Borderline Personality Disorder: Diagnosis, Course, and Treatment - Meet the Scientist Webinar

welcome to the brain and behavior research foundations meet the scientists monthly webinar series I'm dr. Jeff Bernstein president and CEO of the foundation and your host for today's webinar today dr. Brad rush will present borderline personality disorder diagnosis course and treatment the brain and behavioral research foundation is committed to alleviating the suffering caused by mental illness by a wooden grant that will lead to advances and breakthroughs in scientific research the foundation is the largest private funder of mental health research grants since 1987 the Foundation has awarded more than 360 million dollars to fund more than 5,000 grants to more than 4,000 scientists around the world 100% of all donor contributions for research are invested in our grants to scientists who are working to find breakthroughs in disorders such as ADHD anxiety autism bipolar disorder borderline personality disorder depression OCD post-traumatic stress addiction and schizophrenia I'm delighted to introduce dr. Brad Rice he is assistant psychiatrist an assistant medical director and the green hospital and assistant professor of psychiatry at Harvard Medical School he is also the recipient of the 2012 foundation Young Investigator gram today's webinar will begin with its presentation this will be followed by a question and answer period to submit your questions please use the questions tab on the control panel of your screen feel free to submit your questions throughout the presentation and I'll present as many of them as time will allow and now I'm pleased to introduce dr. Brad rush Brad the floor is yours okay well good to be with you let me get this on slideshow and I think we're ready to start uh did you accept to share that I've got it okay perfect okay all right so it's good to be with you I'm going to give what I hope will be a useful overview of borderline personality disorder today and I think what I'd ask folks to do is to hold questions until the end so that I can run through this and answer your questions most efficiently so let me start by giving an outline of the talk I'm going to talk briefly about epidemiology then I'll review some of the symptoms of BPD I'll talk briefly about some theories of borderline personality disorder I'll review the course of borderline personality disorder symptoms as seen through our McLain study of adult development I'm going to talk about the concepts of remission and recovery and borderline personality disorder talk briefly about evidence on psychopharmacological events for BPD and then end by talking about psychotherapists for borderline personality disorder so in terms of the epidemiology it looks as though borderline patients or BPD occurs in about 2% of the population and it occurs in approximately 10% of all psychiatric patients and in 15 to 20 percent of patients who run inpatients units so it looks like it's a pretty substantial portion of the sickest patients BPD has traditionally been thought of as a disorder primarily for women but and about 75 percent is the figure I saw in the dsm-5 but I think we're beginning to rethink this there's a group of McLain who is very interested in treating male borderlines and I think you may see that the ratio of female to male changing in the next few years so what are the symptoms of BPD I've divided them here into five categories first interpersonal second effective that is emotional third impulsive fourth cognitive and last identity disturbance and I'm going to be drawing from two different sources when I talk about the symptoms of borderline personality disorder one is the dsm-5 and the other is the revised diagnostic interview for borderlines put together by my colleagues John Gunderson and Mary Santorini and the source will be denoted here in the slide so the the first symptom is a pattern of intense and unstable interpersonal relationships characterized by alternations between extremes of idealization and devaluation and can I ask is there any way to minimize the the icon from the currently if you click on the orange button with a white arrow at the top left corner that's it okay great thank you so much so so these patients they alternate between feeling very good about people and feeling very bad about people and they may switch within a matter of seconds depending on whether they're feeling frustrated or well attended to well taken care of there is some question about the extent to which borderline patients actually idealize those close to them as opposed to just feeling okay about them in which case the oscillations would be between feeling okay about people you're close to oh and devaluing them as opposed to idealizing them the second interpersonal symptom involves frantic efforts to avoid real or imagined abandonment borderline patients are often very fearful of separation from those they feel close to and will do essentially anything they can to avoid that separation often threatened separations can actually lead to an activation of other borderline symptoms there also other interpersonal symptoms not listed in the dsm-5 one set involves fear of engulfment or annihilation another set of symptoms involves behaviors such as the evaluation manipulation sadism borderline patients when they're angry can be extremely devaluing and they may nip you late to try to prevent the sort of separations or actions from other people that upset them now there are three general categories of impulsive symptoms the first symptoms involve self-injury that is burning oneself cutting oneself hitting oneself I've seen in severe cases borderline patients actually breaking their bones and they do this for several reasons in some cases they're trying to communicate their distress to others and get them to respond in other cases they're trying to soothe themselves that is reduce their distress their depression their anxiety and they often will tell you that actually the physical pain takes them away from the emotional pain the second set of impulsive symptoms involves recurrent suicidal behavior gestures threats in some cases this behavior too can be manipulative in the sense that it is designed to get a certain response from those close to the patient or to communicate a certain level of distress in some cases however the suicidal behavior is really intended to be lethal and some of the most worrisome