Sie sind auf Seite 1von 71

What should we do and not

do in treatment of borderline
personality disorder?

Prof Anthony W Bateman


Glasgow 2006
Acknowledgments
St Anns Hospital, London
Catherine Freeman
Rory Bolton
Countless other clinicians
University College, London
Prof Peter Fonagy
Dr Mary Target
Dr Liz Allison
Menninger/Baylor Department of Psychiatry
Dr Efrain Bleiberg,
Dr Jon Allen
Therapies for BPD
Supportive Psychotherapy
Behavioural
Dialectical Behaviour Therapy (DBT)
Cognitive
ManualAssisted Cognitive Therapy (MACT)
Schema Focused Psychotherapy (SFP)
Psychoanalytic
Transference Focused Psychotherapy (TFP)
Mentalization Based Treatment (MBT)
Outcomes (selected) at baseline &12 months in MACT and
TAU groups
Tyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the treatment of recurrent
deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality Disorders, 18, 102-116.

MACT TAU
Baseline 12 months Baseline 12 months

HADS dep 11.3 7.0 11.2 7.1


HADS anx 14.0 10.3 14.3 10.3
(n=400)

Social function 13.3 9.8 13.3 10.3


(n=400)

GAF 18.7 61 18.6 62


symptoms
(n=402)
Summary of clinical findings
Tyrer, P., Tom, B., Byford, S., et al (2004) Differential effects of manual assisted cognitive behaviour therapy in the
treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. Journal of Personality
Disorders, 18, 102-116.

Neither self-harm episodes, nor other psychometric


assessment outcomes, showed any convincing
differences between MACT and TAU, either at 6 or
12 months.
Possible that a longer period of treatment or greater
engagement in face-to-face treatment, were this
achievable in routine health care settings, would
show more favourable results.
BPD showed an increase in costs in health service usage
with MACT
Manual-assisted cognitive therapy slightly increases the
likelihood of self harm relative to treatment as usual with
PD patients
Dialectical Behaviour Therapy
Initial improvement
Disappointing in follow-up
Replication in inner city London delivered poor results
High drop out
Worse on a number of measures
Level of training required unknown but considered
extensive
Better for self-harm than suicide
Effect on personality function unclear
Poor social-emotional function probably continues
Variable change on depression and hopelessness
Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003)
Dialectical behaviour therapy for women with borderline personality
disorder: 12-month, randomised clinical trial in The Netherlands. Br J
Psychiatry, 182, 135-140.

Figure 2. Frequency of self-mutilating behaviors in the past 3 months at week 22 and week
52 since the start of treatment by treatment condition. DBT indicates Dialectical Behavior
Therapy; TAU indicates treatment-as-usual.
Verheul, R., Van Den Bosch, L. M., Koeter, M. W., et al (2003) Dialectical
behaviour therapy for women with borderline personality disorder: 12-month,
randomised clinical trial in The Netherlands. Br J Psychiatry, 182, 135-140.

Figure 4. Frequency of self-mutilating behaviors in the past 3 months at week 22 and week
52 since the start of treatment by treatment condition and baseline severity group. Membership
of severity groups is determined by median split on the lifetime number of self-mutilating acts
(i.e., <14 versus 14). DBT indicates Dialectical Behavior Therapy; TAU indicates treatment-
as-usual.
Change in Reflective Function as a
Function of Time and Treatment
Trial I:
RCT of Psychoanalytic Partial
Hospital Treatment (18 months)
(Bateman & Fonagy, 1999, 2001, 2003)

Attempted Suicide: NNT (18 months)= 2.1


NNT (36 months)= 1.9
Self-Mutilating: NNT (18 months)= 2.1
NNT (36 months)= 2.0
Inpatient Episodes: ES(18m)= 1.4
ES(36m)= 1.1
Depression: NNT(36m)= 2.1
Limitations
Small sample size
Control treatments undefined
Multi-component treatment
No replication sites yet (no longer true)
Costly, relative to an outpatient treatment
(at least relative to little service)
Only for most chaotic and severe
Length of treatment unclear
Dutch Cohort Study

