Table Of ContentBorderline Personality Disorder
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Borderline
Personality
Disorder
A practical guide
to treatment
Roy Krawitz
Consultant Psychiatrist to the area of borderline
personality disorder,
Health Waikato,
Hamilton,
New Zealand
Christine Watson
Director,
Spectrum,
The Personality Disorder Service for Victoria,
Melbourne,
Australia
3
3
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Preface
The book focuses on work in adult mental health services, and does
not attempt to cover specialist areas (e.g. child, adolescent and
forensic services) or work with indigenous populations. Gender and
sexual abuse issues are important, as 75% of people meeting
diagnostic criteria for borderline personality disorder are female and
70% have a history of sexual abuse. These issues, whilst commented
on, have not been comprehensively addressed in this book as there
are ongoing forums available where they have been and will continue
to be explored.
R.K.
C.W.
January 2003
Acknowledgements
Thanks to clients, colleagues, supervisees, and workshop participants
for the knowledge and opportunities for learning they have
provided. Thanks to the American Psychiatric Association for their
permission to reprint the DSM-IV diagnostic criteria for borderline
personality disorder and the Williams quote, Balance Program for
providing the template on which the ‘‘Fictitious Example of a Crisis
Plan’’ is based, Canadian Family Physician for permission to reprint
the vignette ‘‘Molly’’, the Center for Psychiatric Rehabilitation for
permission to reprint the item by Everett and Nelson, the Cutting
Edge for permission to quote from their newsletter, Guilford Press
for permission to reprint quotations from Rockland, Beck/Freeman
& Associates, Leibenluft, Gardner and Cowdry, and Linehan, Jackson
for permission to use several quotations, the Mental Health
Commission for permission to reprint the section ‘‘Clinician values
and feelings’’, and Williams for permission to adapt and print the
exercise ‘‘Self-exploration of reasons for self-harm’’.
Contents
Terminology page xi
Abbreviations xii
‘‘Molly’’ xiii
Introduction xv
Part 1 Background to treatment
Origins of the label ‘‘borderline personality
disorder’’ 3
History of treatment 4
Epidemiology 4
Diagnosis 6
Comorbidity 9
Clinical boundaries 11
Aetiology 13
Prognosis 15
Morbidity and mortality 18
Morbidity 18
Mortality 18
Health resource usage 19
Health resource use after effective treatment 20
Different treatment models 21
Psychodynamic and psychoanalytically informed
psychotherapy 21
Self psychology 23
Relationship management 24
Cognitive analytical therapy (CAT) 24
Cognitive-behavioural therapies 26
Dialectical behavior therapy (DBT) 26
Commonalities between different models 29
viii BORDERLINE PERSONALITY DISORDER: A PRACTICAL GUIDE TO TREATMENT
Multimodel approach 30
An organizing clinical framework for
mental health clinicians 31
Outcome studies 34
Psychosocial treatments 34
Pharmacological treatments 40
Serotonergic agents 41
Neuroleptic agents 42
Anticonvulsants 42
Older agents (tricyclic antidepressants,
older MAOIs) 42
Other agents 43
Prescribing in the acute situation 44
In summary 44
Part 2 Treatment issues and clinical pathways
Introduction 49
Assessment 49
Risk assessment 54
Differentiating acute and chronic suicidal and
self-harm patterns 54
Crisis assessment 56
Interventions 58
Client–clinician relationship 58
Team/system culture 58
Clinical plan 59
Duration of treatment 69
Prioritizing interventions 69
Empathy and validation 71
Containment/holding 72
Transitional people and items 73
Self-harm 74
Contracts 80
Crisis work 81
Regression at times of crisis 83
CONTENTS ix
Some anti-suicide interventions 84
Acute inpatient services 85
Client-controlled brief acute admissions 91
Pragmatic conceptual frameworks guiding
treatment 94
Cognitive behavioural strategies 101
Behaviour chain and solution analysis 107
Teams 112
Team structure 112
Investing value and status in the
key clinician role 114
Specialist teams 115
Systems 116
Responsiveness of the organization to clinician
needs 116
Staff differences 118
Residential treatment 123
Relatives and friends 125
Principles of effective treatment 127
In summary 128
Part 3 Stigma, language, clinician feelings,
and resourcing
Stigma and discrimination 133
Language – negative terminology 134
Clinician values and feelings 135
Resourcing 137
In summary 138
Part 4 The legal environment
Medicolegal framework 141
Duty of care and institutional responsibilities 142
Professionally indicated risk-taking 145
