BPD Autumn 2016 PSX_003 Counselling Psychology PhDr. Pavel Humpolíček, Ph.D Aline Lampertz 464475 Yurena Febles Arteaga 464375 − By illustrator Shawn Coss − Definition •Instability in Moods Behaviour Self-image Functioning (National Institute of Mental Health, 2016) Serious mental disorder Resultado de imagen de mental disorder png Impulsive actions Unstable relationships Episodes of anger, depression, and anxiety (from a few hours to days) Criteria •DSM-5 (American Psychiatric Association, 2013) • • •Borderline Personality Disorder (BPD) (301.83) • > 1.Avoid real or imagined abandonment 2.Unstable and intense relationships 3.Identity disturbance 4.Impulsivity in at two areas that are self-damaging 5.Suicidal behaviour, gestures, or threats, or self-mutilating behavior 6.Affective instability 7.Chronic feelings of emptiness. 8.Anger 9.Paranoid ideation Indicated by five (or more) of the following: Beginning by early adulthood •More secure with transitional objects Psychotic Symptoms Give up goals Associated features Job losses, interrumpted education, separation/divorce •Self-damaging Resultado de imagen de Secondary wound healing in a psychiatric BPD patient after self-mutilation •Different states of wound healing • •Secondary wound healing in a psychiatric BPD patient after self-mutilation • •Self-damaging http://dccdn.de/pictures.doccheck.com/images/710/2e0/7102e0ad16c0299c869623411059cc95/58377/m_14078 59109.jpg Criteria •ICD-10 (World Health Organization, 1992) 1.Act unexpectedly and without consideration of the consequences. 2.Engage in quarrelsome behaviour and to have conflicts with others. 3.Outbursts of anger or violence. 4.Difficulty in maintaining any course of action that offers no immediate reward. 5.Unstable and capricious mood. 1.Disturbances in and uncertainty about self-image, aims, and internal preferences. 2.Liability to become involved in intense and unstable relationships. 3.Excessive efforts to avoid abandonment. 4.Recurrent threats or acts of self-harm. 5.Chronic feelings of emptiness. 6.Demonstrates impulsive behaviour. •A. F60.30 Impulsive type (3 of them must be present, including “2”) •B. F60.31 Borderline type (≥ 3 of Impulsive type must be present and two of the following): Emotionally unstable personality disorder (F60.3) Resultado de imagen de ancianos Development and Course 30s-40s Greater stability in their relationships and vocational functioning > More impairment for the disorder and risk of suicide in young-adult years Decreases with age Development and Course Resultado de imagen de therapeutic intervention Improvement in the first year of therapeutic intervention > Less stable over time than expected (Skodol et al., 2005; Lenzenweger et al., 2007; Gunderson et al., 2003) Lifelong tendency toward intense emotions, impulsivity, and intensity in relationships but Prevalence DSM-5 (American Psychiatric Association, 2013) > Average population > Predominantly in females > Primary care settings > Outpatient mental health clinics > Psychiatric inpatients Between 1.6% and 5.9% about 75% about 6% about 10% about 20% Resultado de imagen de prevalence Etiology Résultat de recherche d'images pour "gens qui se tiennent la main" Résultat de recherche d'images pour "ADN image" Diagnosis ØUnderdiagnosed or misdiagnosed Ø ØSymptoms that overlap with BPD difficult to distinguish BPD I.e.: a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention (National Institute of Mental Health, 2016). Ø ØRelief when people with BPD realize that others understand their experience and treatment options exist Ø Differential Diagnosis DSM-5 (American Psychiatric Association, 2013) Posttraumatic stress disorder BPD Personality change BPD Symptoms in association with persistent substance use BPD Identity problem Differential Diagnosis Resultado de imagen de differential diagnosis Impact on functioning vBPD can feel angry at members of their family vFamily members feel angry and helpless vParents of BPD patient can have a bad behavior à overinvolvement (i.e.incest) or underinvolvement FAMILY vHigh levels of chronic stress and conflict vDecrease satisfaction of romantic partners vAbuse vUnwanted pregnancy ROMANTIC RELATIONSHIP Resultado de imagen de romantic relationship Resultado de imagen de family Impact on functioning •Splitting - Idealization and Devaluation “Dichotomous thinking” (Beck and Freeman) “All or none thinking” (Linehan) Psychotherapy Shades of grey Impact of functionning •Psychopathology in the extended families of BPD Impact on functioning . Higher risks for affective and impulse disorders Resultado de imagen de FAMILY Studies with