Cover image for Borderline personality disorder : a clinical guide
Title:
Borderline personality disorder : a clinical guide
Author:
Gunderson, John G., 1942-
Personal Author:
Edition:
First edition.
Publication Information:
Washington, DC : American Psychiatric Press, [2001]

©2001
Physical Description:
xxii, 329 pages : illustrations ; 24 cm
General Note:
"Sequel to 1984's classic: Borderline personality disorder"--Cover.
Language:
English
ISBN:
9781585620166
Format :
Book

Available:*

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Central Library RC569.5.B67 G863 2001 Adult Non-Fiction Non-Fiction Area
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Summary

Summary

This text on borderline personality disorder covers topics such as: the borderline diagnosis; differential diagnosis case management; levels of care; pharmacotherapy; cognitive/behavioural therapies; and individual psychotherapies.


Author Notes

John G. Gunderson, M.D., is Professor of Psychiatry at Harvard Medical School. At McLean Hospital in Belmont, Massachusetts, he serves as Director of Psychosocial and Personality Research and of the Outpatient Personality Disorder Service


Table of Contents

About the Authorp. XIII
Prefacep. XV
Acknowledgmentsp. XVII
Introductionp. XIX
1 The Borderline Diagnosisp. 1
Origins of the Diagnosisp. 1
Sidebar 1-1 Where Were the Borderlines Before the Diagnosis?p. 2
Shifts in the Borderline Construct: From Organization to Syndrome to Disorderp. 5
An Explication of the DSM-IV Criteriap. 9
Sidebar 1-2 Borderline Personality as an latrogenic Disorderp. 12
Sidebar 1-3 The Subjective Experience of Being Borderlinep. 13
A Clinical Synthesis: Intolerance of Alonenessp. 15
Sidebar 1-4 British Developmentalists--From Winnicott to Bowlby to Fonagyp. 16
Misuses of the Borderline Diagnosisp. 19
Sidebar 1-5 "Wisdom Is Never Calling a Patient Borderline"p. 21
The Behavioral Specialty: Self-Injurious Behaviorp. 21
Sidebar 1-6 Cutting: Social Contagion or Serious Disorderp. 23
How to Explain the Diagnosisp. 24
Summaryp. 25
Referencesp. 25
2 Differential Diagnosis: Overlaps, Subtleties, and Treatment Implicationsp. 35
Overall Functionp. 35
The Changing Construct: From Schizophrenia to Depression to Posttraumatic Stress Disorderp. 36
Comorbidity and Differential Diagnosisp. 38
BPD and Depressionp. 39
BPD and Bipolar II Disorder/Cyclothymic Personalityp. 41
BPD and PTSDp. 44
BPD and Eating Disordersp. 46
BPD and Substance Abusep. 48
BPD and Somatoform/Somatization Disordersp. 50
BPD and Narcissistic Personality Disorderp. 50
Sidebar 2-1 Is Martha Stewart Borderline? I Think Notp. 51
BPD and Antisocial Personality Disorder (ASPD)p. 54
Summaryp. 57
Referencesp. 57
3 Overview of Treatmentp. 63
Historical Overviewp. 63
Generic Therapeutic Processes and the Functions They Servep. 65
Containmentp. 67
Supportp. 67
Structurep. 68
Involvementp. 68
Validationp. 69
Multiple Modalities and Step-Down Services: An Overviewp. 69
Sociotherapiesp. 70
Generic Sequence of Changep. 70
Sequence of Expectable Changes for BPDp. 72
Sidebar 3-1 Can Consumers Judge Progress?p. 72
Changes Within Four Spheresp. 75
Affectsp. 75
Behaviors: Impulse/Action Patternp. 76
Social Function: Impairmentp. 76
Relationship With Treatersp. 77
General Principles That Guide the Initial Structuring of Treatmentp. 78
Diagnosisp. 78
Comorbidityp. 78
Primary Clinicianp. 78
Short-Term Goalsp. 78
Least Restrictive Safe Treatment Settingp. 79
Types and Sequence of Therapeutic Alliancep. 79
