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The Shack provides a referral service for both people with BPD and for their partners/family who care for them. If you would like to be placed on our database please e-mail your details and let us know the service and experience you provide. This site will always contact you first regarding the referral. Thank you in anticipation for being part of the service this site tries to provide. PRESS RELEASE Copyright 2003 AScribe Inc. HEADLINE: New Program Offers Hope for Borderline Personalities; Renowned Psychiatrist to Head Treatment Center for Borderline Personality Disorder BODY: BELMONT, Mass., May 19 [AScribe Newswire] -- Fear of abandonment, inappropriate rage, impulsiveness, chronic feelings of emptiness and boredom -these are some of the symptoms of borderline personality disorder [BPD], an illness that affects an estimated six million people, mostly women, in the United States today. Despite its prevalence in society, BPD is under diagnosed and when it is diagnosed, treatment is difficult. Now, McLean Hospital hopes to make recovery easier for those with BPD with the opening of The Center for the Treatment of Borderline Personality Disorder, one of only a few programs in the United States designed specifically to treat borderline personalities. John Gunderson, MD, one of the nation's leading experts on BPD, established, and will lead, the program. "Our service offers a full continuum of care and is based on an innovative combination of psychoeducational, dialectical, behavior and psychodynamic therapies, plus medication management," says Dr. Gunderson. "There are few, if any, programs in the country where all these services are available and are provided by experiences clinicians with expertise." Perry D. Hoffman, PhD, president of the National Education Alliance for Borderline Personality Disorder [NEA-BPD], says programs such as McLean's new center is "long overdue. People with BPD need to feel confident they will receive care from experts like John [Gunderson], who fully understand their needs and concerns. BPD is a complex and difficult-to-treat illness and it takes a knowledgeable individual and unique services to understand and treat it adequately." Jennifer, 31, of Boston says she wishes such a program existed four years ago. "My life was a complete wreck," she recalls. "I had been successful in my life because I was able to channel a lot of my anger and focus it on my job, so I was a driven and strong business person. Eventually, that all fell apart and so did the rest of my life. That's when I made my first suicide attempt." Jennifer's story is not an isolated one. Women are typically diagnosed with BPD 75 percent more often than men and like Jennifer, the illness affects every part of their lives. BPD is linked to high rates of divorce, substance abuse, child abuse, physical, sexual and emotional abuse, eating disorders and estrangement from family members. Individuals often engage in self-mutilation and approximately 10 percent commit suicide. "People with borderline personality may look fine from a distance, but once you talk to them, it becomes clear there is a problem. They lead truly desperate lifestyles," explains Dr. Gunderson. "As a group of people, they are very involved in virtually all social public health problems. People with this illness are costly to society, not to mention the emotional toll they take on their friends and family." Jennifer can attest to this. She recalls that while she was in the depths of despair, she appeared outwardly normal to others. Inside, however, she was miserable, classifying everyone in her life as good or evil, depending on the day of the week or even the hour of the day. "Anything could set me off...a friendly glance was interpreted as a glare and that person immediately went from my loved list to the hated list. And I would retaliate in any way available to me," she explains. "Even the tiniest slight from someone would feel like a piercing blow that couldn't possibly be discussed or resolved, but had to be avenged." After visiting a number of psychiatric facilities, Jennifer finally found the clinical services for BPD at McLean. By that time she was anorexic, bulimic and had begun a pattern of self-destructive behavior. Within months of beginning therapy, she started to see a difference in her life. Although she suffered a number of setbacks, including several suicide attempts, she has continued her therapy at McLean and has regained control of her life. "When I arrived at McLean, I was looking at a pretty bleak future. Today, I have a life that is more promising and more fulfilling than I could have ever imagined. I am now in a doctorate program and engaged to