What should we do and not do in treatment of borderline personality disorder?

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What should we do and not do in treatment of
borderline personality disorder?

• Prof Anthony W Bateman
• Glasgow 2006

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Acknowledgments

• St Anns Hospital, London
• Catherine Freeman
• Rory Bolton
• Countless other clinicians
• University College, London
• Prof Peter Fonagy
• Dr Mary Target
• Dr Liz Allison
• Menninger/Baylor Department of Psychiatry
• Dr Efrain Bleiberg,
• Dr Jon Allen

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Therapies for BPD

• Supportive Psychotherapy
• Behavioural
• Dialectical Behaviour Therapy (DBT)
• Cognitive
• Manual Assisted Cognitive Therapy (MACT)
• Schema Focused Psychotherapy (SFP)
• Psychoanalytic
• Transference Focused Psychotherapy (TFP)
• Mentalization Based Treatment (MBT)

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Outcomes (selected) at baseline 12 months in
MACT and TAU groupsTyrer, P., Tom, B., Byford,
S., et al (2004) Differential effects of manual
assisted cognitive behaviour therapy in the
treatment of recurrent deliberate self-harm and
personality disturbance the POPMACT study.
Journal of Personality Disorders, 18, 102-116.
MACT Baseline 12 months TAU Baseline 12 months
HADS dep HADS anx (n400) 11.3 7.0 14.0 10.3 11.2 7.1 14.3 10.3
Social function (n400) 13.3 9.8 13.3 10.3
GAF symptoms (n402) 18.7 61 18.6 62
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Summary of clinical findingsTyrer, P., Tom, B.,
Byford, S., et al (2004) Differential effects of
manual assisted cognitive behaviour therapy in
the treatment of recurrent deliberate self-harm
and personality disturbance the POPMACT study.
Journal of Personality Disorders, 18, 102-116.

• Neither self-harm episodes, nor other
  psychometric assessment outcomes, showed any
  convincing differences between MACT and TAU,
  either at 6 or 12 months.
• Possible that a longer period of treatment or
  greater engagement in face-to-face treatment,
  were this achievable in routine health care
  settings, would show more favourable results.
• BPD showed an increase in costs in health service
  usage with MACT
• Manual-assisted cognitive therapy slightly
  increases the likelihood of self harm relative to
  treatment as usual with PD patients

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Dialectical Behaviour Therapy

• Initial improvement
• Disappointing in follow-up
• Replication in inner city London delivered poor
  results
• High drop out
• Worse on a number of measures
• Level of training required unknown but considered
  extensive
• Better for self-harm than suicide
• Effect on personality function unclear
• Poor social-emotional function probably continues
• Variable change on depression and hopelessness

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Figure 2. Frequency of self-mutilating behaviors
in the past 3 months at week 22 and week 52 since
the start of treatment by treatment condition.
DBT indicates Dialectical Behavior Therapy TAU
indicates treatment-as-usual.
Verheul, R., Van Den Bosch, L. M., Koeter, M. W.,
et al (2003) Dialectical behaviour therapy for
women with borderline personality disorder
12-month, randomised clinical trial in The
Netherlands. Br J Psychiatry, 182, 135-140.
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Figure 4. Frequency of self-mutilating behaviors
in the past 3 months at week 22 and week 52 since
the start of treatment by treatment condition and
baseline severity group. Membership of severity
groups is determined by median split on the
lifetime number of self-mutilating acts (i.e.,
lt14 versus ? 14). DBT indicates Dialectical
Behavior Therapy TAU indicates
treatment-as-usual.
Verheul, R., Van Den Bosch, L. M., Koeter, M. W.,
et al (2003) Dialectical behaviour therapy for
women with borderline personality disorder
12-month, randomised clinical trial in The
Netherlands. Br J Psychiatry, 182, 135-140.
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Change in Reflective Function as a Function of
Time and Treatment
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Trial I RCT of Psychoanalytic Partial Hospital
Treatment (18 months)(Bateman Fonagy, 1999,
2001, 2003)

• Attempted Suicide NNT (18 months) 2.1
• NNT (36 months) 1.9
• Self-Mutilating NNT (18 months) 2.1
• NNT (36 months) 2.0
• Inpatient Episodes ES(18m) 1.4
• ES(36m) 1.1
• Depression NNT(36m) 2.1

