Borderline Personality Disorder: An evidence-based guide for generalist mental health professionals

240 Pages·2013·1.588 MB·English

by  Bateman, Anthony W., Krawitz, Roy

Borderline
Personality
Disorder
An evidence-based
guide for generalist
mental health
professionals
Anthony W. Bateman
Consultant Psychiatrist and Psychotherapist, Barnet,
Enfi eld, and Haringey Mental Health NHS Trust
Visiting Professor, University College, London
Consultant, Anna Freud Centre, London, UK
and
Roy K rawitz
Consultant Psychiatrist and DBT Therapist,
Waikato District Health Board
Honorary Clinical Senior Lecturer, Auckland University,
New Zealand
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2013
The moral rights of the authors have been asserted
First Edition published in 2013
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
British Library Cataloguing in Publication Data
Data available
ISBN 978–0–19–964420–9
Printed and bound in Great Britain by
Clays Ltd, St Ives plc
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Preface
Over the past two decades considerable progress has been made in developing
specialist psychosocial treatments for borderline personality disorder (BPD)
and yet the majority of people with BPD receive treatment within generalist
mental health services rather than specialist treatment centres. It turns out
that this is no bad thing. Many of the lessons learned from the development of
specialist treatments for BPD now inform general psychiatric care and we can
confi dently say that treatment of people with BPD by generalist clinicians is
no longer necessarily suboptimal and may in fact, in some contexts, be equal
to specialist treatments as long as certain principles are followed and interven-
tions are skillfully implemented. This is why this book came about.
T here is increasing evidence that well-organized and skillful generalist psy-
chiatric treatments for BPD, at least when used as comparators to specialist
interventions in research trials, are strikingly effective. We discuss the evi-
dence for this statement in Chapter 2. One of four published and manual-
ized generalist psychiatric treatments used in research—structured clinical
management (SCM)—forms the core of this book. SCM was used as a control
treatment in a randomized controlled trial investigating the effectiveness of
mentalization-based treatment. Patients who received SCM fared well on all
measures. SCM follows organizational and clinical principles considered by
experts to be important in the treatment of people with BPD. Rather than
requiring complex specialist techniques, SCM employs interventions already
in use by generalist mental health clinicians. The book is a development of the
SCM manual used in the randomized controlled trial and we have extended
the information for clinicians, added further suggestions of interventions, and
reviewed some of the other literature on generalist psychiatric treatments.
This is not a book by specialists telling generalists what to do. We fi rmly
believe that generalists are highly skilled clinicians and are able to deliver treat-
ment that is not necessarily within the capability of the specialist. We wrestled
with the terms “general” versus “generalist” clinicians for the book, eventually
choosing generalist despite it being a rather ungainly word in the hope that we
would avoid being considered patronizing or insulting. Generalist emphasizes
the breadth of the clinician’s skill and implies, accurately in our view, an abil-
ity to implement a range of techniques according to specifi c principles and to
integrate them into a coherent treatment endeavour. This book speaks to those
iv PREFACE
skills. It outlines the principles to be followed when treating people with BPD
in mental health services and details a range of effective techniques that can be
used by generalist clinicians in everyday practice without extensive additional
training.
Although the book is organized around the research manual for SCM, it
is more than that. It is a comprehensive, best-practice clinical guideline for
the treatment of BPD in generalist mental health services. The structure of
the book is straightforward. First, we provide considerable information about
BPD; second, we discuss the evidence base for and the characteristics of the
manualized generalist psychiatric treatments that have been tested in research
trials. This is followed by chapters about the general and specifi c clinical com-
ponents of SCM, with an emphasis on practical implementation. Finally, we
outline our approach to involving families and summarize our top ten tips
for effective interventions in the hope that clinicians will go beyond SCM,
both safely and effectively, as they grow increasingly confi dent about treating
people with BPD.
We fi rst encountered people with BPD when working as trainees in general-
ist mental health services and were immediately aware of our lack of under-
standing of their problems and the limited knowledge we had to draw on to
help them. Despite these experiences, or perhaps because of them, we both
