Depersonalization disorder

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Patients with borderline personality disorder are commonly encountered in primary care settings. These patients typically experience a chronically dysphoric and labile mood, self-destructive impulsiveness and chaotic interpersonal relationships. They may also have recurrent, fleeting quasi-psychotic episodes (e.g., rage reactions, paranoia, depersonalization) and a primitive defense structure that is highlighted by "splitting" (i.e., feelings and perceptions are experienced in the extremes of good versus bad). [1] [2]

While the true prevalence of borderline personality disorder is unknown, up to 10 percent of the general population may be affected. [3] The prevalence of the disorder is reported to be 15 percent of all inpatients in psychiatric settings, 27 percent of outpatients with personality disorders and 51 percent of inpatients with personality disorders. [4]

DIAGNOSIS

CRITERIA

Diagnostic confirmation is the first step in the management of patients with borderline personality disorder. According to the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), at least five of eight criteria are required for the diagnosis (Table 1). [5]

An alternative approach to diagnosis centers on the Diagnostic Interview of Borderline Patients, [6] which offers a comprehensive method of identification that is useful in the primary care office (Table 2). If a patient has traits in each of the

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five areas listed, and these symptoms have persisted over a long period (i.e., since adolescence), the diagnosis of borderline personality disorder is likely to be correct.

CHARACTERISTIC BEHAVIORS

A variety of behaviors may suggest the presence of borderline personality disorder. One consistent diagnostic hallmark is a history of self-destructive behavior, often dating back to early adolescence. Self-destructive behavior may take a variety of forms throughout the patient's lifetime and may exist as a repertoire of behaviors at any given moment; 75 percent of habitual self-mutilators use multiple methods. [7] Self-destructive behavior may include self-mutilation (e.g., cutting, burning, biting, bruising) and oral or addictive behaviors (e.g., substance abuse, anorexia nervosa, obesity, bulimia nervosa). Head banging, purposeful sunburning, hair pulling, recklessness or accident-proneness have also been reported.

Three general trends suggestive of borderline personality disorder are observed in the primary care setting: (1) these patients often consume a disproportionate amount of the physician's time, (2) they can be extremely demanding and (3) they tend to experience complicated or incomplete recovery from illness, either organic or functional.

The first of these trends, time consumption, may manifest as frequent and unnecessary telephone calls and visits to the physician's office. Other time-consuming behaviors include the introduction of numerous somatic complaints throughout an office visit and repeated detainment of the physician in the examining room. Office personnel also may have to spend a disproportionate amount of time dealing with seemingly never-ending psychologic and medical issues.

The second trend, "demandingness," may appear as repeated psychologic or medical crises for which these patients must see the physician "that day." They may also demand prompt, simplistic solutions to problems and may pressure the physician to prescribe medications and other items of potential secondary gain. For example, they may request written excuses for unverified illness, disability verification or medical reports lawyers.

The third trend, complicated or incomplete recovery from organic or functional illness, can be extremely frustrating. Patients with borderline personality disorder may consciously or unconsciously create challenging, vague, undiagnosable illnesses, such as chronic viral infection or chronic pain, or may precipitate genuine medical conditions, such as hypoglycemic shock through the abuse of insulin, elevation of serum amylase by stomach punching or simulated sympathetic dystrophy by placing rubber bands on the wrist. These patients also may aggravate legitimate medical conditions by actively interfering with recovery or by not complying with prescribed treatments. For example, they may abuse medications, may not follow up with referrals and tests, or may turn off intravenous drips.

Suicide attempts are common in patients with borderline personality disorder. Up to 75 or 80 percent of these patients report previous suicide attempts. [8] [9] Several authors have suggested that patients with the disorder have an increased likelihood of suicide attempts with concurrent depression or substance abuse. [10] [13]

Completed suicides also occur. Studies suggest that the prevalence rate for completed suicide increases with the length of follow-up. A six- to 36-month follow-up study [14] demonstrated a 4 percent prevalence rate for completed suicide in patients with borderline personality disorders. The prevalence rate was found to increase to 7.4 percent in a four-to seven-year follow-up study. [15] In 15-year and 15- to 20-year follow-up studies, the rates for completed suicide were 8.5 percent [16] and 9.5 percent, [17] respectively. It is generally believed that as many as 10 percent of patients with borderline personality disorder two attempt suicide may eventually succeed.