patients are those who are getting very impulsive ly suicidal they may be feeling fine one hour and the next hour they're suicidal and actually acting on those urges for those folks it's often very difficult to anticipate how to keep them safe and then there's a third category of impulsive symptoms which I would say could be classified as generally impulsive they involve substance abuse impulsive spending or gambling reckless driving yelling breaking things physical assaults binge eating or purging sometimes sexual impulsivity and their other symptoms that I won't mention here which is slightly less common these symptoms in some cases overlap with other disorders which is one of the reasons that borderline personality disorder actually often has other psychiatric disorders co-occurring with it now some people would say that affective symptoms are really the core of this disorder and according to dsm-5 a main symptom borderline personality disorders affective instability due to marked reactivity of mood and I emphasize reactivity here because the emotional changes that borderline patients experience are often in reaction to good or more frequently to bad things that they view is happening to them and the mood changes that they may experience are between feeling okay and feeling depressed they may rapidly go into states of feeling angry or anxious or irritable but these states don't last a long time they usually last a few hours borderline patients may report their mood changes multiple times during the course of the day they rarely last more than a few days and it's this sort of reactivity and the frequency of the mood shifts that's one of the distinguishing features that separates a borderline personality disorder from bipolar disorder and I'll talk a bit about that in a few minutes a second affective symptom is inappropriate intense anger or difficulty controlling anger and then I've listed some other symptoms from the revised diagnostic interview for borderlines chronic anxiety chronic depression feelings of emptiness borderline patients will often say they feel very empty and then there are cognitive symptoms which in my experience are often a relatively small part of a disorder according to the dsm-5 the only cognitive symptoms is transient stress-related paranoia or severe dissociative distances for those of you who don't know what dissociation is it can consist of losing track of time having dissociative amnesia feeling outside one's body or that one's body is not real feeling the environment is around what is not real or physically separated from the environment and these symptoms are thought to get worse when borderline patients are under stress then there are other symptoms such as non delusional paranoia which I actually think is fairly common in borderline personality disorder which is the belief that people may be having malevolent thoughts or intentions concerning the individual when they're not borderline patients often have difficulty reading the emotions and the motives of other people and are likely to interpret even neutral behaviors as being deliberately hostile then there's quasi psychotic thinking when borderline personality disorder was initially coined as a concept back and then 1930s and 1940s it was thought that it was a disorder between being psychotic and neurotic hence the name borderline and borderline patients were thought to have psychotic like symptoms that is maybe they'd have some whose nations maybe they'd be a little delusional they think that someone could be reading their mind or something like that but it wouldn't approach the level of being true psychosis unless they were very stressed out and the last cognitive symptom is odd thinking unusual perceptual experiences in the revised diagnostic intuitive or borderlines this consists of things like superstitiousness and dissociative symptoms which I mentioned above and the last symptom is identity disturbance which is markedly and persistently unstable self-image or sense of self borderline patients may have difficulty identifying really who they are if you ask them they may have difficulty identifying what their values are their view of themself might change significantly depending on how they're feeling and often they can go from feeling okay about themselves to experiencing tremendous shame and self-loathing in a very short period of time so to meet dsm-5 criteria for borderline personality disorder you need to have five of the nine symptoms listed above connected with the dsm-5 and to meet a diagnostic interview for a borderline revised diagnostic interview for borderline criteria for borderline personality disorder you need to achieve a score of at least eight you can see here there 125 items in this questionnaire each scores you score of on a scale of zero to two there are four different sections one for aspect one for cognition one for impulsivity and once your interpersonal symptoms this instrument does not include an item on effect of instability or one on identity diffusion or identity disturbance so you can get a maximum score of ten and score of eight it's what necessary to be classified as borderline so let's move on to talk about what causes borderline personality disorder I've listed some of the different theories here one of the most prominent by Marsha Linehan who proposed that borderline personality disorder was a result of emotional dysregulation coupled with an invalidating environment usually in childhood Marsha really emphasizes the fact that borderline patients have a lot of difficulty controlling their emotions and I think that's absolutely true Jon Gunderson has proposed that the core feature of borderline personality disorder is interpersonal hypersensitivity that is a strong reactivity to the way you feel you're being treated by others which is has some overlap with emotion dysregulation but is focused more in the interpersonal realm the fourth that I've listed hyperbolic temperament has been proposed by my colleague Mary Santorini she believes that the essence of being borderline is having a very reactive temperament that responds very strongly to cues from the environment often in very negative ways and then Auto kernberg has proposed the most psychoanalytic conceptualization of BPD and his theory really is that borderline patients have tremendous difficulty bringing together images of oneself and other people that have negative emotion attached