Effect size:
SCL-90: 1.1
BDI: 2.2
IIP: 2.2
OQ-45: 2.0
Conclusions from treatment trials
RCTs have shown modified psychodynamic
therapies (MBT and TFP) and modified CBT (DBT,
SFT) to be moderately effective
Non-randomised trials show other implementations
of psychodynamic, supportive and CBT interventions
to be somewhat effective
Briefer periods of hospitalisation shown to be more
effective than longer ones
Hospitalisation motivated by suicidal threat is ineffective
(Paris, 2004)
A range of well-organised and co-ordinated
treatments are effective for BPD
Problems, Problems, Problems

Some efficacy of various treatments which


may bring forward natural improvement
More limited effects in severe populations
Questionable generalizability of treatments
High levels of training required
Poor penetration of psychiatric services
Re-mapping the course of
borderline personality disorder
Therapeutic Nihilism About BPD
Early follow-up studies
inexorable progression of the disease
burnt out borderlines
Condition resistant to therapeutic help
intensity and incomprehensibility of emotional
pain
dramatic self-mutilation
ambivalence in inter-personal relationships
wilful disruption of any attempt at helping
Remissions and Recurrences
Among 275 Patients with BPD
Percent

Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283


Time to 12 Month Remission for DIPD
Positive Cases (The CLPS Study)
Proportion not remitting

Time from intake in months


Remission is defined as 12 months at 2 or fewer criteria for PDs; Grilo et al., (2004)
Remission is defined as 2 months at 2 or fewer criteria for MDD JCCP, 72, 767-75.
Summary of Remission Findings
After six years 75% of patients diagnosed with
BPD severe enough to require hospitalisation,
achieve remission by standardised diagnostic
criteria.
About 50% remission rate has occurred by four
years but the remission is steady (10-15% per
year).
Recurrences are rare, perhaps no more than
10% over 6 years.
Treatment has no (or only negative) relationship
to outcome
Impulsive Features, Affective Instability
and Identity Problems of 290 BPD
Percent

Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283


Interpersonal Features of 290 BPD
Patients Followed Prospectively
Percent

Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283


Affective Features of BPD Followed
Prospectively
Percent

Source: Zanarini et al. (2003) Am. J. Psychiat. 160, 274-283


Differential improvement rates of
BPD symptom clusters
Impulsivity and associated self mutilation and
suicidality that show dramatic change
The dramatic symptoms (self mutilation, suicidality,
quasi-psychotic thoughts) recede
Affective symptoms or deficits of social and
interpersonal function are likely to remain present
in at least half the patients.
anger,
sense of emptiness,
relationship problems,
vulnerability to depression
Time to GAF 12 Month Remission for DIPD
Positive Cases (The CLPS Study)
Proportion not remitting

Time from intake in months


Remission is defined as 12 months at 2 or fewer criteria for PDs; Grilo et al., (2004)
Remission is defined as 2 months at 2 or fewer for MDD JCCP, 72, 767-75.
Determinants of remission
When dramatic improvements occur, they
sometimes occur quickly,
often associated with relief from severely
stressful situations (Gunderson, Bender,
Sanislow, et al, 2003)
Co-morbidities undermine the likelihood of
improvement (Zanarini, Frankenburg,
Hennen, et al, 2004)
Persistence of substance use disorders
Implications of Recent Follow Along
Studies
Implication of secondary persistence of
social/functioning impairment
Treatments should be directed at social function
o Social skill building, community/groups
o Vocational rehabilitation; testing; training
o Improve adaptive capabilities (as opposed to decreasing
maladaptive behaviours) e.g. recreational or leisure time
activities
GAF is very relevant outcome measure
Need for better measures sensitive to social
functioning in this population (?APFA)
Partial Hospital RCT: Patients at 5 yrs FU
Partial Hospital RCT: Patients at 5 yrs FU
Partial Hospital RCT: % Attempting Suicide
N=44
NNT (18 months)=2.1
NNT (36 months)=1.9
* NNT (60 months)=2.1
* ***
***

