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Good afternoon, everyone. I'm Dr. David Stifler, and on behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar in our series titled Advanced Addiction Psychotherapy. This is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with Oregon Health and Science University and New York University. I'll turn it over to you, Dr. Blazes. Hello, everybody. Thank you for your attention, and thank you to Dr. Joy Cain for joining us today. We're very grateful. So Dr. Joy Cain is currently the director of the Gunderson Personality Disorders Institute, which is an internationally recognized center for training for empirically supported treatments for borderline personality disorder and research on outcomes as well as other cognitive mechanisms targeted in these interventions. interventions. Her research training began as a postdoctoral fellow under the supervision of John Gunderson, and after three years of research training, Joy Cain developed an intensive residential treatment program, the Gunderson Residence, combining various empirical supported therapies within a milieu setting, emphasizing rehabilitation and social and occupational functioning. At the same time, she expanded and diversified McLean Hospital's adult borderline personality disorder treatment program to include mentalization-based treatment and dialectical behavioral training for PTSD training clinics as outpatient programs to both train clinicians in these approaches while also providing insurance-based cares. She's written multiple books on various applications of Gunderson's good psychiatric management, including one which is just coming out within the next couple of months and is available for pre-order on good psychiatric management for alcohol use disorder. She has also written extensively about the problems of access to care and the scalability of our armamentarium of borderline personality treatments and has published meta-analytic evaluations of the efforts of treatment as usual as well as dropout rates. So we're very grateful that she's joined us to share some of her wisdom and experience and talk about her work about good psychiatric management for borderline personality disorder and alcohol use disorder. Thank you, Dr. Joy Cain. Thank you both for the introduction and for inviting me here to this group of colleagues. I have been working on this book that we just got the proofs for on Friday on the good psychiatric management of alcohol use disorder and borderline personality disorder. And in preparing this book, I've really been kind of aware of how challenging the work you all do is working with people who are living with and trying to recover from substance use disorders. So I'm very touched and appreciative of the fact that you are interested in learning more about the management of borderline personality disorder. So I am going to share my screen, and I really do want to hear from you your questions and how to make this most relevant. So I will stop at times to answer questions to make this most high yield. So Hilary Connery, who is the clinical director of the substance use disorder division here, she works with Roger Weiss in the leadership of that division. She and I worked together to co-edit this book with a number of international collaborators. And this was inspired by the fact that we both worked in these specialty services at this tertiary care center, McLean Hospital. And we found that our teams, no matter how expert and specialized they were, struggled mightily with those individuals who came to treatment with this set of comorbidities. And it shouldn't be such a mystery or struggle to clinically manage people with this profile because it's so common. So we endeavored to try to put together some resources that most clinicians can use in most clinical settings to do better, feel more confident and competent, and provide better care. My conflicts of interest do include the fact that I received some royalties from these books. But how I'm going to start is with just a overview of borderline personality disorder. I'm going to be a little bit lighter in my coverage of alcohol use disorder because I think you all are very savvy in that area. But to start with, as we were discussing before we started the webinar, the status of BPD has really improved in the last two to three decades of work that a number of researchers and treatment developers have committed to, to transform attitudes towards the diagnosis so that people have more hopefulness that it's not only identifiable, but also treatable with a positive prognosis. This is important because these people who have the diagnosis of BPD make up a large proportion of patients in any clinical setting. In psychiatric settings, both inpatient and outpatient settings, statistics show that about a fifth of all mental health clinics involve patients who meet diagnostic criteria for BPD, even though BPD only comprises about 2% of the general population. Of course, everybody knows there's a tremendous amount of stigma, controversy, and sometimes conflict over whether or not to diagnose this disorder. The old debates had to do with whether or not it was BPD or trauma, BPD or mood disorders, or a number of different diagnostic entities. But nowadays, there's more confusion over the categorical and dimensional approaches, and I'll touch on that briefly. While we've developed treatments that really do work for people who have borderline personality disorder, these treatments are intensive and complex. And like the development of other treatments for other diagnoses, there's a no-to-do gap. That is that we've endeavored to study all these treatments that can't be translated into the real world because they require too much training and clinical resource time that is basically unsustainable in most clinical environments. And lastly, when you're working with these patients, a great deal of personal involvement is required, and some of the developments in the way that mental health care is administrated in this day and age really make that more difficult for all of us, regardless of the patient's clinical profile. And what I'll talk a lot more about is that some of the hesitation to diagnose this disorder really has to do with a sense of pessimism for what clinicians can do about it, even in the presence of effective treatments, because there is such limited access to care. As I noted, these are patients who actively seek help from our profession to treat their symptoms from which they're suffering. Even in primary care clinics, those who have BPD are overrepresented. They want support and assistance, and they oftentimes try to broker caregiving relationships in a way that isn't effective and creates a lot of clinical challenges. We see that in the outpatient setting that about 10 to 20% of adults, adult patients, will meet criteria for this disorder, and that's the level of care that the treatments at work are found effective in. So it's that slice of mental health care that we can use the treatments, such as dialectical behavioral therapy, which I know you've learned about, mentalization-based treatment, transference-focused psychotherapy, that have been tested and found to be more effective than treatment as usual. But we see even more elevated rates of people with BPD in inpatient settings and emergency departments presenting with suicidal ideation, and whether it's adults or adolescents, the percentages are significant regardless of the age group. We know that BPD, patients with BPD oftentimes get worse from uninformed treatments, and this is not done negligently or with malice. Treatment of BPD is not done consistently because training is not widely available, and it takes a lot of time, energy, and finances to receive the training that is associated with some of these proven treatments. Because of the symptoms of borderline personality disorder, primarily the interpersonal instabilities, as well as the self-destructive behaviors, many professionals don't feel comfortable treating these patients, not just because of the intensity of the work, but the liability as well. And therefore, that also contributes to the shortage of supply of clinicians who will provide treatment. But in reality, because BPD is a severe disabling and sometimes fatal psychiatric