be married. I see the world around me and the people in my life in a new and wonderful light." Like Jennifer, Mary sought the help of Dr. Gunderson. After 10 years in therapy, she has become an advocate for those with BPD and the need for accessible and appropriate treatment. "This is not an illness that you can get better from after a year or two of treatment. It takes many years for people with borderline to begin to trust and to learn to live their lives differently. Not all doctors, even psychiatrists, know this," says Mary. "Dr. Gunderson and his staff understand that people like me aren't just looking for attention. They know we're just trying to get through life the only way we know how and that with their support and help, we can get better." The Center for the Treatment of Borderline Personality Disorder at McLean Hospital offers state-of-the-art expert care in a comfortable and caring environment, with a continuum of customized care, spanning residential, partial hospital, comprehensive outpatient and individual psychotherapy services. Although the origins of BPD are complicated, both genetic and environmental causes are known to interact. Research has shown that 70 percent of women with BPD have been sexually or physically abused at some point in their lives. Dr. Gunderson and colleagues are conducting research on BPD that examines how the illness responds to treatment, manifests and changes in individuals; why some people can get better and others cannot; and the genetic transmission of BPD in families. Dr. Gunderson will be presenting on borderline personality disorder during the annual meeting of the American Psychiatric Association in San Francisco on Monday, May 19 from 11 am to 12:30 pm and 2 pm to 5 pm; and Wednesday, May 21 from 2 pm to 5 pm. All lectures will be held at the Moscone Center. McLean is the largest psychiatric facility of Harvard Medical School, an affiliate of Massachusetts General Hospital and a member of Partners HealthCare. CONTACT: Site: http://www.mclean.harvard.edu/patient/adult/bpd.php
FORUMS A Clinician’s forum at mhsanctuary for professionals: http://www.mhsanctuary.com/borderline/board3.htm
ISSUES (Article for Primary Care Physicians) THE BORDERLINE PERSONALITY DISORDER NEW MANAGEMENT CONCEPTS by Leland M. Heller, M.D. INTRODUCTION The Borderline Personality Disorder (BPD), a psychoneurological disorder affecting tens of millions [1,2] is now treatable with a combination of medication and other therapies. Fortunately fluoxetine (Prozac) [3] and low dose intermittent neuroleptics [4] can stop most of the mood swings, and many of the irrational behaviors. Untreated, these patients suffer from very painful, difficult lives - and a caring health care professional can make a profound difference. GENERAL DESCRIPTION According to Dr. Rex Cowdry of the NIMH the "BPD is characterized by tumultuous interpersonal relationships, labile mood states, and behavioral dyscontrol set against the background of a relatively stale character structure. While the syndrome can be identified with reasonable reliability, the fundamental nature of the disorder remains unclear..." [ 5] See Table 1 for the DSM-III-R criteria. It is a worldwide phenomenon, being described in the U. S., England, Scotland, Switzerland, Germany, France, Norway, and Japan. [6] It likely affects approximately 2-3% of men and 5-10% of women. [1] Prior to effective medical therapy, managing borderlines was a difficult struggle. Articles in Family Physician [7] and Nursing [8] journals describe them as demanding, manipulative, disruptive, frustrating, non-compliant, and hostile - especially when not medicated properly. WHAT BORDERLINES EXPERIENCE Untreated, a borderline lives an emotional vertigo - experiencing totally unstable moods. These mood swings and most any stress cause a horribly progressive dysphoria. They intensely feel almost every painful emotion at once. Borderlines desperately search for relief, usually by endorphin releasing behaviors that are ultimately self-destructive - such as binge eating, binge spending, aberrant sexual behavior, substance abuse, and reckless driving. When a severe borderline is extremely dysphoric, cutting the skin causes no physical pain and actually relieves the dysphoria. Because untreated borderlines live with constant mood swings and frequent dysphoria, normal psychological functioning is crippled. Understanding this enables the Family Physician to help. Borderlines need to understand their illness, and to be treated properly. MAJOR SYMPTOMS Mood Swings: Mood swings are a fundamental devastating symptom of borderline. Moods can shift inappropriately from hour to hour, even minute to minute. Without appropriate environmental of though-provoked