Why are patients with BPD so difficult to treat.

[softballtennis]

I would think because most people with BPD are very clingy to clinicians, constantly suicidal and have horrible impulse control and participate in self destructive behavior .

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[erg923]

Are you asking or telling?

 

[softballtennis]

Are you asking or telling?

Asking

 

[erg923]

I think they may be hard to treat if you think one "treats" personality traits, yes...

 

[xlithiumx]

I think they may be hard to treat if you think one "treats" personality traits, yes...

For whatever it's worth, BPD is a treatable condition which has both heritable and acquired etiology and does not simply equate to "personality traits." That type of thinking is pretty backward, particularly for a psychologist.

 

[erg923]

For whatever it's worth, BPD is a treatable condition which has both heritable and acquired etiology and does not simply equate to "personality traits." That type of thinking is pretty backward, particularly for a psychologist.

Yes, I am well aware. Thus, if one conceptualizes the disorder as personality traits, then it would be frustrating, no?

If see it for what it is, then it should be no more frustrating than problematic symptom of any other disorder, right? It the very fact that its viewed as personality disorder that the problem.

 

[xlithiumx]

Yes, I am well aware. Thus, if one conceptualizes the disorder as personality traits, then it would be frustrating, no?

If see it for what it is, then it should be no more frustrating than problematic symptom of any other disorder, right? It the very fact that its viewed as personality disorder that the problem.

Ahh. Read you totally wrong. We're on the same page. I get kinda militant about BPD because so many patients are treated so poorly.

 

[birchswing]

I'm in the middle of reading the Buddha and the Borderline right now, as a relative of mine has BPD. Her situation mirrors that of the woman in the book, in that both never received the diagnosis of BPD (even though in each case a psychiatrist had made that determination). My relative has done really well since finding out her diagnosis and getting actual treatment. I made a post about this before asking why psychiatrists seemingly don't tell BPD patients their diagnosis. It seems to be common.

 

[st2205]

Imagine you're a borderline. Now imagine the types of things that bring you relief and imagine the types of coping skills (or lack thereof) you employ. Now try to imagine why you'd want to be motivated to, as you'd view it, have that taken away? What's the incentive?

 

[shan564]

It's difficult to treat because we haven't discovered an easy treatment.

 

[birchswing]

It's difficult to treat because we haven't discovered an easy treatment.

Given what I've read about it, that seems true. But the people I've known and whom I've read about going through DBT start it once they finally get a diagnosis, which is usually decades after the symptoms started and they've already tried many prescription meds (including addictive ones) or gone through 12 step programs for recreational drugs.

So my question is: how much more effective would DBT be if people were diagnosed with BPD at, say, age 14-15? It seems the reason no one would do that is largely because the illness has such a stigma. But it having a stigma seems to lead to people not being treated ever, or if they are, decades after they started having it.

EDIT: Personally, as someone with an anxiety disorder, DBT sounds really cool (from what I've read about it so far in a book I'm reading).

 

[notdeadyet]

So my question is: how much more effective would DBT be if people were diagnosed with BPD at, say, age 14-15? It seems the reason no one would do that is largely because the illness has such a stigma.

You can't diagnose it at that age because adolescents are still developing and many teenagers have BPD traits (or would qualify for the diagnosis, were they adults) but will outgrow it.

 

[OldPsychDoc]

You can't diagnose it at that age because adolescents are still developing and many teenagers have BPD traits (or would qualify for the diagnosis, were they adults) but will outgrow it.

Can't diagnose it perhaps, but inasmuch as the traits of our adolescent "protoborderlines" begin to cause them behavioral problems, you can certainly start using DBT methods to help them manage themselves (and hopefully grow into better adjusted adults that actually might not meet the criteria in their 20s!)

 

[notdeadyet]

Can't diagnose it perhaps, but inasmuch as the traits of our adolescent "protoborderlines" begin to cause them behavioral problems, you can certainly start using DBT methods to help them manage themselves (and hopefully grow into better adjusted adults that actually might not meet the criteria in their 20s!)

