PERSONALITY DISORDERS: BORDERLINE AND BEYOND Dr. Robert Biskin [email protected]

Disclosures ■  No personal financial disclosures ■  Participated in ADHD research funded by Purdue (saw one patient) ■  Participating in PD and ADHD research funded by CIHR ■  Psychotherapeutic training –  Psychodynamic psychotherapy –  Cognitive behaviour therapy –  Dialectical behaviour therapy –  Mentalization-based treatment

Objectives/Rules ■  Rule 1: Know what you are treating –  How to improve diagnosis of personality disorders ■  Rule 2: Treat appropriately –  What treatments to use –  General management strategies ■  Rule 3: Adjust expectations –  Know what to expect out of treatment –  Limits –  Where to refer

Issues?

■  What issues to do people have with patients who seem to have personality disorders?

RULE 1: KNOW WHAT YOU ARE TREATING

Rule 1: Know what you are treating ■  Diagnosing PDs is not too difficult, but requires a different approach than diagnosing other psychiatric disorders ■  Most important step ■  We will review how PDs are diagnosed in DSM-5 ■  Review specific PDs ■  And highlight differences between PDs and other psychiatric disorders that are commonly confused

Caveat about literature on PDs ■ The research on borderline personality disorder (BPD) is excellent –  Reflects an increasing appreciation of the relevance of this diagnosis –  Despite receiving 1/10 the research funding that schizophrenia receives! ■ The research on antisocial personality disorder is very good –  Primarily conducted in forensic settings such as prisons –  These patients do not frequently present for medical (or psychiatric) care –  But sometimes include prisoners without a PD ■ Some epidemiological research covers all the personality disorders ■ Most of the other personality disorders have very, very little research regarding their validity ■ Therefore, proportionally more time will be devoted to BPD

DSM-5 Definition ■ An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: –  Cognition (i.e., ways of perceiving and interpreting self, other people, and events). –  Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response). –  Interpersonal functioning. –  Impulse control. ■ The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. ■ The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. ■ The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. ■ The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. ■ The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Epidemiology of PDs ■ Variable by location, assessment methodology, and sample ■ Range: 4-15% ■ Mean/median 11% of the population has some form of personality disorder –  Prevalence of individual PDs approximately 1-2% ■ 

Many patients with PDs have more than one

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Lifetime prevalence may be as high as 30% (seems too high to me)

■ Gender ratios in epidemiological studies are a bit inconsistent –  Antisocial and narcissistic PDs are more common in men –  Histrionic and dependent PDs are more common in women –  But more women present to treatment in general, giving a skewed picture

Prevalent and frequently seen ■ Patients with PDs also present for treatment more often –  Outpatient psychiatry: 10% of psychiatric outpatients have borderline PD –  Inpatient psychiatry: 20% of psychiatric inpatients have borderline PD –  Family medicine: 6% of family med outpatients have borderline PD ■ Very high rates of comorbidity as well –  BPD: Mood disorder 96%, anxiety disorder 88%, substance use disorder 60% ■ Very high rates of treatment utilization –  Use all types of health care more frequently, including more medications, more psychotherapy, more ER visits, more hospitalizations, more psychiatric appointments, more medical appointments, etc…

PD Clusters ■ Cluster A: “Weird” –  Paranoid PD – 

Schizoid PD

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Schizotypal PD

■ Cluster B: “Wild” –  Antisocial PD – 

Borderline PD

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Histrionic PD

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Narcissistic PD

■ Cluster C: “Worried” –  Avoidant PD – 

Dependent PD

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Obsessive-compulsive PD

■ “Other Specified PD” –  Does not meet full criteria for any PD, but may have many symptoms of many different PDs –  The most common PD (40% of all PDs), indicating a problem with the system

Cluster A - Summary ■  Clarify diagnosis: make sure you are not missing a psychotic disorder –  If sustained (weeks or more) psychotic symptoms are present, think of schizophrenia –  If they are socially odd, eccentric, and have language problems, poor eye contact, and lack of reciprocal social interaction, think of an autism spectrum disorder ■  Cluster A PD patients will generally not present or follow-up with treatment ■  There is little to no evidence about what can be done

