Cognitive behavioural therapies
CBT often includes education, relaxation exercises, coping skills training, stress management, or assertiveness training
In cognitive therapy, the therapist helps you identify and correct distorted, maladaptive beliefs. Behavioural therapy uses thought exercises or real experiences to facilitate symptom reduction and improved functioning. This may occur through learning, through decreased reactivity from repeated exposure to a stimulus, or through other mechanisms.
CBT is an evidence-based treatment for depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, eating disorders, and obsessive-compulsive disorder, as well as several medical conditions (eg, insomnia, smoking, low back pain).
Psychodynamic psychotherapy
Psychodynamic psychotherapy is based upon the idea that childhood experiences, past unresolved conflicts, and previous relationships significantly influence an individual’s current situation in life.
Adult relationships are understood to be a byproduct of unconscious patterns that begin in childhood.
Psychodynamic psychotherapy uncovers the unconscious patterns of interpersonal relationships, conflicts, and desires with the goal of improved functioning
Psychodynamic therapy is used for some psychiatric disorders, including depression, anorexia nervosa, and personality disorders.
IPT
Interpersonal therapy (IPT) addresses interpersonal difficulties that lead to psychological problems.
Interpersonal psychotherapy focuses on the individual’s interpersonal life in four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits.
Interpersonal therapy is an evidence-based treatment for some psychiatric conditions, including depression and eating disorders
Motivational interviewing
Derived from cognitive-behavioral and readiness-to-change models, motivational interviewing seeks to help patients recognize and make changes to maladaptive behaviors, matching strategies to the patient’s stage of readiness to change. Key elements of motivational interviewing include:
a) Expressing empathy
b) Helping the patient identify discrepancies between his or her problematic behaviors and broader, personal values
c) Accepting the patient’s resistance to change
d) Enhancing the patient’s self-efficacy (ie, confidence in his or her capability to surmount obstacles and successfully change)
The use of motivational interviewing has been applied to the treatment of substance use disorders, promoting lifestyle changes (eg, weight reduction, smoking cessation), and encouraging adherence to complex medical treatments (eg, heart failure self-management)
DBT
Dialectical behavior therapy (DBT) is a type of psychotherapy conducted in the context of mental health practice for patients with severe problems in emotional regulation, most commonly patients with borderline personality disorder. DBT includes skills training, mindful practice, and close monitoring of and intervention in crises that may develop.
Sessions are typically more than once a week and supplemented with contacts between sessions as needed
Supportive psychotherapy
Supportive psychotherapy or counseling is to help individuals cope with illness, deal with a crisis or transient problem, and maintain optimism or hope.
Techniques vary but most models emphasize communication of interest and empathy; guidance on available services, advice, respect, praise, and/or encouragement.
Generalised anxiety disorder
Everyone feels anxious or nervous once in a while. That is normal. But being extremely anxious or worried on most days for 6 months or longer is not normal. This is called “generalized anxiety disorder.” The disorder can make it hard to do everyday tasks.
Generalized anxiety disorder (GAD) is characterized by excessive, persistent worrying which is hard to control, and by psychological and physical symptoms of anxiety that together cause significant personal distress and impairment of everyday functioning.
GAD is common and is probably the most common anxiety disorder in people aged over 65 years. Major depression and other anxiety disorders are common comorbidities of GAD
Generalized anxiety disorder is just 1 anxiety disorder. There are others, such as panic disorder and phobias.
People with extreme or severe anxiety feel very worried or “on edge” much of the time. They can have trouble sleeping or forget things. Plus, they can have physical symptoms. For instance, people with severe anxiety often feel very tired and have tense muscles. Some get stomach aches or feel chest “tightness.”
Genetic factors appear to predispose individuals to the development of GAD, though data from twin studies have been inconsistent. GAD shares a common heritability with major depression and with the personality trait of “neuroticism.” Adversity and undesirable life events can exacerbate symptoms of GAD. Neuroimaging and other studies suggest the symptoms of GAD are accompanied by an enhanced emotional responsiveness in fear-related brain circuits.
