understanding borderline personality disorder series
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Understanding Borderline Personality Disorder Series. Treatment Approaches to Help Them Heal Janice R. Morabeto M.Ed. L.S.W. C.H.T. Goals and Objectives:. Review the particular therapeutic challenges with which these individuals present. - PowerPoint PPT PresentationTRANSCRIPT
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Understanding Borderline Personality Disorder
SeriesTreatment Approaches to Help Them Heal
Janice R. Morabeto M.Ed. L.S.W. C.H.T.
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Review the particular therapeutic challenges with which these individuals present.
Discuss the APA guidelines for effective treatment
management for individuals suffering from BPD.
Discuss the treatment approaches which show promise in helping individuals who suffer from BPD as well as their family members.
Goals and Objectives:
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The Challenge of BPD: A brief review APA Guidelines For Effective Treatment Pharmacological Interventions Dialectical Behavior Therapy
◦ Philosophy◦ Principles and Practices
Psychodynamic and Pscyhoanalytic Modalities
Agenda
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Most common personality disorder in clinical settings.◦ 10% of individuals seen in outpatient mental health clinics,
15%–20% of psychiatric inpatients◦ 30%–60% of clinical populations with a personality disorder. ◦ It occurs in an estimated 2% of the general population (1,
136). Borderline personality disorder is diagnosed
predominantly in women, with an estimated gender ratio of 3:1. The disorder is present in cultures around the world.
Five times more common among first-degree biological relatives
Epidemiology
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Research suggests that 1 out of 10 individuals with BPD complete suicide
Chronic Suicidality Among Patients With Borderline Personality Disorder
Joel Paris, M.D.
8-10%
Does not reflect those in the treatment groups
Suicide Rates among BPD
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Particular Therapeutic Challenges
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Abandonment
Emotional Dysregulat
ion
Impulse Dyscontr
ol
Relationship
Polarities
Suicidality
Substance
Abuse/Promiscuit
y
Crisis and
Crazy Making
Core of BPD Suffering
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Suicidality
Attempted Suicide
Suicide Crisis
Threats
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Impulsivity
Substance Use/Abuse/Dependency
Self Harm
Recklessness
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Affective Instability
Anger Dysphoria Anxiety
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Defense Mechanisms
•Projection•Transference•Reaction Formation•Countertransference
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Common Denominators of
Effective Treatment Programs and
ProvidersAmerican Psychiatric Association
PRACTICE GUIDELINE FOR THETreatment of Patients With
Borderline PersonalityDisorder
Originally published in October 2001.
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Monitor patients carefully for suicide risk and document this
assessment; be aware that feelings of rejection, fears of
abandonment, or a change in the treatment may precipitate
suicidal ideation or attempts.
Take suicide threats seriously and address them with the patient.
Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated
for acute suicide risk
Suicide Precautions
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• to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide by:
Chronic suicidality without acute risk
needs to be addressed in therapy (e.g.,
focusing on the interpersonal context of the
suicidal feelings and addressing the need for the patient
Suicide Precautions
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Hospitalization Wrap around services Increasing outpatient visits plus family
watches until the suicide crisis is over
Suicide Precautions
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Involve the family (if otherwise
clinically appropriate and with adequate
attention to confidentiality issues) when patients are
chronically suicidal.
For acute suicidality,
involve the family or significant others if their
involvement will potentially protect the
patient from harm.
Suicide Precautions
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A promise to keep oneself safe (e.g., a “suicide contract”) should not be used as a substitute for a careful and thorough clinical evaluation of the patient’s suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient’s responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.
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Monitor the patient carefully for impulsive or violent behavior, which is difficult to predict and can occur even with appropriate treatment.
Address abandonment/rejection issues of anger, and impulsivity in the treatment.
Arrange for adequate coverage when away; carefully communicate this to the patient anddocument coverage.
Impulsivity
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The following are risk management considerations for boundary issues with patients with borderline personality disorder:
Monitor carefully and explore countertransference feelings toward the patient.
Be alert to deviations from the usual way of practicing, which may be signs of countertransference problems—e.g., appointments at unusual hours, longer-than-usual appointments, doing special favors for the patient.
BOUNDARY VIOLATIONS
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Always avoid boundary violations, such as the development of a personal friendship outside of the professional situation or a sexual relationship with the patient.
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If the patient makes threats toward others (including the clinician) or exhibits threatening behavior, the clinician may need to take action to protect self or others.
Get a consultation if there are striking deviations from the usual manner of practice.
