Dr Sathya Rao
Clinical Director, Spectrum, the Personality Disorder Service for Victoria,
4th Sept 12
Medicare Local
BPD
• BPD is a serious psychiatric illness.
• Feel unsafe in their relationships with others.
• Difficulties in having healthy thoughts and beliefs
about themselves, and others.
• Difficulty controlling emotions and impulses.
• Problems with work, family and social life
• Self-harm and suicidality
• Having BPD is not the person’s own fault – it is a
condition of the brain and mind.
Borderline Personality Disorder
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1% prevalence, 20 % in psych systems
Diagnosed predominantly in women- 75%
Sampling bias
Women are 3 times more likely to seek help
for psychological help than men
• Clinician diagnostic bias- ASPD
BPD
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Highly stigmatized, misunderstood
Ignorance
Lack of scientific evidence
Lack of clinical skills
Mortality and morbidity is high
Significant co-morbidity with other Axis I,II and III
The patients live painful and miserable lives
Severe functional impairment
BPD is a highly stigmatized disorder
John Gunderson
“BPD is to psychiatry
what psychiatry is to
medicine”
Stigma
• MH professionals are the biggest stigmatizers.
• Clinicians are often reluctant to diagnose BPD
because they believe those with this disorder
are doomed for chronicity.
• “Frequent flyers”
• Marsha Linehan had BPD
• Expert on Mental Illness
Reveals Her Own Fight
New York Times 2011
• BPD patients evoke strong emotional response
from health systems
• Frustration to clinicians- therapeutic
pessimism
• Significant utilization of hospital resources
• High costs to society
Tolkien II WHO 2010
But…….we now know that…
• Genetic and environmental factors contribute
to causation of BPD
• Clinical remission is common
• Effective treatments are now available
• Treatments principles can be learnt
• Psychotherapy is the mainstay of treatment
• Pharmacotherapy is only minimally effective
Australia 2011
National Expert reference group
on BPD
NHMRC
National BPD management guidelines
National BPD
Foundation
Spectrum
• State-wide service for personality disorders
• Residential service- 4 bedded unit
• Treatment service- MBT, BMT, ACT groups,
individual therapy
• Secondary consultation service
• Research- Medications, ACT, BMT, MBT,
psychosis, culture etc.
• 30 staff, Two registrar positions
Access to services for BPD
• At 1% prevalence rates,
potentially there are
60,000 persons who may
have BPD in Victoria.
• AMHS care for ? 6000
patients
• Spectrum provides services
to 400 patients
Spectrum
Cost of treating BPD
• Currently we treat 15% of BPD- chaotic
• Ideal treatment with 30% coverage (15, 400
patients)- stepped care -GP to Specialist care
and education would cost $ 4156 per patient
and a total of $ 64 million
Tolkien II Report by Gavin Andrews 2010 for
WHO
Borderline Personality Disorder DSM
IV Criteria
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 five
(or more) of the following:
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation.
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior
covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than a few days).
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Characteristics of a BPD patient
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Female
20’s and 30’s
Childhood abuse, neglect, invalidating background
Fear of abandonment
Dysregulated emotions
Hyper reactive emotionality
Intolerance to loneliness
Crave for IP relationships, have poor IP skills
Rejection sensitive
Often attract dysfunctional relationships
About 40 % are in abusive relationships
Unstable interpersonal relationships
Idealization and devaluation
ZAN BPD Scale
for the assessment of change in DSM-IV borderline psychopathology
In the past week have you:
1. Have any of your closest relationships been troubled by a lot of arguments or
repeated breakups?
2. Have you deliberately hurt yourself physically (e.g.,punched yourself, cut yourself,
burned yourself)? How about made a suicide attempt?
3. Have you had at least two other problems with impulsivity (e.g., eating binges and
spending sprees, drinking too much and verbal outbursts)?
4. Have you been extremely moody?
5. Have you felt very angry a lot of the time? How about often acted in an angry or
sarcastic manner?
6. Have you often been distrustful of other people?
7. Have you frequently felt unreal or as if things around you were unreal?
8. Have you chronically felt empty?
9. Have you often felt that you had no idea of who you are or that you have no identity?
10. Have you made desperate efforts to avoid feeling abandoned or being abandoned
(e.g., repeatedly called someone to reassure yourself that he or she still cared,
begged them not to leave you, clung to them physically)?
