1 / 78

John G. Gunderson, MD

I have no conflict of interest. John G. Gunderson, MD. Good Psychiatric Management ESSPD Conference, Amsterdam September 27, 2012 John Gunderson, MD. BPD: Status Prevalence ~ 20% clinical visits, ~ 2.5% of population Health Care Burden - escalating costs

alicia
Download Presentation

John G. Gunderson, MD

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. I have no conflict of interest John G. Gunderson, MD

  2. Good Psychiatric Management ESSPD Conference, Amsterdam September 27, 2012 John Gunderson, MD

  3. BPD: Status • Prevalence ~ 20% clinical visits, ~ 2.5% of • population • Health Care Burden • - escalating costs • - inconsistent, even harmful care • Lack of treaters • Psychiatry needs to adopt the diagnosis • - genetics without psychopharm • - sustains psychological & social perspective

  4. MYTHS ABOUT TREATMENT OF BPD • BPD patients resist treatment • - most actively seek relief from subjective pain, treatment for their personality • disorder requires education by clinicians. • BPD patients angrily attack their treaters • - excessive anger and fearful wariness towards others, perhaps especially • caregivers, are symptoms. • BPD patients rarely get better • - about 10% remit within 6 months, 25% by a year, and 50% by 2 years even • without extended or stable treatment. • BPD patients get better only if given extended, intensive treatment by experts • - such treatment is only required by a subsample. Intense treatments can easily • become regressive. • Recurrent risk of suicide burdens treaters with excessive responsibility and the • ongoing risk of litigation • - these burdens are symptoms of treatments that are poorly conducted.

  5. GOOD PSYCHIATRIC MANAGEMENT (GPM II): RCT • (McMain & Links, AJP 2009) • Outcome equals DBT: ↓ DSH, • hospitalizations, depression • Therapists: > 5 years experience; • guided by Gunderson & Links Clinical • Guide (2008); met as group with Links

  6. GOOD PSYCHIATRIC MANAGEMENT (GPM) II: Structure • Once weekly individual (if useful) • Psychodynamic (unrecognized motives, • feelings; defenses related to IHS) & • behavioral (accountability, contingencies) • Often includes medication management • PRN family interventions • Split treatments desired (especially groups)

  7. GPM’S RELATION TO OTHER EBT’S • Entry level skills everyone should • know • Good enough for most BPD patients • Those who fail → DBT, MBT, TFP, • etc.

  8. GPM HANDBOOK VS GPM MANUAL • Patients don’t sign consents • To facilitate learning, not to monitor • adherence • DSH/suicide behaviors less emphasized • Interpersonal context emphasized

  9. PRINCIPLES OF GPM • be active (responsive, curious), not reactive • expect patients to be active within treatment, in • controlling their life (agency, accountability) • challenge passivity, avoidance, silences, diversions • support via listening, interest, selective validation

  10. VALIDATION • Seeing the patient’s description as • legitimate and understandable (by you • AND by the patient) • NOT the same as agreeing – often • requires “not knowing” • Orients therapist and patient to • collaboratively “make sense”

  11. PRINCIPLES OF GPM • be active, responsive, curious • expect patients to be active within treatment, in • controlling their life (agency, accountability) • challenge passivity, avoidance, silences, diversions • support via listening, interest, selective validation • focus on life situations; relationships and vocations • Work > love • change is expected

  12. “I’d be glad to meet with you weekly, but would feel reluctant to meet more often until we see whether I can be useful. We’ll both know that by observing whether you feel better and whether these problems in your behavior (e.g., anger, self-harm) and relationships (e.g., distrust, control) diminish”.

  13. GPM: THERAPEUTIC STANCE I • education is essential – even when seemingly • ignored • dyadic – a real relationship, selective self- • disclosure • corrective “container” • - active, non-reactive • - cautious, uncertain, thoughtful • pragmatism – every patient is different; forego • theory if it isn’t working; if not now – wait • realistic expectations of patient’s ability to • change

  14. GPM: THERAPEUTIC STANCE II • “Non-specific factors are central – reliability, listening, • concern • Relational issues are central – attachment, trust, positive • dependency • Situational changes can be essential • “Interpretations” are best offered via questions or • “normalizing” • Mistaken interventions are inevitable, useful, and reversible

  15. GPM: TREATMENT APPROACH: I • the inquisitive stance: your life is interesting, • important, and unique • external → internal; implicit → explicit (Gabbard) • actively address here-and-now interactions • - not knowing (MBT) • - interpretation (TFP) • actively address negative “transference” – impatience, • disdain; “Did I trouble/bother you?”

