Borderline Personality Disorder and the Chronic Headache Patient: Review and Management Recommendations
Address all correspondence to Dr. Joel R. Saper, Michigan Head Pain and Neurological Institute, 3120 Professional Drive, Ann Arbor, MI 48104.
Background.—Physicians and psychologists who treat headache not infrequently encounter patients with borderline personality disorder (BPD). BPD patients frequently suffer from headache, and often pose special problems in treatment. Few guidelines exist for the management of the BPD headache patient.
Objectives.—To provide an overview of current concepts on BPD, including comorbidity, psychopathophysiology, and treatment. To provide an explicit framework for managing borderline behavior in patients with chronic headache.
Methods.—A literature review combined with clinical observations from the tertiary treatment of intractable headache in outpatient and inpatient settings.
Results.—BPD is found in almost 2% of the general population, with increased prevalence in patients with comorbid psychopathology and substance abuse. Severe headaches and migraine appear to be more prevalent in patients with BPD than the general population. A reported history of abuse is common, but must be interpreted with caution. Recent research has found reduced hippocampal volume in women patients with BPD; hypometabolism in the premotor, prefrontal, and anterior cingulate cortex, as well as the thalamic, caudate, and lenticular nuclei; and serotonergic dysfunction. Opioid medications may have an adverse influence on certain clinical features of BPD. Some patients show at least short-term improvement in dissociative behavior when given opioid antagonists. Treatment should combine appropriate pharmacotherapy with ongoing psychotherapy. Early identification of BPD is likely to improve the course of treatment. Treatment often requires explicit contracts, consistent limit-setting, confrontation, and communication between different treating professionals to avoid “splitting.” The recognition and management of the doctor's own countertransference is important to successful management. Noncompliant patients may need to be terminated from treatment.
Conclusions.—Specific management guidelines and the use of explicit treatment contracts can help sustain patients in treatment, reduce the risk of medication abuse, and minimize distress in the treating professional. Headaches and other symptoms in patients with BPD can be successfully managed over the course of a long-term relationship with clearly defined limits.
Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition Revised
Borderline Personality Disorder
The treatment of headache is frequently confounded by the presence of psychological comorbidities. The Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition, Revised (DSM-IV) identifies two basic categories (axes) of psychiatric disorder.1 Axis I (Clinical Disorders) includes syndromes that trouble the patient, and for which the patient seeks relief. Certain Axis I disorders, such as anxiety and depression, occur much more frequently in patients with migraine and chronic daily headache than in the nonheadache population,2-4 and they may be associated with a more difficult prognosis.5 Axis II (Personality Disorders) subsumes enduring, inflexible maladaptive patterns of inner experience and behavior that deviate from the expectations of an individual's culture and peer group and lead to significant functional impairment. In contrast to Axis I disorders, personality disorders often appear to trouble others more than they disturb the patient. Patients may not perceive certain aspects of their own behavior as contributing to their distress, and they blame others. Personality disorders complicate the treatment of Axis I disorders, contribute to a poor prognosis,6 and can frustrate treating professionals.
DSM-IV provides diagnostic criteria for nine specific personality disorders grouped in three clusters.1 Cluster A consists of the “odd-eccentric” group (paranoid, schizoid, and schizotypal). Cluster B includes “dramatic-emotional” behavior patterns (antisocial, borderline, histrionic, and narcissistic). Cluster C incorporates those with “anxious-fearful” characteristics (avoidant, dependent, and obsessive-compulsive). Patients who display mixed aspects of various personality disorders, or who may meet proposed criteria for either passive-aggressive personality disorder or depressive personality disorder may be diagnosed with Personality Disorder Not Otherwise Specified.
Personality disorder traits represent pervasive patterns of interpreting, perceiving, thinking about, and relating to one's environment, as well as to oneself. They are exhibited in a broad spectrum of social and personal contexts. The diagnosis of a personality disorder requires an assessment of an individual's long-term patterns of functioning, although certain traits of behavior may prompt suspicion of its presence. A single interview rarely is sufficient to confirm the diagnosis unless the clinician suspects the possibility of a personality disorder and makes a special effort to inquire about the relevant criteria.7 Certain personality features may be sufficiently subtle so as not to be readily evident. In some disorders, the ability to initially present oneself with charm can mask inaccurate, deceptive, or even delusional interpretations of events, and can be misleading. A proper diagnosis often requires collateral information from others. Finally, some dysfunctional behavioral patterns may erupt only under certain conditions, such as crisis situations or high levels of pain, and do not span a broad enough time period or range of situations to fulfill diagnostic criteria.
