Professor of Clinical Psychiatry Borderline Personality Disorder: Comprehensive Management in Ordinary Clinical Practice Michael H Stone, MD Professor of Clinical Psychiatry Columbia College of Physicians & Surgeons

Borderline Domains Gunderson’s BPD BPD//DSM Borderline Personality Organization: Kernberg Kohut’s Borderline Pers.

BPD: More a Syndrome than a True Personality Disorder The BPD of DSM is composed of a few personality traits (impulsivity, irritability & anger, moodiness), several symptoms (self-damaging acts, suicidal gestures & self-mutilation, anxiety in situations ordinary people handle more easily) and cognitive peculiarities ( enfeebled sense of identity, extreme attitudes in relation to other people, feelings of emptiness, tendency to paranoid ideas or to dissociation. This mixture gives BPD its syndromal character (it is not made up solely of traits). BPD does not occur in the absence of other identifiable conditions. Usually there will be accompanying symptom disorders (from “Axis-I”) and at least the traits of other personality disorders (from “Axis –II”). These other traits may suffice to meet criteria for one of more such disorders,or may fall short of full criteria (in which case one speaks of “features” – as in “BPD with narcissistic & histrionic features”

Common Symptom Disorders that may Accompany BPD Depression (&/or bipolar-II hypomania) Anxiety (“general”, social, panic, PTSD, OCD, agoraphobia) Eating Disorder (anorexia, bulimia, “bulimarexia” – with shifting between the two) Disorders of Craving (besides the eating disor-ders): substance abuse, shoplifting, hoarding, stalking & jealousy, promiscuity, gambling)

Some Less Common Symptoms Disorders in BPD Patients Particularly in those BPD patients who have been subjected to incest (the effects of which are apt to be worse if occurring before age ten, if penetration were involved, and if the relative were a father/stepfather/uncle or other member of the older generation) – a dissociative disorder may develop. Or one may see the signs of Post-Traumatic Stress Disorder. Management may be difficult in these situations. SSRI antidepressants are often recommended for PTSD, yet in general antidepressants are not routinely useful in BPD (though they tend to be extensively over-prescribed). Caution is also necessary, since a proportion of BPD patients are simultan-eously Bipolar-II or Bipolar-III (the hidden bipolars – whose tendency to manic symptoms may be brought to the surface through use of antidepressants). Sensitivity is needed – in knowing when to begin exploring past molestation, lest exploration that is premature or too deep make the patient’s anxiety worse.

Neuroscience Looks at BPD A Meyer-Lindenberg: Scientific Amer Mind, Spring 2009, p 41ff; B King-Casas: Science vol 321, 887-80, 2008 Neuroscience Looks at BPD BPD patients have been shown via fMRI to have abnormally small areas in parts of the limbic system, in many cases: areas subserving negative moods show the greatest reduction in volume. This may mean loss of inhibitory neurones, such that the patients have less effective “brakes” on negative emotion. This may contribute to impulsivity and to overly negative reactions to stressful events. Also: the Ant.Insula may not be giving proper signals that indicate a problem in a relation-ship, leading to poor distinction as to whom one can trust, and later – to general distrust of others.

Mary Zanarini’s Comments on the Essential Nature of BPD Psychopathology Core feature of BPD may be intense inner pain, coupled with an awkward means by which to express this pain. There are affective & also cognitive components. The core features may stem from an interaction of a “hyperbolic” temperament (with a tendency to over-react to stimuli) x “kindling” events usually of a traumatic nature,such as sexual or physical abuse, or intense humiliation, during childhood. Hyperbolic (overheated) temperament Traumatic childhood causing shame, rage, sorrow, terror… Triggering Events: puberty, first love affair, humiliation by relative The acute symptoms are often quicker to resolve, whereas the temperament traits change slowly & relatively little B P D