to them with images of the self and other that have positive emotions attached to them and he thinks this is caused by high levels of temperamental anger that you're born with propensity to feel anger and this sort of drives a wedge in between the negative and positive images and his theory of treatment as we'll talk about subsequently is to try to bring together the positive and the negative in terms of nature versus nurture it looks as though many symptoms of borderline personality disorder have a strong genetic basis we haven't worked it out yet but if you look at genetic studies it looks like many of the symptoms are at least 50% heritable the symptoms may be associated with an abusive neglectful or invalidating environment what section environment is not enough to cause borderline personality disorder and the more we study this we see that it really is a disorder largely of temperament often coupled with environmental factors excuse me so as I said earlier that's often a lot of co-occurrence of other psychiatric disorders with borderline personality disorder which can make it difficult to diagnose it at times some of the disorders that are very common are major depression different anxiety disorders things like panic disorder and post-traumatic stress disorder substance abuse disorders occur very commonly in borderline personality disorder and eating disorders also occur very commonly in my experience among psychiatric disorders it is perhaps the one that is most frequently accompanied by other disorders it's rare when you see someone who's purely borderline and doesn't have some symptoms that might be classified as another psychiatric disorder so there are some diagnostic controversies with respect to borderline personality disorder one is that it's not a valid diagnosis in the eyes of some people because borderline personality disorder is associated with traits of other personality disorders whether it's antisocial personality disorder narcissistic personality disorder avoidant personality disorder so the argument that that group makes is that borderline personality disorder rarely occurs in a pure form so it really doesn't make sense to say okay you have borderline personality disorder and what this group would propose is that all patients be rated dimensionally looking at different types of symptom categories whether it's antagonistic behavior conscientiousness agreeableness a tendency to experience negative emotions that each person would get a score or a rank and one of those categories and that's how you would see the patient the problem with that is it can be difficult to communicate efficiently with other people about patients to be able to say that someone has borderline personality disorder really good notes or denotes a number of features that automatically come to mind when you use the term much harder to do when you're talking about different dimensions then there's another group of researchers who claim that borderline personality disorder is actually a form of affective disorder and in particular bipolar disorder dr. kis skills group has been the group that's advocated for this most strongly I think the evidence is pretty clear right now that borderline personality disorder in most cases is not bipolar disorder there does appear to be some overlap there's a higher incidence of bipolar disorder in borderline patients and in my experience patients who have very unstable bipolar disorder can actually have a number of borderline features but one of the reasons I included this is that I think the very often patients with borderline personality disorder our diagnosis having bipolar disorder and are therefore medicated very heavily and often in ways that really do not help them so the point really is that I think bipolar disorders really over diagnosed at times and many of the patients who were given the diagnosis of bipolar disorder actually a borderline so what happens to the symptoms of borderline personality disorder over time my colleague Mary Zanna Rini has divided these symptoms roughly into two categories one that she calls acute and the other that she calls temperamental this is a list of the acute symptoms things like substance abuse dependence self-mutilation manipulative suicide attempts stormy relationships devaluation manipulation sadism demanding this identity disturbance affective instability and some others which I won't I won't mention but are listed here excuse me and then there are so-called temperamental symptoms the most prominent of which in my opinion are things like chronic depression difficulty with anger chronic anxiety chronic feelings of loneliness and emptiness the non delusional paranoia I mentioned earlier intolerance of aloneness concerns about abandonment or being engulfed or annihilation and general impulsivity is listed here to me unfortunately that doesn't make a lot of sense just because I think impulsivity tends to get better with age but in her study the input the general impulsivity symptoms seem to resolve more slowly than the acute symptoms so these the data I'm going to present now or derived from the McLain study of adult development which started now about 25 years ago had 362 subjects 290 borderline from 72 subjects with other personality disorders and these subjects have been followed every two years now for almost 20 years so this is a graphical representation of what happens to some of the acute symptoms you can see that at two-year follow-up patients hood of the patients who reported substance abuse and dependence 65 percent still reported that but by 10 years less than 10 percent so this goes way down and a lot of the decrease occurs in the first now five-year or occurred in the first five or six years of the study similarly with self-mutilation two years about 60% of the borderline patients reported the who reported self-mutilation initially continued to report it but by ten years it's about eight percent so again it's going way down and in a fairly short period of time if you look at what happens to the symptoms graphically here a similar story with manipulative suicide attempts again by ten years you can see that less than 5% of patients are still engaging in that kind of behavior and four storming relationships you see it's about Oh seventy five percent of patients who initially endorse the symptoms to endorse into two years by six years Istanbul of 40 percent by ten years it's down at about