justification. [9] Dysphoria: A combination of depression, rage, anxiety, and despair - often complicated by shame, humiliation, embarrassment, excitement, terror, jealousy, and self-hate. It can be triggered by mood swings, stress, and emotional pain. Once dysphoria begins, it tens to steadily intensify - possibly due to limbic system malfunction. [5] The sensation is so painful that borderlines will desperately search for a way out - often relying on drugs, alcohol, self-destructive and impulsive behaviors, self-mutilation, and suicide. [9.10] Psychosis: Psychotic thinking often develops when the dysphoria becomes severe. Because of the psychotic episodes, borderlines are said to live at the "border" between reality and psychosis. The main psychotic symptoms are moods, physical sensations and perceptual distortions. The dominant psychotic moods center around worthlessness, badness, rage, and self-destruction. The physical sensations are remarkably similar to temporal lobe epilepsy and include unreality, derealization (familiar things become unreal). Deja-vu, out-of-body experiences, depersonalization (as though no longer yourself), unawareness spells, and feeling like body parts are numb and no longer part of oneself. [9] Psychotic perceptual distortions primarily include transference (incorrectly perceiving a present day person to be like someone hurtful from the past), inappropriate interpretation of motives, and hallucinations. Psychosis can also be brought on by drugs, especially alcohol and marijuana. [1] Splitting: Small children see everything in life as being all good or all bad. This immature psychological defense persists in borderlines, resulting in "black and white thinking." When life events are perceived as bad, dysphoria usually results. When things are good, the borderline frequently feels vulnerable, and fears the black returning - often leading again to dysphoria. Other symptoms: A borderline’s life is defined by inconsistency - mood, identity, trust, behavior, attitudes, values and thoughts. While intelligence is not impaired, [11] organization and structure are [12] - borderlines have trouble following through and completing tasks. Access to memory is frequently impaired. Chronic anger, fear of abandonment (often resulting in manipulative behavior), lack of trust, impulsivity, feelings of emptiness and/or boredom, jumping to incorrect conclusions, and severe PMS are commonly experienced. Comorbidity: Borderlines frequently suffer from other psychiatric illnesses. The most common include depression, [1] anxiety, [13] substance abuse, alcohol abuse, [14] other personality disorders, and eating disorder (approximately 40% of eating disorder inpatients suffer from the borderline). [15] There is no association with schizophrenia. [16] ETIOLOGY Psychological theories alone cannot explain the BPD. Borderlines have significant biological abnormalities - see Table 2. CNS serotonin malfunction is likely involved. Temporal lobe dysfunction is often associated with stress. The BPD is probably a medical predisposition combined with environment insult. There are many psychological theories and concepts, with considerable disagreement among experts in the field. Both overprotective and underprotective parents have been "blamed" as the cause. [16] Most theories center around traumatic childhood experiences, arrested psychological development (especially at the separation/individuation phase), and reliance on maladaptive coping and survival mechanisms. [23,28] Adoption, early parental loss, and incest are often associated with the BPD. [14] The most severe borderline patients suffered from both sexual and physical abuse, usually while very young [6] - chronic dysphoria and derealization are the best predictors. [29] In one study, 81% reported major childhood trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious domestic violence. [30] Genetics: The BPD tends to run in families, six times more likely in first degree relatives. There is an increased family history of alcoholism, substance abuse, other personality disorders, and depression, but not schizophrenia. [16] DIAGNOSIS Psychological tests, such as the MMPI and NIMH Diagnostic Interview Schedule, are only accurate between 85 and 89%. [31,32] Most knowledgeable psychologists can easily arrange for an MMPI. The NIMH test may be more difficult to obtain. If I encounter a patient who has multiple complaints, especially fatigue, headaches, stress, depression, etc. I will often review and discuss the DSM-III-R Borderline criteria to determine if he/she feels 5 or more symptoms are present. If yes, I will usually initiate treatment with fluoxetine (Prozac), evaluating the patient and diagnosis 1 week later.
