_personality disorder in primary care在初级保健的边缘性人格障碍课件

Borderline Borderline Personality Personality Disorder Disorder in Primary Carein Primary Care Ashley Owen, Ph.D.Ashley Owen, Ph.D. Department of Family and Department of Family and Preventive MedicinePreventive Medicine Borderline Personality Disorder (BPD)Borderline Personality Disorder (BPD) Learning Objectives:Learning Objectives: 1.To understand prevalence and related 1.To understand prevalence and related statistics of BPD that are important to statistics of BPD that are important to primary care.primary care. 2.To understand the diagnostic criteria and 2.To understand the diagnostic criteria and conceptualization of BPD.conceptualization of BPD. 3. To discuss the use of structure, boundary-3. To discuss the use of structure, boundary- setting, and constructive responses to setting, and constructive responses to behavior in the context of primary care behavior in the context of primary care treatment.treatment. BPD: BPD: A Little Self ReflectionA Little Self Reflection What Do You Know?What Do You Know? Whats an individual with BPD like?Whats an individual with BPD like? How do you feel when you hear that a How do you feel when you hear that a patient has BPD?patient has BPD? How might you feel after seeing a patient How might you feel after seeing a patient with BPD?with BPD? BPD: BPD: Prevalence and Related StatisticsPrevalence and Related Statistics - - Most people have never heard of BPD even Most people have never heard of BPD even though it accounts for though it accounts for 1/4 of all psychiatric 1/4 of all psychiatric hospital admissionshospital admissions. . - - Affects Affects primarily womenprimarily women. . - - The prevalence rate for the diagnosis of The prevalence rate for the diagnosis of Borderline has been found to be Borderline has been found to be 4 times higher 4 times higher in primary care (6.4%)in primary care (6.4%) than in the than in the general general population (1.6 %).population (1.6 %). BPD: BPD: Prevalence and Related StatisticsPrevalence and Related Statistics Risky:Risky: - - Suicidal ideation very high in primary care Suicidal ideation very high in primary care populations (21.4%)populations (21.4%) - - Up to Up to 10% complete suicide10% complete suicide. . Underidentified in Primary Care:Underidentified in Primary Care: - - About half of patients who have BPD were About half of patients who have BPD were “recognized by their PCPs as having an ongoing “recognized by their PCPs as having an ongoing emotional or mental health problem or had emotional or mental health problem or had received mental health treatment during the received mental health treatment during the past year”.past year”. Gross et al. (2002)Gross et al. (2002) BPD Diagnosis: BPD Diagnosis: ControversialControversial CONS:CONS: May be overdiagnosed by clinicians May be overdiagnosed by clinicians who are frustrated by a “difficult who are frustrated by a “difficult patient“.patient“. Stigma does exist. Stigma does exist. The name Borderline Personality The name Borderline Personality Disorder seems to suggest the Disorder seems to suggest the condition is a personality flaw. condition is a personality flaw. PROS:PROS: Appropriate referral for treatment Appropriate referral for treatment can be extremely helpful.can be extremely helpful. Recognizing BPD may enhance Recognizing BPD may enhance understanding patients with understanding patients with challenging behaviors.challenging behaviors. Physicians may develop rapport, Physicians may develop rapport, feel less frustrated, and even have feel less frustrated, and even have a therapeutic effect by learning a therapeutic effect by learning about BPD.about BPD. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria A pervasive pattern of instability of A pervasive pattern of instability of interpersonal relationships, self- interpersonal relationships, self- image, and affects, and marked image, and affects, and marked impulsivity beginning by early impulsivity beginning by early adulthood and present in a adulthood and present in a variety of contexts. variety of contexts. Five (or more) criteria Five (or more) criteria * * must be met must be met for a diagnosis of BPD.for a diagnosis of BPD. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria Criteria reflect the individualsCriteria reflect the individuals significant difficulty regulatingsignificant difficulty regulating 1.) 1.) EmotionsEmotions * * Shifts in mood usually lasting only Shifts in mood usually lasting only a few hours and rarely more than a few hours and rarely more than a few days a few days BPD: BPD: Diagnostic CriteriaDiagnostic Criteria 1.) 1.) Emotions (contd.)Emotions (contd.) * * Anger that is Anger that is inappropriate, inappropriate, intense or intense or very difficult to control. very difficult to control. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria 2.) 2.) ImpulsivityImpulsivity * * Self-destructive acts, such as self-mutilation or Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than suicidal threats and gestures that happen more than once.once. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria Self-destructive Acts/Self HarmSelf-destructive Acts/Self Harm Those with BPD frequently feel overwhelmed or Those with BPD frequently feel overwhelmed or anxious and seek ways to reduce their frustration, anxious and seek ways to reduce their frustration, stress, or pain. stress, or pain. Dont have an outlet, so Dont have an outlet, so self-injurious behaviors self-injurious behaviors may be experienced may be experienced as releasing pent-up as releasing pent-up emotions. emotions. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria 2.) 