BEST
Have you….
• found that your mood changes suddenly?
• felt you unsure of who you really are or what you
are really like?
• felt spaced out or numb?
• felt as though you were abandoned even though
you really weren't
• deliberately hurt yourself with out meaning to kill
yourself?
• are you able to like yourself
Co occurring disorders
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Depression
Bipolar disorder
PTSD
Eating Disorders
Psychosis
SUD
Kind of comorbid Kingdom
Sub types of BPD
• Given the fact that you require only 5 of 9
criteria to make a diagnosis of BPD according
to DSM IV, one can make a diagnosis of BPD in
256 ways!!!!!
Etiology
• Biological vulnerability
• Environmental factors
• Stress diathesis model
Genetics
• Family history of Mood Disorders and SUDs
are more common in BPD than would be
expected by chance
• Trans-generational patterns
• BPD is significantly heritable
• Strongly genetic. Genetic model-Heritablility
effect 0.69 (1.0 would indicate complete
heritability)
(Widiger and Trull 1992)
(Torgersen et al. Compr Psychiatry 2000; 41: 416-425)
HERITABILITY
Lyons & Plomin/Smoller
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Schizophrenia 85%
Bipolar 80%
BPD 55-68% -(impulsivity/ mood instability)
MDD 45%
Panic Disorder 40%
PTSD 30%
Hyperactive and hyper responsive
Amygdala
Patients with BPD frequently interpret neutral
stimuli as negative.
They over react to negative or even neutral
facial expression.
Hyperactivity of Amygdala.
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A study examining the neural circuitry of emotion-processing deficits in BPD
involving fMRI while viewing a series of photographic images that vary in affective
valence (unpleasant, neutral, and pleasant).
Once aroused the hyperemotional
state of Amygdala takes longer to
revert to baseline in BPD when
compared with normal controls.
Usual cortical control over Amygdala is
reduced
Cortical modulation of Amygdala is
reduced
• Study: BPD patients processing high arousal
stimuli did not show cortical suppression of
Amygdala activity even after the stimuli was
removed, compared for controls
Driving a car with hypersensitive
accelerator and poor breaks
Attachment
• Disorganised attachment
• BPD patients have an hypersensitive
attachment system
Trauma
• Trauma- neglect, abuse
• Child hood sexual abuse is 10 times more
common in women than men
• Large scale studies of childhood sexual abuse
in general population show that 80% of adults
do not develop any psychological problems
• Sexual abuse and BPD
Interpersonal sensitivity
What sets patients off?
• Pushing their buttons
• Triggering attachment systems
• Being misunderstood
• Make them understood
• We need to take responsibility to clear the
misunderstanding
PROGNOSIS
Management of BPD
• BPD is a treatable condition (Gabbard-AJP 2007)
• It is a myth that BPD is untreatable
• Specific effective treatments are now
available
Psychotherapy
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Dialectical-Behavioral Therapy (DBT)
Mentalization-Based Therapy (MBT)
General Psychiatric Management(GMT)
Transference Focused Therapy (TFT)
Schema-Focused Therapy (SFT)
Cognitive Analytic Therapy (CAT)
Supportive Psychotherapy (SP)
• Systems Training for Emotional Predictability and Problem Solving
(STEPPS)
• Cognitive Behavior Therapy (CBT)
• Acceptance and Commitment therapy (ACT)
• Mears- Self Psychology
Psychotherapy outcome research
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Specific technique/model of therapy- 0nly 15%
Expectancy 15%
Common factors 30%
Non specific factors 40%
Matching therapies
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Therapist factors
Patient factors
Resources
Common treatment principles
Curr Psychiatry Rep (2011) 13:60–68
41
• Most patients get better- (45% by 2 years and
85% by 10 years) - no more than 2 diagnostic criteria
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15 % relapse.
• Aim of psychotherapy is to hasten recovery
and aid those who do not recover
spontaneously and work on functional
recovery
Spectrum outcome
1.5 to 2 years of group and or individual
psychotherapy results in significant recovery
for complex BPD patients.
