En wat met diegene die de "borderline" overschrijden? (ik vraag het enkel uit algemene interesse...
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wat bedoel je daarmee?
BORDERLINE PERSONALITY DISORDER Epidemiology — There are no large-scale, population-based epidemiological surveys of borderline personality disorder, but several small studies involving nonclinical samples suggest that the prevalence in the general population is approximately 1 to 3 percent. A survey of patients in an urban primary care practice found that the lifetime prevalence was 6.4 percent. Rates of 20 percent or more have been reported in patients seen in mental health settings. The ratio of female to male cases is at least 2:1. Thus, it is likely that the typical primary care physician sees a substantial number of patients with borderline personality disorder.
Pathogenesis — The cause of borderline personality disorder is unknown. These individuals appear to have higher rates of childhood physical, emotional, and sexual abuse , although the association is not definite. The influence of genetic factors also is not clear.
Clinical features — Patients with borderline personality disorder experience instability in their self image, mood states, interpersonal relationships, and impulse control. The social history usually includes many stormy relationships. At one moment a friend or romantic partner may be viewed as a trusted confidant. A week later, this same individual may viewed as cruel and betraying.
The individual with borderline personality disorder is prone to interpreting relatively minor disagreements or adverse events as a sign that the person he or she depends on wants to end the relationship. The reaction is often anger or threats of self harm, which ironically may alienate the trusted friend who then really does want to end the relationship.
These patients are usually able to acknowledge chronic problems with anger control. They experience repeated marked swings in mood throughout the course of a single day. This sometimes results in an incorrect diagnosis of bipolar disorder; the latter is distinguished by episodes of elevated and depressed mood lasting weeks or months.
In the presence of someone viewed as loyal or trustworthy, the individual with borderline personality disorder is likely to feel confident, energetic, and creative. When a key person in his or her support system is absent or behaves in a way the individual interprets as a sign of impending separation, angry outbursts may rapidly shift into feeling unlovable, hopeless, and suicidal.
These patients are prone to view others as all good or all bad. This phenomenon is called "splitting." Maintaining a rigid classification system often leads the patient to shift between extreme points of view and selectively attend to information in a way that confirms his or her current opinion.
Borderline personality disorder is commonly associated with comorbid Axis I diagnoses. In one study, for example, patients with borderline personality disorder were more than twice as likely to receive a diagnosis of three or more current Axis I disorders as those who did not have borderline personality disorder (70 versus 31 percent), and almost four times as likely to have a diagnosis of four or more disorders. In comparison to patients with other personality disorders, those with borderline personality disorder more frequently received a diagnosis of current major depressive disorder, bipolar disorder, panic disorder with agoraphobia, social and specific phobia, posttraumatic stress disorder, obsessive-compulsive disorder (OCD), eating disorder, and any somatoform disorder. Similar results were noted in the primary care survey cited above. These findings highlight the importance of performing thorough evaluations of Axis I pathology in patients with borderline personality disorder to identify potentially treatable illness.
About 10 to 15 percent of these individuals will die by suicide. Assessing the current risk is difficult since years of suicide threats and medically nonserious gestures may precede an actual suicide. Patients may also engage in nonsuicidal self-injury such as cutting themselves with a razor blade or burning themselves with a cigarette. In these cases, the patient can usually identify the behavior as a compulsive act that relieves tension with no suicidal intent.
Decisions regarding the degree of risk and the appropriate level of intervention are not an exact science and should be shared with a mental health specialist, preferably someone who is familiar with the patient. Often it is an exacerbation of comorbid substance abuse, depression, eating disorders, and medical consequences of impulsive behavior that leads to hospital admission.
Prognosis and response to treatment — Patients with borderline personality disorder may not have good insight into the connection between their behavior and their problems, although they are acutely aware of chronic interpersonal difficulties. This combined with their tendency for forming strong attachments means that these individuals are often willing to commit considerable time and energy to therapy. A practice guideline for the treatment of patients with borderline personality disorder was published in 2001 by the American Psychiatric Association, and can be found online at
www.psych.org/psych_pract/treatg/pg/BPD_05-15-06.pdf.
The problems with "splitting" noted above may be increased by differences between various mental health professionals regarding their perspective on the nature and treatability of borderline personality disorder. A study of over 700 clinicians at eight different university psychiatry departments revealed that nurses (who often see patients only as inpatients during times of crises) were the most pessimistic regarding the benefits of either medications or psychotherapy; they were more likely to view these patients as consciously manipulative. Psychiatrists were moderately positive about the benefits of medications and psychotherapy. Psychologists generally viewed psychotherapy as potentially helpful and thought medications were of little benefit. Social workers shared the psychologists' enthusiasm for psychotherapy and the psychiatrists' optimism about medications playing a useful role.
The limited available data support the opinion that both medications and psychotherapy can play a useful role in patients with borderline personality disorder. The few studies that include a control group and a number of uncontrolled studies suggest that patients demonstrate clinically significant improvement within the first year of psychotherapy. The most effective therapies tend to be those that emphasize a behavioral, skills training approach rather than analyzing unconscious motives. This is not surprising since the original development of the concept of borderline personality disorder grew out of the observations that certain nonpsychotic patients tended to deteriorate to a psychotic-like state when placed in psychoanalysis.
Psychopharmacologic studies suggest that improvement may be possible within the first few months of treatment. While medications do not lead to a remission of symptoms, the symptoms that represent core criteria, such as impulsivity, mood instability, and self-destructive behavior, may improve in response to various drugs. Low to moderate effectiveness has been reported for SSRIs, low-dose antipsychotics, and medications classified as mood stabilizers, such as lithium, valproate, and carbamazepine. Higher doses of antidepressants may be required than in patients with major depression alone. The available studies fail to provide follow-up data on outcomes for more than a few months. Preliminary data also suggests a potential role for omega-3 fatty acids in women with borderline personality disorder, but further study is necessary.
Given the long-term nature of borderline personality disorder, longer duration psychopharmacologic studies are clearly needed. Decisions about medication use are best made by psychiatrists who are familiar with the current literature.
Regardless of the treatment chosen, follow-up studies of 5 to 15 years duration have generally found that about one-half of patients no longer have sufficient severity and frequency of criterion behaviors to meet full criteria for borderline personality disorder. A study of 362 patients hospitalized with borderline personality disorder found that 34.5 percent had remission of the disorder at two years, 49.4 percent at four years, and 68.6 percent at six years; only 5.9 percent of patients with remissions had a recurrence during the six years of follow-up.
Maintaining an effective doctor-patient relationship — Most of these patients will require psychiatric referral for consideration of psychotherapy and drug therapy. A workable doctor-patient relationship is usually possible with the patient's primary care physician as long as the physician avoids becoming a passenger on the patient's emotional roller coaster. If the patient "fires" the physician for not returning a phone call promptly, a pointless transfer to a new physician can often be avoided by informing the patient that you would be willing to make a future appointment to discuss what happened. If the patient disputes the wisdom of a given treatment plan for an upper respiratory infection or chronic back pain, it may be helpful to acknowledge the disagreement and ask the patient to try your plan with the understanding that you will reassess at the next visit.
It is helpful to distinguish teachable from unteachable moments. If the patient is upset, it may be much more effective to wait until the next appointment to discuss a new plan for adjusting insulin doses or managing headaches.
Because of the patient's tendency for "splitting," at any given time two individuals that are part of the patient's medical care team may find themselves on opposite sides of the split. The patient may selectively pass on information about what another team member has said in a way that leads to conflict between team members. It is essential to maintain good communication between professionals to provide coordinated and effective care.
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