Portal de Periódicos da CAPES

Overcoming Borderline Personality Disorder

2011; Lippincott Williams & Wilkins; Volume: 200; Issue: 1 Linguagem: Inglês

10.1097/nmd.0b013e31823fafcc

1539-736X

Eric M. Plakun,

Mental Health and Psychiatry

Borderline personality disorder (BPD) is recognized as a formidable clinical problem. BPD is prevalent, often disabling, carries a lifetime risk of death by suicide of between 5% and 10%, and increases the risk of treatment resistance in comorbid disorders (Plakun, 2011, Skodol et al., 2011). Five evidence-based therapies for BPD have emerged, including three behavioral therapies—dialectical behavioral therapy (DBT), schema-focused therapy, and cognitive behavioral therapy for BPD—and two psychodynamic therapies—transference-focused therapy (TFP) and mentalization-based therapy (MBT). The evidence suggests that both psychodynamic and behavioral approaches are useful when conducted by proficient clinicians. Given how prevalent and serious BPD is, clinicians, patients, and their families deserve help in understanding and treating this disorder. Ms. Porr’s book is a useful resource for families, offering practical guidance and helpful suggestions for families struggling with the experience of having a loved one with BPD. She is a wonderful educator whose language is accessible and illuminating. The emphasis on including family members in treating many who struggle with BPD is welcome, and the family skills training groups that her organization offers are wonderful models for the rest of us, including clinicians. She is a fierce advocate for DBT, although she includes one chapter exploring how family members can use mentalization techniques. Ms. Porr is masterful when she focuses on the importance of destigmatizing BPD for families, patients, and clinicians and when she advocates for families to be involved in treatment, balancing privacy needs with the right of family members to know how their investment in the treatment of their loved one is progressing. Her advice to families to be wary of clinicians misdiagnosing BPD as bipolar disorder is important, as is her advice to find clinicians with expertise treating BPD. She makes accessible and useful for families the underlying neurobiology of BPD of a shrunken hyperactive amygdala unrestrained by prefrontal cortex. She introduces, on page 73, the image of the “TARA tiara.” Here, she is a masterful educator, humorously but precisely creating a visual image to help families remember that their loved one with BPD is inevitably wearing a metaphorical tiara with nine bobbing balls of potential dysregulation that easily overwhelm them (dysregulated impulse control, mood, emotional processing, sleep, pain threshold, memory, anxiety, sensitivity to stimuli, and cognition). Similarly useful are the advice to families to differentiate self-destructive behavior like self-mutilation in BPD from suicide attempts and the advice to take a compassionate nonjudgmental stance, recognizing that the person with BPD is actually doing the best that she or he can, and to listen for the nugget of truth in what is being said by a dysregulated family member with BPD. She helpfully explains the importance of responding authentically; of validating the experience of the person with BPD; of helping them identify, name, and speak authentically about their feelings; and of apologizing authentically in the moments we may fail them and offers useful illustrations on how to use the cycle of rupture and repair as a way to make progress in small steps. The chapter explaining tenets of MBT is among the best in the book. All of these skills are terribly important, but sadly, not all clinicians know how to implement them in the midst of the affect storms and minipsychotic episodes found with BPD. Ms. Porr’s courage and ability to teach them to nonclinical family members is admirable. There is so much to welcome and admire in this book that a reviewer is almost tempted not to mention its biases and the puzzling polarized tone that permeates parts of the book. Championing DBT does not require swipes at other treatment approaches. Residential treatment is vilified as too expensive and simply unnecessary—would this were true, but the clinical course of BPD is so riddled with chronic crises around suicide, self-destruction, and the inability to achieve or sustain age-appropriate functioning in outpatient settings that immersion in a residential treatment milieu may well make sense, with a goal of returning to more competent outpatient functioning after a period of intensive work in a residential setting. Unfortunately, psychodynamic approaches are misunderstood by Ms. Porr and are used as straw men. That MBT is an evidence-based psychodynamic approach is not mentioned. TFP, another psychodynamic evidence-based therapy, is omitted entirely. At one point the “Uh huh” response of a psychodynamic therapist is offered as a stereotype of unhelpful unavailability, disengagement, and aloofness, but by page 148, the same “Uh huh” utterance is proposed as a useful way a parent informed by DBT may reflect back to a loved one with BPD that they are listening and empathically present. In fact, many of the tenets presented as central to DBT have their origins in the psychodynamic stance of empathic technical neutrality (e.g., a nonjudgmental empathic and compassionate stance, recognition that people with BPD are trying to solve problems in their lives and doing the best they can, speaking authentically, identifying and putting into words feelings and their contexts, wondering what part of their experience is actually right, and making progress through attention to the cycle of rupture and repair). Advocacy for one BPD treatment model need not be at the expense of others. Two groups of clinicians expert in treating BPD (the Boston Suicide Study Group and the Group for the Advancement of Psychiatry Psychotherapy Committee) are exploring common factors among evidence-based treatments for BPD. The results from both groups suggest that there is much shared by differing treatment approaches, including a clear framework for treatment, an active therapist style that engages affect, the prioritization of suicide as an issue for discussion, and support for the therapist, among others (Sledge et al., personal communication; Weinberg et al., 2010). Discovering common factors is important because they may be widely taught to clinicians, among whom many have patients with BPD, although few will receive specific training in an evidence-based treatment. Ms. Porr also apparently misunderstands the term treatment resistant, seeing it as an epithet clinicians hurl at patients they lack the skills to treat. Unfortunately, this can happen, but emergence of awareness in the field of the problem posed by the phenomenon of treatment resistance is quite important for those with an interest in BPD. Among our important learning about treatment resistance is recognition that when BPD is present, the risk of a mood disorder failing to respond to effective treatments is significantly increased. Therefore, including the treatment of underlying BPD is essential in working with patients with treatment resistant mood disorders (Skodol et al., 2011), and patients and families should know this. Similarly, there is no assumption in the notion of treatment resistance, as is suggested in the book, that the “resistance” to treatment is located in the patient. In fact, I have suggested that it is located more often in the limitations of our treatment and in us as clinicians (Plakun, 2011). On balance, there is more valuable teaching and guidance than misrepresentation in Ms. Porr’s book, and I would not hesitate to recommend it to families—as long as I included a caution about the tone of partisan advocacy that sometimes undermines its value. Eric M. Plakun, MD, DLFAPA The Austen Riggs Center Stockbridge, MA [email protected] DISCLOSURE The author has nothing to disclose.