Focus on Borderline Personality Disorder- Diagnosis, Management and Survival Skills

Transcription

1 Focus on Borderline Personality Disorder- Diagnosis, Management and Survival Skills Dr Amlan Das, MD, MSc, MRCPsych, FRCPC Consultant Psychiatrist, Grand River Hospital Assistant Clinical Professor of Psychiatry, McMaster University

2 Grand River Hospital Dept. of Psychiatry Day in Psychiatry Wed. Nov. 18, 2015 Presenter Disclosure: Dr. Amlan Das Staff Psychiatrist Grand River Hospital Focus on Borderline Personality Diosrder- Diagnosis, Managament and Survival Skills Relationships with Commercial Interests: None I DO NOT intend to make any therapeutic recommendations that have not received regulatory approval.

3 Grand River Hospital Dept. of Psychiatry Day in Psychiatry Wed. Nov. 18, 2015 Dr. Amlan Das Disclosure of Commercial Support This program has received financial support, in the form of unrestricted educational grants, from the following organizations: Janssen Lundbeck Novartis Otsuka Pfizer Sunovian KW Pharmacy Potential for Conflicts of Interest: None

4 Grand River Hospital Dept. of Psychiatry Day in Psychiatry Wed. Nov. 18, 2015 Dr. Amlan Das Mitigating Potential Bias: Not Applicable

5 Images of BPD ( internet images)

6 CASE Ms Brown is presenting to your office for the 5 th time in the last 2 weeks. She is a regular attender at the local ER with superficial cuts to different parts of her body and often gets discharged the same day. She has history of polysubstance abuse and is not able to hold down a job or relationship for long. She has 4 children from all different partners and currently is fighting in the courts to get custody of her children. She has no family or social supports. Today she is refusing to leave unless you arrange for admission on the psychiatric unit. She also says there is no point in living anymore and she might as well die if you don t meet her needs and you will be responsible. What are your options?

7 General Criteria: DSM V DIAGNOSIS A.An enduring pattern of inner experience and behaviour that deviates markedly from the individual s culture as manifested in two(or more) of the following areas: cognition, affectivity, interpersonal functioning and impulse control B.The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C.The enduring pattern leads to clinically significant distress or impairment in social, occupational or other areas of functioning D.The pattern in stable and of long duration and its onset can be tracked back to at least to adolescence or early adulthood E.The enduring pattern is not better explained as a manifestation or consequence of other mental disorder F.The enduring pattern is not attributable to the physiological effects of a substance or another medical condition

8 DSM V DIAGNOSIS Diagnostic Criteria A. Frantic efforts to avoid real or imagined abandonment.(note: Do not include suicidal or self mutilating behaviour) B. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation C. Identity disturbance: markedly and persistently unstable self image or sense of self. D. Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating, etc) E. Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour F. Affective instability due to a marked reactivity of mood(e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and or rarely more than a few days) G. Chronic feelings of emptiness H. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) I. Transient, stress related paranoid ideation or severe dissociative symptoms

9 Prevalence and Etiology Prevalence varied from % Approximately 75% female in clinical samples. More equal M:F in community samples(grant, 2008) Genes accounted for 69% of the variance in diagnostic concordance in 92 identical and 129 fraternal twins.(torgerson, 2000) 12.6 % of first degree relatives of BPD probands had BPD and 4X higher than non-bpd probands across 9 family studies( White, 2003)

10 Prevalence and Etiology Overly active amygdala for emotional stimuli( emotional sensitivity) with a corresponding decrease in prefrontal activation with affective arousal(emotional reactivity). (Silbersweig 2007) Environmental factors may include childhood neglect or trauma, insecure attachment and family marital or psychiatric problems.(gunderson 2008) MULTIFACTORIAL!!!!

11 Interesting patient presentations Gunderson 2008 Feels cared about appears as a depressed waif Feels alone- appears/feels desperate, impulsive, or disconnected. Feels threatened by rejection appears angry, with self-injury

12 AXIS I Comorbidity Zanarini et al 1998 N= 379 Mood disorders 96% ( Bipolar- 9%) Anxiety Diosrders- 88 % PTSD 55 % Eating Diosrders 53 % (F>M) Substance Abuse Diosrder 64 % (M>F)

13 Borderline(BPD)vs Bipolar(BD) Zimmerman M, et al. Dialogues Clin Neurosci. 2013;15(2): Frequency of BPD in Patients with BD 24 studies, 1255 patients BD-I: 10.7% BD-II: 22.9% Frequency of BD in Patients with BPD 12 studies of BPD in patients with BD 1151 patients BD-I: 9.3% BD-II: 10.1% 15 studies of the full range of PDs in BD patients BPD: most common PD in 4 studies Histrionic PD: most common PD in 4 studies, and tied for most common in 2 studies OCPD: most common PD in 3 studies, and tied for most common in 2 studies N.B. OCPD = obsessive-compulsive personality disorder.