Assessment of a patient with possible GAD should include a careful history, an evaluation for symptoms of GAD as well as alternative or comorbid psychiatric disorders, and a physical exam and laboratory studies to rule out organic causes of anxiety.
Distinguishing GAD from major depression and dysthymia is probably the most difficult part of the disorder’s differential diagnosis, as the conditions share features such as an insidious onset, protracted course, prominent dysphoria and anxiety symptoms. Individuals with depression tend to brood self-critically on previous events and circumstances, whereas patients with GAD tend to worry about possible future events
Treatments include:
1) Psychotherapy – Psychotherapy involves meeting with a mental health counselor to talk about your feelings, relationships, and worries. Therapy can help you find new ways of thinking about your situation so that you feel less anxious. In therapy, you might also learn new skills to reduce anxiety.
2) Medicines – Medicines used to treat depression can relieve anxiety, too, even in people who are not depressed. Your doctor or nurse will decide which medicines are best for your situation.
Some people have psychotherapy and take medicines at the same time.
There is no reason to feel embarrassed about getting treatment for anxiety. Anxiety is a common problem. It affects all kinds of people.
Keep in mind that it might take a little while to find the right treatment. People respond in different ways to medicines and therapy, so you might need to try a few approaches before you find the 1 that helps you most. The key is to not give up and to let your doctor or nurse know how you feel along the way.
GAD tends to run either a chronic course fluctuating in severity over time, or an episodic course with some intervening periods of relative well-being. Comorbid GAD and major depression is more impairing and has a worse prognosis
People with anxiety disorders often have to deal with some anxiety for the rest of their life. For some, anxiety comes and goes, but gets bad during times of stress. The good news is, many people find effective treatments or ways to deal with their anxiety.
Depression
Depression is highly prevalent. The 12-month prevalence of major depression among females and males is 8 and 4 percent. Major depression is less common in older than younger adults.
Depressed people feel down most of the time for at least 2 weeks. They also have at least 1 of these 2 symptoms:
●They no longer enjoy or care about doing the things they used to like to do.
●They feel sad, down, hopeless, or cranky most of the day, almost every day.
Depression can also make you:
●Lose or gain weight ●Sleep too much or too little ●Feel tired or like you have no energy ●Feel guilty or like you are worth nothing ●Forget things or feel confused ●Move and speak more slowly than usual ●Act restless or have trouble staying still ●Think about death or suicide
The cause of major depression appears to involve three broad sets of risk factors, including internalizing factors (eg, genetics and neuroticism), externalizing factors (eg, genetics and substance misuse), and adversity (eg, trauma and parental loss). Social factors and psychologic factors may also contribute to the etiology of depression.
Genes probably contribute vulnerability toward depression that requires additional non-genetic factors to produce the disorder. The concordance rate for major depression in monozygotic twins is about 37 percent. Multiple genetic studies have not yielded robust, replicable findings identifying specific genes linked to risk of developing major depression
Depression can occur secondary to many general medical illnesses.
People who have depression can get 1 or more of the following treatments:
●Medicines that relieve depression
●Counseling (with a psychiatrist, psychologist, nurse, or social worker)
●A device that passes magnetic waves or electricity into the brain
People with depression that is not too severe can get better by taking medicines or talking with a counselor. People with severe depression usually need medicines to get better, and might also need to see a counselor.
Another treatment involves placing a device against the scalp to pass magnetic waves into the brain. This is called “transcranial magnetic stimulation” or “TMS.” Doctors might suggest TMS if medicines and counseling have not helped.
Some people whose depression is severe might need a treatment called “electroconvulsive therapy” or “ECT.” During ECT, doctors pass an electric current through a person’s brain in a safe way.
Both treatment options take a little while to start working.
Many people who take medicines start to feel better within 2 weeks, but it might be 4 to 8 weeks before the medicine has its full effect.
Many people who see a counselor start to feel better within a few weeks, but it might take 8 to 10 weeks to get the greatest benefit.
If the first treatment you try does not help you, tell your doctor or nurse, but do not give up. Some people need to try different treatments or combinations of treatments before they find an approach that works. Your doctor, nurse, or counselor can work with you to find the treatment that is right for you. He or she can also help you figure out how to cope while you search for the right treatment or are waiting for your treatment to start working.
