQ-45: 2.0

14. Conclusions from treatment trials • RCTs have shown modified psychodynamic therapies (MBT and TFP) and modified CBT (DBT, SFT) to be moderately effective • Non-randomised trials show other implementations of psychodynamic, supportive and CBT interventions to be somewhat effective • Briefer periods of hospitalisation shown to be more effective than longer ones • Hospitalisation motivated by suicidal threat is ineffective (Paris, 2004) • A range of well-organised and co-ordinated treatments are effective for BPD

15. Problems, Problems, Problems • Some efficacy of various treatments which may bring forward natural improvement • More limited effects in severe populations • Questionable generalizability of treatments • High levels of training required • Poor penetration of psychiatric services

16. Re-mapping the course of borderline personality disorder

17. Therapeutic Nihilism About BPD • Early follow-up studies • inexorable progression of the ‘disease’ • “burnt out” borderlines • Condition resistant to therapeutic help • intensity and incomprehensibility of emotional pain • dramatic self-mutilation • ambivalence in inter-personal relationships • wilful disruption of any attempt at helping

18. Remissions and Recurrences Among 275 Patients with BPD Percent Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283

19. Time to 12 Month Remission for DIPD Positive Cases (The CLPS Study) Proportion not remitting Time from intake in months Grilo et al., (2004) JCCP, 72, 767-75. Remission is defined as 12 months at 2 or fewer criteria for PDs; Remission is defined as 2 months at 2 or fewer criteria for MDD

20. Summary of Remission Findings • After six years 75% of patients diagnosed with BPD severe enough to require hospitalisation, achieve remission by standardised diagnostic criteria. • About 50% remission rate has occurred by four years but the remission is steady (10-15% per year). • Recurrences are rare, perhaps no more than 10% over 6 years. • Treatment has no (or only negative) relationship to outcome

21. Impulsive Features, Affective Instability and Identity Problems of 290 BPD Percent Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283

22. Interpersonal Features of 290 BPD Patients Followed Prospectively Percent Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283

23. Affective Features of BPD Followed Prospectively Percent Source: Zanarini et al. (2003) Am. J. Psychiat.160, 274-283

24. Differential improvement rates of BPD symptom clusters • Impulsivity and associated self mutilation and suicidality that show dramatic change • The dramatic symptoms (self mutilation, suicidality, quasi-psychotic thoughts) recede • Affective symptoms or deficits of social and interpersonal function are likely to remain present in at least half the patients. • anger, • sense of emptiness, • relationship problems, • vulnerability to depression

25. Time to GAF 12 Month Remission for DIPD Positive Cases (The CLPS Study) Proportion not remitting Time from intake in months Grilo et al., (2004) JCCP, 72, 767-75. Remission is defined as 12 months at 2 or fewer criteria for PDs; Remission is defined as 2 months at 2 or fewer for MDD

26. Determinants of remission • When dramatic improvements occur, they sometimes occur quickly, • often associated with relief from severely stressful situations (Gunderson, Bender, Sanislow, et al, 2003) • Co-morbidities undermine the likelihood of improvement (Zanarini, Frankenburg, Hennen, et al, 2004) • Persistence of substance use disorders

27. Implications of Recent Follow Along Studies • Implication of secondary persistence of social/functioning impairment • Treatments should be directed at social function • Social skill building, community/groups • Vocational rehabilitation; testing; training • Improve adaptive capabilities (as opposed to decreasing maladaptive behaviours) e.g. recreational or leisure time activities • GAF is very relevant outcome measure • Need for better measures sensitive to social functioning in this population (?APFA)

28. Partial Hospital RCT: Patients at 5 yrs FU

29. Partial Hospital RCT: Patients at 5 yrs FU

30. Partial Hospital RCT: % Attempting Suicide N=44 NNT (18 months)=2.1 NNT (36 months)=1.9 NNT (60 months)=2.1 * *** * *** ** ** * p < .05 ** p < .01 *** p < .001 Treatment Follow -up

31. Partial Hospital RCT: Employment

32. Partial Hospital RCT: GAF Scores

33. The outcome paradox in BPD

34. Non-suitability Het alternatief

35. The paradox of the outcome of BPD • Many treatments show moderate effectiveness • The disorder has a positive natural progression, irrespective of treatment • Historically, experts agreed about the treatment-resistant character of the disorder • 97% of patients receive outpatient of care • average of 6 therapists • TAU is only marginally effective (Lieb et al, 2004)

36. The painful conclusion • Some psychosocial treatments impede the patient’s recovery following • The natural course of the disorder • Advantageous social circumstances