The presence of an Axis II disorder in a patient with headache reliably converts even the most apparently straightforward case to a supreme clinical challenge. Among the personality disorders, it is Borderline Personality Disorder (BPD) that often presents the most challenging dilemmas during the treatment of chronic headache. Though not necessarily recognizing it as such, many physicians who share their anecdotes regarding irrationally angry, self-destructive, and demanding patients are often describing patients with BPD. This article will review BPD and will recommend a variety of management approaches that can aid in the treatment of patients with BPD who suffer from headache and related painful phenomena.
CLINICAL FEATURES OF BORDERLINE PERSONALITY DISORDER
One notable feature of BPD that complicates diagnosis and management is the “apparently competent person syndrome”: the same individual may appear extremely competent in some situations (including an initial interview) and extremely dysfunctional in others.8 Patients with BPD are frequently characterized as angry, impulsive, and unpredictable individuals. Their behavior frequently makes other people feel “on edge,” and they may display a hurtful, sullen, or distressed demeanor. They are frequently described by others as nasty and obstinate, often volatile. They may be manipulative and unpredictable. They often exaggerate and distort, and impose intense expectations on others with respect to support and caring. Patients are prone to punish people by silence or by other behaviors, and are frequently offended by trivial disappointments, disagreements, or setbacks. They are frequently impatient, confrontational, and irritable unless their expectations and demands are met.
The term “borderline” was originally introduced by Stern in 1938 to describe the borderline between psychosis and neurosis.9 The first reference to “borderline” patients in Headache was in an article by Violon in 1973.10 However, it was not until 1980 that the condition was elevated to a formal diagnosis by the American Psychiatric Association. The diagnosis of BPD requires that the patient meet at least five of the nine current DSM-IV criteria, as shown in Table 1.1
Table 1.—. DSM-IV Diagnostic Criteria for Borderline Personality Disorder
|1.||Frantic efforts to avoid abandonment.|
|2.||Unstable and intense interpersonal relationships that may vary between extremes of idealization and devaluation (people or circumstances are perceived in black-or-white terms, such as the “great doctor” versus the “terrible doctor”).|
|3.||Identity disturbance: markedly and persistently unstable self-image or sense of self.|
|4.||Impulsivity and reckless behavior that can be self-damaging (excessive spending, sexual indiscretion, substance abuse, high-speed driving, and binge eating).|
|5.||Recurrent suicidal or self-destructive threats or self-mutilating behavior (recurrent self-inflicted wounds with fingernails or other objects, extreme weight fluctuations, overuse of medications, or frank efforts at attention-getting through high-risk behaviors).|
|6.||Affective instability due to reactivity of mood (intense, episodic dysphoria, irritability, and/or anxiety, usually lasting a few hours or rarely more than a few days).|
|7.||Chronic feelings of emptiness.|
|8.||Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, and recurrent physical fights).|
|9.||Transient stress-related paranoid ideation or severe dissociative symptoms.|
Given the volatility and mood swings that mark BPD, it is not surprising that there is some overlap between BPD criteria and criteria for bipolar II disorders, including cyclothymic alterations between hypomania and depression.11 Also, borderline behaviors may occur only in specific situations or in response to provocative situations. The borderline patient may appear extremely competent in some situations (including an initial interview) and extremely dysfunctional in others, a phenomenon Linehan refers to as the “apparently competent person syndrome.”8
There are important differences among borderline patients. For example, patients who meet all borderline criteria have a much higher risk of completing a suicide attempt than those who meet fewer.8 Clinically, we have found it useful to conceptualize three different subtypes of BPD: internally distressed, acting out, and antisocial, as illustrated in Table 2. The internally distressed patient may appear compliant and satisfied, following the maxim of “be polite at all costs,” and yet may still meet at least five of the criteria for a formal BPD diagnosis. They may show little improvement in headache, and quietly drop out of treatment. These patients suffer silently, and may not appear to create the same interpersonal problems for the treating professional as the acting-out and antisocial types. Anger outbursts may occur, but infrequently, or they may be limited to certain relationships such as a spouse, and rarely, if ever, occur in a treatment setting. Careful interviewing can reveal borderline symptoms and set the stage for appropriate psychotherapy referrals and pharmacotherapy. Acting-out and antisocial patients present more flagrant problems in their external behavior. Note that although sustained antisocial behavior is not technically a criterion for BPD, recent evidence has revealed statistically significant comorbidity of BPD and antisocial personality disorder in hospitalized adults, but has failed to find evidence of significant comorbidity between BPD and other personality disorders.12
Table 2.—. Subtypes of Borderline Personality Disorder
|Unstable identity||Labile relationships||Lying, deceit, manipulation|