Management

After the diagnosis of borderline personality disorder has been tentatively established, an overall management plan should be developed. An effective approach needs to incorporate a neutral, structured environment (both in and out of the physician's office) and conservative medical management.

NEUTRAL ENVIRONMENT

Maintenace of a structured environment depends on the physician and staff remaining neutral in attitude and behavior. Emotions should be modulated in times of patients crisis. In particular, anger and other negative emotions need to be avoided when dealing with patients who have borderline personality disorder. Paradoxically, expression of anger by the physician reinforces and intensifies these patients' engagement in the relationship.

Neutrality of behavior entails avoiding excessive accommodation. Patients with borderline personality disorder make unusual requests, which function as unhealthy tests of caring. These may include after-hour appointments, pleas for unusual approaches to medical care and requests for inappropriate house calls or other special favors (e.g., providing unnecessary medication, bringing back mementos from vacation).

In establishing a structured office environment, the physician needs to provide definition, predictability and consistency. An important element is the development of and rigid adherence to consistent interpersonal boundaries. [18] Patients with borderline disorder may have repeated difficulty dealing with these boundaries. They may address the physician by first name, make frequent telephone calls to the physician's home and engage in seductive behaviors. The physician needs to be prepared for boundary violations in advance; it may be helpful to routinely schedule brief, frequent appointments with these patients and to have a third party present during physical examinations. When boundary violations occur, they should be acknowledged in a neutral manner, perhaps in the context of how the physician routinely operates the practice.

Neutrality and boundaries need to be understood and reinforced by the office staff. Limits set by the staff will help clarify the structure of the office environment.

Clarification of the role of the primary car physician is also important to maintaining a structured office environment for patients with borderline personality disorder. The physician should establish a clear division between medical and psychiatric issues. [18] This separation reduces the interpersonal complications that can arise from the complex psychodynamics of these patients. It also enables the physician to avoid being immobilized by their dramatic and often frightening psychologic problems.

Patients who manifest psychiatric problems, such as intense affect or self-destructive feelings, should be supportively referred to a mental health professional. Such referrals can be effective in the context of the individual patient's need to understand his or her own feelings and/or self-destructive drives. The division of labor should be carried out in a mutually cooperative fashion between the professionals involved, with consistency and with frequent contact between the physician and the mental health specialist.

In addition to emphasizing structure in the physician's office, structure in all aspects of these patients' lives needs to be encouraged. Structured environments that are particularly helpful for patients with borderline personality disorder feature a high level of definition, easy availability and access, and the ability of the patient to establish an identity within the environment. Examples of structured situations include frequent appointments with a mental health professional, routine employment and involvement in self-help groups such as Alcoholics Anonymous.

CONSERVATIVE MEDICAL MANAGEMENT

Conservative medical management is the second general component of the office approach to patients with borderline personality disorder. The term "conservative" refers to maintaining balance -- neither overresponding nor underresponding to the patient's medical problems. For example, routine medical evaluation should always be undertaken, but the physician should be cautious about making referals or ordering laboratory tests and procedures. Overuse of diagnostic resources promotes a somatic or "sick" role for the patient.

When the routine medical evaluation is benign, the generic concept of stress as a cause of physical symptoms can be a valuable explanation, particularly when it is communicated in an empathetic manner. This approach offers the physician an opportunity to supportively encourage the patient to discuss life stressors with a mental health professional, a suggestion that further reinforces the division of labor between the primary care physician and the mental health specialist.

A conservative approach is also needed when medication is prescribed. Potentially addictive or lethal drugs should be avoided, and medication use should be monitored for abuse or poor compliance. In general, medication trials for undiagnosed complaints should be avoided. For diagnosed medical problems, it may be helpful to have the patient choose which of a series of "unsatisfactory" medications (i.e., those that the patient has deemed intolerable or has reported to produce vague side effects) should be used. Irregularities in medication compliance, as well as atypical responses or suspicious failures, should always be documented.

The use of psychotoropic medications in patients with borderline personality disorder is a complex issue. These patients may or may not respond to a variety of psychotropic agents, [19]-[23] including heterocyclic antidepressants, monoamine oxidase inhibitors, lithium (Eskalith, Lithane, Lithobid), carbamazepine (Tegretol), antipsychotics and anxiolytics. The maximum response may only be modest at best. The risks of prescribing psychotropic agents include abuse of medication, addiction, overdose and death. Patients may also attempt to control the physician-patient relationship through medication dilemmas. In general, consultation with a psychiatrist is helpful in avoiding problems with psychotropic medications.

