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Mayo School of Continuous Professional Development
Psychiatry Clinical Reviews Borderline Personality Disorder
Brian A. Palmer, MD, MPH October 6-8, 2016
Intercontinental Chicago Magnificent Mile Chicago, IL
©2016 MFMER | 3540366-2
Disclosure
Relevant Financial Relationships
Harvard Medical School – Online CME course - royalties Mayo Clinic Board Review Texts – royalties
Off-Label/Investigational Uses
There are no FDA approved medications for BPD, and we will review brief evidence for medication options.
©2016 MFMER | 3540366-3
Learning Objectives
• Differentiate BPD from mood disorders based on clinical context, course and outcome, and symptoms
• Articulate principles of treatment, including case management
©2016 MFMER | 3540366-4
Personality Disorders
• Cluster A
• Paranoid, schizoid, schizotypal
• Cluster B
• Antisocial, borderline, histrionic, narcissistic
• Cluster C
• Avoidant, dependent, obsessive-compulsive
©2016 MFMER | 3540366-5
BPD Criteria • Interpersonal Hypersensitivity
• Abandonment fears
• Unstable relationships (ideal/devalued)
• Emptiness
• Affective/Emotion Dysregulation
• Affective instability (no elations)
• Inappropriate, intense anger
• Behavioral Dyscontrol
• Recurrent suicidality, threats, self-harm
• Impulsivity (sex, driving, bingeing)
• Disturbed Self
• Unstable/distorted self-image
• Depersonalization / paranoid ideation under stress
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Connected idealizing, dependent,
rejection-sensitive
Threatened devaluing, self-injurious
angry, anxious,
help-seeking
Alone dissociated, paranoid
impulsive, help-rejecting
Desperate
suicidal, anhedonic
BPD’s Interpersonal Coherence
Interpersonal Stress
Support by the other Withdrawal by the other
Holding (hospital, jail,
rescuer)
Gunderson 2014
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Basic Epidemiology
• Prevalence
• Roughly ~20% of clinical samples
• 1.2 - 5.9% of the community samples
• Gender
• Approximately ~75% female in clinical samples
• More equal M:F ratio in community samples
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Heritabilty / Familiality
• Across two twin studies, one family study
• 55% heritabilty for BPD
• Single latent factor accounts for the co-occurrence of interpersonal, emotional, behavioral and cognitive components
Gunderson, Arch Gen Psychiatry, 2011; Kendler, Acta Psychiatr Scand, 2011; Distel, Biological Psychiatry,2009
©2016 MFMER | 3540366-9
You’re seeing a depressed patient with BPD. How to prioritize?
1. BPD should not be diagnosed during a depressive episode.
2. Depression tends to stay “treatment resistant” until BPD improves.
3. Treating depression to remission should precede BPD treatment.
4. The depression in BPD is most commonly bipolar depression.
BPD should
not b
e d...
Depre
ssion te
nds to s
t..
Treatin
g depre
ssion t.
..
The dep
ressio
n in B
P...
0% 0%0%0%
©2016 MFMER | 3540366-10
Make the Diagnosis
• 40% of patients who do have BPD and do not have
bipolar disorder have previously been inaccurately
diagnosed with bipolar disorder
• Comorbid depression does not impact the accuracy of
BPD assessments
Zi
Zimmerman, J Clin Psychiatry, 2010
Morey, Am J Psychiatry, 2010
©2016 MFMER | 3540366-11
Bipolar Diagnosis Issues
• The diagnoses can co-occur – and do!
• CLPS (196 BPD patients)
• 20% with BP (12% BPI, 8% BPII)
• 8% new BP in 2y (4% BP1, 4% BPII)
• MSAD (290 BPD patients)
• 10% baseline BPII
• 6% new BP in 6y (1% BPI, 5% BPII)
Zanarini, Am J Psychiatry, 1998
Zanarini, Am J Psychiatry, 2004; Gunderson, Am J Psychiatry, 2006
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MDQ and MSI BPD screen of 172 pts with BP, BPD, or Both
Dec sleep,
Inc Energy, Activity, Speech
Confident, Hyper
?Unreal
Moodiness, Arguments, Distractibility, Spending
Self Harm, Anger Problems, Mistrustful in
Relationships
?Irritability
BP BPD ?
©2016 MFMER | 3540366-13
Differentiating BPD/Bipolar
Think interpersonally for BPD
• Abandonment intolerance and self-injury in reaction to
interpersonal context.
Think syndromally for BP
• Period of sleep-deprived energy enhancement with increased
goal directed activity
©2016 MFMER | 3540366-14
What to tell a patient about long-term outcomes?
1. The vast majority (>80%) of BPD patients remit, and relapse is rare
2. BPD remission typically includes work and a stable partnership
3. Few (<30%) BPD patients remit, but relapse is rare when they do
4. Sense of self improves before self-injury
1 2 3 4
0% 0%0%0%
©2016 MFMER | 3540366-15
BPD’s Longitudinal Course
Num
ber
of C
rite
ria
(CLP
S)*
10
8
6
4
2
0 2 4 6 8 10
100% 80% 60% 40% 20%
%
Rem
itte
d
(MS
AD
)**
Years of follow-up
6.7
3.8 2.8
34.5
49.4
68.6 80.4 81.7
*From the Collaborative Longitudinal Study of Pers Disorders (i.e., Gunderson, Archives 2011)
**From the McLean Study of Adult Development (i.e., Zanarini, Am J Psych, 2003)
4.2
2.3 1.9 1.7
©2016 MFMER | 3540366-16
Outcomes
• After 10 years one third had full-time work.