2.) Impulsivity(contd.)Impulsivity(contd.) * * Two potentially self-damaging Two potentially self-damaging impulsive behavior patterns. impulsive behavior patterns. These could include:These could include: n n alcohol and other drug abuse, alcohol and other drug abuse, n n compulsive spending,compulsive spending, n n eating disorders,eating disorders, n n gambling, gambling, n n shoplifting, shoplifting, n n compulsive compulsive sexual behavior, sexual behavior, n n reckless drivingreckless driving BPD: BPD: Diagnostic CriteriaDiagnostic Criteria 3.) 3.) Experience of selfExperience of self - not knowing who one is or changing what one - not knowing who one is or changing what one wants to do on a daily basiswants to do on a daily basis * * Marked, persistent identity disturbance shown Marked, persistent identity disturbance shown by uncertainty in: by uncertainty in: self-image, sexual orientation, self-image, sexual orientation, career choice or other long-term career choice or other long-term goals, friendships, goals, friendships, values.values. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria “I have a hard time figuring out my personality. “I have a hard time figuring out my personality. I tend to be whomever Im with.“I tend to be whomever Im with.“ BPD: BPD: Diagnostic CriteriaDiagnostic Criteria * * Chronic feelings of emptiness or boredom.Chronic feelings of emptiness or boredom. “I remember describing the feeling of “I remember describing the feeling of having a deep hole in my stomach. An having a deep hole in my stomach. An emptiness that I didnt know how to fill.” emptiness that I didnt know how to fill.” BPD: BPD: Diagnostic Criteria (contd.)Diagnostic Criteria (contd.) 4.) 4.) Cognitive experiencesCognitive experiences * * transient, stress-related paranoid transient, stress-related paranoid ideation or severe ideation or severe dissociative symptomsdissociative symptoms (Experiencing things as (Experiencing things as unreal)unreal) BPD: BPD: Diagnostic Criteria (contd.)Diagnostic Criteria (contd.) 5.) 5.) Interpersonal relationshipsInterpersonal relationships * * frantic efforts to avoid real or imagined frantic efforts to avoid real or imagined abandonment. abandonment. Note:Note: Do not include Do not include suicidal or self-mutilating suicidal or self-mutilating behavior.behavior. BPD: BPD: Diagnostic CriteriaDiagnostic Criteria * * a pattern of unstable and intense interpersonal a pattern of unstable and intense interpersonal relationships characterized by alternating between relationships characterized by alternating between extremes of idealization and devaluation extremes of idealization and devaluation (chaotic-love/hate)(chaotic-love/hate) BPD: BPD: Diagnostic CriteriaDiagnostic Criteria Additional examples of dysregulation experiences Additional examples of dysregulation experiences in the area of relationships in the area of relationships (Goodwin, 1999)(Goodwin, 1999) - - Alternating clinging and distancing behaviors (I Hate You, Dont Alternating clinging and distancing behaviors (I Hate You, Dont Leave Me). Leave Me). - - Great difficulty trusting people and themselves. Great difficulty trusting people and themselves. - - Sensitivity to criticism or rejection. Sensitivity to criticism or rejection. - - Feeling of “needing“ someone else to survive. Feeling of “needing“ someone else to survive. - - Heavy need for affection and reassurance.Heavy need for affection and reassurance. - - People with BPD tend to have an unusually high degree of People with BPD tend to have an unusually high degree of interpersonal sensitivity, insight, and erpersonal sensitivity, insight, and empathy. Audio segment:Audio segment: KathleenKathleen 3:27-8:403:27-8:40 BPD: BPD: Conceptually SpeakingConceptually Speaking Characteristics stem from the intensity of emotional Characteristics stem from the intensity of emotional instability: instability: Intensity of emotions leads to a tendency to perceiveIntensity of emotions leads to a tendency to perceive n n others behavior as malevolent (related to inappropriate, others behavior as malevolent (related to inappropriate, angry outbursts)angry outbursts) n n abandonment (even minor loss may be experienced as abandonment (even minor loss may be experienced as panic)panic) n n extreme emotional responses to intimacy (manifested in extreme emotional responses to intimacy (manifested in splitting and idealization/devaluing)splitting and idealization/devaluing) n n dissociation (helps the patient separate from the intensity dissociation (helps the patient separate from the intensity of his/her emotions) of his/her emotions) BPD: BPD: Conceptually SpeakingConceptually Speaking Intensity of emotions leads to:Intensity of emotions leads to: n n desperate, impulsive, often unhealthy attempts to make desperate, impulsive, often unhealthy attempts to make themselves feel better or essentially, manage their themselves feel better or essentially, manage their emotions. emotions. n n Whats seen as manipulative or impulsive behaviors are Whats seen as manipulative or impulsive behaviors are desperate attempts to obtain a response from their desperate attempts to obtain a response from their environment.environment. n n The outcome of these behaviors may be soothing and The outcome of these behaviors may be soothing and empowering initially, but behaviors are often self-empowering initially, but behaviors are often self- damaging in the long run.damaging in the long run. BPD: BPD: Conceptually SpeakingConceptually Speaking Difficult to have good relationships if you cant Difficult to have good relationships if you cant regulate emotionsregulate emotions butbut without good relationships its also difficult to without good relationships its also difficult to regulate emotions because much more regulate emotions because much more emotionally vulnerable.emotionally vulnerable. Cyclic problemCyclic problem BPD: BPD: Conceptually SpeakingConceptually Speaking n n Linehan Linehan Individuals with BPD are born with anIndividuals with BPD are born with an innate innate biological