disorder, people with BPD should be able to assume that professionals who treat them have been trained to do so. And you're all here because you want to be one of those professionals. These are the types of people that we see want to be one of those professionals. These treatments at work, which I've named, you're probably all familiar with. There's dialectical behavioral therapy, which I think Melanie Harned talked to you about earlier this year, which is a behavioral approach that targets emotion dysregulation through skills training and behavioral shaping. This is a revolutionary treatment that has been transdiagnostically very powerful, but it is incredibly intensive. I'll tell you when I gave the review of the second edition of the DBT manual, where the number of skills expanded from 43 to over 200, I kind of mischievously said that it was an encyclopedic resource for therapists working with patients with a variety of problems. And it truly takes a lot of effort to be able to administer this treatment. Very dedicated, skilled clinicians will use this, but it's not applicable for most clinicians in most settings. Mentalization-based treatment was developed based on attachment theory and research in the public health service in the UK. And the treatment developers, Peter Fongy and Anthony Bateman, have trialed this, not only against treatment as usual, but also a structured clinical management approach and found it more effective in reducing self-destructive behaviors more quickly, as well as symptoms of BPD. This treatment is less intensive than DBT, but nonetheless intensive in its clinical and training requirements. And similarly, transference-focused psychotherapy, also a dynamic approach, involves two weekly sessions. They're both individual. There's no group component to this approach. And it works using object relations and a transference focus using psychodynamic techniques within the interpersonal relationship of the therapy itself. Now, very few clinicians in the universe will not only learn these approaches, but then translate them into adherent work in their practices. So this cannot actually meet public health needs. GPM is the treatment approach that I think distills common features amongst these different treatment approaches into a package of once weekly or less treatment that really has less ambitious aims. It's to facilitate BPD's natural course of remission, provide corrective experiences, and increase the patient's capacity to function. And I'll tell you more about why that's important. The irony is that despite the advances of these treatments like DBT, MBT, and TFP, there are no differences between these treatments meta-analytically in terms of their effectiveness. And even more kind of humbling is the fact that despite their elegance and intensity, they have small to moderate effect sizes, as well as a kind of lack of superiority in meta-analytic analyses in terms of treatment retention. You may have heard some people say, oh, this treatment retains patients with BPD better than treatment as usual. But let's face it, treatment as usual is not a robust comparator. And if you look across trials, we don't see any superiority of the treatments of interest over comparison treatments. And lastly, treatment intensity does not seem to determine outcome. So that isn't a factor that's going to drive the effectiveness. And we have to consider this in light of the requirements. I don't know how many of you have received these trainings, but I've run all these trainings. And the cost and time required of the clinicians is truly stunning. So even though many people will be motivated to do these trainings, we have to rely on the majority of the workforce to be able to do something good enough, like the treatments at the bottom, general psychiatric management, or structured clinical management. These were approaches developed as comparators with these specialized psychotherapies in randomized control trials. Now, I'm going to argue that we need to use these generalist approaches. They are comparable in their effectiveness to DBT and MBT in some clinical trials, and I'll tell you about that. But more urgently, we need to do this because of the needs of the public's health. We did a paper here in our group that shows that there's only enough providers for the mental health care of patients with BPD seeking treatment if all clinicians accepted patients into their clinical caseloads who had this diagnosis. So in the US, if every provider accepted patients with BPD, they would have to see under 10 patients to contribute to us all meeting public health needs. A lot of countries are not as well equipped as we are. But if we rely on the certified specialists, then no country will ever meet the needs. Even in the Netherlands, which is one of the best equipped countries for specialized treatments for BPD, each therapist trained in these modalities would have to see over 600 patients per year. And the difficulty of these modalities is that they're so intensive that these clinicians can only see at maximum something like 20 to 30 patients in their caseload if they worked full time. Now, just to show you the scope of the problem, if you look at this cutout in the graph, this is the number of people seeking treatment with BPD per clinician certified in specialist evidence-based treatments by country. And in the US, there's 6,000. Unfortunately, the scale of this graph is thousands. There's 6,000 patients in the US per certified therapist. So even though we've made some progress in understanding that BPD is a treatable disorder, we haven't done very well in providing access to the effective treatments that have been developed. So we need a generalist model to meet the public health needs. And John Gunderson was really interested in this because he was really humble about what it took to treat patients with this diagnosis because he was someone who never got DBT, MBT, or TFP training. And he was able to help them just by being interested, optimistic, and knowledgeable about what's known about BPD in the clinical and scientific literature. Therefore, he was totally elated when the results of this trial came out. So I was on the APA Guidelines Revision Committee too, and in re-review of the scientific literature on treatments for BPD, it's kind of stunning that that treatment literature is extremely small, whether it has to do with psychopharmacology or psychotherapies. And with the treatments like DBT, MBT, and TFP, we've had very few trials replicate the findings of the treatment developers in the originally published trials. So Marsha Linehan published a number of positive trials on dialectical behavioral therapy, and the first large group to systematically study DBT outside of Marsha's group was Shelly McMain in Toronto, Canada. And she wanted to have a more decent comparator to DBT than treatment as usual, and so she used this comparison of general psychiatric management that was run by Paul Links. Paul Links had been a co-author or contributor to John Gunderson's clinical guide, which was, for a long time before the rise of these evidence-based treatments, a major resource in directing clinicians who were taking care of these patients. And so Paul Links led a team separately than the DBT team that Shelly led that really just focused on providing good psychiatric care, not doing any skills training, but focusing on the psychopathology of BPD and employing the good elements of psychiatric management that most psychiatric professionals use. And the results were stunning. In this trial that had almost 90 people in both arms, they found that there was no statistically significant difference between GPM and DBT, even though DBT was far more intensive with one-hour individual session weekly, two-hour group therapy, two-hour consultation team for the clinicians, and out-of-session coaching around the clock. GPM in this trial only involved a single session a week, and the clinicians in this team met for 90 minutes a week just to have peer supervision. That wasn't really formatted like a consultation team. And that's probably more intensive than what most people will use in general clinical environments. And I'll talk about scaling that intensity a little bit later on. But even more exciting result from this trial is even in two