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Borderline Personality Disorder and Narcissistic Personality Disorder

We use the term manipulation, manipulative to describe many borderlines. The second is splitting. Ambivalence is addressed but not the great talent these patients have for coming onto an inpatient unit and assigning white hats or black hats to the staff. Projection or projecting identification is another intrapsychic concept thatís not included in the DSM-IV scheme. In terms of narcissistic personality disorder, concepts not included are the profound insecurities that these patients have. When you read the criteria you think of somebody who comes across as being very secure, pompous, cerebral but these patients are extremely insecure. As high as the graph will go in terms of their arrogance and their self congratulatoriness inside they feel just as insecure borderline personality disorder, narcissistic personality disorder, narcisistic, narcississtic, narcistic, border line personality disorder

The second issue not addressed and this is true of borderlines too is the countertransference and transference issues. These patients are quite intimidating. They tend to make us lose our confidence and these are important things to remember in managing these cases that

Epidemiology and other research findings. First, 75% of borderlinesÖ let me mention one thing in overview. Thereís not as much good research on hard data like this for narcissistic character as there is for borderline. I think the reason for this is the borderline is probably more common. These patients are more disruptive. Theyíre more dangerous in terms of harm to themselves, harm to others as well as more litigious and also they require more psychopharmacological intermittent use than the narcissistic characters. So youíre going to find that Iíve found more research to describe these borderlines than the narcissistic characters. 75% of borderlines are women. Why is this? There are three or four different perspectives you can take to

Is there genetic heritage? Is that the way itís mediated? That rather than the little girl being the victim that the genetic profile of the victimizer is passed on and something is manifested in the behavior that is more genetic than in terms of the victimization and the abuse. Iíll come back to that in a minute but itís a controversial concept and yet we still, in spite of the correlation between abuse and borderline pathology, we canít for sure say thereís a causal relationship yet even though operationally we assume that. 11% of outpatients are borderlines, 19% of inpatients are borderlines. Now, 75% of borderlines have a history of at least one self injurious act. Thatís not surprising. 9% of all borderlines commit suicide and the next, I think, is probably one of the most important numbers to remember thatís really scary and that is 35% of borderlines with all eight of the DSM-III criteria commit suicide. Now, thatís a very high number. Thatís competing with bad cancers in terms of the lethality. So certainly if you begin to see a borderline who has most of the criteria beware of self destruction. 75% of borderlines have had childhood sexual abuse. Judy Herring, I think, should get a lot of credit for this observation which really changed our

Behavior therapy, which Iím somewhat trained in and have had some experience taking the risk of being a behaviorist by the seat of my pants in my career, is structured. Itís clear. Thereís a lot of activity on the part of the therapist. Itís more hopeful, I think, a lot of times than psychodynamic therapy and I think these are some of the characteristics that allowed Lenahan to have a better experience holding onto these patients in therapy which

66% of a large population of borderline patients were found, 20 years after hospitalization, to be doing functionally quite well. This is fascinating because it suggests that thereís a significant burnout effect in borderlines. That during middle age something happens whether itís hormones or just life experience or perhaps finally getting a good relationship, these patients gradually become better on their own. 46% of borderline patients reported having been a victim of violence since age 18. 50% of the female patients reported this and 26% of the male patients reported this. Now, this gets into some politically tedious questions that Iím going to launch into. Do adult borderline females have trouble picking their company? Or, the most

I think weíre going to find within the next decade that trauma changes brain structure and function and I think itís important for us to consider that with borderlines who have been traumatized more than most. These observations can be an all or one effect. They could be causes or they can be incidental. So weíve got much to learn about these kinds of correlations. Certainly the neuropsychiatrists would have us immediately, with any kind of data like this, jump on the band wagon, saying, "Aha, weíve found the cause of this behavior" but it may be that itís only effect. One study about

Now, you would think with personality disorder that something like that should remain static for most of oneís life but she found that after three years, 60% of these patients no longer met criteria. So she looked at what happened to them during those three years. I donít recall whether she controlled the therapy. To my recollection the therapy didnít make any difference but she didnít find that successful therapy necessarily explained this. There are three different observations she made among this population of patients that lost their criteria. One is that they had achieved something significant and if you think about the narcissistic character thinking they have already achieved a lot, if indeed a good achievement comes along, sometimes the rest of the personality defect can go away. The second thing is many of these patients developed a good relationship. A good relationship allows you not to

Next I want to focus on some contextual realities that are affecting the treatment of borderlines and narcissistic personality disorder patients. The first is managed care. If you talk to Otto Kernerg believes that managed care is wrong. That long term intensive psychodynamic psychotherapy should be funded and eventually will be. He has, from this podium, described it as an experiment on treatment which will be shown later with good research to work and so therefore ought to be funded. On the other side of the camp would be the managed care. That is their belief that symptom focused briefer therapies, in fact, is probably better care than long term psychodynamic psychotherapy.