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Limitations

• Small sample size
• Control treatments undefined
• Multi-component treatment
• No replication sites yet (no longer true)
• Costly, relative to an outpatient treatment (at
  least relative to little service)
• Only for most chaotic and severe
• Length of treatment unclear

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Dutch Cohort Study
Effect size SCL-90 1.1 BDI 2.2 IIP 2.2 OQ-45
2.0
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Conclusions from treatment trials

• RCTs have shown modified psychodynamic therapies
  (MBT and TFP) and modified CBT (DBT, SFT) to be
  moderately effective
• Non-randomised trials show other implementations
  of psychodynamic, supportive and CBT
  interventions to be somewhat effective
• Briefer periods of hospitalisation shown to be
  more effective than longer ones
• Hospitalisation motivated by suicidal threat is
  ineffective (Paris, 2004)
• A range of well-organised and co-ordinated
  treatments are effective for BPD

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Problems, Problems, Problems

• Some efficacy of various treatments which may
  bring forward natural improvement
• More limited effects in severe populations
• Questionable generalizability of treatments
• High levels of training required
• Poor penetration of psychiatric services

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Re-mapping the course of borderline personality
disorder
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Therapeutic Nihilism About BPD

• Early follow-up studies
• inexorable progression of the disease
• burnt out borderlines
• Condition resistant to therapeutic help
• intensity and incomprehensibility of emotional
  pain
• dramatic self-mutilation
• ambivalence in inter-personal relationships
• wilful disruption of any attempt at helping

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Remissions and Recurrences Among 275 Patients
with BPD
Percent
Source Zanarini et al. (2003) Am. J. Psychiat.
160, 274-283
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Time to 12 Month Remission for DIPD Positive
Cases (The CLPS Study)
Proportion not remitting
Time from intake in months
Grilo et al., (2004) JCCP, 72, 767-75.
Remission is defined as 12 months at 2 or fewer
criteria for PDs Remission is defined as 2
months at 2 or fewer criteria for MDD
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Summary of Remission Findings

• After six years 75 of patients diagnosed with
  BPD severe enough to require hospitalisation,
  achieve remission by standardised diagnostic
  criteria.
• About 50 remission rate has occurred by four
  years but the remission is steady (10-15 per
  year).
• Recurrences are rare, perhaps no more than 10
  over 6 years.
• Treatment has no (or only negative) relationship
  to outcome

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Impulsive Features, Affective Instability and
Identity Problems of 290 BPD
Percent
Source Zanarini et al. (2003) Am. J. Psychiat.
160, 274-283
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Interpersonal Features of 290 BPD Patients
Followed Prospectively
Percent
Source Zanarini et al. (2003) Am. J. Psychiat.
160, 274-283
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Affective Features of BPD Followed Prospectively
Percent
Source Zanarini et al. (2003) Am. J. Psychiat.
160, 274-283
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Differential improvement rates of BPD symptom
clusters

• Impulsivity and associated self mutilation and
  suicidality that show dramatic change
• The dramatic symptoms (self mutilation,
  suicidality, quasi-psychotic thoughts) recede
• Affective symptoms or deficits of social and
  interpersonal function are likely to remain
  present in at least half the patients.
• anger,
• sense of emptiness,
• relationship problems,
• vulnerability to depression

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Time to GAF 12 Month Remission for DIPD Positive
Cases (The CLPS Study)
Proportion not remitting
Time from intake in months
Grilo et al., (2004) JCCP, 72, 767-75.
Remission is defined as 12 months at 2 or fewer
criteria for PDs Remission is defined as 2
months at 2 or fewer for MDD
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Determinants of remission

• When dramatic improvements occur, they sometimes
  occur quickly,
• often associated with relief from severely
  stressful situations (Gunderson, Bender,
  Sanislow, et al, 2003)
• Co-morbidities undermine the likelihood of
  improvement (Zanarini, Frankenburg, Hennen, et
  al, 2004)
• Persistence of substance use disorders

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Implications of Recent Follow Along Studies

• Implication of secondary persistence of
  social/functioning impairment
• Treatments should be directed at social function
• Social skill building, community/groups
• Vocational rehabilitation testing training
• Improve adaptive capabilities (as opposed to
  decreasing maladaptive behaviours) e.g.
  recreational or leisure time activities
• GAF is very relevant outcome measure
• Need for better measures sensitive to social
  functioning in this population (?APFA)