years of follow-up, there were no differences between these approaches that good generalist care could be affected. You see that there's no differences in both the 12-month outcomes and the two-year outcomes in terms of BPD symptom reduction, quality of life improvement, symptom distress reduction, anger expression, depression, and interpersonal functioning. So John, who is a pretty mischievous person, he was gloating about this. And I remember when I was a postdoctoral fellow, I was sitting right in this office with him when he received a call from Marsha Linehan that where she said, hey, we found out that your treatment works as well as mine. And he did a victory lap saying, well, who needs to know Marsha Linehan when people can actually practice good psychiatric management and do a good enough job with people that they'll see in most clinical settings. Furthermore, another finding from this MCMAIN trial showed that there were factors related to dropout that are particularly relevant to the topic today and the adaptation of GPM to BPD and a common comorbidity. Unfortunately, in this trial, we saw a high rate of dropouts across conditions. About 38% of all participants dropped out, whether they were in GPM or DBT. That's a pretty high rate. And dropouts were associated with lower reliance, obviously, as well as higher Axis I comorbidity, lifetime suicide attempts, and baseline anger. But patients who had higher Axis I comorbidity that were assigned to GPM had a lower risk of dropout than in DBT. It may be because DBT has more demands in it, but it also could be that GPM is inherently psychiatric and there are components that have to do with actual psychiatric management of other disorders as well as medications. So this is what led us to really trying to adapt GPM to different clinical profiles, including its comorbidities. This is the first major one to really look at BPD and AUD, but we've also written adaptations to look at, for instance, BPD and eating disorders in adolescents. So these are in development. But why did we start with alcohol use disorder first? Simply because, first of all, it's very common. The literature shows that the rate of concurrent alcohol use disorder in individuals with BPD is almost half of all people in these scientific samples. And over lifetime, over half of all individuals with BPD will meet criteria for alcohol use disorder. And we all know clinically, you don't need a study to verify this, that there are shared risk factors for both disorders. But what I'll say also is that there's a cumulative and distinct potentiated risk when we see BPD in combination with alcohol use disorder. Both disorders involve heightened impulsivity, but even controlling for impulsivity and negative affectivity, those with BPD will have greater alcohol-related problems. We also know that in terms of negative affectivity, those who have BPD who use alcohol will have a higher variability of emotional states than those with BPD who do not use alcohol. And both disorders involves a lot of sensation-seeking behaviors that can be reckless and self-destructive. BPD may elevate the rate of consumption and maximize the rewarding positive effects of alcohol and minimize the stressful negative ones that's found in some research studies. And we also know that these two disorders are not just stress sensitivity disorders, but they're stress-generating disorders. They're externalizing disorders that also produce behavioral responses to stress that generates more stressful events. I don't think you'll be surprised to know that BPD worsens the severity in course of AUD. You probably have seen this clinically, but it will make sense. BPD predicts earlier onsets of drinking, psychological problems related to drinking, and lifetime severity of alcohol dependence. So it should be considered when you're evaluating patients who have alcohol use disorder. And BPD, as well as antisocial personality disorder, uniquely predicted a majority of alcohol-related symptoms and course variables, even when controlling for comorbidities in gender in one study. And we also know that there is a vulnerability to AUD in individuals with BPD, whether they have remitted from the disorder or not. The same rate of new onsets of AUD occurred in both remitted and non-remitted patients with BPD in a longitudinal study that was run by Mary Zanarini. And of course, AUD worsens BPD. This is not mysterious. There's more limited treatment response when these things co-occur with higher dropout rates and greater functional problems, such as unemployment and limited school achievement in those who have AUD than just BPD alone. And why this is important is that BPD is a personality disorder, and all of our personality development and stabilization occur in the context of experiences in school and work. And those major activities that start to define us and organize our relationships with others. So this slide just depicts something that I've just mentioned, that BPD traits early in life start to predict future alcohol problems, and then a greater risk for onset of AUD and relapses, even when sobriety is achieved. And that in and of itself increases or exacerbates BPD symptoms, and there creates a circular effect incrementally increasing poor prognosis and outcomes. And those with BPD may use alcohol or rely on alcohol more for coping reasons. In this study of drinking motives and differences between the impact of drinking on those with BPD versus those without BPD, these Kaufman and colleagues found that people with BPD will report that they use alcohol more for coping than those who don't have BPD, and they have higher levels of affective instability and impulsivity. Interestingly, even though they have the same level of alcohol use, number of drinks on a typical drinking day or number of drinking days, as the non-BPD group, they have far more alcohol-related problems associated with their use. And I don't have to tell this group that alcohol use escalates the risk for suicide, which is already multiply or exponentially increased for the BPD population. And alcohol use is a major modifiable risk factor across psychiatric disorders, and it can respond to treatment when it rises to the occasion of an AUD. All that considered, I don't think it's good enough to assume that you should treat one first and then another, because that's really what happens in clinical practice, and it just seems to not work. When I was running a residential program, we would try to send people to substance use treatment programs, and they would invariably have a lot of difficulty in those programs because of their BPD symptoms. And then when they would come to our program with the requirements of some periods of sobriety, we wouldn't really have the proper tools to adequately address their substance use disorders in general and their alcohol use disorders in particular. And once they left residential treatment, they tended to really be unsupported in getting treatment and resources to help them stay sober. Despite the prevalence of this set of co-occurring disorders, there are no effective treatments that have been adequately tested or implemented in the literature, which is just shocking. A lot of people know about dialectical behavioral therapy, and it's been implemented in a number of settings where substance use disorders are treated, but the trials on the efficacy of DBT in patients who have both BPD and substance use disorder is really limited. Linehan herself did a study in 1999, which only had 12 people in the DBT arm and 15 in the treatment-as-usual arm. And they found that DBT was better at increasing days abstinent than treatment-as-usual, but that was one study. And another study done by a European group in 2002 that was slightly larger did not find differences between DBT and treatment-as-usual in alcohol-related outcomes, only in BPD-related outcomes, which may still argue for its use. But lastly, Harned published a secondary analysis of a trial on self-injury, self-harm, and BPD, where DBT was compared to treatment by community experts. And DBT was associated with more alcohol-free days and full or partial remission from substance use disorder, but that trial was not expressly for a population of individuals who had this comorbidity. Schema therapy has also been adapted