Prognosis
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Spontaneous remission - 75% recover by 35 -40 yrs
90% recover with improved functioning by age 50
Treatment speeds up remission
Treatment as usual - Remission rates:
1/3rd at 2 yrs
1/2 at 4 years
2/3rd at 6 years
3/4th at 10 years
• Good treatment leads to faster remission
• MBT- 60% remission by 1 year
(CMAJ-2005)
Zanarini study
AJP 2006 -10 years of follow-up -290 patients
• 242 of 290 patients (88%) with at least one follow-up
interview had a remission
(Remission was defined as no longer meeting either of our study criteria sets for borderline personality disorder: DIB-R or
DSM-III-R.)
• Time to remission (defined as the follow-up period at
which remission was first achieved).
 39.3% - 2nd year follow-up
 22.3% - 4th year follow-up
 21.9% -6th year follow-up
 12.8% -8th year follow-up
 3.7% - 10th year follow-up.
• Recurrences-rare-6%
• 25 patients-8.6% lost for follow-up before remission
10 year F/U study
Gunderson AGP 2011
• High rates of remission (85%)
• Low rates of relapse (12%)
• Severe and persistent impairment in social
functioning
• Even after remission only 25%- full time work
40% receiving disability payments at 10 years
• 80% of BPD sample had life time MDD.
Collaborative Longitudinal Personality
Disorders Study- 10 year F/U
• Most patients eventually get a life
• They find a place in the world
• Stop wanting to kill themselves
• KEEP THEM ALIVE…….
16 year follow up study
• Remission: 99% achieved symptomatic
remission for a 2 year period and 78% for a 8
year period
• Recovery: 60% achieved recovery lasting for 2
years
• Recurrence: 10% after 8 year period-36%
after 2 year period
Zanarini et al, AJP May 2012
• Remission is not equivalent to
recovery
• Few people with BPD require life
long treatment
Summary
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High rates of remission
Takes long to remit
Relatively low recurrence
BPD has a better symptomatic outcome than
MDD or Bipolar Disorder
Prognostic factors
• Substance abuse (Strongest
predictor) If no substance abuse-4 times faster
remission-4 times more chances of remission
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Stable relationship
Stable occupation
Severity of trauma- sexual abuse
Late onset BPD
Treatment principles
Management versus Treatment
Diagnosis
• Make a comprehensive assessment that
includes:
• Thorough clinical history
• Developmental background- abuse, neglect,
trauma
• Pattern of self harm behaviours
• Details of suicidal attempts
• Readiness for psychotherapy
Communicate the diagnosis
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Choose an appropriate time
Be hopeful
Non-judgemental manner
Long term nature of treatment
Provide appropriate references, websites
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http://www.spectrumbpd.com.au
http://www.bpdcentral.com
http://www.mhsanctuary.com/borderline
http://www.soulselfhelp.on.ca
http://www.borderlinepersonalitytoday.com
Education and support to family/carer
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Carer burden
DE stigmatize
Psycho-education to family
Tell family what they can do to help their loved ones
In a very small proportion of cases it may not be
appropriate to involve family
• Remain non judgemental, do not impose your own
morality on patient/family
Attend to co morbidities
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Axis I
Axis III
SUD
Gambling
Depression and BPD
• Depression commonly co-occurs with BPD.
• The lifetime rate of co-occurrence of major
depression and BPD was 83% in a large study
• The symptoms of depression and BPD overlap,
so that it is challenging to accurately diagnose
depression when the disorders co-exist.
Depression and BPD
• When MDD co-occurs with BPD the quality of the
depression is different from that of depression
without BPD.
• Depression in BPD is characterized by:
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Triggered by IP and life events
Brief duration
rarity of melancholic symptoms
No persistent psychotic symptoms
deep sense of inner badness
feelings of loneliness, emptiness, boredom
Interpersonal dynamics (sense of rejection/fear of abandonment etc)
Depression and BPD
• Depression co-occurring with BPD does not
respond as well to antidepressant treatment
as depression in the absence of BPD
• Treatment of depression alone does not result
in remission of BPD
• But treatment of BPD with psychotherapy
tends to result in remission of BPD as well as
co-occurring depression
Depression and BPD
MDD is not a significant predictor of outcome
for BPD, but BPD is a significant predictor of
outcome for MDD. Clinicians should thus
prioritize the treatment of BPD when BPD
and MDD co-occur.
Offer long term psychological
intervention
1. BPD Specific psychotherapies is the best
option
2. If that is not possible offer supportive
psychotherapy using common treatment
principles
3. If even that is not possible think of how to be
therapeutic with out doing psychotherapy?
