Management planning for borderline personality disorder

Overview of BPD

BPD is the most common personality disorder in clinical settings, and it is present in cultures around the world. It causes marked distress and impairment in social, occupational and role functioning, and it is associated with high rates of self-destructive behavior (e.g. suicide attempts) and completed suicide.


The essential feature of BPD is a pervasive pattern of instability of interpersonal relationships, affects and self image, as well as marked impulsivity. These characteristics begin by early adulthood and are present in a variety of contexts.

DSM-5 Diagnostic Criteria for borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealisation and devaluation
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)
  5. Recurrent suicidal behavior, gestures or threats, or self mutilating behaviour
  6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Formulation and implementation of a treatment plan

When the psychiatrist first meets with a patient who may have BPD, a number of important issues related to differential diagnosis, aetiology, the formulation, and treatment planning need to be considered.

The initial assessment

1. Initial assessment and determination of the treatment setting

The psychiatrist first performs an initial assessment of the patient, and determines the treatment setting (inpatient vs. outpatient). Since patients with BPD commonly experience suicidal ideation (and 8-10% commit suicide), safety issues should be given priority in the initial assessment. A thorough risk assessment should be done before a decision can be reached about whether outpatient, inpatient or another level of care is needed.

The emergency department

The initial assessment setting is often the emergency department. Management seeks to maintain safety, detect disorders and problems amenable to treatment and engage the person in psychiatric treatment or other follow-up. Assessment should balance privacy and dignity with safety considerations.

A high index of suspicion for suicide risk is prudent and prevention of suicide remains an objective of treatment and follow-up in all settings.

Psychiatric assessment

Medical and psychiatric assessment should be integrated and acute psychiatric assessment and management include: engaging the patient and establishing a therapeutic alliance; comprehensive assessment of risk of harm to self (and others); conducting and recording a comprehensive mental state examination; psychosocial assessment; identifying and initiating treatment for any underlying mental disorders; co-ordinating treatment planning with patient, family and other health services; documenting the assessed status of the person’s safety at transitions of care and at discharge from hospital; and enhancing resilience and promoting adaptive coping strategies.

Early engagement improves the assessment and promotes identification of underlying psychiatric disorders and psychosocial vulnerability, and of protective factors. Psychiatric assessment is not complete until cognitive function has returned to normal, particularly if impaired by overdose (e.g. benzodiazepines).

Indications for partial hospitalisation (or brief inpatient hospitalisation if partial hospitalisation is not available) include:

  • Dangerous, impulsive behavior unable to be managed with outpatient treatment
  • Non-adherence with outpatient treatment and a deteriorating clinical picture
  • Complex comorbidity that requires more intensive clinical assessment of response to treatment
  • Symptoms of sufficient severity to interfere with functioning, work and family life that are unresponsive to outpatient treatment.

Indications for brief hospitalisation:

  • Imminent danger to others
  • Loss of control of suicidal impulses or serious suicide attempt
  • Transient psychotic episodes associated with loss of impulse control or impaired judgment
  • Symptoms of sufficient severity to interfere with functioning, work or family life that are unresponsive to outpatient treatment or partial hospitalisation

Indications for extended hospitalisation include:

  • Persistent and severe suicidality, self destructiveness, or non-adherence to outpatient treatment or partial hospitalisation
  • Comorbid refractory Axis I disorder (e.g. eating disorder, mood disorder) that presents a potential threat to life
  • Comorbid substance abuse or dependence that is severe and unresponsive to outpatient treatment or partial hospitalisation
  • Continued risk of assaultative behaviour toward others despite brief hospitalisation
  • Symptoms of sufficient severity to interfere with functioning, work or family life that are unresponsive to outpatient treatment, partial hospitalization and brief hospitalisation

2. Comprehensive evaluation

Once an initial assessment has been done and the treatment setting determined, a more comprehensive evaluation should be completed as soon as clinically feasible. Such an evaluation includes assessing the presence of comorbid disorders, degree and type of functional impairment, needs and goals, intrapsychic conflicts and defenses, developmental progress and arrests, adaptive and maladaptive coping styles, psychosocial stressors and strengths in the face of stressors. The psychiatrist should attempt to understand the biological, interpersonal, familial, social and cultural factors that affect the patient.