Cluster A PD – Paranoid PD ■  A pervasive pattern of distrust and suspiciousness of others ■  Perceive others as malevolent, without sufficient basis ■  Sees threats everywhere and in all comments, and hold grudges ■  These patients rarely present for any medical or psychiatric care ■  Frequently drop-out of any treatment ■  Do not try to engage too much as it may push them away more quickly

Cluster A PD – Schizoid PD ■  Consistently detached from social interactions and relationships, with little or no interest in developing any relationships ■  Does not care about the response, praise, or criticism of others ■  Restricted range of emotions and expression with little joy ■  Very solitary (stereotype of a hermit) ■  May be seen more frequently in families of patients with schizophrenia ■  Almost never present for treatment ■  They will do what they want anyways

Cluster A PD – Schizotypal PD ■ Discomfort with and reduced capacity for close relationships –  Suspiciousness ■ Also has cognitive or perceptual distortions –  Ideas of reference (not delusions) –  Odd or magical/supernatural beliefs outside of cultural norms ■ Eccentric –  Odd speech patterns ■ PD that is most closely associated to schizophrenia –  Aggregates in families of patients with schizophrenia ■ Slight chance of “converting” to schizophrenia, but not that common ■ Antipsychotic medications may be of some help at low doses

Cluster B PD - Summary ■  Area with the most research ■  Area that causes the most problems ■  Accurate diagnosis is important –  Differentiation between BPD and other disorders –  Identification of ASPD ■  General advice for this cluster will be given later too

Cluster B PD – Antisocial PD ■ Disregard for and violation of the rights of others –  Lies, steals, cheats, cons ■ Does not follow rules, is frequently arrested –  Consistently irresponsible ■ Impulsive ■ Lack of remorse ■ ASPD is only diagnosis that cannot be made in people under 18 years of ago

Cluster B PD – Antisocial PD ■ Over time, the law breaking and impulsivity get better ■ Seen in men more frequently than women ■ Patients with ASPD present to treatment for several reasons: –  Depressed mood, anxiety, boredom –  Substance use (highly comorbid) –  Brought by police for an evaluation ■ Treatment for comorbid conditions, especially substance use disorder, is warranted ■ No demonstrated treatment for ASPD

Cluster B PD – Antisocial PD ■ 

Management –  Clear limits about what you can provide ■ 

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Do address medical concerns and treat appropriately ■ 

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But watch for misuse of medications

Repeatedly encourage/refer to substance use treatment ■  ■ 

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Do not cross your own limits

This is the most important predictor of outcome Avoid prescribing substances that can be misused (opiates, benzos, stimulants)

If patient is interested, they can seek therapy privately ■  ■  ■  ■ 

No specialized treatment exists for this population Continuing to work is likely beneficial in the long run No (few) specialized psychotherapy programs would accept them They are likely to drop out anyways without making progress

Cluster B PD – Borderline PD ■  Requires 5 out of 9 criteria ■  Impulsivity 1) Impulsivity in two areas (not self-harm) – ex. spending, sex, drugs, binge eating 2) Recurrent suicidality and/or self-harm – suicide attempts, cutting oneself ■  Up to 85% of patients have attempted suicide ■  Similar numbers have engaged in self-harm ■  Often lots of shame about self-harming, rarely done manipulatively

Cluster B PD – Borderline PD ■  Cognitive 3) Transient paranoia or dissociation – feeling like people are watching or want to hurt the person, feeling disconnected from themselves or reality, like things are a dream ■  Different from psychosis only due to time course, otherwise can have same types of delusions and hallucinations ■  “Do you feel like people are looking at you when you walk outside?” ■  “Do you ever feel disconnected from yourself or reality? Like you are in a dream?”

Cluster B PD – Borderline PD ■  Affective (mood related) 4) Affective instability – mood fluctuates quickly, frequently (multiple times per day), and often in response to external cues ■  ■  ■ 

“Do you moods change a lot? Within minutes or hours?” “When you feel X does it last for days without changing much?” Often switches between sadness, anger, anxiety –  Euphoria is unlikely

5) Chronical emptiness – feel completely alone and hollow 6) Anger – frequently feels and acts on anger with shouting and fighting 7) Identity disturbance – constantly changing goals, values, opinions, preferences

Cluster B PD – Borderline PD ■  Interpersonal 8) Frantic efforts to avoid abandonment – afraid of being abandoned, clings on to others 9) Unstable and intense relationships – idealize and devalues others, frequently breaking up and getting back together, many short relationships ■  ■ 

Most useful criteria to screen for BPD “What are relationships like for you? Romantic, friend, work relationships?”

