hot items in management in addiction and borderline personality disorders

Hot items in management Hot items in management of of

Borderline Personality Borderline Personality Disorder with Disorder with

Alc./Drug DependenceAlc./Drug DependenceBy By

Ahmed Albehairy, M.DAhmed Albehairy, M.DPsych. ConsultantPsych. Consultant

MOHPMOHP

IntroductionIntroduction

Within literature, Within literature,

co morbidity with BPD ranges;co morbidity with BPD ranges;

from 5.2% to 32%. Among opiate addicts, from 5.2% to 32%. Among opiate addicts,

12% of cocaine-dependent inpatients. 12% of cocaine-dependent inpatients.

17% Within a polysubstance abuse. 17% Within a polysubstance abuse.

32% met criteria for BPD during periods of 32% met criteria for BPD during periods of both drug use and abstinence.both drug use and abstinence.

Addiction. 102(7):1140-1146, July 2007.Addiction. 102(7):1140-1146, July 2007.

Darke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, MareeDarke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, Maree

IntroductionIntroduction

Addiction. 102(7):1140-1146, July 2007.Addiction. 102(7):1140-1146, July 2007.Darke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, MareeDarke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, Maree

Assessment Assessment 1- The scope of brain disease:1- The scope of brain disease: in addiction (1997,2006)in addiction (1997,2006)

reward systems, reward systems, (hedonic responses and the reinforcement of (hedonic responses and the reinforcement of use ,use ,diminishing cognitive control (choice)).).

stress systems involving, for example, CRFstress systems involving, for example, CRF. ( stress-induced . ( stress-induced reactivity). reactivity).

Intracellular signaling mechanisms that produce synaptic plasticity can convert drug-induced signals, into long-term alterations in neural function and consolidate drug taking behavior into compulsive use ,and long term memory, relapse risk.

Koob GF. The neurobiology of addiction: a neuroadaptational view relevant for diagnosis. Addiction 2006; 101s1:23-30 Koob GF. The neurobiology of addiction: a neuroadaptational view relevant for diagnosis. Addiction 2006; 101s1:23-30

John oldman, borderline personality comes of age, editorial,2009, : 166,509-511John oldman, borderline personality comes of age, editorial,2009, : 166,509-511 Torgen S,Lygren S, et al : a twin study of personality disorder, comp psych 2000: 41: 416-425Torgen S,Lygren S, et al : a twin study of personality disorder, comp psych 2000: 41: 416-425

Assessment Assessment

1- The scope of brain disease: 1- The scope of brain disease: in BPDin BPD - Torgeson and colleagues found that 68% of - Torgeson and colleagues found that 68% of

BPD are heriditary.2000BPD are heriditary.2000 - hyperactivity to –ve stimuli / inc. –ve affect ,---- - hyperactivity to –ve stimuli / inc. –ve affect ,----

hyperactive amygdala and limbic system.hyperactive amygdala and limbic system. - lack of capacity for cognitive context and affect - lack of capacity for cognitive context and affect

control ---- dec. activity of preorbitofrontal and control ---- dec. activity of preorbitofrontal and ant.cingulate.ant.cingulate.

- though long term psychotherapy is used in - though long term psychotherapy is used in intervention , it is considered as long term intervention , it is considered as long term learning and memory change in the brain.learning and memory change in the brain.

AssessmentAssessment2- Diagnosis :2- Diagnosis :- Categorical vs Dimensional.Categorical vs Dimensional. ( traits, grouping that combines the present dependence and abuse ( traits, grouping that combines the present dependence and abuse

criteria and a second group that constitutes hazardous drinking).criteria and a second group that constitutes hazardous drinking).

- Descriptive vs psychodynamic .Descriptive vs psychodynamic . ( neurobiological disposition and psychological development)( neurobiological disposition and psychological development)

- Dependence & abuse vs BPD.Dependence & abuse vs BPD. ( source of behavioral dyscontrol & affective dysregulation )

- DSM-V underway, BPD ( retained as borderline disorder, axis I, and given to

adolescents).

AssessmentAssessment

Pathogenesis of BPDPathogenesis of BPD

Endophenotype

Impulsive aggression.Affect instability.

Unstable Interpersonal Relationships

-Excessive intensity.-Overvalued expectation.

-Unfounded anxieties.- Cognitive perceptual symptoms

Insecure attachment

Developmental derailmentInadequate parental support


3- Risk, should be assessed in 3- Risk, should be assessed in every every session in BPDsession in BPD

- suicidality, idea, gesture, plan, trial.suicidality, idea, gesture, plan, trial. overdoseoverdose- Self harm. - harm to others. Self harm. - harm to others. - impulsivity.impulsivity.- Aggression.Aggression.- Relapse.Relapse.