Absolutely. And the recognition that many-to-most border lines are made and not born: family therapy can be key.

 

[whopper]

• The behaviors these people elicit are usually frustrating for most people.
• Most of us psychiatrists aren't trained to treat it despite what we think.
• The signs and symptoms don't get better quickly.
• For some borderlines, they are in the area that just makes us fear getting sued. They often-times threaten suicide or something else dangerous, and hospitalization usually accomplishes nothing positive and generates a large bill that the patient will have difficulties paying. Yet if we don't admit them and they hurt themselves, this could be the springboard for a malpractice lawsuit. It's the ultimate no-win situation for us.

The only times I've seen hospitalization work for borderlines are the ones that go into a hospital for a few years because in that environment they can get consistent DBT for an extended duration and will likely attend their therapy sessions because they have nowhere else to go.

The problem there is this is not appropriate for most situations because the patient can't pay for it and even if they were to volunteer for such treatment, they'd want out of the hospital or not be appropriate to stay in there for more than a few days at most. This type of situation only exists, from what I've seen, when a patient is in there for forensic reasons, hence the state pays for it, and they can't get out until a judge lets them. Judges usually take their time on these things because the last thing they want is to let a person go and then that same person end up being on the news a few days later doing something else destructive.

 

[MacDonaldTriad]

I once attended a lecture on the pharmacologic treatment of borderline PD. Seductive topic so well attended, but I haven’t seen a room so full of disappointment since the premier of Star Trek V: The Final Frontier. Here is a quick summary:

If labile, mood stabilizers
If anxious, anxiolytics
If depressed, antidepressants
If not labile, but impulsive, mood stabilizers
Oh, and don’t forget, probably they should be on an antipsychotic as “ego glue” just so we can cover every category of psychotropic.

The truth is that patients with borderline PD have behaviors that are maladaptive, but adaptive enough to serve their needs. The chief complaints are often coming from their support systems. We can teach them skills that can help replace the maladaptive patterns with more healthy and less destructive defense mechanisms, but the desperation that drives this engine is still close to the surface. If you are cursed with an ugly shade of carrot red hair, you can dye it, but you still have the makeup of someone with ugly carrot red hair. Optimists believe that borderline PD is learned, and can be unlearned; pessimists are supported by a high frequency of treatment failures. It is just plain tough.

 

[smalltownpsych]

One reason that BPD is so difficult to treat is that it has interpersonal instability as the key diagnostic feature. This leads to a lot of counter-transference and frustration. Also, medications become part of that transference/counter-transference. In other words, the patient idealizes the new med for a couple of weeks and it is the solution, then it suddenly stops working and the doctor who prescribes it is devalued. Pretty frustrating to work with. I have a modicum of success with BPD because I am good at not going for the ride as I like to call transference/counter-transference enactments. It is essential to stay grounded in a solid theory of treatment and maintain the therapeutic frame. Easier said than done.

 

[whopper]

The truth is that patients with borderline PD have behaviors that are maladaptive, but adaptive enough to serve their needs.

A reason why most of them won't follow up with DBT therapy on their own.

but I haven’t seen a room so full of disappointment since the premier of Star Trek V: The Final Frontier. Here is a quick summary:

I'm wondering what the presenter thought. There isn't good data strongly supporting use of psychotropics for borderline PD. The APA did print guidelines on psychotropic treatment of borderline PD but it's way way out of date and even by their own admission it's too old to be considered. I read them, I don't agree with them. It's along the lines of what the presenter gave.

There's a facility near me doing Ketamine research for someone suicidal and this happens with a lot of borderlines. From what I'm hearing, and I haven't read the data, the problem they're having is it works great--for a few hours to maybe days. Then the borderlines come back thinking that this should be ongoing treatment because it made them feel better.