|Recurrent suicidal ideation||Self-harm behaviors||Lack of remorse|
|Sense of emptiness||Impulsive recklessness||Pervasive irresponsibility|
|Internal rage and emotional storm||External verbal displays of anger||Aggressive destruction of objects, |
|Feels abandoned||Struggles with intimacy |
(“I hate you – don't leave me”)61
|Maintains intense resentment |
(“I'm going to get you”)
|Dissociation, numbness||Paranoia||Unlawful behavior|
BPD individuals often feel unappreciated, cheated, or discontent. They believe that they are misunderstood. Terms such as obstructive, pessimistic, and immature are frequently applied to them, and they blame others for the distress or disruption that their behavior causes. Many, but not all, BPD patients are unable to achieve the social status they seek, and this may reflect either rejection or other obstacles that result from their behavior and erratic personal nature. They often have repeated failures, including educational efforts and marriages, and they may complicate their own lives and those around them by their behavior. BPD patients may have stress-provoked transient psychotic events; some are paranoid in nature and can be prolonged. Failed relationships, hormonal changes, and other factors that often alter stability can cause an escalation. A loss of boundary-setting influences through divorce, death, rejection, or other situations can be provocative and cause decompensation.
The borderline struggle with feelings of emotional distress, irrational anger, “numbness,” and suicidal ideation is succinctly captured in this poem from one of our patients, which she titled “Ode to Prozac”:
To feel or not to feel,
that is the question.
Is it better to battle
the demons of rage
Or wallow in the
non-existence of numbness?
Perhaps the question is –
COURSE OF ILLNESS
The course of the illness is such that recognition is often possible in adolescence. However, rates of remittance are relatively high for adolescents. One study found that only 33% patients diagnosed with BPD between the ages of 17 and 19 still met criteria after 2 years,13 in contrast to 60% to 70% of borderline adults in a similar follow-up interval.14 The pattern, by definition, is persistent and pervasive, reflecting the way a person thinks, feels, and behaves through a good part of his or her life. Patients with BPD often come to the attention of the health care system in their early 20's, and may show impaired function throughout the next decade.15 Some patients show gradual improvement over time, whereas others may experience a notable deterioration in functioning in their 40's, particularly when there is a significant loss of a previously supportive relationship, such as a marriage. Long term follow-up studies after 10 to 25 years find about two-thirds of borderline patients doing “fair” to “well,” although there is a wide range of outcomes.16 Over a 14-year period, the suicide rate in 198 traced BPD patients in psychiatric treatment was 8.6%, or about 55 times the annual rate for Caucasian persons in the U.S. population.15 The rates for patients who met all of the criteria for BPD were significantly higher (36%) than for those meeting five to seven criteria (7%).17 Chronic hostility and antisocial behavior make for a poor prognosis.15
PREVALENCE AND COMORBIDITY
An understanding of prevalence rates can help raise the clinician's sensitivity to the diagnosis of BPD. Based on community surveys, about 10% to 11% of the population meets the criteria for at least one Axis II personality disorder,18 with a range of about 10% to 13%.19, 20 BPD is found in almost 2% of the general population,21,22 with a range between 1.1% and 4.6%.20
Prevalence rates increase in the presence of Axis I disorders, particularly with recurrent major depression23 and bipolar II disorders,24 occurring in about 11% of psychiatric outpatients and 15% to 19% of psychiatric inpatients.8,22 BPD is associated with an increased risk for substance-related disorders and antisocial disorders. One study found evidence of substance abuse (e.g., benzodiazepines, opioids, and cannabis) in 76% of hospitalized patients with diagnosed BPD, with even higher rates in those with antisocial features.25 In a group of 200 psychiatric inpatients and outpatients referred for treatment of personality disorders, BPD was significantly associated with current substance use disorders (excluding alcohol and cannabis) and with lifetime alcohol, stimulant, and other substance use disorders (excluding cannabis).26 Among hospitalized adolescents, BPD is significantly more prevalent in those with a combination of both major depression and substance use disorders than is the case for either depression or substance misuse alone.27
Significant headaches are a common complaint in patients with BPD. Hegarty evaluated 112 sequential patients (24 men and 88 women) who had been diagnosed with BPD and were attending outpatient and emergency psychiatric departments in a metropolitan hospital center.28 The overall prevalence of severe headache was 60.4% in those with BPD, clearly substantially higher than in the general population. Fifty percent of the women and 24% of the men were diagnosed with migraine, three to four times the expected prevalence rate for the general population.29 Accompanying symptoms included suicide attempts (20% of men and 63% of women), violent outbursts, and substance abuse. In women more than men, a history of impulse control was noted. The author emphasized that depression, suicidality, impulsivity, violence, and migraine all have been associated with a central biochemical disturbance, in particular, serotonergic dysregulation. Perhaps serotonergic and other biochemical mechanisms are common to BPD and certain headache disorders.30