TREATMENT Medications: Prozac (fluoxetine): Prozac appears to increase serotonin. It is a breakthrough medication for borderlines - eliminating most mood swings, chronic anger, chronic emotional pain, emptiness and boredom within 3 days. A daily a.m. 20 mg. dose is usually effective. For most side effects (nausea, jitteriness, agitation), reduce the frequency to every 2 or 3 days. If fatigue develops, switch to an evening dose. While for a few patients the serotonin deficiency symptoms resolve permanently in 6-12 months, most need to take the medication long term. In my experience, clomipramine (Anafranil) and sertraline (Zoloft) have shown similar efficacy. Neuroleptics: Can be effectively used on a prn basis during stress or dysphoria, or prophylactically for stressful situations. I prefer Haldol 0.5 - 1 mg every 4-6 hours as needed (side effects are rarely a problem at this low dose). Navane (thiothixene) [3] and Mellaril (thioridazine) [4] have been proven effective. High doses, especially in hospitalized patients, are also effective. [4] Tegretol (carbamazepine): Can markedly reduce episodes of behavioral dyscontrol. [5] Extremely effective for unreality, chronic dysphoria, incest crisis, relationship dissolution, extreme anger, dissociative symptoms, and when neuroleptics are ineffective. Dosing and blood levels are comparable to treating temporal lobe epilepsy. Thyroid: Many borderlines have symptoms of hypothyroidism, with "low normal" thyroid blood tests. Approximately 1/3 of borderlines have an impaired TSH response to TRH. [33,34] Vitamin B12 deficiency: Approximately 20% of borderlines have low vitamin B12 levels, with symptoms of fatigue, leg stiffness, and dysesthesias. Medications to Avoid: Xanax (alprazolam) can markedly worsen behavioral dyscontrol. [5] Elavil (amitriptyline) increases suicide threats, demanding and assaultive behavior, and paranoid ideation. [35] MAO inhibitors have helped borderline symptoms, but may be dangerous due to the impulsivity and behavioral dyscontrol borderlines can experience. Psychological Counselling: Borderlines need a multidisciplinary approach. A good therapist is necessary, and borderlines should be strongly encouraged to get into counseling. For some, a psychologist/family physician team is very effective. Referral to a psychiatrist may be necessary. Psychiatric hospitalization is occasionally required, especially for strong suicidal ideation. Stress Reduction: Borderlines need to keep their stress level down, and to use neuroleptics when under stress. Physical exercise, relaxation techniques, and TM (Transcendental Meditation) can be very helpful. Spiritual Healing: Making peace with God and one’s spiritual self is very important. The AA (Alcoholics Anonymous) approach can help, especially with destructive behavior patterns. Borderlines generally hate themselves. I try to get them to understand that they have a "good" soul that has been "stuck" in a broken biological computer. Self-esteem: Since most borderlines experience self-hate, strong efforts must be made to build a strong and secure self-esteem. Retraining the Brain: Borderlines must learn to think differently. Cassette tapes, books, and affirmations can teach them how. I strongly encourage borderlines to purchase and listen to the "How to Stay Motivated" tape series (or at least "Success and the Self-Image") by Zig Ziglar. (1-800-527-0306). Borderlines need to listen to positive/motivational tapes frequently and persistently. Brian Tracy’s "The Psychology of Achievement," and others (Earl Nightingale, Denis Waitley, Robert Schuller) from Nightingale /Conant (1-800-323-5552) are excellent subsequent tapes. Borderlines must be convinced to read positive/inspirational books. I recommend How to Win Friends and Influence People by Dale Carnegie, The Power of Positive Thinking by Norman Vincent Peale, Seeds of Greatness by Denis Waitley, Unlimited Power by Anthony Robbins, Your Erroneous Zones by Wayne Dyer, and books by Leo Buscalia and Norman Cousins. Affirmations: Saying a meaningful phrase in a repetitive, broken record like manner - are very effective. The borderline needs to say these affirmations dozens of times daily, and within a few weeks they will subconsciously accept new and much needed positive concepts. I recommend phrases like "I like myself and feel terrific," "I am lovable," and "I’m a success." This technique is very powerful.
FINAL COMMENTS The borderline personality disorder is common and now treatable with a combination of medications, psychological counseling, and self-help approaches. Untreated borderlines suffer painful, destructive lives. They are victims of an illness they don’t want and didn’t cause. They deserve to be helped, and the primary care physician is in the best position to initiate treatment.
