Handling the Care of Patients With BPD
ORLANDO, Fla.—Delivering a borderline personality disorder (BPD) diagnosis can feel tricky, leaving some clinicians afraid of sparking negative reactions and wondering if they should tell patients at all.
Mark Zimmerman, MD, does share the diagnosis with patients, he told attendees during a session at Psych Congress 2018.
“It’s been my experience that, quite frankly, some patients do get angry. A very small number but a very well-defined group of individuals that I’ve treated are upset when diagnosed with BPD. And that’s individuals who are mental health professionals,” said Dr. Zimmerman, director of outpatient psychiatry and the partial hospital program at Rhode Island Hospital in Providence. “They do not like to be diagnosed with BPD.”
Clinicians aside, evidence does not suggest that telling patients they have BPD undermines the therapeutic relationship, he explained.
In fact, a study in press conducted by Dr. Zimmerman and colleagues at the partial hospital program involving 1093 patients with BPD, major depressive disorder, anxiety disorder, or post-traumatic stress disorder found that patients with BPD were just as likely as others to indicate their clinicians were interested in them and understood their problems.
“Clinicians should approach the diagnosis of BPD in the same way they make any other psychiatric diagnosis,” he said.
CAUSE FOR OPTIMISM
Because BPD is not familiar to many patients, educational materials explaining the disorder are helpful, Dr. Zimmerman said. A common question is whether BPD is curable.
Prospective longitudinal studies suggest patients will get better. The vast majority will remit symptomatically, providing cause for optimism.
“It’s not an unrelenting, downhill chronic course,” Dr. Zimmerman said.
Although a variety of medications are prescribed to treat BPD, and polypharmacy is quite common in the patient population, no medication is approved anywhere in the world for BPD treatment, he pointed out. The American Psychiatric Association recommends psychotherapy as first-line treatment and medications for specific symptom treatment, such as selective serotonin reuptake inhibitors for affective dysregulation or impulsivity, despite a lack of evidence.
“I do prescribe medication. I deal with my own cognitive dissonance knowing there’s a lack of data. I just have to deal with that,” said Dr. Zimmerman, who always refers, and often requires, therapy, too. “But I also talk about what the role of medication might be, that there is no magic pill. My goal with medication is to help them feel more emotional control.”
And if improvement comes via a placebo effect, so be it, he said.
He cautioned against polypharmacy as well as medicating patient crises, and advised that switching medications is preferable to augmenting them.
TAKING A LONG VIEW
Other practical tips shared during the session included the importance of stability and predictability in interactions with patients with BPD, family involvement, and emphasizing to patients that they are not their disorder.
“You may have BPD,” he often clarifies, “but you are not borderline.”
A long-term outlook is also essential, he said.
“The number one rule in treating BPD is, I don’t want my patients to die. This is a disorder with a high risk of mortality,” Dr. Zimmerman told attendees. “I know if I keep them in treatment, there’s a 50-50 chance in a decade they’re going to be feeling a lot better.
“I’m thinking long-term because I know the prognosis can be good.”
“Update on borderline personality disorder: what every clinician needs to know.” Psych Congress 2018: Orlando, Florida; October 25, 2018.