Title: by Glen O' Gabbard, M'D' Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor
1byGlen O. Gabbard, M.D.Brown Foundation Chair
of PsychoanalysisandProfessor of Psychiatry
Baylor College of Medicine
CHALLENGES INHERENT IN COMBINING PHARMACOTHERAPY
AND PSYCHOTHERAPY
2Treatment Strategies with BPD
- Psychotherapy
- Medication
- APA Practice Guidelines on Borderline Personality
Disorder 2001
3Principles 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
5Mentalization
- 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
6Mentalization (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
7Development of Mentalization
?
- Psychic equivalence mode lt3, ideas or
- perceptions are not felt to be representations,
- but rather accurate replicas of the way reality
-
- is.
8Development of Mentalization (continued)
- Pretend mode characteristic of play, in
- which the childs ideas are experienced as
- representational rather than a direct
- reflection of reality.
?
9Secure 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
10Linkage 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
11Trauma 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
12Transference-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.
14Figure 1 Projective Identification Step 1
bad self
bad object
good self
good object
patient
treater
Patient disavows and projects bad internal object
onto treater.
15Figure 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.
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17Figure 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).
18Promoting 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
19Promoting 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
20Principles 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
21Clinical 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
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24Medication 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
25CHRONIC STRESS
26Hyperresponsiveness 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
27Hyperresponsiveness 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
28Hyperresponsiveness of HPA Axis in Abused Females
with BPD (cont.)
n 24
100 ?g CRH
n 11
n 15
29Hyperresponsiveness of HPA Axis in Abused Females
with BPD (cont.)
- Conclusion
- A history of sustained childhood abuse is
associated with hyperresponsiveness of
ACTH release
30Implications
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
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33SSRIs 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
34SSRIs (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
35SSRIs (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
36Fluvoxamine 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
37Fluvoxamine 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
39SSRI 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.
40Challenges
- Transference to the medication
- Medication as resistance to psychotherapy
41Challenges (cont.)
- The impact of SSRIs on identity diffusion
- The loss of affective response leading to secret
noncompliance
42Challenges (cont.)
- Collaborative treatment arrangements
- Management of splitting
- The myth of the med check
43CONCLUSIONS
- Borderline personality disorder is best
understood and treated without either-or
dichotomies of brain and mind. - Psychosocial factors produce biological changes
in the brain.
44CONCLUSIONS (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.