Borderline Personality Disorder : A Clinical Guide

by Gunderson, John G.

• ISBN13: 9781585620166
• ISBN10: 1585620165
• Format: Hardcover
• Copyright: 2001-03-01
• Publisher: Amer Psychiatric Pub Inc

Summary

This sequel to Gunderson's 1984 Borderline Personality Disorder reflects the explosion of information, expertise, and specialization in borderline personality disorder, covering all recognized treatments for the clinical care of borderline patients. Integrating scientific advances with clinical lore, it offers a sophisticated--and uniquely comprehensive--look at treatment literature, clinical perspectives, and treatment modalities.

Author Biography

John G. Gunderson, M.D., is Professor of Psychiatry at Harvard Medical School and Director of Psychosocial and Personality Research and Chief of Ambulatory Personality Disorder Services at McLean Hospital, Belmont, Massachusetts. He has worked in the diagnostic and treatment of borderline patients since 1969, including carrying out important studies helping to define the diagnosis and differentiate it from other disorders. He continues to work in advancing effective treatments today.

Table of Contents

About the Author	xiii
Preface	xv
Acknowledgments	xvii
Introduction	xix
The Borderline Diagnosis	1	(34)
Origins of the Diagnosis	1	(4)
Where Were the Borderlines Before the Diagnosis?	2	(3)
Shifts in the Borderline Construct: From Organization to Syndrome to Disorder	5	(4)
An Explication of the DSM-IV Criteria	9	(6)
Borderline Personality as an latrogenic Disorder	12	(1)
The Subjective Experience of Being Borderline	13	(2)
A Clinical Synthesis: Intolerance of Aloneness	15	(4)
British Developmentalists-From Winnicott to Bowlby to Fonagy	16	(3)
Misuses of the Borderline Diagnosis	19	(2)
``Wisdom Is Never Calling a Patient Borderline''	21	(1)
The Behavioral Specialty: Self-Injurious Behavior	21	(3)
Cutting: Social Contagion or Serious Disorder	23	(1)
How to Explain the Diagnosis	24	(1)
Summary	25	(1)
References	25	(10)
Differential Diagnosis: Overlaps, Subtleties, and Treatment Implications	35	(28)
Overall Function	35	(1)
The Changing Construct: From Schizophrenia to Depression to Posttraumatic Stress Disorder	36	(2)
Comorbidity and Differential Diagnosis	38	(3)
BPD and Depression	39	(2)
BPD and Bipolar II Disorder/Cyclothymic Personality	41	(3)
BPD and PTSD	44	(2)
BPD and Eating Disorders	46	(2)
BPD and Substance Abuse	48	(2)
BPD and Somatoform/Somatization Disorders	50	(1)
BPD and Narcissistic Personality Disorder	50	(4)
Is Martha Stewart Borderline? I Think Not	51	(3)
BPD and Antisocial Personality Disorder (ASPD)	54	(3)
Summary	57	(1)
References	57	(6)
Overview of Treatment	63	(22)
Historical Overview	63	(2)
Generic Therapeutic Processes and the Functions They Serve	65	(4)
Containment	67	(1)
Support	67	(1)
Structure	68	(1)
Involvement	68	(1)
Validation	69	(1)
Multiple Modalities and Step-Down Services: An Overview	69	(1)
Sociotherapies	70	(1)
Generic Sequence of Change	70	(2)
Sequence of Expectable Changes for BPD	72	(3)
Can Consumers Judge Progress?	72	(3)
Changes Within Four Spheres	75	(3)
Affects	75	(1)
Behaviors: Impulse/Action Pattern	76	(1)
Social Function: Impairment	76	(1)
Relationship With Treaters	77	(1)
General Principles That Guide the Initial Structuring of Treatment	78	(1)
Diagnosis	78	(1)
Comorbidity	78	(1)
Primary Clinician	78	(1)
Short-Term Goals	78	(1)
Least Restrictive Safe Treatment Setting	79	(1)
Types and Sequence of Therapeutic Alliance	79	(1)