ETIOLOGY, PREDISPOSITION, AND PATHOPHYSIOLOGY
The etiology of BPD is complex and probably involves a confluence of genetic and other biological factors, as well as environmental influences. Gender differences exist. The disorder is gender linked and is significantly more common in young women than in men.31 Seventy-six percent of BPD patients are women, and only 24% are men.14
Linehan has proposed a biosocial theory involving the following factors:32
1. An inherent emotional vulnerability, probably genetic, marked by:
• Frequent and intense emotional responses
• Inability to self-regulate emotion
• Difficulty in returning to an emotional baseline
2. A “perfect” or “chaotic” family environment that in some way serves to invalidate the patient's identification and expression of emotion, interfering with normal attachment
3. Child abuse as a significant complicating factor in many (but not all) cases
From a psychological point of view, childhood neglect, emotional trauma, and abuse (often sexual) are considered potential origins and are more frequently found in the reported history of those with BPD (40% to 86% with a history of alleged sexual abuse) than for the general population (22% to 34%).33 Furthermore, the severity of the reported abuse history correlates with the severity of borderline symptoms.33 A recent large-scale community-based longitudinal study of 639 individuals found that those with a documented abuse history in their state records were four times more likely to be diagnosed with a personality disorder in early adulthood, and that documented childhood physical abuse, sexual abuse, and neglect were each associated with an increase in personality disorder symptoms in early adulthood.34
However, the patient's recall of abuse and documented history of abuse are not perfectly correlated.34 The accuracy of “abuse” reports has been questioned because individuals with BPD either intentionally or otherwise misinterpret or distort many of the important events and relationships of their lives. A recent survey of clinical psychologists found that patients with BPD were rated as especially likely to misinterpret or misremember social interactions, to lie manipulatively and convincingly, and to have voluntarily entered destructive sexual relationships, possibly even at young ages, than patients with other personality disorders or the “typical outpatient.”35
Linehan's proposed theory acknowledges a significant biological component and raises the possibility of abnormal limbic system activity in BDP patients, and/or dysfunction in neocortical control of limbic responses. Using magnetic resonance imaging, Driessen's group found that women with BPD had nearly 16% smaller volumes of the hippocampus and 8% smaller volumes of the amygdala than healthy controls. When BPD and control subjects were considered together, hippocampal volumes were negatively correlated with extent and the duration of self-reported early traumatization.36 Recent PET scan research by De La Fuente and colleagues found relative hypometabolism in patients with BPD at the level of the premotor and prefrontal cortical areas, the anterior part of the cingulate cortex, and the thalamic, caudate, and lenticular nuclei when 10 inpatients with BPD were compared with 15 age-matched controls.36 Total theta power during a laboratory pain procedure (cold pressor test) was significantly higher in self-mutilating BDP patients who report no pain during self-injury than in depressed and normal controls.37
There is also a growing body of evidence that some patients with BPD, particularly those with dissociative episodes who report no pain during self-mutilation, have a fundamental disturbance in their endogenous pain control system. Some form of self-mutilation occurs in 70% to 80% of BDP patients, and approximately 60% of this group reports feeling no pain during self injury.38 This group of BDP patients appears to experience generalized difficulties in pain perception.38-42
Self-mutilation appears to play a powerful role in mood regulation for some patients, who report mood elevation and decreased feelings of dissociation in the aftermath of self-injury.43 One of our BDP patients spoke of the “incredible power rush” she experienced after cutting her upper arm with a razor blade. Several studies have shown a reduction in self-injurious thoughts and behaviors following administration of an opioid antagonist such as naltrexone,44-46 with one study suggesting a rebound increase in self-injurious thoughts when naltrexone was discontinued.46
Based on these observations, Bohus has suggested that increased activity of the endogenous opioid system contributes to dissociative symptoms in BPD. These data also imply that opioid analgesics may have an adverse influence on some borderline patients, and potentiate severe borderline behavior.47 In addition to evidence for serotonergic dysregulation,30 an endogenous opioid disturbance may help account for the comorbidity of BDP and severe headaches, as well as substance abuse. It is also possible that some patients may behave in ways that increase the likelihood of headaches as a means of regulating distressing moods, alternating between cycles of physical pain and mental anguish. One of our BDP patients put it this way: “It feels good to feel bad.” Another stated “I know this sounds disturbed, but I'm almost grateful when I get the headache,” because it allowed her to deflect her attention from other stressful events in her life.