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Partial Hospital RCT Patients at 5 yrs FU
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Partial Hospital RCT Patients at 5 yrs FU
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Partial Hospital RCT Attempting Suicide
N44 NNT (18 months)2.1 NNT (36 months)1.9 NNT
(60 months)2.1






p lt .05 p lt .01 p lt .001
Follow -up
Treatment
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Partial Hospital RCT Employment
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Partial Hospital RCT GAF Scores
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The outcome paradox in BPD
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Het alternatief
Non-suitability
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The paradox of the outcome of BPD

• Many treatments show moderate effectiveness
• The disorder has a positive natural progression,
  irrespective of treatment
• Historically, experts agreed about the
  treatment-resistant character of the disorder
• 97 of patients receive outpatient of care
• average of 6 therapists
• TAU is only marginally effective (Lieb et al,
  2004)

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The painful conclusion

• Some psychosocial treatments impede the patients
  recovery following
• The natural course of the disorder
• Advantageous social circumstances

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Suggestive evidence for the reality of iatrogenic
harm

• Classic follow-up of patients treated in the
  1960s and 1970s (Stone, 1990)
• 66 recovery only achieved in 20 years
• 4 times longer than recent studies
• One year hospitalisation is significantly less
  effective than 6 months hospitalisation (Chiesa
  et al, 2003)
• The iatrogenic effects of hospitalisation persist
  at 72 months follow-up
• Brief manual-assisted cognitive therapy slightly
  increases the likelihood of self harm relative to
  treatment as usual with PD patients (Tyrer et al,
  2004)

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Suggestive evidence for the reality of iatrogenic
harm

• Karterud et al 530 patients high intensity
  treatment v 330 low intensity
• Low intensity better for the BPD-patients.
• lower number of dropouts (27 versus 32)
• higher number of patients achieving reliable
  change in GAF which was maintained at one year
  follow-up.
• Improvements in treatment outcome may be a
  consequence of the changing pattern of healthcare
  in the US
• reduced the likelihood of iatrogenic
  deterioration associated with damaging side
  effects of lengthy psycho-social treatment

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Iatrogenesis, psychotherapy and BPD

• Pharmacological studies assume the possibility of
  and test for adverse reactions
• Psychotherapy is assumed to be at worse inert
• No systematic studies of adverse reactions to
  psychotherapy
• No theory of adverse reaction
• Adverse reaction must link to mechanisms of change

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How change occurs in therapy with BPD

• Interpersonal mechanism of change
• Change occurs not through insight, catharsis, or
  negotiation
• Change occurs through new emotional experience in
  the context of attachment salient interactions
• Not the content of therapy but the process of
  treatment

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Adverse reactions and ordinary mechanisms of
therapeutic change

• Psychotherapies interface with a range of
  processes associated with technique (distorted
  cognitions, coherence of narrative, expectations
  of the social environment, expectations of the
  self hope)
• A generic factor in common to all these
• Consideration of ones experience of ones own
  mental state alongside that which is presented
  through therapy (by the therapist, by the group)
• Assumes appreciating the difference between ones
  experience of ones own mind and that presented by
  another person
• We assume that the integration of current
  experience of mind with alternative views is
  foundation of the change process (Allen and
  Fonagy, 2002)

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Reduced appreciation of mind ? vulnerability to
therapy

• Individuals with BPD have impoverished model of
  mental function
• Own and others
• Schematic, rigid, extreme ideas about states of
  mind
• Creates vulnerability to
• Emotional storms
• Impulsive actions
• Problems of behavioural regulation
• Consequently unable to compare
• A self-generated model
• Model presented by mind expert
• Maladaptive consequences
• Accept alternatives uncritically, without
  integration, (untherapeutic)
• Reject them wholesale ? drop-out of therapy

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The danger of psychotherapies for BPD

• The therapists general stance may often in
  itself be harmful, however well-intentioned
• I think what you are really telling me ..
• It strikes me that what you are really saying
• I think your expectations of this situation are
  distorted
• A person who cannot discern the subjective state
  associated with anger cannot benefit from
• Being told that they are feeling angry
• And what the underlying reasons for the anger
  might be

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The fate of assertions about the inner world of
BPD patients

