Treatment of Borderline Personality Disorder. A Guide Evidence-Based PracticeRichard Balon, MD
Wayne State University, Detroit, MI, USA
Most clinicians are ambivalent at best when it comes to treating borderline personality disorder. As Joel Paris writes in the Preface to his book on treating borderline personality disorder (p vii), “Patients with borderline personality disorder (BPD) are famous for being difficult… The most famous symptoms of BPD are chronic suicidal ideation, repeated suicide attempts, and self-mutilation. These are patients we worry about…and are afraid of losing. Patients with BPD make therapists sweat” (p viii). Therefore, many clinicians try to avoid patients with BPD or limit the number in their practice to a minimum. However, these patients need our help and we should not and cannot avoid them.
By Joel Paris; The Guilford Press; New York, New York; 2008; ISBN: 978-1-59385-834-6; pp 260; $35.00 (hardcover).
In contrast to those with other personality disorders, BPD patients do not see themselves as normal and “suffer greatly and seek help” (p vii). We need to improve our skills in helping them. This small volume, written by an experienced clinician who devoted most of his professional life to studying BPD, is an attempt to help the rest of us learn how to handle, treat, and help these difficult patients. As Dr. Paris emphasizes in the Preface, the difference between his and many other books on this topic is the emphasis on evidence-based practice. Interestingly, as he notes, Medline and PsycInfo list more than 3,500 articles on BPD, with at least 200 new papers published every year.
The book is divided into Preface and 3 parts (13 chapters): I. Definitions, II. Causes, and III. Treatment. In 3 chapters Part I focuses on “Making the diagnosis,” “The boundaries of BPD,” and “Personality and development.” The chapter on diagnosing BPD discusses 3 approaches: the DSM system, domain approach, and dimension systems. The chapter presents many useful and important points. For example, “the term borderline is a misnomer” as it is not an entity on the border with psychosis, and the term “borderline” does not describe the salient features of the entity. Dr. Paris also argues that “BPD does not actually belong on Axis II. In principle, Axis I describes symptomatic conditions, whereas Axis II describes trait disturbances. However, even the most severe mental disorders, such as schizophrenia, reflect both. BPD is rooted in trait vulnerability, but can present with as many symptoms as the major psychoses” (p 17). Paris closes his discussion by stating that there are many problems with the BPD diagnosis, yet it would be a mistake to eliminate or dismiss this category (p 23).
The chapter on BPD boundaries reviews issues such as comorbidity; co-occurrence; BPD and psychosis; BPD, depression and dysthymia; BPD and bipolar spectrum; BPD and posttraumatic stress disorder; BPD and attention-deficit/hyperactivity disorder; and BPD and other Axis II disorders. The discussion of BPD and bipolar disorder is interesting and provocative. Paris writes that the “current ‘mania’ to see all kinds of mental disorders as mania could be described as bipolar imperialism” (p 34), and states that because he sees BPD and bipolar disorder as distinct, he refuses to diagnose BPD if a patient has classic bipolar disorder, either type I or type II (p 34). The chapter on personality and development deals with the trait domains that underlie BPD—emotional dys-regulation (affective instability), impulsivity or disinhibition, cognitive dysfunction, and problems in interpersonal relationships (this domain may be a consequence of the other domains).
Part II attempts to address causes of BPD in 2 chapters focused on “Risk factors” (genetics, neurotransmitters, psychological issues, child abuse, trauma, social factors) and “A general model” (basically a multidimensional model). These 2 chapters are the typical fare on etiology of the unknown seen in most psychiatric texts.
Part III consists of 8 chapters: “Outcome,” “Pharmacotherapy,” “Psychotherapy,” “Guidelines for management,” “Therapeutic interventions,” “Problems in therapy,” “Suicidality and hospitalization,” and “Research directions,” and finally gets to treatment, the core issue of this volume. Starting the treatment discussion with a debate on outcome may be unusual, but is important and interesting. The author mentions that BPD patients usually are young and asks, “Why don’t we see old patients? Do they die, disappear, or get better?” (p 97). Dr. Paris points out that BPD patients have a high suicide rate and also an unusually high rate of early death. Nevertheless, this does not completely explain the “disappearance” of older patients. As noted later, most BPD patients improve with time but complete remission is less likely than gradual improvement followed by a plateau of stability (p 112). “The prognosis of BPD is relatively good, with an outcome that is much better than for other major mental disorders” (p 112).