to the treatment of substance use disorder. And in the three trials published using that approach, there were no differences between schema therapy and treatment-as-usual, so it's not recommended. But there is one treatment that I'll talk a bit about because it's been incorporated into our approach. It's called dynamic deconstructive psychotherapy. It's an outstanding treatment that was developed by Robert Gregory at SUNY Upstate, where he runs this fantastic program for at-risk individuals who struggle with substance use disorder, suicidality, and personality disorders. And he basically combined psychodynamic theory, that is, object relations theory, with an appreciation of neurobiological considerations having to do with emotional processing problems that those with both disorders will really struggle with. So this is the only treatment in the literature that was trialed on the combination of BPD and alcohol use disorder in one study that was done with a naturalistic cohort comparison and two RCTs, but they're small RCTs. And what he found was that DDP, which is a very sophisticated but pragmatic treatment, it was delivered by residents in psychiatry. And even in the hands of early career clinicians, they found that DDP was superior to treatment-as-usual in reducing alcohol use, parasuicidal behaviors, and care utilization. In the follow-up study, though, DDP was superior to treatment-as-usual on BPD symptom reduction, but was not statistically significantly better than treatment-as-usual on alcohol use reduction. So there's still a lot more that needs to be studied in this area. So given how common AUD is in BPD, it's just totally surprising that there hasn't been more work in this area. Now, GPM has similarly not been studied in a sample that has the specific comorbidities of AUD and BPD, but what has been done has been an analysis of a 10-session variant that's employed as the entry point of treatment in a specialty personality disorder service in Switzerland. And what this team did, headed by Uli Kramer and Stefan Kali, is that they had an analysis comparing those who had BPD to those who had BPD and a substance use disorder in terms of their response to this 10-session GPM. And they found that actually, contrary to expectations, the people who had BPD and SUD did not do worse in terms of their general outcomes. Both groups had a reduction in general symptoms, in BPD symptoms, and an increase in therapeutic alliance, but surprisingly, the last two findings were even more amplified in the BPD and SUD group. So brief good psychiatric management for BPD focused only on BPD seems to be effective for improvement for BPD, independent of whether or not there is a substance use disorder. Of course, that's not compelling enough evidence, and this is an approach that needs to be studied, but we're at the first step of manualization, and hopefully that will be studied after this book is published. So there are some myths about the treatment of BPD and AUD, some of which I've mentioned, that I'll just review here. A lot of people think that BPD can only be treated by DBT or something like it, and that's actually not true. It's only true for subsample. Coherent treatment delivered by interested and informed clinicians work. And in that DBT GPM trial with Shelley McMain and Paul Links, one of the critical design factors was that GPM was delivered by people who liked treating patients with BPD and knew something about it. And that was sufficient to have results that were comparable to a much more intensive, sophisticated treatment. There's also the myth that these treatments should be done sequentially. Oftentimes we punt it in the BPD world to the substance use disorder world, and say you need to get treatment for your alcohol use disorder first. That can be very challenging to the treatment in the AUD programs, and rarely does that kind of really go smoothly without some challenges in the long run. There's also, on the other side, that BPD can be treated primarily without a focus on AUD. And this was one very hard lesson I had to learn through experience, is that I've treated a lot of patients or supervised a lot of care of patients with BPD who have really made huge strides in their recovery. But invariably, AUD was one of the major factors that kept patients ill or destabilized at times. And it was the number one factor that promoted the risk of death by suicide. There's also a myth that there are those with BPD who can drink responsibly. The idea that these individuals do not need alcohol use monitoring, but the monitoring of drinking should be routine in the care of those who have BPD. Because people with BPD are more likely to develop this disorder in their lifetime, even when they improve in terms of their BPD symptoms. Like I said, the rate of new onsets in remitted patients with BPD is equivalent or comparable to the rate of new onsets in non-remitted individuals. And some people think that the suicidality and self-harm in BPD should be treated before AUD and obviously I don't need to tell you the treatment of alcohol use disorders and problems is critical for reducing risk of self-injury and suicide. So this handbook is now in press. We've worked together with a huge team. You can probably tell I caught people off guard with taking this picture, but this is our international team of experts on both sides of the diagnostic fence that included substance use disorder experts such as Robert Gregory, Rocco Iannucci here at McLean, Hillary Connery, Jeff DeVito, with a number of my colleagues who have been instrumental in advancing the cause of GPM. And I thank them for their contributions to this work. So I'm just gonna go over a brief overview and then I'm gonna take some questions. So what does GPM-AUD involve? These are the 10 chapters that are now in the book. We go over some basic facts about the prevalence, prognosis course and existing treatments for GPM-AUD. You've already gotten a preview in this first extended lecture I've ever given on this book and its contents. Then we go over some core principles that kind of organize the treatment approach. The common factor of the treatments that work for BPD is that they have a coherent formulation of how BPD works, what drives its symptoms. And in GPM, the idea is that interpersonal hypersensitivity drives the symptoms of BPD and you can clinically manage or predict the symptoms based on what happens in someone's interpersonal world. Then there's a chapter written by Robert Gregory and myself on DDP's integration with GPM and then a chapter on making the diagnosis and psychoeducation. There is a chapter on setting the framework or getting started with these kinds, the GPM-AUD approach, as well as one on managing suicidality and self-harm in this population. There's a great chapter on pharmacotherapy that mostly has to do with the treatment of alcohol use disorder, because there are no medications that are FDA approved for BPD or found reliably effective for the disorder. And then the eighth chapter is on using multiple modalities of treatment in the community to expand the support system of individuals with these disorders. Similarly, there's a chapter on levels of care, as well as a summary chapter by Hilary Connery and myself on pragmatically putting it all together in real world settings. So I'm gonna take a little bit of a break to see if there's any questions, and then we will finish up. We did have one in the study mentioned on DBT versus GPM. The question was curious, how many psychiatrists who had expertise in BPD for the GPM arm had training in DBT? She said, it seems like it's hard to be a quote expert without at least having read some of Linehan. That's a really good question. I do not know, that's not published in the actual study results. I think Paul Links has been trained in DBT, but there were adherence scales used and one of the specific charges of the GPM group was to not do DBT. So the big difference was they did know skills training, they didn't allude to skills. There was a focus on both safety and emotion processing, but without the use of behavioral techniques or skills. It really mostly had to do with components of good psychiatric management, like assessment, managing the alliance, reviewing symptoms, following up after a suicide attempt or