Descriptors “frequent flyers” “help-rejecting complainers”

Descriptors “frequent flyers” “help-rejecting complainers” emotional hypochondriacs (secondary gain) egocentric irresponsible, fickle “love intoxicated”

Sources of Stigma Reaction to anger, neediness (countertransference) The perception of willful treatment resistance (“help rejecting complainers”)

“Negative Therapeutic Reactions” a) Unconscious guilt b) Unconscious envy – need to destroy therapists offerings c) Unconscious identification with a sadistic object Kernberg, OF 1977

Sources of Stigma BPDs self concept: “bad”, “evil”, “damaged”, “small child” (Zanarini et al. 2001) Reaction to anger, neediness (countertransference) The perception of willful treatment resistance (“help rejecting complainers”) Cross-sectional exposure (“frequent flyers”) Misinformation about heritability and prognosis Unrealistic expectations of competence

Consequences of Stigma avoidance and misinformation by professionals

“Despite its prevalence, enormous public health costs, and the devastating toll it takes on individuals, families, and communities, [borderline personality disorder] only recently has begun to command the attention it requires”. House Resolution 1005, April 1, 2008

Consequences of Stigma an “unwanted diagnosis” by patients confirming their worst fears about themselves avoidance and misinformation by professionals under-utilization of the diagnosis (~ 2-6% in one OPC) failure to provide adequate didactic training or capable clinical supervision lack of parity; fair reimbursement

“I dread being diagnosed as borderline. It conveys that I’m malicious and manipulative.”

REPONSES TO DIAGNOSIS OF BPD (N = 30) WORSE BETTER Shame Likability Hope Overall Rubovszky et al.

Psychoeducation for BPD - 30 with workshop about BPD vs. 20 wait listed - PE decreases impulsivity and unstable relations over next 12 weeks - “a useful and cost efficient form of pre-treatment” Zanarini & Frankenburg, JPD 2008

Minimal BPD Didactic Training Objectives (? 6 Hours) i) Knowledge of the DSM diagnostic criteria and their meaning i) Awareness of its prognosis and heritability ii) How to assess and manage deliberate self- harm and suicidal threats iv) The role and liabilities of medication v) The role and outcomes from BPD-specific therapies

Four Models About the Interface between MDD & BPD And their Implications about Course BPD is Primary: BPD can cause 2  signs and symptoms of MDD; its improvements will be followed by a decrease in MDD MDD is Primary: MDD can cause 2  BPD Phenomenology; its improvements will be followed by a decrease in BPD BPD & MDD are Unrelated: Changes in the course in either disorder will not effect the other Overlapping Etiology: Changes in either disorder will effect the course of the other disorder; but will do so weakly or inconsistently

AD COOCCURRENCE IN BPD No. BPD % with AD % General Type AD No. Studies Subjects All (CLPS****) Population* MDD** (50%)17% Bipolar I*** (12%) 1.6% Bipolar II*** (8%) 2-3% Cyclothymic*** % 1% * Kessler et al., 1994 ** Koenigsberg et al. 1999; Gunderson et al *** Paris et al * *** McGlashan et al. 2000

BPD COOCCURRENCE IN AD No. AD Type AD No. Studies Subjects % with BPD MDD* % Bipolar I** % Bipolar II** % * Koenigsberg et al. 1999; Gunderson et al ** Paris et al., 2005

FAMILY STUDIES Increased Prevalence in Relatives Probands MDDBipolar IBipolar IIBPD MDD YES* Yes* ? ? Bipolar I Yes* YES* Yes* No Bipolar II Yes Yes* YES ? BPD ? No ? YES *Replicated Family Study data

Cross-lagged Panel Analysis Relating Borderline and Depressive Psychopathology over 3 Years (N = 570) BOR_B DEP_B BOR_6 DEP_6 BOR_12 DEP_12 BOR_24 DEP_24 BOR_36 DEP_36.75***.78***.68***.81*** ***.33***.20***.09*.17***.11* Note: BPD = Borderline features, assessed at Baseline (B) and 6, 12, 24 and 36 month follow- alongs; DEP = Depression diagnostic status assessed at these intervals. ***p <.001, **p <.01, *p <.05.

INTERACTIONS OF AXIS I WITH BPD Effect Co-Occurring Axis I Disorder ↓ BPD Course ↓ Axis I Course ↑ Med Use Subst Ab NO YES ? MDD ? YES Bipolar NO YES ED NO YES ?

