Acceptabilité et faisabilité de la psychothérapie par les patients avec trouble de personnalité limite

Abstract

Background Borderline Personality Disorder (BPD) is a pervasive pattern of instability and impulsivity associated with serious psychosocial limitations and a significant risk of suicide (4–10 %). The prevalence of this disorder is around 1.8 % in the general population. In a public health perspective, the high financial cost arising from this disorder (around 17,000€ per year) requires optimizing their care utilization carefully. This medico-economic aspect converges with clinical observations of instability in the health network; BPD patients meet at least seven psychiatrists. Indeed, psychotherapy is less accessible, particularly in some geographic area. Objective Discuss strength and weakness of psychotherapy for BPD in the real world. Method Through a non systematic literature review, we present data on the availability and use of health services by people with BPD. Results The effectiveness and limitations of psychotherapeutic approaches, considered as the gold-standard therapy, are reviewed. All the psychotherapies assessed by Randomised Control Trials seem to be effective. However, not all the psychotherapies have the same level of evidence for core symptoms of BPD. Furthermore both the length of most of the psychotherapies suggested to these unstable patients and the number of participants (Dialectic Behavioral Therapy and Mentalization Based Treatment) needed to constitute the team for some of them are serious limitations. Moreover, even available, as shown by observational studies, high drop-out in studies they have a limited acceptability for BPD themselves. Some of them have less drop-out (Dialectic Behavioral Therapy) or a better therapeutic alliance (Schema Focused Psychotherapy) than other one. A presentation of alternatives to psychological approaches is proposed, particularly an example of a Quebec multidisciplinary care organization covering the range of service needs of people with BPD. Conclusions The heterogeneity of clinical situations grouped in the BPD is confronted with the limits of a dichotomous approach (structured psychotherapy or chaotic utilization of care), manifested by a reduced acceptability of care today. This encourages them to rethink the consistency of the service offer to these severe patients.