Management Issues The first-line treatment for BPD is psychotherapy [cf. Amer J Psychiatry report 2001] Psychotropic medications are seen as ancillary or adjunctive. The report (relying mainly on Paul Soloff’s research) recommended mild anxiolytics for anxiety symptoms (avoiding benxodiazepines insofar as possible), neuroleptics in low doses for cognitive distortions, and mood stabilizers for those with marked mood swings (e.g., medications like lamotrigine or lithium). Zanarini emphasizes that BPD patients (the majority of whom are women) have, as a group, experienced more sexual abuse than have patients with other pers. disorders. As to which thpe of psychotherapy: Though some still adhere to the belief that one form is distinctly superior to the others, there is less and less support for this. Yet it is important to be grounded in one specific form of therapy – that constitutes one’s foundation as a therapist. From there one can acquire familiarity and knowledge of some of the techniques of the other main approaches – for use when & if needed.

Common Personality Configurations that may Accompany BPD Narcissistic Histrionic (akin to “Infantile”) Antisocial Depressive-Masochistic Avoidant Paranoid Schizotypal Hypomanic

Therapists Need to Take into Account the Total “Profile” of Personality Traits High High Low Low T I R N A T I E T N S I T Y x x x x x x x x Na Hi AS DM Av Par Sty O-C Pag Dpr Hyp other

Therapists Need to Take into Account the Total “Profile” of Personality Traits High High Low Low x x x x x x x x x x Na Hi AS DM Av Par Sty O-C Pag Dpr Hyp other

Good vs Bad Prognosis, as judged by the array of other traits The BPD patient who showed the profile of traits in the first diagram (red lines) was predominantly histrionic, masochistic, avoidant, depressive, and narcissistic. This is a much more favorable situation, prognostically, than the profile of the second BPD patient (green lines), who was predominantly narcissistic, antisocial, paranoid, passive-aggressive, and hypomanic. Such a patient would be less amenable to any of the treatment approaches now in common usage, whereas the first might do well with any of a variety of approaches.

Demographic & Background Factors FAVORABLE Supportive family Some favorable work history Average or better intelligence Fairly good academic record; talent Minimal or no substance abuse No incest history Some self-mutilation & suicide gest- ures, few or no attempts Middle class or better status UNFAVORABLE Chaotic, unsupportive family No work history Below average intelligence, No talent or interests; poor in school Heavy drug abuse; refusal of A.A. History of incest (esp. before age 10) Several near-lethal attempts Poverty In trouble with the law

No Two BPD Patients are Entirely Alike Background Other Factors Symptoms Pers. Traits X X Great Diversity within the BPD Domain

Optimal Management Depends on the Mixture Relevant to each Patient CURRENTLY WIDELY USED TREATMENT METHODS Transference Focused Psychotherapy [TFP] Dialectic Behavior Therapy [DBT] Cognitive-Behavioral Therapy [CBT] Mentalization-Based Therapy [MBT] Schema-Based Therapy [SBT] Supportive Psychotherapy [SPT]

Therapeutic Approaches & their Primary Goals TFP – improvement in object relations DBT – better emotional regulation CBT – reduce maladaptive cognitions SFT - create more adaptive schemata MBT – enhance reflective function SPT - set limits, encourage, calm emotional storms, educate about life

The Situation with Typical Borderline (BPD) Patients CBT aims at making ideas & behaviors more realistic and adaptive The typical BPD patient has problems in all these areas DBT aims at skill building & Sx reduction MBT aims at the improvement of reflective functioning SFT aims at modifying core beliefs TFP aims at modifying maladaptive object relations

Integrated Therapy for BPD as championed by Dr John Livesley Therapists who work with Borderline patients have usually been trained in one of the main treatment approaches. It is important to acquire familiarity with several other methods – so that one can bring to the therapy a more integrated and flexible approach. Especially in the opening phases of the treatment, BPD patients will often be chaotic, impulsive, self-destructive in various ways – and will require limit setting and other supportive interven-tions. Many will require different forms of group therapy designed to help BPD patients gain control over impulses to abuse substances, to regulate eating patterns, to curb tendencies to sexual promiscuity & to unsafe sex or to shop-lifting & other forms of petty theft, to taking up with strangers in bars, and to other forms of inappropriate or reckless behaviors. Much effort will be directed to converting the patient’s tendency to “act out” into talking with the therapist instead of behaving self-destructively.