hospitalization. GPM is much more task oriented than explicitly technique or intervention focused in terms of like the various sorts of DBT interventions. So whether or not that kind of affected the efficacy of that arm or not is unknown. But what I will say is that recently when I was in Australia, I have a colleague from the Netherlands who's a leader in the center of excellence for the treatment of personality disorders, who did a review of the adherence level in these various trials. And actually, even though Shelly McMahon is one of the foremost experts in DBT and the clinicians in her program are known to be very adherent and skilled in DBT, their adherence rate was not actually very high. Achieving high adherence to any of these treatments is very difficult. Okay, so no other questions? Chris, you're muted. Able to allow people to ask their own questions because I think that might be a good thing. Yeah, Samara, I'm gonna allow you to speak if you're still there. It looks like you can ask your question about treatment. And if you're there, you'll have to unmute yourself. We can- Yeah, we can, let's go on to the next one. Maybe she'll be back. Dr. Sharif, I'm gonna unmute you so you can ask your question. Trying to find you. Oh, there you go. Hello. Hi. Hi, I have a question regarding, you said that BPD, the component of AUD is prevalent, whether in the future or present, but what about the treatment of ADHD? Is it still prevalent? And if so, how do we deal with that? In the future or present, but what about other drugs of abuse like cocaine, heroin, and other like ecstasy or anything? Are there any anecdotal or real evidence that they do tend to go into future BPD patients? There is an elevation of BPD diagnosis amongst those populations and vice versa. The reason we focus on AUD is that AUD is even more common than any specific other drug use disorder. So because that one is so kind of clearly treatable and so common, we decided to focus on that alone because there's just much more written on it. But in the chapter written by Hilary Connery at the end about putting this all together in the real world, she does talk about things like cannabis use disorder and cigarette smoking and prescription drug management. So we don't really delve into those things because there's so much material we had to cover just on the management of AUD, which we think the widest population of mental health professionals can actually employ. So stay tuned, we'll have to tackle those issues at some other point in time. Thank you for answering that. You're welcome, good question. Well, shall I go back? Because I think I have enough material to kind of answer the question about what to do about treatment. Okay. So in the interest of time, I'm gonna skim this part about making the diagnosis and doing some psychoeducation because I don't think I need to tell this group about how to assess for alcohol use disorder. But I have to say, as someone who doesn't work in the area of alcohol use disorder treatment as my specialization, I learned a lot from this process. And I think patients really need to have a conversation about how much alcohol they're using, whether or not they have an alcohol use disorder. Because even the concept of how much constitutes a drink is surprising to a lot of people, myself included. And what constitutes heavy alcohol use and binge drinking is important for patients to know. Because when you ask them about that, they may not have the same idea of how much alcohol consumption will qualify for those kind of descriptions. And what we advise for making the diagnosis for both disorders is that we want you to do this to organize care for the treatment of patients who can have very chaotic courses of not only symptoms, but treatment and engagement. And it will provide some expectations about how treatment will unfold, as well as the patient's expectations about the utility of medications and psychosocial interventions. A lot of people want to not pathologize patients, but we are in healthcare. And the medicalization of treatment that is actually routine in the treatment of substance use disorders actually helps to reduce stigma for BPD as well. Because it's not an option between labeling something or not. It's the option between providing an objective clinically useful label or handle or concept around a very difficult experiences or a moralistic judgment about a person's character or their worth as a person. Because a lot of people with BPD, instead of knowing they have BPD, they'll just think they're broken beyond repair or they're a horrible spouse, mother, sister, whatever. So it can actually reduce stigma and instill some sort of hopeful focus for what they can do to make for change. The BPD itself also helps people manage their countertransference as clinicians. And most importantly, it helps patients make sense of their experience, whether it uses a disease model of addiction or the interpersonal stress sensitivity model of BPD, which I'll share with you. So I don't need to tell you the symptoms of alcohol use disorder. You can find them in the DSM. But what I will say is you want to continue to engage in motivation using motivational interviewing, which is, as you know, one of the best validated and most widely disseminated psychosocial interventions for AUD. And when we prepared this book, I was starting to think actually motivational interviewing is completely underutilized for people who have BPD. It addresses things that are common to both disorders, ambivalence about change, splitting black and white thinking that is, and problems in stability of having agency or feeling in control of one's life. So I think we in the BPD world need to do that more. You're probably also familiar with the diagnostic criteria of BPD. That's cut up in four sectors as well. There are the interpersonal features that are the most distinguishing. There are the impulsive self-damaging features that are the most common ones to bring people into clinical attention, but the most likely to remit earlier. And then there's the affective symptoms that have the highest negative predictive value, meaning that in the absence of mood instability, the likelihood that someone does have BPD is going to be low. And in network analyses of BPD, the three central nodes are interpersonal features, affective dysregulation, and problems with identity. Now, another way to cut this to bring in the neurocognitive part of this is that we conceptualize at the core of borderline personality disorder, both interpersonal hypersensitivity as demonstrated through the unstable relationships and frantic efforts to avoid abandonment combined with emotional dysregulation that DBT centralizes in the treatment of BPD. Now, both, regardless of what comes first, chicken or the egg, they interact and create states of high arousal. And under high arousal, there's impaired cognitive control and emotional psychological processing. This in part gives rise to both impulsivity and disinhibited reckless behavior without an appreciation of realistic consequences, as well as cognitive dysfunction and dysregulation as we see in the symptoms of paranoia and dissociation, especially under stress. And with all these areas of instability and dysfunction, people are going to have a more negative, confused, contradictory, and unstable sense of self, that is identity. We all use our identities to stabilize, organize, and make more predictable our decision-making and our behavioral repertoire. So when we have identity instability or diffusion, that makes it not only hard to be self-directed and cope effectively, but it also makes it very hard to relate to others and for others to relate to us. So this is a very characteristically destabilizing disorder that people really have a lot of painful suffering from. So making a diagnosis puts some clarity on the experience and in the absence of being able to make a coherent narrative about what one's problems are, making a diagnosis starts to scaffold individuals' understanding of their problems so that they can do something about it. We know that people with BPD who are told about their diagnosis are equally as satisfied with their psychiatric evaluations as those who receive other psychiatric diagnoses. And these conversations about BPD generally bring relief