One of the unfortunate negative effects that she found was these patients after the year, the borderline patients didnít feel better. This concerned her. Iíve had personal conversations with her about this. One way you could rationalize it is that as the behavior became more controlled, less self injurious acts, better quality relationships, adherence to the therapy, much of the behavior had improved but the inner life had not

The second contextual reality. Fewer psychiatric residency programs are including intensive psychotherapy experiences, a trend which invites less insight into transference and countertransference factors whenever borderline or narcissistic patients confront them. I consider this a real disaster because psychiatrists are still going to be considered the experts in the management of mental illness and if we are asked to see a patient in consultation who one of our colleagues is in a struggle with and obviously locked into a transference/countertransference struggle will we be able to recognize it if we hadnít been to the same program as a resident. So I strongly advocate it in our residency program and fortunately weíre still able to give our residents at least a few hours of this kind of experience during their three years. If they pick up a troublesome patient, let the patient glom onto them and under supervision begin to experience those kinds of transferences that you get dealing with these very troubled patients.

Remember that these patients sue. These are the patients that are most likely to sue us. If you donít recognize the kind of transference potential, donít recognize your own anger beginning to build up, youíre going to raise the likelihood of being sued by one of these patients if itís not a good therapy outcome. So I really believe that. I hope that we can maintain this kind of training in the future.

Then a third context which Iíve already alluded to is evidence is emerging that childhood sexual trauma may be an important correlate with the implication of it being a determinant. I think the jury is still out in terms of us proving that the trauma itself caused the adult borderline behavior or whether thereís something about the genetic loading that led the victimizer to victimize the child, etc., etc. So there are all these different effectors you come up with and theorize about how the childhood trauma and the adult borderline behavior interrelate. Certainly when I first came into psychiatry about 30 years ago these patients were just considered hateful. I mean, there was very little sympathy for borderlines. We tried to treat them but we had labels like "dirtballs" and terrible terms like that that described these patients that you dreaded seeing in the Emergency Room. I think since

With the varying abuse thereís also emerged this terrible controversy between the recovered memory therapists and The False Memory Foundation. I think most of you are probably aware of this controversy. We hear less and less now about recovered memory therapy but many families, of course, were destroyed by the emergence of these kind of memories some of which were later retracted by the patient. So thereís much sadness, I think, sadness when these kind of controversies emerge. I guess the position I take is to keep an open mind and continue to collect data from an individual patient that Iím seeing without having that particular ax to grind other than trying to get to know my patient better.

So much for the three contextual realities. Letís focus on 12 practical strategies for the management of borderline/narcissistic patients. Where did I get these strategies? Over the years Iíve been asked to see a lot of patients in consultation who were troubling clinicians or in trouble with clinicians and these 12 statements that Iíve come up with represent the 12 most common statements I make back to the other professional asking me to see the patient. So I culled my own experience seeing troubled cases and these are some of the pieces of wisdom that Iíve come up with that might have prevented some of the mishaps that occur. Now, my thesis is really in two parts. First, that psychodynamic insight allows us to understand these patients and that behavioral strategies allows us to help them. The second thesis is it has more therapeutic power in the relationships outside of therapy than in the patientís relationship with the therapist which raises some controversy but I will elaborate on that in a little bit. I want you to think of integrative therapy with these patients. Integrative meaning using psychodynamic, behavioral, individual, family, groups using pharmacology. All these things are critical to help these desperate patients and particularly with borderline patients I think we might have the best model in a true biopsychosocial entity that requires treatment from biopsychosocial spheres.

The first strategy. If you canít or donít like the patient, get consultation immediately or get out of the alliance. This advice applies not only to psychotherapy but also to pharmacotherapy. I donít think itís a bad thing if we try to like a patient and just find no redeeming value in the patient and feel that sense of dread every time the patient makes an appointment to see us. I think if you go get consultation and you canít unlock some insight about why thatís happening that you can get beyond itís better to refer the patient to somebody else. This is true even of the medication of the patient. Iíll get to the medication in a bit but the mishap that can occur if the pharmacologist doesnít like the patient and some poor old psychotherapist is trying to do the psychotherapy it can be a disastrous situation.

