General Psychiatric Management Research Articles

The effectiveness of psychological interventions for borderline personality disorder for those who misuse substances: a systematic review and narrative synthesis

Purpose This study aims to identify and critically appraise literature exploring the effectiveness of psychological interventions in improving borderline personality disorder (BPD) symptomatology for individuals who misuse substances. Design/methodology/approach Systematic searches across six databases (PsycINFO, Embase, Scopus, Medline, CINAHL and ProQuest), hand searching and citation chaining were conducted between June and August 2021. Key search terms included BPD, substance use, therapy and effect. Study and sample characteristics, interventions, outcome measures and key findings were extracted. Quality assessment and a narrative synthesis approach were used to explore strengths, limitations and relationships between and within studies. Findings Seven eligible reports were included and showed mostly adequate quality. Mixed samples, designs, outcomes, definitions and implementation varied. Treatment completion did not differ significantly between those who did and did not misuse substances. Interventions demonstrated effectiveness in relation to psychiatric symptoms, hospital admissions, self-efficacy and impulsive and self-mutilating (cutting, burning, etc.) behaviours. No effects were found for suicidal or parasuicidal (threats, preparation and attempts) behaviours. Research limitations/implications This review only considers individuals with diagnoses of BPD who are not accessing substance misuse treatment. Radically open dialectical behaviour therapy (DBT), therapeutic communities and other interventions are available as interventions for substance misuse (Beaulieu et al., 2021). Based on the findings of this review, it should not be assumed that such interventions affect substance misuse rather than BPD symptomatology. Therefore, future research might explore the effectiveness of these interventions on BPD symptomatology despite this not being the primary target for intervention. Practical implications Despite McCrone et al. (2008) noting the cost of this population’s difficulties to both themselves and services, the limited number of studies in this area is astonishing. Despite a lack of quality in the data available, there i some evidence to support the use of DBT and general psychiatric management (GPM) interventions for those with BPD and concurrent substance misuse. It is therefore of principal importance that health and social care services action Public Health England’s (2017) recommendations. Individuals with coexisting BPD and substance misuse would then receive support from any professional they see, who could then refer for psychological therapies. Originality/value Although the reports appear to show that DBT, integrated therapies and GPM may be effective for this population, conclusions cannot be drawn with high levels of confidence due to heterogeneity among studies. The findings indicate that future, high-quality research is needed to test the effects of interventions on BPD symptomatology for those who misuse substances. Randomised controlled trials with sufficient statistical power, homogeneous outcomes and standardised methodological approaches are needed.

Brief psychiatric treatment for borderline personality disorder as a first step of care: Adapting general psychiatric management to a 10-session intervention.

The considerable demand versus supply gap of evidence-based treatments for borderline personality disorder (BPD) indicates the need for modular steps of care to tailor fit between individual patients' needs along the trajectory of their clinical course and effective interventions. These trajectories may or may not include lengthy specialized psychotherapies. Good psychiatric management (GPM) for BPD is being practiced by an increasing number of mental health professionals as a basic starting block of mental health services in the community. It remains an open question what duration of GPM is optimal, what the content of a shortened version of GPM may be, and how such brief treatment may be integrated into larger long-term treatment plans for patients with BPD. The present practice review elaborated on a brief version of GPM, addressed its conceptual background and the notion of stepped care in the treatment of BPD, and discussed the clinical tasks and contents of brief psychiatric management in 10 sessions (or lasting 4 months). It also summarized the moderate evidence base of brief forms of GPM: 2 randomized controlled trials of 10-session GPM, and 1 randomized controlled trial of a 6-session GPM psychoeducational group, have found medium-to-large effects in reducing BPD symptoms. Finally, this review offered 2 clinical vignettes of patients either stepping up or down the intensity of their treatment to illustrate how to implement brief GPM and suggested open avenues for future development and clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Management of Psychiatric Disorders in Patients with Respiratory Diseases.

Management of Psychiatric Disorders in Patients with Respiratory Diseases.