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The Full Report can be found at:
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Effective Treatment Modalities
“What the caterpillar calls the end of the world, the master calls a butterfly”
Richard Bach, Illusions: The adventures of a reluctant Messiah
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Psychotropic Medications
Dialectical Behavior Therapy DBT
Transference Focused Psychotherapy◦TFP
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Affective Dyscontrol Symptoms
Impulsive-Behavioral Dyscontrol Symptoms
Cognitive-Perceptual Symptoms
Pharmacological Interventions
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Serotonin Selective Reuptake Inhibitors◦ Fluoxetine Prozac◦ Sertraline Zoloft◦ Venlafaxine Effexor
Affective dysregulation, Impulsive-behavioral dyscontrol Cognitive-perceptual difficulties
Medication Regimes (APA guidelines)
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Aggression, Irritability, Depressed mood, Self-mutilation Some somatic complaints (headaches/PMS)
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Amitriptyline Elavil, Endep Imipramine Norpramin, Pertofrane Desipramine Janimine, Tofranil
Decreased depressive symptoms and indirect hostility
Enhanced attitudes about self-control
Tricyclic and heterocyclic antidepressants
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Effective for the “associated” symptoms
Depersonalization, Paranoid symptoms, Obsessive-compulsive symptoms Helplessness Hopelessness
Tricyclic and heterocyclic antidepressants
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Lithium
Mood-stabilizing Anti-aggressive effects
Mood Stabilizers
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Divalproex Depakote, Epival Carbamazepine Tegretol, Epitol
May be useful in treating behavioral dyscontrol and affective dysregulation in some patients with borderline personality disorder, although further studiesare needed
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Haloperidol Haldol Perphenazine Etrafon, Trilafon Thiothixene Navane
Improvement in impulsive-behavioral symptoms, global symptom severity, and overall borderline psychopathology. Similar efficacy found in the adolescent population
Neuroleptics
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Dialectical Behavior Therapy
Marsha Linehan (1993)
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Suicidal
Behaviors
Behaviors
interfering
with therapy
Behaviors
interfering with
quality of life
Dialectical Behavior Therapy
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1. Enhance and maintain the client’s motivation to change
2. Enhance the client’s capabilities 3. Ensure that the client’s new capabilities
are generalized to all relevant environments
4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities
5. Structure the environment so that treatment can take place.
Five Critical Functions
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Self Dysregulation
Cognitive Dysregulation
Behavioral Dysregulation
EmotionalDysregulation
Core of BPD Suffering: DBT
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Synthesis
Thesis Antithesis
Balancing Act of DBT: Remember Philosophy
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Radical Acceptance◦ Of the Client◦ Teach to the Client
Self Environment Others
Major Strategies
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Giving Self Up to the moment◦ Focused Consciousness◦ Breathing◦ Thought Stopping◦ Radical Acceptance
Mindfullness
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Radical Acceptance of Others’ Point of View Listening Skills
◦ Repeating back Self-Assertion
◦ Making a Request◦ Saying No◦ Expressing Self, Using I statements
Conflict Resolution Skills
Interpersonal Relatedness
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Teach and Use Socratic Discussion◦ Identifying Differences between
Thoughts Evaluations Behavioral/Emotional Reactions
ABC’s of CBT
Cognitive Skills
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TFP is an intense form of psychodynamic psychotherapy designed particularly for patients with borderline personality organization (BPO)◦ a minimum of two and a maximum of three 45 or
50-minute sessions per week. It views the individual as holding
unreconciled and contradictory internalized representations of self and significant others that are affectively charged.
Transference Focused Psychotherapy Otto Kernberg
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The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The consistent interpretation of these distorted perceptions is considered the mechanism of change.
Kernberg designed TFP especially for patients with BPO. According to him, these patients suffer from identity diffusion, primitive defense operations and unstable reality testing.
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Suicidal or homicidal threats
Overt threats to treatment continuity
Dishonesty or deliberate withholding
Contract breaches
Acting out in sessions
Acting out between sessions
Nonaffective or trivial themes
TFP
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Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 48, 1060-1064.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, 371-390.
Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.
Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182, 135-140.
References
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1. Clarkin, JF, Yeomans, FE, & Kernberg, OF (1999). Psychotherapy for Borderline Personality. New York: J. Wiley and Sons.
2. Kernberg, OF, Selzer, MA, Koenigsberg, HA, Carr, AC, & Appelbaum, AH. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.
3. Koenigsberg, HW, Kernberg, OF, Stone, MH, Appelbaum, AH, Yeomans, FE, & Diamond, DD. (2000). Borderline Patients: Extending the Limits of Treatability. New York: Basic Books.
4. Yeomans, FE, Clarkin JF, & Kernberg, OF (2002). A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ: Jason Aronson.
5. Yeomans, FE, Selzer, MA, & Clarkin, JF. (1992). Treating the Borderline Patient : A Contract-based Approach. New York: Basic Books
References
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Borderline personality disorder: The treatment dilemma. Author(s): Oldham, J.M.Published: 1997Source: Journal of the California Alliance for the Mentally IllNumber of Pages: 13-15
Cognitive-Behavioral Treatment of Borderline Personality Disorder Author(s): Linehan, M.Published: 1993
Cognitive-Behavioral Treatment of Borderline Personality Disorder Author(s): Linehan, M.Published: 1993
Dialectical behavior therapy for borderline personality disorder. Author(s): Linehan, M.M.Published: 1987Source: Bulletin of the Menninger ClinicVolume: 51Number of Pages: 261-276
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PRACTICE GUIDELINE FOR THE
Treatment of Patients With
Borderline Personality
Disorder
WORK GROUP ON BORDERLINE PERSONALITY DISORDER
John M. Oldham, M.D., Chair
Glen O. Gabbard, M.D.
Marcia K. Goin, M.D., Ph.D.
John Gunderson, M.D.
Paul Soloff, M.D.
David Spiegel, M.D.
Michael Stone, M.D.
Katharine A. Phillips, M.D. (Consultant)
Originally published in October 2001. A guideline watch, summarizing
significant developments in the scientific literature since publication of this
guideline, may be available in the Psychiatric Practice section of the APA
web site at www.psych.org.