Magazine article Clinical Psychiatry News

Therapies for Borderline Do Work, Albeit Slowly

Magazine article Clinical Psychiatry News

Therapies for Borderline Do Work, Albeit Slowly

Article excerpt

SAN FRANCISCO -- Seven forms of psychotherapy have been proven in randomized clinical trials to be effective in treating borderline personality disorder.

No one knows why so many approaches work, but there are some common elements among them, Dr. Glen O. Gabbard said at the meeting. Researchers and clinicians are trying to figure out which psychotherapy might be best for any subset of patients who have borderline personality disorder.

Within each individual patient, too, there are aspects of the disorder that might respond to one form of therapy, while another aspect of the disorder requires a different therapeutic approach, said Dr. Gabbard, professor of psychiatry and chair of psychoanalysis at Baylor College of Medicine, Houston.

Psychotherapies that are effective in treating borderline personality disorder include dialectical behavior therapy, mentalization-based therapy, transference-focused psychotherapy, schema-focused therapy, supportive psychotherapy, systems training for emotional predictability and problem solving, and general psychiatric management with dynamically oriented therapy.

All provide a systematic conceptual framework of pathogenesis and treatment that helps patients organize their internal chaos and make sense of it. Research shows that the therapeutic alliance is the key factor, while the technique gets credited with only 12%-15% of therapeutic change across different kinds of therapy.

In each of the psychotherapies, change happens through similar underlying neu-rophysiologic processes: increased activity of the prefrontal cortex modifies amygdala hyperactivity, and the therapeutic relationship is used to sharpen patients' ability to reappraise their assumptions, perceptions, and "knee-jerk" beliefs, he said. 'All seven models have somebody sitting with patients and helping them sharpen self-observation."

Within individual patients, some aspects of the disorder respond to insight, while others require internalization of the therapeutic relationship over time.

The therapeutic relationship by itself is not enough, however. "We might overvalue that," Dr. Gabbard said. The therapeutic frame is an envelope within which the therapist helps the patient impose a way of thinking to manage unbearable affect states, "those that can't be borne by one person alone. You need somebody else to help you through that," he said. The aim is to help patients develop their own capacity for thinking and feeling their experience.

Building "procedural memories" requires multiple repetitions to develop new neural networks of self and other, which don't replace old maladaptive neural networks but gradually supersede them over time. …

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