Misconceptions hinder good psychiatric management of BPD

Nov. 11, 2016

Borderline personality disorder (BPD) is a severe psychiatric illness affecting 2 to 3 percent of the population. It is marked by pervasive instability in interpersonal relationships, moods, behavior and self-image, and although it commonly co-occurs with major depressive disorder, it is often more subjectively severe, with distinct symptoms and treatment responses.

Dialectical-behavioral therapy, developed in the late 1980s as a therapy for patients who are chronically suicidal, is the most widely practiced of the empirically validated treatments for BPD, and in multiple controlled trials, it proved superior to treatment as usual for BPD across most domains. But a pivotal study, published in The American Journal of Psychiatry in 2009, found that general psychiatric management — a combination of psychodynamically informed therapy and symptom-targeted medication management — was as effective at reducing suicidal and self-injurious episodes and other BPD symptoms as dialectical-behavioral therapy was.

Brian A. Palmer, M.D., M.P.H., a psychiatrist specializing in borderline personality disorder and psychiatric education at Mayo Clinic's campus in Rochester, Minnesota, says general psychiatric management, when delivered by psychiatrists experienced in BPD using specific techniques and approaches, can provide care on a par with more-expensive and intensive dialectical-behavioral therapy. "The reality is that good treatment can and usually does result in significant improvement in patients with this misunderstood disorder, whereas poor treatment is unhelpful and can make patients worse," he explains.

Dr. Palmer, who trains psychiatrists in the general psychiatric management of BPD based on the pioneering work of John G. Gunderson, M.D., describes three common mistakes clinicians make: treatment of mood symptoms only, lack of treatment goals, and failure to anticipate and understand BPD challenges.

Treatment of mood symptoms only

"At its core, BPD is an interpersonal disorder," he says. "A common mistake is focusing on the mood symptoms without appreciating the interpersonal context in which they occur. Depression is unlikely to improve until BPD improves, and BPD is the single largest cause of persistent depression." Dr. Palmer and co-author Kei Yoshimatsu described the unique features and clinical trajectory of BPD depression in an article published in Harvard Review of Psychiatry in 2014.

Lack of treatment goals

Good psychiatric management teaches that continued therapy is contingent on progress during treatment. But Dr. Palmer says the dictate is often ignored because clinicians fear it will trigger the fear of abandonment common in patients with BPD. "Anchoring the treatment in goals outside the therapeutic relationship helps guard against complicity with the patient's avoidance of work or school and helps ensure that treatment is accountable for progress," he explains.

Another obstacle is the common misperception that patients with BPD rarely get better — often driven by a sampling error in residency training, where patients who have not yet improved may be seen frequently in the emergency department or inpatient unit. But Dr. Palmer notes that long-term outcome studies have shown the vast majority of patients with BPD achieve remission. About 10 percent remit within six months, 25 percent within a year, 45 percent within two years and close to 80 percent by 10 years, even without extended or stable treatment. "Change is an expected and natural course of treatment, and patients are expected to be active within treatment in controlling their lives," Dr. Palmer says.

Failure to anticipate and understand BPD challenges

Another misperception is that the recurrent risk of suicide burdens clinicians with excessive responsibility and ongoing litigation risks. Although BPD is characterized by recurrent suicidal gestures or threats and self-mutilating behavior, Dr. Palmer points out that successful litigation is rare and usually seen in poorly conducted treatments, including those with boundary crossing. "Successful clinicians anticipate and manage BPD symptoms effectively," he says. "Case management, including a focus on functional involvement, solving real-life problems, and the appropriate level of care and support, particularly during transitions, may be the most important aspect of treatment. The second most important aspect is therapy that helps patients make narrative sense of their inner experience — moving from 'I feel like cutting,' to 'I feel alone and afraid; I see a pattern and here's what I can do.' That is a well-managed case."

Dr. Palmer is also involved in orienting inpatient care to effectively address BPD and teaching other specialists, including internists, gastroenterologists, neurologists and pediatricians, effective principles for managing patients with BPD.

For more information

McMain SF, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. The American Journal of Psychiatry. 2009;166:1365.

Yoshimatsu K, et al. Depression in patients with borderline personality disorder. Harvard Review of Psychiatry. 2014;22:266.