and are accepted by patients, even by adolescents. The problem is oftentimes diagnosis is delayed and we see patients receive their diagnosis 15 years after they started to have symptoms. And that actually leaves them neglected in getting the care they need for the formative years of their life from adolescence into young adulthood. So once you make the diagnosis, all you need to do, and you can do this in the emergency room and inpatient settings, in any general mental healthcare setting, you can make the diagnosis, even with meeting the patient once, if they meet diagnostic criteria and go over the symptoms so that they can personalize it. When you go over the DSM, just ask them, do they have examples? And it helps them start to understand themselves and their problems in terms of something that they have that's treatable rather than something that they are. It also teaches them that they're not alone. A lot of people have these problems and they can get better because the naturalistic course predicts high rates of remission. And we also tell them about the biological basis that it has a high degree of heritability, higher than depression. It's around 40 to 60%, meaning that there are biological or genetic factors that contribute. So it's not their fault, and nor is it their parents. So it kind of de-stigmatizes the disorder. In terms of the naturalistic course, two major longitudinal studies done here in the US, both at McLean and in other academic centers, such as Yale, Columbia, and Brown, found that about 80% of all people who meet criteria for BPD at baseline, either in outpatient or inpatient clinics, will achieve remission. And that the rate of relapse is actually pretty low. It's around 20%. But the problem is the functional improvement, despite remission, is not very robust. So this is the CLIP study of improvement in functioning according to GAF scores over 10 years time. And despite the 80% remission, we see the GAF scores remain pretty low for BPD and lower than the functional scores of other personality disorders in major depression. And why this is, is multifold. But one consideration that I think has to do with this whole idea of dimensionalization is that BPD may represent some general or core dysfunction amongst all the personality disorders. In a factor analytics study that used a bifactor approach, Carla Sharp and her colleagues found that if you look at all the personality disorders and you look at their loading on either a general factor or specific factors related to each diagnosis, all of the BPD symptoms mapped onto the general factor. And the interpretation of this is that BPD represents the core structure of a personality disorder, that is problems of managing oneself and problems of managing relationships. And it also may be a severity index that when other personality disorders become disabling or dysfunctional enough, they rise to the occasion of meeting the BPD symptoms as well. And this is a factor that predicts risk for psychiatric complexity and chronicity because it's a reflection of low resilience. If you're unstable in your relational functioning, your emotional regulation, your behavioral control and your cognitive functions, such as identity and paranoia dissociation, then you are going to have low resilience and poor functioning over time. So the model that we use that ties this together in terms of BPD and its related disorders is this interpersonal hypersensitivity model, which I've expanded to be a little bit more transdiagnostic to be a stress and interpersonal hypersensitivity model. And it goes a little bit like this. John Gunderson wrote in 1996 that borderline personality disorder is characterized by an intolerance of aloneness. People with this disorder have frantic efforts to avoid abandonment and unstable relationships because they have insecurity and low confidence in managing on their own. So they over invest in and are overly preoccupied in mutually exclusive relationships on which they put a lot of pressure to derive direction, a sense of value and a sense of security. So when they're connected, they're still stress sensitive and vulnerable, but they're more active and secure in their efforts to cope and engage with others. It's almost like that safe zone in the polyvagal kind of model of trauma that people who have BPD, when they feel like they have someone there for them that cares for them, they can be relatively well constituted, but they remain dependent, insecure and hypervigilant to any stress or threat to their connection to others. So any real or perceived threat to them, their relationship and their sense of value or their ideal sense of self that's oftentimes influenced by the availability of others, that can actually elicit a threatened state. And when people are in this threatened state because they didn't get what they wanted, they expected some idealized situation like someone would never leave them or always be perfectly caretaking or perfectly understanding. When that kind of idealized notion of the relationship is threatened, they go into a fight or flight response, which may take the form of self-harm or angry devaluation. And these fight or flight responses are self-regulatory, but ineffective. And they typically actually elicit confusion, anger, irritation or anxiety in others, which can elicit their withdrawal. So the very thing that these individuals fear that is abandonment will be precipitated by their stress reaction. Then when they're left alone, they feel untethered, uncontained and unanchored from reality in terms of appreciation of consequences that is in the form of reckless impulsivity or in a realistic appraisal of the intention of others such as in paranoia. And lastly, they may be disconnected from a realistic experiencing of themselves in the form of dissociation. And when they feel this uncontained, they may enter a more dangerously unreachable state of despair and suicidality. And this is when they're more at risk for more serious action that could be seriously injurious or fatal. It's at this phase that oftentimes the signal goes up for unilateral interventions that reduces the agency and involvement of the individual with BPD and other people rescue, confront, or contain, actually in many ways, including hospitalization and even jail, that may reconstitute social contact and bring them up to one of these upper states that actually are more workable. The problem is neurocognitive capacity fluctuates in these states. So when someone's feeling more connected or even more threatened, they're more able to process information than when they're alone or just sparing. So the ability to process information from the external world and understand the context of what's going on and what decisions need to be made in the face of problems is going to diminish as the person becomes more disconnected. And alcohol, of course, can interact with escalating the rate of fluctuation from the top to bottom and can interact with these states in neurocognitive processing. And the evaluation of how drinking alcohol or consuming alcohol affects this interpersonal hypersensitivity process is something that you can employ in your meetings with your patients. Now, lastly, a sense of agency and self-esteem will also fluctuate in these states. When somebody with BPD is connected to someone else who's important, they will have more of an ability to do things about their problem and self-esteem, but that's their very vulnerability. They can't be self-reliant without the dependency, the idealized dependencies in their life. But in GPM, we want to actually teach patients that self-reliance is the antidote to interpersonal hypersensitivity. If you're that reactive and sensitive to the availability of others, learning how to sometimes manage on yourself and take care of yourself is going to actually promote a sense of control and enrich or stabilize your relationships. So clinically, we're actually teaching people to lean in in these upper two states where patients can be more collaborative, have better neurocognitive processing, even though it gets shaky in the threatened state, and also have more agency. But we too often wait until they descend into these lower two states and intervene unilaterally, only reinforcing the dependencies they have on others. So what