■  Other common symptoms include feeling sad (dysphoria) and intense anxiety, often in social situations

What is it like to have Borderline PD? •  Imagine if all your internal experiences were multiplied by 10. That would mean that all sadness, love, anxiety, and confusion would be incredibly intense •  And then imagine that your internal states were hypersensitive to external stimuli. You can be super sad one moment, and then after someone says something, you become super angry. This would leave you feeling as if you have no control over your internal experiences and your life •  So you oscillate between giving up (ex. thinking of suicide) and trying intense behaviours to regain some control (self harm, drugs, sex, "manipulation", getting angry, etc...) •  These methods work in the short term! But they cause long term problems

BPD vs. bipolar disorder ■ 

Duration of symptoms –  Patients with BPD have mood fluctuations that last minutes to days ■  ■ 

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But will often have a baseline feeling of sadness that pervades their life Lability is always part of their life

Patients with bipolar disorder have mood states that last many days to weeks ■  ■ 

These episodes are distinct from their usual self Friends and family will notice that they are “different”

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Other symptoms –  Most symptoms of bipolar disorder only occur during the manic or depressed episodes –  Most symptoms of BPD occur constantly

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Relationship problems are more consistently associated with BPD

BPD vs. major depression/ anxiety disorder ■ 

Duration of problems –  “I have been sad since I was a child” – more likely personality disorder –  “I was ok until about 6 months ago” – more likely MDD

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Sadness and anxiety are part of BPD –  Very high rates of comorbidity –  But poor response to standard treatments

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Look for other symptoms –  Relationship difficulties (chaotic relationships, fear of abandonment) –  Anger and impulsivity (less common in MDD/anxiety disorders)

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Think of PD in non-responders to standard treatments

BPD vs. PTSD ■ 

Note: “Complex PTSD” is not a recognized diagnosis –  There are no standard criteria sets and this is not a clinically useful term

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Most patients with BPD will experience traumatic events in their lives –  Most do not have PTSD

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Quick and dirty way to distinguish: if people can talk about their traumatic events reasonably (including some appropriate crying), they are not as likely to have PTSD (characterized by avoidance of memories of the trauma) –  If they want to “deal with” or “process” or “understand” their past, they are unlikely to have PTSD

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Chaotic relationships may again be the point of distinction

BPD vs. ADHD ■  Patients with BPD will appear to have attention problems and complain of this –  Discrimination between poor attention and dissociation: ■  ■ 

Dissociation occurs in BPD, usually when stressed, and is an unpleasant feeling Poor attention occurs in all situations, mostly when bored

■  Look for impulsive symptoms used to manage intense emotions (indicative of BPD) –  “Do you do impulsive things when you are feeling lousy?” ■  Look for chronic suicidality ■  Patients with BPD who are given stimulants are unlikely to benefit much from them and may want increasing doses

Diagnostic tools for BPD ■ 

Self-report questionnaires exist –  No consensus on which is best –  The Borderline Personality Questionnaire has best balance of sensitivity and specificity ■  ■ 

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80 yes/no items Takes 10 minutes to complete and 1 minute to score

Questionnaires to diagnose other disorders will inaccurately identify patients with BPD as having another disorder, so be cautious with questionnaires

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(Neuro)psychological testing is not helpful –  No consistent findings

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No imaging or laboratory studies necessary if problems have been chronic –  Be wary of symptoms onset after head trauma

Cluster B PD – Borderline PD ■ BPD has a heritability of about 0.5 ■ Major risk factor is a history of abuse or neglect –  But not all patients who have BPD have been abused –  And not all people who have been abused develop BPD ■ Biosocial theory of BPD: –  There is a biological vulnerability to dysregulation (including emotions and behaviours) in a child –  The child is “difficult” and requires particular responses from parents –  There are parents who are unable to give the responses the child needs –  Act in an invalidating manner (deny or disregard or dismiss child’s emotions and thoughts)

Cluster B PD – Borderline PD ■  Patients with BPD get better within 4 years with or without treatment ■  But many still have functional problems ■  Medications are not appropriate treatment –  Many medications have been tried –  None have convincing evidence –  None treat the core problems of BPD –  They are also less likely to be effective for comorbid disorders (such as depression)