Most people with BPD need specialist treatment
that is primarily structured and organized
around their core symptoms
Psychotherapy
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Dialectical-Behavioral Therapy (DBT)
Mentalization-Based Therapy (MBT)
General Psychiatric Management(GMT)
Transference Focused Therapy (TFT)
Schema-Focused Therapy (SFT)
Cognitive Analytic Therapy (CAT)
Supportive Psychotherapy (SP)
• Cognitive Behavior Therapy (CBT)
• Acceptance and Commitment therapy (ACT)
• Mears- Self Psychology
Psychotherapy is a biological
treatment
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Induces changes in brain
Neurogenesis
Increased intercellular connections
Cortical control over Amygdala
Medications
• Meds for core BPD traits?
 Meds for managing BPD crisis?
 Meds for co morbidity?
 Meds to add to augment Psychotherapy ?
 Rational Polypharmacy?
• How long do we prescribe?
• Meds to add to augment Psychotherapy
Psychotropic medications
• Single most widely and uniformly used
treatment for BPD
• Not based on good evidence
• It is an adjunct to psychotherapy
• Avoid polypharmacy and high doses
• Treat co-morbidity- but expect less than robust
clinical response
Psychotropic medications
• 25% patients attempt suicide with prescribed
medications
• 20% will benefit from medications to some
extent
• Use medications sparingly and rationally
Cochrane review BJP 2010
The current evidence from RCTs suggests that
mood stabilisers and Atypical antipsychotics,
may be effective for treating a number of core
symptoms and associated psychopathology,
but the evidence does not currently support
effectiveness for overall severity of BPD.
Pharmacotherapy should therefore be
targeted at specific symptoms.
• Psychotropics should not be used as the main
treatment for BPD, as they can only make
small improvements in some of the symptoms
of BPD.
• Medications do not improve the BPD itself.
• May consider using medicines for a limited
period of time to manage specific symptoms.
Psychotropic medications
• Topiramate and Lamotrigine are effective
against anger, aggression and mood instability.
They may be used as first-line medications for
managing anger and aggression in BPD.
• Aripiprazole is effective against anger,
aggression, depression, paranoid thinking,
anxiety and interpersonal sensitivity.
• Fluvoxamine is effective in controlling rapid
mood shifts.
Medications
• Selective serotonin reuptake inhibitors (SSRIs),
such as Fluoxetine, appear to have some beneficial
effect on mood instability, anger and impulsivity.
• Low-dose atypical antipsychotics (Olanzapine)
have some positive effect on impulsivity,
aggression, interpersonal relationships depression
and global functioning.
• Omega-3 fatty acids can reduce depression and
aggression. The safety of this drug in pregnancy
makes it an attractive option.
Medications
• Mood stabilisers and antipsychotics are
more effective than antidepressants in
the treatment of BPD.
• There is inadequate evidence to support
use of Benzodiazepines for treating BPD.
• The risk of dependence and overdose
outweigh the possible benefits of
benzodiazepines, if any.
Medications
• Not enough research has been done to see whether
Sodium Valproate is useful for treating BPD
symptoms in the absence of comorbid bipolar
disorder. It may be used in BPD patients to treat the
symptoms of interpersonal sensitivity, anger and
aggression.
• Side effects -weight gain and teratogenicity.
• Therefore, Sodium Valproate may not be the drug of
first choice for treating behavioral dyscontrol
associated with BPD.
A drug for BPD?
• Anti Amygdala agent?
• Methylenedioxymethamphetamine
(MDMA)
• Ketamine antagonists
• ? Oxytocin enhances Mentalization
Medications
• It is best to make a collaborative decision with the
patient when considering medication options
(Stephan et al 2007).
• There is no current medication that is approved for
the management of BPD
Self harm
• Chronic suicidal ideations
• Self- injurious acts (DSH)
• Suicidal attempts
• Suicidal gestures
• Suicidal fantasies
• Suicidal threats
Suicidal ideation - J Paris
• Suicidal ideation is common, so that one
cannot assume that, by itself, the presence of
suicidal ideas indicates a high risk.
• Chronically suicidal patients can think about
or attempt suicide over the course of many
years. Problems often begin in childhood, but
the clinical picture of suicidal ideas and
attempts presents clinically in adolescence.
Suicide
• BPD -Spectrum experience- about 5%
• Zanarini long term follow up- 4.6% in 10 years
• It is very difficult to predict accurately who is
at risk.