14 BD vs BPD Factors Suggesting BD 1.Manic symptoms 2.Family history of BD 3.Neurobiological abnormality 4.Medication is necessary for positive treatment response Factors Suggesting BPD 1.Multiple suicide attempts 2.History of sexual abuse 3.Psychotherapy is necessary for positive treatment response Non-differentiating factors 1.Mood lability 2.Impulsivity Ref: Ghaemi SN, et al. Acta Psychiatr Scand. 2014;

15 BD-II vs BPD Bayes A, Parker, G, et al. Curr Opin Psychiatry. 2014;27(1): Factors Suggesting BD-II 1.Family history of BD or major mood disorder 2.Clear onset 3.Failure to remit 4.Melancholic, agitated, and mixed features when depressed 5.Uncharacteristic euphoria, creativity, grandiosity 6.Autonomous mood swings 7.Responds to mood stabilizers 8.Increased rate of ADHD Non-differentiating factors 1.Atypical features 2.Suicidality and self-mutilation 3.Childhood trauma 4.Comorbidity with anxiety and substance use disorders ADHD = attention-deficit/hyperactivity disorder.

16 Pearls of diagnosis Erstwhile AXIS 1 diagnosis should trump personality disorder but real life patients are likely to be diagnostically confusing. Collateral history is important. Premorbid personality is important personality disorder symptoms are often present is late teens. Remember comorbidity. Chicken or egg which came first

17 Pharmacotherapy Psychotherapy MANAGEMENT Managing suicidality

18 Pharmacotherapy No specific medication. Focus on treating co-morbidity. Focus on specific symptoms. Avoid multiple medication and insane doses( > ½ on 2 or more meds). Mood stabilisers and second generation antipsychotics do not have any significant effectiveness on severity of borderline personality disorder ( Lieb et al, BJP (2010) 196,4-120)

19 Pharmacotherapy Mood stabilisers- Impulsivity, anger and anxiety vs emotional lability Antipsychotics help with anger, behavioural problems and cognitive perceptual abnormalities Affective instability does not respond well to mood stabilisers. SSRIs anger and anxiety vs mood and impulsivity Benzodiazepines Dysinhibition, behavioural dyscontrol, addiction,etc

20 PHARMACOTHERAPY

21 Cochrane systemic review of RCT (Lieb et al, BJP (2010) 196,4-120) Affective dysregulation: - 1 st line ( topiramate,valproate,lamotrigine). - +ve results for SGA( Ari and Olz) & FGA ( Haloperidol) Impulsive behavioural dyscontrol (Lamotrigine and Topiramate) Cognitive-perceptual symptoms SGA(ARI and OLZ) SSRI lack robust evidence for specific symptoms.

22 Non pharmacological Treatments Dialectical behavioural therapy ( emotional dysregulation) most research available CBT ( Maladaptive cognitions). Mentalisation Based therapy. General Psychiatric Management

23 Different Treatments (empirically validated) Dialectical Behavioural Therapy- Linehan et al.,1993,2006 Mentalisation Based Treatment- Bateman and Fonagy,199,2001,2003,2008 Transference focussed Psychotherapy- Clarkin et al.,2007;levy et al.,2006 Schema focussed Therapy- Giesen-Bloo et al.,2006 System training for Emotional Predictability and Problem solving(stepps)- Blum et al.,2008 General Psychiatric Management- McMain et al,2009

24 Dialectical Behavioural Therapy Good evidence. Marsha Linehan. Emotional dysregulation is a manifestation of temperamental variable interacting with invalidating environment. Combination of CBT and Acceptance/validation therapy. Aim is to learn strategies to modulate emotional dysregulation.