The symptoms of depression are a little different for teenagers than they are for adults. Some teenagers are moody or sad a lot of the time. That makes it hard to tell when they are really depressed. Teenagers who are depressed often seem cranky. They get easily “annoyed” or “bothered.” They might even pick fights with people. Also, when treating a teenager, doctors and nurses usually suggest trying counseling first, before trying medicine. That’s because there is a small chance that depression medicines can cause problems for some teenagers. Even so, some depressed teenagers need medicine. And most experts agree that depression medicine is safe and appropriate to use in teenagers who really need it.
Some depression medicines can cause problems for an unborn baby. But having untreated depression during pregnancy can also cause problems. If you want to get pregnant, tell your doctor but do not stop taking your medicines. The two of you can plan the safest way for you to have your baby.
It’s also important to talk with your doctor if you want to breastfeed after your baby is born. Breastfeeding has lots of benefits for both mother and baby. Some depression medicines are safer than others to use while breastfeeding. But having untreated depression after giving birth can also cause problems, so do not stop taking your medicines. Your doctor can work with you to plan the safest way for you to feed your baby.
SSRIs
SSRIs (selective serotonin reuptake inhibitors) – SSRIs are usually the first medicines prescribed when they are treating someone with depression. SSRIs often work well, are safe, and have fewer side effects than many of the other medicines. Some examples of SSRIs include citalopram (brand name: Celexa), fluoxetine (brand name: Prozac), and sertraline (brand name: Zoloft).
Antidepressant side effects
If you have minor side effects when you start taking an antidepressant, try staying on the medicine for a few weeks. Minor side effects often go away after your body gets used to the new medicine. If side effects do not go away or worry you, mention your problems to your doctor. They might have suggestions for how to reduce or deal with your side effects. They can also help you switch your medicine safely if it isn’t the right one for you.
Each of the medicines is different. In general, side effects from the most commonly used antidepressants can include:
●Feeling anxious, jittery, or restless ●Having trouble sleeping ●Feeling tired ●Headaches ●Nausea, diarrhea, or constipation ●Dry mouth ●Problems with sex ●Weight gain
SNRIs
SNRIs (serotonin-norepinephrine reuptake inhibitors) – SNRIs work in a similar way to SSRIs, but they also have other effects. Doctors sometimes suggest these medicines when SSRIs do not help enough. Examples of SNRIs include duloxetine (brand name: Cymbalta), venlafaxine (brand name: Effexor), and desvenlafaxine (brand name: Pristiq). SNRIs can increase your blood pressure. Let me know if you have high blood pressure.
Atypical antidepressants
Atypical antidepressants – Atypical antidepressants include bupropion (brand name: Wellbutrin) and mirtazapine (brand name: Remeron). These medicines do not tend to cause sex-related side effects, so doctors sometimes give them to people who have those side effects with other antidepressants. Bupropion does not cause weight gain, and it can be especially helpful to people who lack energy or smoke, but it can cause jitteriness. Mirtazapine increases appetite and can cause weight gain, so doctors sometimes give it to people with low appetite.
Serotonin modulators
Serotonin modulators – Serotonin modulators include trazodone, vilazodone (brand name: Viibryd), and vortioxetine (brand name: Trintellix). Trazodone is often used to improve sleep, so doctors sometimes prescribe it to people who have trouble sleeping. Vilazodone is more likely than other antidepressants to cause nausea, vomiting, and diarrhea.
TCA’s
TCAs (tricyclic and tetracyclic antidepressants) – TCAs are not used as much as SSRIs, SNRIs, and atypical antidepressants. That’s because TCAs can cause more side effects, such as constipation and drowsiness. In addition, TCAs can disrupt the heart’s rhythm and cause other serious problems. In elderly people, these medicines can also cause falls, confusion, and memory problems. Even so, TCAs can help some people with depression, especially if they do not get better with SSRIs, SNRIs, or atypical antidepressants. Some examples of TCAs include nortriptyline (brand name: Pamelor) and desipramine (brand name: Norpramin).