Sidebar 3-2 Myths About Alliance With Borderline Patientsp. 80
Countertransferencep. 80
Summaryp. 81
Referencesp. 82
4 Case Management: The Primary Clinicianp. 85
Qualificationsp. 86
Responsibilitiesp. 86
Liability Issuesp. 88
Sidebar 4-1 Guidelines to Avoid Liabilityp. 89
Relationship Managementp. 89
Managing Safetyp. 91
Assessing Suicidalityp. 91
A Preventive Stancep. 92
Responding to "Feeling Unsafe"p. 92
Sidebar 4-2 Is Contracting for Safety Safe?p. 93
Responding to Recurrent Suicidality: The "Principle of False Submission"p. 97
Implementing Changesp. 100
Boundaries, Violations, and Setting Limitsp. 101
Splits, Splitting, and the Principle of Split Treatmentp. 102
Sidebar 4-3 How Psychotherapeutic Technique Relates to Level of Carep. 104
Summaryp. 105
Referencesp. 105
5 Levels of Care: Indications, Structure, Staffingp. 107
Selecting or Changing a Level of Carep. 108
Level IV Hospital Treatment-Makes Therapy Possiblep. 110
Sidebar 5-1 Is Long-Term Hospitalization Desirable for BPD?p. 110
Goals: Contain Patients for Safety, Assessments, and Treatment Planningp. 112
Structurep. 113
Staffp. 113
Level III Residential/Partial Hospital Care-Basic Socializationp. 114
Goalsp. 115
Sidebar 5-2 Vocational Counseling: Should He or She Return to School, Pursue a Career, or Become a Caregiver?p. 116
Staffp. 117
Structurep. 118
Sidebar 5-3 Empirical Support for a Psychoanalytic Day Hospitalp. 120
Level II Intensive Outpatient Care-Behavioral Changep. 122
Goalsp. 123
Componentsp. 124
Level I Outpatient Care-Interpersonal Growthp. 126
Summaryp. 127
Referencesp. 128
6 Pharmacotherapy: Clinical Practicesp. 131
Historyp. 131
Overall Role of Medicationsp. 132
Sidebar 6-1 Listening to Prozac: Can SSRIs Cure BPD?p. 133
Getting Startedp. 135
Sidebar 6-2 "I Don't Know If It Will Help"p. 135
The Prescribing Psychiatrist's Rolep. 136
With the Borderline Patientp. 136
As the Primary Clinician (Psychiatrist/Therapist)p. 136
As the Psychopharmacologist Only (Split Treatment)p. 138
Sidebar 6-3 Liability Hazards of Split Treatmentp. 138
Symptom Chasingp. 139
Attitudes, Meanings, and Attributionsp. 140
Transference-Countertransference Issuesp. 141
Contraindications/Discontinuancep. 143
Summaryp. 145
Referencesp. 146
7 Pharmacotherapy: Selection of Medicationsp. 149
Introductionp. 149
Overviewp. 149
Comorbidity and Differential Diagnostic Considerationsp. 152
Selective Serotonin Reuptake Inhibitors: The Usual Starting Pointp. 153
Behavioral Symptom Resistance to SSRIsp. 155
Mood Symptom Resistance to SSRIsp. 155
Cognitive Symptomsp. 157
Summaryp. 158
Referencesp. 158
8 Cognitive-Behavioral Therapies: Dialectical Behavior Therapy, Cognitive Therapies, and Psychoeducationp. 163
Overviewp. 163
Historical Contextp. 164
Clinical Cautionsp. 164
Growth in the Use of Cognitive-Behavioral Therapy With BPDp. 166
Basic Operant Conditioning Applications for All Treatment Settingsp. 166
Dialectical Behavior Therapy (DBT)p. 168
DBT Theoryp. 168
The Basic DBT Servicesp. 169
Empirical Supportp. 173
Sidebar 8-1 DBT's Limitations: Checking the Floodp. 174
Perspective on DBTp. 179
Cognitive Therapiesp. 179
Sidebar 8-2 Makes Sense, But Does it Work? Part 1-Preliminary Findings on Brief Cognitive Therapyp. 181
Psychoeducation for Patientsp. 182
Summaryp. 184
Referencesp. 185
9 Family Therapiesp. 189
Introductionp. 189
Historyp. 190
Therapists and Countertransferencesp. 192
Getting Started: Overcoming Resistancep. 193
Sidebar 9-1 "You Can't Talk to My Parents"p. 194
Phase 1 Initial Family Meetingsp. 195
