by Glen O' Gabbard, M'D' Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor - PowerPoint PPT Presentation

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by Glen O' Gabbard, M'D' Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor

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CHALLENGES INHERENT IN COMBINING PHARMACOTHERAPY AND PSYCHOTHERAPY ... aggressive behavior, particularly verbal aggression, and affective lability ... – PowerPoint PPT presentation

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Title: by Glen O' Gabbard, M'D' Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor


1
byGlen O. Gabbard, M.D.Brown Foundation Chair
of PsychoanalysisandProfessor of Psychiatry
Baylor College of Medicine
CHALLENGES INHERENT IN COMBINING PHARMACOTHERAPY
AND PSYCHOTHERAPY
2
Treatment Strategies with BPD
  • Psychotherapy
  • Medication
  • APA Practice Guidelines on Borderline Personality
    Disorder 2001

3
Principles of dynamic psychotherapy
  • Maintain flexibility
  • Expressive and supportive techniques work
    synergistically
  • Transference interpretation is a high-risk,
    high-gain procedure
  • Establish conditions that make psychotherapy
    viable
  • Allow transformation into the bad object
  • Promote mentalization

4
  • M E N T A L I Z A T I O N

5
Mentalization
  • The ability to understand ones own and others
    behaviors in terms of mental states (thoughts,
    feelings, motivations)
  • An appreciation and recognition that such
    perceived states are subjective, fallible,
    malleable and based on only one of a range of
    possible perspectives

  • Fonagy and Target, 1996

6
Mentalization (cont.)
  • exists on a continuum
  • varies from one context to the next
  • is a feature of implicit procedural memory
  • is not related to introspection

  • Fonagy 1998

7
Development of Mentalization
?
  • Psychic equivalence mode lt3, ideas or
  • perceptions are not felt to be representations,
  • but rather accurate replicas of the way reality
  • is.

8
Development of Mentalization (continued)
  • Pretend mode characteristic of play, in
  • which the childs ideas are experienced as
  • representational rather than a direct
  • reflection of reality.

?
9
Secure Attachment and Mentalization
  • Mentalization depends on a caregiver who treats
    the child as a mental agent and ascribes mental
    status to that child.
  • Attachment security promotes the development of a
    sense of ones own minds and an awareness that
    others have minds.

  • Fonagy Target 1997

10
Linkage Between BPD and Insecure Attachment
  • Research links BPD with insecure attachment
    either preoccupied or unresolved/disorganized
  • The failure to resolve trauma appears to
    distinguish the BPD group
  • Stalker and
    Davies 1995
  • Alexander et al 1998

  • Patrick et al 1994

11
Trauma and Mentalization
  • Trauma leads to a defensive withdrawal from the
    mental world.
  • BPD patients cope with abuse by avoiding
    reflection on the content of the caregivers
    mind, which prohibits resolution of abuse
    experiences.

  • Allen 2001, Fonagy 1998

12
Transference-Countertransference Significance
  • The patients failure of mentalization may
    activate a terrorized state, which in turn leads
    to an incapacity to think and reflect.
  • Through projective identification, patients may
    enact the victimized self with the therapist cast
    in the role of persecuting object.

13
  • Patient may colonize the mind of the therapist
    through insistent accusations and intensely
    emotional conviction.
  • Therapists may lose capacity for mentalization
    and think in the same way the patient does.

14
Figure 1 Projective Identification Step 1
bad self
bad object
good self
good object
patient
treater
Patient disavows and projects bad internal object
onto treater.
15
Figure 2 Projective Identification Step 2
bad self
bad object
good self
good object
patient
treater
Treater unconsciously begins to feel and/or
behave like the projected bad object in response
to interpersonal pressure exerted by the patient.
This step may be referred to as projective
counteridentification.
16
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17
Figure 3 Projective Identification Step 3
modified bad self
modified bad object
good self
good object
patient
treater
Treater contains and modifies the projected bad
object, which is then re-introjected by the
patient and assimilated (introjective
identification).
18
Promoting Mentalization
  • Focus on patients elaboration of emotional
    states that trigger acting out
  • Observe the patients moment-to-moment changes in
    feelings and reflecting, and reflect those back
    to the patient
  • Encourage exploration of therapists feelings and
    mental state
  • Judicious use of self-disclosure

19
Promoting Mentalization(cont.)
  • Be neither intrusive nor inattentive
  • Consistency, constancy and coherence
  • More here and now than there and then
  • Help the patient generate multiple perspectives
  • Therapist constructs a representation of the
    patient

20
Principles of Dynamic Psychotherapy
  • Set limits when necessary
  • Establish and maintain the therapeutic alliance
  • Manage splitting between psychotherapy and
    pharmacotherapy
  • Help the patient reown aspects of the self that
    are disavowed and/or projected elsewhere
  • Monitor countertransference feelings

21
Clinical Manifestations of Splitting
  • Alternating expression of contradictory behaviors
    and attitudes that the patient regards with lack
    of concern and bland denial
  • The compartmentalization of individuals into all
    good and all bad camps
  • A coexistence of contradictory self
    representations that alternate with one another

