I Hate You—Don't Leave Me (26 page)

Practitioners from Chile, recognizing the difficulty of providing intensive individual care for borderline patients, developed a group therapy system, Intermittent-Continuous Eclectic Therapy (ICE).
¹⁶
Weekly ninety-minute group therapy sessions are conducted in ten-session cycles. Patients may continue with further rounds, as they and their therapists choose. A psychodynamic viewpoint guides understanding of the patient, but interpretations are minimized. The first part of each session is an open, supportive period in which unstructured discussion is encouraged; the second half is arranged like a classroom, in which skills are taught to handle difficult emotions (as in DBT and STEPPS).

All of these “alphabet-soup” treatment designs endeavor to standardize the therapy, most utilizing manual-based programs, and have attempted to develop controlled studies to determine efficacy. All have evolved studies demonstrating the superiority of the formalized therapy over a comparative, nonspecific, supportive “treatment as usual.” Some research has studied comparative results among these treatments.

One study compared the results of yearlong outpatient treatments for borderline patients with three different approaches: DBT, TFP, and a psychodynamic supportive therapy.
¹⁷
Patients in all three groups demonstrated improvement in depression, anxiety, social interactions, and general functioning. Both DBT and TFP showed significant reduction in suicidal thinking. TFP and supportive therapy did better in reducing anger and impulsivity. TFP performed best in reducing irritability and verbal and physical assault.

A three-year Dutch study compared results of treating borderline patients with SFT versus TFP.
¹⁸
After the first year, both treatment groups experienced comparable significant reductions in BPD symptoms and improvement in quality of life. By the third year, however, SFT patients exhibited significantly greater improvement and had fewer dropouts. A later study from the Netherlands compared cost-effectiveness of these two psychotherapy designs.
¹⁹
This investigation attempted to measure cost of treatment with improvement in quality of life over time (determined by a self-administered questionnaire). Although quality of life measures after TFP were slightly higher than after SFT, the overall cost for comparable improvement was significantly more efficient with SFT.

Although these studies are admirable attempts to compare different treatments, all can be criticized. Patient and therapist selection, validity of measures used, and the plethora of uncontrolled variables that impact on any scientific study make attempts to compare human behavioral responses very difficult. Continued studies on larger populations will illuminate therapeutic approaches that will be beneficial for many patients in aggregate. But given the complex variations rooted in our DNA, which make one person so different from another, unveiling the “best” treatment that will be ideal for every individual is surely impossible. The treatment that demonstrates superiority in a majority of patients in a study may not be the ideal choice for
you
. This is no less true in the area of medications, where we find one size does
not
fit all.

Thus, the primary point to be gleaned from these studies is not which treatment works best, but that psychotherapeutic treatment
does
work! Unfortunately, psychotherapy has been figuratively and literally devalued over the years. Psychological services, in general, are reimbursed at a remarkably lower rate than medical services. Insurance payment to a clinician for an hour of noninterventional interaction with a patient (diet and behavioral adjustments to diabetes, instruction on caring for a healing wound, or psychotherapy) is a fraction of the payment for a routine medical procedure (minor surgical intervention, steroid injection, etc.). For one hour of psychotherapy, Medicare and most private insurance companies pay less than one-tenth of the reimbursement rate directed for many minor outpatient surgical procedures.

As the United States continues its quest to provide health care to more people in more affordable ways, there will be temptations to mandate treatments that are shown to be grossly equivalent, but less expensive. It will be important to maintain flexibility in such a system, so that we do not denigrate the
art
of medicine, which allows individuality in the sacred relationship between doctor and patient.

In the future, advances in genetic and biological research may suggest how therapies can be “individualized” for specific patients. Just as no single medicine is recognized as better than the others in treating
all
BPD patients, no single therapeutic approach can be better for all, despite attempts to compare approaches. Therapists should direct specific therapy approaches to different patient needs, rather than try to apply the fictional
best
approach to everyone. For example, borderline patients who are significantly suicidal or engaged in serious self-mutilating behaviors may initially respond best to cognitive/behavioral approaches, such as DBT. Higher functioning patients may respond better to psychodynamic protocols. Financial or scheduling limitations may favor time-limited therapies, whereas repeated destructive life patterns might dictate a need for longer-term, more intensive protocols.

Just as most medical specialties (e.g., ophthalmology) have developed subspecialty areas for complicated situations or for the parts of the organ involved (e.g., retina, cornea), optimal treatment of BPD may be heading in the same direction. Specialized centers of care for BPD, for example, featuring experienced, specially trained professionals could offer more efficient treatment regimens.

Medications: The Science and the Promise

One pill makes you larger, and one pill makes you small ...

—From “White Rabbit,” by Jefferson Airplane

Doctors are men who prescribe medicines of which they know little, to cure disease of which they know less, in human beings of whom they know nothing.

—Voltaire

 

 

 

While psychotherapy is the recognized primary treatment for BPD, most treatment plans include recommendations for inclusion of drug therapy. However, medications often present highly charged dilemmas for borderline patients. Some are bewitched by the alluring promise of drugs to “cure” their “borderline.” Others fear being transformed into zombies and resist any medication. As scientists have not yet isolated the
borderlinus
virus, there is no single “antibiotic” that treats all aspects of BPD. However, medications are useful for treating associated symptoms (such as antidepressants for depression), and for taming self-defeating characteristics, such as impulsivity.

Despite Voltaire's plaint, doctors are learning more and more about how and why medications treat disease. New discoveries in the genetics and neurobiology of BPD help us understand how and why these medications can be effective.