the 10 percent level but then there are the more temperamental symptoms and I'm not going to be talking about all of the temperamental or acute symptoms here but the temperamental symptoms you can see resolved more slowly by by 10 years almost forty percent of the patients who initially endorsed chronic or major depression are still endorsing it with anxiety it's it's a similar story and with feelings of loneliness and emptiness again almost 40 percent of borderline patients are still endorsing this at ten years intolerance of aloneness that's a little better picture again a little over eighty percent to two years have been by the the ten-year or mark of follow-up it's probably about twenty five percent or so so you know again the it's better than some of the purely affective symptoms but still higher than the more acute symptoms so in summary and looks as though in general the impulsive symptoms of BPD improve most rapidly although effective instability improves substantially over time difficulties with anxiety anger and depression remain common quasi psychotic thinking also improves substantially over time but odd thinking and unusual experiences things like dissociation and non delusional paranoia remain common active interpersonal symptoms such as storm your relationships improves significantly but symptoms tied to the experience of separation as opposed to behaviors around that fears or separation and so forth those appear to be more persistent but and so just to summarize the acute symptoms that were reported in the 10-year follow-up by less than 15% of the patients with reported of a baseline so overall they go way down whereas temperamental symptoms appears decline more slowly but looked at another way when you look at the most persistent symptoms and look at their median time to remission that's the time that to remission to 50% of them in the study you see that the median time for mission for chronic depression feelings is helplessness hopelessness worthlessness anxiety general impulsivity intolerance of lowness and dependency masochism that's about six to eight years so the point to be made here is these symptoms are getting better just that they're getting better much more slowly and continue to be present a lot of borderline patients and then looking at the symptoms which were perhaps slowest to remit the median countermission for things like symptoms like chronic anger frequent angry acts chronic loneliness emptiness that was in about eight to ten years so just to make one more generalization of two more generalizations about this the acute symptoms generally seem to be more impulsive and to have a more active assertive component where's the temperamental symptoms in general and I know I'm oversimplifying your but in general they're more likely to involve things like fearfulness and passivity so let's talk about the concepts of remission and recovery in borderline personality disorder doctors an arena defined remission as not meeting either DSM 3r or revised diagnostic interview for borderline criteria for BP day for at least two years with sustained remission being meeting the same criteria but for four years and then she defined recovery as achieving remission for at least two years and also having improved psychosocial functioning and here I think that forged definition of mental health which is to live well into loved well continues to serve us when she opera operationalized the definition of good psychosocial functioning it would be that subjects had to have at least one emotionally sustaining relationship with a close friend life partner spouse and that subjects would have to go to school or were consistently competently and on a full-time basis so in her study Pacific excuse me ninety-three percent of the subjects achieved at least two years of remission over ten years and remission again is improvement in symptoms not necessarily improvement it's like a social functioning the good news of our mission is that if 86 percent of the subjects in her study achieved a sustained remission lasting at least four years and the factors that seem to predict remission were being younger when you enter the study not having history of childhood sexual abuse no family history of substance abuse disorder a good vocational record and then three what I consider to be temperamental symptoms the anxious of the absence of anxiety or an anxious cluster personality disorder comorbid with your borderline personality disorder high levels of agreeableness and low levels of neuroticism which simply means low levels of a tendency toward negative emotions so this is a graphical representation of comparing remission sustained remission and recovery from borderline personality disorder it is another way of showing what I just said graphically about remission but if you look at recovery you can see that Matt is much harder to achieve that at four years about 27% of subjects in the study had achieved recovery and by ten years still only 50% of subjects had achieved what we defined as a recovery now you know you can look at this as either the glass being half empty or half full I would say in some ways it's good news because it shows that borderline patients actually can not only get better in terms of their symptoms but in terms of their functioning when I first started working in the field to give someone the diagnosis of borderline personality disorder was equivalent to saying they were chronic and untreatable we now know that's no longer true and that in fact many borderline patients do improve but there's still a lot more room for us to find ways to help borderline patients get better dr. Mary Santorini's proposed building in some sort of psychosocial rehabilitation into patients treatment to help them be able to function better particularly at work which is a good segue into the next slide which is that of those patients who fail to achieve good psychosocial functioning do it was primarily due to failures in the vocational realm not the social realm so borderline patients seem to be able to over time develop at least some close relationships but I think it's much harder for them to achieve success vocationally and in fact 98% of borderline patients who did not achieve good psychosocial functioning did not do so because they were unable to function consistently well with a full-time job or academic program and that actually makes sense to me in some ways because I think