25 DBT- different components Distress Tolerance Crisis Survival Strategies Acceptance Strategies Emotion Regulation Interpersonal Effectiveness Skill Mindfulness

26 DBT ELEMENTS

27 DBT Improved scores on anger measure,gaf and GSA Decreased inpatient LOS, therapy attrition severity and frequency of parasuicidal behaviour Encouragement, validation, empowerment, believe that patient can change and learn new behaviours.

28 General Psychiatric Management Heavily influenced by Gunderson and based on APA guidelines Shown to be as effective as DBT Uses clinicians who have an interest and experience in treating BPD Focuses on attachment relationships related to emotion dysregulation as a primary goal. Shares features with DBT supervision/consultation weekly, helping relationship, validation and empathy, emotion focus,etc Less attention to self harming behaviours

29 Managing suicide risk Represent 9-33% of all suicides. At least 1 suicide attempt %, 10% complete suicide (Black 2004,Oldham 2006) In ER, half of the chronically suicidal patients meet criteria for BPD. Lifetime risk for suicide estimated to be %. History of suicidal behavior is found in 60-78% of individuals with BPD. Self injury (cutting, burning,bruising,head banging,biting)- 75% Lithium(long term) lowers rates and attempts 13 fold compared to not on lithium or discontinued.( Ref: Baldessarini et al 2001).

30 Managing suicide risk

31 Managing suicide risk Risk of suicide higher than general population. BPD plus major depressive episode- More lifetime attempts Comorbid patients have higher levels of objective planning and most serious attempt Comorbid subjects more self-mutilative behavior, more suicide threats, and attempts. APD plus BPD high risk for suicide; particularly men. Collaborative Longitudinal Personality Disorders Study (Yen et al. 2003) - Prospective 2 year follow up - Baseline BPD and drug abuse disorders predicted suicide attempts

32 Managing suicide risk Suicide attempters have more recent life events,at home, with family, financially,etc Difficult to assess risk in patients with multiple attempts. Multiple attempts and even self-injurious, behaviors increase risk. Self-injury patients - more depression, hopelessness, impulsivity, and underestimate lethality of acts.

33 Pearls of Management Aggressive treatment of co-morbid condition Presence of substance use disorders closely associated with failure to remit. Improvement in BPD lessens risk of MDE; resolution of MDE little impact on BPD. Understanding what medication means to the patient is crucial because whenever medication is introduced into any therapy, it has repercussions on the transference process. ( Silk, 1996) Chronic suicidality vs acute suicidality do not belittle patient- express genuine concern and ask how can I help?, use BCA(behaviour chain analysis), repeatedly clarify your limits as a physician, follow up and hold the patient responsible for using the safety/crisis plan, help patient problem solve and explore alternatives. Careful documentation and careful communication Manage counter transference

34 SURVIVAL SKILLS Countertransference. Validation Goal setting Long term outcome

35 Countertansference Very important to understand to manage the patient Recognise negative feelings that you get when you see these patients Boundary setting and enforcing and reinforcing the boundaries Its not all your fault and definitely you are not the worst doctor the patient has seen in all their life

36 Use of validation Validation does not automatically imply liking, approval or preference - M Linehan 1997 Validating does not mean you are praising the patient. Different components of validation : 1. Listening and observing 2. Accurate reflection 3. Articulating the unverbalized 4. Validation in terms of past learning or biological dysfunction 5. Validating behaviour as reasonable in the moment 6. Treating the person as valid, radical genuineness

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38 Goal setting and ABC CAMP GOALS Controllable Achievable Measurable Positive SMART GOALS Specific Measurable Achievable Realistic Time Focused A B C ANTECEDENTS what exactly happened before BEHAVIOUR exactly what are we analysing CONSEQUENCES exactly what happens afterwards, particularly what happens to make the behaviour rewarding or aversive

39 Behavioural Chain Analysis 1.Choose a problem 2. Formulate in terms of behaviour: Feelings, thoughts, actions of the client 3. Be very specific: what, frequency duration, how much, where,etc 4. Figure out the problem, what leads to and maintains the behaviour 5. Why the patient is having difficulty resolving the problem? 6. What skills the patient needs to solve the problem and what skills he/she is lacking?

40 BPD longitudinal course

41 SUMMARY Treatable condition Different types of treatment available Treatment of co-morbidity is very important Remissions from BPD common 88% over 10 years follow up (Zanariniet al 2006).Remissions are stable; recurrence of BPD is uncommon. Gunderson et al (2006) Watch out for countertransference and seek supervision if needed

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43 T H A N K S