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Dr Sathya Rao Clinical Director, Spectrum, the Personality Disorder Service for Victoria, 4 th Sept 12 Medicare Local.

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Presentation on theme: "Dr Sathya Rao Clinical Director, Spectrum, the Personality Disorder Service for Victoria, 4 th Sept 12 Medicare Local."— Presentation transcript:

1 Dr Sathya Rao Clinical Director, Spectrum, the Personality Disorder Service for Victoria, 4 th Sept 12 Medicare 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 life Self-harm and suicidality Having 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 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

4 BPD 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

5 BPD is a highly stigmatized disorder John Gunderson “BPD is to psychiatry what psychiatry is to medicine”

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 Marsha Linehan had BPD Expert on Mental Illness Reveals Her Own Fight New York Times 2011

8 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

9 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

10 Australia 2011

11 National Expert reference group on BPD

12 NHMRC National BPD management guidelines

13 National BPD Foundation

14 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

15 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

16 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

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 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 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 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

19 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)?

20 BEST

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't deliberately hurt yourself with out meaning to kill yourself? are you able to like yourself

22 Co occurring disorders Depression Bipolar disorder PTSD Eating Disorders Psychosis SUD Kind of comorbid Kingdom

23 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!!!!!

24 Etiology Biological vulnerability Environmental factors Stress diathesis model

25 Genetics Family history of Mood Disorders and SUDs are more common in BPD than would be expected by chance (Widiger and Trull 1992) Trans-generational patterns BPD is significantly heritable Strongly genetic. Genetic model-Heritablility effect 0.69 (1.0 would indicate complete heritability) (Torgersen et al. Compr Psychiatry 2000; 41: )

26 HERITABILITY Lyons & Plomin/Smoller Schizophrenia 85% Bipolar 80% BPD 55-68% -(impulsivity/ mood instability) MDD 45% Panic Disorder 40% PTSD 30%

27 Hyperactive and hyper responsive Amygdala

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 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

35 Interpersonal sensitivity

36 What sets patients off? Pushing their buttons Triggering attachment systems Being misunderstood Make them understood We need to take responsibility to clear the misunderstanding

37 PROGNOSIS

38 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

39 Psychotherapy 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

40 Psychotherapy outcome research Specific technique/model of therapy- 0nly 15% Expectancy 15% Common factors 30% Non specific factors 40%

41 Matching therapies Therapist factors Patient factors Resources Common treatment principles 41Curr Psychiatry Rep (2011) 13:60–68

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 outcome 1.5 to 2 years of group and or individual psychotherapy results in significant recovery for complex BPD patients.

44 Prognosis Spontaneous remission - 75% recover by yrs 90% recover with improved functioning by age 50 (CMAJ-2005) Treatment speeds up remission Treatment as usual - Remission rates: 1/3 rd at 2 yrs 1/2 at 4 years 2/3 rd at 6 years 3/4 th at 10 years Good treatment leads to faster remission MBT- 60% remission by 1 year

45 Zanarini study AJP 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% - 2 nd year follow-up  22.3% - 4 th year follow-up  21.9% -6 th year follow-up  12.8% -8 th year follow-up  3.7% - 10 th 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 functioning Even after remission only 25%- full time work 40% receiving disability payments at 10 years 80% of BPD sample had life time MDD.

47 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…….

48 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

49 Remission is not equivalent to recovery Few people with BPD require life long treatment

50 Summary High rates of remission Takes long to remit Relatively low recurrence BPD has a better symptomatic outcome than MDD or Bipolar Disorder

51 Prognostic factors Substance abuse (Strongest predictor) If no substance abuse-4 times faster remission-4 times more chances of remission Stable relationship Stable occupation Severity of trauma- sexual abuse Late onset BPD

52 Treatment principles

53 Management versus Treatment

54 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

55 Communicate the diagnosis Choose an appropriate time Be hopeful Non-judgemental manner Long term nature of treatment

56 Provide appropriate references, websites

57

58 Education and support to family/carer 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

59

60 Attend to co morbidities Axis I Axis III SUD Gambling

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 study The symptoms of depression and BPD overlap, so that it is challenging to accurately diagnose depression when the disorders co-exist.