10.4314/ajns.v9i2.70411

Background Deliberate self-harm with stone- or hammer-driven nail through the cranium is unusual. The need is stressed for comprehensive radiological evaluation with computed tomography (CT) scan, with or without angiography, and removal through an open cranial procedure under general anaesthesia, rather than extraction through a burrhole under local anesthetic infiltration. Methods We present here a 27-year old male who presented at our Teaching Hospital setting with a self-inflicted hand-driven intracranial nail to the left parietal region. He had a detailed neurological examination, was evaluated pre-operatively with computerised tomography of the brain and underwent an open cranial procedure under general anaesthesia for nail retrieval. Psychiatric unit evaluated and managed him for chronic depression. Results The transparietal, intraventricular 10cm long nail was retrieved and associated abscess evacuated by an open cranial procedure. Pre-operative neurological impairments regressed and his mood stabilized with anti-depressants. He was discharged without further deficits and has remained well for over four years Conclusion Self-inflicted hand-driven intracranial nail is a very rare form of penetrating cranio-cerebral trauma. Preoperative computerised tomography scan of the brain, meticulous open cranial removal under general anaesthesia and psychiatric management enable discharge without further injury or deficits. On the other hand, removal through a burrhole or just pulling out the nail would not allow intraoperative visualisation of associated lesions; the latter also predispose to further vascular and parenchymal brain injuries, worsening neurolological impairments. Key words: Intracranial Nail; Open Cranial Procedure; Psychiatric Evaluation.

Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management.

No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment. From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment. Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043). Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.

The Role of Interactional Agreeableness in Responsive Treatments for Patients With Borderline Personality Disorder.

It has been shown that agreeableness of patients with borderline personality disorder (BPD) had an impact on therapy process and outcome (Hirsh, Quilty, Bagby, & McMain, 2012). The goal of our study was to test whether agreeableness affects the therapeutic alliance and outcome assessed after brief treatment for BPD, and whether this link is moderated by therapist responsiveness. We compared two types of interventions (N = 60) in 10-session treatments (Kramer et al., 2014): a general psychiatric management (GPM)-based treatment and the same treatment supplemented with motive-oriented therapeutic relationship (MOTR), based on plan analysis case conceptualizations (PA; Caspar, 1995), as operationalization of therapist responsiveness. The results showed that there was a significant link between agreeableness and outcome for the GPM, but not for the MOTR. No links between agreeableness and the therapeutic alliance were found in both conditions. MOTR enables suppression of the influences of the patient's initial characteristics on the therapeutic results.

General psychiatric management: An evidence-based treatment for borderline personality disorder in the college setting

ABSTRACTBorderline personality disorder (BPD) is a prevalent psychiatric illness that often first presents at college. If left untreated, BPD can lead to severe disability or fatality. While multiple evidence-based treatments for BPD exist, most are resource intensive and, therefore, difficult to implement at the typical college mental health center. However, general psychiatric management (GPM) is an evidence-based intervention for BPD that can be flexibly implemented in nonspecialized, resource-constrained environments. This principle-driven alternative to more intensive BPD-focused treatments provides a practical framework for treating college students with BPD. The aim of this article is to provide an introduction to the techniques of GPM within the college mental health setting. With a case vignette, we illustrate how GPM techniques might be brought to bear on such a treatment.

Specialized psychotherapies for adults with borderline personality disorder: A systematic review and meta-analysis.

Objective:Borderline personality disorder affects up to 2% of the population and is associated with poor functioning, low quality of life and increased mortality. Psychotherapy is the treatment of choice, but it is unclear whether specialized psychotherapies (dialectical behavior therapy, mentalization-based treatment, transference-focused therapy and schema therapy) are more effective than non-specialized approaches (e.g. protocolized psychological treatment, general psychiatric management). The aim of this systematic review is to investigate the effectiveness of these psychotherapies.Methods:PubMed, PsycINFO, CINAHL, EMBASE and CENTRAL were searched from inception to November 2017. Included randomized controlled trials were assessed on risk of bias and outcomes were meta-analyzed. Confidence in the results was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Results:A total of 20 studies with 1375 participants were included. Specialized psychotherapies, when compared to treatment as usual or community treatment by experts, were associated with a medium effect based on moderate quality evidence on overall borderline personality disorder severity (standardized mean difference = –0.59 [95% confidence interval: –0.90, –0.28]), and dialectical behavior therapy, when compared to treatment as usual, with a small to medium effect on self-injury (standardized mean difference = –0.40 [95% confidence interval: –0.66, –0.13]). Other effect estimates were often inconclusive, mostly due to imprecision.Conclusion:There is moderate quality evidence that specialized psychotherapies are effective in reducing overall borderline personality disorder severity. However, further research should identify which patient groups profit most of the specialized therapies.