**
**

* p < .05
** p < .01
Treatment Follow -up *** p < .001
Partial Hospital RCT: Employment
Partial Hospital RCT: GAF Scores
The outcome paradox in BPD
Non-suitability
Het alternatief
The paradox of the outcome of BPD
Many treatments show moderate effectiveness
The disorder has a positive natural progression,
irrespective of treatment
Historically, experts agreed about the treatment-
resistant character of the disorder
97% of patients receive outpatient of care
average of 6 therapists
TAU is only marginally effective (Lieb et al, 2004)
The painful conclusion
Some psychosocial treatments impede
the patients recovery following
The natural course of the disorder
Advantageous social circumstances
Suggestive evidence for the reality
of iatrogenic harm
Classic follow-up of patients treated in the 1960s and 1970s
(Stone, 1990)
66% recovery only achieved in 20 years
4 times longer than recent studies
One year hospitalisation is significantly less effective than 6
months hospitalisation (Chiesa et al, 2003)
The iatrogenic effects of hospitalisation persist at 72 months follow-
up
Brief manual-assisted cognitive therapy slightly increases
the likelihood of self harm relative to treatment as usual with
PD patients (Tyrer et al, 2004)
Suggestive evidence for the reality
of iatrogenic harm
Karterud et al 530 patients high intensity treatment v 330
low intensity
Low intensity better for the BPD-patients.
lower number of dropouts (27% versus 32%)
higher number of patients achieving reliable change in GAF which
was maintained at one year follow-up.
Improvements in treatment outcome may be a
consequence of the changing pattern of healthcare in the
US
reduced the likelihood of iatrogenic deterioration associated with
damaging side effects of lengthy psycho-social treatment
Iatrogenesis, psychotherapy and
BPD
Pharmacological studies assume the possibility
of and test for adverse reactions
Psychotherapy is assumed to be at worse inert
No systematic studies of adverse reactions to
psychotherapy
No theory of adverse reaction
Adverse reaction must link to mechanisms of
change
How change occurs in therapy with
BPD
Interpersonal mechanism of change
Change occurs not through insight, catharsis,
or negotiation
Change occurs through new emotional
experience in the context of attachment salient
interactions
Not the content of therapy but the process
of treatment
Adverse reactions and ordinary
mechanisms of therapeutic change
Psychotherapies interface with a range of processes
associated with technique (distorted cognitions, coherence
of narrative, expectations of the social environment,
expectations of the self hope)
A generic factor in common to all these:
Consideration of ones experience of ones own mental state
alongside that which is presented through therapy (by the therapist,
by the group)
Assumes appreciating the difference between ones
experience of ones own mind and that presented by another
person
We assume that the integration of current experience of
mind with alternative views is foundation of the change
process (Allen and Fonagy, 2002)
Reduced appreciation of mind
vulnerability to therapy
Individuals with BPD have impoverished model of mental
function
Own and others
Schematic, rigid, extreme ideas about states of mind
Creates vulnerability to
Emotional storms
Impulsive actions
Problems of behavioural regulation
Consequently unable to compare
A self-generated model
Model presented by mind expert
Maladaptive consequences
Accept alternatives uncritically, without integration, (untherapeutic)
Reject them wholesale drop-out of therapy
The danger of psychotherapies for
BPD
The therapists general stance may often in itself
be harmful, however well-intentioned
I think what you are really telling me ..
It strikes me that what you are really saying
I think your expectations of this situation are distorted
A person who cannot discern the subjective
state associated with anger cannot benefit from
Being told that they are feeling angry
And what the underlying reasons for the anger might
be
The fate of assertions about the
inner world of BPD patients
It can only be accepted as true or rejected
outright
Dissonance between patients inner
experience and external perspective is not
appreciated bewilderment instability
by challenging and undermining the
patients own enfeebled representation of
inner experience more rather than less
mental and behavioural disturbance
The Fonagy & Bateman Principle

A therapeutic treatment will be effective to the


extent that it is able to enhance the patients
mentalising capacities without generating too
many iatrogenic effects
Clinical Implications
The Focus of Psychotherapy is
Often on Autobiographical Memory