4- Differential diagnosis:4- Differential diagnosis:

ADHD, PTSD, Dissociative Identity ADHD, PTSD, Dissociative Identity Disorder, Major depression, Bipolar Disorder, Major depression, Bipolar Disorder, schizophrenia.Disorder, schizophrenia.

5- Co-morbities.5- Co-morbities.

6- family.6- family.

AssessmentAssessment7- cognitive errors in 7- cognitive errors in

drug dependencedrug dependence

Cues Internal & external

Drug related believes

Anticipatory and Drug oriented

Automatic thoughts

Urge And

craving

Facilitating believes

Instrumental and Behavioral strategy and

actions

Continued useOr relapse


7- cognitive errors in 7- cognitive errors in BPDBPD- Use of drug to cope with stress.Use of drug to cope with stress.- Hopelessness.Hopelessness.- Negative beliefs about self.Negative beliefs about self.- Poor impulse control, difficulty in using thoughts Poor impulse control, difficulty in using thoughts - Doubling sense of emptiness.Doubling sense of emptiness.- Drug is the only source of friends.Drug is the only source of friends.- Dichotomous vision.Dichotomous vision.


8- skills deficits:8- skills deficits:

- Mindfulness. is the capacity to pay - Mindfulness. is the capacity to pay attention, nonjudgmental, to the present attention, nonjudgmental, to the present momentmoment

- Interpersonal effectiveness.Interpersonal effectiveness.

- Emotion regulation .Emotion regulation .

- Stress tolerance .Stress tolerance .


9- Decisional capacity9- Decisional capacity

“ “ WHAT”, principal of partial incompetenceWHAT”, principal of partial incompetence

10- transference.10- transference.

Louis C. Charland Ph.D.Louis C. Charland Ph.D.

Departments of Philosophy and Psychiatry & Faculty of Health SciencesDepartments of Philosophy and Psychiatry & Faculty of Health Sciences

University of Western OntarioUniversity of Western Ontario

London Ontario Canada N6A 3K7London Ontario Canada N6A 3K7

Email: [email protected]: [email protected]

Tools of intervention Tools of intervention

PsychotherapyPsychotherapy

Crisis interventionCrisis intervention

CBTCBT

DBTDBT

- Interpersonal effectiveness , Emotion regulation,- Interpersonal effectiveness , Emotion regulation,

Stress tolerance, MindfulnessStress tolerance, Mindfulness

Mentalization- based therapy.Mentalization- based therapy.

Tools of interventionTools of intervention

DBTDBT Mindfulness and interpersonal Mindfulness and interpersonal

effectivenesseffectiveness :Describe, express, assert, :Describe, express, assert, reinforce, mindful, appear confident, negotiate, reinforce, mindful, appear confident, negotiate, gentle, interested, validate, easy manner.gentle, interested, validate, easy manner.

Distress toleranceDistress tolerance: distraction, self sooth the : distraction, self sooth the five senses, improve the moment, pros cons five senses, improve the moment, pros cons thinkingthinking

Emotion regulationEmotion regulation: describe, interpretation, : describe, interpretation, interfereinterfere

Tools of interventionTools of intervention

PsychopharmacologyPsychopharmacology

BPDBPDSuicidality---- lithium , AED, clozapineSuicidality---- lithium , AED, clozapine

Impulsivity, affective unstability --- SSRI,AED, atypical APImpulsivity, affective unstability --- SSRI,AED, atypical AP

Self Harm--------- opiate antagonist up to 300 naltrexone /daySelf Harm--------- opiate antagonist up to 300 naltrexone /day

Evident depression or psychosis, lapse in reality testing. Evident depression or psychosis, lapse in reality testing. Identity diffusion---- AP

ALC/Drug dependenceALC/Drug dependence

Impulsivity , craving , anhedonia, sense of emptiness.Impulsivity , craving , anhedonia, sense of emptiness.Disclosures–2007– Ross J. Baldessarini, M.D. Alkermes, Auritec, Biotrofix, IFI, Janssen, JDS, Lilly, Merck,

Questionnaire for Questionnaire for a guideline consensus for a guideline consensus for

treating treating BPD & ALC/Drug dependenceBPD & ALC/Drug dependence

Thank youThank you

hot items in management in addiction and borderline personality disorders

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