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Borderline Personality Disorder

Perspectives on Treatment

New York (Aug 21, 2009)

Unhappy looking young woman

NewYork-Presbyterian Hospital doctors presented two different approaches to treating patients with borderline personality disorder (BPD) at the American Psychiatric Association meeting in San Francisco in May. Dr. Barbara Stanley presented "Dialectical Behavior Therapy and Beyond: Strategies and Interventions for Suicidal Individuals with Borderline Personality Disorder," with an emphasis on the use of safety planning. Dr. Frank Yeomans discussed Transference Focused Psychotherapy for BPD in a talk entitled: "Aiming for Change in Personality Structure."

About Borderline Personality Disorder

"BPD is a multi-faceted syndrome whose main characteristics include extreme and rapid shifts from one intense emotion to another, very chaotic and stormy interpersonal relationships, and dramatic impulsive behaviors such as wrist cutting, suicide attempts, and overdoses," said Dr. Yeomans. "In the past 15 to 20 years, researchers have developed a number of specialized treatments for BPD such as Transference Focused Therapy, Dialectical Behavioral Psychotherapy, Supportive Psychodynamic Therapy, and Mentalization Based Treatment, which are each based on somewhat different views of the core pathology in BPD."

Dr. Stanley notes that, "In recent years, Mentalization Based Treatment, a psychodynamic psychotherapy that focuses on attachment, has shown efficacy for BPD."

Safety Planning in Suicidal Patients with BPD

Suicide attempts are common in people diagnosed with BPD: Between 60 to 70 percent of patients with BPD attempt suicide, and about 10 percent of those attempts succeed. Risk factors for suicide in BPD include a history of multiple suicide attempts and significant, persistent substance use.

"BPD patients who attempt suicide are typically either hospitalized," said Dr. Stanley, "or we keep our fingers crossed and hope that they come back safe for their follow-up appointment with the therapist." With Dr. Greg Brown at the University of Pennsylvania, Dr. Stanley developed a technique to bridge the gap between hospitalization and a future appointment with a doctor. In this approach the patient and therapist work together to develop a written document called a safety plan. This technique is one of several that Dr. Stanley developed based on principles of Dialectical Behavior Therapy (DBT) and cognitive therapy (CT), which clinicians can use in their general psychiatric practices even if they do not practice DBT or CT. "The idea behind this is that suicidal urges ebb and flow, and the plan can help patients get through the peak of their urge. The plan also includes 'means restriction', an effort to remove means such as medication or a gun that people can use to kill themselves," she said. "This gives people time for their urges to subside."

Creating an Individualized Plan

Each plan is highly individualized. "Working together with the patient we figure out what they consider a strongly distracting activity that will take their mind off their urges for a time," noted Dr. Stanley. "For some people this will be surfing the web, for others listening to music, going for a run, or taking a shower. The patient and therapist also identify social places where the patient can go and be around other people such as a local coffee shop or church, and identify people who can take the patient's mind off of the urge and get outside themselves."

When patients recognize that they are in crisis they follow the plan, step by step. If step 2 does not decrease the suicidal urge, they move on to step 3, and so forth. The basic components of the safety plan include:

  • Recognizing the warning signs of an impending suicidal crisis
  • Identifying and employing internal coping strategies on their own
  • Contacting other people in healthy social settings to distract themselves from suicidal thoughts
  • Contacting family members or friends who can help them resolve the crisis and with whom they can discuss their suicidal urges
  • Contacting mental health professionals or agencies

Drs. Stanley and Brown developed this approach for adolescent boys and girls, and it has also been adopted by the Veterans Health Administration and is now used by every veteran who is at risk for suicide, she said.

Bridging the Gap Between Medical Visits

Dr. Stanley is testing other approaches to bridging the gap between the ER and the doctor's visit through a series of studies in the emergency department at NewYork-Presbyterian/Columbia University Medical Center. "Suicidal individuals often do not stay in treatment," she said. "As many as 38 percent of people who attempt suicide and are hospitalized for three months do not engage in outpatient treatment after discharge, and 73 percent of people who attempt suicide are not in treatment one year after their suicide attempt."

Through two pilot studies, Dr. Stanley is researching ways to increase the likelihood that suicidal patients seen in the ER will engage in treatment in the three months after their visit to the ER to decrease their risk of suicidal thoughts and behavior in that time period. In one study the researchers are assessing the effectiveness of a problem-solving interview and in the other of a brief motivational interview.