MDD and BPD overlap descriptively, but when co- occurring BPD is primary

BPD & BIPOLAR DISORDERS % BPD with Bipolar I & II20% % Bipolar I with BPD11% % Bipolar II with BPD16% % BPD who become bipolar  10% Gunderson et al. 2006

FAMILY STUDIES Increased Prevalence in Relatives Probands MDDBipolar IBipolar IIBPD MDD YES* Yes* ? ? Bipolar I Yes* YES* Yes* No Bipolar II Yes Yes* YES ? BPD ? No ? YES *Replicated Family Study data

New Onsets of Bipolar I and II in Borderline and Other Personality Disorder Samples BPD (N = 164) OPD (N = 401) Bipolar I 7 (4.3%) 6 (1.8%) Bipolar II 6 (3.7%) 6 (1.8%) Bipolar I and II 13 (7.9%) 12 (3.1%) * Two patients have onsets of both Bipolar I and II

INTERACTIONS OF AXIS I WITH BPD Effect Co-Occurring Axis I Disorder ↓ BPD Course ↓ Axis I Course ↑ Med Use Subst Ab NO YES ? MDD ? YES Bipolar NO YES ED NO YES ?

Bipolar D and BPD overlap descriptively, but not familiarly, and when co-occurring BPD is independent

BPD & Bipolar Disorder Diagnoses ∙ Bipolar disorder is frequently overutilized (only 57% were confirmed with SCID) ∙ 26% of false + Bipolar patients have BPD ∙ 40% of BPD patients had false + Bipolar dx ∙ Overuse of Bipolar dx is 2° to expected response to meds and the extensive marketing of mood stabilizers ∙ Underuse of BPD is 2° to it’s lack of a medication–based therapy and its need for psychosocial treatment Zimmerman et al. J Clin Psychiatry Jan 2010

Overview Treatment of BPD is not done consistently or well Most clinicians don’t like treating BPD patients There is a shortage of well-trained BPD treaters

TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER From Psychoanalytic Primacy to Multiple Modalities (notably psychoeducation, cognitive/behavioral and psychopharmacological)

TRENDS IN TREATMENT OF BORDERLINE PERSONALITY DISORDER From Possible Improvement to Probable Remission From Psychoanalytic Primacy to Multiple Modalities (notably psychoeducation, cognitive/behavioral and psychopharmacological) From Clinical Expertise to Evidence-based From Generic to Disorder-specific

THE FRAMEWORK FOR EXPECTABLE CHANGES Areas ofRelevant Expectable DisturbanceInterventions Time for Change Subjective state Concerned attention, Hrs./Weeks Dysphoric feelings validation Reality testing Problem solving Medication Behavior Clarification (esp. in-Rx months examples) of defense purpose and maladapttive consequences Interpersonal Style Confrontation 6-18 months Pattern recognition Here-and-now interactional analysis Intrapsychic Defense and transference analysis >2 years Organization Corrective experiences, real relationships From Gunderson, 2001

BehavioralPSA DBTSFT MBTTFP

DBT Most influential Most validated Most understandable/learned Most accessible

DBT TFPMBT Behavioral focus Cognitive focus Transference focus Interpretation Defense analyses Support + - +

Effective Manualized BPD Treatments Show: 1. They are better than TAU. 2. BPD patients require specifiably different and disorder-specific interventions. 3. PSA therapy can be manualized – standardized and replicated (up to a point) 4. Adherence and competence can be measured and shown to correlate with effectiveness.

Mentalization: a common theme of all therapies for BPD All psychotherapies develop an interactional matrix in which the mind becomes a focus Therapists consider the patient by communicating their representations to them experience of patient is of another human having their mind in mind  Process more important than content Adapted from Bateman, 2004

Are EBT’s Worth Learning: 1. Will I do better by my next patient as a result of the training? 2. Is the increment of increased effectiveness worth the time and expense of getting trained?

FIVE SHARED CHARACTERISTICS OF EFFECTIVE THERAPIES (DBT, TFP, MBT, SFT) FOR BPD - Structure (goals, roles) - Coherent theory with trained practitioners (self- selected) - Active: support and challenge - Focus on feelings  recognition  sources (chain analyses)  experiencing - Countertransference: recognition & management

WHY DO THIS WORK? Pride in skills (“If you can treat borderline patients, you can treat anyone”) Personal growth Having a highly personal, deeply appreciated, life-changing role