This has a huge impact on the health and well-being of our community and is a contributor to our rising suicide rate. An international meta-analysis, published in JAMA Psychiatry , has provided irrefutable evidence that clinically developed, online psychological therapy provides a highly effective and accessible solution to this growing problem.
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Black Dog Institute Director Prof Helen Christensen , one of the study authors and a global leader in the development and delivery of online mental health tools, says this important finding cannot be ignored by our governing health bodies. These data are summarized and presented in Table 1. First Author. Sample Origin. Sample Description. Sample Size. Assessment of Borderline Personality. Prevalence of Borderline Personality.
Gatchel Sansone Manchikanti Workman Patients referred to a physical therapy pain management program. Dersh Braden Fischer-Kern A Summary of the Existing Data. In summarizing these data, a total of eight studies have been published to date, with the first appearing in Most of these studies have consisted of patient samples residing in the United States. Study samples have been diverse and included participants from community, primary care, and tertiary care settings.
Sample sizes have varied from 17 to participants, with the number of participants in all eight studies totaling In analyzing these data, one simple approach is to average the percentages of BPD in the various studies. To account for all findings, if a given study used three assessment measures, then each percentage would be included in the total tally. Using this approach for all reported percentages, the averaged prevalence rate of BPD in these collective studies is This percentage seems credible given that it closely reflects the percentage reported by Dersh and colleagues.
Using a semi-structured interview for diagnosis, considered the benchmark for personality disorder diagnosis, Dersh et al found a prevalence rate for BPD of This percentage is close to the averaged percentage we calculated. Given the high rates of BPD in patients with chronic pain syndromes, we advise clinicians to consider every chronic pain patient for this personality dysfunction. While the DSM-5 criteria are the preferred means of diagnosis, these criteria can be challenging to use. Second, some of the criteria are difficult to pose as questions to patients e.
So while we enthusiastically endorse the DSM-5 criteria for BPD, they are sometimes challenging to operationalize in medical settings. As a caveat, these measures tend to be over-inclusive and may generate false positives.
Therefore, these measures are conceptualized as detecting borderline personality symptomatology , rather than confirming the disorder itself. Three self-report measures are well-known in the literature. The SHI is displayed in Table 2 and may be reproduced for clinical use without charge. Made medical situations worse, on purpose e. Been promiscuous i. Set yourself up in a relationship to be rejected? Engaged in emotionally abusive relationships? Tortured yourself with self-defeating thoughts? Have you engaged in any other self-destructive behaviors not asked about in this inventory?
If so, please describe below. As an alternative to DSM-5 diagnosis and self-report measures, clinicians may briefly inquire about BPD symptoms using the core criteria contained in another assessment, the Diagnostic Interview for Borderlines. These criteria were originally developed within the context of a semi-structured interview.
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The criterion for quasi-psychotic phenomena appears to be less essential to diagnosis, but clinically noteworthy. These six items, and their accompanying sub-criteria, are presented in Table 3 in checklist fashion for ease-of-use in the clinical setting. Using this modified approach to diagnosis, the clinician utilizes closed-ended questions e. The interview should only take about 5 minutes.
Any of the preceding approaches can yield a reasonably accurate diagnosis of this disorder. Because of the potential stigma associated with the diagnosis of BPD, clinicians should always use some systematic process for diagnosis rather than an impressionistic approach or hunch, particularly before documenting the diagnosis of BPD in the medical record. Once confirmed, this diagnosis generally guides the clinician in the selection of a treatment course. The diagnosis of BPD somewhat modifies the treatment approach to patients with non-malignant chronic endogenous pain.
Second, for bona fide pain syndromes, a reasonable philosophy to establish at the outset of treatment with the patient is the following: We will attempt to improve your pain symptoms, but we are not likely to totally eradicate them. Hopefully, the patient will support these goals.
Third, subsequent medical management should err on the conservative side i. For example, after consideration of low-risk interventions e. Because of the potential for self-destructive behavior among patients with BPD, the use of medications that are high-risk in overdose may not be feasible for some patients e.
Fourth, the clinician should always keep in mind that patients with BPD have inherent self-regulation difficulties. Because of this clinical feature, these individuals are prone to opioid-analgesic misuse and addiction. As for other suggestions, pain management contracts are useful e. In keeping with this philosophy, no major changes in medication should take place in the absence of the primary clinician e. Finally, the clinician may consider a referral to a psychiatrist or other mental health professional.
There are a number of evidence-based treatments for BPD, such as dialectical behavior therapy, mentalization-based therapy, schema-focused therapy, and transference-focused therapy. From a purely speculative position, eventually a cognitive-behavioral treatment program likely will be developed for these challenging patients. To maximize success, these programs will have to be delivered in the medical setting where the patient receives treatment, perhaps via DVD. They may also be less likely to experience the resolution of pain symptoms as well as more likely to seek disability. Research indicates that individuals with BPD are both highly pain tolerant as well as highly pain intolerant, depending on the context of the pain.
A Unifying Framework
Explicitly, during acute self-injury events, pain tolerance tends to be high, whereas with non-malignant chronic endogenous pain, pain tolerance tends to be low. When comorbid BPD is present in the patient with non-malignant chronic endogenous pain, we recommend an overall conservative approach to pain management with close monitoring of controlled medications by one primary clinician.
Although outcome studies of patients with pain and BPD are generally lacking, the clinician might anticipate a chronic course without full resolution of pain symptoms. Overall, these patients tend to be very challenging to manage. Emergency Medicine Reports Card. Reprints Share. Authors: Randy A. Statement of Financial Disclosure To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. BPD in Cluster B group consists of personality dysfunctions characterized with dramatic, emotional, and erratic features and is unique because these individuals have inherent difficulties with self-regulation i.
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