Effects of substance use disorder on treatment process and outcome in a ten-session psychiatric treatment for borderline personality disorder

BackgroundDual diagnosis is common in Borderline Personality Disorder (BPD), one of the most common being Substance Use Disorder (SUD). Previous studies have shown that general psychiatric management (GPM) was effective in reducing borderline symptoms.In the present study, we tested whether the short GPM was as effective in the BPD + SUD as in the BPD group.MethodsWe analysed a group of 99 patients presenting a BPD. 51 of these patients presented a SUD. The BPD group and the BPD + SUD group received a manual-based short variant of the GPM treatment. Previous studies have shown that a 10-session version of GPM was effective in reducing borderline symptoms at the end of the treatment (Psychother Psychosom 83:176–86, 2014).ResultsWe found no significant difference in the reduction of general symptoms, which diminished in both groups. The specific borderline symptoms were also reduced in both groups, but there was a slightly higher reduction of the borderline symptoms in the SUD group. The therapeutic alliance progressed positively in all groups. Moreover, the alliance increased more over time in the SUD group.ConclusionThe short variant of GPM seems to be effective in BPD treatment independently from the presence of SUD. Therefore, this treatment could be an effective entry-level treatment for patients with dual diagnosis as well as patients with BPD only. Further studies are needed to confirm efficacy and long-term outcome.Trial registrationThe trial was registered at ClinicalTrial.gov (identifier NCT01896024).

Alliance Rupture and Resolution in Dialectical Behavior Therapy for Borderline Personality Disorder.

The aim of this exploratory study was to investigate alliance rupture and resolution processes in the early sessions of a sample of clients who underwent 1 year of standard dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were three recovered and three unrecovered clients drawn from the DBT arm of a randomized controlled trial that compared the clinical and cost-effectiveness of DBT and general psychiatric management. Alliance rupture and resolution processes were coded using the observer-based Rupture Resolution Rating Scale. Unrecovered clients evidenced a higher frequency of withdrawal ruptures than recovered clients. Withdrawal ruptures tended to persist for unrecovered clients despite the degree of resolution in the prior session, unlike for recovered clients, for whom the probability of withdrawal ruptures decreased as the degree of resolution increased. This study suggests that alliance rupture and resolution processes in early treatment differ between recovered and unrecovered clients in DBT for BPD.

Outcome Trajectories and Prognostic Factors for Suicide and Self-Harm Behaviors in Patients With Borderline Personality Disorder Following One Year of Outpatient Psychotherapy.

This study examined suicide and self-harm trajectories in 180 individuals with BPD receiving dialectical behavior therapy or general psychiatric management in a randomized controlled trial. Suicide and self-harm behaviors were assessed at baseline, every four months throughout treatment, and every 6 months over 2 years of follow-up. Latent class growth mixture modeling identified suicide and self-harm trajectories. Multinomial logistic regression analyses examined baseline patient characteristics. Three latent subgroups were identified. The largest responded rapidly to treatment and sustained a favorable response post-discharge. The second progressed slowly during treatment but achieved and maintained a favorable response. A third subgroup showed a rapid favorable response during treatment, however symptoms returned to near baseline levels post-discharge. This third subgroup had higher baseline depression, emergency department visits, and unemployment. BPD patients with high baseline health care utilization, depression, and unemployment may benefit from modifications to treatment specifically targeting these issues.

General Psychiatric Management for Suicidal Patients, With Remarks on Chronicity: Contending With the Angel of Death.

Assessing, managing, and treating suicidal patients, particularly those with chronic suicidality, challenge clinical decision making and emotional self-management in trainees and seasoned practitioners. Educators and trainees have noted needs for additional teaching materials in these areas. This article assists in addressing these gaps. We reviewed diagnostic and phenomenological characteristics encountered in acutely and chronically suicidal patients, their comprehensive assessment, general approaches to management, risk mitigation and safety planning, and psychological and biological interventions. Integrating information from research and clinical experience-based literature, we offer concise guidance on comprehensive psychiatric management for the varieties of acutely and chronically suicidal patients encountered in practice. By actively engaging suicidal patients and their families, systematically attending to warning signs, conducting risk mitigation and safety planning, and using psychological and biological treatments as indicated, clinicians are likely to reduce suicidal ideation, plans, and attempts in patients and might reduce completed suicides.