This is exactly what I was fearing with the use of Ketamine. An unethical doctor could give it out, not give out the right treatment, and then have someone who is forced to go back and back and back, pay a large fee, when it really isn't getting them better in the long-run and because they don't know their options, they think this is the only thing that will get them better.

I'm not saying Ketamine should be dropped as a treatment approach. More research needs to be done but so far I'm not impressed.

 

[st2205]

What are everyone's thoughts on fish oil? Seems like it may have some marginal benefit, just like pretty much everything else. Personally, I think it's BS, but for the sake of "doing something," I'm thinking I may want to favor this method rather than something much more pricy and just as ineffective.

 

[MacDonaldTriad]

The APA did print guidelines on psychotropic treatment of borderline PD but it's way way out of date and even by their own admission it's too old to be considered.

This was in 1989 now that I think about it. Now that it is 25 years later, drugs still don't work on this.

 

[MacDonaldTriad]

What are everyone's thoughts on fish oil? Seems like it may have some marginal benefit, just like pretty much everything else. Personally, I think it's BS, but for the sake of "doing something," I'm thinking I may want to favor this method rather than something much more pricy and just as ineffective.

I think fish oil isn’t snake oil. It is one of the few things at GNC that has some evidence of being helpful. At least it probably does no harm while it may help prevent cardiovascular disease even if its mood stabilizing effects are just so so.

 

[whopper]

The data I've seen with fish oil shows it can work, but don't expect it to do much. It may also be more beneficial in preventing illness than getting rid of it once it's there. There was some significant data showing that if one is at high risk for schizophrenia, it could reduce the odds of getting it.


Aw nuts, the guy who's considered the authority on fish oil and mental illness gave a lecture at my department several weeks ago and I forgot his name. He recommended about 2 g a day, not of the fish oil but the omega 3s in it (the EPA and DHA) that comprise about 300 mg per 1000 mg fish oil gel capsule. To achieve that we're talking 6-7 g of fish oil a day.

I myself took about 1 g of fish oil a day but ramped it up 6g because my triglycerides are through the roof and I needed to take fenofibrate. (Why the heck this is, I don't know. I work out including doing cardio 3x a week, lift weights, and I don't eat bad). It could purely be placebo but since I bumped it up, I feel more focused, more at calm, and as if I'm on some type of beneficial psychotropic.

Also bear in mind there's recent data showing it could increase the risk of prostate cancer.
http://www.nlm.nih.gov/medlineplus/podcast/transcript090313.html

 

[Ceke2002]

The truth is that patients with borderline PD have behaviors that are maladaptive, but adaptive enough to serve their needs. The chief complaints are often coming from their support systems. We can teach them skills that can help replace the maladaptive patterns with more healthy and less destructive defense mechanisms, but the desperation that drives this engine is still close to the surface. If you are cursed with an ugly shade of carrot red hair, you can dye it, but you still have the makeup of someone with ugly carrot red hair. Optimists believe that borderline PD is learned, and can be unlearned; pessimists are supported by a high frequency of treatment failures. It is just plain tough.

I'm afraid I have to agree with this. I suppose on the optimistic side you could say that a combination of treatment, along with years of my own 'self' work now means I no longer meet diagnostic criteria for BPD. But does that mean I'm miraculously cured with absolutely no residual issues at all? No, it doesn't. I might not fit neatly into one diagnostic category anymore, but I still have Axis II traits, and I'm still in treatment working on what I suppose might be considered a sort of generalised personality disorder (among other things). Of course if you're grading on some sort of curve and looking at my progress in terms of where I've come from (basically being a walking billboard for Borderline Personality Disorder) to where I am now, then yeah I've done pretty damn well, but 'pretty damn well' doesn't equate to 'hallelujah I'm cured!'. I think that's where some of the frustration comes from, both from those trying to treat BPD, and those who are on the diagnostic end of that treatment - there are excellent treatments out there that do work to reduce symptoms, they may even work well enough to reduce symptoms to the point that the diagnosis can now be take off the table, but it then becomes more a matter of long term management because 'no longer fits diagnostic criteria' doesn't mean the patient will never be faced with the prospect of dealing with residual symptoms and issues that are bound to re-emerge from time to time. There is no magic pill, and no amount of magic words that can eradicate the maladaptive emotions, in particular, of a personality disorder completely and that can be hugely frustrating for everyone involved.