The Importance of Flexibility as advocated by Judd & McGlashan Work with BPD patients is not for everyone. What is needed is flexibility and creativity within an ethical and commonsense frame. This means, among other things, careful attention to countertransference, including the temptation to acquiesce to the patient’s desire to “actualize” the transference. BPD patients are very prone to wanting the therapist to BE a friend or parent or lover, rather than to talk with the therapist about why such wishes had become so pressing and urgent. Many an incest victim, for ex., were raised in an atmosphere where “love” was shown through sexual molestation. BPD patients from such a background often have a hard time understanding that it is quite unnecessary for a therapist to repeat such behavior in order to show respect, kind regard, interest, sympathy, etc. The patient has, in effect, to learn the language of ordinary communication of feeling via words – since she (it will usually be a “she”) was raised only on the language of action.

More on Judd & McGlashan [TH Judd & TH NcGlashan: A Developmental Model of BPD. APPI, 2003 Re: Empathy…Empathic capacity may be part of our genetic heritage as an important element in our equipment for survival. It requires the experience of our intentions being understood & responded to – by significant others (the parents, for starters) in a consistent manner. Work with BPD patients requires a better than average ability to maintain consistent empathy, since the patient often fails in this endeavor toward self, therapist, and other people. The evolutionary psychiatrists, McGuire and Troisi, have underlined how BPD patients are exceedingly hungry for attachment. Toward that end, they often become manipul-ative, seductive, clingy, demanding – with their therapists. Yet they are also prone to be exploited by bosses, friends, therapists and others – from whom they so ardently (and all too often, blindly) seek this attachment.

A Management Issue: Dealing with dichotomous thinking All clinicians who deal with BPD patients make reference to their tendency to dichotomous (that is, all-or-none) thinking, as is often manifest in the defense of “splitting.” They seem unable to hold opposite sets sets of feelings in consciousness – at the same time. They instead swing between extreme positive//loving attitudes and extreme negative//hateful attitudes. When they are in the one state, they become unaware of the other attitudinal state (which seems to go “off-line” temporarily). One side-effect of this pathology of thought is “paradoxical behavior.” The patient behaves as though the other person is “all bad” at one moment; there may then be a sudden shift in attitude, and the person is seen as “all good.” Therapists working with this phenomenon have the task of getting the patient to move away from these extreme positions – toward INTEGRATION, where the patient can begin to understand the complexity of human feelings, and that they do actually hold simultaneous-ly contrasting attitudes toward self and other. This in time permits more calm and less chaotic, less exaggerated, and more realistic and more consistent feelings to emerge.

Inordinate Anger As Judd & McGlashan emphasize, treating BPD patients requires that we can deal adaptively with their frequent flashes of anger – often amounting to full-blown rage. We need to withstand the outpouring of anger, without taking it personally, without being intimidated, and without making premature//inappropriate responses. BPD patients are notorious for visiting on us the same kinds of devaluation and contempt that they may have experienced when still living with their original families. It is our job to understand this and, in a humane and compassionate yet firm way, deal with it. We try to get the patient to THINK about the anger rather than to ACT: “OK, I can see you’re boiling over with rage right this minute! Let’s see if we can take a step back and think about what probably triggered that anger…let’s hear what comes to mind…” BPD patients who have been traumatized tend often to reenact rather than to recollect what happened to them in the past, or to recollect what incident in the here-and-now may have sparked the old traumatic memory.

The Importance of Motivation Collaborative Relationship Motivation Kernberg has also emphasized the importance of Genuine Concern about one’s condition – as an important element in successful treatment of BPD patients.