Final Comment

Patient with borderline personality disorder are both frustrating and challenging for primary care physicians. Essential skills include an awareness of behaviors that are suggestive of the diagnosis and the abiliy to formulate a management plan that incorporates a neutral environment and conservative treatment. These skills enable the primary care physician to take a reasonable approach to the medical management of patients with borderline personality disorder.

REFERENCES

[1] Kernberg OF. Severe personality disorders: psychoterapeutic strategies. New Haven, Conn.: Yale University Press, 1984:16.

[2] Chatham PM. Treatment of the borderline personality. New York: Aronson, 1985:76-8.

[3] Stone MH. Borderline personality disorder. In: Michels R, Cavenar JO Jr, eds. Psychiatry. 2d ed. Vol 1. Philadelphia: Lippincott, 1986: 1-15.

[4] Widiger TA, Rogers JH. Prevalence and comorbidity of personality disorders. Psychiatr Ann 1989; 19:132-6.

[5] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3d ed rev. Washington, D.C.: American Psychiatric Association, 1987:346-7.

[6] Gunderson JG, Kolb JE, Austin V. The diagnostic interview for borderline patients. Am J Psychiatric 1981; 138:896-903.

[7] Favazza AR. Why patients mutilate themselves. Hosp Community Psychiatry 1989; 40:137-45.

[8] Gunderson JG. Borderline personality disorder. Washington, D.C.: American Psychiatric Press, 1984:87.

[9] Fyer MR, Frances AJ, Sullivan T, Hurt SW, Clarkin J. Suicide attempts in patients with borderline personality disorder. Am J. Psychiatry 1988; 145:737-9.

[10] Friedman RC, Aronoff MS, Clarkin JF, Corn R, Hurt SW. History of suicidal behavior in depressed borderline inpatients. Am J Psychiatry 1983; 140:1023-6.

[11] Friedman RC, Corn R. Suicide and the borderline depressed adolescent and young adult. J. Am Acad Psycholanal 1987; 15:429-48.

[12] Frances A, Fyer M, Clarkin J. Personality and suicide. Ann NY Acad Sci 1986; 487:281-93.

[13] Crumley FE. Adolescent suicide attempts and borderline personality disorder: clinical features. South Med J 1981; 75:546-9.

[14] Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M, Bolinger JM. Borderline: an adjective in search of a noun. J Clin Psychiatry 1985; 46:41-8.

[15] Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG. The validity of DSM-III borderline personality disorder. A phenomenologic, family history, treatment response, and long-term follow-up study. Arch Gen Psychiatry 1983; 40:23-30.

[16] Paris J, Brown R, Nowlis D. Long-term follow-up of borderline patients in a general hospital. Compr Psychiatry 1987; 28:530-5.

[17] Stone MH, Stone DK, Hurt SW. Natural history of borderline patients treated by intensive hospitalization. Psychiatr Clin North Am 1987; 10:185-206.

[18] Gutheil TG. Borderline personality disorder, boundary violations, and patient-therapist sex: medicolegal pitfalls. Am J Psychiatry 1989; 146:597-602.

[19] Ellison JM, Adler DA. Psychopharmacologic approaches to borderline syndromes. Compr Psychiatry 1984; 25:255-62.

[20] Gardner DL, Cowdry RW. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psyhiatry 1986; 143:519-22.

[21] Cowdry RW. Psychopharmacology of borderline personality disorder: a review. J Clin Psychiatry 1987; 48 (Suppl): 15-25.

[22] Frances A, Soloff PH. Treating the borderline patient with low-dose neuroleptics. Hosp Community Psychiatry 1988; 39:246-8.

[23] Links PS, Steiner M. Psychopharmacologic management of patients with borderline personality disorder. Can J Psychiatry 1988; 33: 355-9.

RANDY A. SANSONE, M.D. is assistant clinical professor of psychiatry at the University of Oklahoma College of Medicine and staff physician at Laureate Psychiatric Clinic and Hospital in Tulsa. Dr. Sansone is a graduate of Ohio State University. College of Medicine, Columbus, where he also completed a residency in psychiatry.

LORIA A. SANSONE, M.D. is in group practice at Springer Clinic in Tulsa, Okla. A graduate of Ohio State University College of Medicine, Dr. Sansone completed a family practice residency at Miami Valley Hospital in Dayton, Ohio.

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