Cluster B PD – Borderline PD ■ 

Medications are too frequently used for BPD –  All are off-label medications –  If you start a medication, be clear about limited value (generally to “take the edge off”, reduce hostility, or dampen impulsivity a bit) –  Be clear that the work that needs to be done requires psychotherapy ■ 

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Stop medications before starting another one ■ 

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Polypharmacy adds side effects with no evidence based benefit

Avoid medications that can be lethal in overdose ■ 

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This helps avoid patients looking for the “easy” solution with medications

SSRIs and atypical antipsychotics may be safest

Avoid medications with high side effect burdens ■ 

SSRIs may have the least burden

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If pushed, I will try an SSRI in about 25% of patients with BPD –  Results are typically poor after 6 months (placebo effect lasts a few months)

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And try low dose quetiapine (25-50mg bid prn) for sleep and crises as a prn

Cluster B PD – Borderline PD ■ Psychotherapy! ■ Many types of psychotherapy have been developed to treat BPD ■ Therapy is usually a combination of individual therapy and group therapy as outpatients (hospitalization rarely helpful) ■ Best studies therapy is dialectical behaviour therapy (DBT) –  Focuses on helping patients develop skills in regulating their emotions, managing relationships effectively, tolerating and accepting difficult emotions and situations, and being able to stay mindful of the present moment –  Therapy lasts one year –  Helps with comorbid disorders too –  More on this later

Cluster B PD – Histrionic PD ■ Excessive emotionality –  Rapidly shifting, but shallow –  Dramatic ■ Attention seeking –  Often inappropriately sexually seductive and focused on appearance ■ Thinks relationships are more intimate than they really are ■ Take cultural context into account, as some elements are highly variable between cultures ■ No evidence-based treatment exists ■ A “dead” diagnosis

Cluster B PD – Narcissistic PD ■  Grandiose sense of self-importance –  Fantasies of unlimited power, success, beauty, love, brilliance –  Believes he or she is special or unique ■  Needs admiration –  Sense of entitlement ■  Lacks empathy –  Takes advantage of others –  Arrogant

Cluster B PD – Narcissistic PD ■  Often present for treatment for sadness or anxiety because others do not appreciate them properly or the world does not live up to their fantasies –  Very sensitive to feeling injured after criticism or defeat ■  May be two types –  Grandiose narcissism –  Vulnerable narcissism ■  Psychotherapy may help at times –  Evidence is limited

Cluster C - Summary ■  High conceptual, genetic, and symptoms overlap between some cluster C PDs and other psychiatric disorders ■  The category with the most functional and most dysfunctional disorders ■  This group may benefit from community organizations and activities more than other groups (like exposure therapy) –  Uphouse –  Golden Age Association (Cummings center) –  CLSC peer support groups

Cluster C PD – Avoidant PD ■  Social inhibition –  Fears being shamed, ridiculed, or rejected ■  Feelings of inadequacy and being inferior to others ■  Hypersensitive to negative evaluation ■  Overlaps with social anxiety disorder and may be the same underlying disorder ■  Therefore, as for social anxiety disorder, treatment is psychotherapy (CBT) and antidepressants like the SSRIs

Cluster C PD – Dependent Personality Disorder ■ Excessive need to be taken care of –  Difficultly making decisions without advice and reassurance ■ Submissive and clinging behaviour –  Won’t argue or disagree ■ Fears of separation ■ No clear evidence for treatment ■ Likely best to gradually encourage autonomy and independence by building and reinforcing life skills – Referral to community and work organizations are helpful

Cluster C PD – ObsessiveCompulsive PD ■ Excessively preoccupied with orderliness, perfection, and being in control –  Focused on rules, lists, order, organization so much that the point is lost –  Perfectionism –  Difficulty delegating ■ Lack of flexibility, openness, spontaneity –  Overly devoted to work –  Lack of flexibility about morality, ethics, or values –  Rigid and stubborn ■ Many of these can symptoms can functional and helpful if not at an extreme and represent high levels of conscientiousness

Cluster C PD – ObsessiveCompulsive PD ■  Remember: OCPD is very different from OCD –  There are no obsessions or compulsions in OCPD ■  OCPD is the only PD associated with good occupational functioning ■  But present due to being overwhelmed when they are not able to be in control ■  No clear treatment for OCPD ■  But one preliminary study of CBT for perfectionism ■  Very difficult to treat because of fear of losing control

