1. Treating Borderline Personality Disorder in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 11/20/2014

2. Disclosures and Learning Objectives Learning Objectives – Be able to name three evidence-based therapies for BPD – Be able to list the three basic tenets of Relationship Management – Know 7 ways to improve outcomes in Borderline Personality Disorders – Appreciate the role of hope in the treatment of BPD Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

3. Assessing Borderline Personality Disorder Review BPD Review Pharmacotherapy Review Psychotherapy Review Relationship Management Review Office Management Review the UK approach Next Week

4. Borderline Personality Disorder, DSM-IV TR 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 5 (or more) of the following 9 criteria: Frantic efforts to avoid abandonment, imagined or real A pattern of unstable, intense relationships Identity disturbance; unstable self-image or sense of self Impulsivity in at least two potentially damaging areas Recurrent suicidal behaviors, gestures, threats, self harm Affective instability due to market reactivity of mood Chronic feelings of emptiness Inappropriate intense anger or difficulty controlling anger Transient paranoia or severe dissociative symptoms http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_per sonalidad_psicosis/material/dsm.pdf

5. Borderline Personality Disorder 1-4% of the general population 6% of a primary care clinic population – 50% had no mental health treatment that year – 43% not recognized by PCP has having any emotional or mental health problems. http://archinte.jamanetwork.com/article.aspx?articleID=210746 Higher rates of common health problems, perhaps due to medication-induced obesity – Diabetes, Hypertension – Chronic Back Pain – Arthritis, Fibromyalgia http://www.nimh.nih.gov/health/publications/borderline-personality- disorder/Borderline_Personality_Disorder_508_141959.pdf

6. Borderline Personality Disorder and Health Medically self-sabotaging behavior Increased perceptions of illness Pain syndromes (BPD in 50% of chronic pain patients) Prescription misuse and abuse HIV Skin picking or excoriation (1 in 4 have BPD) Factitious illness Plastic Surgery (more surgeries, less satisfaction) Rheumatoid Arthritis (40% have BPD?) Disability (3 times more likely) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012616/pdf/PE_1_2_19.pdf

7. Treating BPD - Pharmacology SSRIs are recommended by the APA – Fluvoxamine, Sertraline, Fluoxetine Mood stabilizers – Depakote may be helpful for rage – Lamictal and Topomax may help Low-dose Antipsychotics – Abilify, Olanzapine Avoid benzodiazepines http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-guide.pdf http://emedicine.medscape.com/article/913575-medication http://www.bpddemystified.com/treatments/medication/

8. Treating BPD - Psychotherapy Dialectic Behavioral Therapy Mentalization-Based Therapy Transference Focused Psychotherapy Schema-Focused Therapy General Psychiatric Management Systems Training for Emotional Predictability and Problem Solving http://www.bpddemystified.com/treatments/medication/

9. BPD – Relationship Management Social Contract – Patient is intelligent, responsible and in control – PCP does not make decisions or give advice Relationship Management – Do no harm – Reduce chaos and curtail the distorted relationship between patient and health care – Consider therapy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf http://www.powells.com/biblio/62-9781138004993-1

10. Relationship Management, continued Interview techniques – Slowing down the interview – Using fewer words – Increasing the use of silence – Responding with empathetic neutrality – Assuming a position contrary to assigned attributes http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf

11. BPD – Office Management Structure, Structure, Structure Remain calm and go for the emotion Watch for splitting Notice your own feelings Open, honest discussions about the role of emotions and life stressors in medical concerns Partner up for physical exams Educate about BPD Know that Suicide and Self Harm will be issues http://www.ncbi.nlm.nih.gov/pubmed/17484331 http://www.learningace.com/doc/1139736/439fcb618548f7a4d233ad1696bca6de/borderline-presentation-4-16-09-print- version

12. BPD – The UK Approach People with BPD should not be excluded from healthcare Work in partnership to develop autonomy and promote choice Develop an optimistic and trusting relationship – Many have experienced trauma – Recovery is possible – Be open, engaging, non-judgmental, reliable Anticipate the end of relationships and support transitions http://www.nice.org.uk/guidance/cg78/resources/guidance-borderline-personality-disorder-pdf

13. Summary Borderline Personality Disorder can disrupt healthcare BPD improves with time and hard work Treatment of BPD includes – Avoiding harm – Management of relationships – Therapy – Medications

14. The End! Happy Thanksgiving! See you on December 4! http://www.allindiacelebration.com/wp-content/uploads/2014/11/Thanksgiving-Pictures-4.jpg