62 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:  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)

63 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

64 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.

65 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?

66 Most people with BPD need specialist treatment that is primarily structured and organized around their core symptoms

67 Psychotherapy 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

68 Psychotherapy is a biological treatment Induces changes in brain Neurogenesis Increased intercellular connections Cortical 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 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

71 Psychotropic medications 25% patients attempt suicide with prescribed medications 20% will benefit from medications to some extent Use medications sparingly and rationally

72 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.

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 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.

76 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.

77 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.

78 A drug for BPD? Anti Amygdala agent? Methylenedioxymethamphetamine (MDMA) Ketamine antagonists ? Oxytocin enhances Mentalization

79 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

80 Self harm Chronic suicidal ideations Self- injurious acts (DSH) Suicidal attempts Suicidal gestures Suicidal fantasies Suicidal threats

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 years It is very difficult to predict accurately who is at risk % of BPD will attempt to kill themselves

83 Suicide Mean age of completion years (SD of 10 years) Age when they are most threatening of suicide- 20’s Most 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 etc Acts tend to follow a pattern in each case

85 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

86 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”

87 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

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 pattern Change in chronic pattern

90 Suicide Chronic risk Acute risk Why should we differentiate?

91 High Lethality Method Low Lethality Method Chronic pattern New pattern Acute High Risk Admit High Chronic Risk Careful community treatment Low Chronic Risk Treat as usual Acute Low Risk Assess why change in self harm pattern

92 NHMRC guideline draft

93 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 year old, relationship break up + Depression+ substance abuse, h/o sexual abuse by father

94 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.

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 possible Develop a management plan Help 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 practitioners Under 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 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

101 Crisis plan Develop a crisis plan Emergency family/carer contact information Emergency 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

104 Long term perspective

105 Therapeutic relationship Engagement Therapeutic relationship is central to change Active 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 deprivation But no need to focus on past trauma

108 Therapeutic stance Reliability Warm engagement Interactive Interested Curious Active Validating Non judgemental Empathy Tolerance Self responsibility

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 responsiveness Consistency Reliability Warm engagement

110 Flexible and limit set Limit setting should not be rigid and at the expense of healthy flexibility

111 Stay in the moment- here and now issues

112 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

113 Focus on patients mind not behaviours

114 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.

115 Take a not knowing stance- MBT- “Colombo” approach Take a Mentalizing stance- help them understand the mental states behind behaviours- their/ others Colombo

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, anger BPD patients lose it more easily, more often and in a wide range of situations.

117

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 patients Any one treating BPD patients must seek supervision

122 Emotions that we feel about BPD Annoyance Anger Hopelessness Frustration Hatred Very strong empathy Love

123 How to deal with Countertransference? 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

124 Transparency

125 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

126 The patient with BPD is doing the best she can even when her behaviour is maladaptive and/or out of control.

127 Crises Crises 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? 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

129 Manage self-harm Evaluate risk – suicide, aggression, non suicidal self injury, accidental death, self- destructive 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?

130 Seek supervision Have 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.

132 Psycho analysis is dangerous -J Gunderson

133 Problem solving approach

134 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

135 Collaboration Active 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 patients Avoid 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 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.

139 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.

140 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).

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 strategies BPD patients who are actively using substances may not benefit from psychotherapy Past trauma- address only if patient is interested and when appropriate

143 Treatment strategies Challenge the patients- lateness, superficiality, incivility, absent I feel sad is not = to I am sad/depressed- cognitive diffusion Help 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 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.

146 Marsha Linehan 1993 Excessive 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 for Handing over the responsibility to some one else

149 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

150 How to deal with BPD patients in crisis? 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

151 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

152 Take home message Diagnose and educate patient and family BPD is a treatable condition (Gabbard-Editorial- AJP2007) 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.

153

154 ACT manual

155 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

156 Thank you


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