37. Suggestive evidence for the reality of iatrogenic harm • Classic follow-up of patients treated in the 1960s and 1970s (Stone, 1990) • 66% recovery only achieved in 20 years • 4 times longer than recent studies • One year hospitalisation is significantly less effective than 6 months hospitalisation (Chiesa et al, 2003) • The iatrogenic effects of hospitalisation persist at 72 months follow-up • Brief manual-assisted cognitive therapy slightly increases the likelihood of self harm relative to treatment as usual with PD patients (Tyrer et al, 2004)

38. Suggestive evidence for the reality of iatrogenic harm • Karterud et al 530 patients high intensity treatment ‘v’ 330 low intensity • Low intensity better for the BPD-patients. • lower number of dropouts (27% versus 32%) • higher number of patients achieving reliable change in GAF which was maintained at one year follow-up. • Improvements in treatment outcome may be a consequence of the changing pattern of healthcare in the US • reduced the likelihood of iatrogenic deterioration associated with damaging side effects of lengthy psycho-social treatment

39. Iatrogenesis, psychotherapy and BPD • Pharmacological studies assume the possibility of and test for adverse reactions • Psychotherapy is assumed to be at worse inert • No systematic studies of adverse reactions to psychotherapy • No theory of adverse reaction • Adverse reaction must link to mechanisms of change

40. How change occurs in therapy with BPD • Interpersonal mechanism of change • Change occurs not through insight, catharsis, or negotiation • Change occurs through new emotional experience in the context of attachment salient interactions • Not the content of therapy but the process of treatment

41. Adverse reactions and ordinary mechanisms of therapeutic change • Psychotherapies interface with a range of processes associated with technique (distorted cognitions, coherence of narrative, expectations of the social environment, expectations of the self – hope) • A generic factor in common to all these: • Consideration of one’s experience of ones own mental state alongside that which is presented through therapy (by the therapist, by the group) • Assumes appreciating the difference between ones experience of ones own mind and that presented by another person • We assume that the integration of current experience of mind with alternative views is foundation of the change process (Allen and Fonagy, 2002)

42. Reduced appreciation of mind  vulnerability to therapy • Individuals with BPD have impoverished model of mental function • Own and others’ • Schematic, rigid, extreme ideas about states of mind • Creates vulnerability to • Emotional storms • Impulsive actions • Problems of behavioural regulation • Consequently unable to compare • A self-generated model • Model presented by ‘mind expert’ • Maladaptive consequences • Accept alternatives uncritically, without integration, (untherapeutic) • Reject them wholesale  drop-out of therapy

43. The danger of ‘psychotherapies’ for BPD • The therapist’s general stance may often in itself be harmful, however well-intentioned • ‘I think what you are really telling me ….. • It strikes me that what you are really saying… • I think your expectations of this situation are distorted’ • A person who cannot discern the subjective state associated with anger cannot benefit from • Being told that they are feeling angry • And what the underlying reasons for the anger might be

44. The fate of assertions about the inner world of BPD patients • It can only be accepted as true or rejected outright • Dissonance between patient’s inner experience and external perspective is not appreciated  bewilderment  instability by challenging and undermining the patient’s own enfeebled representation of inner experience  more rather than less mental and behavioural disturbance

45. The Fonagy & Bateman Principle A therapeutic treatment will be effective to the extent that it is able to enhance the patient’s mentalising capacities without generating too many iatrogenic effects

46. Clinical Implications

47. The Focus of Psychotherapy is Often on Autobiographical Memory “You‘re born, you deconstruct your childhood, and then you die “

48. Dysregulation of attentional capacities • With individuals whose attachment relationships have been disorganized we may anticipate quite severe problems in affect regulation and attentional control along with profound dysfunctions of attachment relationships • Exploratory psychotherapy techniques are likely to dysregulate the patient’s affect • It is wise to anticipate difficulties in effortful control

49. Disorganisation of self • The therapist should be alert to subjective experiences indicating discontinuities in self structure (e.g. a sense of having a wish/belief/feeling which does not ‘feel like their own’.) • It is inappropriate to see these states of minds as if they were manifestations of a dynamic unconscious and as indications of the ‘true’ but ‘disguised’ or ‘repressed’ wish/belief/feeling of the patient • The discontinuity in the self will have an aversive aspect to most patients leading to a sense of discontinuity in identity (identity diffusion)

50. Projection of alien self • Patients will try to deal with discontinuous aspects of their experience by externalisation (generating the feeling within the therapist) • The tendency to do this had been established early in childhood • It is not going to be reversed simply by bringing conscious attention to the process – therefore interpretation of it is mostly futile