that when you know someone they may be much more tolerant of your instability than a workplace a boss somebody doesn't know you as well might respond to that sort of instability so I've included one slide about neurobiology here I think I want to do that because after all I am talking to for the brain and behavior foundation I'm not going to spend a lot of time on this not because it is important but because at this point unfortunately neurobiology or our understanding of the neurobiology the disorder really does not inform diagnosis and treatment very significantly so what we know is that in borderline patients the insula and amygdala areas that generate emotion are hyper activated in tasks that involve negative emotion and we know that simultaneously areas of the brain which are more new were newer evolutionarily like the anterior cingulate cortex or the prefrontal cortex these areas which regulate emotion they're actually under activated in tasks that involve negative emotion so the simplified way to look at it is that you know borderline patients are primed to react strongly to things and that they don't have the neurobiological equipment to regulate their emotions as effectively as the average person excuse me so let me say a few words about the psycho pharmacologic treatment for a borderline personality disorder and I'll talk about psychosocial treatments I'm going to list or discuss three different categories of medication that we use to treat borderline patients the first is the mood stabilizers which all it turns out happen to be anti-seizure medications the first is lamotrigine which has been found to reduce mood instability anger and general impulsivity and borderline personality disorder and a study that I did and also in some studies that came out of Europe the second medication is valproic acid which my colleagues dr. Franken bergen's an arene II found reduced anger and borderline personality disorder third medication is topiramate which has been found possibly to reduce anger in borderline personality disorder the last is a medication called oxcarbazepine which may reduce impulsivity and borderline personality disorder of these medications I would say that now pro Cassatt is hard to use in part because it has so many side effects so I probably would not use that much attempts to cause weight gain and other side effects which patients have difficulty tolerating the other medications I think are generally better tolerated by patients but I need to say that as with the other medications here you know the effects you get are fairly modest with all these medications they're really not curative so the next category of medication is the antipsychotics which also have mood stabilizing properties I've listed three of them here these are second-generation antipsychotics one is arrow peppers ole which has been found possibly to reduce anger and borderline personality disorder the second is lanza pain which may reduce paranoid thinking in borderline personality disorder and last is quetiapine which a recent study showed might reduce the overall severity of borderline personality disorder of these medications again I think first of all you need to see if they probably have fairly modest effects and the other point to make about them is that they all have pretty significant side effects each one of these medications in particular can cause significant weight gain with olanzapine being the worst offender there so if you're dealing with a population where you're concerned about keeping them healthy physically you need to be very cautious about using these medications and again the the response you're going to get probably won't be that robust I mean in the system they take some of the edge off symptoms but I think you're going to continue to see a lot of borderline personality disorder symptoms even if you have some response to the medicine and then the last category is the antidepressants the only medication I mentioned here is phenelzine which may reduce anger and borderline personality disorder there is a concept known as history dysphoria which has been around for about 40 or 50 years which overlaps heavily with symptoms of borderline personality disorder and it's been shown that the monoamine oxidase inhibitors phenelzine being one of them actually can successfully treat this disorder and dr. Soloff when he studied phenelzine back in 2003 found that it might reduce anger and borderline personality disorder but again I think this is not necessarily an easy drug to use because you need to be on a special diet to be on phenelzine it has multiple side effects including weight gain I think there probably are a very small number of patients with borderline personality disorder who do respond significantly to this I've had colleagues talk about the occasional cures with the monoamine oxidase inhibitors but I think that's really the exception rather than the rule so I'm going to spend the rest of the talk talking about psychosocial treatments for borderline personality disorder and I've listed five of them here I'm only going to talk about four of them because schema therapy is a form of treatment that most of the clinicians I know really don't seem to understand so I'll be talking about dialectical behavior therapy that's DBT mentalization based therapy transference focused psychotherapy and general psychiatric management so the first of these is DBT which was created by Marsha Linehan back in the late 1980s it's a skills-based treat and it employs the concepts of mindfulness and dialectics for those of you who don't know what mindfulness is it is really the capacity to observe oneself and describe oneself in a way that is non-judgmental dialectics simple or a dialectic is simply a situation which two opposites are somehow related and the most poignant example I can think of in DBT is the dialectic between on the one hand accepting where you are at the moment and not trying to force change in that moment on the one hand the other side of the dialectic is yes pushing hard for change not accepting where you are and pushing forward and to think dialectically would be to say that both of these things can be true simultaneously or almost simultaneously DBT is a very structured treatment which is one of the reasons I think it's been most widely disseminated it involves one hour of GRU treatment and one hour of individual skills coaching each week there are four modules