 

[MacDonaldTriad]

I'm afraid I have to agree with this. I suppose on the optimistic side you could say that a combination of treatment, along with years of my own 'self' work now means I no longer meet diagnostic criteria for BPD. But does that mean I'm miraculously cured with absolutely no residual issues at all? No, it doesn't. I might not fit neatly into one diagnostic category anymore, but I still have Axis II traits, and I'm still in treatment working on what I suppose might be considered a sort of generalised personality disorder (among other things). Of course if you're grading on some sort of curve and looking at my progress in terms of where I've come from (basically being a walking billboard for Borderline Personality Disorder) to where I am now, then yeah I've done pretty damn well, but 'pretty damn well' doesn't equate to 'hallelujah I'm cured!'. I think that's where some of the frustration comes from, both from those trying to treat BPD, and those who are on the diagnostic end of that treatment - there are excellent treatments out there that do work to reduce symptoms, they may even work well enough to reduce symptoms to the point that the diagnosis can now be take off the table, but it then becomes more a matter of long term management because 'no longer fits diagnostic criteria' doesn't mean the patient will never be faced with the prospect of dealing with residual symptoms and issues that are bound to re-emerge from time to time. There is no magic pill, and no amount of magic words that can eradicate the maladaptive emotions, in particular, of a personality disorder completely and that can be hugely frustrating for everyone involved.

As always Ceke, you said this much better than I did.

 

[Ceke2002]

As always Ceke, you said this much better than I did.

*blushes* Thank you

 

[smalltownpsych]

I'm afraid I have to agree with this. I suppose on the optimistic side you could say that a combination of treatment, along with years of my own 'self' work now means I no longer meet diagnostic criteria for BPD. But does that mean I'm miraculously cured with absolutely no residual issues at all? No, it doesn't. I might not fit neatly into one diagnostic category anymore, but I still have Axis II traits, and I'm still in treatment working on what I suppose might be considered a sort of generalised personality disorder (among other things). Of course if you're grading on some sort of curve and looking at my progress in terms of where I've come from (basically being a walking billboard for Borderline Personality Disorder) to where I am now, then yeah I've done pretty damn well, but 'pretty damn well' doesn't equate to 'hallelujah I'm cured!'. I think that's where some of the frustration comes from, both from those trying to treat BPD, and those who are on the diagnostic end of that treatment - there are excellent treatments out there that do work to reduce symptoms, they may even work well enough to reduce symptoms to the point that the diagnosis can now be take off the table, but it then becomes more a matter of long term management because 'no longer fits diagnostic criteria' doesn't mean the patient will never be faced with the prospect of dealing with residual symptoms and issues that are bound to re-emerge from time to time. There is no magic pill, and no amount of magic words that can eradicate the maladaptive emotions, in particular, of a personality disorder completely and that can be hugely frustrating for everyone involved.

Great post and I think it points out a major problem with our diagnostic symptom based on symptom clusters. I "cure" patients with BPD all the time if you go by meeting diagnostic criteria as the standard for having the diagnosis. In short, once we get past the NSSI and SI, which is usually fairly early in treatment for many of my patients who meet the criteria, then two out of nine diagnostic criteria are no longer met and that in of itself is usually enough. I continue treatment far beyond that point because that is usually when the real work begins.

A big part of that treatment being forming new relationship patterns. These patterns of relating are learned in early childhood and take a lifetime of work changing. In my opinion, interpersonal relationships is where we all can benefit from improvement and the diagnosis of BPD tends to be reserved for the more extreme examples of interpersonal difficulty. Also, if you look at some of the work of Daniel Stern or Allan Schore about the self-regulating other, it really helps to clarify the how and why on a neurobiological level that disruptions in relationships in early childhood lead to problems with emotional regulation in adulthood.