Special attention should be paid to the differential diagnosis of borderline personality disorder versus Axis I conditions. Treatment planning should address comorbid disorders from Axis I (eg substance use disorders, depressive disorders, PTSD) and Axis II as well as borderline personality disorder, with priority established according to risk or predominant symptoms. When priority is given to treating comorbid conditions, it may be helpful to caution patients or their families about the expected rate of response or extent of improvement. The prognosis for treatment of these Axis I disorders is often poorer when borderline personality disorder is present. It is usually better to anticipate realistic problems than to encourage unrealistically high hopes.

3. Establishing the treatment framework

It is important to establish a clear and explicit treatment framework at the outset of treatment. This is also called “contract setting”. The patient and the clinician can then refer to this agreement later in the treatment if the patient challenges it.

Patients and clinicians should establish agreements about goals of treatment sessions (eg symptom reduction, personal growth, improvement in functioning) and what role each is expected to perform to achieve these goals. It is essential for patients and clinicians to work toward establishing agreements about 1) when, where and what frequency sessions will be held; 2) a plan for crises management; 3) clarification of the clinician’s after hours availability.

Principles of psychiatric management

Psychiatric management forms the foundation of psychiatric treatment for patients with borderline personality disorder. It consists of an array of ongoing activities and interventions that should be instituted for all patients. These include providing education about borderline personality disorder, facilitating adherence to a psychotherapeutic or psychopharmacological regimen that is satisfactory to both the patient and psychiatrist, and attempting to help the patient solve practical problems, giving advice and guidance when needed.

1. Responding to crises and safety monitoring

Psychiatrists should assume that crises, such as interpersonal crises or self-destructive behaviour, will occur. Psychiatrists may wish to establish an explicit understanding about what they expect a patient to do during crises and may want to be explicit about what the patient can expect from them. There is often a tension between the psychiatrist’s role in helping patients to understand their behaviour and the psychiatrist’s role in ensuring patients’ safety and in managing problematic behaviours.

Patients with borderline personality disorder commonly experience suicidal ideation and are prone to make suicide attempts or engage in self-injurious behaviour (eg cutting). Monitoring patient’s safety is a critically important task. It is important that psychiatrists always evaluate indicators of self-injurious or suicidal ideas and reformulate the treatment plan as appropriate. Before intervening to prevent self-endangering behaviours, the psychiatrist should first assess the potential danger, the patient’s motivations, and to what extent the patient can manage his or her safety without external interventions. When the patient’s safety is judged to be at serious risk, hospitalization may be indicated. Even in the context of appropriate treatment, some patients with borderline personality disorder will commit suicide.

2. Establishing and maintaining a therapeutic framework and alliance

Patients with BPD have difficulty developing and sustaining trusting relationships. This issue may be a focus of treatment as well as a significant barrier to the development of treatment alliance necessary to carry out the treatment plan. Therefore, the psychiatrist should pay particular attention to ascertaining that the patient agrees with and accepts the treatment plan; adherence and agreement cannot be assumed. Agreements should be explicit.

The first aspect of alliance building, referred to as “contract setting”, is establishing an agreement about respective roles and responsibilities and treatment goals. The next aspect of alliance building is to encourage patients to be actively engaged in the treatment, both in their tasks (eg monitoring medication effects or noting and reflecting on their feelings) and in the relationship (eg disclosing reactions or wishes to the clinician). Psychotherapeutic approaches are often helpful in developing a working alliance for a pharmacotherapy component of the treatment plan. Reciprocally, the experience of being helped by medication that the psychiatrist prescribed can help a patient develop trust in his or her psychotherapeutic interventions.

3. Providing education about the disorder and its treatment

At an appropriate point in treatment, patients should be familiarised with the diagnosis, including its expected course, responsiveness to treatment, and, when appropriate, pathogenic factors. Many patients with BPD profit from ongoing education about self care (eg safe sex, potential legal problems, balanced diet). Families or others – especially those who are younger – living with individuals with BPD will also often benefit from psychoeducation about the disorder, its course and its treatment.

4. Coordinating the treatment effort

Providing optimal treatment for patients with BPD who may be dangerously self-destructive frequently requires a treatment team that involves several clinicians. If the team members work collaboratively, the overall treatment will usually be enhanced by being better able to help patients contain their acting out (via fight or flight) and their projections onto others. It is essential that ongoing co-ordination for the overall treatment plan is assured by clear role definitions, plans for management of crises, and regular communication among the clinicians.