BEHAVIORS THAT NEGATIVELY INFLUENCE OR SABOTAGE TREATMENT
The patient with BPD is frequently an individual who, early in the course of headache treatment, will give signs of the disturbance and will come to the attention of the alert physician, psychologist, or staff as a result of these behaviors. Several of these pathognomic behavioral patterns are identified in Table 3.
Table 3.—. Behaviors That Negatively Influence or Sabotage Treatment
|1.||The malignant “hug sign” (coined by Robert Hamel, P.A.-C, 1993), including inappropriate and physical and/or emotional “hugging.” Patients will demonstrate early in the relationship overly familiar physical and verbal behavior and a tendency to prematurely glorify with praise (often followed by sharp criticism when disappointed). Frequently encountered statements may include, “You are the first physician who has ever taken my symptoms seriously”; “I know you will make me better”; “You are the best physician I've ever seen.” Bringing gifts and food to staff is often characteristic following the first visit.|
|2.||Pushing limits, insatiable neediness, and inappropriate requests for medications or other special favors.|
|3.||Irritability or anger with the physician or staff (often expressed through others) when demands are not met.|
|4.||A recurring pattern of chaos, distress, or unexplained clinical phenomena, such as unusual and extreme side effects, disruptive behavior, manipulative behaviors, etc.|
|5.||Severe reactions to any distancing, limit-setting, or reduction in medications; adjusting medication downward can be perceived as abandonment, generating a drama of escalating behavior and accusations.|
|6.||Behaviors that serve to “split” physician from other physicians, staff members from each other, or other ways to interfere with orderliness in the day-to-day patient-doctor relationship.|
|7.||Persistent efforts to acquire more medication than prescribed, excessive usage, and the use of devious means to obtain prescriptions.|
|8.||Perceiving events of care in an “all or nothing” fashion (reflects the extreme idealization and devaluation pattern). The care is seen as all good or all bad, a physician's statement of encouragement is seen as a promise to help, or a physician's limit setting is perceived as an accusation, as in “You called me a drug addict.”|
|9.||Failure to take responsibility for behaviors. This manifests in the “blame game” whereby others are blamed for the plight of the patient, without a willingness to accept responsibility for one's own behavior.|
These behaviors and others make it very difficult to treat the headaches of patients with BPD. Patients may also exhibit “pain-panic” or cephalgiaphobia, a term we believe was first used by Harvey Featherstone, MD. Significant, uncontrolled fear over anticipated painful events prompts excessive and obsessive drug-taking behavior and, ultimately, medication overuse. Simple patterns of drug overuse/misuse and rebound, as well as frank addictive disease, occur in patients with headache and BPD, and attempts to set limits often result in sharp, confrontational interactions.
The use of opioids in patients with BPD and headache is likely to be very troublesome and may result in serious overuse/misuse patterns, if not an intensification of disruptive behaviors. Hospitalization can be disorderly, and often leads to confrontational behavior and interaction, splitting of staff and other patients, and frequently, though not always, an unsuccessful stay.
It may be that the presence of pain provides a means to control relationships and avoid “abandonment.” Relief of pain may threaten stability and the means with which to control others.