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder

Objective: The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists’ understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist’s use of MOTR. Method: The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session. Results: Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition. Conclusions: The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

Escalating Ingestion of Razor Blades in a Patient With Borderline Personality Disorder.

To the Editor: The means employed in self-injury vary widely among patients with borderline personality disorder and so may the magnitude of the damage inflicted. Deliberate foreign body ingestion (DFBI) constitutes a distinct behavioral syndrome that is frequently associated with borderline personality disorder. While with other forms of self-injurious behavior the patient usually achieves an immediate release of tension, such release is not generally the case in DFBI, as is illustrated in the present case. Case report. A 23-year-old woman who had previously been diagnosed with borderline personality disorder, according to ICD-10 criteria, presented with an increase in self-injurious behaviors after a recent miscarriage. The patient herself contacted police regarding increasing suicidal tendencies, which led to her admission to a psychiatric ward. Physical examination at admission revealed old scars and superficial cuts on arms and legs as well as new deep cuts all over her torso. The patient received individual psychotherapy sessions as well as group skills training. During her stay, she repeatedly swallowed quartered pieces of broken razor blades, which she wrapped in wads of chewing gum. During the span of several weeks, she swallowed in excess of 30 such razor blade pieces essentially without complications. She always notified staff sometime after the act. Ingestion of razor blade pieces was confirmed by x-ray (Figure 1A). For the most part, these fragments were passed with no difficulty. However, several larger pieces were recovered endoscopically either for diagnostic purposes or because the patient had complained of pain in her abdomen. Figure 1. Repeated Ingestion of Broken Razor Blades in a Patient With Borderline Personality Disorder In all, the patient underwent 4 gastroscopy or colonoscopy sessions (Figure 1B and 1C). Luckily for the patient, no transmural lesions had occurred. At this point, it was deemed impossible to discharge the patient from the hospital because she was considered at acute risk of suicide. Subsequently, she attempted to swallow one-half of a 2-edged razor blade without chewing gum, which resulted in immediate esophageal perforation and, consequently, in mediastinal emphysema and an esophagotracheal fistula. The patient required intensive care and several courses of endoscopic sponge therapy to close the esophageal defect. During this time, she was regularly seen by liaison psychiatry. She gradually began to engage more actively in psychotherapeutic treatment. In parallel, self-injurious behaviors decreased, and the patient was eventually discharged. An elective readmission for dialectical behavior therapy was scheduled. Deliberate foreign body ingestion is a frequent occurrence in patients with borderline personality disorder, but may also occur in patients with psychosis, malingering, and pica. The latter condition is defined as the persistent ingestion of nonnutritive materials such as chalk or clay at an age at which this behavior is developmentally inappropriate. The course of DFBI is frequently chronic. Treatment is difficult. Evidence-based therapeutic interventions are largely lacking.1 In borderline personality disorder, most self-injurious behaviors are a means of affect regulation and frequently lead to a swift release of tensions. In general, this release does not appear to be the reason behind DFBI.1 The main drivers behind DFBI in borderline personality disorder seem to be an inappropriate need for attention as well as a desire to test the limits of the therapeutic relationship. Management of DFBI in borderline personality disorder poses a great challenge because of potentially lethal complications and the need for rapid medical attention. Here, it is the special role of the consultant-liaison psychiatrist to bridge the gap between medical and physical health care and to support medical and surgical colleagues in grappling with countertransference issues commonly involved in treating such patients. In our experience, it is frequently during the early period after a major complication has occurred that the patient becomes more open to psychotherapeutic interventions. Ideally, general psychiatric management and stabilization will gradually enable the patient to benefit from a specific psychotherapeutic intervention such as dialectical behavior therapy.1,2

Emotion regulation in borderline personality disorder: the role of self-criticism, shame, and self-compassion: (commentary on Emotional processing in a ten-session general psychiatric treatment for Borderline Personality Disorder: a case study).