• It can only be accepted as true or rejected
  outright
• Dissonance between patients inner experience and
  external perspective is not appreciated ?
  bewilderment ? instability by challenging and
  undermining the patients own enfeebled
  representation of inner experience ? more rather
  than less mental and behavioural disturbance

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The Fonagy Bateman Principle

• A therapeutic treatment will be effective to the
  extent that it is able to enhance the patients
  mentalising capacities without generating too
  many iatrogenic effects

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Clinical Implications
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The Focus of Psychotherapy is Often on
Autobiographical Memory
Youre born, you deconstruct your childhood, and
then you die
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Dysregulation of attentional capacities

• With individuals whose attachment relationships
  have been disorganized we may anticipate quite
  severe problems in affect regulation and
  attentional control along with profound
  dysfunctions of attachment relationships
• Exploratory psychotherapy techniques are likely
  to dysregulate the patients affect
• It is wise to anticipate difficulties in
  effortful control

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Disorganisation of self

• The therapist should be alert to subjective
  experiences indicating discontinuities in self
  structure (e.g. a sense of having a
  wish/belief/feeling which does not feel like
  their own.)
• It is inappropriate to see these states of minds
  as if they were manifestations of a dynamic
  unconscious and as indications of the true but
  disguised or repressed wish/belief/feeling of
  the patient
• The discontinuity in the self will have an
  aversive aspect to most patients leading to a
  sense of discontinuity in identity (identity
  diffusion)

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Projection of alien self

• Patients will try to deal with discontinuous
  aspects of their experience by externalisation
  (generating the feeling within the therapist)
• The tendency to do this had been established
  early in childhood
• It is not going to be reversed simply by bringing
  conscious attention to the process therefore
  interpretation of it is mostly futile

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Doctor, I feel very depressed
That was just a joke to break the ice. Now dont
immediately cry you silly cow!
That woman is clearly not ready for therapy.
I can understand with such a sad face
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Psychic equivalence

• Characterised by conviction of being right that
  makes entering into Socratic debates mostly
  unhelpful
• Patients commonly assume that they know what the
  therapist is thinking - claiming primacy for
  introspection (i.e. saying that one knows ones
  own mind better than the patient) will lead to
  fruitless debate
• Therapist may make ill advised attempt to
  defend position
• Grandiosity and idealization are also expectable
  consequences of an unquestioning mind

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Psychic equivalence

• It is not the action itself that carries most
  meaning in this mode but deviation from action
  that is contingent with the patients wishes
• Self-harm, suicide attempts and other dramatic
  actions tend to bring about contingent change in
  the behaviour of most people - patient
  experiences a sense of being cared about
• Misuse of mentalisation may be linked to such
  pseudo-manipulativeness and involve realistic
  risk of harm to the patient or interactive partner

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Pseudomentalizing

• Challenging pseudo-mentalisation in the pretend
  mode can provoke extreme?reactions because of the
  vacuum it reveals
• Pretend mode pseudo-mentalisation denies the
  therapist's own sense of reality and the
  therapist can be left feeling excluded and trying
  harder to connect to the patients discourse
• The patients experience of lack of meaningful
  connection to reality can be the prompt and drive
  behind the search for connection but the
  connections found are often random, complex,
  untestable and confusing exploration is
  unproductive

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Iatrogenesis

• Therapeutic interventions run the risk of
  exacerbating rather than reducing the reasons for
  temporary failures of mentalising
• Non-mentalising interventions tend to place the
  therapist in the expert role declaring what is on
  the patients mind which can be dealt with only
  by denial or uncritical acceptance
• To enhance mentalising the therapist should state
  clearly how he has arrived at a conclusion about
  what the patient is thinking or feeling
• Exploring the antecedents of mentalisation
  failure is sometimes but by no means invariably
  helpful in restoring the patients ability to
  think

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Therapist Stance

• Not-Knowing/Inquisitive
• Neither therapist nor patient experiences
  interactions other than impressionistically
• Identify difference I can see how you get to
  that but when I think about it it occurs to me
  that he may have been pre-occupied with something
  rather than ignoring you.
• Acceptance of different perspectives
• Active questioning
• Monitor you own mistakes
• Model honesty and courage via acknowledgement of
  your own mistakes
• Current
• Future
• Suggest that mistakes offer opportunities to
  re-visit to learn more about contexts,
  experiences, and feelings