MAOIs
MAOIs (monoamine oxidase inhibitors) – MAOIs are not used very often because they can cause a lot of side effects, and because people who take them must avoid certain foods and medicines. Still, MAOIs can help people who have depression along with other problems or who do not get better with other medicines. Some examples of MAOIs include selegiline (sample brand name: Emsam patch), tranylcypromine (brand name: Parnate), and phenelzine (brand name: Nardil). If you need to follow a special diet, your doctor or nurse can give you list of foods that are safe to eat
BPAD
Bipolar disorder (sometimes called “manic depression”) is a brain disorder that causes extreme changes in mood and behavior. Bipolar disorder can run in families.
People with bipolar disorder can feel much happier or much sadder than normal. If you have bipolar disorder, you might feel very happy for many days and then feel very sad.
When your mood is very happy, you can also:
●Get angry quickly
●Be more active than normal
●Feel like you have special powers
●Feel like you don’t need sleep
●Make poor choices without thinking
●Start lots of things and not finish them
Other times, your mood might be very sad for most of the day, every day. When your mood is very sad, you can also:
●Lose or gain a lot of weight
●Have trouble falling asleep or sleep too much
●Feel very tired
●Not enjoy things
●Feel bad about yourself
●Think about death or hurting yourself
People with bipolar disorder might have trouble at work or school. They might not get along well with their family and friends.
Depending upon the study, the estimated lifetime prevalence of bipolar disorder among adults worldwide is 1 to 3 percent. The mean age of onset for bipolar I disorder is 18 years and for bipolar II disorder 20 yo. The ratio of men to women who develop bipolar disorder is approximately 1:1
The pathogenesis of bipolar disorder is not known. However, family, twin, and adoption studies demonstrate that genetic factors are involved. In addition, altered brain structure and function are present in bipolar disorder; it is not clear whether these changes precede onset of bipolar disorder or represent its consequences. One model of the functional neuroanatomy of bipolar I disorder hypothesizes that early developmental processes (eg, establishing white matter connections and pruning the prefrontal cortex) within brain networks that modulate emotional behavior are disrupted; this leads to decreased connections among prefrontal networks and limbic structures, especially the amygdala . The risk of developing bipolar disorder appears to involve environmental factors as well, as indicated by the finding in monozygotic twins that the concordance rate of bipolar disorder is not 100 percent. Advancing paternal age, which is associated with increased genetic mutations during spermatogenesis, can increase the risk of bipolar disorder in one’s offspring. Stressful life events such as childhood maltreatment may be associated with onset of bipolar disorder and a more severe course of illness. Obstetrical complications do not appear to play a role in the pathogenesis of bipolar disorder.
Bipolar disorder is treated with medicine. Medicines sometimes take a while to start working. Plus, it sometimes takes a few tries to find the right medicine or combination of medicines.
You and your doctor will work together to find the medicine that works best for you. All of the medicines for bipolar disorder affect the brain. They can:
●Keep your mood stable and prevent big mood changes
●Calm your mind
●Make your sadness go away
Medicines sometimes cause side effects.
You might also need to stay in the hospital for a short time. When a bipolar disorder mood episode starts, you might be at risk of hurting yourself or others. You might hear voices that other people do not hear. You might believe things that are not true. But if you are at the hospital, the doctors can treat these symptoms and keep you safe.
Some people whose bipolar disorder makes them feel very sad might need “shock treatment” to get better. Doctors call this treatment ECT. During ECT, doctors pass a small amount of electricity (called an “electrical current”) through a person’s brain in a safe way. This causes chemical changes in the brain that relieve severe depression.
In addition to medicine, psychotherapy (counseling) can help. This involves meeting with a therapist to talk about your feelings, thoughts, and life. There are different types of psychotherapy. In general, they all focus on helping you learn new ways of thinking and behaving, so you can better cope with your bipolar disorder.