• BPD has a markedly negative effect on MDD (“treatment resistance”) until BPD remits, but MDD has only modest effects on BPD’s course.
• BPD is most common reason for persistence of depression.
Gunderson Arch Gen Psychiatry 2011; Yoshimatsu and Palmer, Harvard Rev Psychiatry
2014; Skodol Am J Psychiatry 2011
©2016 MFMER | 3540366-17
Clinically
• Patients improve, problems persist (work matters)
• Impulsive symptoms decline more rapidly than affective symptoms
• 20% overlap with bipolar. No impact of bipolar on BPD course,
modest impact of BPD on bipolar course.
• Think interpersonally for BPD diagnosis and treatment.
©2016 MFMER | 3540366-18
Empirically Validated Treatments • Dialectical Behavioral Therapy (DBT)
• Linehan et al., 1993, 2006
• Mentalization Based Treatment (MBT)
• Bateman & Fonagy, 1999, 2001, 2003, 2008
• Schema Focused Therapy (SFT)
• Giesen-Bloo et al., 2006
• Transference Focused Psychotherapy (TFP)
• Clarkin et al., 2007; Levy et al., 2006
• Systems Training for Emotional Predictability & Prob. Solving (STEPPS)
• Blum et al., 2008
• General Psychiatric Management (GPM)
• McMain et al., 2009 (after Gunderson & Links)
©2016 MFMER | 3540366-19
A Spectrum of Approaches
Cognitive Behavioral Psychodynamic
DBT MBT
STEPPS SFT TFP
GPM
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Dialectical Behavioral Therapy
• Most widely available and studied.
• Skills group, behavioral therapy, skills coaching, consultation team.
• Core dialectic:
acceptance AND change
• Skills group most important
Linehan, et. al JAMA Psychiatry 2015
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Mentalization Based Treatment
• Longest study shows gains in symptom reduction over 8 years
• Simple, general approach that does not require detailed knowledge of skills but a general understanding of a mentalizing process
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General (“Good”) Psychiatric Management
• As effective as DBT
• Features
• Psychoeducation, interpersonal focus
• Case management emphasized (work, volunteer)
• Pragmatic; integration of psychopharm, groups
McMain, Am J Psych, 2009
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Effective Clinical Management of BPD
Spring 2017
Los Angeles
John Gunderson, MD
Brian Palmer, MD
Robin Kissell, MD
ce.mayo.edu
©2016 MFMER | 3540366-24
Common Features of Effective TX
• Structured (groups and individual work), coherent and stable, not reactive
• Crisis planning
• Supervision for managing countertransference
• Therapists are active
• Monitoring progress and goals
• Making narrative sense of internal experience
• Not common but should be: anchor treatment in life outside treatment
©2016 MFMER | 3540366-25
With respect to medications…
1. Benzodiazepines improve overall outcome by reducing anxiety.
2. Atypical antipsychotics are effective for the cognitive/ perceptual symptoms of BPD.
3. Mood stabilizers are unhelpful for BPD
4. SSRI’s have superior efficacy to other classes of medications for BPD.
Benzo
diaze
pines im
p...
Atypic
al antip
sychotic
...
Frequent m
edicatio
n...
SSRI’s h
ave superio
r e...
0% 0%0%0%
©2016 MFMER | 3540366-26
Meds: Key Principles
1) Collaborate to determine goals and set accurate expectations
decrease mood lability,
normalize sleep,
decrease transient psychotic symptoms
2) Measure the effectiveness of the intervention
3) Use a methodical approach to medication trials. Don’t add without
subtracting.
4) Be aware of the dynamics.
©2016 MFMER | 3540366-27
Reactive Treatment: Perilous
• Persons with BPD often seek treatment REACTIVELY
• Example: Migraine Headaches • more medication overuse headaches
• more unscheduled (acute) office visits
• lower overall treatment response
Rothrock, Headache, 2007
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At a Glance
Anti-psychotics
Anti-depressants
Mood Stabilizers
Anger ++ + +++
Mood o o +
Anxiety o + ++
Impulsivity + o +++
Cognitive-Perceptual
++ o o
Functioning + o ++
Adapted from Ingenhoven, J Clin Psych, 2010
©2016 MFMER | 3540366-29
Specific agents best studied
• Mood stabilizers
• Best studied with most favorable safety profile: lamotrigine (200 mg)
and topiramate (200-250 mg)
• Antipsychotics
• Aripiprazole (15 mg) and olanzapine (2.5-10 mg), quetiapine (150 mg)
• Antidepressants
• MAOI’s, fluoxetine (more with impulsivity/aggression, esp in males)
• Benzodiazepines (esp alprazolam) have no role in BPD
Rippoll, Dialogues Clin Neurosci, 2013
©2016 MFMER | 3540366-30
Learning Objectives
• Differentiate BPD from mood disorders based on clinical context, course and outcome, and symptoms
• Articulate principles of treatment, including case management
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