The chapter on pharmacotherapy reviews various psychotropics prescribed for BPD, including neuroleptics, selective serotonin reuptake inhibitors, mood stabilizers, and other substances, such as omega-3 fatty acids, but surprisingly not benzodiazepines, bupropion, mirtazapine, or stimulants. The main message of this chapter is that drugs are overprescribed for BPD and evidence is too weak to recommend any drug for these patients.
The chapter on psychotherapy, as one would expect, focuses on dialectical behavior therapy (DBT), but also reviews other cognitive therapies, psychodynamic psychotherapies, group therapy, and psycho-education. Although DBT is heavily promoted, there are several issues about this therapy that have not been fully addressed. As Dr. Paris emphasizes, it has been suggested that a complete treatment could require several years, yet DBT has been tested for only 12 months (p 141). DBT also is resource-intensive and expensive, and its implementation has been spotty exactly for these reasons. The author concludes that the most important factor in psychotherapy is the quality of the alliance between the therapist and the patient. In discussing the guidelines for management, Dr. Paris states that psychotherapy is the cornerstone of managing patients with BPD (p 150).
He also cautions clinicians to be realistic—not every patient will fully recover, and we need to give up on the idea of a definite or curative treatment (p 151). He also emphasizes that “getting a life is central to recovery” (p 155) and the most important part of getting a life is finding work; in fact, “finding work takes priority over love” (p 156). The chapter on therapeutic interventions provides guidance on how to talk to a BPD patient, build alliances, and target core dimensions of BPD. I found the chapter on problems in therapy very interesting. Dr. Paris suggests that higher frequency of sessions with BPD patients often is counterproductive. “The more frequently patients come, the more dependent on therapy they become” (p 184). This chapter also addresses issues such as attendance (does it underscore the lack of readiness for therapy on patient’s part?), telephone calls (“I do not give out my phone number. When patients demand contact, I tell them that waiting for the next session is part of the treatment,” [p 187]), therapist-patient boundaries, sharing the BPD diagnosis with the patient (“discussing the diagnosis is the first step in a structured psychoeducational program” [p 191]), involving the family (parents are not to blame for BPD, having a child with this disorder is a terrible burden [p 192]), split treatment, length of therapy, intermittent therapy, and termination issues (“By leaving the door open … termination becomes easier” [p 200]).
The next chapter on suicidality and hospitalization emphasizes that suicidal thoughts have little value as predictors of suicide. It also discusses suicide attempts, suicide completion, chronic suicidality, and managing suicidality (“If you spend all your time trying to prevent suicide, you end up not being able to work with your patients” [p 212]; “Paradoxically, therapists who can tolerate suicidal ideation may be helping patients with BPD to stay alive. These are people who need to be suicidal, and we cannot take the option away from them too rapidly” [pp 212-213]). Dr. Paris also writes that “With a few exceptions, patients with BPD should not be hospitalized, because there is no evidence that admission to a ward has any value” (p 213), and “Trying to manage patients who are moving in and out of hospital wards is like jogging through a hurricane” (p 214). Another soothing bon mot of this chapter is the statement that “Suicide, however traumatic, is a normal part of therapy practice. If you have never had one, you are probably not treating sick patients” (p 214). The final part of this chapter addresses a painful issue for all clinicians—”Will I be sued?” The answer is yes, but the question is whether you were negligent. The final brief chapter, typical for many recent books, attempts to provide research directions.
This volume is highly practical, well and wittily written, and clearly not just evidence-based, but also based on the author’s vast clinical experience. The text contains useful case vignettes. The chapters end with a bulleted summary of clinical implications. The book has some weaknesses; for instance, Part II on causes is not very practical—as I pointed out, many books tend to summarize a lot of useful and useless literature on etiology, a habit not exactly valuable in books on management. The book could have been shorter, focusing only on management. Nevertheless, this is a solid book for every practicing clinician who deals with BPD patients.
Annals of Clinical Psychiatry ©2009 American Academy of Clinical Psychiatrists