To remain well after your symptoms have gone away, you will probably:
●Keep taking medicine every day to help prevent big changes in your mood and behavior
●Go to psychotherapy sessions to help you get along better with family and friends
Self management strategies
SELF-MANAGEMENT
Patients who are capable of taking responsibility for their health may benefit from self-management strategies that include measures to:
●Calm oneself and cope with stress (eg, scheduling relaxing activities or learning mindfulness-based stress reduction).
●Optimize medical management by adhering to treatment and being aware of prodromal signs. Regular mood charting may be helpful.
●Maintain hope (eg, understanding that bipolar disorder is a medical disorder that can be treated and if current treatment is not working sufficiently, there are many other alternatives).
●Engage in physical activity and exercise (eg, bicycle riding or walking).
●Maintain a healthy diet.
Risks of avoiding pharmacotherapy for women with bipolar disorder during pregnancy
Risks of avoiding pharmacotherapy — For bipolar patients who are receiving preconception or prenatal maintenance pharmacotherapy, discontinuing treatment includes the following risks
●It is not known if maintenance drugs that are discontinued provide the same level of prophylactic efficacy after they are restarted.
●Stopping treatment may increase the risk of recurrent mood episodes, particularly if medications are discontinued abruptly (eg, in less than two weeks).
●Treating recurrent episodes during pregnancy may be difficult and expose the fetus to more medications at higher doses compared with pharmacologic maintenance of euthymia.
●Postpartum mood episodes may occur more frequently in patients who are not treated with maintenance pharmacotherapy during pregnancy. A meta-analysis of eight prospective and retrospective observational studies found that postpartum mood episodes occurred in more patients who were medication free during pregnancy (n = 385), compared with patients who used prophylactic pharmacotherapy during pregnancy (n = 60)
Options for women with BPAD considering pregnancy
General principles — Preconception and prenatal maintenance treatment for bipolar patients is usually provided by perinatal or general psychiatrists in collaboration with obstetricians and primary care clinicians
After considering medical advice about the risks of fetal exposure to medications and the risks of avoiding preconception and prenatal maintenance pharmacotherapy, bipolar patients can choose to:
●Maintain existing pharmacotherapy throughout conception, the pregnancy, and birth.
●Switch medications before they try to conceive to avoid drugs with a greater risk of teratogenicity.
●Discontinue pharmacotherapy prior to conception and restart medications during the second or third trimester (when organogenesis is completed).
●Discontinue pharmacotherapy prior to conception and remain medication-free throughout conception, the pregnancy, and delivery.
PTSD
Post-traumatic stress disorder, or “PTSD,” is a condition that can happen after people see or live through a trauma. A trauma is an intense event that involves serious injury or death, or the chance of serious injury or death.
The one-year prevalence of posttraumatic stress disorder (PTSD) has been found to range from 1 to 6 percent in the general adult population across the world.
Many different types of trauma can result in PTSD, including military combat, sexual or physical assault, disasters, childhood sexual abuse, sudden death of a loved one, severe physical injury or sudden-onset medical illness, and intensive care unit hospitalisation
The symptoms of PTSD include:
●Reliving the trauma through thoughts and feelings – People can have upsetting memories, nightmares, or flashbacks. Flashbacks are when people “see” or feel the trauma over and over again.
●Feeling “numb” and avoiding certain people or places – People avoid thinking about the trauma and avoid people and places that remind them of it. Some people also feel “numb.” They might not enjoy activities they used to enjoy or feel part of the world around them.
●Having intense feelings, such as anger, fear, or worry – People might frighten or startle easily. Many people have trouble sleeping.
The pathophysiology of PTSD is not well understood. However, differences in neuroanatomy, neurotransmitters, and brain functioning have been found in individuals with the disorder. Previous exposure to trauma appears to increase the risk of developing PTSD with subsequent traumatic events
Individuals with PTSD experience marked cognitive, affective, and behavioral responses to stimuli reminding them of trauma they experienced, eg, flashbacks, severe anxiety, and fleeing or combative behavior. They compensate for this intense arousal through avoidance, emotional numbing, and diminished interest in people and activities.
PTSD is commonly accompanied by comorbid psychiatric conditions, including depression, substance use disorders, and somatic symptoms.