Myths About Alliance With Borderline Patients	80	(1)
Countertransference	80	(1)
Summary	81	(1)
References	82	(3)
Case Management: The Primary Clinician	85	(22)
Qualifications	86	(1)
Responsibilities	86	(2)
Liability Issues	88	(1)
Guidelines to Avoid Liability	89	(1)
Relationship Management	89	(2)
Managing Safety	91	(6)
Assessing Suicidality	91	(1)
A Preventive Stance	92	(1)
Responding to ``Feeling Unsafe''	92	(1)
Is Contracting for Safety Safe?	93	(4)
Responding to Recurrent Suicidality: The ``Principle of False Submission''	97	(3)
Implementing Changes	100	(1)
Boundaries, Violations, and Setting Limits	101	(1)
Splits, Splitting, and the Principle of Split Treatment	102	(3)
How Psychotherapeutic Technique Relates to Level of Care	104	(1)
Summary	105	(1)
References	105	(2)
Levels of Care: Indications, Structure, Staffing	107	(24)
Selecting or Changing a Level of Care	108	(2)
Hospital Treatment-Makes Therapy Possible	110	(4)
Is Long-Term Hospitalization Desirable for BPD?	110	(2)
Goals: Contain Patients for Safety, Assessments, and Treatment Planning	112	(1)
Structure	113	(1)
Staff	113	(1)
Residential/Partial Hospital Care-Basic Socialization	114	(8)
Goals	115	(1)
Vocational Counseling: Should He or She Return to School, Pursue a Career, or Become a Caregiver?	116	(1)
Staff	117	(1)
Structure	118	(2)
Empirical Support for a Psychoanalytic Day Hospital	120	(2)
Intensive Outpatient Care-Behavioral Change	122	(4)
Goals	123	(1)
Components	124	(2)
Outpatient Care-Interpersonal Growth	126	(1)
Summary	127	(1)
References	128	(3)
Pharmacotherapy: Clinical Practices	131	(18)
History	131	(1)
Overall Role of Medications	132	(3)
Listening to Prozac: Can SSRIs Cure BPD?	133	(2)
Getting Started	135	(1)
``I Don't Know If It Will Help''	135	(1)
The Prescribing Psychiatrist's Role	136	(3)
With the Borderline Patient	136	(1)
As the Primary Clinician (Psychiatrist/Therapist)	136	(2)
As the Psychopharmacologist Only (Split Treatment)	138	(1)
Liability Hazards of Split Treatment	138	(1)
Symptom Chasing	139	(1)
Attitudes, Meanings, and Attributions	140	(1)
Transference-Countertransference Issues	141	(2)
Contraindications/Discontinuance	143	(2)
Summary	145	(1)
References	146	(3)
Pharmacotherapy: Selection of Medications	149	(14)
Introduction	149	(1)
Overview	149	(3)
Comorbidity and Differential Diagnostic Considerations	152	(1)
Selective Serotonin Reuptake Inhibitors: The Usual Starting Point	153	(2)
Behavioral Symptom Resistance to SSRIs	155	(1)
Mood Symptom Resistance to SSRIs	155	(2)
Cognitive Symptoms	157	(1)
Summary	158	(1)
References	158	(5)
Cognitive-Behavioral Therapies: Dialectical Behavior Therapy, Cognitive Therapies, and Psychoeducation	163	(26)
Overview	163	(3)
Historical Context	164	(1)
Clinical Cautions	164	(2)
Growth in the Use of Cognitive-Behavioral Therapy With BPD	166	(1)
Basic Operant Conditioning Applications for All Treatment Settings	166	(2)
Dialectical Behavior Therapy (DBT)	168	(11)
DBT Theory	168	(1)
The Basic DBT Services	169	(4)
Empirical Support	173	(1)
DBT's Limitations: Checking the Flood	174	(5)
Perspective on DBT	179	(1)
Cognitive Therapies	179	(3)
Makes Sense, But Does it Work? Part 1-Preliminary Findings on Brief Cognitive Therapy	181	(1)
Psychoeducation for Patients	182	(2)
Summary	184	(1)
References	185	(4)
Family Therapies	189	(26)
Introduction	189	(1)
History	190	(2)
Therapists and Countertransferences	192	(1)
Getting Started: Overcoming Resistance	193	(2)
``You Can't Talk to My Parents''	194	(1)