22
  • P H A R M A C O T H E R A P Y

23
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24
Medication Strategies for Borderline Personality
Disorder Target Symptoms
Affective Dysregulation Symptoms SSRIa
Low-dose atypical antipsychotic
Lamotrigine Topiramate Clonazepamb MAOIc
Lithium
Impulsive Behavioral Symptoms SSRI Low-dose
atypical antipsychotic Lithium
carbonate MAOI Valproate Carbamazepine Naltrexone
(if self-mutilation and/or alcohol abuse are
present)
  • Cognitive Perceptual
  • Symptoms
  • Low-dose atypical
  • antipsychotic
  • Risperidone
  • Olanzapine
  • Aripiprazole
  • SSRI

aSSRI selective serotonin reuptake inhibitor bDo
not use alprazolam as it may result in
disinhibition cMAOI monoamine oxidase inhibitor
should be used with considerable caution
because of dietary restrictions
25
CHRONIC STRESS
26
Hyperresponsiveness of HPA Axis in Abused Females
with BPD
  • 39 BPD patients were given a combined
    dexamethasone/CRH test using 11 healthy
    subjects as controls
  • 24 had sustained childhood abuse
  • 15 did not have sustained childhood abuse
  • or co-morbid disorders
  • Rinne et al Biol.
    Psych 521102-1112, 2002

27
Hyperresponsiveness of HPA Axis in Abused Females
with BPD (cont.)
  • Chronically abused BPD patients had a
    significantly enhanced ACTH cortisolresponse to
    the DEX/CRH challenge compared with non-abused
    subjects

28
Hyperresponsiveness of HPA Axis in Abused Females
with BPD (cont.)


n 24
100 ?g CRH
n 11
n 15
29
Hyperresponsiveness of HPA Axis in Abused Females
with BPD (cont.)
  • Conclusion
  • A history of sustained childhood abuse is
    associated with hyperresponsiveness of
    ACTH release

30
Implications
Affect State
Persecuting Object
Victimized Self
Hypervigilant Anxiety
  • The affect state of anxiety and hypervigilance
    associated with HPA hyperreactivity is linked to
    a specific internal object relationship involving
    a persecuting object and a
    victimized self

31
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32
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33
SSRIs Personality Disorders
  • 4 double-blind placebo-controlled trials
  • Improvements in anger, impulsive aggressive
    behavior, particularly verbal aggression, and
    affective lability
  • Salzman
    et al 1995 Markovitz 1995

  • Coccaro and Kavouissi 1997 Rinne et al 2002

34
SSRIs (cont.)
  • May increase verbal declarative memory and
    hippocampal volume

  • Vermetten Vythilingam 2003
  • May reduce the hyperreactivity of
    hypothalamic-pituitary-adrenal axis by reducing
    hypersecretion of CRF

35
SSRIs (cont.)
  • In animal studies, paroxetine after 3 weeks
    reverses the increase in CRF mRNA expression, CRF
    concentration and the increased HPA axis response
    to stress secondary to early life trauma
  • When treatment stops, the indices return to their
    usual abnormal values


  • Nemeroff 2003

36
Fluvoxamine in BPD
  • 30 female BPD patients were given a combined
    dexamethasone- and corticotropin-releasing
    hormone test (DEX/CRH) before and after
    fluvoxamine treatment at 150 mg/day
  • 17 patients had a history of sustained childhood
    abuse 13 patients had no abuse history

  • Rinne
    et al 2003

37
Fluvoxamine in BPD (cont.)
  • Both 6- and 12-week fluvoxamine treatments were
    associated with a significant reduction of ACTH
    and cortisol response to the DEX/CRH test
  • The magnitude of the reduction was dependent on
    the presence of sustained childhood abuse


  • Rinne et al 2003

38
Concentration time curve of ACTH response to
DEX/CRH challenge pre- and
post-fluvoxamine (FLVX) treatment for abused (n
17) and not abused (n 13) BPD subjects.

Rinne et al 2003
39
SSRI Impact on Psychotherapy
  • ? Hyperreactivity of HPA Axis facilitates
    mentalization, awareness of internal states, and
    alters the relationship with the therapist
  • When the terrorized, hypervigilant state in the
    patient is reduced, the therapists
    countertransference is diminished and his/her
    capacity to think and work psychotherapeutically
    is less likely to be eroded by intense affect
    states in the patient.

40
Challenges
  • Transference to the medication
  • Medication as resistance to psychotherapy

41
Challenges (cont.)
  • The impact of SSRIs on identity diffusion
  • The loss of affective response leading to secret
    noncompliance

42
Challenges (cont.)
  • Collaborative treatment arrangements
  • Management of splitting
  • The myth of the med check

43
CONCLUSIONS
  • Borderline personality disorder is best
    understood and treated without either-or
    dichotomies of brain and mind.
  • Psychosocial factors produce biological changes
    in the brain.

44
CONCLUSIONS (cont.)
  • Medication and psychotherapy work synergistically
    to make changes in the brain over time.
  • The language of mind is necessary for
    psychotherapy, but its impact is on the brain as
    well as on the creation of a theory of mind.
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