For adults newly treated for PTSD, we suggest first-line treatment with a trauma-focused psychotherapy that includes exposure rather than a serotonergic reuptake inhibitor (SRI) (Grade 2C). An SRI is a reasonable alternative for patients who prefer medication to psychotherapy, or when a trauma-focused psychotherapy including exposure is not available.
Trauma-focused psychotherapies that include exposure have been supported by multiple clinical trials in adults with PTSD and include exposure therapy (eg, prolonged exposure), a combination of exposure and a cognitive therapy (also known as trauma-focused cognitive behavioral therapy; eg, cognitive processing therapy), and with eye movement desensitization and reprocessing.
Cognitive therapy aims to help patients correct erroneous cognitions. Behavioral therapy for PTSD seeks to decrease symptoms through exposure. Cognitive-behavioral therapy includes both cognitive and behavioral components, often along with other components such as education and coping skills training.
Exposure therapy programs for PTSD typically incorporate the patient’s recall of the traumatic event (imaginal exposure) and/or confrontation with real-life, safe situations that remind the patient of the event (in vivo exposure). Re-experiencing the trauma through exposure allows it to be emotionally processed so that it can become less painful.
Eye movement desensitization and reprocessing (EMDR) makes use of exposure as well as saccadic eye movements in the treatment of PTSD. EMDR is efficacious for PTSD. It is not known if the movements are necessary for the therapy to be efficacious.
Interpersonal therapy and mindfulness-based stress reduction show promise for patients with PTSD and may be considered for those patients who are unwilling to accept an exposure-based therapy
A patient presentation with extreme fear and avoidance favors the use of an exposure technique, while presentation with extreme guilt and trust issues favors cognitive therapy or exposure therapy. For patients who are difficult to engage emotionally, virtual reality exposure could be added where available, as its evocative nature renders it more difficult to avoid.
PTSD patients with a co-occurring substance use disorder or borderline personality disorder may benefit from treatment with a combination of trauma-focused psychotherapy that includes exposure and substance use treatment or dialectical behavioral therapy, respectively.
For PTSD patients who experience significant sleep disturbance, most typically nightmares, we suggest treatment with prazosin 30 to 60 minutes before bedtime (Grade 2C) rather than other medications.
Patients who respond favorably to an SRI should continue to take it for at least six months to a year to prevent relapse or recurrence.
For patients who have not improved after eight or more sessions with a particular psychotherapy, we favor second-line treatment with augmentation or switching to another trauma-focused psychotherapy that includes exposure or an SRI. The choice between psychotherapy and medication as second-line treatment can be made based on treatment availability and/or patient preference.
For patients who do not respond to the SRI after 8 to 10 weeks at the highest tolerated dose in the therapeutic range and do not want a trial of a trauma-focused psychotherapy that includes exposure, we favor a trial of a second SRI rather than other medications.
For PTSD patients treated with medication who fail to respond to two SRI trials and do not want a trial of a trauma-focused psychotherapy that includes exposure, we treat with a second generation antipsychotic rather than other medications. For patients with a minimal response to an SRI, we favor monotherapy with quetiapine; if a partial response, we favor augmentation with quetiapine or risperidone.
EDMR
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that some liken to CBT but also incorporates saccadic eye movements during exposure.
The technique involves the patient imagining a scene from the trauma, focusing on the accompanying cognition and arousal, while the therapist moves two fingers across the patient’s visual field and instructs the patient to track the fingers. The sequence is repeated until anxiety decreases, at which point the patient is instructed to generate a more adaptive thought. An example of a thought initially associated with the traumatic image might include, “I’m going to die,” while the more adaptive thought might end up as, “I made it through. It’s in the past.”
Most, but not all, systematic reviews and meta-analyses have concluded that EMDR is an efficacious treatment for PTSD
BPD
Borderline personality disorder (BPD) is a common illness, with a point prevalence in the United States general population estimated to be 1.6 percent and a lifetime prevalence of approximately 6 percent. Borderline personality disorder is a mental disorder. People with this disorder have unstable relationships and extreme mood changes, such as sudden shifts to anger or sadness. They sometimes do things that seem extreme and can even be violent. Plus, they act without thinking about the consequences.