The team members must also have a clear agreement about which clinician is assuming the primary overall responsibility for the patient’s safety and treatment. This individual serves as a gatekeeper for the appropriate level of care (whether it be hospitalisation, residential treatment, or day hospitalisation), oversees the family involvement, makes decisions regarding which potential treatment modalities are useful or should be discontinued, helps assess the impact of medications, and monitors the patient’s safety. Because of the diversity of knowledge and expertise required for this oversight to function, a psychiatrist is usually optimal for this role.

5. Monitoring and reassessing the patient’s clinical status and treatment plan

It is important to monitor the treatment’s effectiveness in an ongoing way.

a) Recognising functional regression

Patients with BPD sometimes regress early in treatment as they begin to engage in the treatment process, getting somewhat worse before they get better. Examples of such regressive phenomena include dysfunctional behaviour (eg cessation of work, increased suicidality, onset of compulsive overeating) or immature behaviour. This may occur when patients believe that they no longer need to be as responsible for taking care of themselves, thinking that their needs can and will now be met by those providing treatment.

When the decline in functioning is sustained, it may mean that the focus of treatment needs to shift from exploration to other strategies (eg behavioural modification, vocational counselling, family education or limit setting). Of special significance is that such declines in function are likely to occur when patients with BPD have reductions in the intensity or amount of support they receive, such as moving to a less intensive level of care. Clinicians need to be alert to the fact that such regressions may reflect the need to add support or structure temporarily to the treatment by way of easing the transition to less intensive treatment. Regression may also occur when patients perceive particularly sympathetic, nurturant, or protective inclinations in those who are providing their care. Under these circumstances, clinicians need to clarify that these inclinations do not signify a readiness to take on a parenting role.

b) Treating symptoms that reappear despite continued pharmacotherapy

An issue that frequently requires assessment and response by psychiatrists is the sustained return of symptoms, the previous remission of which had been attributed, at least in part, to medications. Assessment of such symptom “breakthroughs” requires the knowledge of the patient’s symptom presentation before the use of medication. Medications can modulate the intensity of affective, cognitive and impulsive symptoms, but they should not be expected to extinguish feelings of anger, sadness and pain in response to separations, rejections or other life stressors. When situational precipitants are identified, the clinician’s primary focus should be to facilitate improved coping. Frequent medication changes in pursuit of improving transient mood states are unnecessary and generally ineffective.

c) Obtaining consultations

Clinicians with overall or primary responsibilities for patients with BPD should have a low threshold for seeking consultation because of:

  1. The high frequency of countertransference reactions and medicolegal liability complications
  2. The high frequency of complicated multicenter, multimodality treatments; and
  3. The particularly high level of inference, subjectivity, and life/death significance that clinical judgments involve.

The principle that should guide whether a consultation is obtained is that improvement (eg less distress, more adaptive behaviours, greater trust) is to be expected during treatment. Thus, failure to show improvement in targeted goals by 6-12 months should raise considerations of introducing changes in the treatment. When a patient continues to do poorly after the treatment has been modified, consultation is indicated as a way of introducing and implementing treatment changes. When a consultant believes that the existing treatment cannot be improved, this offers support for continuing this treatment.

6. Special issues

a) Splitting

Splitting signifies an inability to reconcile alternative or opposing perceptions or feelings within the self or others, which is characteristic of BPD. As a result, patients with BPD tend to see people or situations in “black or white”, “all or nothing”, “good or bad” terms. When splitting threatens continuation of treatment, clinicians should be prepared to examine the transference and countertransference and consider altering treatment. This can be done by offering increased support, by seeking consultation, or by otherwise suggesting changes in the treatment. Clinicians should always arrange to communicate regularly about their patients to avoid splitting within the treatment team. Integration of clinicians helps patients integrate their internal splits.

b) Boundaries

Clinicians/therapists vary considerably in their tolerance for patient behaviours (eg phone calls, silences). It is important to be explicit about these issues, thereby establishing “boundaries” around treatment relationship and task. It is important to be consistent with agreed upon boundaries. It remains the therapist’s responsibility to monitor and sustain the treatment boundaries. Certain situations – eg practicing in a small community, rural area or military setting may complicate the task of maintaining treatment boundaries.

