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Descriptors

Descriptors. “frequent flyers” . “help-rejecting complainers”. Descriptors “frequent flyers” “help-rejecting complainers”. egocentric . irresponsible, fickle . “love intoxicated”. emotional hypochondriacs (secondary gain). Sources of Stigma.

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Descriptors

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  1. Descriptors • “frequent flyers” • “help-rejecting complainers”

  2. Descriptors • “frequent flyers” • “help-rejecting complainers” • egocentric • irresponsible, fickle • “love intoxicated” • emotional hypochondriacs (secondary • gain)

  3. Sources of Stigma • Reaction to anger, neediness (countertransference) • The perception of willful treatment resistance • (“help rejecting complainers”)

  4. “Negative Therapeutic Reactions” • Unconscious guilt • Unconscious envy – need to destroy • therapists offerings • Unconscious identification with a • sadistic object • Kernberg, OF 1977

  5. Sources of Stigma • 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 • BPDs self concept: “bad”, “evil”, “damaged”, • “small child” (Zanarini et al. 2001)

  6. Consequences of Stigma • avoidance and misinformation by professionals

  7. “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

  8. Consequences of Stigma • 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 • an “unwanted diagnosis” by patients confirming • their worst fears about themselves

  9. “I dread being diagnosed as borderline. It conveys that I’m malicious and manipulative.”

  10. REPONSES TO DIAGNOSIS OF BPD (N = 30) WORSE BETTER Shame Likability Hope Overall Rubovszky et al.

  11. 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

  12. Minimal BPD Didactic Training Objectives • (? 6 Hours) • Knowledge of the DSM diagnostic criteria • and their meaning • Awareness of its prognosis and heritability • How to assess and manage deliberate self- • harm and suicidal threats • iv) The role and liabilities of medication • v) The role and outcomes from BPD-specific • therapies

  13. 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

  14. AD COOCCURRENCE IN BPD No. BPD % with AD % General Type ADNo. StudiesSubjectsAll (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

  15. BPD COOCCURRENCE IN AD • No. AD • Type ADNo. StudiesSubjects% 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

  16. FAMILY STUDIES Increased Prevalence in Relatives Probands 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

  17. Cross-lagged Panel Analysis Relating Borderline and Depressive Psychopathology over 3 Years (N = 570) .75*** .78*** .68*** .81*** BOR_6 BOR_B BOR_12 BOR_24 BOR_36 .09* .20*** .17*** .11* .01 .06 .04 .04 DEP_6 DEP_24 DEP_B DEP_12 DEP_36 -.08 .38*** .38*** .33*** 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.

  18. INTERACTIONS OF AXIS I WITH BPD EffectCo-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 ?

  19. MDD and BPD overlap descriptively, but when co-occurring BPD is primary

  20. 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

  21. FAMILY STUDIES Increased Prevalence in Relatives Probands 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

  22. 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 II6 (3.7%) 6 (1.8%) Bipolar I and II13 (7.9%) 12 (3.1%) * Two patients have onsets of both Bipolar I and II

  23. INTERACTIONS OF AXIS I WITH BPD EffectCo-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 ?

  24. Bipolar D and BPD overlap descriptively, but not familiarly, and when co-occurring BPD is independent

  25. 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

  26. 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

  27. TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER • From Psychoanalytic Primacy to Multiple Modalities • (notably psychoeducation, cognitive/behavioral and • psychopharmacological)

  28. TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER • From Psychoanalytic Primacy to Multiple Modalities • (notably psychoeducation, cognitive/behavioral and • psychopharmacological) • From Clinical Expertise to Evidence-based • From Generic to Disorder-specific • From Possible Improvement to Probable Remission

  29. THE FRAMEWORK FOR EXPECTABLE CHANGES Areas of Relevant Expectable Disturbance Interventions Time for Change Subjective state • Concerned attention, Hrs./Weeks Dysphoric feelings validation • Reality testing • Problem solving • Medication Behavior • 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

  30. BehavioralPSA DBT SFT MBT TFP

  31. DBT • Most influential •Most validated •Most understandable/learned • Most accessible

  32. DBTTFPMBT Behavioral focus+ - - Cognitive focus- - + Transference focus- + - Interpretation- + - Defense analyses - + + Support + - +

  33. Effective Manualized BPD • Treatments Show: • They are better than TAU. • 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.

  34. 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

  35. Are EBT’s Worth Learning: • Will I do better by my next patient as a • result of the training? • Is the increment of increased effectiveness worth the time and expense of getting trained?

  36. 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

  37. 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

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