• 60-70% of BPD will attempt to kill themselves
Suicide
• Mean age of completion 30-37 years (SD
of 10 years)
• Age when they are most threatening of
suicide- 20’s
• Most suicides do not occur during a
crisis
Chronic self harm in BPD
• Refers to any self harm acts or suicidal threats
that are repetitive in nature, not aimed at
death, but at conveying the patient’s urgent
need for help in the face of unmanageable
distress.
• E.g. Overdose, threats to asphyxiate, jump off
a bridge etc
• Acts tend to follow a pattern in each case
Chronic self harm - functions
• Maladaptive means of surviving
• To communicate something the patient
doesn’t believe will be ‘heard’ otherwise
• To hold on to some sense of control in
her life
• To escape from inner suffering, but not
to die
Paris
BPD patients can often tolerate
distress only if they know that
they can escape it ... by
suicide...therefore they become
“half in love with death”
Why do they Self harm ?
1. They are adaptive though pathological
2. Coping and self-soothing
3. Expression of anger
4. Perceived or real rejection
5. A way of preventing suicide
• We do not admit patients to manage self injurious acts
Risk of Non suicidal self injury
Risk of Suicide
Non suicidal self- injurious acts (DSH)
High lethal acts (CO poisoning, Hanging)
Low lethal acts (Cutting, minor OD)
Chronic pattern
Change in chronic pattern
Suicide
Chronic risk
Acute risk
Why should we differentiate?
High Lethality Method
High Chronic Risk
Acute High Risk
Careful community treatment
Admit
New
pattern
Chronic
pattern
Low Chronic Risk
Acute Low Risk
Treat as usual
Assess why change in self harm
pattern
Low Lethality Method
NHMRC guideline draft
Detecting potentially high risk situations
• Change in the chronic pattern of suicidal/self harm
behaviour
• Co existing psychotic features/ depression/substance
abuse
• Substance + Depression increases risk to 42%
• All DSM criteria present – 36% suicide rate
• Relationship breakdown / loss of occupation
• Sexual abuse by father
• Highest risk - 35-40 year old, relationship break up +
Depression+ substance abuse, h/o sexual abuse by father
Risk of Suicide
Risk factors predictive of suicide attempt change
over time.
• MDD predicts risk of suicide only in the short
term (12 months)
• Poor psychosocial functioning has persistent and
long-term effects on suicide risk.
• Half of BPD patients have poor psychosocial
outcomes despite symptomatic improvement.
• A social and vocational rehabilitation model of
treatment is needed to decrease suicide risk and
optimize long-term outcomes.
• The management of chronic suicidality is
based on a different set of principles than
those developed for acute suicidality.
• Admission to a hospital has never been shown
to be helpful, but there is evidence for the
value of day hospitals.
One of the key elements in treating chronically
suicidal patients is to tolerate and accept risks.
Management of chronic self harm
behaviour
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Formulate the functionality
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Avoid hospitalization as much as possible
Develop a management plan
Help the patient understand the
emotional dynamics
(case examples)
Risk management and chronic suicidality
• The management of chronic suicidality in
patients with BPD represents a significant risk
of burnout and ‘empathy fatigue’ in treating
practitioners
• Under response to suicidal presentations may
occur when desensitised to suicide
• There are no medications or
psychotherapeutic techniques to reduce
suicidal ideations immediately
Contract
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Have a clear therapeutic contract
Explain how you understand the disorder
The rationale for the treatment is outlined
The treatment structure is discussed
Limits explained
Anticipate problems, emotions that are likely
to arise during the course of therapy
Crisis plan
• Develop a crisis plan
• Emergency family/carer contact information
• Emergency contact information for patient
and family- local AMHS, your contact
information etc
Structure
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Therapy
Treatment plan
Crisis plan
Do’s and don’ts
Sessions
Consistency – from all treatment providers
Fear of abandonment
• At discharge from hospitals
• Romantic relationships
• “You are much better.... You are making great
progress.. You can do it...”
• GO SLOW
Long term perspective
Therapeutic relationship
• Engagement
• Engagement
• Engagement
• Engagement
• Engagement
• Engagement
• Engagement
Therapeutic relationship is central to change
Active and collaborative therapeutic alliance with
the clients.
The therapeutic relationship
• Provides opportunity for re-nurturance
and the experience of at least one good
enough attachment and relationship...