RULE 2: TREAT APPROPRIATELY

Rule 2: Treat appropriately ■  Patients with PDs have multiple medical and psychiatric needs that are not often met –  (They are not the most reliable patients, so it is a difficult situation) ■  Patients with PDs present for problems frequently ■  In other words, they need treatment and ask for it, but not always for the right problems

Stigma and PDs ■ Patients with PDs are highly stigmatized ■ They are seen as untreatable ■ They are seen as abusing the system ■ They are disliked and ignored by physicians and other medical staff ■ They receive inferior treatment compared to patients with other major depressive disorder or medical conditions ■ It is hard to understand why patients with PDs do what they do.

Stigma and PDs ■  Patients with PDs are generally doing the best that they can ■  They are doing what they know works ■  It may only work in the short-term, but that is better than the suffering that they are experiencing ■  Please be aware of this as most of the stigma against PDs is in the medical and mental health systems

Psychoeducation ■  Providing a clear diagnosis can be very helpful –  Can help people learn on their own –  National Education Alliance for Borderline Personality Disorder ■ 

www.borderlinepersonalitydisorder.com

–  NIMH Borderline personality disorder website ■ 

http://www.nimh.nih.gov/health/topics/borderlinepersonality-disorder/index.shtml

–  DO NOT GO ON RANDON WEBSITES OR YOUTUBE! ■ 

Huge stigma with inaccurate information

■  Single session of psychoeducation has been proven to be helpful ■  People often feel like it “makes sense” and they “fit”

Psychoeducation ■ 

Describe symptoms –  Affective instability, anger, and emptiness (with general low mood) –  Impulsivity –  Self-harm and suicide –  Relationship problems & people are “all good or “all bad”

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Course

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Treatments –  Emphasize therapy to “learn skills you didn’t learn in your childhood” –  De-emphasize medications

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Emphasize that this was not something the person chose, but an illness like any other –  Develops from a combination of genetics and environment –  No single event or person is a cause, but multiple things all together

Books ■ 

DBT Skills Training Handouts and Worksheets –  Marsha Linehan –  The skills book used in DBT therapy –  Has all the relevant information, but is mostly handouts and worksheets

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The Dialectical Behavior Therapy Skills Workbook –  Matthew McKay –  Self-help DBT books with lots of exercises that are mostly easy to follow

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Overcoming Borderline Personality Disorder –  Valerie Porr –  Very useful for families, introduces DBT

DBT Theory: A Useful Framework ■  “The central aim of DBT as a whole is to replace ineffective, maladaptive, or unskilled behavior with skillful responses” (Linehan, 1993) ■  In DBT, problem behaviors are seen as LEARNED RESPONSES to unbearable pain; impulsive behaviors are actually highly effective emotion regulation strategies. ■  The patient sees maladaptive behaviors as the solution to problems; the therapist sees the maladaptive behaviors as themselves the problems to be solved ■  BPD develops from combination of temperamentally (biological) dysfunctional emotional regulation and invalidating environment in a transactional process

DBT - Approach ■ 

Dialectics –  Balance two opposing views –  Prevents black and white thinking –  Balance validation and change strategies

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Validation –  Helps patient feel understood –  Reduces need for behaviours that express or reduce distress

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Change –  Provide skills for patients to learn how to deal with emotions differently –  Strong emphasis on homework and practicing these skills in therapy

Some DBT Assumptions ■  Individuals are doing the best they can. ■  Individuals need to do better, try harder and be more motivated to change. ■  Individuals want to improve. ■  Individuals may not have caused all of their own problems but they have to solve them anyway

Validation ■  Validation is an extremely important part of DBT ■  What to validate: –  The patient’s emotions and expression –  The patient’s behaviours by labelling –  The patient’s cognitions by reflecting –  The patient’s ability to attain their goals ■  When dysregulated, validate: –  Difficulty with tasks –  Emotional pain –  Reasons for feeling out of control

Levels of validation ■ 

Level 1: Listening with complete awareness, without bias or judgment

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Level 2: Accurate reflection of what the patient says, nonjudgmentally

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Level 3: Articulate the non-verbalized thoughts, emotions, or behaviours of the patient –  This is mentalizing what the patient is experiencing and reflecting that