that are taught in the group treatment which has a very didactic feel to it the first is mindfulness the second component or module is emotion regulation the third is to stress tolerance and the last is interpersonal effectiveness now you can see here it can excuse me that there's no module dealing with impulsivity which is a major symptom of borderline personality disorder I would say that that's really built into the module on distress tolerance but probably could be more of a direct focus in the treatment um the duration of DBT is in general twelve months that's about how long it takes to run through the different modules many patients stay in treatment for another twelve months to review those modules to continue to try to develop their skills and there are some people who are patients who were in DBT even longer than that but the treatment was designed to end within 24 months and the studies of DBT have generally been of treatment no longer than 24 months the next form of treatment is metallization based treatment and this is based on the notion that individuals with borderline personality disorder suffer from deficit deficits and the ability to mentalize that is to understand the beliefs emotions desires needs and sort of mental states in general of both themselves and other people if funny game Bateman hypothesize that some of us may have to do with not having adequate protective attachment growing up but in any event what borderline patients present with in their view is this inability to mentalize which causes a lot of the symptoms so the treatment hypothesizes that mentalizing goes offline when attachment to an emotionally significant person is disrupted and really what floating in Bateman would say is there's sort of an ideal level of attachment which stimulates mentalizing if you feel too distant from someone you won't be mentalizing if you feel too close and comfortable you won't be mental of thought or mental izing it's sort of that in-between area when you're likely to mentalize the most their treatment involves helping borderline patients improve this ability with one individual session in one group session per week and you walk into the room with your therapist and you're asked to start mentalizing about a problem this occurs after a treatment contract is put in place which may not be formalized but involves crisis intervention necessary so I don't want to give the impression that there isn't some crisis intervention involved but the mainstay of the treatment is helping patients be able to mentalize and I think the important point to make about this also is that in the views of Bateman and phoney G mentalizing accurately if you will that is coming with jet up with just the right interpretation of one's own mental state or another person's mental state it's not necessarily as important is the fact that you're doing it just trying to mentalize in itself and practicing that skill whether you're completely on target seems to ameliorate a lot of the symptoms of borderline personality disorder and the duration of their treatment is 18 months so in some ways the most psychoanalytic of the treatments for BPD is transference focus psychotherapy developed by out of kernberg John Clark Caen and their group down at Cornell and this is based on the hypothesis as I mentioned earlier that borderline personality disorder is a psychological organization in which the images of self and others associated with negative emotions do not integrate with such images associated with positive emotions so in other words patients with BPD they can't really tolerate feeling ambivalent about themselves about others or and put another way they can truly develop an emotionally balanced view of themselves or other people and kernberg labels this process splitting so the treatment involves twice-weekly individual sessions with a therapist for up to several years and it expects the patients will actually reenact the split views and the self than others in the treatment and that the therapist will help them achieve a more emotionally integrative view of themselves and others and it centers on a contract between the patient and the therapist that they have to mutually agree on and if the contract specifies advance how crises will be managed it typically specifies that there's no between session contact and that the patient will get him or herself to a hospital if necessary to maintain safety the contract requires a certain number of hours a week meaningful work or activity so it really asks a certain level of function which i think is extremely important and it's expected that there will be multiple violations of the contract in the early stages of treatment in particular and that it could take months and maybe longer to actually work out the contract so working out the contract is actually a key piece of the treatment this is the most open-ended of the treatments now I'm going to be mentioning today and last of all I'm going to talk about general psychiatric management that is GPM which has been propagated by dr. John Gunderson it's based on his notion that BPD is caused by interpersonal hypersensitivity involved psychodynamic principles and also medication management so it's the only one of the treatments that involves more psychological approach and medication management with the medication management being targeted toward mood instability and pulse ibbity and aggressiveness and just a few points about it at the outset the clinician who's doing this treatment makes clear that he expects the patient to get better emphasizes functioning and provides a lot of cycle education about BPD and interestingly the goal of a treatment is not reduction in symptoms primarily it is to improve psychosocial functioning that is in working relationships with improvements in symptoms being in the service of that being secondary and this is the most or the least structured of all the treatments I mentioned in that there's no specified intensity it might start out as once a week and rapidly move to once every other week or once every two weeks and there's no specified duration it could go on indefinitely so I want to emphasize that all these psycho therapies share certain aspects first of all they're focused in the here-and-now they may at times discuss a patient's past but they're very much focused in here now they all have some sort of crisis management for patients who are actively suicidal with