Most of us have totally obnoxious borderline patients in our practice and some of our colleagues might ask us, "How in the world can you stand to be with so and so?" Itís funny because when I think of the difficult patients I have like this I can find something interesting or redeeming about them in spite of the fact that thereís much about them that I agree is obnoxious. If I couldnít find that little bit of the patient to like or to feel helpful about, what I should do is listen to my own advice and get the patient another therapist or pharmacologist.

The second strategy. Be frank and straightforward with these patients. Share with them basically anything you might be likely to unload with a colleague after a session with that patient. Ideally use the patient as a supervisor. Now thatís a complicated strategy. What Iím trying to get at is to be authentic with the patient if at all possible. With many of these patients thatís very difficult to do. One inspiration for this is the story told by Kernberg. I think he published this back in í76 in the Journal of the American Psychoanalytic Association. Unfortunately I donít have that reference in my bibliography. He describes treating an anorectic, episodic, alcoholic young woman in her 20s who was borderline and she had an engulfing mother. Every time the patient would begin to get in trouble the mother knew about, the mother would just sort of swoop down and grab hold of the patientís life and take charge which was immensely disturbing to the patient and counterproductive.

As therapy was progressing with the patient one day he began to smell alcohol on her breath during successive visits, began to notice that she was losing weight and began to feel this enormous conflict with himself. Part of him as the physician wanted to commit her and save her life. Another part of him, as a psychoanalyst, wanted to respect her autonomy and sort of listened to the process as he showed her empathy. Things didnít get any better as successive sessions went on and one day he found himself saying to the patient with a certain amount of authenticity, "I donít know what to do about you. Iím in a bind. If I become a physician, Iím like your engulfing mother. If I do nothing you might seriously harm yourself. What am I to do?" With that, the patient burst into tears and began to talk about the mirror image of that quandary because part of her wanted him to be the engulfing mother and to save her and to take charge of her life. Another part of her wanted him to be the ideal parent, from her perspective, who was going to magically somehow help her make it through this dangerous period. So by his being authentic with the patient about his quandary, kind of using her as a supervisor asking the critical question, this allowed her then to take the risk of exposing the part of her quandary that she hadnít up to that point and I think thatís an inspiring vignette.

The kind of statements that are hard to make to a patient that requires a lot of courage of authenticity would be to say to a patient, "You frighten me." Or hereís a hard one. "Why do you wear such provocative clothes?" Certainly female borderlines a lot of times provoke us males with dress thatís provocative and what do you do about this? Do you just sort of sit and either enjoy it which can be a dangerous slippery slope. Or do you feel a little nervous but donít say anything about it. Or is there some way you can begin to have the patient notice that sheís doing this and begin to take some responsibility for what it means. Thatís a very awkward situation.

Another statement you might make to a patient, certainly all of you have felt like saying this, "Your anger makes me dread these appointments." Now, these are just three examples of the kind of authentic statement that I think is really useful to say with these kind of patients and this can apply both to the narcissistic intimidating patient as well as to borderline patients with all the emotional instability.

Okay, strategy number three. Avoid getting into the position of being angry at the patient. If the patientís making you angry you arenít setting limits appropriately or you may be stuck in counter transference distortion. Remember that suicidal risk increases if the therapist gets angry or rejects them. Again, this overlaps with the charge to be authentic and also the charge not to treat a patient you donít like. However, we can like a patient and feel like weíre being authentic but the patient will begin doing something that begins to make us angry. It may be calling us too frequently. Iíll get to telephone calls in a minute. It may be not paying the bill on time. It may be not showing up or always coming late and itís really important to get this out on the table, to try to figure out some sort of clever strategy to set limits so that the patient doesnít abuse you this way. Very often getting a consultation is a way to clarify it.

I urge all of you, most of you I think have finished your residency program, some of you recently, and you will begin to be tempted to sort of do it on your own but I think all of us, regardless of the years of experience youíve got, need to have a ready consultant, a colleague or a mentor who you can call up and have a ten minute phone conversation with or have a patient see in order to get these problems spots taken care of. This can really help with the anger. One thing you got from med school, I think one of the ways I try to not be angry with these patients is to take a posture of fascination. In other words, if some intimidating or pompous narcissist or some provocative angry borderline comes into my office, if I can sort of sit back and be fascinated by what Iíve seen in the office rather than getting entangled personally sometimes it protects me from getting angry. Iím thinking of a surgeon I knew in med school at the University of Pennsylvania whose name was Blakemore and he was a surgeonís surgeon. His typical patient would be a late middle aged obese woman who had a hysterectomy some years ago, had her gallbladder taken out some years ago, probably at least one bowel obstruction which had been dissected, resected and then they would be sent to Blakemore with yet another impending obstruction.