The Time Factor Many of the currently popular therapies have been compared recently by means of randomized control studies [RCS], involving 2 or 3 different approaches. The studies are usually carried out for a year or two. There is an inherent problem in such design, since patients with BPD often require much more time in treatment - five or six years or even more. The results of these studies tend to focus on the symptom-dimension of BPD – since many of the symptoms (self-cutting, substance abuse…) can be alleviated within the time-frame of the study. But helping the borderline patient establish a harmonious relationship with a sexual partner or to achieve social success to the point of having a good circle of friends often takes much longer. Borderline patients who have not completed school or college, and who have spotty work records may also require longer time periods before they can become financially independent. Longer time in treatment is usually necessary, and so is long-term follow-up.

More than One Approach is Often Necessary Year 1 2 3 4 5 6 > 6 Period of chaos & impulsivity; need for limit- setting, support & validation… Therapy may now decrease to once a week instead of two. Need for medica- tion may be less. Acting out is now less & therapeutic alliance is stronger; TFP or another dynamic Rx or DBT, CBT useful Tapering of session frequency may be in order; focus is on close relations,work & dystonic traits…

The Patient’s Cognitive Style Therapists need to pay attention to the patient’s inherent cognitive style. Some BPD patients, at least at the outset, appear to have little capacity for self-reflection//introspection//putting themselves in the shoes of the other person (mentalization). A psychodynamic type of psychotherapy will be difficult to set in motion with such patients. They tend to forget their dreams or else not to work well with them if they do occasionally recall one. They may respond better and more quickly to cognitive/behavioral/schema-based approaches. Some (though not all) will in time develop better reflective capacity, at which time a more dynamic approach may prove fruitful. But no one approach is good for all BPD patients. Sometimes the degree of earlier traumatization is so overwhelming that deep reflection upon it would (certainly in the beginning) be overwhelming also. I had occasion in December 08 in London to hear about BPD patients – incest victims to the maximum, who had disemboweled themselves or had cut their genitals. Such patients are likely to be too ill, too disturbed, to deal (at first, maybe forever) with transference issues.

Mechanisms Intrinsic to Any Therapeutic Modality A therapeutic relationship that fosters support & security via accurate empathy, non-possessive warmth, and therapist’s genuine- ness, as emphasized by Carl Rogers… Technical interventions that provide new learning experiences, and new opportunities to apply newly acquired interpersonal skills and new occupational skills

Factors Related to Outcome The specific treatment modality (such as CBT, DBT, TFP, MBT…) appears to account for only a modest percentage (in the range of 10%) of the variance Almost half the variance in outcome is accounted for (in the range of 40%) by the general mechanisms embodied in any and all the approaches The large remainder is accounted for by the qualities inherent in the borderline patient: strength of motivation, level of perseverance; whether the patient can form a meaningful attachment, versus being “dismissive” in attachment style. Therapists’ ability to deal with stormy emotions, rage outbursts, emergency situations – forms part of this portion also.

Self-Cutting in BPD: Response to Therapy Approximately similar success rate in diminishing the tendency to self-damaging acts – with TFP, MBT, DBT .9 .5 .1 Likelihood of Parasuicidal Acts,such as Wrist cutting, Non-lethal Suicidal gestures Year 0.25 0.5 0.75 1.0

Hierarchy of Treatment Goals (as emphasized by TFP, DBT) Attention to suicidality Preserve therapeutic relation Deal with life-threatening symptoms [drug abuse, anorexia] Deal with other symptoms [mild depression, bulimia] Deal with key personality traits [jealousy, irritability] Attend to key object relations Work on life-goals, aspirations, hobbies; urge patient to work or attend school, if pertinent (as emphasized by Livesley) Phase 1: safety & support Phase2: containment (support, medication if indicated) Phase 3: Control & Regulation (toleration of strong affects, etc) Phase 4: Exploration and Change (can be cognitive, dynamic, interpersonal…) Phase 5: Integration and Synthesis (via dynamic or cognitive interventions)