Initial Family Meetings	195	(4)
Families of Married Borderline Patients	196	(1)
Problem Identification	196	(1)
Psychoeducation	197	(1)
Support	198	(1)
Finessing the Guilt Issue	198	(1)
Establishing an Alliance	199	(2)
Resistance to the Borderline Diagnosis	199	(1)
Resistance to Being Involved in Treatment	200	(1)
End of Phase 2: Transition From Treatment to Therapy	201	(1)
Psychoeducational Family Therapy	201	(7)
Single-Family Interventions	202	(1)
Adaptations for a Multiple Family Group (MFG)	202	(1)
Three Stages of Psychoeducational Family Therapies	203	(2)
``Good Cop/Bad Cop'': A Parental Problem	205	(2)
Makes Sense, But Does it Work?--Part 2: Preliminary Findings of the PE/MFG	207	(1)
Psychodynamic Family Therapy	208	(1)
Summary	209	(1)
References	210	(5)
Appendix: Suggested Psychoeducational Printed Materials, Videos, Films, and Web Sites	215	(98)
Printed Materials	215	(2)
Overviews	215	(1)
Family Issues	216	(1)
Instructive Books	216	(1)
Newsletters	217	(1)
Videos	217	(1)
Films	217	(1)
World Wide Web	218	(1)
Interpersonal Group Therapy	219	(16)
Introduction	219	(1)
Indications	220	(1)
IPG Structure, Duration, and Leaders	221	(2)
Structure: Group Size and Meeting Schedule	221	(1)
Duration	222	(1)
Group Therapists	222	(1)
Getting the Group Started	223	(3)
Membership	223	(1)
Engagement	224	(1)
Makes Sense, But Does It Work?--Part 3: Preliminary Findings on Efficacy of IPG	225	(1)
Establishing a Contract	226	(1)
Processes of Therapy	227	(5)
Interpersonal Learning	228	(1)
Cohesion	228	(1)
Owning and Expressing Hostilities	229	(2)
Split Treatment: Communicating With Primary Clinicians and Other Therapists	231	(1)
Outside-the-Group Contacts	231	(1)
Summary	232	(1)
References	232	(3)
Individual Psychotherapies, Phase 1: Getting Started	235	(26)
Introduction	235	(2)
Getting Started	237	(5)
The Problem of Dropouts	237	(1)
Contracting Roles	238	(2)
Anticipating Problems in Psychotherapy	240	(2)
Structuring the Therapeutic Frame (External Boundaries)	242	(6)
Bills	243	(1)
Frequency	244	(2)
Scheduling	246	(1)
Seating	246	(1)
What Is the Role of Psychoanalysis for BPD Patients?	247	(1)
Therapists	248	(7)
Qualifications	248	(4)
Qualities	252	(1)
Listening to Kernberg or Linehan: Can Charisma Cure BPD?	253	(2)
Engagement	255	(2)
Summary	257	(1)
References	258	(3)
Individual Psychotherapies, Phases 2, 3, and 4: Processes of Change	261	(32)
Prior Literature	262	(8)
Outcome Studies	262	(5)
Psychoanalytic Contributions	267	(2)
The Debate of the 1970s	269	(1)
Overview of Change Processes	270	(1)
A Relational Alliance	271	(8)
Positive Dependency	279	(5)
Transitional Objects-From Concept to Phenomenon	279	(3)
Is Regression Therapeutic?-The Two Margarets	282	(2)
Secure Attachment, The Working Alliance, and Consolidation of Self	284	(1)
Impasses	285	(2)
Summary	287	(1)
References	288	(5)
Future Considerations	293	(20)
The Diagnosis: Self-Disorder and Relationship to DSM-IV Axes I and II	293	(1)
The Search for the Core Psychopathology of Borderline Personality Disorder	294	(3)
Brain Meets Mind: Frontiers for BPD in the Neurosciences	297	(3)
Is BPD a Brain Disease or Not?	297	(3)
Development of Specialists and Special Services	300	(3)
Credentialing Therapists	302	(1)
Standards of Care	303	(1)
Public Awareness and Advocacy	304	(4)
Borderline Personality Disorder on the Internet-Proceed Enthusiastically...With Caution	305	(2)
Were a Famous Borderline to Go Public	307	(1)
The Swiss Foundation	308	(1)
Summary	309	(1)
References	309	(4)
Index	313