APA guidelines for BPD

[9point75]

---

Members do not see this ad.

So apparantly the APA has long ago published practice guidelines for borderline personality. They recommend SSRI as first line pharmacotherapy. How come everyone in my neck of the woods is on seroquel and depakote?😕

 

[strangeglove]

Because they have bipolar disorder, damn it! Don't you understand? Nobody understands! (cue self-injury)

 

[atsai3]

So apparantly the APA has long ago published practice guidelines for borderline personality. They recommend SSRI as first line pharmacotherapy. How come everyone in my neck of the woods is on seroquel and depakote?😕

Their psychiatrists are probably chasing symptoms. Around here everyone is on aripiprazole... which doesn't do squat for either borderline or bipolar.

 

[Suedehead]

Because they have bipolar disorder, damn it! Don't you understand? Nobody understands! (cue self-injury)

 

[IAmAUser]

.

 

[whopper]

This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The March 2005 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.

from the APA site concerning the guidelines.

By the way, the APA psychiatric newspaper recently had interviews with psychiatrists mentioning that psychotherapy really is the way to treat the disorder. Meds can help, but they should be viewed as limited in benefit and not the mainstay of treatment. Most psychiatrists don't know how to do DBT. While I believe more should learn DBT (and a disclaimer, I haven't yet taken a DBT course yet though my wife has), psychiatrists should at least refer borderline PD patients to DBT therapy.

 

[Shikima]

Personally speaking, I view it to be a mood lability/impulsivity disorder. I look at the overall tone of the behavior and the ensuing consequences and then I look to my mood stabilizers to help. My biggest mainstay after that, like Whopper, is talk therapy -- I want them calmed down so they can go through the process.

 

[Suedehead]

Personally speaking, I view it to be a mood lability/impulsivity disorder. I look at the overall tone of the behavior and the ensuing consequences and then I look to my mood stabilizers to help. My biggest mainstay after that, like Whopper, is talk therapy -- I want them calmed down so they can go through the process.

medicines don't address the underlying problem of BPD. they may help, but only adjunctively. they've notoriously not helped much and can even distract from the real work needed. Marsha Linehan told our faculty that they should be on no meds when they start therapy, then a medicine within the frame of their therapy may help particular symptoms.

and I'd avoid a mood stabilizer if I could at first. I'd start, if anything, an SSRI to help with low mood and general rejection sensitivity. their mood lability/impulsivity is usually relationally driven. an SSRI may (don't hold your breath) help.

 

[whopper]

Agree with the above, and especially do not give out a substance of abuse such as a benzodiazepine. Given the parasuicidal tendencies of several borderline patients, it could be the equivalent of giving out a loaded gun, not to mention giving a demographic prone to subtance abuse and problems with delayed gratification another wrench to throw in the works.

Unfortunately, the vast majority of psychiatrists I've seen treat the disorder in a manner very much out of tune with what the research directs us to do. That research suggests that DBT is the way to go. I've said several times that I understand that since several psychiatrists don't know how to do DBT, they could offer medication, but they need to clearly state it's limitations and that it's not the first-line recommended treatment. To not address this could mislead a patient into believing they do not need something more than the medication.

I tell my borderline PD patients that I do prescribe meds to an analogy.

"Imagine a box where you insert your hand, and while it's in there, a hammer constantly pounds against your hand. The solution is to pull your hand out. That's what psychotherapy will hopefully do. Giving you psychotropic medication can help, but it's like giving you an aspirin while your hand is still caught in the box and it won't do anything to get your hand out."

 

[Manicsleep]

Medications used to treat borderlines should focus on the symptoms in the context of a therapeutic approach. Here is a head to trial using Gunderson's psychodynamic method and medications.



A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder (Am J Psychiatry 2009; 166:1365–1374)

I think Linehan has done great work but really she just found a way to approach borderlines. It is an amazing approach for which she deserves a lot of credit. However, you can make that approach with many kinds of therapy and meds can definitely help. SSRIs are better than mood stabilizers because they are safer but if you need a mood stabilizer or an antipsychotic, the SSRI is not going to work.

Don't memorize the cookbook, be the iron chef. The concept is everything.

 

[IAmAUser]

.