Sidebar 9-2 Families of Married Borderline Patientsp. 196
Problem Identificationp. 196
Psychoeducationp. 197
Supportp. 198
Sidebar 9-3 Finessing the Guilt Issuep. 198
Phase 2 Establishing an Alliancep. 199
Resistance to the Borderline Diagnosisp. 199
Resistance to Being Involved in Treatmentp. 200
End of Phase 2: Transition From Treatment to Therapyp. 201
Phase 3 Psychoeducational Family Therapyp. 201
Single-Family Interventionsp. 202
Adaptations for a Multiple Family Group (MFG)p. 202
Three Stages of Psychoeducational Family Therapiesp. 203
Sidebar 9-4 "Good Cop/Bad Cop": A Parental Problemp. 205
Sidebar 9-5 Makes Sense, But Does it Work?-Part 2: Preliminary Findings of the PE/MFGp. 207
Phase 4 Psychodynamic Family Therapyp. 208
Summaryp. 209
Referencesp. 210
Appendix Suggested Psychoeducational Printed Materials, Videos, Films, and Web Sitesp. 215
Printed Materialsp. 215
Overviewsp. 215
Family Issuesp. 216
Instructive Booksp. 216
Newslettersp. 217
Videosp. 217
Filmsp. 217
World Wide Webp. 218
10 Interpersonal Group Therapyp. 219
Introductionp. 219
Indicationsp. 220
IPG Structure, Duration, and Leadersp. 221
Structure: Group Size and Meeting Schedulep. 221
Durationp. 222
Group Therapistsp. 222
Getting the Group Startedp. 223
Membershipp. 223
Engagementp. 224
Sidebar 10-1 Makes Sense, But Does It Work?-Part 3: Preliminary Findings on Efficacy of IPGp. 225
Establishing a Contractp. 226
Processes of Therapyp. 227
Interpersonal Learningp. 228
Cohesionp. 228
Owning and Expressing Hostilitiesp. 229
Split Treatment: Communicating With Primary Clinicians and Other Therapistsp. 231
Outside-the-Group Contactsp. 231
Summaryp. 232
Referencesp. 232
11 Individual Psychotherapies, Phase 1: Getting Startedp. 235
Introductionp. 235
Getting Startedp. 237
The Problem of Dropoutsp. 237
Contracting Rolesp. 238
Sidebar 11-1 Anticipating Problems in Psychotherapyp. 240
Structuring the Therapeutic Frame (External Boundaries)p. 242
Billsp. 243
Frequencyp. 244
Schedulingp. 246
Seatingp. 246
Sidebar 11-2 What Is the Role of Psychoanalysis for BPD Patients?p. 247
Therapistsp. 248
Qualificationsp. 248
Qualitiesp. 252
Sidebar 11-3 Listening to Kernberg or Linehan: Can Charisma Cure BPD?p. 253
Engagementp. 255
Summaryp. 257
Referencesp. 258
12 Individual Psychotherapies, Phases 2, 3, and 4: Processes of Changep. 261
Prior Literaturep. 262
Outcome Studiesp. 262
Psychoanalytic Contributionsp. 267
Sidebar 12-1 The Debate of the 1970sp. 269
Overview of Change Processesp. 270
Phase 2 A Relational Alliancep. 271
Phase 3 Positive Dependencyp. 279
Sidebar 12-2 Transitional Objects-From Concept to Phenomenonp. 279
Sidebar 12-3 Is Regression Therapeutic?-The Two Margaretsp. 282
Phase 4 Secure Attachment, The Working Alliance, and Consolidation of Selfp. 284
Impassesp. 285
Summaryp. 287
Referencesp. 288
13 Future Considerationsp. 293
The Diagnosis: Self-Disorder and Relationship to DSM-IV Axes I and IIp. 293
The Search for the Core Psychopathology of Borderline Personality Disorderp. 294
Brain Meets Mind: Frontiers for BPD in the Neurosciencesp. 297
Sidebar 13-1 Is BPD a Brain Disease or Not?p. 297
Development of Specialists and Special Servicesp. 300
Credentialing Therapistsp. 302
Standards of Carep. 303
Public Awareness and Advocacyp. 304
Sidebar 13-2 Borderline Personality Disorder on the Internet-Proceed Enthusiastically...With Cautionp. 305
Sidebar 13-3 Were a Famous Borderline to Go Public...p. 307
The Swiss Foundationp. 308
Summaryp. 309
Referencesp. 309
Indexp. 313

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