both parents Studies with mother Studies with father •Uncaring and overcontrolling Zweig-Frank , Paris J., 1997; Weaver, Clum, 1993; Parker, Roy, Wilhelm et al. (1999) •Insecure attachment •The perception of a lack of caring Nickell et al. (2002) •Not too many studies about fathers •Negative image Baker et al. (1992) •Unempathetic Guttman, Laporte, 2000 •Egocentric Golomb, Ludolph & Westen (1994) •Conflictual Allen, Abramson, Whitson et al., 2005 •Overinvolved Liotti & Pasquini, 2000 •Age •Perpetrators of sexual abuse •Less affectionate Johnson, Cohen, Chen, et al., 2006 • •Over-involved / under involved Allen & Farmer, 1996 •More unfavorable in all aspects Bandelow et al. (2005) Impact of functioning •Psychopathology in the parents of BPD patients Unflattering light Children of mothers with BPD ØLess available for positive engagement ØDisorganized ØInsensitive ØLower self-esteem ØExhibited more emotional and behavioral problems ØMore harm avoidant ØMore impulsive ØMore psychiatric diagnoses ØHigher prevalence ØLess sensitive with offspring ØChildren had less desire to interact, less satisfied, less competent and more distressed Resultado de imagen de children Treatment and Therapies It is important for people with BPD and their relatives, couple, friends and others to be patient and to receive appropriate support during treatment (National Institute of Mental Health, 2016). Resultado de imagen de treatment Medication A systematic review and meta-analysis of randomised controlled trials Cochrane collaboration (Stoffers et al., 2010) Impact isolated symptoms of BPD or the symptoms of comorbid conditions Haloperidol à anger Flupenthixol à likelihood of suicidal behaviour Aripiprazole à interpersonal problems and impulsivity. Olanzapine à affective instability, anger, psychotic paranoid symptoms, and anxiety Ziprasidone à not significant. Placebo had a greater ameliorative impact on suicidal ideation than olanzapine did Valproate semisodium à depression, interpersonal problems, and anger Lamotrigine à impulsivity and anger; Topiramate à interpersonal problems, impulsivity, anxiety, anger, and general psychiatric pathology Carbamazepine à not significant. Amitriptyline à depression Mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate à no effect. Omega-3 fatty acid à less suicidality and improve depression From 2010, trials with these medications have not been replicated and the effect of long-term use have not been assessed. RESULTS Antipsychotics Mood stabilizers Antidepressants Serious side effects from some of these medications Medication should not be used specifically for BPD and its individual symptoms or associated behaviou0r (UK National Institute for Health and Clinical Excellence, 2009) Considered in the general treatment of comorbid conditions Medication Ingenhoven, Lafay, Rinne et al. (2010) Psychotherapy Main treatment for people with BPD (Leichsenring et al., 2011) Psychotherapy may alleviate some symptoms but more studies are needed (National Institute of Mental Health, 2016) Individual or group format Trust the therapist Résultat de recherche d'images pour "attention" Cognitive Behavioural Therapy Identify and change beliefs and/or behaviours that cause inaccurate perceptions of themselves & others Observable behaviours BPD: Maladaptative shemata and behaviours > •Fear of abandonment •Conviction of unlovability •Exaggerated guilt Dichotomous thinking (Beck & Freeman, 1990) Psychic schemata or “inner scripts” Cognitive Behavioural Therapy •Marsha Linehan (1993) • Dialectical Behaviour Therapy Term ‘dialectical’ •Synthesis of opposites •Polarized opposite feelings •Attitudes of the patient •Need for acceptance and for change ØMinimizes suicide or attempts of self-harm behaviours ØCombines standard CBT techniques (emotion regulation) with Mindfulness, Distress tolerance, Acceptance & Interpersonal effectiveness ØOne individual session per week with a therapist & Weekly group session ØPhone calls to the therapist are allowed Condition: •Conversation lead to the abstention (suicide or self-cut) •Cut short the call if the patient calls after having self-damaging Résultat de recherche d'images pour "attention" •Marsha Linehan (1993) Dialectical Behaviour Therapy Resultado de imagen de hospital Resultado de imagen de suicide attempts Resultado de imagen de throwing medication New York-Presbyterian Hospital https://www.youtube.com/watch?v=KJA53l91LSk Resultado de imagen de new york presbyterian hospital Resultado de imagen de new york presbyterian hospital Polarized attitudes and oscillating behaviours Psychodynamic Psychotherapy • Psychodynamic