TABLE 1 - DSM - III-R CRITERIA "A pervasive pattern of instability of mood, interpersonal relationships, and self-image, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following: 1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation. 2) impulsiveness in at least two areas that are potentially self-damaging, for example, spending, sex, substance abuse, shoplifting, reckless driving, binge eating, (do not include suicidal/self-mutilating behavior covered in No. 5) 3) affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days 4) inappropriate, intense anger or lack of control of anger, for example, frequent displays of temper, constant anger, recurrent physical fights 5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior 6) marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, preferred values 7) chronic feelings of emptiness or boredom 8) frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behavior covered in No. 5)" Those who suffer from the Borderline Personality Disorder have at least 5 of the 8 criteria. TABLE 2 - BIOLOGICAL ABNORMALITIES 1) Abnormal neurological soft signs (such as awkward gait, left-right confusion, and difficulty with pronation/supination and finger-thumb opposition). [17] 2) Abnormal REM sleep. [18,19] 3) IV procaine, normally sedating, causes dysphoria in BPD. [20] 4) Abnormal auditory P300 on EEG - sharing a dysfunction of auditory neurointegration with schizophrenia. [21] 5) EEG abnormalities in 1/3 - ½, not usually correlating with symptoms. [22,23] 6) Altered platelet alpha 2-adrenergic receptor bind sites. [24] 7) Low platelet monoamine oxidase activity. [25] 8) Low circadian melatonin profile. [18] 9) Abnormal lithium transport. [26] 10) Normal head CT’s. [22,27] 11) Cases of BPD have been described from CNS trauma and infection. [27] TABLE 3 - SUMMARY OF TREATMENT 1. Prozac 20 mg daily (clomipramine) Anafranil and other SSRI’s may prove to be just as effective Link To: http://www.biologicalunhappiness.com
LINKS http://pdf.uchc.edu/ This is the site of the Personality Disorder Foundation whose mission is to:
http://www.ncbi.nlm.nih.gov/PubMed/ PubMed, a service of the National Library of Medicine, provides access to over 11 million citations from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources. http://www.biologicalunhappiness.com/ Leland M. Heller M.D. is an expert at treating the biological disorders he discusses in his book "Biological Unhappiness" (depression, anxiety attention deficit disorder, ADHD, borderline personality disorder, obsessive compulsive personality disorder, generalized anxiety disorder, obsessive compulsive disorder, bipolar disorder, cyclothymia, phobias, panic disorder, pain and substance abuse, PMS - premenstrual disorder, and what he calls 'fractured enjoyment).'" http://www.menninger.edu/tmc_info_articles_borderline.html ###With a prevalence in the U.S. population of 1.8–4 percent, borderline personality disorder is one of the most common personality disorders. It is diagnosed three times more often in females than males, usually in young adulthood. http://www.mentalhelp.net/articles/dbt1.htm ###An Overview of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder By Barry Kiehn and Michaela Swales http://apt.rcpsych.org/cgi/content/full/6/3/211 by Joseph Santoro, Ph.D., Michael Tisbe, M.D, Michael Katsarakes Supervised Lifestyles Behavioral Heath Systems Borderline personality disorder (BPD) affects as many as six million Americans. It accounts for about 25% of all psychiatric hospitalizations. As many as thirteen percent of males and seven percent of females commit suicide (Stone, 1990). Approximately, 69% of people with BPD are also substance abusers (Miller et al., 1993). The causes of BPD are not well understood. Therapist folklore often labels people with BPD as difficult and treatment-resistant patients. http://www.mentalhealth.org.au/ Australian Mental Health site then search for Borderline Personality Disorder http://www.psychcentral.com/disorders/sx10t.htm Borderline personality disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish between reality from their own misperceptions of the world and their surrounding environment. While this may seem like a type of delusion disorder to some, it is actually related to their emotions overwhelming regular cognitive functioning. http://www.mentalhelp.net/disorders/sx10t.htm ###Treatment of people who suffer from Borderline Personality Disorder
LATEST TREATMENT INFORMATION BPD Treatment article A committee of experts appointed by the American Psychiatric Association has issued a new guide to the treatment of borderline personality, one of the most complicated and difficult problems that confronts psychotherapists. The difficulty comes from the variety of severe and constantly changing symptoms that have given this condition a reputation as the "unspecialized" psychiatric disorder. The moods of borderline patients are erratic, their personal relationships are turbulent, and their self-image is unstable. They suffer from persistent feelings of emptiness, relieved by occasional periods of well-being founded on an unrealistic view of their circumstances. They are often anxious or severely depressed and may have panic attacks. They have difficulty controlling anger, which may take the form of black moods, chronic irritability, or temper tantrums. They often endanger themselves and others through reckless driving, extravagant spending, impulsive sexual behavior, drinking, and drug use. Under stress, they may develop paranoid ideas or dissociative symptoms (such as seeing themselves or the world as unreal). They often think about suicide, make suicide threats, overdose, or mutilate themselves by cutting or burning. Borderline personalities are highly susceptible to feelings of rejection or abandonment, and they may respond to attempted separation or distancing with rage, accusations, or suicide threats and attempts that make others