To diminish the problems associated with boundary issues, clinicians should be alert to their occurrence. Clinicians should then be proactive in exploring the meaning of the boundary crossing – whether it originated in their own behaviour or that of the patient. If the patient keeps testing the agreed upon framework of therapy, clinicians should explicate its rationale. Clinicians should seek consultation or personal psychotherapy or both whenever there is a risk of boundary violation.

c) Transference and projective identification

 

Principles of treatment selection

1. Type

Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective for the treatment of BPD. Clinical experience suggests that most patients with BPD will need some form of extended psychotherapy in order to resolve interpersonal problems and maintain lasting improvements in their personality and overall functioning. Pharmacotherapy often has an important adjunctive role, especially for diminution of targeted symptoms such as affective instability, impulsivity, psychotic-like symptoms and self-destructive behaviour. Although no studies have compared a combination of psychotherapy and pharmacotherapy with either treatment alone, clinical experience indicates that many patients will benefit from a combination of psychotherapy and pharmacotherapy.

2. Focus

Patients with BPD frequently have comorbid Axis I and other Axis II conditions. Treatment planning should address comorbid axis I and axis II disorders as well as BPD, with priority established according to risk or predominant symptoms. For patients with axis I conditions and coexisting borderline traits who do not meet full criteria for BPD, it may be sufficient to focus treatment on the axis I conditions alone, although the therapy should be monitored and the focus changed to include the borderline traits if necessary to ensure the success of the treatment.

3. Flexibility

Because of the heterogeneous nature of BPD and because of each patient’s unique history, the treatment plan needs to be flexible, adapted to the needs of the individual patient. Flexibility is also needed to respond to the changing characteristics of patients over time (eg at one point, the treatment focus may be on safety, whereas at another, it may be on improving relationships and functioning at work). The psychiatrist may need to use different treatment modalities or refer patients for adjunctive treatments (e.g. behavioural, supportive or psychodynamic psychotherapy) at different times during the treatment.

4. Role of patient preference

Successful treatment is a collaborative process between the patient and the clinician. Patient preference is an important factor to consider when developing an individual treatment plan. The psychiatrist should explain and discuss the range of treatments available for the patient’s condition, the modalities he/she recommends, and the rationale for having selected them. Take time to elicit the patient’s views about this provisional treatment plan and modify it to the extent feasible to take into account the patient’s views and preferences.

5. Multiple vs. single clinician treatment

Treatment may be provided by more than one clinician, each performing separate treatment tasks, or by a single clinician performing multiple tasks; both are viable approaches to treating BPD. Multiple clinician treatment has the advantage of bringing more types of expertise to the patient’s treatment, and may better contain the patient’s self-destructive tendencies. However, it also carries the risks of treatment fragmentation due to patients’ propensity for engaging in “splitting”, as well as difficulties of maintaining good collaboration of the entire treatment team.

Specific treatment strategies for the clinical features of Borderline Personality Disorder

Although there is a long clinical tradition of treating BPD, there are no well-designed studies comparing pharmacotherapy with psychotherapy. Nor are there any systematic investigations of the effects of combined medication and psychotherapy to either modality alone. In clinical practice, the two treatments are often combined.

1. Psychotherapy

Two psychotherapeutic approaches have been shown to have efficacy in RCTS: psychoanalytic/psychodynamic therapy and dialectical behavioural therapy. Both have three key features:

  1. Weekly meetings with an individual therapist
  2. One or more weekly group sessions
  3. Meetings between therapists for consultation/supervision

Dialectical behaviour therapy (DBT)

DBT combines behavioural and psychoeducational elements and has four components: individual therapy; group-based skills training; out-of-hours telephone contact; and therapist supervision group. Patients are exposed to stimulation, requiring emotional and behavioural adaptation. When compared to treatment as usual alternative therapy referrals), DBT reduced repeated parasuicide during the year of treatment and the subsequent 6 months [80] [II], but there was no difference at further follow-up [82]. The Cochrane review also reported a beneficial effect versus ‘treatment as usual’.

One characteristic of both DBT and psychodynamic therapy involves the length of treatment. The studies of extended treatment suggest that substantial improvement may not occur until after approximately one year of psychotherapeutic intervention has been provided and that many patients require even longer treatment.

There is a large clinical literature describing psychoanalytic/psychodynamic individual therapy for patients with BPD. Most of these clinical reports document the difficult transference and countertransference aspects of the treatment, but they also provide considerable encouragement regarding the ultimate treatability of BPD.

The limited literature on group therapy for patients with BPD indicates that group treatment is not harmful and may be helpful, but it does not provide evidence of any clear advantage over individual psychotherapy. Studies of combined individual dynamic therapy plus group therapy suggest that nonspecified components of combined interventions may have the greatest therapeutic power.