embarked on a career working with people with BPD, gradually sharing our
experience and knowledge, mostly gleaned from our clients/patients, with
other mental health clinicians.
That observation raises the issues of who we , the authors, are, coming as
we do from opposite sides of the globe. We both have considerable psychi-
atric experience working in public health services. One of us (AB) is a psy-
chiatrist with dynamic leanings whilst the other (RK) is a psychiatrist with
behavioral orientation. We hope that as a team we have enough in common
to provide a unifi ed view, enough difference to add breadth and plurality to
our exposition, and adequate open-mindedness not to be too reverential to
our favored approaches. On the whole our collaboration has run smoothly
and it has become apparent that our differences are narrower than might be
assumed from our distinctive perspectives. Certainly we think that combin-
ing our knowledge and experience has strengthened the book.
We hope that the book is reader- and clinician-friendly; parts are set out so
that they can be easily copied to support treatment and we give a liberal sprin-
kling of consumer comments to illustrate many of our points. We are only too
aware of the many faults of omission in the book. We have not tackled in detail
the issues of ethnicity, class, social context, and gender in relation to BPD.
Apropos of the latter, like many contemporary authors we have been stymied
PREFACE v
by the problem of pronouns, but, in the end, decided to mix and match, some-
times using the possibly less grammatically obtrusive, but patriarchal, “he”
and at other times “she.” For the most part we have avoided the grammatically
clumsy “they” with a singular verb and the clumsy “s/he”. We had a similar
struggle with a decision on whether to use the terms “client,” “service user,”
“consumer” or “patient”. “Client” is considered to imply equality and collabo-
ration whilst “patient” is often taken to indicate a hierarchical interaction. So,
believing that neither portrayal is necessarily accurate, we have used both “cli-
ent” and “patient.” We have also used “consumer” when we report comments
given to us by people with BPD, or their families, where they had experience
of the services and treatments. We have avoided “service user,” which lacked
fi nesse.
It is our hope that this book will be a modest contribution to improving gen-
eralist psychiatric treatments for people with BPD. Above all we hope that the
information and clinical suggestions contained in the book will help general-
ist clinicians approach people with BPD not only with increasing confi dence
about being able to offer effective treatment, but also with a level of commit-
ment and seriousness that many clients have arguably been deprived of in the
past both in their personal lives and in their contact with services.
Anthony W. Bateman
Roy Krawitz
London, UK, and Auckland/Waikato,
New Zealand, July 2012
This page intentionally left blank
Contents
1 Borderline personality disorder 1
2 Generalist psychiatric treatments for borderline personality
disorder: the evidence base and common factors 34
3 Structured clinical management: general treatment
strategies 56
4 Structured clinical management: core treatment strategies 80
5 Structured clinical management: team strategies 112
6 Structured clinical management: inpatient treatment and
prescribing 124
7 Family and friends 143
8 Top ten additional resource-effi cient treatment strategies 174
Epilogue 203
References 205
Index 223
This page intentionally left blank
Chapter 1
Borderline personality disorder
Summary
◆ Community lifetime prevalence of BPD is 1% (Grant et al., 2008;
Schwartz, 1991), with equal rates of males and females in the Grant et al.
study (2008).
◆ 70% of those diagnosed are female (Schwartz, 1991).
◆ It is likely that males are underrepresented and underdiagnosed in men-
tal health settings and more likely to be found (but not diagnosed) in
substance-use centers and in the justice system.
◆ 40–70% of those diagnosed have a history of past sexual abuse.
◆ 46% of people with BPD have a history of being victims of adult violence
(Zanarini et al., 1999).
◆ Prevalence of people with BPD is estimated at community clinics to
be about 11% and 20% in inpatient units (Swartz, Blazer, George, &
Winfi eld, 1990).
◆ 75% of people with BPD have a history of having self-harmed on at least
one occasion (Dubo, Zanarini, Lewis, & Williams, 1997).
◆ Most experts in the fi eld accept BPD as a valid recognizable condition.
◆ For a DSM-IV-TR diagnosis of BPD, fi ve or more of the criteria listed in
DSM-IV-TR are required.
◆ It is important that diagnosis is only one part of understanding the
unique individuality of the person.
◆ It is important that the diagnosis is integrated with other ways of under-
standing the person.
◆ Severe dissociation and persistent self-harm are often discriminating
features in making a diagnosis.
◆ Co-occurring Axis 1 and II conditions are the norm.
◆ Suicide rates in older studies were 10% and are lower now with better
treatments.