feel guilty or protective. Related to this fear of rejection is their habit of alternately vilifying and praising, blaming and exonerating, disparaging and extolling others and even themselves " what psychiatrists call "splitting." It seems that much of the time borderline patients can see others only as either satisfying their needs or threatening them. They regard one person in their lives as evil and another as a saint, one as kind and another as cruel " and these roles may be exchanged if the favored person says or does something disappointing. As the long and varied list of symptoms suggests, borderline patients use more kinds of psychiatric medications and psychotherapy than any others. To further complicate matters, they often have other serious problems " chronic depression, eating disorders, drug or alcohol addiction, post-traumatic stress disorder, attention deficit disorder, and panic disorder " which usually must be addressed at the same time by the same mental health professionals. For the treatment of borderline personality, the psychiatrists' expert committee, called the Work Group on Borderline Personality, recommends psychotherapy with psychiatric management " that is, coordination of the various aspects of care, including giving advice, helping with practical problems, anticipating and responding to crises, setting limits on the patient's behavior, explaining the disorder and its treatment to the patient and the patient's family (psychoeducation), and prescribing medications when necessary. The plan must be flexible, because these patients often develop unexpected problems and symptoms. The Work Group urges therapists to start by evaluating the patients' needs, goals, and emotional conflicts, the sources of stress in their lives and their typical ways of coping with it. Establishing a therapeutic alliance " a working agreement on the means and ends of treatment " is both especially important and especially difficult with borderline patients, because they are mistrustful and emotionally volatile. The Work Group recommends an informal agreement stating the aims of therapy, the timing of therapeutic sessions, and billing procedures. The arrangements should also include a plan for responding to crises, including suicide threats. The agreement should state not only the therapist's responsibilities but also the patient's (for example, taking prescribed drugs and warning the therapist about suicidal thoughts or plans). There are no formulas for psychotherapy with borderline patients. The choice of treatments is different for different persons and at different stages. Therapists may use a variety of behavioral and cognitive techniques, and sometimes couples or family therapy or vocational counseling. The experts of the Work Group mention all of these methods with approval but recommend more specifically two treatments: psychodynamic therapy and dialectical behavior therapy, a form of cognitive behavioral therapy with some special features. Their recommendation is based mainly on clinical experience, along with a few controlled studies. Psychodynamic therapy is not so much a well-defined therapeutic technique as a certain way of approaching patients and listening to their life stories. It originated with Freud's ideas about the influence of unconscious impulses and their conscious disguises. Interpretation, the distinguishing feature of psychodynamic therapy, means making the unconscious become conscious by linking a feeling, thought, symptom, or action to an unconscious meaning; for example, the therapist might say to a patient, "Your tendency to undermine yourself when everything is getting better is a way to assure that your treatment will continue. " The purpose of interpretation is to free patients from unacknowledged drives and motives that interfere with their ability to satisfy present needs. Psychodynamic therapy requires special attention to the relationship between the patient and the therapist, and especially to the transference " the strong feelings derived from earlier emotional attachments that emerge in the intimate therapeutic situation. Patients may reenact old emotional conflicts by directing these feelings at the therapist. To help patients understand what is going on, psychodynamic therapists interpret the transference; for example, "Your anger at me may be connected with the frustration you felt in relation to your mother. " Therapists themselves may have their own strong reactions to the patient, known as the countertransference " anger, competitiveness, fantasies of taking on the role of a lover or parent or savior. Psychotherapists must not act on these feelings but make use of them for a better understanding of the patient. That means they must know themselves well enough to recognize the signs of countertransference, understand their responses, and when necessary, consult a colleague or supervisor. Psychodynamic therapists use other devices besides interpretation. One is confrontation, or directing the attention of patients to issues they have been avoiding: "Talking only about medications is a way of avoiding discussion of the feelings that make you think about committing suicide. " Another is clarification: "You become tired when you feel guilty about denying your husband's wishes. " Most dynamic therapists also provide supportive therapy " listening calmly to the patient and offering comfort, reassurance, and advice. Whether they take an exploratory and interpretive or a supportive approach depends on what they judge the borderline patient needs and can tolerate at any given time. In dialectical behavior therapy, the other recommended technique, therapists concentrate chiefly on distorted thinking and behavior, without direct attention to unconscious impulses. This treatment works on the assumption that the underlying problem of borderline patients is poor regulation of the emotions " hypersensitivity to every influence and difficulty