The most effective treatment for high-functioning BPD?

[ClinPsycMasters]

There is the good ol' CBT and of course, the much ballyhooed DBT. Some recent studies also support the effectiveness of the following: mentalization-based therapy, transference-focused psychotherapy, and schema-focused therapy. Some of these studies focus more on the more severe side of the illness, on suicide attempts/ideation and cutting. This may not apply to higher-functioning BPD patients, ones who have prominent narcissistic traits and function quite well in certain areas in their life.

If one were to spend a significant amount of time learning a new kind of therapy for BPD (specially higher-functioning ones), one that you have found to be effective-- based on research and clinical experience, which one would it be? I'd appreciate an informed opinion from a mental health professional who treats BPD patients, and has some familiarity with these other therapies as well as DBT.

Thanks.

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[Therapist4Chnge]

I seem to remember you mentioning you have people in your life with these challenges.....so I hope this isn't asking for how to deal with them, because that would be against SDN Policy.

 

[ClinPsycMasters]

I seem to remember you mentioning you have people in your life with these challenges.....so I hope this isn't asking for how to deal with them, because that would be against SDN Policy.

When did I mention that? 😕

p.s. I did receive an infraction, on June 15 2010, for making a post asking who has "excellent visuospatial memory" (similar to this thread here:http://forums.studentdoctor.net/showthread.php?t=736418) and how to improve mine, for which I was penalized since you perceived it to be of "cognitive rehabilitation" nature when in fact I was asking for ways to improve my memory not restore it.

 

[whopper]

What exactly do you mean by a high functioning bpd? That leaves a lot of room for interpretation.

 

[ClinPsycMasters]

What exactly do you mean by a high functioning bpd? That leaves a lot of room for interpretation.

That's a good question. Let me start by saying that I've had a couple of patients during last few months that really left an impression on me. I was doing cognitive assessment (and an extended interview to see if they'd be willing--and meet the criteria--to participate in research), and during this whole thing I grew more and more irritated. The whole time they were complaining, blaming the hospital, family members, doctors, etc. I was afraid of saying the wrong thing. I was feeling victimized by them, but also feeling very sorry for their troubles and wanting to come to their rescue and save them from the stupid impersonal and cold medical system. I did try to help them out and make their future visit much more comfortable but then unpredictably they'd start speaking down to me, in an almost abusive way, as if they felt offended by my concern.

I was discussing this with a psychiatrist, a researcher who was involved with the project and met with these patients too. He was quite desperate to have more participants and told me not to take their behavior personally. He told me that the patients most likely have BPD with narcissistic traits, and referred to them as "high-functioning BPD." He said it's much easier to help the typical BPD patients but these BPD patients won't even admit they have a problem.

So I have developed an interest in learning more about these sorts of BPD patients and proper treatment. I did read up on BPD but there is not much info on these other kinds of patients. It's a frightening combination of personality traits.

 

[whopper]

I may be wrong, but are these truly BPD?

I'm just making sure, and I believe you're a better mental health professional than my question implies.

I've noticed, among wealthier and type A people, their sense of entitlement is up. They, because they are demanding, may seem like borderline PD (because they're ticking us off), but in reality, they're just entitled.

I've had a few occasional very wealthy family members of patients expect me to do way more than I'm capable of..."Doctor, what's wrong with you? You can't cure my daughter of schizophrenia?" "Doctor, you can't discharge her to that group home! There's an ice cream store 3 blocks away. You and I know she'll eat ice cream like there's no tomorrow!"

I had a patient whose family was pushing this stuff on me. The patient was stable for discharge and wanted discharge. They threatened to sue me. I informed them that since she didn't want to be in the hospital, they could arrange for her to be there against her will if they got a guardian (no judge would allow that, she was able to take care of herself on her own), but here's the big zinger....

They'd also have to pay for her voluntary stay at the hospital. After they found that out, I could've discharged her to Afghanistan and they wouldn't have cared.

(there's actually much more to this story than that, including a case manager that was feeding them a lot of misinformation, but you get the point).

 

[ClinPsycMasters]

Thank Whopper. I guess it could be that they were just so very entitled. And I've met narcissistic people but they were really something else. They worked in a nail salon but came from an upper social class.

The narcissistic part was quite evident to me. At times they were the oblivious narcissist and at other times the hypervigilant one. The shift in identity was most interesting to me, plunging from an arrogant authoritarian position to depths of victimhood and back up again with no middle ground.

The research psychiatrist, who did not assess them for personality disorders but met with them briefly a couple of times, felt that there was an underlying BPD though did not deny the narcissism. This particular psychiatrist sees a lot of BPD patients but is always inundated with work and research, so I rarely get to speak to him or meet him in person. Heck, I went to a lecture of his and asked for a copy of his notes, which he promised to supply me with, but 20 emails (and six months later) and still nothing. I do work more often with another psychiatrist, a very kind and personable lady, but she sticks to her subject of expertise, dementia, and stays clear of discussions about personality disorders and so forth. But I digress.