  16. GPM: TREATMENT APPROACH: II • • Interest in the patient’s interpersonal • experience • Slow down cliches, assumptions, • attributions, shortcuts • Curiosity about the interpersonal context • (and thoughts) preceding feelings and • behaviors

  17. BUILDING A NARRATIVE • “I’d like you to be able to make sense of yourself and your • life” • autobiography • How does this relate to • - “last session” • - “past experience” • “Have you noticed a pattern”? • That seems to recur whenever • - “you start work (etc.)” • - “I go away (etc.)” • chain analyses

  18. SEQUENCE OF EXPECTABLE CHANGES Relevant Target AreaChanges TimeInterventions 1. Subjective distress/ ↓ anxiety & depression 1-6 wks support, situational dysphoria changes, ↑ self awareness 2. Behavior ↓ self-harm, rages 2-6 mos ↑ awareness of self & & promiscuity interpersonal triggers ↑ problem solving strategies 3. Interpersonal ↓ devaluation, 6-12 mos ↑ mentalization, ↑ ↑ assertiveness, & stability of attachment “+ dependency” 4. Social function school/work/domestic 6-18 mos ↓ fear, failure & responsibilities abandonment, coaching Adapted from Gunderson JG, Links P. Borderline Personality Disorder: A Clinical Guide. Second Edition. Washington, DC. American Psychiatric Press, Inc. 2008

  19. PROCESSES OF CHANGE • “Think First” – cognitive learning • “Get a Life” – social rehabilitation • Corrective experiences – therapist as caretaker and role model

  20. Good Psychiatric Management Section 2: Interpersonal Hypersensitivity

  21. INTERPERSONAL HYPERSENSITIVITY AS BPD’s CORE • BPD has a unifying latent genetic core (~ 55% H) • Interpersonal features are the most discriminating • Interpersonal events predict remissions/relapses, • SIB, dissociation, suicide • BPD has elevated cortisol and HPA reactivity and • neurohormone deficits • Childhood disorganized attachments, separation • problems, and hypersensitivity predict adult BPD

  22. BPD’s DIAGNOSTIC COHERANCE HELD(ATTACHED)- DEPRESSED, REJECTION-SENSITIVE, IDEALIZING, COLLABORATIVE THREATENED (ACTIVATED SYSTEM) - ANGRY, SELF-PUNITIVE, MANIPULATIVE, DEVALUATIVE ALONE (PRIMITIVE COGNITION) - DISSOCIATED, PARANOID, DESPERATELY IMPULSIVE

  23. BPD’s INTERPERSONAL COHERENCE Connected idealizing, dependent, rejection-sensitive Interpersonal Stress (perceived hostility, separation, criticism) Threatened devaluative, self-injurious angry, anxious help-seeking Supportby the other (↑ involvement, rescue) Withdrawal by the other (physical or emotional) Aloneness dissociation, paranoid impulsive, help-rejecting Holding (hospital, jail, rescuer) Despair suicidal, anhedonic

  24. GPM & HYPERSENSITIVITY (cont) • explains need for psychotherapist activity • lends itself to practical here and now issues • explains the ambivalence of suicide attempts • explains the role of hospitals, structure, and • reliability (disorganization – containment) • lends itself to caution, uncertainty, “not • knowing” • interpersonal events precede moods & • behavior change

  25. Good Psychiatric Management Section 3: Making the Diagnosis

  26. Genetic Disposition • Heritability ~ 55% • (> MDD, < Schizophrenia) • Affective, Impulsive, Interpersonal and • Cognitive elements are united by a latent • core factor; two candidates: • - dysregulated • - emotionality • - interpersonal hypersensitivity

  27. AMYGDALA HYPERACTIVITY(Ekman Faces) Activation map showing regions in the amygdala slice in which activation exceeded the criterion threshold level of P<0.005 for the NC and BPD groups for each of the 4 facial expressions. NC = normal control. - Donegan et al. Biol Psych 2003;54:1284

  28. RESPONSE TO FACIAL EXPRESSIONS A hyperactive amygdala may be involved in the predisposition to be hypervigilant and overreactive to relatively benign emotional expressions Misreading neutral faces as angry could create problems in relationships…

  29. BPD’s Longitudinal Course 10 8 6 4 2 100% 80% 60% 40% 20% 80.4 81.7 68.6 6.5 % Remitted** Number of Criteria* 49.4 4.1 3.8 2.7 2.3 34.5 1.5 1.7 0 2 4 6 8 10 Years of follow-up *From the Collaborative Longitudinal Study of Personality Disorders (Gunderson et al. Arch Gen Psych 2011;68(8):827-837) **From the McLean Study of Adult Development (Zanarini et al. AJP 2003; 160:274-283)

  30. Ten Year Probability* of Relapse for BPD** 100 80 60 40 20 Relapse defined as: > 12 month % Relapsed 7.8 9.2 12.2 7.9 4.3 2 4 6 8 10 Time from first 12 months (Yrs) *Survival analyses **DIPD Positive