The published literature on couples therapy in patients with BPD suggests that couples therapy may be a useful and at times essential adjunctive treatment modality, since inherent in the very nature of the illness is the potential for chaotic interpersonal relationships. However, couples therapy is not recommended as the only form of treatment for patients with BPD. Clinical experience suggests that it is relatively contraindicated when either partner is unable to listen to the other’s criticisms or complaints without becoming too enraged, terrified or despairing.

There is only one published study of family therapy for patients with BPD, which found that a psychoeducational approach could greatly enhance communication and diminish conflict about independence. Published clinical reports differ in their recommendations about appropriateness of family therapy and family involvement in the treatment. Clinical experience suggests that family work is most apt to be helpful and can be of critical importance when patients with BPD have significant involvement with, or are financially dependent on, the family. Failure to enlist family support is a common reason for treatment dropout. Family therapy is not recommended as the only form of treatment for patients with BPD

2. Pharmacotherapy and other somatic treatments

A pharmacological approach to the treatment of BPD is based upon evidence that some personality dimensions of patients appear to be mediated by dysregulation of neurotransmitter physiology and are responsive to medication. Pharmacotherapy is used to treat state symptoms during periods of acute decompensations well as trait vulnerabilities.

Pharmacotherapy may be guided by a set of basic assumptions that provide the theoretical rationale and empirical basis for choosing specific treatments. First, BPD is a chronic disorder.

Pharmacotherapy has demonstrated significant efficacy in many studies in diminishing symptom severity and optimizing functioning. However, cure is not a realistic goal – medications do not cure character. Second, BPD is characterized by a number of dimensions; treatment is symptom specific, directed at particular behavioural dimensions, rather than the disorder as a whole. Third, affective dysregulation and impulsive aggression are dimensions that require particular attention because they are risk factors for suicidal behaviour, self-injury and assaultiveness and are thus given high priority in selecting pharmacological agents. Fourth, pharmacotherapy targets the neurotransmitter basis of behavioral dimensions, affecting both acute symptomatic expression (eg anger treated with dopamine blocking agents) and chronic vulnerability (eg temperamental impulsivity treated with serotonergic agents). Symptoms common to both axis I and II disorders may respond similarly to the same medication.

Symptoms exhibited within three behavioural dimensions seen in patients with BPD are targeted for pharmacotherapy: affective dysregulation, impulsive-behavioural dyscontrol and cognitive-perceptual difficulties.

a) Treatment of affective dysregulation symptoms

Affective dysregulation in patients with BPD is manifested by symptoms such as mood lability, rejection sensitivity, inappropriate intense anger, depressive “mood crashes”, and temper outbursts. Patients displaying these features should be treated initially with one of the SSRIs. Research trials of SSRIs for the treatment of BPD have ranged in duration from 6 to 14 weeks for acute treatment studies, with continuation lasting up to 12 months. Studies have been reported with fluoxetine (in doses of 20-80mg/day), sertraline ( 100-200mg/day), and the mixed SNRI venlafaxine (up to 400mg/day). A reasonable trial of SSRI treatment for patients with BPD is at least 12 weeks.

There has been much interest in the use of anti- depressants for DSH. Case reports describe intense suicidal ideation and urges to self-harm after starting SSRI treatment or increasing the dosage . Clinicians should inform patients (and their carers where appropriate) that increased agitation and/or suicidal thoughts may accompany the start of SSRI treatment or with increase in dosage.

Patients at risk of DSH may be vulnerable to toxicity in all psychoactive medications, not just antidepres-sants. An Australian study of hospital-treated patients found that deliberate self-poisoning recurred after a brief interval and that the agent was often a prescribed psychotropic medication. The relative toxicity of antidepressants, antipsychotics, benzodiaze- pines and anticonvulsants in deliberate self-poisoning has been quantified. Clinicians should look for low relative toxicity when selecting any psycho-active drug for patients at increased risk of deliberate self-poisoning.

In patients with severe behavioural dyscontrol, low dose neuroleptics can be added to the regimen for a rapid response; they may also improve affective symptoms.

Mood stabilisers are another second-line (or adjunctive) treatment for affective dysregulation symptoms in patients with BPD. Lithium carbonate, cabamazepine and valproate have been used for the treatment of mood instability in patients with an axis II disorder, but there is a surprising paucity of empirical support for their use in BPD. Lithium has the most research support in RCTs studying patients with personality disorders. These studies focused primarily on impulsivity and aggression rather than mood regulation. A meta-analysis of major mood disorders found that lithium reduced the risk of suicide and DSH by 8.6 times (from 3.2 per 100 patient years to 0.37).

