Presentation on theme: "Borderline Personality Disorder"— Presentation transcript:
1 Borderline Personality Disorder Dr Sathya RaoClinical Director, Spectrum, the Personality Disorder Service for Victoria, 4th Sept 12Medicare Local
2 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 lifeSelf-harm and suicidalityHaving BPD is not the person’s own fault – it is a condition of the brain and mind.
3 Borderline Personality Disorder 1% prevalence, 20 % in psych systemsDiagnosed predominantly in women- 75%Sampling biasWomen are 3 times more likely to seek help for psychological help than menClinician diagnostic bias- ASPD
4 BPD Highly stigmatized, misunderstood Ignorance Lack of scientific evidenceLack of clinical skillsMortality and morbidity is highSignificant co-morbidity with other Axis I,II and IIIThe patients live painful and miserable livesSevere functional impairment
5 BPD is a highly stigmatized disorder “BPD is to psychiatry what psychiatry is to medicine”John Gunderson
6 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”
7 Expert on Mental Illness Reveals Her Own Fight Marsha Linehan had BPDExpert on Mental Illness Reveals Her Own FightNew York Times 2011
8 BPD patients evoke strong emotional response from health systems Frustration to clinicians- therapeutic pessimismSignificant utilization of hospital resourcesHigh costs to societyTolkien II WHO 2010
9 But…….we now know that…Genetic and environmental factors contribute to causation of BPDClinical remission is commonEffective treatments are now availableTreatments principles can be learntPsychotherapy is the mainstay of treatmentPharmacotherapy is only minimally effective
15 Access to services for BPD SpectrumAt 1% prevalence rates, potentially there are 60,000 persons who may have BPD in Victoria.AMHS care for ? 6000 patientsSpectrum provides services to 400 patients
16 Tolkien II Report by Gavin Andrews 2010 for WHO Cost of treating BPDCurrently we treat 15% of BPD- chaoticIdeal 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 millionTolkien II Report by Gavin Andrews 2010 for WHO
17 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 self-mutilating 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
18 Characteristics of a BPD patient Female20’s and 30’sChildhood abuse, neglect, invalidating backgroundFear of abandonmentDysregulated emotionsHyper reactive emotionalityIntolerance to lonelinessCrave for IP relationships, have poor IP skillsRejection sensitiveOften attract dysfunctional relationshipsAbout 40 % are in abusive relationshipsUnstable interpersonal relationshipsIdealization and devaluation
19 ZAN BPD Scale for the assessment of change in DSM-IV borderline psychopathology In the past week have you:Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?Have you deliberately hurt yourself physically (e.g.,punched yourself, cut yourself, burned yourself)? How about made a suicide attempt?Have you had at least two other problems with impulsivity (e.g., eating binges and spending sprees, drinking too much and verbal outbursts)?Have you been extremely moody?Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?Have you often been distrustful of other people?Have you frequently felt unreal or as if things around you were unreal?Have you chronically felt empty?Have you often felt that you had no idea of who you are or that you have no identity?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)?
21 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'tdeliberately hurt yourself with out meaning to kill yourself?are you able to like yourself
22 Co occurring disorders DepressionBipolar disorderPTSDEating DisordersPsychosisSUDKind of comorbid Kingdom
23 Sub types of BPDGiven 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!!!!!
24 Etiology Biological vulnerability Environmental factors Stress diathesis model
25 GeneticsFamily history of Mood Disorders and SUDs are more common in BPD than would be expected by chance (Widiger and Trull 1992)Trans-generational patternsBPD is significantly heritableStrongly genetic. Genetic model-Heritablility effect (1.0 would indicate complete heritability) (Torgersen et al. Compr Psychiatry 2000; 41: )
28 Patients with BPD frequently interpret neutral stimuli as negative. They over react to negative or even neutral facial expression.Hyperactivity of Amygdala.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).
29 Once aroused the hyperemotional state of Amygdala takes longer to revert to baseline in BPD when compared with normal controls.
30 Usual cortical control over Amygdala is reduced
31 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
32 Driving a car with hypersensitive accelerator and poor breaks
33 Attachment Disorganised attachment BPD patients have an hypersensitive attachment system
34 Trauma Trauma- neglect, abuse Child hood sexual abuse is 10 times more common in women than menLarge scale studies of childhood sexual abuse in general population show that 80% of adults do not develop any psychological problemsSexual abuse and BPD
42 Most patients get better- (45% by 2 years and 85% by 10 years) - no more than 2 diagnostic criteria 15 % relapse.Aim of psychotherapy is to hasten recovery and aid those who do not recover spontaneously and work on functional recovery
43 Spectrum outcome1.5 to 2 years of group and or individual psychotherapy results in significant recovery for complex BPD patients.
