Treating Borderline Personality Disorder
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 11/20/2014
Disclosures and Learning Objectives
• Learning Objectives
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Be able to name three evidence-based
therapies for BPD
Be able to list the three basic tenets of
Relationship Management
Know 7 ways to improve outcomes in
Borderline Personality Disorders
Appreciate the role of hope in the
treatment of BPD
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Assessing Borderline Personality Disorder
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Review BPD
Review Pharmacotherapy
Review Psychotherapy
Review Relationship Management
Review Office Management
Review the UK approach
Next Week
Borderline Personality Disorder, DSM-IV TR
A pervasive pattern of instability of interpersonal relationships, self
image, and affects, and marked impulsivity beginning by early
adulthood and present in a variety of contexts, as indicated by 5 (or
more) of the following 9 criteria:
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Frantic efforts to avoid abandonment, imagined or real
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A pattern of unstable, intense relationships
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Identity disturbance; unstable self-image or sense of self
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Impulsivity in at least two potentially damaging areas
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Recurrent suicidal behaviors, gestures, threats, self harm
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Affective instability due to market reactivity of mood
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Chronic feelings of emptiness
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Inappropriate intense anger or difficulty controlling anger
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Transient paranoia or severe dissociative symptoms
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_per
Borderline Personality Disorder
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1-4% of the general population
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6% of a primary care clinic population
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50% had no mental health treatment that year
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43% not recognized by PCP has having any
emotional or mental health problems.
http://archinte.jamanetwork.com/article.aspx?articleID=210746
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Higher rates of common health problems, perhaps
due to medication-induced obesity
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Diabetes, Hypertension
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Chronic Back Pain
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Arthritis, Fibromyalgia
http://www.nimh.nih.gov/health/publications/borderline-personalitydisorder/Borderline_Personality_Disorder_508_141959.pdf
Borderline Personality Disorder and Health
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Medically self-sabotaging behavior
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Increased perceptions of illness
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Pain syndromes (BPD in 50% of chronic pain patients)
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Prescription misuse and abuse
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HIV
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Skin picking or excoriation (1 in 4 have BPD)
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Factitious illness
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Plastic Surgery (more surgeries, less satisfaction)
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Rheumatoid Arthritis (40% have BPD?)
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Disability (3 times more likely)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012616/pdf/PE_1_2_19.pdf
Treating BPD - Pharmacology
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SSRIs are recommended by the APA
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Mood stabilizers
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Depakote may be helpful for rage
Lamictal and Topomax may help
Low-dose Antipsychotics
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Fluvoxamine, Sertraline, Fluoxetine
Abilify, Olanzapine
Avoid benzodiazepines
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-guide.pdf
http://emedicine.medscape.com/article/913575-medication
http://www.bpddemystified.com/treatments/medication/
Treating BPD - Psychotherapy
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Dialectic Behavioral Therapy
Mentalization-Based Therapy
Transference Focused Psychotherapy
Schema-Focused Therapy
General Psychiatric Management
Systems Training for Emotional
Predictability and Problem Solving
http://www.bpddemystified.com/treatments/medication/
BPD – Relationship Management
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Social Contract
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Patient is intelligent, responsible and in control
PCP does not make decisions or give advice
Relationship Management
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Do no harm
Reduce chaos and curtail the distorted
relationship between patient and health care
Consider therapy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
http://www.powells.com/biblio/62-9781138004993-1
Relationship Management, continued
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Interview techniques
– Slowing down the interview
– Using fewer words
– Increasing the use of silence
– Responding with empathetic neutrality
– Assuming a position contrary to
assigned attributes
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
BPD – Office Management
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Structure, Structure, Structure
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Remain calm and go for the emotion
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Watch for splitting
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Notice your own feelings
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Open, honest discussions about the role of
emotions and life stressors in medical concerns
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Partner up for physical exams
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Educate about BPD
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Know that Suicide and Self Harm will be issues
http://www.ncbi.nlm.nih.gov/pubmed/17484331
http://www.learningace.com/doc/1139736/439fcb618548f7a4d233ad1696bca6de/borderline-presentation-4-16-09-print-
BPD – The UK Approach
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People with BPD should not be excluded from
healthcare
Work in partnership to develop autonomy and
promote choice
Develop an optimistic and trusting relationship
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Many have experienced trauma
Recovery is possible
Be open, engaging, non-judgmental, reliable
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Anticipate the end of relationships and support
transitions
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http://www.nice.org.uk/guidance/cg78/resources/guidance-borderline-personality-disorder-pdf
Summary
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Borderline Personality Disorder can
disrupt healthcare
BPD improves with time and hard work
Treatment of BPD includes
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Avoiding harm
Management of relationships
Therapy
Medications
The End!
Happy
Thanksgiving!
See you on
December 4!
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