 

[Manicsleep]

coincidentally gunderson has a bpd review in nejm today

With audio and everything!

I, unlike some of my more academic colleagues, don't remember references off the top of my head except for the big articles. I only remembered because of the NEJM article today.

 

[whopper]

Agree with the above. There's also the phenomenon of someone with borderline PD and cyclothymia or whose presentation could fit either. In this type of case a medication trial to see if there's any benefit IMHO is warranted, but also educate the patient that there may be more than one disorder and your thought process as to the treatment approach.

 

[Shikima]

Medications used to treat borderlines should focus on the symptoms in the context of a therapeutic approach. Here is a head to trial using Gunderson's psychodynamic method and medications.



A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder (Am J Psychiatry 2009; 166:1365–1374)

I think Linehan has done great work but really she just found a way to approach borderlines. It is an amazing approach for which she deserves a lot of credit. However, you can make that approach with many kinds of therapy and meds can definitely help. SSRIs are better than mood stabilizers because they are safer but if you need a mood stabilizer or an antipsychotic, the SSRI is not going to work.

Don't memorize the cookbook, be the iron chef. The concept is everything.

Thanks, much more eloquently said than my attempt.

 

[Suedehead]

Agree with the above. There's also the phenomenon of someone with borderline PD and cyclothymia or whose presentation could fit either. In this type of case a medication trial to see if there's any benefit IMHO is warranted, but also educate the patient that there may be more than one disorder and your thought process as to the treatment approach.

I would say most pts with true BPD would meet criteria for cyclothymia (and a number of other DSM disorders). not sure if a it would represent a true comorbidity or just a typical BPD symptom soup.

 

[Manicsleep]

I would say most pts with true BPD would meet criteria for cyclothymia (and a number of other DSM disorders). not sure if a it would represent a true comorbidity or just a typical BPD symptom soup.

I am not sure about most borderlines meeting the criteria but borderlines and mood disorders/schizoaffective disorder are commonly codiagnosed. I have always believed this is because of the symptom checklist phenomenon combined with borderline patients having a lot of comorbidity in both mood and substance use.

I try not to get too carried away with the DSM, especially because in the current climate there are a lot of people who simply cannot look beyond that one resource. It's important to step away, see the big picture and be a physician.

 

[Suedehead]

I am not sure about most borderlines meeting the criteria but borderlines and mood disorders/schizoaffective disorder are commonly codiagnosed. I have always believed this is because of the symptom checklist phenomenon combined with borderline patients having a lot of comorbidity in both mood and substance use.

I try not to get too carried away with the DSM, especially because in the current climate there are a lot of people who simply cannot look beyond that one resource. It's important to step away, see the big picture and be a physician.

I agree. My point is that these 'comorbidities' are likely problems of nosology and not representations of someone actually having 2 or 3 disorders.

 

[Majesty]

I try not to get too carried away with the DSM, especially because in the current climate there are a lot of people who simply cannot look beyond that one resource. It's important to step away, see the big picture and be a physician.

Ugh...speaking of borderlines and diagnosing. I have a male borderline on the unit now. Everyone (ok only 2 people) has diagnosed him with ASPD but he is plain borderline.

I wonder how often this misdiagnosis happens. I always hear that the antisocial is the "male borderline" but I have seen enough male borderlines next to male antisocials to know that its just not the case. Male borderlines are proof that satan is real and there is a hell.

 

[kugel]

Ugh...speaking of borderlines and diagnosing. I have a male borderline on the unit now. Everyone (ok only 2 people) has diagnosed him with ASPD but he is plain borderline.

I wonder how often this misdiagnosis happens. I always hear that the antisocial is the "male borderline" but I have seen enough male borderlines next to male antisocials to know that its just not the case. Male borderlines are proof that satan is real and there is a hell.

I do think they are separate entities, and I believe many male borderlines get dx'd with antisocial, and many female antisocials get dx'd with borderline. My explanation goes something like:
The antisocial will try to get what he wants by any means necessary; lying, seducing, cheating, begging, bullying, threatening, and will change tactics in a heartbeat once it's clear that the first method isn't working.
The male borderline can't seem to get anything he wants, because he says he wants one thing but his behavior all seems directed toward getting him something else entirely.