personality disorders (axis ii)...“there is a monster in me and you know it! i want to be well,...
TRANSCRIPT
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PERSONALITY DISORDERS (AXIS II)
Cluster A (eccentric)?Paranoid?SchizoidSchizotypal
Cluster B (dramatic)AntisocialBorderline?Histrionic!Narcissistic
Cluster C (anxious)Avoidant?DependentObsessive-compulsive
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MOOD INSTABILITYmood labilitysuicidal, self-mutilating behaviorsemptinessabandonment fears
BEHAVIORAL DYSCONTROLself-defeating impulsivityanger
INTERPERSONAL PSYCHOPATHOLOGYunstable relationshipsidentity disturbance
COGNITIVE-PERCEPTUAL DISTORTIONSdissociation
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“There is a Monster in me and you know it!I want to be well, but the Monster gets me and won’t let go.
No matter how good it gets, the Monster has its way with me and tells me what to do.It scares me.It won’t let me sleep.It makes me go up and down and back and forth,and I hate it.
I will die if it doesn’t let me alone.”
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1010--25% of Patients in Psychiatric Treatment 25% of Patients in Psychiatric Treatment Satisfy Criteria for Satisfy Criteria for
BPD!BPD!So…Why Don’t We Make the Diagnosis?So…Why Don’t We Make the Diagnosis?
• MISDIAGNOSIS
• STIGMA
• INSURANCE
• BIAS
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DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES
XXXXXXADDchild~8%
XXXXXXBAD>25~2%
XXXXXXXXBPDBPD<<teen~6%
CONTIN-UOUS
PSYCHSELF-DESTR
DRUGABUSE
I-PERSCONFL
RAGEMOODINST
IMPUL-SIVE
Dxage
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DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSESDxage
IMP MOODINST
RAGE I-PERSCONFL
DRUGABUSE
SELF-DESTR
PSYCH CONTIN-UOUS
BPDBPD<<teen X X X X X X X XBAD>25 X X X X XMDD<25 X X XADD~6 X X X X XSUDteen X X X X XIED>teen X X XSCZ>teen X X X X X X
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PROGNOSISPROGNOSIS
1. 99% remission after 16 years
2. Recovery in 60% in 24 months—with Tx
3. Recovery in 50% in 10.5 years—w/o Tx
4. 10% relapses (after 8 year remission)
5. Persistent impairment in social/work function
6. 10% suicide
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POSITIVE PROGNOSTIC FACTORSPOSITIVE PROGNOSTIC FACTORS
1. Self-discipline
2. Talent
3. Likeableness
4. Physical attractiveness
5. Supportive relationships
6. Intelligence
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TREATMENT OF BPDTREATMENT OF BPD(circa 1990)(circa 1990)
1. Long-term, intensive, individual psychotherapy.
2. Drugs may sometimes help.
3. Thank you for your attention. Let’s eat
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PHARMACOTHERAPY
symptom 1st choice 2nd choice 3rd choice 4th choiceMoodinstability
SRI different SRI or SNRI
add NL,clonazepam;or switch to MAOI
add MS
Impulsedyscontrol
SRI add NL add MS;or switch toMAOI
Cognitive/perceptualdistortions
NL add SRI or MAOI;or differentNL
SRI= serotonin reuptake inhibitorNL= neuroleptic
MAOI= monoamine oxidase inhibitorMS= mood stabilizer
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EFFECTIVE PSYCHOTHERAPEUTICEFFECTIVE PSYCHOTHERAPEUTIC
TECHNIQUESTECHNIQUES
1. Dialectical Behavioral Therapy (DBT)--Linehan
2. Systematic Training for Emotional Predictability and Problem Solving (STEPPS)
--Bartels, Blum
3. Schema Focused Therapy (SFT)--Young
4. Mentalization Based Therapy (MBT)--Fonagy, Bateman
5. Transference Focused Therapy (TFP)—Kernberg
6. Good Psychiatric Management (GPM)--Gunderson
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THE SET SYSTEMOF
COMMUNICATION
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X
X
“Tough Love”