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While treatment of bipolar disorder challenging , the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms.
The concept of treatment resistance deserves reconsideration. Originally formulated in psychoanalytic terms, resistance in treatment referred to the inevitable ways patients unconsciously express their psychology in terms of defense mechanisms and transference enactment. This form of resistance provides a window into the patient’s problems; therefore, it is a major focus of the inquiry and intervention. Modern psychiatry defines treatment resistance as a lack of response to adequate treatment. Both conceptualizations locate treatment resistance within the patient, rather than as a product of limited, underdeveloped, and ineffective treatments. As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.
Trait Stages of Diagnosis for Borderline Personality Disorder
Treatment resistance is highly prevalent across most psychiatric disorders-even in common diagnoses generally associated with positive outcomes, such as depression. There are many more obstacles to effective treatment (Figure 1) than the patient’s psychological resistance alone. Identification of specific factors that diminish treatment response may provide more useful points of intervention than the label of treatment resistance.
Comorbid disorders contribute to poor treatment response. Treatment guidelines are often based on a false assumption that patients present with single disorders that respond to specific evidence-based treatments. Regardless of increasing attention to problems of comorbidity, guidelines for combining and prioritizing the treatment of different diagnoses remain largely underdeveloped.
Comorbid personality disorders complicate treatment. Over 50% of patients in specialized psychiatric settings have personality disorders.1 These patients are more likely to face social adversity, suffer from complex comorbidities, and drop out of treatment or not adhere to medication regimens-all of which contribute to an increased risk of a lack of response to treatment. The presence of a personality disorder, particularly borderline, predicts persistence of anxiety and substance use disorders as well as poorer outcomes in depressive disorders. Moreover, 13% of those who complete suicide have personality disorders.2
Clinicians often see patients with personality disorders as treatment resistant-and, in some cases, untreatable.3 While it is true that patients with personality disorders may be challenging to treat, they are treatable. The self-defeating coping skills and difficulty with relationships that are central to personality disorders make a productive treatment alliance difficult to sustain. Clinicians prototypically react with feelings of frustration, disengagement, incompetence, confusion, helplessness, and even rage.4 The identification of these countertransference reactions can facilitate the diagnosis of personality disorders but can overwhelm and disturb clinicians, leading them to avoid diagnosis and personalize problems as a product of either the patient’s immutable character or the clinician’s limitations.
Our progress in understanding and treating borderline personality disorder (BPD) illustrates the benefits of centralizing the personality disorder diagnosis in care management. For over half a century, patients with BPD were identified by their negative therapeutic reactions, that is, worsening with what was thought to be otherwise appropriate treatment. While pessimism and stigma about the disorder remain, our notion of BPD’s prognosis has radically improved with research.
A major longitudinal study of BPD and other personality disorders with 16 years of follow-up showed that virtually all subjects with BPD achieve sustained remission for at least 2 years, and 78% sustain remission for 8 years. Recovery, that is attending work or school and sustaining at least one meaningful relationship, occurred for 60% of patients for 2 years, and was maintained in 40% over 8 years.5 This evidence suggests that the majority of individuals with BPD (and other personality disorders) can achieve remission and most can recover some sustained functioning, which challenges the notion that patients themselves resist treatment.
Research findings also demonstrate that BPD responds to a variety of treatments. Several specialized psychotherapies formulated for BPD-dialectical behavior therapy (DBT), mentalization-based treatment (MBT), schema-focused psychotherapy, and transference-focused psychotherapy (TFP)-reduce self-injury, suicide attempts, and hospitalizations.6 These gains remain 3 years after the beginning of treatment.6,7
Although the results are positive for long-term treatment effectiveness for BPD, difficulty in learning and implementing these psychotherapies because of their specialization and intensity renders them largely unavailable to most patients and clinicians.8 The difficulty in providing or referring patients to effective care is therefore a major factor in treatment resistance and challenges to treating BPD.
A recent meta-analysis of evidence-based psychotherapies for BPD suggests that structure and focus on BPD-related problems such as self-harm and suicidality, rather than intensity, determine outcomes.9 The small-to-medium effect sizes related to the efficacy of evidence-based therapies disappear in studies where the control treatment is structured. Intensity (ie, duration and exposure) did not appear to influence outcomes. This meta-analysis did not show significant differences between DBT and psychodynamic approaches (which included MBT and TFP). It also reported that cognitive behavioral therapy performed no better than control conditions, which indicates that structured treatment alone is not sufficient; the treatment needs to focus on BPD. These findings suggest that evidenced-based treatments might be simplified and still retain effectiveness by maintaining structure and specificity for BPD patients.
The findings from 2 large outpatient trials of DBT and MBT support the idea that less intensive but structured, informed, and systematic care of BPD patients can be effective. General Psychiatric Management (GPM)10 and Structured Clinical Management11 were compared with outpatient DBT and MBT, respectively. Both specialized and generalist approaches yielded similar decreases in suicidality and non-suicidal self-injury and improvements in interpersonal functioning and quality of life.6,7 While further research is needed, these findings suggest that treatment resistance can be overcome with informed and structured care. We propose the following strategies.
Diagnosis and psychoeducation
Good care for BPD begins with a diagnosis. Many clinicians avoid telling patients, particularly adolescents, that they have a personality disorder. But the BPD diagnosis can be made reliably before the age of 18, and early intervention is needed for better outcomes.12 When the diagnosis is made objectively and optimistically, patients typically feel less alienated and alone, as well as more hopeful. Sitting down with a patient to review the diagnostic criteria for BPD is an opportunity for clinicians and patients to think together about how each criterion can be applied to challenges the patient faces.
