Treating the Difficult Patient. Borderline Personality Disorder Curley Bonds, MD Presentation by Amber Kondor , MD Telemental Health and Psychiatric Consultation Los Angeles County DMH. Special Thanks – Ricardo Mendoza, MD
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Treating the Difficult Patient
Borderline Personality Disorder
Curley Bonds, MD
Presentation by Amber Kondor, MD
Telemental Health and Psychiatric Consultation
Los Angeles County DMH
Ricardo Mendoza, MD
Chief Mental Health PsychiatristTelemental Health and Psychiatric ConsultationLos Angeles Co. Dept. of Mental Health
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.
Five (or more) criteria must be met for diagnosis of BPD.
(1) Frantic efforts to avoid real or imagined abandonment (not including self-mutilating behavior)
“I’ve damaged so many relationships through the need for control and the fear of being left, and for a long time I thought that fear was justified” – anonymous blogger
Patients with BPD will often stay in physically and emotionally abusive relationships, just so they won’t be alone.
(2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
(3) Identity disturbance: markedly and persistently unstable self-image or sense of self
Uncertainty of self-image, sexual orientation, career choice or other long term goals, friendships, values
“Sometimes I feel as though I’m two different people, ripping at each other” – anonymous blogger with BPD
(4) Impulsivity in at least 2 areas that are potentially self-damaging (spending, sex, drugs, recklessness, binge eating)
(5) Recurrent suicidal behavior, gestures, or threats, or self –mutilating behavior
(6) Affective Instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety – for hours to days at a time)
(7) Chronic feelings of
“Constantly being terrified of abandonment and confused over everything you are isn’t a walk in the park; it’s a depressing, stressful, soul-destroying way to exist.” – anonymous blogger with BPD
(8) Inappropriate, intense anger or difficulty controlling anger
WHAT DO YOU MEAN I CAN’T HAVE MORE XANAX???
(9) Transient, stress-related paranoid ideation or severe dissociative symptoms
What are you likely to encounter in your office?
LaForge, E. (2007)
“I see that you’re angry, and we can continue talking about this if you will lower your voice.”
(note the recognition of the emotion, and clear request for appropriate behavior)
If the patient doesn’t respond – leave the room, indicating that when their behavior is appropriate, the conversation can resume.
1. A 44-Year-Old Woman WithBorderline Personality Disorder; JAMA, February 27, 2002—Vol 287, No. 8 1035
2. LaForge, E. (2007). The Patient with Borderline Personality Disorder. Journal of the American Academy of Physician Assistants. 20,46-50.
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington: American Psychiatric Association.
Davison, SE. (2002). Principles of managing patients with Personality Disorder. Advances in Psychiatric Treatment. 2002, 8:1-9.
Gross, R, et al. Borderline Personality Disorder in Primary Care. Archives of Internal Medicine, 2002; 162(1):53-60.
LaForge, E. (2007). The Patient with Borderline Personality Disorder. Journal of the American Academy of Physician Assistants. 20,46-50.
Ward, R.,(2004). Assessment and Management of Personality Disorders. American Family Physician. 2004 Oct 15;70(8):1505-1512.
Literature to consider: Sansone, R. and Sansone, L. Borderline Personality Disorder in the Medical Setting: Unmasking and Managing the Difficult Patient.