The etiology of the disorder is unknown. Most hypotheses state that a combination of interacting factors causes BPD, including environmental experiences such as childhood trauma, genetic predisposition, and neurobiological abnormalities
People with borderline personality disorder often have:
●Unstable relationships
●Sudden shifts in how they see themselves or others
●Extreme mood changes, such as sudden feelings of rage, deep sadness, or total emptiness
●Problems with risk-taking – For example, they sometimes take illegal drugs or have unsafe sex, and they can be violent with themselves or others.
●Trouble thinking clearly or logically when overcome by emotion
Part of the reason that people with borderline personality disorder have unstable relationships is that they tend to see people in their life as all good or all bad. At one moment, they might feel close to a loved one; at the next moment they might feel disgusted by that person. People with borderline personality disorder can also misunderstand the reactions of others. For instance, they might think a person who likes them actually hates them.
People with borderline personality disorder often think about suicide. Roughly 1 in 10 people with the disorder actually kill themselves. For this reason, it’s very important that people with borderline personality disorder be treated by a professional who has experience with the disorder.
Many people with borderline personality disorder have other mental problems, too. For example, they might have depression, anxiety, or eating disorders, or they might abuse drugs or alcohol.
Prospective, longitudinal studies of patients with BPD have found high rates of remission and recurrence, challenging traditional conceptualizations of BPD as chronic and persistent. Follow-along studies have found remission rates of 85 percent to almost 100 percent over 10 to 16 years. Symptomatic remission was associated with later, small improvements in psychosocial functioning
The main treatment for borderline personality disorder is psychotherapy. There are different types of psychotherapy that can help. In general, they all focus on helping you learn new ways of thinking and behaving, so that you have less extreme mood changes and feel more at ease.
Many people with borderline personality disorder also benefit from medicines to help with mood changes, anger, and other symptoms.
The optimal duration of psychotherapy is not known, but patients often require many months to years of treatment. The types of psychotherapy that have proven to be effective include: •Dialectical behavior therapy •Mentalization-based therapy •Transference-focused therapy •“Good psychiatric management” •Cognitive and behavioral therapies •Schema-focused therapy
Psychoeducation is an important component of psychotherapy for BPD. Patients and families need information about the disorder, its signs and symptoms, possible causes, course, and treatment options. Pamphlets and books are available for patients and family members from numerous sources.
In patients with BPD and a co-occurring mood or anxiety disorder, both diagnoses should be subjects of clinical attention, but treatment should focus principally on BPD. Research and our clinical experience suggest that effective treatment of BPD, rather than the co-occurring disorder, is more likely to lead to remission or improvement of both disorders.
In patients with a co-occurring substance use disorder, treatment of the substance use disorder should take precedence over BPD (other than for issues of safety). Physiologically dependent patients, if willing, should undergo medically supervised withdrawal followed by maintenance treatment.
For patients who continue to experience severe, impairing BPD symptoms despite receiving evidence-based psychotherapy, we favor symptom-focused adjunct medication treatment:
•For BPD patients with disruptive, stress-related, cognitive-perceptual experiences (such as dissociation, disturbed identity, paranoid ideation, and hallucinations), we suggest treatment with a low-dose, second-generation antipsychotic rather than an antidepressant or mood stabilizing drug (Grade 2B).
•For BPD patients with severe impulsivity or behavioral dyscontrol (such as interpersonal hostility and aggression, self-injury, recklessness), we suggest treatment with a mood stabilizer rather than an antidepressant or antipsychotic drug (Grade 2B)
•For BPD patients with severe affective dysregulation (such as depressed mood or dysphoria, mood lability, anxiety, and anger), we suggest first-line treatment with a mood stabilizer rather than an antidepressant (Grade 2B). A low-dose antipsychotic would be a reasonable alternative.
DBT
DBT is a well-studied, evidence-based variation of CBT that includes an emphasis on behaviorally analyzing and managing a hierarchy of treatment targets, including suicidal/dangerous behavior, treatment-interfering behavior, and quality of life interfering behavior. It consists of weekly individual psychotherapy with a DBT-trained therapist and group skills training for approximately one year.