does it mean to lean in on these top two states? It means that you're really trying to understand that when someone feels threatened, you have to actually be more interpersonally available. Help them think first to help them with their flipped lid of not having cognitive control to thinking more clearly in just scanning the environment and understanding what's going on. What are the people, places, and things? What happened in your relationship that caused you to get in a fight or caused you to self-harm? Then you can make a number of basic psychotherapeutic maneuvers, just helping them sequence events, tell you what happened, attribute meaning, and also gain perspective. These are three maneuvers in deconstructive dynamic psychotherapy that are just common procedure in many psychotherapies, whether it's behavioral or psychodynamic. You also want to work out disagreements and misunderstandings that also contributes to ability to change perspectives and gain some more flexibility in thinking. Also, integrate splits by helping people understand the limitations in idealized versions of themselves and others, that people have a lot to offer and have their good sides, but also that is combined with limitations, vulnerabilities, and disappointments. This is where you try to detoxify the sense of threat into something more usual, like a disappointment or a disillusionment in the belief in something. This is where, when you have a more integrated appreciation of the good and bad in things, you can explore ambivalence using things like motivational interviewing, define boundaries around oneself and others, and consider self-reliance and good self-care as an antidote to the hypersensitivity to others. Lastly, this simple model helps you manage relational dynamics and counter-transference. It's in leaning in that you listen non-defensively, try to understand what the patient wishes and wants, and their disappointments and what they got, so that you can reframe their sense of threat or badness into something that's a disappointment, that is part of reality. You sidestep the tendencies or the temptations to become either over-involved as an idealized caregiver in the upper state of connectedness, or punitive and rejecting in the threatened state. On top of this very simple formulation, there are some key principles of GPM that are very simple, that you probably already use in your work. We don't want to reinvent the wheel with these kind of fancy terms and procedures that take a lot of training and supervision to employ. We simply say that we want to be active, responsive and curious, not reactive to people who have BPD. Set a treatment contract, outline roles and goals, and then work on them collaboratively. You want to support by listening, showing interest and providing selective validation. This can get very hard with patients with both disorders. And you want to not make the therapy itself so precious because of the tendency to idealize others. You want to decrease your expertise and increase their sense of agency. And you do that by focusing on their life without you outside of treatment and their capacity to do independent work as a kind of stabilizing factor that may help their relationships, their important relationships be more survivable. You want to use a professional, predictable approach to care where you're adhering to standards and protocols, but be real, honest, candid, take risks so that you can share what you're observing with the patient that may feel scary to disclose in the face of their volatility. Actually talking about things can be really containing. As we said, we emphasize agency and accountability, especially given the dependency tendencies of those with BPD. And we want to medicalize the approach to stabilize and standardize care and de-stigmatize the problem. So in this last stretch, I'm going to talk about how we've integrated some key principles from this much more specialized but pragmatic psychodynamic approach, DDP, that Robert Gregory developed. And his major concept within this treatment is that people with BPD and AUD have both emotional processing deficits that lead to a lot of its symptoms and an embedded sense of badness that drives the dysfunction and keeps a person psychiatrically stuck. So when it comes to emotional processing, what he said, and these are his slides, is that emotional processing in stable times for all of us will happen through the cerebral cortex. But for those who have BPD and AUD, they oftentimes are processed, emotions are oftentimes processed by the subcortical system. So what does that mean? It means that the centers of the brain in the amygdala and ventral striatum that are related to panic responses, fight or flight, and seeking responses are going to express that negative emotion rather than being processed and evaluated and reappraised through the cortical regions of the brain. So that panic, arousal, and irritability, as well as separation distress are the things they get that are manifested when someone's having high emotional arousal. And this actually also promotes the kind of involvement of the ventral striatum, which mediates seeking or impulsive pleasure-related behaviors, as well as dependent attachment. So this culminates in something that we also see, which is overgeneralized, nonspecific memories. You hear a lot of patients with these disorders talk in overgeneralized terms that actually don't get you anywhere in the psychotherapeutic process, and simplistic polarized schemas. All the treatments that work for BPD target these processes in trying to get people to be far more specific use of chain analyses and be more dialectical or integrated or have more perspective in their thinking. So what you'll see when there's cortical underactivation and emotional processing is that there are problems in verbal representation of experience, that is problems of autobiographical or episodic memory and affect labeling. And we know through the scientific literature that people who have low appreciation of affect also have interpersonal problems and identity disturbances. So the way that DDP addresses this is by helping people just practice the act of associating different events, what happened in their day-to-day experiences that led up to alcohol use or problematic BPD symptoms. There's also a problem of creating more complex, realistic, integrated understandings of what happens in a person's life that is attributing meaning. So that once a person is able to have greater associations or more stable capacity for associations, you want to move them to having some sort of meaning making on top of an understanding of what happened. And then once that's stabilized further down in the treatment, you promote perspective taking, what he calls alterity. And this perspective taking promotes the capacity to tolerate differences of opinion and promotes what he calls individual relatedness, individuated relatedness, rather than dependency or opposition. So there are some fundamental principles that Robert distilled for implementation across a number of different treatment approaches, but he's basically saying if you're just going to take these fundamental principles from DDP and incorporate them into what you do, you're going to treat patients with both disorders more effectively and more stably, with more competence and confidence. So the first of these principles, they're not going to be that foreign to you, is to use a judgment-free zone. This supports patient autonomy and openness, and we have to learn how to manage our feelings of frustration, hopelessness, or helplessness that just come with working with this patient population. This will facilitate that more flexible, nuanced alterity or perspectives taking and help people be more reflective to understand themselves more effectively and clearly so that they can make better decisions. Because of their difficulty with autobiographical or episodic memory, you want to help them build narratives. This contributes to higher level emotional processing. That's what we do in psychotherapy generically. We just have them tell you what happened. That's a basic starting point that I emphasize over and over again in my supervision of clinicians using other modalities such as MBT. You also want to ask questions about when things started. You