treatment Transference-Focused Psychotherapy Resultado de imagen de Transference-Focused Psychotherapy Disturbed relationships Focus of treatment: Distorted perceptions of self & others transference Reassignation of extreme + or – images from one person to another Mechanism of change: interpretation of distorted perceptions -Learn to reflect feelings -Intense changes in emotions Transference-Focused Psychotherapy Resultado de imagen de hospital Resultado de imagen de suicide attempts Resultado de imagen de better physical condition Group therapy > Combined with individual Dynamic Therapy and group therapy: The greatest therapeutic power (McGlashan, 1986) Not harmful and helpful (American Psychiatric Association, 2001) Homogeneous group of BPD is recommended Resultado de imagen de group therapy •TCs Therapeutic communities Structured environments where people with a range of complex psychological conditions and needs come together to interact and take part in therapy Aim à help people with emotional and self-harming problems by teaching them social interaction skills Most TCs are residential, such as in large houses, where people can stay for around one to four days a week > Taking part in individual & group therapy + doing other activities to improve social skills and self-confidence, i.e.: üHousehold chores üMeal preparation üGames, sports & other recreational activities üRegular community meetings – people discuss issues that have arisen in the community National Health Service (NHS), 2016 •TCs Therapeutic communities Guidelines on what is considered acceptable behaviour within the community: not drinking alcohol, no violence & no attempts at self-harming. Guidelines broken à leave the TC While some people with BPD have reported that the time spent in a TC helped their symptoms, there's not yet enough evidence to tell whether TCs would help everyone with BPD National Health Service (NHS), 2016 •Support groups Online spaces Some organizations now offer online support groups, discussion boards, blogs & online communities as additional ways to connect with others in similar situations. - Fellow members of online spaces offer validation - Members give tips and techniques that have worked for others. It can be an additional support for in-person groups and may be especially helpful if there are no groups in the area where the patient lives. > Mental Health America has its own support community through Inspire which enables individuals to connect on a variety of issues and topics related to mental health. Other types of psychotherapy Supportive Psychotherapy Dynamic Deconstructive Therapy (DDT), Schema-Focused Therapy (SFT) or Mentalization-Based Therapy (MBT) vSupportive Psychotherapy vDynamic Deconstructive Therapy v Schema-Focused Therapy v Mentalization-Based Therapy Combination of psychotherapies Résultat de recherche d'images pour "pouce vert" Research is needed to improve other core features of this disorder (Skodol et al., 2005) Pharmacotherapy with psychotherapy Unclear Fluoxetine (antidepressant) Dialectical Behaviour Therapy No benefits (Simpson and colleagues, 2004) Olanzapine (antipsychotic) Dialectical Behaviour Therapy An additional benefit (Soler et al. 2005) No Benefit in other study (Linehan, McDavid, Brown, Sayrs & Gallop, 2008) Fluoxetine and interpersonal therapy was superior to fluoxetine plus clinical management Family therapy • Résultat de recherche d'images pour "famille image" Family therapy Common reason to stop the treatment Résultat de recherche d'images pour "attention" Greater knowledge about BPD was associated with greater family member distress, burden, depression, and hostility Hoffman et al. (2003) v vOnly clinical experience vUseful vNot recommended as only form of treatment vNot recommended when partner is unable to listen to the other’s criticisms (Seeman, & Edwardes-Evans, 1979). • vSettle and strengthen the relationship vClarify the nonviability of the relationship vEducate and clarify for the partner of the BPD patient the process that is taking place vMay struggle to accommodate the patient’s alternating patterns of idealization and depreciation • - dysphoric and self-doubting, • - too attentive and exhibit reaction formation . vExplore and change maladaptive reactions and problematic interactions •APA Practice Guideline (American Psychiatric Association, 2001) Couples therapy Résultat de recherche d'images pour "couple" SPOUSE Transcranial magnetic stimulation Résultat de recherche d'images pour "transcranial magnetic stimulation" Improvements in Impulsivity Suicidality Agression McKenzie & Nasrallah (2003)