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Therapist/Patient Problem
THERAPY STIMULATES ATTACHMENT SYSTEM
DISCONTINUITY OF SELF
EXPLORATION
ATTEMPT TO STRUCTURE by EFFORT TO CONTROL SELF
/OR OTHER
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Therapist/Patient Problem
ATTEMPT TO STRUCTURE by EFFORT TO CONTROL SELF
/OR OTHER
RIGID SCHEMATIC REPRESENTATION NON-MENTALIZING CON
CRETE MENTALIZING (PSYCHIC EQUIVALENCE) PSEUDO
MENTALIZING (PRETEND) MISUSE OF MENTALIZING
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FAQs about Mentalization Based Treatment

• Do you use validation?
• Yes
• observing and reflection - two aspects of
  validation are common to every therapy and are an
  essential aspect to MBT.
• Direct validation
• DBT - used to confirm the patients experience
  and contingent response as being understandable
  in a specific context.
• MBT follows the same principles but the focus is
  on exploration and on elaborating a multi-faceted
  representation based on current experience
  particularly with the therapist.

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FAQs about Mentalization Based Treatment

• Does the mentalizing therapist self-disclose
• Yes. But no more than you would in everyday
  interaction.
• Explanation of the reasons for your reaction is
  useful especially when challenged by the patient
• Answer appropriate questions prior to exploration
  in order not to use fantasy development as part
  of therapy
• Careful self-disclosure
• Verifies a patients accurate perception
• Underscores the reality that you are made to feel
  things by him which is an essential aspect of
  treatment

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FAQs about Mentalization Based Treatment

• Do you use fantasy development about the
  therapist?
• No
• Stimulating fantasy about the therapist is likely
  to be experienced as fact
• Confirms the patients distorted beliefs or
  assumptions
• Borderline patient does not retain an as if
  quality or observing ego when operating in
  psychic equivalence

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Thank you for mentalizing!

• For further information
• anthony_at_abate.org.uk

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Trial II Outpatient Implementation of
Mentalization Based Therapy for Borderline
Personality Disorder
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Design of pilot study of out-patient MBT
Eligible consecutive patients SCID III plus
Clarkin Severity (N56)
Patients randomised (N50)
Patients not randomised due to refusal (N6)
Minimisation for Age (18-25, 26-30,
gt30) Gender Antisocial PD 32 Experimental
control ratio
Naturalistic follow-up Where consent to research
now or later
Mentalization Based Treatment Individual and
Group Psychotherapy 18-months (N30)
Non-manualised therapies Individual or group
supportive psychotherapy 18-months plus normal
care (N20)
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Pilot Study out-patient MBT
Patients in treatment (N50)
Non-manualised therapy group Individual, group,
other psychotherapy plus normal care 18-months
(N20)
Mentalization Based Treatment Individual and
group psychotherapy 18-months (N30)
3-months SCL-90, BDI, SpielST, IIP,
SAS 6-months Sui Self-harm Inventory Hospital
Admission Service Usage e.g.AE
3-months SCL-90, BDI, SpielST, IIP,
SAS 6-months Sui Self-harm Inventory Hospital
Admission Service Usage e.g.AE
Drop-out3
Drop-out7
Intention to treat analysis(N)
Intention to treat analysis (N)
18 Months Follow-up (N?)
18 Months Follow-up (N?)
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Pilot Study Attempted Suicide (NNT3.8)

PH outcome
p lt .05 p lt .01 p lt .001
Trend O/P MBT W.45, Chi squared 38.7, df3,
plt.001 Trend Control W.16, Chi squared 9.33,
df3, plt.05
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Self-Mutilating Behavior (NNT6.7)
n.s.
PH outcome
p lt .05 p lt .01 p lt .001
Trend O/P MBT W.20, Chi squared 17.5, df3,
plt.001 Trend Control W.08, Chi squared 4.5,
df3, n.s.
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Self Rated Depression (BDI)

PH outcome
ANOVA Significance of interaction term F2.4, 83
6.6, plt.01
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Some progress but limitations

• Bigger sample size
• Control treatments defined
• Two-component treatment
• Replication sites in UK and Netherlands
• Cheaper than most outpatient treatments
• Requires less training of staff team
• BUT
• Effective component not yet clear
• Measuring mechanisms of change.

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Slides

• http//www.psychol.ucl.ac.uk/
• psychoanalysis/anthony.htm