This area is a passion of mine and we have a long way to go, but when I started grad school most clinicans believed that patients with BPD could not be really be helped and that has changed with the introduction of DBT and improved understanding of this particular model of maladptive interpersonal and emotional functioning.

 

[Ceke2002]

Great post and I think it points out a major problem with our diagnostic symptom based on symptom clusters. I "cure" patients with BPD all the time if you go by meeting diagnostic criteria as the standard for having the diagnosis. In short, once we get past the NSSI and SI, which is usually fairly early in treatment for many of my patients who meet the criteria, then two out of nine diagnostic criteria are no longer met and that in of itself is usually enough. I continue treatment far beyond that point because that is usually when the real work begins.

A big part of that treatment being forming new relationship patterns. These patterns of relating are learned in early childhood and take a lifetime of work changing. In my opinion, interpersonal relationships is where we all can benefit from improvement and the diagnosis of BPD tends to be reserved for the more extreme examples of interpersonal difficulty. Also, if you look at some of the work of Daniel Stern or Allan Schore about the self-regulating other, it really helps to clarify the how and why on a neurobiological level that disruptions in relationships in early childhood lead to problems with emotional regulation in adulthood.

This area is a passion of mine and we have a long way to go, but when I started grad school most clinicans believed that patients with BPD could not be really be helped and that has changed with the introduction of DBT and improved understanding of this particular model of maladptive interpersonal and emotional functioning.

I haven't read any Daniel Stern or Allan Schore's work, but my Psychiatrist is no doubt familiar with them (I'd be surprised if he wasn't, personality disorders and their treatment is one of his top levels of interest and specialty). I agree that beyond the basic 'get the patient no longer qualifying for a diagnosis' format of treatment, a lot of the real work does begin beyond that. When I did still tick all, well nearly all, the diagnostic boxes treatment, at times, did feel a little 'paint by numbers' - reduce symptom XYZ by doing ABC, repeat ABC as needed to continue reduction of XYZ - the work I'm currently doing with my Psychiatrist feels like it's going a lot deeper than that, beyond just symptoms and qualifiers and down to the nitty gritty of really beginning to understand the developmental core and how it continues to effect me even to this day.

 

[MacDonaldTriad]

So what you are saying is that beyond DBT, there may be a role for more insight oriented analytic work? Such Heresy! It is old school, I like it.

 

[vistaril]

I can offer what I've seen work with many patients in my community: There are a couple veteran psychologists specifically trained to work with dbt patients in private practice. The primary care physicians who interact with these obvious borderlines, instead of referring them to a psychiatrist to be thrown into the usual treatments(polypharm med mgt appts and a nonspecialized therapist within the practice who is likely only sorta skilled in supptve therapy alone), they just bypass psychiatry and get in straight with these psychologists. That way the patients avoid cycling through a neverending string of antipsychotics and mood stabilizers and actually get a little bit better.....

sure, it's more work for a family medicine physician or internist or obgyn to arrange for this than just send in a referral to the local outpt psych group, but it's better care I believe.

of course, the downside is that many patients can't afford it. medicare won't pay their rates, but medicare will pay for med mgt appts and Abilify.

 

[Ceke2002]

So what you are saying is that beyond DBT, there may be a role for more insight oriented analytic work? Such Heresy! It is old school, I like it.

One of the many reasons why I happen to think my Psychiatrist is pretty darn awesome. 😀

 

[smalltownpsych]

So what you are saying is that beyond DBT, there may be a role for more insight oriented analytic work? Such Heresy! It is old school, I like it.

Going old school! Love it. I use some of the DBT stuff, which works, to reduce the symptoms, then I start using Kernberg and Kohut to really get down to business.