the possible exception of transference focus psychotherapy which as I said as soon as the patient may manage this on her own and the other point to make is it just not clear that any one of these treatments is more effective than the others they all seem to work and while one might be better for a particular patient I can't say that one is the definitive psycho therapeutic treatment so let me summarize what I've said today BPD is a common psychiatric disorder that includes emotional instability impulsivity and interpersonal difficulties it appears to have at least some genetic component and the role of environmental factors is less clear I want to say again most patients with borderline personality disorder improve it has a better prognosis than bipolar disorder although most borderline patients achieve a remission of symptoms only about half achieved recovery from this disorder and more recent data would suggest it's a little better than that but probably the most recent information I saw is about 60% something like that might achieve a recovery for at least two to four years remissions achieved by borderline patients are usually stable that is remissions of symptoms not recovery impulsive symptoms in BPD typically remit early in the course of disorder affective symptoms in borderline personality disorder with the exception of affective instability tend to remit more slowly if at all and most borderline patients achieve improvements in psychosocial functioning but these improvements may not be stable the difficulties in psychosocial functioning for borderline patients are most often explained by difficulties in achieving and sustaining competent vocational functioning and then in terms of treatment several medication classes may be helpful in treating the BPD but the effects of the medications are generally not curative and that psycho therapies remain the mainstay of treatment for BPD as I said before there's no one psychotherapeutic approach that's most effective and also interestingly enough many patients with BPD improve and actually may achieve remission or recovery without intensive treatment you know it's not uncommon for some of the healthier borderline patients who present in their late teens to by their mid-twenties even without intensive treatment to be doing a lot better and perhaps meet criteria for recovery so that's all I have to say thank you for your attention I'll take any questions Brad thank you for just a very full presentation really geared towards a lay public and I appreciate that we have a couple questions asking about the studies that you presented in terms of remission and recovery of symptoms over ten years what was the type of treatment that those people received during that period of time that's an excellent question because it was a naturalistic study treatment was not controlled for most of the patients were in some kind of treatment at least initially but when the study started there were not there was not manualized treatment the way there is now there Marsha Linehan was probably doing DBT but I don't think she had published her book yet maybe she had but it was just getting started so I would say that almost none of the patients who were in the study received any of the manualized treatments that were mentioned they received supportive psychotherapy perhaps more psychodynamic psychotherapy a very high percentage the more on medications and many they were still on large quantities of medications so it doesn't really say much about what treatments might have led to improvement okay that's that's very helpful one of the areas of questions come from family members about what can they do how can they help their loved ones often it's frustrating when they do try to help and get pushed away what can family members how do what do they do that's an excellent question so I think the first thing you want to do is to get educated about the disorder and increasingly at least hear McLain we are doing a lot of work with families of patients with borderline personality disorder and I think there's actually a you know family connections group that's that's national so I think that you you want to be responsive you want to be attentive to the pain of borderline patients what you don't want to do is to give them the impression that they are not expected to function because no work in itself is really important to people getting better being out there in the world having relationships is for the people getting better so say you know just to automatically take the point of view that some was too sick to work and shouldn't be expected to do so I think often is not in their best interest you know when I started working in MacLean we had borderline patients hospitalized for very long periods of time we found out that was regressive and many of them probably could have recovered if they had been asked to do more at an earlier stage of illness but because they were kept in the hospital for long periods of time they were institutionalized I think that all the current treatments now including even the residential treatments for the sickest patients here at MacLean would ask the patient's try to work so I think it's also important that you connect with other people who have family members with this disorder to share the pain and hear how they deal with it because I think when you're feeling like you're alone in Avenel in trying to connect or take care of or at least interact with someone who's very ill with this disorder it could be of very dispiriting at times they all very very good advice um and in your experience um then symptoms start to occur during teenage years um which is often a you know a time of you know some difficulty in general well what do you see that sort of differentiates more typical teenage behavior from somebody who might be showing some of the early signs and symptoms of borderline personality disorder well I think that teenagers are temperamental II much more unstable so you naturally see more affective instability I think if you see that someone is engaging in self-mutilation if they are engaged in multiple forms of impulsivity not just a substance abuse but maybe you know several different forms of impulsivity that may be a tip-off I think you know the one thing that really runs through the different theories of borderline personality disorder from my point of view is the doctors and Ernie's concept of a hyperbolic temperament