Perhaps I should study Kernberg's concept of borderline personality organization-- as it does cover both pathological narcissism and BPD. Obviously the treatments I noted above are more specific to BPD not BP organization. When it comes to NPD, psychodynamic therapy is one therapy that I think might be able to make any lasting changes.

 

[Manicsleep]

I believe this was discussed on another thread but the diagnosis of 'disorder' is too often placed on those who simply have traits.

The entitled people spoken of earlier may have strong cluster B traits but are high functioning so they don't actually have any disorder.

 

[OldPsychDoc]

That's a good question. Let me start by saying that I've had a couple of patients during last few months that really left an impression on me. I was doing cognitive assessment (and an extended interview to see if they'd be willing--and meet the criteria--to participate in research), and during this whole thing I grew more and more irritated. The whole time they were complaining, blaming the hospital, family members, doctors, etc. I was afraid of saying the wrong thing. I was feeling victimized by them, but also feeling very sorry for their troubles and wanting to come to their rescue and save them from the stupid impersonal and cold medical system. I did try to help them out and make their future visit much more comfortable but then unpredictably they'd start speaking down to me, in an almost abusive way, as if they felt offended by my concern.
...

I find this a good time to take more of a Motivational Interviewing perspective--"What is it that you want for an outcome here? How can you get there? Is there something you might be doing right now that is blocking the progress?" Be empathetic, but support self-efficacy...

 

[whopper]

I went to a private school where a lot of the people there were spoiled brats.

IMHO several of them had some borderline traits, and had some of the elements of that disorder. It was a product of having rich parents who spent hardly any time with their children, and then dumped them in a private school for most of the year. Some of these children were then shipped off to private summer schools or camps for the summer. I knew a few that only saw their parents about 3 weeks out of the entire year.

Several of these people ended up having cluster B traits, but they did not have enough criteria for borderline PD. They had a healthy amount of narcicism, and many could not continue the family status because they didn't have the mental discipline to continue to run the family fortune. Others, well they inherited mommy and daddy's business, but the business was to the degree where it was now idiot-proof. E.g. one guy I knew, his dad owned a private college. He took it over. All he had to do was sit in meeting and nod his head. He didn't know WTF he was doing other than earning a few million a year.

Others I've seen who are successful are so because they are hard working, and they want quick results. They are sometimes inpatient.

All in all, working with people in a high SES can present with different but even more frustrating challenges than those in a low SES.

One of the patient's I had who came from a wealthy family, the mother was homemaker and spent every free moment researching the disorder. She had a feeling that if she spent enough time, she could cure her son. She tried to have me do a number of ridiculous things such as entertain the notion that his schizophrenia was caused by a caffiene allergy. (He drank about 3 cokes a day, no signs or allergy whatsoever). Every single quack idea she got from the internet, she tried to have me investigate it, wanting me to spend about 10 hrs a week on each of these quack theories.

As much as I sympathised with her situation (hey, if my kid had a bad case of Clozaril-resistant schizophrenia, I'd probably be as bad), the case was ticking the heck out of me.

but are high functioning so they don't actually have any disorder.

They may indeed have the disorder, or enough to meet a personality DO NOS dx. Many wealthy people I've known have dysfunctional family structures. There's a mix of narcissism, entitlement, borderline PD among other issues.

But since they are wealthy, they can get away with it. They can afford to maintain their dysfunction. Can't get the kids to clean up their rooms? The maid will do it. Can't discipline the children? Send them off to private school. Problem with the wife? Get a mistress. In some of these cases--they'll get a boutique doctor to prescribe them Xanax.

They certainly IMHO would meet enough to be diagnosed, but since they don't have to see a mental health professional anyways, their money buffering them from needing or wanting extra help, they don't get a diagnosis.

 

[rpkall]

There's a type of therapy called dynamic deconstructive psychotherapy (DDP) which has some elements of mentalization based therapy and psychodynamic therapy (importance of attention to transference and the therapist-patient relationship as an instrument of recovery itself) that seems to work well with BPD patients and has some common sense parameters and treatment guidelines that make it more "manualized" and researchable than some others. You could google that either in the literature or on Google as I believe there is some good free material on one of the psychiatry program websites where it is studied most. 😉

 

[ClinPsycMasters]

I find this a good time to take more of a Motivational Interviewing perspective--"What is it that you want for an outcome here? How can you get there? Is there something you might be doing right now that is blocking the progress?" Be empathetic, but support self-efficacy...

excellent advice!