44 Prognosis Spontaneous remission - 75% recover by 35 -40 yrs 90% recover with improved functioning by age 50 (CMAJ-2005)Treatment speeds up remissionTreatment as usual - Remission rates:1/3rd at 2 yrs1/ at 4 years2/3rd at 6 years3/4th at 10 yearsGood treatment leads to faster remissionMBT- 60% remission by 1 year
45 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-up22.3% - 4th year follow-up21.9% -6th year follow-up12.8% -8th year follow-up3.7% - 10th year follow-up.Recurrences-rare-6%25 patients-8.6% lost for follow-up before remission
46 10 year F/U study Gunderson AGP 2011 High rates of remission (85%)Low rates of relapse (12%)Severe and persistent impairment in social functioningEven after remission only 25%- full time work 40% receiving disability payments at 10 years80% of BPD sample had life time MDD.
47 Collaborative Longitudinal Personality Disorders Study- 10 year F/U Most patients eventually get a lifeThey find a place in the worldStop wanting to kill themselvesKEEP THEM ALIVE…….
48 16 year follow up studyRemission: 99% achieved symptomatic remission for a 2 year period and 78% for a 8 year periodRecovery: 60% achieved recovery lasting for 2 yearsRecurrence: 10% after 8 year period-36% after 2 year periodZanarini et al, AJP May 2012
49 Remission is not equivalent to recoveryFew people with BPD require life long treatment
50 Summary High rates of remission Takes long to remit Relatively low recurrenceBPD has a better symptomatic outcome than MDD or Bipolar Disorder
51 Prognostic factorsSubstance abuse (Strongest predictor) If no substance abuse-4 times faster remission-4 times more chances of remissionStable relationshipStable occupationSeverity of trauma- sexual abuseLate onset BPD
54 Diagnosis Make a comprehensive assessment that includes: Thorough clinical historyDevelopmental background- abuse, neglect, traumaPattern of self harm behavioursDetails of suicidal attemptsReadiness for psychotherapy
55 Communicate the diagnosis Choose an appropriate timeBe hopefulNon-judgemental mannerLong term nature of treatment
58 Education and support to family/carer Carer burdenDE stigmatizePsycho-education to familyTell family what they can do to help their loved onesIn a very small proportion of cases it may not be appropriate to involve familyRemain non judgemental, do not impose your own morality on patient/family
60 Attend to co morbidities Axis IAxis IIISUDGambling
61 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 studyThe symptoms of depression and BPD overlap, so that it is challenging to accurately diagnose depression when the disorders co-exist.
62 Depression and BPDWhen MDD co-occurs with BPD the quality of the depression is different from that of depression without BPD.Depression in BPD is characterized by:Triggered by IP and life eventsBrief durationrarity of melancholic symptomsNo persistent psychotic symptomsdeep sense of inner badnessfeelings of loneliness, emptiness, boredomInterpersonal dynamics (sense of rejection/fear of abandonment etc)
63 Depression and BPDDepression co-occurring with BPD does not respond as well to antidepressant treatment as depression in the absence of BPDTreatment of depression alone does not result in remission of BPDBut treatment of BPD with psychotherapy tends to result in remission of BPD as well as co-occurring depression
64 Depression and BPDMDD 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.
65 Offer long term psychological intervention BPD Specific psychotherapies is the best optionIf that is not possible offer supportive psychotherapy using common treatment principlesIf even that is not possible think of how to be therapeutic with out doing psychotherapy?
66 Most people with BPD need specialist treatment that is primarily structured and organized around their core symptoms
68 Psychotherapy is a biological treatment Induces changes in brainNeurogenesisIncreased intercellular connectionsCortical control over Amygdala
69 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
70 Psychotropic medications Single most widely and uniformly used treatment for BPDNot based on good evidenceIt is an adjunct to psychotherapyAvoid polypharmacy and high dosesTreat co-morbidity- but expect less than robust clinical response
71 Psychotropic medications 25% patients attempt suicide with prescribed medications20% will benefit from medications to some extentUse medications sparingly and rationally
72 Cochrane review BJP 2010The 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.
73 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.
74 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.
75 MedicationsSelective 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.
76 MedicationsMood 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.
77 MedicationsNot 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.
78 A drug for BPD? ? Oxytocin enhances Mentalization Anti Amygdala agent? Methylenedioxymethamphetamine (MDMA)Ketamine antagonists? Oxytocin enhances Mentalization
79 MedicationsIt 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
81 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.