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Level 4: Explain how the patient’s behaviour is understood in the context of their lives (past experiences, genetic risks, etc…)

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Level 5: Find ways to explain how the patient’s behaviour makes sense given the current situation and explain to patient

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Level 6: Radical genuiness –  Respond to the patient as a person

Validation example ■  Sue presents with conflict with her roommate because Sue only showers once per week. She does sponge bathe herself every day, but the roommate finds that inacceptable –  Invalidating approach: “Showering is easy. Just take your clothes off, turn on the water, and get in. Why can’t you do that more regularly? It takes longer to sponge bathe yourself.” –  Validating approach: “It must be very difficult for you to shower. I may not know why, but I know that you know how to shower, so there is something particularly uncomfortable about it for you. Let us work to removing the roadblocks to showering.”

Validation example continued ■  There are no “small steps” –  If it was a small step, as it may seem to the therapist, that does not make it a small step to the patient –  Calling it a “small step” invalidates their experience and difficulty and makes them feel like a failure if they are unable to do it ■  What is a small step to me is different than what is a small step to you

Doing DBT Skills ■  DBT skills can be used in many patient groups ■  In practice, you can pick and choose ■  But evidence only exists for the whole package ■  Mindfulness: Observing –  Goal is to increase focus on what is going around you and within you and reduce the effect intense emotions have on you –  Sit for 2 minutes and listen without describing –  Encourage patients to seek out mindfulness/meditation/ yoga practice

My Favourite DBT Skills ■ 

Non-judgmental –  There is no point to providing judgments of good or bad –  They are more often turned against oneself –  Let go judgments

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Effectiveness –  Focus on doing what is most likely to help you achieve your desired goal –  “Play by the rules”

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Validation of emotions –  All emotions that you experience are valid/important/legitimate and occur for a reason –  You do not need to act on an emotion to prove to yourself it is valid

My Favourite DBT Skills ■ 

Positive experiences –  Do positive things to feel better –  Do different to feel different

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Opposite action –  After validating your own emotion, do the opposite –  Approach instead of run, be active instead of depressed, do something nice (for anyone) instead of lashing out angrily

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Radical acceptance –  Accept that you are unable to change what has happened in your life –  Do not fight against the past or against things that are unchanging –  Accept that where you are now (or before) may be painful –  Do not try fighting against reality, you will lose

Mentalization: A Clear Framework ■  Mentalization is the ability to identify (and hopefully understand): –  One’s own thoughts and emotions –  The thoughts and emotions of others ■  Patients with BPD have a deficit in mentalization –  They have difficulty identifying and explaining what they are thinking or feeling –  They often misinterpret the thoughts, emotions, and actions of others ■  More likely to accurately identify anger in others ■  Less likely to identify everything else

Mentalization-Based Therapy ■ 

MBT is a therapy that aims to help people improve their “mentalization muscles”

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Officially, it is conducted in both individual and group therapy

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But can overlap with many other interventions and adapted easily to other contexts

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“What do you think was going on in X’s mind?” “What else could have been going on?” “What do you think you were thinking at feeling then?” “Do you think you could have been experiencing other things too?”

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Help out by saying “I wonder if you were thinking/feeling X”

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Be clear about the difference between a thought, an emotion, and an action

Work and School ■ 

Most robust long-term predictors of positive outcome are –  Higher education –  Avoiding drugs and alcohol

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Much time in specialized therapy is spent encouraging/insisting on school and work

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We do not put patients off work and insist that they return –  Structure of work and school gives them something to do –  And helps build relationships (even if only superficial) –  And builds meaning in life

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Refer to community organizations or welfare office to help people return to work –  Ometz –  L’Arrimage –  Emploi Quebec (especially good for youth)

RULE 3: ADJUST EXPECTATIONS

Course of PDs ■  PDs usually start in late adolescence or early adulthood –  They CAN be diagnosed in children or adolescents, but symptoms must be present continuously for at least one year ■  In general, everyone’s personality changes over their life, mostly between childhood and young adulthood

■  PDs get better with time –  People often do not meet criteria for PD when followedup several years later –  Especially borderline and antisocial PDs