Youre born, you deconstruct


your childhood, and then you
Dysregulation of attentional
capacities
With individuals whose attachment relationships
have been disorganized we may anticipate quite
severe problems in affect regulation and
attentional control along with profound
dysfunctions of attachment relationships
Exploratory psychotherapy techniques are likely
to dysregulate the patients affect
It is wise to anticipate difficulties in effortful
control
Disorganisation of self
The therapist should be alert to subjective
experiences indicating discontinuities in self
structure (e.g. a sense of having a
wish/belief/feeling which does not feel like their
own.)

It is inappropriate to see these states of minds as


if they were manifestations of a dynamic
unconscious and as indications of the true but
disguised or repressed wish/belief/feeling of the
patient

The discontinuity in the self will have an aversive


aspect to most patients leading to a sense of
discontinuity in identity (identity diffusion)
Projection of alien self
Patients will try to deal with discontinuous
aspects of their experience by externalisation
(generating the feeling within the therapist)

The tendency to do this had been established


early in childhood

It is not going to be reversed simply by bringing


conscious attention to the process therefore
interpretation of it is mostly futile
That was just a joke That woman is
Doctor, I feel to break the ice. clearly not ready
very depressed Now dont immediately for therapy.
cry you silly cow!
I can understand
with such a sad face
Psychic equivalence

Characterised by conviction of being right that makes


entering into Socratic debates mostly unhelpful
Patients commonly assume that they know what the
therapist is thinking - claiming primacy for introspection
(i.e. saying that one knows ones own mind better than
the patient) will lead to fruitless debate
Therapist may make ill advised attempt to defend
position
Grandiosity and idealization are also expectable
consequences of an unquestioning mind
Psychic equivalence

It is not the action itself that carries most meaning


in this mode but deviation from action that is
contingent with the patients wishes
Self-harm, suicide attempts and other dramatic
actions tend to bring about contingent change in
the behaviour of most people - patient
experiences a sense of being cared about
Misuse of mentalisation may be linked to such
pseudo-manipulativeness and involve realistic
risk of harm to the patient or interactive partner
Pseudomentalizing
Challenging pseudo-mentalisation in the pretend mode
can provoke extremereactions because of the vacuum it
reveals
Pretend mode pseudo-mentalisation denies the therapist's
own sense of reality and the therapist can be left feeling
excluded and trying harder to connect to the patients
discourse
The patients experience of lack of meaningful connection
to reality can be the prompt and drive behind the search
for connection but the connections found are often
random, complex, untestable and confusing exploration
is unproductive
Iatrogenesis

Therapeutic interventions run the risk of exacerbating


rather than reducing the reasons for temporary failures of
mentalising
Non-mentalising interventions tend to place the therapist
in the expert role declaring what is on the patients mind
which can be dealt with only by denial or uncritical
acceptance
To enhance mentalising the therapist should state clearly
how he has arrived at a conclusion about what the patient
is thinking or feeling
Exploring the antecedents of mentalisation failure is
sometimes but by no means invariably helpful in restoring
the patients ability to think
Therapist Stance

Not-Knowing/Inquisitive
Neither therapist nor patient experiences interactions other than
impressionistically
Identify difference I can see how you get to that but when I think
about it it occurs to me that he may have been pre-occupied with
something rather than ignoring you.
Acceptance of different perspectives
Active questioning

Monitor you own mistakes


Model honesty and courage via acknowledgement of your own
mistakes
o Current
o Future
Suggest that mistakes offer opportunities to re-visit to learn more
about contexts, experiences, and feelings
Therapist/Patient Problem
THERAPY STIMULATES
ATTACHMENT SYSTEM DISCONTINUITY
OF
EXPLORATION SELF

ATTEMPT TO STRUCTURE
by
EFFORT TO CONTROL SELF &/OR OTHER
Therapist/Patient Problem