Nature-nurture arguments about the cause of physical and mental disease have raged for decades, of course, but with the expansion of knowledge of heritability, gene mapping, and molecular genetics over the past quarter century, the role of nature has become better understood. One approach to this controversy is through the use of “twin studies”: in this type of study, identical twins (possessing the same genetic makeup) who are adopted into different households are examined years later for the presence of the disease. If one twin exhibits BPD, the likelihood that the other, reared in a different environment, will also be diagnosed with BPD is as much as 35 percent to almost 70 percent in some studies, thus giving greater weight to the nature argument.
¹
Specific borderline traits, such as anxiety, emotional lability, suicidal tendencies, impulsivity, anger, sensation-seeking, aggression, cognitive distortions, identity confusion, and relationship problems, can also be highly genetic.

Heritability also extends to family members. Relatives of borderlines exhibit significantly greater rates of mood and impulse disorders, substance abuse, and personality disorders, especially BPD and antisocial personality.
²

Our humanness emerges from the elaborate and unique chain of chromosomes that determine the individual. Although one specific gene alone does not determine our fate, a combination of DNA codings on different chromosomes do contribute to vulnerability for illness. Individual genes have been associated with Alzheimer's disease, breast cancer, and other maladies; however, other chromosomal loci and environmental factors also contribute. Molecular genetics has identified specific gene alterations (polymorphisms) that are associated with BPD. Interestingly, these genes are involved with production and metabolism of the neurotransmitters, serotonin, norepinephrine, and dopamine. These neurotransmitters facilitate communication between brain cells and influence which genes are turned on or off. Alterations in these neurotransmitters have been associated with mood disorders, impulse dysregulation, dissociation, and pain sensitivity.

Other endocrine (hormone) neurotransmitters have been implicated in borderline pathology. NMDA (N-methyl-D-aspartate) dysregulation has been noted in BPD (as well as in some other illnesses) and implicated with dissociation, psychotic episodes, and impaired cognition.
³
Disruptions in the body's opioid (endorphin) system has been demonstrated in BPD and associated with dissociative experiences, pain insensitivity (particularly among self-mutilating individuals), and opiate abuse.
⁴
Acetylcholine is another neurotransmitter affecting memory, attention, learning, mood, aggression, and sexual behavior, which has been linked to BPD.
⁵

Chronic or repeated stress can also disrupt the neuroendocrine balance. Stress activates the hypothalamic-pitiutary-adrenal (HPA) axis, which secretes cortisol and activates the body's immune system. In the usual acute stress situation, this system activates the “fight-flight” mechanisms of the body in a productive way. An internal feedback mechanism acts like a thermostat to then turn down the axis and return the body to equilibrium. However, ongoing stress dismantles the regenerative circuit and the stress alarms continue unabated, inflicting negative impact on the body, including shrinkage in characteristic areas of the brain. This pattern has been observed in several disorders, including BPD, PTSD, major depression, and certain anxiety disorders.

Disturbances in brain function have been frequently associated with BPD. A significant subset of borderline patients have experienced a history of head trauma, encephalitis, epilepsy, learning disability, EEG (electroencephalogram, or brain wave) abnormalities, sleep pattern dysfunction, and abnormal, subtle neurologic “soft signs.”
^6
,
7

Sophisticated brain imaging—such as fMRI (functional magnetic resonance imaging), CT (computerized tomography), PET (positron emission tomography), and SPECT (single photon emission computed tomography)—has elucidated some of the anatomical and physiological deviations associated with BPD. As already noted (see chapter 3), these studies seem to imply overactivity of those parts of the brain involved with emotional response (the limbic system), which includes such deep brain structures as the amygdala, hippocampus, and cingulate gyrus, while demonstrating underactivity of the outer parts of the brain involved with executive thinking and control, such as the prefrontal cortex.
⁸

With these advances in genetics and neurobiology, scientists will eventually be able to subtype more discretely different presentations of pathology, and, based on this knowledge, doctors may be able to more precisely “customize” a particular drug to a particular patient. To use an analogy: Our current understanding of psychiatric illnesses is roughly similar to our understanding of infections in the early and mid-1900s, before doctors could adequately culture the infecting agent. At that time, it was generally acknowledged that all antibiotics were equally beneficial—penicillin was just as effective, among all patients with infections, as any other antibiotic. However, when scientists discovered how to culture individual strains of bacteria and establish their sensitivities to particular antibiotics, doctors could prescribe a specific drug with the greatest likelihood of success. In other words, doctors were not simply treating infection or pneumonia; they were treating the specific strain,
staphylococcus aureus
. Similarly, in the future, the hope is that we will be able to “culture” the psychiatric illness and determine the best treatment. We will be treating the individual's unique biology, not simply the diagnosis. As a result, the concept of “off-label” (in which a medicine is prescribed for a condition not formally approved—see page 200) will become moot, since the medicine will be directed toward a specific biological process, rather than a particular diagnosis.

Discoveries in the exploding fields of genetics and brain physiology have led to new drugs for many physical and mental conditions. Great advances have been achieved in pharmacology, especially in the area of biotechnology; in short, numerous psychotherapeutic drugs have been developed in the last twenty years, and the evidence suggests that some have proved effective in treating BPD. Although no medication is targeted specifically for BPD, research has demonstrated that three primary classes of medicines—antidepressants, mood stabilizers, and neuroleptics (antipsychotics)—ameliorate many of the maladaptive behaviors associated with the disorder.
⁹