Today, I closed the poll about treatment and BPD. The results showed that the majority of people with BPD are NOT in treatment. I have started a new poll about substance abuse and BPD.
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Kiera Van Gelder shared with me today an excellent article she wrote about “coming off the couch” and admitting/sharing that you have BPD. It’s time to fight the stigma of BPD.
![]() Anti-depressants and Depression I believe that it has. Why? Well, there are a number of reasons that depression is a catch-all diagnosis. One certainly is the influence of the pharmaceutical industry given that billions of dollars are spent on anti-depressants each year. Also, doctors who are not mental health professionals (like GP’s) are prescribing anti-depressants if their patients are “depressed”. Unfortunately, sometimes depression is not accurate. Many times when people say “I’m feeling depressed” they are really expressing that they are feeling emotional pain. Sometimes emotional pain is normal, sometimes a great deal of emotional pain is not normal and becomes problematic. When someone is feeling too much emotionally, it is not depression. Depression is usually a problem when someone is feeling a strong lack of emotions – causing a lack of interest in the usual activities (including sex) that once gave us pleasure. Although many configurations of “depression” exist (because it is a non-specific term nowadays), the configuration in which one lacks emotions is alexythimia, although if one lives without pleasure it’s called anhedonia. I suspect that most people, when they describe being “depressed” are really describing a combination of anhedonia (where they can’t enjoy anything anymore) and social anxiety. As I said above, another configuration that is referred to as “depression” is when the emotional pain becomes too overwhelming. In this case the person is feeling too much and would possibly beg for anhedonia because, while the pleasure would not be present, at least the pain would go away. I think that BPD probably involves more of this kind of “depression” than other disorders. The constant emotional pain leads people to doing anything to stop it (thus, this site’s name), including substance abuse, sexual promiscuity, risk-taking, self-injury and other seemingly self-defeating behaviors. How can this be explained? How can someone be in such emotional pain all the time? One explanation comes from the study of u-opiods in the brain. A recent study by Stanley and Siever showed that people with BPD have too few u-opiods (the precursor for natural pain-killing neuro-chemicals) AND have over-active u-opiod receptors. This combination provides a baseline of pain and, when opiods are added, the brain feasts on these pain-killing substances with the over-active receptors. This is why some people with BPD can ingest large quantities of pain killers to seemingly little effect (or less effect than those without the disorder). I have heard people with BPD say they only feel “normal” while taking pain killers. So, the question here is two-fold: First, are anti-depressants an appropriate treatment for emotional pain that is not really “depression”? And secondly, if not, what is? Low-dose pain-killers? On the director’s blog at the NIMH (National Institute of Mental Health), Director Dr. Thomas Insel discusses the name of borderline personality disorder:
He concludes with this:
Psychiatric News May 7, 2010
Volume 45 Number 9 Page 15 © American Psychiatric Association
Remission Common in BPD, but Good Functioning LagsRecovery from BPD is akin to a process of maturation—it occurs slowly, but once a level of functioning is reached, patients tend to maintain that level and fall back only in the face of major stressors. A substantial majority of patients with borderline personality disorder (BPD) experience remission of symptoms, and their remission tends to be stable over time compared with other mental disorders—but only half of patients also achieve good social and vocational functioning. Those were among the findings of a 10-year study of remission and recovery in BPD patients. The study was published online in AJP in Advance on April 15 and will appear in the June print edition of the American Journal of Psychiatry. “Symptomatically, this is a good prognosis,” said Mary Zanarini, Ed.D., lead author of the study, in an interview with Psychiatric News. “The idea that people with BPD never get better isn’t true. But as much as they get better symptomatically, it’s clear that we need to pay attention to psychosocial and vocational functioning. Just to talk about symptoms isn’t enough.” In the study, 290 inpatients at McLean Hospital in Belmont, Mass., who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for BPD were assessed at admission using a series of semi-structured interviews and self-report measures. The same instruments were readministered every two years for 10 