Is hospitalisation for people with borderline personality disorder an effective intervention for crisis management and treatment?

Prof Anthony W Bateman

Role for in-patient treatment of complex and severe personality disorder

n Nature of personality disorder itself Ø Attachment disorder Ø Sense of agency and autonomy Ø Socially derived epistemic trust Ø Risk – suicide and violence

n Evidence base

Attachments and the development

of social understanding

Psychological Self:

2nd Order Representations

Physical Self: Primary

Representations

Representation of self-state: Internalization of object’s image

Constitutional self in state of arousal

Expression

Reflection

Resonance

Infant CAREGIVER

symbolic organisation of internal state

signal non-verbal

expression

Affect & Self Regulation Through Mirroring

With apologies to Gergely & Watson (1996) Fonagy, Gergely, Jurist & Target (2002)

How Attachment Links to Affect Regulation

DISTRESS/FEAR

Exposure to Threat

Proximity seeking

Activation of attachment

The forming of an attachment bond

Down Regulation of Emotions EPISTEMIC

TRUST

BONDING

Attachment Disorganisation in Disrupted Early Relationships

DISTRESS/FEAR

Exposure to threat

Proximity seeking

Activation of attachment

The ‘hyperactivation’ of the attachment system

Adverse Emotional Experience

DISTRESS/FEAR

Adverse emotional experience rooted in

traumatic relationships

Inhibition of mentalisation

Intensification of attachment needs

Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse

Inaccurate judgements of affect, Delayed development of mentalization understanding

Failure to understand how emotions relate to situations and behavior

Sensitive caregiving

Caregiver’smentalizingoftheinfantactsasthe

prototypicalostensivecue

Secure attachment

Epistemic trust

Learningchannelopens(selec6vely)

Self-control & self-

learning Learning about the

world

Thislaysthefounda7onsfor…

Learning about others

Whichenables… Mentalizing

Successful navigation of social world

Neglect/a;achmenttrauma

Ostensivecuesarenotprocessed,wereabsent

ormisleading

Insecure/disorganizedaAachment

Absenceofepistemic

trust

Learningchannelisclosed,indiscriminatelyopenorbothbyturns

Epistemichyper-vigilance

Excessivecredulity

Epistemicdilemma

Mentalizingdifficul6es

Problemsnaviga7ngsocialworld

Problemsunderstanding

othersInall3cases,theindividualstrugglestolearneffec7vely

abouteitherselforworld

Evidence for

in-patient treatment

Psychodynamic therapy for BPD: Uncontrolled trials n  Chiesa, Fonagy, Holmes et al., 2004 (Am J. Psychiat.)

Ø  Three treatment models for personality disorder: o  Cassel 1-year programme o  A phased ‘step down’ programme 6 mo. residential and 1 yr outpatient o  A general community psychiatric model.

Ø  210 patients DSM-III-R criteria of PD allocated according to geographical criteria

Ø  Outcome evaluated at 6, 12 and 24 months on general symptom severity, social adaptation, self-harm and suicide attempts, rates and duration of hospital re-admissions and number of outpatient psychiatric visits

Ø  By twenty-four months patients in the step down condition showed significant improvements on all measures.

Ø  Patients in the long-term residential model showed significant improvements in symptom severity, social adaptation and global functioning; no changes were achieved in self-harm, attempted suicide and readmission rates.

Ø  Patients in the general psychiatric group showed no improvement on all variables except self-harm and hospital readmissions over the same period.

Ø  The results of this study suggests that a specialist, phased step down program, which includes long-term psychosocial outpatient treatment following a period of hospitalization, is more effective than both long-term residential treatment and general psychiatric treatment in the community for personality disorder.

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SCL-90 SAS GAS

Step downInpatientTAU

Clinically Relevant Change in symptom severity, social adjustment and global functioning at 72-month FU

Self-mutilation

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Parasuicidal Behaviour

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Hospitalisation

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StepdownTAU

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45000

Baseline Treatment period Year follow-up

One stageStep downTAU

Mean cost per person of two psychosocial treatment programs compared to TAU

Beecham et al. (2006)

Studies of treatments for antisocial personality disorder (ASPD)

n  Taylor 2000 Ø  Describes outcomes from a seven-year follow-up of 700 individuals treated in

a therapeutic community unit within Grendon Prison Ø  Outcomes contrasted with 142 allocated to a waitlist but not admitted to the

unit, and 1,400 inmates from the general prison population. Ø  Although there were some indications of reduced rates of re-offending, control

for prior criminal histories reduces the apparent impact of this result Ø  Link between length of stay and better outcome, with individuals who stayed

less than one year showing no treatment effect. n  Thornton, Mann , Bowers, & al, 1996

Ø  Evaluated progress in a dedicated unit for sex offenders within Grendon Ø  Better outcomes than for inmates with similar forensic histories treated within

the general therapeutic program Ø  This benefit was restricted to those with at least two previous sexual

convictions

Psychodynamic therapy for BPD: Uncontrolled trials

n  Menninger study (overviewed in Wallerstein, 1989) Ø Treated 42 patients with intensive psychodynamic therapy

(psychoanalysis, expressive psychotherapy, or supportive psychotherapy)

Ø Carried out in 1950s, and follow-up has continued since Ø Of 27 patients for whom full follow-up data were available,

good outcomes were obtained in 11, and a partial resolution in a further 7

Ø Better outcomes in patients with higher levels of ego strength.

