Download The Anxiety Disorders Some Practical Questions & Answers

The Borderline Patient
A Patient-Centered, Evidence-Based Diagnostic and
Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
February 18, 2011
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
3These are complicated and exasperating patients; your gut instincts will not serve you well.
2Please
Why is this important?
• 10 to13-percent of the population
will meet the criteria for one or
more of the personality disorders
during their lifetimes.
• These people often seek medical
care.
• They are some of the most
difficult patients you will ever
attempt to serve.
• Patients with Borderline
Personality Disorder (BPD) are
especially challenging.1,2
• Recognizing their underlying
disorders and managing these
patients appropriately won’t
entirely eliminate the challenges
these patients pose, but it will
make your professional life easier.
1When
2
• After mastering the information
in this presentation, you will be
able to identify
– The general diagnostic criteria
for a personality disorder,
– The three “clusters” of
personality disorders and the
characteristics of each cluster.
– The specific diagnoses
contained in each cluster,
– The diagnostic criteria for
Borderline Personality Disorder
(BPD),
– Some of the associated features
of BPD,
– A differential diagnosis,
– A typical treatment plan, and
– Some expected treatment
challenges.
a primary care physician calls you in the afternoon, you know it’s important.
“A patient just told me that she loves me. What do I do now?”
What are the general diagnostic
criteria for a personality disorder?
• An enduring pattern of inner experience
and behavior that differs from the
expectations of the culture. This pattern is
evident in
–
–
–
–
•
•
•
•
•
1We
Ways of perceiving and interpreting things
Emotional responses
Interpersonal functioning
Impulse control
Pattern is inflexible and pervasive
Pattern leads to distress or impairment1,2,3
Pattern is stable and of long duration
Not due to another mental disorder
Not due to substance use
all have personality quirks. This is much more than that.
make the diagnosis, you must uncover evidence of social or occupational impairment or distress.
3The people in their lives finally wash their hands of them in hopeless frustration.
2To
What specific diagnoses are included
here?1,2,3
• The odd or eccentric cluster of Personality
Disorders
– Paranoid (suspicious)
– Schizoid (withdrawn)
– Schizotypal (withdrawn and weird)
• The dramatic or erratic cluster
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–
–
–
Antisocial (disregard for rights of others)
Borderline (unstable and impulsive)
Histrionic (attention-seeking)
Narcissistic (self-centered)
• The anxious or fearful cluster
– Avoidant (social discomfort)
– Dependent (needy)
– Obsessive-Compulsive (perfectionist)
1These
diagnoses frequently coexist and overlap.
usually takes more than one interview to make the diagnosis.
3Always ask screening questions.
2It
How might a patient with BPD
present?
• This is a 25-year-old single
graduate student.
• “I’ve been thinking of killing
myself.”
• “My boyfriend went alone on a
vacation to Europe.”
• “I told him we needed some
time apart.”
• “We were like Siamese twins
and I couldn’t stand it.”
• “But I can’t believe he would
leave me like this.”
• “I feel abandoned and empty.”
• “I am angry that he would make
me feel like this.”
• “He should have known it was
only a test.”
• “Sometimes I cut myself
because that is the only way to
let the pain out.”1
• “I can’t stand to be with
someone and I can’t stand to be
without someone.”
• “I’ve been in several different
graduate programs, but the
faculty members never turned
out to be as nurturing as they
claimed.”
• “My parents divorced when I
was nine, and we’ve not been
close.”
• “Nothing I do will ever please
my mother, and I hate her.”
• “I couldn’t get by without the
money she gives me though.”
• When talking about her
relationship with her boyfriend,
she alternated between
distraught sobbing and barelycontained rage.
• Listen to a patient here.
What are the diagnostic criteria for
BPD?
• A pervasive pattern of instability of interpersonal
relationships, self-image and affects
• Marked impulsivity beginning by early adulthood
and present in a variety of contexts
• Five or more of the following:
– Frantic efforts to avoid real or imagined
abandonment
– Pattern of unstable and intense relationships1
– Unstable self image
– Impulsivity
– Recurrent suicidal behavior or self-mutilating
behavior
– Mood instability
– Chronic feelings of emptiness
– Intense anger
– Stress-related suspicion or dissociation
1I’ve
been stalked at home, church and on vacation by these patients.
What associated features might you
see?
• These people tend to undermine themselves and
rarely achieve the level of accomplishment they
might otherwise reach.
• Transient psychotic symptoms are common.1,2
• Suicide is a constant risk.
• Substance abuse is common.
• Physical disability from failed suicide attempts
and self mutilation is common.
• Physical and sexual abuse along with conflict and
neglect are often found in their early histories.
• They often also suffer from concomitant mental
disorders.
1These
2These
patients can be downright spooky.
patients do dramatic and unexpected things.
What other diagnoses might your
include in the differential diagnosis?
• Mood disorders1
• Other personality disorders
– Dependent
– Histrionic
– Narcissistic
• Personality change due to a general
medical condition
• Personality changes associated with
chronic substance use
• The underlying personality diagnosis
often only becomes clear over time.
1Episodic
Axis I disorders often obscure underlying personality disorders.
What might a typical treatment plan
look like?
• Counseling
– Long-term treatment is
generally required.
– The setting and
acceptance of limits is
necessary.
– A recognition of
pathologic patterns of
impulsive behavior is
essential.
– Patience is demanded.
– Boundaries must be set
and respected.
– Discharge from
treatment is sometimes
the most helpful
therapy.1,2
1You
will not be able to help everyone.
them if you can’t trust them or can’t stand them.
2Transfer
• Medication
– All medications are
double-edged swords.
– Avoid sedatives
altogether.
– Antidepressants may be
necessary at times.
– Atypical antipsychotics in
low dosages have been
helpful in some cases.
– Lithium may help to
prevent suicide—or it
may be the instrument of
the patient’s demise.
What are some of the treatment
challenges you can expect?
• Noncompliance is the rule.
• These patients will demand a special relationship
with you and special treatment from you, and
they will never be satisfied.
• These patients will be exceptionally demanding.1
• You will likely feel very frustrated, helpless,
resentful and angry. (And that is only the
beginning.)
• They will draw you in with their need, lead you to
believe no one else can help them and then
devastate you with their enraged contempt.
• If you fail to set limits, they will terrorize you with
their demands.
• If you fail to respect professional boundaries, they
will ruin your personal and professional lives.
• But these people really need help.
• If you are not up to it, find them the help they
need.
1A
patient once told me that it was my job to accept whatever she said and never confront her.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
Where can you learn more?
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1,2Please
American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
note that you must master all of the information in a basic neurology textbook and a basic psychiatry
textbook to do well on the comprehensive, standardized final examination.
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
Are there other questions?
www.somc.org
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