ATTEMPT TO STRUCTURE
by
EFFORT TO CONTROL SELF &/OR OTHER

RIGID SCHEMATIC REPRESENTATION


NON-MENTALIZING
CONCRETE MENTALIZING (PSYCHIC EQUIVALENCE)
PSEUDO MENTALIZING (PRETEND)
MISUSE OF MENTALIZING
FAQs about Mentalization Based
Treatment
Do you use validation?
Yes
o observing and reflection - two aspects of validation are
common to every therapy and are an essential aspect to MBT.
Direct validation
o DBT - used to confirm the patients experience and contingent
response as being understandable in a specific context.
o MBT follows the same principles but the focus is on
exploration and on elaborating a multi-faceted representation
based on current experience particularly with the therapist.
FAQs about Mentalization Based
Treatment
Does the mentalizing therapist self-disclose
Yes. But no more than you would in everyday
interaction.
o Explanation of the reasons for your reaction is useful
especially when challenged by the patient
o Answer appropriate questions prior to exploration in order not
to use fantasy development as part of therapy

Careful self-disclosure
o Verifies a patients accurate perception
o Underscores the reality that you are made to feel things by
him which is an essential aspect of treatment
FAQs about Mentalization Based
Treatment
Do you use fantasy development about the
therapist?
No
o Stimulating fantasy about the therapist is likely to be
experienced as fact
o Confirms the patients distorted beliefs or
assumptions
o Borderline patient does not retain an as if quality or
observing ego when operating in psychic
equivalence
Thank you for
mentalizing!

For further information


anthony@abate.org.uk
Trial II:
Outpatient Implementation of
Mentalization Based Therapy for
Borderline Personality Disorder
Design of pilot study of out-patient MBT
Eligible consecutive patients
SCID I&II plus Clarkin Severity
(N=56)

Patients not randomised


Patients randomised (N=50)
due to refusal (N=6)

Minimisation for: Naturalistic follow-up


Age (18-25, 26-30, >30) Where consent to research
Gender now or later
Antisocial PD
3:2 Experimental control ratio

Non-manualised therapies:
Mentalization Based Treatment
Individual or group
Individual and Group
supportive psychotherapy
Psychotherapy 18-months
18-months plus normal care
(N=30)
(N=20)
Pilot Study out-patient MBT
Patients in treatment
(N=50)

Mentalization Based Treatment: Non-manualised therapy group


Individual and group psychotherapy Individual, group, other psychotherapy
18-months (N=30) plus normal care
18-months (N=20)

3-months: SCL-90, BDI, SpielS&T, IIP, SAS 3-months: SCL-90, BDI, SpielS&T, IIP, SAS
6-months: Sui & Self-harm Inventory 6-months: Sui & Self-harm Inventory
Hospital Admission Hospital Admission
Service Usage e.g.A&E Service Usage e.g.A&E

Drop-out=3
Drop-out=7
Intention to treat analysis(N=)
Intention to treat analysis (N=)

18 Months Follow-up (N=?) 18 Months Follow-up (N=?)


Pilot Study: % Attempted Suicide (NNT=3.8)

PH outcome

* p < .05
** p < .01
Trend O/P MBT: W=.45, Chi squared= 38.7, df=3, p<.001 *** p < .001
Trend Control: W=.16, Chi squared= 9.33, df=3, p<.05
% Self-Mutilating Behavior (NNT=6.7)

n.s.

PH outcome

* p < .05
** p < .01
Trend O/P MBT: W=.20, Chi squared= 17.5, df=3, p<.001 *** p < .001
Trend Control: W=.08, Chi squared= 4.5, df=3, n.s.
Self Rated Depression (BDI)

**

PH outcome

Pair-wise
comparisons
* p<.05
** p<.01
*** p<.001

ANOVA: Significance of interaction term: F2.4, 83 = 6.6, p<.01


Some progress but limitations
Bigger sample size
Control treatments defined
Two-component treatment
Replication sites in UK and Netherlands
Cheaper than most outpatient treatments
Requires less training of staff team
BUT
Effective
component not yet clear
Measuring mechanisms of change.
Slides

http://www.psychol.ucl.ac.uk/
psychoanalysis/anthony.htm