Ø Those with high levels of ego strength and better quality of interpersonal relationships responded better to psychoanalytic or expressive therapy than supportive.

Ø Those with low ego strength responded better to supportive psychotherapy with hospitalization where necessary

Psychodynamic therapy for BPD: Uncontrolled trials n  Gabbard et al. 2000

Ø  Prospective, naturalistic study of outcomes from a cohort of patients treated in two inpatient programs using therapeutic community principles

Ø  Although program content was broadly consistent, treatment offered was on the basis of clinical judgment, and the length of stay varied widely (median 58 days)

Ø  Of 689 patients admitted, data are reported on (a possibly unrepresentative) 216 who completed treatment and were available for followup at one year.

Ø  Although all patients were classified as having ‘serious’ PD, the precise composition of the group is unclear - around half had a diagnosis of PD-NOS, or of mixed PD, and 35% a diagnosis of BPD.

Ø  Significant improvements were noted on a range of measures, which were sustained at followup

Ø  E.g. while at admission only 3.7% of patients had scores greater than 50 on the Global Assessment Scale, at discharge this rose to 55%, and 66% at one year.

Ø  This report is limited by lack of information on the specific treatments received, and the reporting of outcome data only for those cases available to followup

Attachment problems?

n  Indication that BPD with enmeshed attachment style engaged in in-patient treatment

n  4 subject committed suicide prior to 6 months point in one-stage sample in Cassel study

n High drop out rates Ø Over-stimulation Ø Activation of avoidant strategies

Patients in in-patient units are more severe than those in out-patient

services?

Conclusions

n Who should be admitted for treatment? Ø Inadequate knowledge to tell us Ø Evidence that in-patient treatment may be toxic Ø No evidence that in-patient treatment is safer

or more effective than treatment outside hospital

Conclusion: Avoid in-patient treatment as a treatment method BUT what about crises?

In-Patient admission for crisis management?

Examples of Symptoms

n  Acute symptoms: self-mutilation, suicide attempts, fleeting psychotic symptoms

n  Temperamental symptoms: angry feelings and acts, distrust and suspiciousness, abandonment concerns

Time to 12 Month Remission for DIPD Positive Cases (The CLPS Study)

00.10.20.30.40.50.60.70.80.9

1

0 6 12 18 24 30 36 42 48

BPD (n=201) MDD (n=95)

Prop

ortio

n no

t rem

ittin

g

Remission is defined as 12 months at 2 or fewer criteria for PDs; Remission is defined as 2 months at 2 or fewer criteria for MDD

Time from intake in months Grilo et al., (2004) JCCP, 72, 767-75.

Acute Symptoms

n  Resolve relatively quickly

n  Are the best markers for the disorder

n  Are often the main reason for expensive forms of psychiatric care, such as inpatient stays

n  Are akin to the positive symptoms of schizophrenia

Self-Mutilation

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Baseline 2-YearFollow-Up

4-YearFollow-Up

6-YearFollow-Up

8-YearFollow-Up

10-YearFollow-Up

BPDOPD

% o

f Pat

ients

OPD=other personality disorder. Adapted from: Zanarini MC, et al. Am J Psychiatry. 2003;160:274-283.

Temperamental Symptoms

n  Resolve relatively slowly

n  Are not specific to BPD

n  Are associated with ongoing psychosocial impairment

n  Are akin to the negative symptoms of schizophrenia

Chronic Anger/Frequent Angry Acts

Adapted from: Zanarini MC, et al. Am J Psychiatry. 2003;160:274-283.

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Baseline 2-YearFollow-Up

4-YearFollow-Up

6-YearFollow-Up

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10-YearFollow-Up

BPD

OPD

% o

f Pat

ients

Good Psychosocial Functioning Over Time

n  Patients with BPD and axis II comparison subjects improve

n  However, the functioning of patients with BPD remains more impaired than that of comparison subjects

Does this suggest that in-patient treatment is contra-indicated?

In-Patient admission

for suicidality?

BPD and risk of suicide

n  9-13% of all suicides n  50% of chronically suicidal patients in ER

meet criteria for BPD n  Lifetime risk for suicide estimated to be

3-10.3% n History of suicidal behaviour in 60-78% of

individuals with BPD

Antisocial Personality Disorder

n  17% of adolescents meet criteria for conduct disorder or ASPD

Marttunen, M. J., Aro, H. M., Henriksson, M. M., et al (1991) Mental disorders in adolescent suicide. DSM-III-R axes I and II diagnoses in suicides among 13- to 19 year-olds in Finland. Arch Gen Psychiatry, 48, 834-839.

n Suicide attempts 3.7 times higher for ASPD than for community comparison subjects

n  9x greater if < 30yrs Beautrais, A. L., Joyce, P. R., Mulder, R. T., et al (1996) Prevalence and comorbidity of mental disorders

in persons making serious suicide attempts: a case-control study. Am J Psychiatry, 153, 1009-1014.