PSYCHOTHERAPY AND PHARMACOTHERAPY
The most useful treatment for BPD appears to be a combination of psychotherapy and pharmacotherapy.48 One of the more well accepted and evaluated behavioral therapies is referred to as dialectical behavioral therapy, developed by Linehan.32,49,50 This therapy contains elements of behavioral, cognitive, and supportive psychotherapy. The criteria for BPD are frankly discussed with the patient, and borderline behaviors that emerge in the therapeutic relationship are identified and discussed, with the therapist combining expressions of empathy (“I can understand this is difficult for you”), with problem solving (“what are you going to do about it?”). The program also includes psychosocial skills training, including the cultivation of “mindfulness” (distinction between the emotional and reasonable mind, developing the “wise mind” that integrates reason and emotion), interpersonal skills, techniques for regulating emotion, and increasing distress tolerance. Therapy is often conducted weekly, in both individual and group sessions. Controlled outcome studies provide good support for its effectiveness.50-52 Other approaches to psychotherapy, including psychodynamic approaches, also have support.53-55 Note that one area of common ground between both behavioral and psychodynamic treatment for BPD is the emphasis on the explicit development of a therapeutic contract between patient and doctor, with clear expectations, ground rules, and boundaries.8,53 Regardless of the approach, psychotherapy for BPD requires highly skilled therapists, takes time, and requires frequent visits.
Pharmacological treatments are of potential value. No treatment is universally effective, but most psychiatrists administer some medication to control symptoms. Haloperidol can help reduce anger and hostility, but may not be well tolerated long-term.56,57 In our experience and in anecdotal reports from others, atypical neuroleptics (olanzapine, quetiapine, and risperidone) may be of considerable value in some patients, particularly when combined with other agents (see below). They are useful for impulse control, psychotic-type symptoms, depression, and anxiety. Headache benefit is possible. Dosages should generally be kept low.
Tricyclic antidepressants may be of value in patients with depression, but may also increase anger and lessen impulse control. MAO inhibitors may be useful in some patients.56
Open-label trials of fluoxetine,58 as well as sertraline, have unproven efficacy in reducing self-injury, suicidality, affective instability, rage, impulsivity, psychosis, and obsessionality. No single SSRI has emerged as the treatment of choice, and individuals failing one may respond to another. Use of a medication program with both serotonergic and antidopaminergic effects may be particularly helpful for some patients.59
Lithium and the anticonvulsants are sometimes effective in managing anger, impulse control, and pain. Divalproex and carbamazepine are both noted to be of potential benefit. Divalproex has established headache control benefits as well, and may thus be of particular value.60
Opioids should generally be avoided. For some patients, opioids may result in an escalation of dissociative, antisocial, and other harmful behaviors.47 Other medications and substances with a potential disinhibiting effect, such as anxiolytics and alcohol, may increase behavioral dyscontrol and generally should be avoided. As discussed in more detail above, opioid antagonists (naloxone and naltrexone) may help reduce self-injurious behavior and dissociation, but have not been employed as ongoing treatments.44-46
Medications are frequently abused. Because dependency on drugs is a significant risk, long-term maintenance therapy has not been shown to be of particular benefit, but short-term adjunctive use of medication may be important in the management of patients with BPD.
BEHAVIORAL MANAGEMENT OF THE BORDERLINE PATIENT WITH HEADACHE
A key factor in approaching a patient with BPD and headache is the setting of firm limits and expectations regarding behavior and treatment.48,53,54 Precise limits must be established and boundaries must be defined. Specific goals must be identified. Inappropriate behaviors must be confronted, and there must be an insistence upon psychological/psychiatric treatment. The following guidelines are recommended as soon as the diagnosis is suspected:
Identify potential problems early;
• Set limits and establish boundary definitions regarding treatment, drug use, and behavior;
Emphasize the goal of enhancing the patient's sense of responsibility and self-efficacy: she or he can learn to effectively manage problems that may arise in treatment.
Establish the principle that the problems are not “someone else's” fault, and that the patient must accept his/her role in his/her own distress and therapy (internal locus of control);
Focus on specific goals for treatment;
Confront behavior problems with firmness, candor, and consistency;
Identify splitting behaviors and avoid becoming a “victim”; do not enable the patient or “buy into” the trap;
Insist as a condition of care that coordinated psychological/psychiatric treatment be undertaken;
Establish a treatment contract; and
Discontinue treatment when appropriate.
