For GPs: Articles of interest

Borderline Personality Disorder: Patients’ or Therapists’ Crisis?

Dr Seema Sharma MBBS FRANZCP Consultant Psychiatrist, Drug & Alcohol Unit, Northside Clinic, Greenwich and Northside West Clinic, Wentworthville.

People with a diagnosis of Borderline Personality Disorder are the ones who need most nurturing and containment but they manage to burn out the professionals and partners who look after them. They journey from crisis to crisis, presenting as self harm attempts and drug overdoses resulting in multiple Emergency admissions. Affective instability (mood fluctuations) and inappropriate intense anger lead to multiple relationship-breakups causing disintegration of their inner and outer world.

These patients require acknowledgement and validation of their distress. A fine balance between giving support, containing crisis and promoting autonomy has to be incorporated in their management. Their sensitivity to perceived rejection and abandonment can lead to doctor shopping. They sack you before you confront them.

It is a turbulent road between crises. They vacillate between idealisation and devaluation. They adore you and hate you in different sessions and sometimes in the same session. It is important to be empathically attuned and non judgmental in your dealings with them. Consistency and predictability of your responses are the key factors in building their trust in you. Therapeutic alliance is the single most important factor in determining positive outcomes. It is imperative to be mindful of their over-familiarity and boundary transgressions.

Referral to psychiatrist to diagnose and treat co-morbidities like depression, bipolar affective, substance dependence and eating disorders is very significant aspect of their management. Close liaison with treating psychiatrist and crisis team is essential to avoid splitting and abusing of prescribed drugs. Putting firm structure in place like collection of drugs from only one pharmacy and limit setting the number and duration of sessions are important strategies to use with them.

Last but not least is being aware of transference and counter-transference issues. Transference is the patient’s feeling towards the doctor based on their previous important relationship eg you representing an authoritative/abusive figure from their past who is trying to control them. Counter-transference is the doctor’s feelings and attitudes towards patients which are transferred from doctor’s previous relationships. The awareness of these phenomena is helpful in their long term management.

Further reading:

• Bateman,A & Fonagy, P (2004) Psychotherapy for Borderline Personality Disorder. London:  Oxford University Press
• Gabbard G O Psychodynamic Psychiatry in Clinical Practice: American Psychiatry Press Inc
• Kolla NJ: et al Demonstrating Adherence to Guidelines for the Treatment of patients with Borderline Personality Disorder. Can J Psychiatry 2009, 54(3): 181-189