Antisocial Personality Disorder Laub, J. H. & Vaillant, G. E. (2000) Delinquency and mortality: A 50-year follow-up study of 1,000 delinquent and nondelinquent boys. Am J Psychiatry, 157, 96-102.

n  Lifetime risk of suicide estimated to be 5% n Deaths due to violent causes more

common n Equal proportions died by suicide n ASPD + BPD high risk for suicide in males

Narcissistic Personality Disorder

n  Less common diagnosis in clinical settings n  Little data available n  Israeli soldiers Schizoid 37.2%; NPD 23.3% Apter, A., Bleich, A., King, R. A., et al (1993) Death without warning? A clinical postmortem

study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry, 50, 138-142.

n NPD or traits make more successful suicide attempts than patients without NPD

Stone, M. H. (1989) Long-term follow-up of narcissistic borderline patients. Psychiatric Clinics of North America, 12, 621-641.

Prediction ‘v’ Assessment

n  It is not possible to predict suicide due to the low base rates of the behavior and its uniqueness to the individual

n Goal of suicide assessment is not to predict suicide but rather to place a person along a putative risk continuum, to appreciate the bases of suicidality, and to allow for a more informed intervention

Risk Factors

n Concentrate on modifiable risk factors rather than fixed factors (age, gender, SE status)

n Higher risk relative to other psychiatric disorders

n May occur at different times in course of disorder than other psychiatric disorder

Substance Abuse Disorder

n  Links et al prospective follow-up BPD + SAD, BPD alone, SAD plus traits, traits alone Ø Comorbid subjects showed more self-mutilative

behaviour, more suicide threats and attempts

CLPD study

n Prospective follow-up n Baseline BPD and drug abuse disorders

predicted suicide attempts n Controlling for BPD, worsening of MDD and

Substance Abuse Disorders in month preceding predicted suicide attempts

Affective instability and suicidal behaviour in BPD in CLPD study n CLPD – 621 subjects over 2 years follow-

up Ø Affective instability, identity disturbance,

impulsivity predicted behaviours Ø Affective instability predicted attempts

n Reactive mood shifts more associated than negative mood

Lethality of suicide attempt Soloff et al (2005)

n  High lethality best predicted by low SE class, comorbid ASPD, extensive treatment histories, and greater intent but also: Ø Older Ø With children Ø Lower educational achievements Ø Lower socio-economic class Ø Comorbid – with MDD Ø Family history of substance abuse Ø Greater number of lifetime attempts

Clinical Risk and BPD

n Multiple attempts and self-injurious behaviour increase risk

n Frequent self-harm may inoculate practitioner judgement to level of risk

n Self-injury patients underestimate lethality of acts, show more depression, hopelessness and impulsivity

Conclusions?

Acute and Chronic Risk and BPD

Chronic level of risk

General level of risk in population

Acute exacerbation of risk

Time course

Clinical Risk and BPD

n Acute risk related to: Ø Major depression Ø Substance abuse Ø Discharge compulsory – against patient wishes Ø Negative life events – low family support Ø Manipulation ‘v’ dissociative state

Clinical Risk and BPD

n Common myths about admission Ø It is never useful – should be expected and

may be necessary to prevent suicide Ø Patient will regress – little evidence Ø It will make them worse

Clinical Risk and ASPD

n Need to assess risk of violence as well as suicide

n Suicides with conduct disorder or ASPD all had a history of violence

Marttunen M. 1994. Psychosocial maladjustment, mental disorders and stressful life events precede adolescent suicide. Psychiatrica Fennica 25: 39-51.

Clinical Risk and ASPD

n  Factor 1 Ø  Interpersonal/affective – superficial charm, grandiosity,

deceitfulness, absence of remorse, callousness, inability to take responsibility for actions, manipulation

n  Factor 2 Ø  Impulsive behaviour/social deviance – impulsivity, lack of long

term goals, parasitic lifestyle, juvenile delinquency, early behavioural problems, need for stimulation

n  Aids clinician to decide on risk to self and risk to others

n  Inform in-patient admission related to vulnerability of other patients

Clinical Risk and NPD

n Risk increases when depressed n Suicidal behaviour has several meanings

Ø Increase self-esteem with mastery Ø Death before dishonour Ø Revengeful Ø Belief of indestructibility Ø Attack on imperfect self

Clinical Risk and NPD

n Routinely monitor for depression and narcissistic injury

n Reduce access to means n Make others aware of risk n Establish relationship in which narcissism is

stabilised and promoted if thin-skinned.

Summary

n BPD – differentiate acute from chronic risk Ø Mood instability and/or negative mood intensity

may predict risk n ASPD – risk of violence to be assessed

with suicide risk n NPD – depression may be indicator but

may be unpredictable high risk at other times