Once a BPD patient has been diagnosed or is strongly suspected as having BPD, explicit discussion of a treatment contract is essential. Although the contract may be verbal, we have found written contracts to be very helpful. Contracts can be standardized and reviewed point by point, or they may dictated in front of the patient. Elements of an effective treatment contract are shown in Table 4.
Table 4.—. Elements of an Effective Treatment Contract
|1.||Emphasize patient responsibility for compliance (not staff's responsibility)|
| || Agreement to comply|
| || Acceptance of drug and dose limitations|
| || Agreement to ongoing psychotherapy, and to ensure that communication occurs between physician and therapist|
| || Agreement to possible psychiatric referral when necessary|
|2.||Agree upon goals of treatment and time limitations for outpatient visits, length of hospitalization, etc.|
|3.||Identify appropriate expectations for pain control|
| || Complete pain relief is not possible|
| || Agreement to tolerate some level of pain until best treatments can be found|
| || Medications must be used according to established limits, even when pain is not well-controlled|
|4.||Require patient participation in self-help behavior (e.g. relaxation and exercise)|
|5.||Specify unacceptable disruptive behavior and consequences|
| || No intense anger expressions or outbursts|
| || No profanity|
| || No throwing objects|
| || No self-harm|
| || No destruction of property|
| || No medication excesses or limit violations|
|6.||Specify means of informing staff of suicidal feelings and self-harm|
|7.||Identify consequences for noncompliance or failure to keep contract|
| || Transfer to other physician, psychiatrist|
| || Discontinuance of care|
The effectiveness of contracts is illustrated in the following example. A recently hospitalized headache patient proudly proclaimed that she had “trashed” the last hospital room she was in, as well as loudly cursed the staff who evaluated her. As part of her preadmission contract, she specifically agreed not to do any trashing, verbally or physically, with the explicit written understanding that the consequence for noncompliance would be immediate discharge. The hospital stay remained orderly.
Borderline patients provoke strong feelings in the treatment provider (countertransference), including intense anger, as well as anxiety. They can be adept at instilling professional guilt over treatment decisions. Alternatively, they can also be quite seductive and charming. The treatment provider may be tempted to transgress normal professional boundaries, make special exceptions, or respond to the patient in an overly friendly way. The BPD patient may then later blame the physician for failing to sustain special treatment, or having deceived them in some way. Or, the patient may continue to praise the doctor and then display anger with staff. The borderline patient can also trigger rescue fantasies and awaken narcissism. The doctor may believe that he or she may be the only one capable of effectively treating this patient. BPD patients are particularly sensitive to nonverbal cues, and will sense the doctor's internal distress even when the content of the doctor's speech is straightforward. They will also test limits repeatedly.
The treating professional must remain aware of countertransference and use it as a diagnostic tool (i.e., the emergence of such feelings increases the likelihood of a BPD diagnosis). Sometimes the doctor must make a special effort to remain calm during the course of the professional visit, not erupt in an explosive outburst when provoked, and yet assertively confront disruptive borderline behavior.
• Recognize that borderline disruptive behavior is a symptom of the patient's pathology; do not take it personally.
• Acknowledge your own negative emotions (e.g., “I find myself feeling angry when you raise your voice because it has a negative effect on my other patients who can hear you, and that is not acceptable”). Let your words convey your feelings, rather than relying on an angry vocal tone.
• Confront problem behavior with directness, but with compassion. Straightforward and frank disapproval of behavior that sabotages treatment is essential to the development and maintenance of a constructive therapeutic relationship.
• Avoid enabling; don't give in on unreasonable requests simply as a means of temporarily assuaging the patient or getting her/him out of the office.
• Avoid the reinforcement of splitting behavior; do not be seduced by the patient's excessive praise early in treatment or criticism of other doctors.
Do not acquiesce or tolerate manipulation, anger, or any other unacceptable behavior because this reinforces and sets the stage for continuing problems in treatment. A suggested statement to patients who are angry and disruptive: “I know that anger is a problem for you. Your anger is also a problem for my staff and me. Anger cannot be tolerated when it is as inappropriate as is yours. Anger is also important in headache provocation. You must address your anger and control it as part of your treatment. It is your responsibility. If it is not controlled, we can no longer provide care.”
Acknowledgment: Special thanks to Robert Hamel, P.A.-C for his astute clinical observations.