years. At the 10-year mark, 249 patients remained in the study. (Of the 41 patients who were no longer in the study, 12 had committed suicide, seven died of other causes, nine discontinued their participation, and 13 were lost to follow-up.) Recovery was defined as not only remission of symptoms, but being able to function both socially and vocationally. Social functioning was defined as having at least one emotionally sustainable relationship with a friend, spouse, partner, or other non-blood-related individual. Vocational functioning was defined as the ability to perform full-time work competently and consistently. ![]() Study results showed that 93 percent of the patients achieved remission of symptoms lasting at least two years, and 86 percent achieved remission lasting at least four years. However, only 50 percent achieved the full definition of recovery including social and vocational functioning (see chart). Zanarini speculated that many patients may have temperamental problems—anger and/or extreme abandonment issues—that persist after the remission of symptoms and that hold them back socially and vocationally. “All of our manualized treatments for BPD are aimed at acute symptoms—self-mutiliation and suicidality—and those are the symptoms that remit the most quickly,” she told Psychiatric News. She said that a rehabilitation model of treatment incorporating training in life skills—use of public transportion, budgeting, personal care, and vocational training—is key to fully addressing the recovery needs of patients who achieve remission of BPD symptoms. The study’s other notable finding was that despite the difficulty many patients have in achieving full recovery, both remission of symptoms and full recovery, when they do occur, tend to be stable over time. Of those who achieved recovery, only 34 percent relapsed. Of those who achieved a two-year remission of symptoms, 30 percent had a symptomatic recurrence, and of those who achieved a sustained remission at four years, only 15 percent experienced a recurrence. Zanarini and colleagues noted in their report that those rates compare favorably with remission and recurrence rates for common Axis I disorders studied longitudinally, such as major depression and dysthymic disorder. “[T]he high rate of sustained symptomatic remission and the low rate of symptomatic recurrence after sustained remission are among the most optimistic findings about borderline personality disorder reported to date,” they said. In an interview with Psychiatric News, Zanarini said, “Depression and bipolar disorder tend to remit quickly but recur much more often. Recovery from BPD is more akin to the process of maturation. It occurs slowly, but once you achieve a certain level, you stay there, and it takes some enormous stressor to push you back.” Joel Paris, M.D., an expert in BPD, reviewed the study for Psychiatric News. He said that it confirms and extends findings from the Collaborative Longitudinal Personality Disorders Study and the McLean Study of Adult Development. This study found that while symptomatic improvement is sufficient for many patients to stop meeting criteria for the disorder—such as no longer cutting themselves or overdosing—functional improvement is much slower. “The study suggests that while BPD is by no means incurable, many patients continue to function at a low level for years,” Paris said. “So what are the clinical implications? On the one hand, when we thought that BPD was a life sentence, we avoided treating patients who can in fact be helped. And some people do make a full recovery, going on to live normal lives. On the other hand, other cases are more chronic. If we become too optimistic, we may mislead our patients into expecting the impossible and not provide the supportive and rehabilitative services they need.” “Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-Year Prospective Follow-Up Study” is posted at <http://ajp.psychiatryonline.org/pap.dtl>. From the LA Times:
An abstract on MBT: Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required. http://focus.psychiatryonline.org/cgi/content/abstract/8/1/55 Here is a chart comparing DSM-IV personality disorders to DSM-V personality types. Notice that NPD, Paranoid, Schizoid, and others have no DSM-V comparable disorder and are a combination of prominent personality traits. DSM-5 Type and Trait Cross-Walk
From the Menninger Clinic… about mentalizing.: Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg I reopened the diagnosis poll now that I am getting more traffic. I have noticed in my email list and in general that BP’s go through at least 8 therapists before they start being real with someone. My wife has been through at least 10 therapists before she admitted to the suicidal ideation and the self-injury. She immediately dropped a therapist who diagnosed her with BPD. Is that you guy’s experience as well? |
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