The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.
Components of DBT
- Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
- Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
- Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.
The 4 Modules of Dialectical Behavior Therapy
1. Mindfulness
Observe, Describe, and Participate are the core mindfulness “what” skills. Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question
- Interpersonal Effectiveness
The interpersonal response patterns –how you interact with the people around you and in your personal relationships
This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
- Distress Tolerance
They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation.
Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness - Emotion regulation include:
- Learning to properly identify and label emotions
- Identifying obstacles to changing emotions
- Reducing vulnerability to “emotion mind” (Accumulate positive experiences, Build mastery, Cope ahead, Pl physical health, Eat, Avoid mind altering substances, Sleep, Exercise ABC PLEASE)
- Increasing positive emotional events
- Increasing mindfulness to current emotions
- Taking opposite action
- Applying distress tolerance techniques
Good psychiatric management
Good psychiatric management” — “Good psychiatric management” is a manualized treatment. Compared with the other therapies listed here, this approach involves less of a distinct conceptual model and less specified psychotherapeutic techniques. Instead, it provides a set of principles and practices to meet the patient’s clinical needs and assist the general psychiatrist in avoiding many of the pitfalls that can occur in the treatment of BPD. Examples include:
●Informing the patient of his/her diagnosis and what we know about BPD
●Concentrating upon the patient’s life outside of therapy by establishing long-term goals and focusing on the best ways to achieve them
●Teaching how the disorder impacts relationships and how to acquire skills to better manage emotions within those relationships
●The therapist’s role is that of a real person who is active, responsive, and validating
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Attachment8
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FFT / USM Report0
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Preparing Psychiatric Report- Not USM/FFT4
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Forensic-ethical14
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Antisocial Personality Disorder2
-
Rural psychiatry position statement 6511
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Rural psychiatry- professional and ethical issues5
-
Boundary violations and ethical considerations18
-
Medically unexplained symptoms4
-
Consultancy thinking, CANMEDS approach9
-
Perinatal1
-
Treatment resistant depression6
-
SSRIs and side effects15
-
ECT19
-
Psychoeducation30
-
Anxiety disorders treatment guidelines43
-
First episode psychosis guidelines0
-
Bipolar affective disorder0
-
Lithium23
-
Old age mood25
-
Mood guidelines126
-
Trainee burnout13
-
MS and depression20
-
Hepatitis and depression11
-
Generalised anxiety disorder26
-
Panic disorder15
-
Treatment non-adherence1
-
Gender identity18
-
OCD20
-
Social anxiety disorder16
-
Body dysmorphic disorder15
-
Illness anxiety disorder15
-
Transcultural issues in the identification and management of mental disorders6
-
Adult ADHD12
-
Benzodiazepine dependence1
-
Service development and allocation of resources4
-
Management of pt suicide5
-
Genetic testing in psychiatry4
-
Self harm in adolescents6
-
OTP87
-
Schizophrenia guidelines46
-
First episode psychosis guidelines22
-
Nicotine dependence9
-
MSE10
-
Encoporesis0
-
Delusional jealousy3
-
Scholar1
-
Old age13
-
Epilepsy and psychosis11
-
Substance use disorders1
-
Psychiatric emergencies4
-
ASD21
-
Lewy body dementia9
-
School refusal8
-
Anorexia nervosa18
-
Capacity3
-
Research8
-
Cultural formulation9
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Discharge against medical advice1
-
Intellectual disability5
-
PTSD33
-
Gambling9
-
Motivational interviewing10
-
Recovery model4
-
Ethical and professional issues3
-
Stigma0
-
Tourettes12
-
Critical incident management19
-
Sexual offending6
-
Assessment and treatment of sexually abnormal behaviour20
-
A guide to clinical ethics in psychiatry14
-
Mock exam theme44
-
Alternative to acute admission30
-
Adolescent forensic psychiatry38
-
rTMS7
-
Fetal alcohol spectrum disorder1
-
Mnemonics5