Suicide ■ Majority of people who commit suicide meet criteria for a PD on psychological autopsy ■ Lifetime risk of suicide is variable between PDs and data is limited ■ Borderline PD – lifetime risk is approximately 10% –  Most suicides occur in 30s after multiple failed treatments –  Rarely occur in 20s (which is when they most often present to hospital –  Treatment may reduce the risk of completed suicide (hard to study) ■ Antisocial PD – lifetime risk is 8-15% ■ Other PDs are associated with increased risk of completed suicide, but not as strongly –  Rate of suicide attempts is much higher as well

Functional Status of PDs ■  Functioning is not great –  Higher rates of divorce/separation –  Lower levels of education –  Lower rates of employment, social class, and more frequently receiving welfare ■  Lower quality of life –  PDs are more strongly related to quality of life than other psychiatric disorders, physical health, socioeconomic factors, demographic factors, or life situations –  Those with more symptoms (criteria) have lower QOL

Realistic Expectations ■  People will not “be happy” –  No matter how much medication or therapy they receive –  This often reflects a discomfort with unpleasant/intense emotions that is at the core of BPD –  Life is full of all emotions, including joy, sadness, anger, fear, etc… ■  Tell patients to watch the Pixar movie “Inside Out”

■  Goal of treatment is to have more ways to deal with difficulties/crises and to learn how to be less responsive to intense emotions ■  Incremental gains with the goal of “building a life worth living”

Realistic Expectations for MDs ■  Patients with PDs will continue to present for care and always be higher service users than people with no PDs ■  They will still present with problems… hopefully less frequently ■  In treatment, our goal is to get them to be more productive members of society, including work, friends, and connections –  And ideally to act less on impulsive urges –  Suicidal thoughts will likely always be present “as a way out”

What is the most general approach? • Validate patients experiences 3/4 of the time • Encourage them to develop skills to help the manage their emotions • But they need to change and validation alone will prolong the problems • Patients with BPD can be terrified of change because it means giving up what little sense of control they have, so you have to convince them that you have something to offer and also to practice, because without practicing what is worked on in therapy, there will be no change (1/4 change) • Help patients to think in the long term

Limit Setting ■ 

Set all limits in advance

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Be clear with patients about the limits of your practice –  Can limit phone contacts –  Can limit appointment frequency (or absences) –  Can limit appointment duration –  Do not tolerate inappropriate, rude, violent, or angry behaviour

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But, still provide enough time to care for their health appropriately –  Ask yourself if you are spending far too much time with just one or two patients ■ 

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Then cut back the time given to them

Ask yourself if you intentionally avoid/dismiss just one or two patients ■ 

Then push yourself to treat them like all other patients

SUMMARY

Rule 1: Know what you are treating ■  The first step in treating BPD is diagnosing it –  Do not be afraid to identify BPD –  The stigma is in the minds of the mental health professionals –  BPD can also be diagnosed (and treated) in children and adolescents ■  Psychoeducation is important (both for patients and family) –  Single session of psychoeducation can reduce symptoms ■  Resources and books available online ■  AMI-Quebec –  Special program for family members of people with BPD

Rule 2: Treat appropriately ■  Limit sessions to a fixed amount of time at a fixed frequency ■  Address one issue at a time (per appointment?) ■  Encourage agency (developing control) –  Encourage work/school/hobby as way to be active and productive –  Higher level of education is only predictor for better long term functioning

Rule 3: Adjust Expectations ■  Patients with PDs generally get better with time ■  Functional status remains a problem ■  Suicide is a risk, but try not to be afraid of suicidality –  You can’t do anything to prevent suicide anyways –  Tell them they can always go to the ER or a crisis center

Who to consult in psychiatry ■ 

Montreal has many services for patients with BPD –  But they are very fragmented and difficult to access –  Often only take people who meet full criteria and not sub-threshold symptoms

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Two are non-sectorized

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Anglophone patients: –  MUHC Personality Disorder Clinic –  Special referral form from an MD –  Telephone: 514-934-1934, ex. 35532 –  Fax: 514-843-2858

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Francophone patients: –  Albert Prevost Clinique des troubles relationnels –  Patients call themselves –  Telephone: 514-338-3227 and request the clinic

Private Therapy Options ■  Argyle Institute –  514-931-5629 –  Mostly English –  Flexible cost ■  Victoria Institute –  514-954-1848 –  Mostly French –  Somewhat flexible cost –  Groups for PDs

THANK YOU!