so if you used to be someone who just seems extremely sensitive extremely reactive and then you know that is a tip-off they may have a borderline personality disorder if they can't maintain stable relationships even with friends that's a tip-off I think it you know it becomes clear by the time someone reaches the late teens the early teens I think it's just more fluid so really by the time some of the 16 17 18 if they don't seem to be moving along a developmental trajectory where they're more stable where they're you know acting a little less impulsively where they're they're not able to develop a stable intimate relationships then I'd be worried but you know as I said a lot of borderline patients never get to treatment or they're not even patients they're individuals they never get to treatment and they seem to get better on their own as long as they're not in an environment which is overwhelming stressful is that can really throw people off course and you mentioned for family members learning about the disorder support groups with other people living with that often it it has a really difficult course a difficult situation for siblings and not just the parents we have brought a family what you know how do you how do you approach that when when dealing with patients and families how would you approach the siblings yeah you have the question well you want to give them education as well I think you know they they will need to learn I think it will be important that they understand that borderline patients even though they may cause others a lot of the stress or fundamentally not bad people they often feel really terrible about their behavior after they've had an angry outburst or done something that's very disruptive so I think it's important to understand as a parent or sibling that just because someone is treating you badly in the moment doesn't mean that they actually really want to treat you badly they may be doing this despite themselves I think that you want to learn how not to do things which get someone with borderline personality disorder which are really big triggers on the other hand you know you can't walk on eggshells around them all the time I think if the world is too accommodating then it sends a message that they don't have to modify their behavior and actually try to do better and again I think as with with parents you know you may want to connect with other people who've had the experience that you've had so that's it in a nutshell but I can't and I think William Lee's involved in being educated and well actually let me step back for a second you know that there's a concept we use here at MacLaine very heavily which is validation and I think it's really important that one validate the pain borderline patients without coddling them so let me leave it is that I think it's such a good important point that you're making because nobody decides oh I wish I had a disorder whether it be an diabetes or borderline personality disorder finally decides they want it people just have it and I think sensitivity to that is always important yeah I want to ask you in in our last remaining moments what do you see is the future of treatment where are we going in terms of research where we go in terms of treatment what do we have in front of us over the next period of time well I would say that the last 15 to 20 years have really been very productive in terms of developing psycho therapies for borderline personality disorder and understanding what happens to the people's symptoms over time but we clearly have a much better grasp of that and we have some limited data on how medications work and to what extent they work I do think that you know the the era when we're going to be developing a lot of new pure psycho therapies may be over I think we will see more of a rehabilitation component built into treatment you know again more of a funk and emphasis on psychosocial functioning always I think that you know we want to get more treatment out there for people you know the treatments I mentioned today even though they're not four times a week psychoanalysis they're pretty expensive and not accessible to a lot of people so I think we'll probably see more group therapies and maybe some online a treatment thority is some people like doctors an arena who've developed online modules to borderline patients learn about themselves and then I think as we understand the neurobiology of the disorder what I suspect we're going to see maybe is more integrated treatment finding medications that enable particular kinds of exposures in psychotherapy with reduction in the painful emotions associated with those exposures so you know it turns out that some of the best treatment for borderline personality disorder gets the patients to expose themselves to things they would otherwise shy away from and if you can find some way to block the painful response and make that exposure easier I think you will actually open up a window on a therapeutic response which doesn't exist at the moment well I think very hopeful Brad I want to thank you for an outstanding presentation and more importantly for the work that you've done in this very important area so thank you very much it's been a pleasure I also wanted and I also want to thank all the people who've joined us today the research we fund is made possible through private donations so if you'd like to make a contribution please visit BBI Foundation org or call one eight hundred eighty nine eight two eight nine this webinar has been recorded if you've missed any portion or would like to share it with a family member or friend please visit the webinar page on our website finally I hope people will join us again next month when dr. Carolyn Rodriguez assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine presents a webinar on obsessive-compulsive disorder this will take place on Tuesday June 13th at 2 o'clock Eastern Time once again thank you for joining us and enjoy the rest of your day take care

Channel: Brain & Behavior Research Foundation

Views: 69,038

Rating: 4.8518519 out of 5

Keywords: depression, bipolar disorder, anxiety, brain research, narsad grants, symptoms, recovery, behavior research, warning signs, treatments, cure, diagnosis, hope, borderline personality disorder, bpd, borderline, personality disorder, borderline personality disorder treatment

Id: Q6fbPjiEqeU

Length: 61min 15sec (3675 seconds)

Published: Thu May 11 2017