tendencybiological tendency to react to react more intensely to lower levels of stress more intensely to lower levels of stress than others and to take longer to than others and to take longer to recover. recover. BPD: BPD: Office ManagementOffice Management 1.) Structure, structure, structure1.) Structure, structure, structure Actively structure the interviewActively structure the interview Respond to repeated office calls by voicing commitment to Respond to repeated office calls by voicing commitment to the relationship within the context of negotiated the relationship within the context of negotiated boundary setting.boundary setting. Schedule brief, frequent visits and give verbal outline of the Schedule brief, frequent visits and give verbal outline of the territory to be addressed in future visits, when a long list territory to be addressed in future visits, when a long list of issues or new last-second issues are brought up.of issues or new last-second issues are brought up. LaForge, E. (2007)LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 2.) Remain calm and empathetic to diffuse hostility.2.) Remain calm and empathetic to diffuse hostility. Respond to emotional outbursts by:Respond to emotional outbursts by: recognizing feelings while requesting appropriate behavior. recognizing feelings while requesting appropriate behavior. “I can see how you might be angry about this, and Id like “I can see how you might be angry about this, and Id like to talk with you about it if you can lower your voice”.to talk with you about it if you can lower your voice”. If the patient does not respond:If the patient does not respond: voice awareness of the heightened emotion at present voice awareness of the heightened emotion at present and the need for a break until this is reduced, when the and the need for a break until this is reduced, when the conversation will resume.conversation will resume. LaForge, E. (2007) LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 3.) Beware of Splitting3.) Beware of Splitting Beware that agreeing with an a devalued view of another Beware that agreeing with an a devalued view of another treater, may be a form of splitting, unhelpful to the treater, may be a form of splitting, unhelpful to the patients treatment.patients treatment. or thator that Being overly protective of another treaters goodness, may Being overly protective of another treaters goodness, may invalidate the perceptions of the individual with BPD.invalidate the perceptions of the individual with BPD. LaForge, E. (2007) LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 4.) Look out for counter-transference4.) Look out for counter-transference Positive counter-transference:Positive counter-transference: Clinician unconsciously responds to idealization in a manner Clinician unconsciously responds to idealization in a manner so as to continue extracting accolades from the patient.so as to continue extracting accolades from the patient. Ex. “giving in” to excessive special requests, responding to Ex. “giving in” to excessive special requests, responding to requests for medications that are not medically warranted.requests for medications that are not medically warranted. Negative counter-transference:Negative counter-transference: Clinician unconsciously responds to devaluation by ignoring, Clinician unconsciously responds to devaluation by ignoring, avoiding, or devaluing complaints.avoiding, or devaluing complaints. LaForge, E. (2007)LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 5.) Open honest discussion of the role of 5.) Open honest discussion of the role of emotions/life stressors in medical concerns.emotions/life stressors in medical concerns. Chronic rotating physical complaints: attempt to Chronic rotating physical complaints: attempt to focus on a specific complaint with brief discussion of focus on a specific complaint with brief discussion of patients psychosocial concerns.patients psychosocial concerns. LaForge, E. (2007)LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 6.) Partner-up for physical 6.) Partner-up for physical examinations.examinations. LaForge, E. (2007)LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 7.) Educate about BPD if appropriate7.) Educate about BPD if appropriate Reviewing the diagnostic criteria for BPD with Reviewing the diagnostic criteria for BPD with the patient may lead the patient the patient may lead the patient to feel more understood by theto feel more understood by the provider. This may help the provider. This may help the patient accept treatment patient accept treatment efforts in general.efforts in general. LaForge, E. (2007)LaForge, E. (2007) BPD: BPD: Office ManagementOffice Management 8.) Know that suicide and self-harm will be issues.8.) Know that suicide and self-harm will be issues. Patients with BPD are likely Patients with BPD are likely to acknowledge suicidal to acknowledge suicidal thoughts very commonly.thoughts very commonly. Take these behaviors seriously, Take these behaviors seriously, assess and document consistently, assess and document consistently, consider options if needed, but also consider options if needed, but also know that suicidal ideation and self harm are ways in know that suicidal ideation and self harm are ways in which patients with BPD cope with their disorder.which patients with BPD cope with their disorder. If you are too uncomfortable with this, refer to someone If you are too uncomfortable with this, refer to someone else.else.LaForge, E. (2007)LaForge, E. (2007) Office Management/Conceptualization: Office Management/Conceptualization: Marshas advice to youMarshas advice to you The “manipulative” patientThe “manipulative” patient “One wants to conceptualize the behavior in a way “One wants to conceptualize the behavior in a way that will keep you liking the patient”that will keep you liking the patient” (Goodwin,1999)(Goodwin,1999) O