help them sequence and structure their episodic memory so that it starts to make more sense to them and build more meaning. You want to support self-esteem to undercut denial and inject hope because the denial system maintains self-esteem through minimizing the severity of drinking and shifting responsibility onto others, sometimes creating a fantasy of control over drinking. So if you can kind of show positive regard to the patient, it will support them both in terms of their vulnerabilities related to interpersonal hypersensitivity, their sense of threat, as well as their ability to approach their drinking problems. Then you want to check in regularly. Do this as a routine. Patients may avoid mentioning worsening drinking behaviors and talk about other matters other than their drinking when they need that support and accountability most. That's probably not news to this group. You want to inform, not advise. Educate and help people think for themselves. Psychoeducation is inherent in both treatment approaches, but this is only to help patients weigh pros and cons and let them decide what's best for them. Because if you advise them too much and force them in any particular direction, that may produce a disowning of personal responsibility or control struggles. And you want to integrate splitting, like I talked about. Lean in between the connectedness and threat to explore polarized perspectives and problems of ambivalence, because splitting undermines the capacity for balanced decision-making or realistic decision-making regarding relationship management and drinking. And lastly is building authentic relatedness. And this is kind of like the end point of all treatments at work, is for people to be authentic and expressive in their relatedness, to be able to be cared for, but also be individuated and separate from someone that matters to them. And that will help them to be able to be more inclusive and to be able to be more And that will help them tolerate the closeness of a relationship and separation from it. Alcohol is thought to provide a sense of closeness without vulnerability, and that may be the role in this particular patient population. And we're running out of time, so I'm going to rush through this. But these are some strategies to balance attachment needs and autonomy. Some of them I've already gone over. But this thing, a target on the therapist, that is inherent in both GPM and DDP. We want patients to have a mind of their own. Encourage disagreement. Tell them what you think as just your opinion, and let them say what they think. Tolerate their decisions, even when you don't agree with them. But make sure they know that you want them to be in charge of their own decisions and responsibility for the consequences. And I'm not going to be able to go over the part on managing safety. You'll have to read the book on that one. But what I will say is that in the treatment of these two disorders, we want you to use community resources to broaden the social safety net for people who don't tolerate being alone through use of things that you're familiar with, group therapies, 12-step programs, mutual self-help, and family support groups. This stabilizes social support and organizes values and interaction, and the sobriety culture enables belonging and decision-making that promotes self-reliance and self-care. Different levels of care, like residential care and intensive outpatient, are other ways to create a social network when someone's feeling vulnerable. And the benefit of things like AA as a mutual self-help group is that it works through social network changes and targets shared symptoms of both disorders as seen here. And the good news about this is that people who are interpersonally hypersensitive are also interpersonally stabilized and influenceable. So there's a lot of power in relationships. So I encourage you with this last message to do this work. Use anything you learned today. Just incorporate it in what you already do, and you will already be doing better. And you will develop pride in your skills to treat this patient population, because if you can treat BPD and AUD, you can manage most clinically challenging situations or personally challenging situations, and you will address major public health problems in a cost-effective way. So thanks to the team. And you can learn standard GPM online at this address. And I'll stop sharing. Well, thank you so much, Dr. Choi-Kain. And we might have a time for a couple of questions if people want to raise their hand. But I have a quick one. Have you ever put together a cheat sheet? Yes. Actually, we are making a set of GPM worksheets that can be used for patients and clinicians following things like goal-setting, med management, psychoeducation, and we should make a cheat sheet for GPM-AUD. I didn't go over managing safety, which has its own chapter, as well as medication management that has like a kind of set of principles, but that will be in the book. Just going through, if we have maybe one question. Could you talk about how to diagnose BPD in the context of active AUD? In a residential setting, I often find that many of the BPD symptoms improve so much after 30 to 60 days of abstinence. And that could be, you're totally right, Hilary, it could be related to the intensive treatment and unstructured setting. When people with BPD are less alone and they're kind of, that intervention to reconnect them to others can actually improve BPD symptoms in and of themselves. So that is, you hit the nail right on the head with that consideration. But generally, if you talk to patients who seem like they may have BPD on top of the AUD, I think you qualitatively can identify them. People will tell you, yes, I have these problems, whether I'm drinking or not, and others will be less vulnerable or it will be less exacerbated when they're sober. The problem I've seen in my practice is that it takes a long time for some people with BPD to get sober, so they're effectively symptomatic with BPD and need some support for both ends of their symptom presentation. So, you know, I think what I would say is you can diagnose it tentatively and ask the patient if they think that it's relevant and something that they'll need more help with after they become sober, and they will be able to determine that once they do. Well, we are at the hour. Thank you again, Dr. Choi-Kain. I certainly feel smarter for having attended this session, and we'll see everybody in two months. We have the next month off and our next presentation is Dr. Chris Berkman from UCSF talking about group therapy. So thank you everybody for your attention. Thank you, Dr. Choi-Kain. Thank you, and have a great summer, everyone. Thank you, Dr. Stifler and Blazes.
Video Summary
Dr. Joy Cain and Dr. Choi-Kain discuss the challenges and importance of providing effective treatment for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder (AUD). They highlight the prevalence, myths, and complexities associated with these disorders. Both experts emphasize the need for a comprehensive approach like Good Psychiatric Management (GPM) and Dynamic Deconstructive Psychotherapy (DDP) to improve symptoms and therapeutic alliance. The importance of addressing both disorders concurrently to reduce risks like self-harm and suicide is underscored. Dr. Choi-Kain introduces principles from Dialectical Behavior Therapy (DBT) and GPM to manage safety, utilize community resources, and improve outcomes for individuals with BPD and AUD. The experts advocate for accessible and effective treatment options to meet the public health needs of those with these complex disorders. They also touch on the potential improvement of BPD symptoms with abstinence and emphasize the significance of addressing emotional processing deficits and developing tools for managing BPD and AUD.
Keywords
Dr. Joy Cain
Dr. Choi-Kain
borderline personality disorder
BPD
alcohol use disorder
AUD
Good Psychiatric Management
GPM
Dynamic Deconstructive Psychotherapy
DDP
Dialectical Behavior Therapy
DBT
The content on this site is intended solely to inform and educate medical professionals. This site shall not be used for medical advice and is not a substitute for the advice or treatment of a qualified medical professional.
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