 

[ClinPsycMasters]

One of the patient's I had who came from a wealthy family, the mother was homemaker and spent every free moment researching the disorder. She had a feeling that if she spent enough time, she could cure her son. She tried to have me do a number of ridiculous things such as entertain the notion that his schizophrenia was caused by a caffiene allergy. (He drank about 3 cokes a day, no signs or allergy whatsoever). Every single quack idea she got from the internet, she tried to have me investigate it, wanting me to spend about 10 hrs a week on each of these quack theories.

As much as I sympathised with her situation (hey, if my kid had a bad case of Clozaril-resistant schizophrenia, I'd probably be as bad), the case was ticking the heck out of me.

Whopper, were you finally able to concoct a drug cocktail that could help the kid?

Many wealthy people I've known have dysfunctional family structures. There's a mix of narcissism, entitlement, borderline PD among other issues.

But since they are wealthy, they can get away with it. They can afford to maintain their dysfunction. Can't get the kids to clean up their rooms? The maid will do it. Can't discipline the children? Send them off to private school. Problem with the wife? Get a mistress. In some of these cases--they'll get a boutique doctor to prescribe them Xanax.

They certainly IMHO would meet enough to be diagnosed, but since they don't have to see a mental health professional anyways, their money buffering them from needing or wanting extra help, they don't get a diagnosis.

Excellent! Your explanation describes the particular family I mentioned earlier very well. They did seem to have borderline and narcissistic traits but what astonished me the most was how much these older ladies had been buffered from the harsh realities of the world, by their wealth, social class, and their particular family culture and dynamics.

If I may digress a bit, I do think that environmental factors (sociocultural and historical forces, economics, politics) can encourage narcissism and/or black and white thinking. Of course narcissism is not always a sign of having lived a privileged life. Sometimes it's about living your whole life in the paranoid-schizoid position (Klein), focusing on survival and nothing more. So I see narcissism both in some of the wealthiest and some of the poorest patients.

Though there may be a genetic component to ethnic differences, cultural factors seem to explain so much. In a series of studies, Twenge and colleagues have taken note of increasing levels of narcissism in college students over the years. They've also shown that Blacks--later generations in particular--are the most narcissistic and Asians (and Middle Easterners) are the least. They explain their findings by referring to cultural factors and in particular, individualism: "The United States is generally considered to be one the most individualistic nations while countries within Asia and the Middle East are relatively low in individualism." (1)

Returning to the topic, I do at times come across Chinese patients who have lived here for decades, yet do not speak a single word of English, whatsoever. In Vancouver, where I work, there is a large Chinese population. Hence, if a particular Chinese person is able to have all his needs met through contact with other people of the same culture, he does not have to adapt to the reality of the external world at all. To go a step further, a whole population and a whole country, would not have to adapt to the larger reality at the international level, if it is able to remain completely autonomous.

These examples are not provided as criticism but more as a way to build on what Whopper said about families that "can afford to maintain their dysfunction." What I'm saying is that what may be perfectly functional in one setting, can by very dysfunctional in another. It is only through contact with those who do not share their reality that people are pulled out of their subjective world for a brief period of time. Sitting there, with those two ladies, it was hard to imagine that their behavior must have been functional enough at home/work, yet they had never seen a therapist nor had been forced/encouraged to change their behavior to adapt to my version of the real world. I do have my own set of dysfunctional behaviors (unique to certain conflictual relationships) but to act like that in every situation, and not adapting even slightly to the situation at all, would cause enough problems for me that I would adapt soon enough. Then again, if I were that wealthy....

(1) Foster JD, Campbell W, Twenge JM. 2003. Individual differences in narcissism: inflated self-views across the lifespan and around the
world. J. Res. Personal. 37:469–86.

 

[whopper]

Whopper, were you finally able to concoct a drug cocktail that could help the kid?

Yes, but not well.

He was tried on over 6 antipsychotics at the maximum dosages. He was finally put on Clozaril, and that was the only medication that made a difference. Despite being on a very high dose of Clozaril, and Depakote, and Lithium, he still had psychotic sx that IMHO would continue to signifcantly affect his quality of life.

He was, however, improved to the point where I could discharge him to a group home....

Which his mother did not like because there was an ice cream store nearby.....

 

[Manicsleep]

But since they are wealthy, they can get away with it. They can afford to maintain their dysfunction. Can't get the kids to clean up their rooms? The maid will do it. Can't discipline the children? Send them off to private school. Problem with the wife? Get a mistress. In some of these cases--they'll get a boutique doctor to prescribe them Xanax.

Maintaining a dysfunction with a variety of coping mechanisms and being high functioning are 2 very different things. An untreated personality disorder should not be called high functioning.