This case study evaluates the efficacy of a 10-session manualized version of general psychiatric management (GPM) with a female patient diagnosed with borderline personality disorder (BPD), severe depressive disorder, and schizotypal traits. The authors hypothesized that increases in adaptive emotional processing would lead to increases in therapeutic alliance and treatment outcome. Hypotheses were not supported, and in fact, ‘a general outcome deterioration tendency and an unchanged alliance level was observed’ (p. 7). The patient’s level of emotional processing remained at the stage characterized by harsh self-criticism and shame. The authors speculate that it may take more than 10 sessions for changes in emotional processing to occur and that the patient may have been in a state where she would have benefited more from containment, support, and structure. While this case did not demonstrate therapeutic efficacy of the 10-session GPM treatment or gains in emotional processing, it does represent an attempt to explore possible mechanisms of change in the treatment of borderline personality disorder. The elucidation of mechanisms of change could potentially lead to refinement and modification of currently effective treatments and improvements in therapeutic effectiveness. Difficulties in emotion regulation are characteristic of many forms of psychopathology (Gross & Munoz, 1995). As BPD is uniquely characterized by difficulties in emotional regulation, improvements in emotional regulation would appear to be a potential core mechanism in effective treatments for BPD. In support of this, Goodman et al. (2014) reported improvement in emotion regulation associated with decreased amygdala activation in BPD

Developing personalised integrated psychotherapy for patients with personality disorders

Several psychotherapy treatments specifically developed for patients with borderline personality disorder (BPD) have proven to be effective.1 General psychiatric management (GPM) is one of the therapies that have been shown...

Handbook of Good Psychiatric Management for Borderline Personality Disorder

Handbook of Good Psychiatric Management for Borderline Personality Disorder

Effects of Motive-Oriented Therapeutic Relationship in a Ten-Session General Psychiatric Treatment of Borderline Personality Disorder: A Randomized Controlled Trial

Background: Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD). The present randomized controlled study using an add-on design is the first study to test this assumption in a 10-session general psychiatric treatment with patients presenting with BPD on symptom reduction and therapeutic alliance. Methods: A total of 85 patients were randomized. They were either allocated to a manual-based short variant of the general psychiatric management (GPM) treatment (in 10 sessions) or to the same treatment where MOTR was deliberately added to the treatment. Treatment attrition and integrity analyses yielded satisfactory results. Results: The results of the intent-to-treat analyses suggested a global efficacy of MOTR, in the sense of an additional reduction of general problems, i.e. symptoms, interpersonal and social problems (F_{1, 73} = 7.25, p < 0.05). However, they also showed that MOTR did not yield an additional reduction of specific borderline symptoms. It was also shown that a stronger therapeutic alliance, as assessed by the therapist, developed in MOTR treatments compared to GPM (Z₅₅ = 0.99, p < 0.04). Conclusions: These results suggest that adding MOTR to psychiatric and psychotherapeutic treatments of BPD is promising. Moreover, the findings shed additional light on the perspective of shortening treatments for patients presenting with BPD.

Factors Related to Dropout From Treatment in Two Outpatient Treatments for Borderline Personality Disorder

Patients with borderline personality disorder frequently drop out prematurely from psychotherapy. This study examined factors related to treatment attrition in 180 patients enrolled in a randomized controlled trial comparing 1 year of Dialectical Behavior Therapy (DBT) to General Psychiatric Management (GPM). Completers and dropouts were compared on a range of variables, including demographics, Axis I and Axis II disorders, anger and impulsivity, therapeutic alliance, and treatment condition. The participants were on average 30.36 years old and 86% were female. Regression analyses revealed that individuals who dropped out had higher levels of anger (p = .01), greater Axis I comorbidity (p = .03), poorer therapeutic alliance (p = .003), and a higher number of lifetime suicide attempts (p = .05). An interaction was also found between Axis I comorbidity and treatment condition, with significantly lower rates of dropout seen in individuals with high Axis I comorbidity who were assigned to GPM compared to those assigned to DBT (p < .001).

Fitness Regimen Helps Seriously Mentally Ill People Lose Weight

Fitness Regimen Helps Seriously Mentally Ill People Lose Weight