in regaining equilibrium once strong feelings are aroused. As developed by the psychologist Marsha Linehan, the process involves a year of individual therapy once a week, along with 21/2 hours of group skills training for behavior change, with homework assignments. Cognitive therapy and practice in meditation may be added. Several therapists work with the patient, and they meet weekly as a group to review the case. People with borderline personality disorder have often been neglected or abused as children, or believe they have been. When some of their most serious symptoms have been treated and a therapeutic alliance is established, reviewing these memories may help the therapist to understand their changing moods, chronic anger, fear of abandonment, and expectations of betrayal. But paying too much attention to the distant past may allow the patient to avoid responsibility for present actions. The Work Group recommends neither dismissing memories of abuse nor necessarily taking them as historical truth. It is more important to acknowledge the reality of the underlying feelings and help patients cope with them. The Work Group strongly urges psychotherapists who work with borderline patients to take every opportunity to consult colleagues and supervisors. Getting another point of view is important because making judgments about these patients is complicated, and because problems of transference and countertransference are constantly arising. Always in dialectical behavior therapy and often in psychodynamic therapy, more than one professional is directly engaged. The participation of two collaborating therapists may be useful for curbing the patient's self-destructive impulses. It also provides some protection for both the patient and the therapist against a relationship so close and exclusive that it promotes unrealistic attitudes and a transference that is too intense. Another problem therapists often encounter in treating borderline personality is the need to establish boundaries " limiting the therapist's and patient's involvement in each other's lives. People with borderline personality may call in the middle of the night, request special favors, offer inappropriate gifts, demand meetings outside of therapeutic sessions, and in general try to develop a personal rather than a professional relationship with the therapist. The Work Group advises therapists to lay out the boundaries explicitly and justify them. For example, a therapist might say, "When I tell you something about my personal life, it limits your opportunity to understand more about what you might imagine if you did not know it. " Or, "If you call me every time you are worried, your safety might depend too much on my guesses." A sexual relationship with a borderline patient "sometimes a danger because of intense transference and countertransference feelings " is a serious boundary transgression and a serious violation of professional ethics. The expert guidelines suggest that therapists be alert for a tendency to get too close to the patient " prolonging therapeutic sessions, doing special favors, seeing the patient at odd hours. To avoid the danger of falling into a sexual relationship, they suggest examining countertransference feelings, consulting another professional, and if necessary ending the treatment "which they point out is always a delicate matter with borderline patients because of their intense reactions to what they regard as rejection or abandonment. Sometimes the need to help these patients understand themselves is in conflict with the need to guarantee their safety. The Work Group emphasizes the importance of treating depression in borderline patients and taking all suicide threats seriously "if necessary involving the family or, again, consulting another professional. A promise not to commit suicide (no-suicide contract) is not sufficient, according to the experts, although some therapists may want to discuss the patient's responsibility to minimize the risk of suicide when the therapeutic alliance is negotiated. Borderline patients may have to be hospitalized briefly because of immediate danger and, rarely, for a longer time because of persistent suicidal tendencies, a serious drug or alcohol problem, or a life-threatening eating disorder. The Work Group recommends medications for three kinds of symptoms in borderline patients: unstable moods, impulsive behavior, and distorted thinking or perception. For the long-term treatment of mood disorders, including not only depression but also intense anger, temper tantrums, and hypersensitivity to rejection, they suggest an antidepressant, usually an SSRI, such as fluoxetine (Prozac) or sertraline (Zoloft). A mood stabilizer (lithium or an anticonvulsant) can be added if necessary. The same drugs are used to reduce the risk of dangerously impulsive behavior " violence, self-mutilation, reckless spending, and so on. But these drugs generally take weeks to begin working, so other medications may be needed for the immediate relief of unstable moods and impulsive tendencies. For temporary relief of anxiety, the Work Group recommends benzodiazepines such as lorazepan (Ativan), with a warning that these patients risk addiction and misuse. Antipsychotic drugs in low doses curb impulsive behavior in the short run and, in the long run, reduce the influence of paranoid thoughts, hallucinations, and dissociative symptoms. Finally, the Work Group recommends some topics for further research, including: How much psychotherapy is necessary and how long should it continue? Which features of psychodynamic and dialectical behavior therapies are effective and which are superfluous? What is the relative value of different kinds of psychotherapy for borderline patients with different symptoms? Which drugs should be used for which symptoms and for how long? Resources Article's URL: http://www.health.harvard.edu ### |
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