It is important to inform patients that social and vocational recovery is more difficult to achieve than symptom remission alone. These challenges and their course of treatment can be delivered in a clinical management approach that is not primarily psychotherapeutic. An essential part of this is to explain that difficulties in the clinical relationship are to be expected. This allows both patient and clinician to manage these disruptions, rather than react in overly personalized or pejorative ways.
The clarification of treatment goals and expectations, as well as predictions about therapeutic challenges, functions primarily to educate the patient. Psychoeducation alone can reduce symptoms of interpersonal instability and impulsivity.13 With a shared understanding of how interpersonal and emotional sensitivities connect to self-destructive tendencies (ie, self-harm or suicide attempts), the patient and clinician can communicate and collaborate around symptom management in a consistent way.
Management of suicidality and self-harm
Evidence-based treatments for BPD stabilize high-intensity interchanges between self-destructive patients and their clinicians by providing an established framework for managing self-destructive behaviors. Good clinical management of any psychiatric diagnosis guides mental health professionals to establish a plan that patients can use when they have urges to hurt themselves at the beginning of treatment. When self-destructive problems arise, patients then have resources mapped out so that independent management can increasingly replace reflexive reliance on hospitalization or paging. According to GPM, clinicians can actively evaluate suicide risk by weighing risk factors (eg, prior attempts, access to means, dangerousness of plans, assessment of intent, substance use, and depression) against protective factors (eg, social supports, capacity to use skills and entertain alternatives). After these episodes, clinicians and patients can analyze what is working in the safety plan and what needs modification.
Chain analyses, reviews of the various events and internal reactions leading to self-destructive urges, are used in many evidence-based treatments for BPD.8 The chain analysis helps clinicians and patients to better understand what has happened and revise safety plans accordingly. With a shared system of managing safety and a shared expectation that reducing suicidality and self-harm is a focus of treatment, more treatment collaboration rather than resistance occurs.
Management of comorbidities
BPD rarely presents without major comorbidity. Most patients with BPD also suffer from depression and anxiety disorders, and many have problems with substance use, eating, and other personality disorders. However, useful and scientifically informed guidelines for prioritizing focus on BPD over other comorbidities are provided in GPM (Figure 2).10 These guidelines encourage clinicians to prioritize BPD over its most common comorbidities of depression, panic disorder, generalized anxiety, and other personality disorders, because these comorbidities are less likely to remit if BPD symptoms do not improve. Moreover, randomized controlled trials of existing evidence-based treatments for BPD report concomitant reductions in depression and anxiety during and after treatment.6
Other comorbidities, such as substance dependence, anorexia, and mania, must be prioritized over BPD treatments, because these disorders interfere with the learning required in BPD treatment. New evidence indicates that BPD and PTSD can be treated effectively at the same time. PTSD symptoms may even improve with the treatment of BPD alone.14
These empirically informed guidelines mitigate the chaos and reactivity that challenge clinicians in their management of multiple comorbidities by providing an organizational framework. Improving BPD by enhancing coping and interpersonal functioning is likely to increase self-regulation and the sustainability of supportive relationships, while decreasing stressors. Informed management of comorbidities with BPD can reduce treatment resistance, with a focus on a central and treatable source of vulnerability and dysfunction.
Conservative prescribing of pharmacological and somatic therapies
No medication is FDA-approved for the treatment of BPD. Few randomized controlled trials have tested pharmacological treatments for BPD, and their results are inconclusive. European guidelines from the National Institute for Clinical Excellence state that existing evidence is insufficient to support any prescribing of medications, except for the treatment of diagnosable comorbidities. American Psychiatric Association guidelines, informed by meta-analysis of the small number of existing pharmacology studies, advocate for judicious use of mood stabilizers and antipsychotics for BPD symptoms related to affective instability, impulsivity, and cognitive perceptual symptoms.
Antidepressants show minimal benefit in the treatment of core BPD features. Similarly, BPD patients respond to ECT inconsistently, with lower degrees of antidepressant response and higher rates of relapse compared with patients without personality pathology.15 These psychopharmacological and somatic therapies for BPD patients should be used judiciously to target the symptoms of true comorbidities, rather than features of BPD. Conservative prescribing can reduce the burden of polypharmacy and exposure to an increasing number of treatments that are unlikely to achieve the desired results.
Treatment resistance reconsidered
The concept of treatment resistance deserves reconsideration, especially in the case of BPD. While the treatment of BPD is challenging and potentially complex, the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms. Furthermore, exposure to adequate care is not the norm, since intensive evidence-based treatments for BPD are not easily learned or implemented. Structured generalist approaches, such as GPM, offer tips such as psychoeducation, systematic and informed management of self-destructive tendencies and comorbidities, and conservative use of pharmacological and somatic treatments. BPD may render comorbid disorders less responsive to therapy, but this may be an argument that treating BPD helps stabilize the expectable challenges and thereby reduces treatment resistance overall.
Dr. Choi-Kain is Director, Adult Borderline Center and Training Institute and McLean Gunderson Residence at McLean Hospital in Belmont, MA, as well as Assistant Professor of Psychiatry at Harvard Medical School in Boston; Mr. Glasserman and Ms. Finch are research assistants, McLean Hospital, Harvard Medical School.
The authors report no conflicts of interest concerning the subject matter of this article.
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