Carbamazepine has demonstrated efficacy for impulsivity, anger, suicidality and anxiety in patients with BPD. It has been reported to precipitate melancholic depression in patients with BPD who have a history of this disorder, and it has the potential to cause bone marrow suppression.

Valproate demonstrated modest efficacy for depressed mood in patients with BPD in one small RCT. Open label case reports suggest that this medication may also decrease agitation, aggression, anxiety, impulsivity, rejection sensitivity, anger and irritability in patients with BPD. Although the use of carbamazepine and valproate is widespread, psychiatrists should be aware of the lack of solid research support for their use in patients with BPD.

Although there is a paucity of data on the efficacy F ECT for patients with BPD, much of the available data suggest that depressed patients with a personality disorder generally have a poorer outcome with ECT than depressed patients without a personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with BPD and severe axis I depression that has been resistant to pharmacotherapy, affective features of BPD are unlikely to respond to ECT.

b) Treatment of impulsive behavioural dyscontrol symptoms

SSRIs are the treatment of choice for impulsive, disinhibited behaviour in patients with BPD. Clinical experience suggests that the duration of treatment following improvement of impulsive aggression should be determined by the clinical state of the patient, including his or her risk of exposure to life stressors and progress in learning coping skills.

When behavioural dyscontrol pose a serious threat to the patient’s safety, it may be necessary to add a low-dose neuroleptic to the SSRI. Although this combination has not been studied, RCTs of neuroleptics alone have demonstrated their efficacy for impulsivity in patients with BPD.

Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium, although this combination has not been studied in patients with BPD.

The use of carbamazepine or valproate for impulse control in patients with BPD appears to be widespread in clinical practice, although empirical evidence for their efficacy for impulsive aggression is limited and inconclusive. Preliminary evidence suggests that the atypical neuroleptics may have some efficacy for impulsivity in patients with BPD, especially severe self-mutilation and other impulsive behaviours arising from psychotic thinking.

Opioid antagonists (e.g. Naltrexone) are sometimes used in an attempt to decrease self-injurious behaviour in patients with BPD. However, empirical support for this approach is very preliminary, since their efficacy has been demonstrated only in case reports and small case series.

c) Treatment of cognitive-perceptual (psychotic) symptoms

Low dose neuroleptics are the treatment of choice for these symptoms. Low dose neuroleptics appear to have a broad spectrum of efficacy in acute use, improving not only psychotic like symptoms, but also depressed mood, impulsivity, hostility and anger. Prolonged use of neuroleptic medication alone in patients with BPD has been associated with progressive nonadherence and dropout from treatment. There is currently a paucity of research on the use of neuroleptic medication as long-term maintenance therapy for patients with BPD, although many clinicians regularly use low dose neuroleptics to help patients manage their vulnerability to disruptive anger.

If response to treatment with low dose neuroleptics is suboptimal after 4-6 weeks, the dose should be increased into a range suitable for treating axis I disorders and continued for a second trial period of 4-6 weeks. Although there are no published RCTs of atypical neuroleptics in patients with BPD, open label trials and case studies support the use of clozapine for patients with severe, refractory psychotic symptoms “of an atypical nature” or for severe self-mutilation. Clozapine is best used in patients with refractory BPD, given the risks of agranulocytosis.

Neuroleptics are often effective for anger and hostility regardless of whether these symptoms occur in the context of cognitive-perceptual symptoms or other types of symptoms.

Risk management issues

General considerations

Attention to risk management issues is particularly important when treating patients with BPD, given the potential for self injury, violent behaviour and suicide, as well as impulsivity, splitting, problems with the therapeutic alliance, and transference and countertransference problems. General risk management considerations in patients with BPD include:

  • Good collaboration and communication with other clinicians who are also treating the patient are necessary.
  • Attention should be paid to careful and adequate documentation, including assessment of risk, communication with other clinicians, the decision-making process, and the rationale for treatment used.
  • Attention should be paid to any transference and countertransference problems that have the potential to cloud good clinical judgment. The clinician should be especially aware of the potential for splitting to occur and should resist taking on the role of the “all good” or rescuing clinician.
  • Close collaboration and communication with other team members are important.
  • Consultation with a colleague should be considered and may be useful for unusually high-risk patients (e.g. when suicide risk is very high), when the patient is not improving, or when it is unclear what the best treatment approach might be.
  • Termination of treatment with a patient with BPD must be managed with care. Careful attention must be paid to timing, transfer and discussion with the patient. If the treatment process is unusually difficult or complex, obtaining a consultation should be considered.
  • Psychoeducation about the disorder is often appropriate and helpful from both a clinical and risk management perspective. When appropriate, family members should be included, with attention to confidentiality issues. Psychoeducation should include discussion of the risks inherent in the disorder and the uncertainties of the treatment outcome

Suicide

Suicidal threats, gestures and attempts are very common among patients with BPD, and 8%-10% commit suicide. Managing suicide risk therefore poses important clinical and medicolegal challenges for clinicians. However, it can be difficult to address suicide risk in these patients due to a number of reasons:

  • Suicidality can be acute, chronic, or both and responses to these types of suicidality differ in some ways.
  • Given the tendency of patients with BPD to be chronically suicidal and to engage in self destructive behaviours, it can be difficult to discern when a patient is at imminent risk of making a serious suicide attempt.
  • Even with careful attention to suicide risk, it is often difficult to predict serious self-harm or suicide since this behaviour can occur impulsively and without warning.
  • Given the potential for difficulties in forming a good therapeutic alliance, it may be difficult to work collaboratively with the patient to protect him or her from serious self harm or suicide.
  • Even with good treatment, some patients will commit suicide.

Risk management considerations for suicidal behaviour in patients with BPD include:

  • Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or change in the treatment may precipitate suicidal ideation or attempts.
  • Take suicide threats seriously and address them with the patient. Taking action (e.g. hospitalisation) in an attempt to protect the patient from serious self harm is indicated for acute suicide risk.
  • Chronic suicidality without acute suicide risk needs to be addressed in therapy. If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide.
  • Actively treat comorbid axis I disorders, with particular attention to those that may contribute to or increase the risk of suicide (e.g. MDD, BPAD, alcohol/drug abuse or dependence).
  • If acute suicidality is present and not responding to therapeutic approaches being used, consultation with a colleague should be considered.
  • Consider involving the family (if otherwise clinically appropriate and with adequate attention to confidentiality issues) when patients are chronically suicidal. For acute suicidality, involve the family or significant others if their involvement will potentially protect the patient from harm.
  • A promise to keep oneself safe (e.g. a “suicide contract) should not be used as a substitute for careful and thorough clinical evaluation of the patient’s suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient’s responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.

Anger, impulsivity and violence

Anger and impulsivity are hallmarks of BPD and can be directed at others, including the clinician. The following are risk management considerations for anger, impulsivity and violence in patients with BPD:

  • Monitor the patient carefully for impulsive and violent behaviour, which is difficult to predict and can occur even with appropriate treatment.
  • Address abandonment/rejection issues, anger and impulsivity in the treatment.
  • Arrange for adequate coverage when away; carefully communicate this to the patient and document coverage.
  • If the patient makes violent threats towards others (including the clinician) or exhibits threatening behaviour, the clinician may need to take action to protect self or others.

Boundary issues

There is a risk of boundary crossings and violations with patients with BPD. Risk management considerations for boundary issues with patients with BPD include:

  • Monitor carefully and explore countertransference feelings toward the patient.
  • Be alert to deviations from the usual way of practicing, which may be signs of countertransference problems – e.g. appointments at unusual hours, longer than usual appointments, doing special favours for the patient.
  • Be aware of the need to transfer care to anther clinician at times.
  • Get a consultation if there are striking deviations from the usual manner in practice.

Take home message

    1. BPD is the most common personality disorder in clinical settings. It causes marked distress and impairment in social, occupational and role functioning, and is associated with high rates of self-destructive behaviour (e.g. suicide attempts) and completed suicides.
    2. Clinicians should be aware of the high prevalance of comorbid disorders with BPD (e.g. mood disorders, substance-related disorders, eating disorders, schizophrenia), which can complicate the clinical picture and need to be addressed in the treatment
    3. Psychiatric management is based on psychotherapy, complemented by symptom-targeted pharmacotherapy.
    4. Risk management is an important aspect of care, and requires effective co-ordination and communication between all parties involved in the care of the individual with BPD
    5. Issues such as splitting and boundary violation are pertinent in patients with BPD. It is the clinician’s responsibility to be aware of these issues and address any factors contributing to their development.
    6. Consultation should be sought in treatment-resistant cases.

