Rawalpindi

The management of patients with borderline personality disorder takes time but the efforts are worth it and hence it feels very rewarding to treat such patients. Since majority of the sufferers are females, managing one patient even to some extent is beneficial to the whole family.

Consultant General Adult Psychiatrist at the NHS (Hampshire, UK) and Member of the Royal College of Psychiatrists Dr. Saadia Muzaffar expressed this while delivering a guest lecture arranged by Institute of Psychiatry & World Health Organisation Collaborating Centre at Benazir Bhutto Hospital on ‘Diagnosis and Management of Borderline Personality Disorders’.

Consultants, postgraduate trainees serving at the institute along with psychiatrists, psychologists and students attended the lecture.

Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of ongoing instability in moods, behaviour, self-image, and functioning. A person with BPD may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days. Some people with BPD also have high rates of co-occurring mental disorders, such as mood disorders, anxiety disorders, and eating disorders, along with substance abuse, self-harm, suicidal thinking and behaviours, and suicide, reveal studies.

In the introductory speech at the lecture, Head of Institute of Psychiatry Professor Fareed Minhas talked about the ethical dilemmas in patients with borderline personality disorder, especially in the domains of boundary settings, transference, counter-transference and confidentiality.

He emphasized on the massive physical and psychiatric co-morbidities in such patients and stated that although it is either easy or hard to diagnose it, it is even harder to manage, because the illness tends to simmer but does not completely eliminate.

Dr. Saadia started her lecture by talking about her interest in the management of borderline patients. On diagnosis of BPD, she highlighted the overlap of features between BPD and Bipolar Affective Disorder patients and the fact that it is more acceptable to make a diagnosis of the later.

She highlighted the importance of a rich childhood history including the details and age of onset of self harm, circumstances during childhood such as bullying, abuse in house, whether the patient has been looking after an ill family member. Asking about whether a patient was brought up in an environment where expression of anger was promoted rather than inhibited, gives us an additional information that he or she might have developed a tendency to bottling up anger inside resulting in self harm, she said.

She said it is a privilege to get to know some of the deepest and horrendous secrets of patients’ lives so the matter of confidentiality is of utmost importance in a patient-doctor relationship and hence the entitled trust should be maintained at all costs.

“Inpatient admissions must be short; about 72 hours maximum, in order to minimise disorganized relationship building between the patient and the hospital staff or other patients,” she said.

She described the different criteria for the diagnosis in detail; particularly giving importance to the identity disturbance in such patients since an increase in eating disorders has been reported in the United Kingdom, in the form of unstable self image, Body Dysmorphic Disorder, Anorexia Nervosa, binge eating and co morbid depression and anxiety almost always accompanies it. Secondly, impulsivity is another aspect demanding attention owing to the high rates of substance misuse, promiscuity, reckless driving and self harming behaviour in such patients.

Proceeding to the management of the patients, she mentioned the role of psychotherapy to be of prime importance, involving therapies like Dialectal behavioural therapy, Schema focused therapy, Mentalisation based Therapy, Cognitive Analytical Therapy and Transference Focused Therapy.

The role of medicines, she added, is only indicated when other strategies fail and they work best in combination with Dialectical Behavioural Therapy or Cognitive approach.

She ended with the take home message of being patient and consistent with borderline patients since it takes time and effort to deal with them however efforts never go futile and do some good in one way or the other. “Treating such patients is a challenge and they might make us feel inadequate at times but it is at this point that one must seek supervision and be careful not to take such patients’ poor progress or negative feedback personally.” Eventually, insight is the end of the pathway of management of Borderline Personality, she concluded.

Consultant at the Institute of Psychiatry Dr. Azeem gave the concluding remarks by acknowledging the challenging nature of the topic along with the critical issues of boundary settings and overwhelming value of psychotherapy in such patients.