Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice

273 Pages·2008·2.83 MB·English

by  Joel Paris MD

TREATMENT OF BORDERLINE
PERSONALITY DISORDER
Treatment of
BORDERLINE
PERSONALITY
DISORDER
A Guide to Evidence-Based Practice
JOEL PARIS
THE GUILFORD PRESS
New York London
© 2008 The Guilford Press
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Library of Congress Cataloging-in-Publication Data available from the Publisher.
ISBN 978-1-59385-834-6 (cloth : alk. Paper)
To my colleagues
in the personality disorders research community
About the Author
About the Author
Joel Paris, MD, is a Research Associate at the Sir Mortimer B. Davis–
Jewish General Hospital in Montreal. Since 1994, he has been a Full
Professor at McGill University and served as Chair of its Department
of Psychiatry from 1997 to 2007. He has supervised psychiatric
evaluation with residents for over 30 years and has won many
awards for his teaching. Dr. Paris is a past president of the Associa-
tion for Research on Personality Disorders. Over the last 20 years, he
has conducted research on the biological and psychosocial causes
and the long-term outcome of borderline personality disorder. Dr.
Paris is the author of 135 peer-reviewed articles, 11 books, and 25
book chapters. He is also Editor in Chief of the Canadian Journal of
Psychiatry.
vi
Preface
Preface
Patients with borderline personality disorder (BPD) are famous
for being difficult. Their problems can challenge even the most expe-
rienced therapists.
The most frightening symptoms of BPD are chronic suicidal
ideation, repeated suicide attempts, and self-mutilation. These are
the patients we worry about—and are afraid of losing. After a diffi-
cult session, therapists may not be sure if they will ever see the pa-
tient again or whether someone will telephone to report a suicide.
Even in patients not threatening suicide, therapists face serious
difficulties. BPD is associated with many symptoms, and each one
presents problems. Mood instability is difficult to manage and shows
only a weak response to medication. Impulsive behaviors, both in
and out of therapy, are highly disruptive. Intimate relationships are
often chaotic, and this pattern can repeat itself in treatment, disrupt-
ing the therapeutic alliance. Cognitive symptoms (paranoid ideas, de-
personalization, and auditory hallucinations) also present problems
for management.
Given this clinical picture, there can be no doubt that BPD is a
serious mental illness. While BPD is classified as a personality disor-
der, it differs from most of the other categories listed on Axis II of
DSM-IV-TR. Many people with personality disorders see themselves
as normal. This is not true of patients with BPD, who suffer greatly
and seek treatment.
vii
viii Preface
Patients with BPD make therapists sweat. These are the cases on
which we are most likely to obtain consultations from colleagues.
BPD is often the focus of case conferences and invited talks and
workshops by experts in the field.
Even so, BPD can be ignored. All too frequently, it is diagnosed
as a variant of major depression or bipolar disorder. Moreover, pa-
tients with BPD are often mistreated. They receive prescriptions for
multiple drugs that provide only marginal benefit. They do not al-
ways get the evidence-based psychotherapy they need.
THE PURPOSE OF THIS BOOK
Because BPD is a troubling clinical problem, it has been the subject
of an enormous scientific literature: Medline and PsycInfo list over
3,500 articles, with at least 200 new papers published every year.
Only a few diagnoses have such a strong research base.
This book aims to aid clinicians in understanding this literature
and in showing how empirical data can inform clinical management.
Although much about BPD remains unknown, science is beginning to
unlock its secrets. This book will show how research can come to the
aid of the harried clinician. Even though we are only beginning to
understand the causes of the disorder, the outlook for patients is
much better than previously thought, with several methods of psy-
chotherapy proven effective. Although therapy can be difficult, we
know much more than we did in the past about what works (and
what doesn’t).
Thus, this book differs from many others in its emphasis on
evidence-based practice. I am profoundly committed to this ap-
proach. Much of what has been written on BPD in the past has been
based on clinical opinion. But no matter how long you have prac-
ticed, the generalizability of your experience is limited by the patients
you see and by your own preconceptions. These biases are precisely
what research corrects for.
In principle, everyone agrees that treatment for mental disorders
should be based on empirical findings. But the problem is that, all
too often, there are not enough data to go on. We are forced to make
decisions based on what we have done before or on our “gut feel-
ings.” Yet there are now enough rigorous investigations that one can
ground the principles of management in empirical data.
I present clinical vignettes of patients with BPD to illustrate these
Preface ix
principles. I also describe my approach to therapy. But it is not possi-
ble to write a book on the treatment of BPD with an evidence base
for every intervention. Inevitably, some of what I have to say must be
based on my own experience. On the other hand, everything I recom-
mend will be at least consistent with current empirical evidence.
I reference many previous books on the treatment of BPD. I have
learned a great deal from each of them. However, research findings
and clinical trials have often been used to support a single method of
therapy. In contrast, this book teases out the essential elements of all
successful therapies.
Thus I avoid identifying myself with any “school of thought.” I
have always thought that excessive allegiance to any single perspec-
tive, whether cognitive or psychodynamic, is an obstacle to under-
standing patients. Instead, I draw on whatever ideas have the most
science behind them and make the most clinical sense.
To show how research can be translated into practice, each
chapter ends with a bulleted section reviewing the implications of
empirical findings for therapy. Although I cannot make the treatment
of BPD easy, I will show how it can be rational.
HOW THIS BOOK IS ORGANIZED
The book is divided into three parts. Part I focuses on the problems
in defining BPD and in describing patients. Chapter 1 reviews prob-
lems in the DSM definition: Making the diagnosis more specific
could make treatment more specific. Chapter 2 examines the bound-
aries of BPD to determine whether it is “really” a form of some other
condition such as depression, schizophrenia, or posttraumatic stress
disorder. It presents a detailed critique of the currently influential
view that BPD falls within the bipolar spectrum. Chapter 3 reviews
the development of BPD in childhood and adolescence and describes
research directions that identify traits that are precursors of disorder.
Part II reviews research on the etiology of BPD. Chapter 4 re-
views biological, psychological, and social risk factors associated
with the disorder. Chapter 5 presents a model combining all these
factors into an integrative model.
Part III reviews research on treatment and makes recommenda-
tions for management. Chapter 6 reviews data on the long-term out-
come of patients with BPD and describes their implications for ther-
apy. There are new (and encouraging) findings from large-scale