Dear @Ellie
NUMBER ONE FORM;
I forgot to delete something...the medication perscribed .......
I've been trying to work out how to send this to you. You asked for this copy from my Psychotherapist when you first joined; a good printout of a diagnosis for BPD. I wrote to you about how to get it but.....my slow understanding of the computer techniques ...I must always take into consideration whenever I say...oh cool,,,,I've got information on that!!
So, this is it. Without the pretty different colours that make a paper look so pretty.
Then there is second in a following post....please bear with me while I send it :0)
PP
The new england journal of medicine clinical practice
Borderline Personality Disorder
John G. Gunderson, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.
A26-year-old woman is brought to the emergency room by an anxious-looking man who explains that she became angry and suicidal, stat- ing that her “life had no value” and that she would “like to end it all” after he criticized her. Her history includes five previous emergency room visits (twice involving self-inflicted cuts that required sutures) and two psychiatric hospitaliza- tions after overdoses. Adolescent adjustment reaction and major depressive disorder have been diagnosed in the past, and she has been treated with certain meds.. How should she be evaluated and treated?
The Clinical Problem
Borderline personality disorder (BPD) is present in about 6% of primary care pa- tients1 and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics.2 In clinical settings, about 75% of per- sons with the disorder are female, although this percentage is lower in community- based samples.3,4 Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury.5 Such episodes result in an average hospital stay of 6.3 days per year and nearly one emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.6,7
Table 1 summarizes the criteria for the diagnosis of BPD, according to the Di-
agnostic and Statistical Manual of Mental Disorders, fourth edition. Recurrent suicidal
threats or acts, when combined with fears of abandonment, are by themselves strong-
ly indicative of the diagnosis.8 Though these signature criteria make BPD easy to
recognize, the diagnosis is often underused.9,10 A major reason for this is the per-
ception that the recurrent crises, emotional volatility, and self-injurious behavior that
characterize patients with BPD are willful and manipulative episodes rather than
11,12
genetic factors13,14 — rates in the same range as those reported for hypertension.15 All the major components of the disorder (e.g., interpersonal hypersensitivity, affec- tive dysregulation, and impulsivity) have likewise been shown to track in families.14 Studies involving the use of magnetic resonance imaging or positron-emission to- mography in patients with BPD have shown a hyperresponsive amygdala and im- paired inhibition from the prefrontal cortex during tasks involving exposure to facial expressions, reactions to emotionally charged words, and interpersonal coopera- tion.16-18 There is evidence that neurohormones, such as oxytocin and opioids, medi- ate the exaggerated fears of rejection and abandonment that are characteristic of BPD.19 Environmental influences also appear to be important in the pathogenesis of the disorder; insecure attachment, childhood neglect or trauma, and family marital or psychiatric problems are recognized risk markers.2
n engl j med 364;21 nejm.org may 26, 2011
From the Psychosocial and Personality Research Program, McLean Hospital, Belmont, MA. Address reprint requests to Dr. Gunderson at the Psychosocial and Personality Research Program, McLean Hospital, 115 Mill St., Belmont, MA 02478, or at jgunderson@mclean.harvard.edu.
N Engl J Med 2011;364:2037-42.
Copyright © 2011 Massachusetts Medical Society.
An audio version of this article
is available at NEJM.org
signs of an illness.
BPD is significantly heritable, with 42 to 68% of the variance associated with
2037
The New England Journal of Medicine
Downloaded from nejm.org at WESTERN AUSTRALIA DEPT OF HEALTH on June 21, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved.
The new england journal of medicine
Strategies and Evidence
Diagnosis
The most distinctive characteristics of patients with BPD are their hypersensitivity to rejection and their fearful preoccupation with expected abandonment (Table 1).30 Patients with the dis- order feel that their lives are not worth living unless they feel connected to someone they be- lieve really “cares,” yet their perception of “car- ing” generally involves unrealistic levels of avail- ability and validation. Within such relationships, an initial idealization can dramatically shift to devaluation when rejection is perceived. In addi- tion to this external “splitting,” patients with BPD typically have internal splitting (i.e., vacillation between considering oneself a good person who has been mistreated, in which case anger pre- dominates, and a bad person whose life has no value, in which case self-destructive or even sui- cidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing di- chotomous thinking.
BPD is usually diagnosed in young adulthood, but signs of it often become evident in adoles- cence.31 Early markers include body-image prob- lems, severe shame, the search for exclusive re- lationships, extreme sensitivity to rejection, and behavioral problems, including deliberate self- harm.32 Although these phenomena may occur in adolescents without BPD, their presence is predictive of long-term social disability and an increase in the risk of adult BPD by a factor of nine.31
The diagnosis of BPD is most easily estab- lished by asking patients whether they believe that the criteria for the disorder characterize them. Clinical experience suggests that by par- ticipating in the diagnosis, patients with BPD may be more likely to accept it. Although clinicians who think of a BPD diagnosis as pejorative (chronic and untreatable) may be reluctant to disclose it,8,12 patients and their families often find it helpful to be informed of the diagnosis. Such disclosure frames treatment plans, estab- lishes reasonable expectations, and may improve compliance.33 Clinical experience suggests that patients and their families are often relieved to learn that there are other people with similar symptoms and that there are effective treatments.