Corrective IP relationship....... Emotional
maturity.....
Have a developmental understanding of the
individual
• Treatment is based on an acknowledgement
of early childhood experiences , including (in
many cases) the effects of trauma and
deprivation
• But no need to focus on past trauma
Therapeutic stance
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Reliability
Warm engagement
Interactive
Interested
Curious
Active
Validating
Non judgemental
Empathy
Tolerance
Self responsibility
• Self-responsibility: Clients should be encouraged to
take responsibility for themselves and their actions and
be supported to take up an autonomous position.
Likewise, clinicians should have an awareness of their
own responsibility.
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Empathic responsiveness
Consistency
Reliability
Warm engagement
Flexible and limit set
Limit setting should not be
rigid and at the expense of
healthy flexibility
Stay in the moment- here
and now issues
Therapeutic optimism
Maintain hope
• Research tells us that
chronically suicidal
individuals get better
• We can therefore remain
optimistic and positive,
even in the face of
frightening suicidal threats
Focus on patients mind not behaviours
Focus on patients mind
• Patients with BPD have difficulty
reflecting on what is happening in
their own minds or in the minds of
others when they are stressed or
when the attachment system is
stimulated- i.e. they loose the ability
to mentalize in those situations.
Colombo
• Take a not knowing stanceMBT- “Colombo” approach
• Take a Mentalizing stancehelp them understand the
mental states behind
behaviours- their/ others
Mentalization
• Ability to understand our minds and minds of
others.
• Most of us can and will lose ability to
Mentalize now and then- love, anger
• BPD patients lose it more easily, more often
and in a wide range of situations.
Toleration of fluctuations in the clinical course
Driving a car with hypersensitive
accelerator and poor breaks
Patient is in drivers seat- you are a driving
instructor- an empathic one
Attend to emotions
• Be aware of your own emotional reactions
• Countertransference is common and to be
expected.
• It is inevitable when you are dealing with
BPD patients
• Any one treating BPD patients must seek
supervision
Emotions that we feel about BPD
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Annoyance
Anger
Hopelessness
Frustration
Hatred
Very strong empathy
Love
How to deal with Countertransference?
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Recognise it
Name it
Become aware of it
Reflect upon it
Metabolise it
Do not react
Speak to your colleagues/seek supervision
Be aware of the potential for romantic
countertransferences
Transparency
If you make mistakes, own up and
apologise
• Be open and honest
• Accept that in dealing with
complex situations mistakes
will sometimes be made
• If one makes a mistake it is
helpful to acknowledge it
and apologise
• The patient with BPD is doing the best she
can even when her behaviour is maladaptive
and/or out of control.
Crises
• Crises are inevitable in the lives of patients
with BPD and do not represent a failure of
treatment.
How to deal with BPD patients in crisis?
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Listening
Validation style interviewing
Problem solving approach
Dealing with here and now issues
Supportive counselling
Reassurance
Wise prescription of PRNs
Organizing support
Organizing practical help
Assess risk
Safety planning
Liaison with relevant stakeholders
Manage self-harm
• Evaluate risk – suicide, aggression, non
suicidal self injury, accidental death, selfdestructive behaviour etc.
• Acute risk/chronic risk
• High lethal/low lethal methods
• Understand the chronic pattern- specific to
each patient
• Ask them why they self-harm?
Seek supervision
Have mechanisms that
facilitates reflective
practice
• Do not necessarily need to work through
childhood traumas in therapy.
• Instead, therapy needs to be a springboard for
making meaningful investments in work and
relationships.
Psycho analysis is dangerous
-J Gunderson
Problem solving approach
Skills training
• Help patients to learn interpersonal skills
• Teach them to tolerate distress, regulate
emotions-DBT
• Encourage them to “get a life”- job, healthy
relationships
Collaboration
• Active and on going collaboration with patient
and family (where appropriate and possible).
• Patient is encouraged to co author treatment
plan.
Treatment Contracting
• This indicates both you and the patient share
the responsibility for treatment.
• Together, you should both identify the goals,
purpose and practical arrangements of
treatment (such as frequency of
appointments).
Why treatment plans?
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Generate empathy
Manage anxiety of clinicians
Validates patients
Avoid chaos/inconsistency among
treatment providers (splitting playing one practitioner against
another)
Principles of drawing up a successful treatment plan for a patient with BPD
treated in an AMHS?