Controversial Issues in the Management of BPD “T/A” (Therapist/Administrator) Split. Some clinicians see advantages in the therapist confining efforts just to the psychotherapy of hospitalized BPD patients; the admini-strator handles other matters such as hospital-passes, medications, visitors, etc. If the therapist is not a psychiatrist, then medications have to be managed by a psychiatrist. Other clinicians are comfortable with the approach in which the therapist – if an MD – handles the medications (if needed) as well. Decisions about visitors, weekend passes etc are usually made according to the recommendations of the whole treatment team (whether or not there is a T/A split). Suicidality. For BPD patients who have made significant suicidal acts, hospitalization is often necessary. The length of stay tends to be much shorter (in the US at least) than was the case years ago. The rationale is: lengthy stays may make the patient too dependent upon the hospital, and may interfere with re-adjustment to life on the outside. BPD patients who are parents with small children probably should be allowed to return home as soon as practicable. Adolescents from destructive homes may, however, benefit from longer time away from home (in hospital or halfway house…)

Controversial Issues, cont’d Handling Suicidal BPD Patients BPD patients who call their therapists, threatening suicidal acts, pose considerable challenges concerning what is the best tactic for confronting the threat. DBT recommends that – faced with such phone calls – if the patient has not as yet actually made an act of self harm, the therapist will discuss with the patient what was the problem or life crisis that prompted the wish for self-harm and also for the call. The effort here is to help the patient deal more adaptively with the crisis and then NOT do the self-injurious action. But if the patient had already done the act, the therapist does not continue the call, lest the patient achieve a counterproductive “secondary gain” by first making the act and then begging for sympathy. TFP in similar situations will often recommend that the patient go to the nearest hospital emergency unit and get the necessary care. Both these approaches have merit, and will be useful in many cases. But there will always be exceptions. Not all suicidal patients can be trusted to go on their own to a hospital. And if a patient called the DBT therapist about a very serious act, a more extended conversation may be necessary (to urge hospitalization or to prevent the situation from becoming more life-threatening). Clinical judgment is always needed.

Peculiarities in the Treatment Course & in the Life Course of BPD Patients BPD patients will often quit treatment prematurely with one therapist, and then seek another. The drop-out rate is thus quite high (~ 40%), which is discouraging. But eventually the patient will find another therapist with whom he or she will feel more comfortable, and may then make rapid improvements [cf. Dr Heller’s Pt]. This means that the eventual success rate tends to be better than what we would have forecast, if we only paid attention to the high drop-out rate. In long-term (10 to 25 year) follow-ups of BPD patients, about 2/3 of the patients achieve a Global Assessment Score in the mid-60 range. Many will have stopped making suicide gestures and self-mutilations, will have (once past age 30) found a good friend or a sexual partner, and will not longer satisfy DSM criteria for BPD. Depending on the age at which the patient was first treated, the suicide rate, nevertheless, will be substantial: 3 to 9% (depending on the mix of positive and negative factors).

Summary Comment The typical BPD patient has problems with Emotional Regulation (which are addressed with special attention in DBT), in Object-Relations (addressed with special emphasis in TFP), and shows abnormalities in cognition (a tendency to black&white thinking, paranoid reactions, dissociation, “past-life” experiences…) (addressed in CBT), as well as maladaptive inner scripts or “schemata” (addressed in Schema Focused Therapy, or in CBT), and deficits in reflective function (addressed in MBT, TFP) besides which there are usually frequent life crises (especially at the beginning) that will require elements of limit setting, psycho-education, 12-step programs, validation, skills-training, sympathy, encouragement – such as are offered in Supportive Psycho-therapy & in DBT.

Summary, cont’d Usually – collaborative and cooperative exchanges between therapist & patient are the primary healing elements. The therapist’s task is, while still adhering mainly to the approach adopted in the therapist’s original training, is to remain flexible and adaptive enough to select interventions from some of the other approaches that might prove most useful at any given moment in the course of the treatment. It will at times be prudent to refer the patient to specialists in one or another of the alternative approaches, if more extensive application of those approaches proves necessary. Where substance abuse is a major factor, enrollment in AA or Narcotics Anon etc will be essential; other forms of group therapy may be indicated for gamblers, eating disorder patients, and the like. All this makes for an integrated therapy. No single approach stands out as superior across the board to all the others. All include effective interventions (many of which will be quite similar, albeit expressed in a different vocabulary).