Most surgeons would consider this a nightmare to open up that belly and to look at the matting of adhesions. But what Blakemore would do he would open up the belly and all of a sudden you would see this mat of adhesions and heíd sort of step back and say, "Isnít that amazing? Look at what nature can do." Weíd stand there for four or five hours holding a retractor watching him make these very tedious dissections and the sort of joy he got out of the complexity and the tedium of treating these patients with adhesions I think was infectious and that kind of mindset helps with these kinds of patients.

I also think that one way to avoid getting angry is to be clever and I just want to brag about one clever strategy I came up with. I have a patient on Medicaid and for those of you who have looked closely at what you can do with a Medicaid patient in terms of charging for no show you canít do that. Itís really illegal if youíre on a Medicaid contract to charge a patient for a no-show but I sort of sleezed around that a little bit by saying to a patient who didnít show up that I was going to have her make a $10 security deposit. So I didnít say I was going to charge her for not showing, I just

Pharmacologic management. I could talk for a whole area on this one. We are physicians. We should act like physicians with these patients and when they need medication we should give it to them. These patients have troubled brains that invite not only just about every psychotropic drug that has been designed but probably some that we donít have designed yet. There has been no good controlled double blind studies with borderlines. Itís not surprising because this is a very difficult population to manage in a controlled setting. There have been some interesting studies to demonstrate the benefits of mood stabilizers but these are open studies, often retrospective. Recently two studies have come out about Clozaril suggesting that this is a good control of some borderline behavior. One recent study included patients with chronic psychosis who also had borderline personality disorder being treated benefitted by Clozaril. Again, open studies, retrospective so therefore the scientific validity I think is

Benzodiazepines are controversial. Most of us are wary about giving benzodiazepines to patients like this for their anxiety but I do have a couple of patients that have a supply of, usually Ativan, lorazepam who self medicate when theyíre feeling anxious and do it responsibly. I also have many disastrous patients who use them with alcohol and do very poorly.

Naltrexone, of course, has the unique ability to cut down the impulse to self abuse. It blocks the endorphin system. Iíve seen it work nicely and it certainly mood stabilizes. A lot of people think the borderline personality disorder is nothing but rapid cycling bipolar and this may be the case and it may be that mood stabilizers can help with a lot of their behavior. But I think the juryís still out in terms of whether it really is rapid cycling or bipolar or whether itís comorbid.

Suggestion number eleven. Be willing to take a break from therapy when no progress is being made. A reassessment after a three month respite, for example, may crystallize therapeutic alliances and goals. Certainly whenever you admit somebody to the inpatient unit, I used to be an attending on our inpatient service and a lot of borderlines would come in there and sometimes they were on five or six different medications, they would have a couple of therapeutic alliances and they were really overdosing on everything therapeutic. So we would often dramatically 

Number twelve and last suggestion is a series of briefer therapies with the same therapists during times of pain or crisis. They serve these patients better than one long term alliance. Certainly, a lot of us feel like weíve failed when the borderline patient comes to see us for only eight months and yet I think a lot of us will see a patient like that and they can come easily and leave easily if thatís the way we behave and then the patient feels like they can return to us with subsequent life catastrophes.

I have done this with a few patients and itís worked out quite well. Certainly on the inpatient unit, I have seen this work out. It used to be that when a borderline would come into the unit, we would kind of take charge and make sure that the patient didnít manipulate us and try to leave too soon. Nowadays, this is one of the few situations, I think, where managed care has helped us. We let the patient in easily and we let them go easily so itís not uncommon to have a patient come in feeling profoundly suicidal to be admitted during the evening, get the TLC of the night nursing staff and then the next morning be all scrubbed and ready to leave and "Thank you very much. Iím not suicidal anymore."

I donít think thereís anything wrong if the patient has ongoing care to allow that kind of thing to happen. A child having to sort of come and go to get away from parent, coming back to reembrace parent in order to find confidence. I think a lot of times our borderlines need to do the very same thing in treatments with us, either in hospital therapies or individual therapy.

Just to summarize, a few words Iíll leave with you. Biopsychosocial, certainly about borderline. We donít know much bio about narcissistic characters but Iím sure we will find out some in the future. Integrative therapies. Think in terms of individual, psychodynamic, behavioral, family, group, psychopharmacological. Mixing them all together. Not feeling like youíve got to do one or the other. Be sure to get consultations. Have somebody in