Borderline Personality Disorder

1
Drug Studies in B.P.D 1

• Ganislow McGlachlan reviewed 28 studies
• 19 out of 28 on B.P.D
• Treatment Strategies
• Antidepressants for mood stabilisation
• Lithium and CBZ for mood stabliisation
• transient psychotic symptoms - neuroleptics
• impulsivity with CBZ and SSRIs
• Most of studies small and poor design
• Short duration and short follow-up

2
Guidelines for Management

• Think of BD not BPD
• Regard the emotional dysregulation and
  dyscontrol
• behaviours as both biological and learned
• components
• Stick with it but dont overdo it
• Look for change at about ten years
• Treat mood disturbance as actively as you can
• Use brief hospital admissions dont strive not
  to admit
• Watch out for increasing social isolation as
  borderline
• symptoms subside
• Have all acute ward staff learn some basic
• DBT techniques

3
Borderline Personality Disorder ?
The concept / diagnostic boundaries The natural
history Drug treatment Other treatment
studies Guidelines for Management
4
Stability of diagnosis / natural history

• Early studies show poor prognosis / outcome
• Borderline syndrome and organisation
• Follow up for 5 years or less
• Pre DSM III
• Prevailing psychoanalytic zeitgeist
• Often defined by treatment failure
• Perjorative Labelling borderline

5
Werble B. Archives Gen. Psych. 1970

• Grinker RR, Werble B and Dryce 1968
• The Borderline Syndrome Basic Books
• N 51
• Follow up 3 - 5 years
• Prospective, inpatient
• No improvement, low functioning, 1/3
  re-admitted

6
Paris J Brown, R Nowlis 1987

• Comprehensive Psychiatry 1987 Vol 28
• 
  1988 Vol 29
• All D.I.B Borderline Personality Disorder
• N 322
• 15 year follow up
• Less impulsivity with time
• 23 re-admitted mainly due to unstable
• social functioning
• Limited pleasurable activities

7
Drug Studies in B.P.D 2

• Soloff - low dose haloperidol
• Gaolberg - low dose thiothixine
• Cowdry - alprazalem
• - carbamazepine
• - trifluperazine
• - tranylcypromine
• Frankenburg - clozapine
• Salzman - fluoxetine

8
Stability of diagnosis / natural history

• 2nd generation studies
• Used Gundersons D.I.B. / DSM III
• Tighter less subjective research designs
• Longer follow up 15 years

9
McGlachlan T.H. Bardenstein KK Archives 1986

• Chestnut lodge study N 89
• Long term outcome of borderline personality
• Arch. Gen. Psych. 1986
• Mean follow up 15 years
• Good outcome increased with time
• Good work functioning
• Suicide rate 3
• Personal stability by avoiding intimacy

10
Drug Studies
Soloff PH. Et al (1993) Efficacy of
phenelzine and haloperidol in borderline
personality disorder Arch. Gen Psych. 1993 50
377 - 85 Cornelius JR et al (1990) Fluoxetine
trial in borderline personality
disorder Psychopharm. Bull 1990 26 151 -
64 Cowdry RW et al (1988) Pharmacotherapy
of borderline personality disorder Arch. Gen
Psych. 45 111 - 9
11
Stone et al The PI 500

• New York State Psychiatric Institute Studies
• N 550 personality dis. 205 Borderline PD
• Follow up 10 - 23 years
• Improvement in functioning after 5 - 10 years
• not before
• Journal of Personality Disorders 1987

12
Drug Studies BPD 3

• Low dose neuroleptics benefit those who have
• ideas of reference, paranoid ideation or
• dissociative reactions to stress
• Alprazolam increases behavioural dyscontrol
• Equivocal or negative results from
• amitriptyline on mood symptoms / increased
  dyscontrol
• Better results from MAOIs but high
• non - tolerance rate
• Carbamazepine
• decreased behavioural dyscontrol
• improved mood
• better able to tolerate negative
• affect without acting out
• Equivocal results from Fluoxetine

13
Delivery of Acute Care

• Tyrer et al 1994 Psychol. Medicine
• Compared Early Intervention Service (EIS)
• with standard hospital treatment
• EIS Group did better
• 1.2 days inpatient treatment EIS
• 9.3 days standard hospital treatment
• 50 patients had personality disorder
• Personality Disorder patients did better with
• standard hospital care
• - greater improvement in depressive symptoms
• - greater improvement in social functioning
• Linehans studies fit in here

14
Outpatient Treatment

• Perry et al metanalysis of psychotherapy
  studies
• for personality disorder
• Effect size 1.04 self report
• Effect size 1.13 observer rating
• Require longer courses of psychotherapy
• improvement occurs around 50 sessions
• Patients with least disturbance do best
• particularly with traditional forms of
  psychotherapy
• 
  (Paris 1996)
• Suicidal behaviour increases in 1st year
• of psychotherapy
  (Waldinger 1987)
• decreases in years 2 - 5

15
Day patient treatment

• Piper et al 1993 hospital and community
  psychiatry
• Time limited dynamic group orientated
• 42 drop out rate
• only 14 had Borderline Personality Disorder
• Bateman (In press)

16
Assertive Community Treatment ACT

• In vivo assistance and training of patients
• ACT workers provide care not just broker it
• Staff teamwork emphasis
• High staff patient ratio (caseload N 10)
• ACT lowers treatment costs for non
• schizophrenic psychosis
• Cost for Schizophrenia same
• Costs for Personality Disorders doubled
• - no clear benefit
• Stein Test (Archives 1980)

17
Borderline Personality Disorder
Borderline Personality Disorder 1994 The
Psychiatric Clinics of North America Share I.A.
Ed W B Saunders, Philadelphia Kernbeg O.F.
(1994) Chapter I in above. Aggression, Trauma
and Hatred in the treatment of Borderline
patients pp 701 - 7014 Van der Kolk et al (1994)
Chapter 2 in above. Trauma and the development
of Borderline Personality Disorder pp 715 - 730
18
Borderline Disorder not B.D.P.

• Symptoms and behaviours define it
• No different to severe OCD, Anorexia Nervosa
• Is this the same disorder as complex PTSD
• or Disorder of Extreme Stress ? (DES)
• Not trait based changes with time

19
Borderline Personality Disorder
75 female 2 general population 10 psychi
atric outpatients 30 - 60 psychiatric
inpatients with personality disorder
20
Borderline Personality Disorder DSM IV

• A pattern of instability in personal
  relationships,
• self image and affects, and marked impulsivity
  which
• begins by early adulthood
• Fear of abandonment
• Unstable interpersonal relationships
• Disturbance of self identity
• Impulsivity
• Recurrent self harm
• Labile affect
• Chronic feelings of emptiness
• Uncontrollable anger

21
Emotionally unstable personality disorder I.C.D.
10
Impulsive type 3 of 5 criteria borderline
type 3 of impulsive criteria and 2 from
borderline
22
Borderline Personality Disorder Diagnosis

• Validity and reliability of most DSM IV
• Axis II diagnoses close to zero
• Gunderson BPD has higher validity and
• reliability if structured interview used
• BPDs meet criteria for between 4 - 6
• Other Axis II labels
• Why is BPD not in Axis I