82 Suicide BPD -Spectrum experience- about 5% Zanarini long term follow up- 4.6% in 10 yearsIt is very difficult to predict accurately who is at risk.60-70% of BPD will attempt to kill themselves
83 Suicide Most suicides do not occur during a crisis Mean age of completion years (SD of 10 years)Age when they are most threatening of suicide- 20’sMost suicides do not occur during a crisis
84 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 etcActs tend to follow a pattern in each case
85 Chronic self harm - functions Maladaptive means of survivingTo communicate something the patient doesn’t believe will be ‘heard’ otherwiseTo hold on to some sense of control in her lifeTo escape from inner suffering, but not to die
86 ParisBPD patients can often tolerate distress only if they know that they can escape it ... by suicide...therefore they become “half in love with death”
87 Why do they Self harm ? They are adaptive though pathological Coping and self-soothingExpression of angerPerceived or real rejectionA way of preventing suicideWe do not admit patients to manage self -injurious acts
88 Risk of Non suicidal self injury Risk of Suicide
89 Non suicidal self- injurious acts (DSH) High lethal acts (CO poisoning, Hanging)Low lethal acts (Cutting, minor OD)Chronic patternChange in chronic pattern
90 SuicideChronic riskAcute riskWhy should we differentiate?
91 High Lethality Method New pattern Chronic pattern Low Lethality Method High Chronic RiskCareful community treatmentAcute High RiskAdmitChronic patternLow Chronic RiskTreat as usualAcute Low RiskAssess why change in self harm patternLow Lethality Method
93 Detecting potentially high risk situations Change in the chronic pattern of suicidal/self harm behaviourCo existing psychotic features/ depression/substance abuseSubstance + Depression increases risk to 42%All DSM criteria present – 36% suicide rateRelationship breakdown / loss of occupationSexual abuse by fatherHighest risk year old, relationship break up + Depression+ substance abuse, h/o sexual abuse by father
94 Risk of SuicideRisk 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.
95 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.
96 One of the key elements in treating chronically suicidal patients is to tolerate and accept risks.
97 Management of chronic self harm behaviour Formulate the functionality (case examples).Avoid hospitalization as much as possibleDevelop a management planHelp the patient understand the emotional dynamics
98 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 practitionersUnder response to suicidal presentations may occur when desensitised to suicide
99 There are no medications or psychotherapeutic techniques to reduce suicidal ideations immediately
100 Contract Have a clear therapeutic contract Explain how you understand the disorderThe rationale for the treatment is outlinedThe treatment structure is discussedLimits explainedAnticipate problems, emotions that are likely to arise during the course of therapy
101 Crisis plan Develop a crisis plan Emergency family/carer contact informationEmergency contact information for patient and family- local AMHS, your contact information etc
102 Structure Therapy Treatment plan Crisis plan Do’s and don’ts Sessions Consistency – from all treatment providers
103 Fear of abandonment At discharge from hospitals Romantic relationships “You are much better.... You are making great progress.. You can do it...”GO SLOW
105 Therapeutic relationship EngagementTherapeutic relationship is central to changeActive and collaborative therapeutic alliance with the clients.
106 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.....
107 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 deprivationBut no need to focus on past trauma
109 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.Empathic responsivenessConsistencyReliabilityWarm engagement
110 Flexible and limit setLimit setting should not be rigid and at the expense of healthy flexibility
114 Focus on patients mindPatients 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.
115 ColomboTake a not knowing stance- MBT- “Colombo” approachTake a Mentalizing stance- help them understand the mental states behind behaviours- their/ others
116 Mentalization Ability to understand our minds and minds of others. Most of us can and will lose ability to Mentalize now and then- love, angerBPD patients lose it more easily, more often and in a wide range of situations.
118 Toleration of fluctuations in the clinical course
119 Driving a car with hypersensitive accelerator and poor breaks
120 Patient is in drivers seat- you are a driving instructor- an empathic one
121 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 patientsAny one treating BPD patients must seek supervision
122 Emotions that we feel about BPD AnnoyanceAngerHopelessnessFrustrationHatredVery strong empathyLove
123 How to deal with Countertransference? Recognise itName itBecome aware of itReflect upon itMetabolise itDo not reactSpeak to your colleagues/seek supervisionBe aware of the potential for romantic countertransferences
125 If you make mistakes, own up and apologise Be open and honestAccept that in dealing with complex situations mistakes will sometimes be madeIf one makes a mistake it is helpful to acknowledge it and apologise
126 The patient with BPD is doing the best she can even when her behaviour is maladaptive and/or out of control.
127 CrisesCrises are inevitable in the lives of patients with BPD and do not represent a failure of treatment.
128 How to deal with BPD patients in crisis? ListeningValidation style interviewingProblem solving approachDealing with here and now issuesSupportive counsellingReassuranceWise prescription of PRNsOrganizing supportOrganizing practical helpAssess riskSafety planningLiaison with relevant stakeholders
129 Manage self-harmEvaluate risk – suicide, aggression, non suicidal self injury, accidental death, self-destructive behaviour etc.Acute risk/chronic riskHigh lethal/low lethal methodsUnderstand the chronic pattern- specific to each patientAsk them why they self-harm?
