Why is bpd hard to treat

They may also hold the mistaken belief that treatment is ineffective for BPD patients. Some providers who do see patients with BPD are not approaching diagnosis and treatment appropriately, recent data suggests. Research that appeared last year in European Psychiatry investigated how psychiatrists differentiate between bipolar disorder and BPD. Show More. 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. 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.

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.

Moreover, randomized controlled trials of existing evidence-based treatments for BPD report concomitant reductions in depression and anxiety during and after treatment. 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. These empirically informed guidelines mitigate the chaos and reactivity that challenge clinicians in their management of multiple comorbidities by providing an organizational framework.

Informed management of comorbidities with BPD can reduce treatment resistance, with a focus on a central and treatable source of vulnerability and dysfunction. 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.

Conservative prescribing can reduce the burden of polypharmacy and exposure to an increasing number of treatments that are unlikely to achieve the desired results. 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. Glasserman and Ms. The authors report no conflicts of interest concerning the subject matter of this article.

The frequency of personality disorders in psychiatric patients. These patients will never be easy to treat , but when their particular forms of resistance to treatment are understood as learned behaviors that have served adaptive function, we can move toward a more empathic and sympathetic therapeutic posture.

Resistance can then be replaced by more truly adaptive responses. Stern A. Psychoanalytic investigation and therapy in the borderline group of neuroses. Psychoanal Q.

Knight RP. Borderline states. Bull Menninger Clin. J Pers Disord. Subsyndromal phenomenology of borderline personality disorder: year follow-up study. Am J Psychiatry. Linehan MM.

New York: Guilford; Young JE. Rev ed. Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. J Clin Psychiatry. Treatment-resistant depression. Fan AH, Hassell J. Bipolar disorder and comorbid personality pathology: a review of the literature. New episodes and new onsets of major depression in borderline and other personality disorders.

J Affect Disord. Borderline Personality Disorder and Resistance to Treatment. July 31, Lois W. Most therapists throw up their hands when it comes to treating people with BPD. Dozens of people with borderline personality disorder have shared their stories with us over the years, expressing the pure frustration they experience in trying to find a therapist willing and able to work with them see, for example.

They often recount stories of having to go through therapists in their local geographic vicinity like others might go through a box of tissues at a funeral. Borderline personality disorder is a legitimate, recognized mental disorder that involves long-standing and negative patterns of behavior that cause a person great distress. People with BPD need help as much as the person with depression, bipolar disorder or anxiety.

Borderline personality disorder is best treated with a specific type of cognitive-behavioral therapy called Dialectical Behavior Therapy DBT.

This specific type of psychotherapy requires specialized training and education in order to use it productively and ethically. Few therapists bother to learn this technique, however, because of the trouble that is commonly associated with people with BPD. Plus, they think, they may not even get reimbursed for treatment of this concern because generally most insurance companies do not cover payment for treatment of personality disorders no matter how much pain the person is in.

The stigmatization and discrimination of people with borderline personality disorder needs to stop within the mental health profession.