Appendix One:

Spectrum

Spectrum is a statewide service in Victoria that supports and works with local Area Mental Health Services to provide treatment for people with personality disorder. Spectrum focuses on those who are at risk from serious self-harm or suicide and who have particularly complex needs.
Spectrum was established in late 1998 with two main aims:

  • to provide support to state mental health services in the process of change towards new treatment strategies.
  • to provide specialised intensive assessment and treatment services for clients with particularly complex needs.

Spectrum supports the treatment of people who have severe or borderline personality disorder who are being treated by Victorian State Government funded Area Mental Health Services (AMHS, CAMHS and other state-wide mental health services). There is an emphasis on those who are at risk from serious self-harm or suicide, who have particularly complex needs.

Who can make a referral?

Spectrum invites referrals from Victorian AMHS, CAMHS and other statewide mental health services who are working with people with a diagnosis of severe or borderline personality disorder. If ongoing Spectrum involvement is being requested, the referral needs to be received from a case manager within the AMHS, CAMHS or statewide service.

People with a diagnosis of severe or borderline personality disorder whose current treatment is from the primary mental health sector (such as general practice, Commonwealth funded private mental health clinicians) or from non-clinical mental health services (such as PDRS’s or Community Health Centres) must first be accepted for treatment within a Victorian Area Mental Health Service in order to receive further treatment at Spectrum.

Spectrum programs

Spectrum provides a range of programs to support AMHS and CAMHS mental health clinicians and their clients, including secondary consultation with clinicians plus group treatment and individual treatment with clients. Spectrum treatment is designed to complement AMHS and CAMHS treatment approaches.

Spectrum programs are designed primarily to assist mental health clinicians within Victorian area mental health services to better meet the needs of their clients with severe or borderline personality disorder. These clients typically have severe interpersonal difficulties, a long history of self-harm and/or suicide attempts and particularly complex needs.

Spectrum is funded to provide services for people with borderline personality disorder who:

  • Have current involvement from a Clinical Area Mental Health Service in Victoria
  • Are aged between 16 and 64 years
  • Live in the state of Victoria.

If an individual with severe or borderline personality disorder is involved in a Spectrum program, the Area Mental Health Service needs to continue their work with the client throughout the period of Spectrum’s involvement.

Spectrum provides a range of programs including:

Secondary Consultation

A secondary consultation can assist clinicians from area mental health services in their work with clients who have severe or borderline personality disorder.

Assessment

Spectrum provides a specialist clinical assessment service to clients for whom a Spectrum treatment service is being considered, or where a mental health clinician has requested an assessment for a particular purpose.

Direct Treatment

Spectrum works in partnership with Victorian Area Mental Health services to provide direct treatment to people with personality disorders. This might include a group or individual treatment in the community, or residential treatment. Treatment is based on a full assessment and designed with the client and their team.

Care Co-ordination and Treatment For Clients with Complex Needs

The Chief Psychiatrist in Victoria may refer sometimes clients with particularly complex needs. Sometimes a Spectrum assessment may identify an exceptionally severe and chronic presentation. Spectrum can provide clinical leadership and direct work in some instances.

Professional Development

Spectrum offers a range of professional development workshops in a central location. These workshops are designed to assist mental health clinicians better meet the needs of their clients with severe or borderline personality disorder.

Spectrum is also involved with:

  • Research
  • Advocacy

References:
1. DSM-IV-TR
2. Practice Guideline for The Treatment of Patients with Borderline Personality Disorder American Psychiatric Association 2010
3. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Deliberate Self Harm 2003
4. NICE Clinical Guideline for the treatment and management of Borderline Personality Disorder
5. Flewett, T. et al. Management of Borderline Personality Disorder British Journal of Psychiatry 2003, 183: 78-79


Henry CaudleAUTHOR | Dr Henry Caudle
Dr Caudle is a psychiatrist with special interests in the management of eating disorders, psychosomatic medicine, pain psychiatry, addiction psychiatry and mental health problems associated with general medical and surgical illness.

 

Consulting suite for outpatient appointments
PH | 03 9805 4309  FAX | 03 9805 4388

Intake clinician for inpatient referrals and enquiries
PH | 03 9805 4338  FAX | 03 9805 4233 FAX | ERC.intakeclinician@epworth.org.au

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