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Active input from the patient — it is best if the patient co-authors the plan, but if
the patient is not ready or is not cooperative, the clinicians can develop an interim
plan to guide their work. Input from all relevant and appropriate clinicians, teams
and stakeholders
Sociodemographic details of the patient
Names and contact details of all clinicians, teams and carers involved in the
patient’s care
A case formulation
A diagnostic summary with Axis I comorbidities
Details of risk assessment that outline patterns of chronic self injurious behaviours
and acute suicide risk situations , together with
An understanding of the underlying reasons for these behaviours
other known risks
a list of helpful and unhelpful interventions for these.
• a clear description of roles of all clinicians or teams involved
(or both)
• frequency of clinician and team contacts with the patient
• alternatives if the clinician is not available on the day
• indications for admission
• role of psychotherapy and medications
• a list of helpful and unhelpful interventions
• A crisis plan no longer than one page is an important part of
the treatment plan. It is also important that both the
treatment and crisis plans are periodically reviewed and
updated.
Components of a care plan for a
person with BPD
The care plan should identify:
• short-term goals for treatment
• long-term goals for treatment
• situations that trigger distress or increase risk
• self-management strategies that reduce stress and risk
• strategies that have been used in the past with the aim of reducing
distress, but were not helpful or made things worse
• who to contact in an emergency
• health professionals involved in the person’s treatment
• all others helping with the person’s treatment (e.g. family/carers,
friends), including their role in supporting the person
• the planned review date
• who has a copy of the plan (list people and services).
• Treatment contracts should not be seen as
punishment for poor behaviour.
• They should be an opportunity to address
motivation, elicit commitment, as well as
establishing clear expectations and
boundaries.
Treatment strategies
• BPD patients who are actively using
substances may not benefit from
psychotherapy
• Past trauma- address only if patient is
interested and when appropriate
Treatment strategies
• Challenge the patients- lateness, superficiality,
incivility, absent
• I feel sad is not = to I am sad/depressedcognitive diffusion
• Help identify and break the self-defeating
interpersonal patterns
Joel Paris
“In nearly 40 years of
practice, I cannot
identify a single case
where a patient with a
PD killed himself/
herself after being sent
home from an ED”
Mary Zanarini
• I have almost never considered
hospitalization as an option in
treating BPD.
• I do not regard a hospital ward as a
safe place, but as a potentially toxic
environment that I have no wish to
inflict on my patients.
• Over the last 30 years, I have
only had one patient with BPD
who committed suicide while in
an outpatient therapy.
Marsha Linehan 1993
Excessive precaution instituted in hospitals to
prevent suicide may only reinforce the
pathology itself
• Often when patients don’t need admission
they demand for it, when they do need
admission they refuse it.
In patient admission
• Tired of managing self harm and suicidality
• Wish to be cared for
• Handing over the responsibility to some one
else
Response to a BPD crisis
• Stay calm – avoid expressing shock or anger
• Focus on here and now – avoid discussing past
experiences or relationship problems
• Show empathy and concern
• Clearly explain your role (and those of other staff)
• Assess person’s risk
• Make a follow-up appointment and refer to
appropriate services
How to deal with BPD patients in crisis?
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Listening
Validation style interviewing
Problem solving approach
Dealing with here and now issues
Supportive counselling
Reassurance
Wise prescription of PRNs
Organizing support
Organizing practical help
Assess risk
Safety planning
Liaison with relevant stakeholders
Avoid excessive / long-term
hospitalisations
• Prolonged admissions do not help-fosters
regression and inhibit self-responsibility
• Minimal hospitalization
• Clear plans for managing admissions
• ECT does not help
Take home message
• Diagnose and educate patient and family
• BPD is a treatable condition (Gabbard-EditorialAJP2007)
• Psychotherapy is the treatment of choice
• Medications are only partially effective
• Treatment is long term
• BPD is a remitting disorder
• Keep them safe and alive
• Encourage patients to get a life
• Help them manage work and relationships
• Having BPD is not the patient's own fault – it is a
disorder of the brain and mind.
ACT manual
Some useful links
Aftercare
Spectrum
Personality Disorder.org.uk
BPD Central
Borderline Personality Resource Centre
International Society for the Study of Personality Disorders (ISSPD)
National Education Alliance for Borderline Personality Disorder (NEA-BPD)
Orygen Youth Health
DBT Self-Help
Thank you