130 Seek supervisionHave mechanisms that facilitates reflective practice
131 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.
134 Skills training Help patients to learn interpersonal skills Teach them to tolerate distress, regulate emotions-DBTEncourage them to “get a life”- job, healthy relationships
135 CollaborationActive and on going collaboration with patient and family (where appropriate and possible).Patient is encouraged to co author treatment plan.
136 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).
137 Why treatment plans? Generate empathy Manage anxiety of clinicians Validates patientsAvoid chaos/inconsistency among treatment providers (splitting - playing one practitioner against another)
138 Principles of drawing up a successful treatment plan for a patient with BPD treated in an AMHS? 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 stakeholdersSociodemographic details of the patient Names and contact details of all clinicians, teams and carers involved in the patient’s careA case formulationA diagnostic summary with Axis I comorbiditiesDetails of risk assessment that outline patterns of chronic self injurious behaviours and acute suicide risk situations , together withAn understanding of the underlying reasons for these behavioursother known risks a list of helpful and unhelpful interventions for these.
139 a clear description of roles of all clinicians or teams involved (or both) frequency of clinician and team contacts with the patientalternatives if the clinician is not available on the dayindications for admissionrole of psychotherapy and medicationsa 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.
140 Components of a care plan for a person with BPD The care plan should identify:short-term goals for treatmentlong-term goals for treatmentsituations that trigger distress or increase riskself-management strategies that reduce stress and riskstrategies that have been used in the past with the aim of reducing distress, but were not helpful or made things worsewho to contact in an emergencyhealth professionals involved in the person’s treatmentall others helping with the person’s treatment (e.g. family/carers, friends), including their role in supporting the personthe planned review datewho has a copy of the plan (list people and services).
141 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.
142 Treatment strategiesBPD patients who are actively using substances may not benefit from psychotherapyPast trauma- address only if patient is interested and when appropriate
143 Treatment strategiesChallenge the patients- lateness, superficiality, incivility, absentI feel sad is not = to I am sad/depressed- cognitive diffusionHelp identify and break the self-defeating interpersonal patterns
144 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”
145 Mary ZanariniI 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.
146 Marsha Linehan 1993Excessive precaution instituted in hospitals to prevent suicide may only reinforce the pathology itself
147 Often when patients don’t need admission they demand for it, when they do need admission they refuse it.
148 In patient admission Tired of managing self harm and suicidality Wish to be cared forHanding over the responsibility to some one else
149 Response to a BPD crisis Stay calm – avoid expressing shock or angerFocus on here and now – avoid discussing past experiences or relationship problemsShow empathy and concernClearly explain your role (and those of other staff)Assess person’s riskMake a follow-up appointment and refer to appropriate services
150 How to deal with BPD patients in crisis? ListeningValidation style interviewingProblem solving approachDealing with here and now issuesSupportive counsellingReassuranceWise prescription of PRNsOrganizing supportOrganizing practical helpAssess riskSafety planningLiaison with relevant stakeholders
151 Avoid excessive / long-term hospitalisations Prolonged admissions do not help-fosters regression and inhibit self-responsibilityMinimal hospitalizationClear plans for managing admissionsECT does not help
152 Take home message Diagnose and educate patient and family BPD is a treatable condition (Gabbard-Editorial-AJP2007)Psychotherapy is the treatment of choiceMedications are only partially effectiveTreatment is long termBPD is a remitting disorderKeep them safe and aliveEncourage patients to get a lifeHelp them manage work and relationshipsHaving BPD is not the patient's own fault – it is a disorder of the brain and mind.
155 Some useful links Spectrum Personality Disorder.org.uk BPD Central AftercareSpectrumPersonality Disorder.org.ukBPD CentralBorderline Personality Resource CentreInternational Society for the Study of Personality Disorders (ISSPD)National Education Alliance for Borderline Personality Disorder (NEA-BPD)Orygen Youth HealthDBT Self-Help