PURLs
Patient overusing antianxiety meds? Say so (in a letter)
Helping patients stop—or reduce—their use of benzodiazepines needn’t take long. In some cases, all it takes is a carefully crafted letter.
Although the research has focused primarily on borderline PD, these approaches can be applied to other PDs. These therapies focus on understanding one’s emotional and behavioral patterns, developing a healthy self-concept, and improving interpersonal relationships—areas that are relevant treatment targets across all PD types.
Indeed, studies of day treatment programs that explicitly welcome patients with a range of PD types have had promising findings.27 Day treatment involves an intensive array of therapies, mostly in a group format; patients work together to support and embolden one another to make positive changes. Unfortunately, FPs may be challenged to find appropriate services for patients who are amenable to psychotherapy; public mental health resources tend to lag far behind best practices in the case of PD.
Medication might improve symptoms, not personality deficits
Most research on pharmacotherapy for PDs has focused on borderline PD; findings have been mixed and fairly limited.28 Medication cannot address underlying identity and relational deficits, and will not result in remission of PD. Nonetheless, judicious, circumscribed use of medications to target specific symptoms may be helpful for some patients. Selective serotonin reuptake inhibitors can reduce anger and impulsive aggression in patients with borderline PD.28,29
Atypical antipsychotics may help reduce impulsive aggression or transient psychotic symptoms.28-30 For example, olanzapine and aripiprazole can reduce anxiety, anger/aggression, paranoia, and interpersonal sensitivity in borderline PD.31,32 Mood stabilizers such as valproate, lamotrigine, and topiramate may also help some borderline patients, although they do so by reducing impulsivity and aggression rather than improving core unstable identity and affect.28,29
Carefully obtained informed consent is necessary because of the danger of adverse effects with many of these medications; for example, antipsychotics have been associated with metabolic syndrome and weight gain that can threaten a patient’s already fragile self-image.33 Polypharmacy is also a potential problem: Well-intentioned physicians may be prompted to offer multiple medications in response to patients’ unremitting complaints of distress, when a psychotherapeutic approach may need to be the primary treatment. The bottom line is that medications do not resolve personality dysfunction, and are best used symptomatically as adjuncts to psychotherapy.28,30
Steps you can take during the office visit
Although it is not feasible for most FPs to provide comprehensive treatment for PD, key elements from specialized therapies can be integrated into your management of these patients. Steps you can take include using validation, promoting mentalization, and managing countertransference.
Validation, which is a component of DBT, is providing the expressed acknowledgement that the patient is entitled to her feelings. This is not the same as agreeing with a position the patient has taken on an issue, but rather conveying the sense that one sees how the patient might feel the way she does. A study of women with borderline PD and substance abuse found a validation intervention by itself was significantly helpful.34 Validation can contribute to a “corrective emotional experience.” For instance, your supportive acknowledgement of a patient with a history of abuse or neglect may counter the patient’s expectation of being invalidated, and over time this can reduce the patient’s defensive rigidity.
Mentalization. Psychodynamic treatment involves a similar tack; clinicians empathize with the patient’s emotional state while also demonstrating a degree of separateness from the emotion.23-25 This promotes mentalization in the patient—the ability to contemplate one’s own and others’ subjective mental states.18 Mentalization is often impaired in PD patients, who presume to “know” what others are thinking. A patient, for instance, “just knows” that her friend secretly hates her, based on a vaguely worded text message.
You can help patients with mentalization by taking an inquisitive “not knowing” stance and by emphasizing a collaborative and reflective approach toward a given problem—to examine the issue together, from all sides. You can point out that while a patient is entitled to feel whatever he is feeling, it may not be in his best interest to act on the feelings without adequately considering the potential consequences of the action. This helps the patient to distinguish thoughts, feelings, and impulses from behavior. It also teaches the value of anticipatory thinking, impulse control, and affect regulation.
Countertransference. Managing your emotional reactions to a patient with PD is a well-documented challenge.35 Your feelings about the patient, known as countertransference, can range from considerable concern and sympathy to severe frustration, bewilderment, and frank hostility. A common reaction is the sense that one must “do something” to respond to the patient’s emotional distress or interpersonal pressure. This may trigger an impulse to give advice or offer tests or medications despite knowing that these are unlikely to be helpful. A more useful response may be to tolerate such feelings and listen empathically to the patient’s frustration. Recognizing subtle countertransference can guard against extreme reactions and maintain an appropriate clinical focus. Discussion with a trusted colleague can be helpful.