Transference Focused Psychotherapy

Transference focused psychotherapy (TFP) is a modified form of psychodynamic psychotherapy developed by clinician-researchers under the leadership of Dr. Otto Kernberg at NewYork-Presbyterian Hospital/Weill Cornell Medical Center's Personality Disorders Institute. "TFP is based on the concept that people with BPD have an underlying identity disturbance," said Dr. Yeomans. "They lack a coherent sense of self, which, combined with temperamental vulnerability, leads to the behavioral manifestations of BPD. While other therapeutic approaches tend to focus on behaviors and cognition, TFP works in the area of identity integration and its impact on affects and cognitions."

Dr. Yeomans explained that emotions can be seen as the expression of an internal object representation. "In the course of every infant's early development, mind and identity are built up gradually under the influence of internalized dyadic experiences of self and other important caretakers marked by intense emotion. Some internalized experiences are marked by positive affect – warmth, love, happiness, and satisfaction, while others are experiences of extremely negative affect – fear, anxiety, anger, and hatred. Early in an individual's development these emotionally-charged representations of oneself and others are segregated into two camps: either all-positive or all-negative.

"In the course of normal development these negative and positive affective extremes become integrated and more nuanced over time – corresponding better to the complexity of life," he said. "We hypothesize that, in BPD, the negative and positive extremes are not integrated, resulting in highly polarized black and white thinking – things are either all good or all bad. This is related to corresponding internal representations of oneself as all good or all bad or others as all good or all bad, and explains the chaotic relationships and the extreme shifts from one intense affect to another."

TFP is based on a here-and-now analysis of how the patient is experiencing the relationship with the "other," who, in the therapeutic context, is the therapist. "In TFP we combine the immediate activated emotion and the engagement of a cognitive capacity to observe what is going on in the moment. We feel that you've got to observe, discuss, and reflect upon the affect as it's being experienced in relation to the other."

In a 2007 study, Drs. Otto Kernberg and John Clarkin directed a study that randomized 90 patients to one of three treatments: transference focused psychotherapy (TFP), dialectical behavioral therapy (DBT), and supportive psychodynamic therapy (SPT) for a one-year course of treatment (Clarkin et al, American Journal of Psychiatry, 164, p. 922-928). The primary outcome domains they measured were suicidality, anger/aggression, and impulsivity; secondary outcome domains were social adjustment, depression, anxiety, and irritability. The researchers also studied a hypothesized mechanism of change, a mental function called reflective function. Each group showed overall positive change but in the DBT group, while there was significant change in suicidality, anxiety, depression, and social adjustment, there was no change in anger/aggression or impulsivity. In SPT there was significant positive change in all but suicidality. In all six domains there was significant positive change in the TFP group.

Dr. Yeomans and his colleagues hypothesize that the mechanism of change is linked to reflective function, which is closely correlated to mentalization, the capacity to accurately perceive and understand one's own internal states of mind and those of others. Reflective function (RF) is measured on a scale from minus one to nine. "A person who is minus one has a grossly distorted, overly concrete, and unintegrated sense of self and of others, while a rating of nine on the RF scale reflects someone who has unusually complex, elaborate, or original reasoning about one's mental states and those of others, with five being considered average RF." In the Weill Cornell clinical trial (Levy et al, Journal of Consulting and Clinical Psychology, 74, pp.1027-1040), there was a significant difference between the treatment groups, with TFP the only one that showed a significant increase in reflective functioning (from 2.9 to 4.1). "By encouraging this constant reflection on feelings in the moment, TFP offers a deep level of internal psychological change and enables the person to develop a more complex sense of the entirety of their emotional self and that of others," Dr. Yeomans said.

Faculty Contributing to this Article:

Barbara Stanley, PhD is a Clinical Psychologist and Research Scientist in the Department of Molecular Imaging and Neuropathology at the New York State Psychiatric Institute (an affiliate of NewYork-Presbyterian Hospital), and on the faculty of Columbia University College of Physicians and Surgeons

Frank Yeomans, MD, PhD is an Attending Psychiatrist at NewYork-Presbyterian Hospital, an Associate Professor of Psychiatry and Director of Training at the Personality Disorders Institute at Weill Cornell Medical College, and a Lecturer in Psychiatry at the Columbia University College of Physicians and Surgeons.

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