  31. MEAN GAF SCORES 80 70 60 50 40 30 20 0 BPD OPD MDD Mean GAF Scale Baseline 1 2 4 6 8 10 Study Year Gunderson et al., Arch Gen Psychiatry 2011

  32. CRITERIA FOR THE DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER Five or more of the following criteria must be met: Interpersonal hypersensitivity Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation Affective dysregulation Affective instability because of a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) Chronic feelings of emptiness Impulsivity Impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending money, sex, substance abuse, reckless driving, binge eating) Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior Cognitive/self Identity disturbance with markedly and persistently unstable self-image or sense of self Dissociative symptoms and/or transient, stress-related paranoid ideation

  33. BENEFITS OF DISCLOSING BPD DIAGNOSIS • Diminishes sense of uniqueness/alienation • Establishes realistically hopeful expectations • Decreases parent blaming and increases • parent collaboration • Increases patient alliance and compliance with • treatment • Prepares clinicians for their patient’s • hypersensitivity and to be aware of • countertransference

  34. RESPONSES TO DIAGNOSIS OF BPD (N = 30) WORSE BETTER Shame Likability Hope Overall Rubovszky et al. unpublished

  35. PRINCIPLES OF PSYCHOEDUCATION FOR FAMILIES • Mental illness is a problem within the person; families • effect its origins and course. • Being informed about etiology, therapy, and course is • alliance building. • Psychoeducation can diminish harmful anger, • criticism. • “Bad” parents are mainly uninformed or ill, rarely • malevolent. • Families are heavily burdened; new management • strategies can reduce this burden. • Gunderson & Links, 2008

  36. Good Psychiatric Management Section 4: Getting Started

  37. GPM: ALLIANCE BUILDING • address cc: subjective distress & ADL’s (sleep, diet) • - medications ? • psychoeducation (hope) • enlist patients’ involvement • - homework • - email • situational stressors (calls, conjoint meetings) • availability: “Yes, but …”

  38. GPM GOALS • making them is alliance building • making them is a goal, not required (“real • world”) • guided by feasibility (short term, simple) • differences should not be addressed • emphasizes “getting a life” (work > love)

  39. ANTICIPATE CHALLENGES • When difficulties are expected/assumed, therapists • can be less reactive and more useful • Convey expectations about hypersensitivity to • aloneness, rejection • Expect (? welcome) anger, bids to test availability; • non-reactive stance

  40. Algorithm for Intersession Availability (“call me if needed”) No calls ~ 30% OK ~ 55% Repeated Calls (non-crisis) ~ 15% OK Crisis • In next session: • “was it useful? If so, why?” (aloneness, • care, etc.) • “did you wonder how I (the clinician) felt • about being called” • “might it be managed otherwise?” “Why not call?” Alternative plan • Change content of calls • abbreviate • problem solve • email • Change “rules” • only for crises • call before, not after • use ER or emails Set limit Set limit

  41. COMMON PROBLEMS • Refusal to accept the framework • Patient doesn’t “connect” • Treater dislikes patient • Patient won’t leave a dysfunctional • relationship with prior treater

  42. Good Psychiatric Management Section 5: Managing Suicidality

  43. BPD’S “BEHAVIORAL SPECIALTY”: • SUICIDALITY & SELF-HARM • The risk of suicide is significant – estimates vary from 3% to • 10% • - this rate is particularly high within the young female • demographic • About 75% self-harm; amongst these, 90% do so repeatedly • - self-harm increases the risk of suicide 15 to 30 times • Suicidal acts are ambivalent: If rescued, I want to live. If not, • I prefer to die. • - the average number of suicide attempts is 3 • - suicide occurs once per 23 attempts • From B. Stanley (2001), S. Yen (2004, 2005, 2009)

  44. ALGORITHM FOR SELECTING LEVEL OF CARE VIS A VIS SELF-ENDANGERING BEHAVIORS Assess Suicidal Non-Suicidal Not dangerous Dangerous Medically dangerous dangerous Hospital or Residential OPC OPC Not Severe Severe OPC Recurrent Infrequent Levels of Care OPC = outpatient clinic/office practice IOP = intensive outpatient (> 3 hours /week multimodel) Residential = structured living environments Hospital Residential or IOP IOP or OPC

  45. MANAGING SAFETY: SEVEN BASIC PRINCIPLES • Assess risk – differentiate nonlethal from true suicide intention • Don’t ignore or derogate – express concern • Ask what the patient thinks could help – foster sense of “self- • agency”

  46. MANAGING SAFETY: SEVEN BASIC PRINCIPLES • Assess risk – differentiate nonlethal from true suicide intention • Don’t ignore or derogate – express concern • Ask what the patient thinks could help – foster sense of “self- • agency” • Clarify precipitants (chain analysis) – seek interpersonal events • Be clear about your limits; i.e., not being omniscient • or omnipotent

More Related