Inside the Mind of a Specialist in Borderline Personality Disorder – Interview with A/Prof Sathya Rao

WHAT ATTRACTED YOU TO PSYCHIATRY?

I was interested in medicine, teaching, and philosophy. Psychiatry was the obvious choice.

WHAT ARE THE BIGGEST CHALLENGES THAT PSYCHIATRY FACES IN YOUR OPINION?

• Mental illness continues to be stigmatised.
• Public psychiatry is grossly under-resourced and inaccessible to a vast majority of patients for an adequate length of time.
• Psychiatry is still outside of mainstream medicine.
• Our treatments (biological interventions) remain very non-specific and produce significant side effects.
• Psychotherapy is grossly underutilised and is at risk of being lost.
• Our classificatory systems are very arbitrary.
• The advances in information technology are likely to have a significant impact on the future of psychiatry but our profession remains less engaged with it.

WHAT WAS YOUR MOTIVATION AROUND SETTING UP SPECTRUM, A UNIQUE PERSONALITY DISORDER SERVICE IN VICTORIA?

Spectrum was set up in 1999 to provide services for people with severe personality disorders and assist public mental health services in Victoria to better understand the treatment of individuals with severe or borderline personality disorders (BPD).

At that time there was a considerable stigma around BPD. Patients were often either refused services (partly because it was thought that BPD was not a mental illness but ‘just’ a personality disorder) or they were admitted to psychiatric facilities for prolonged periods of time because of fear of suicide. I joined Spectrum in 2006.

Spectrum has undergone numerous modifications. We now provide some intervention for about 500 patients. We take referrals from primary, public and private sectors. We have limited resources and therefore focus our attention on very unwell patients who are managed by public services and offer limited services to primary and private sectors.

CAN YOU TELL US A LITTLE MORE ABOUT THE SERVICE AND THE PATIENTS YOU SEE?

Spectrum is a clinical centre of excellence for BPD. It is a state-wide personality disorder service for Victoria that supports and works with public mental health services to provide treatment for personality disorders.

Spectrum strives to apply best available evidence to improve treatment and recovery for people with borderline personality disorder.

Spectrum focuses its interventions for patients who are at risk from serious self-harm or suicide and who have particularly complex needs.

The Spectrum team work with Victorian Mental Health Services, Corrections, Justice System, MH Support Services, Private Psychiatrists and General Practitioners to provide Telehealth consultation and advice, or direct client assessment, care planning, goal setting and therapeutic interventions in the clinics. Spectrum works closely with the consumer and carer groups across Victoria and the Australian BPD Foundation.

Prior to the establishment of Spectrum, clinicians were less well trained in the treatment of personality disorders and there was significant therapeutic nihilism. Spectrum provides training for about 1000 clinicians each year and has done so for about 18 years. This has changed the landscape for personality disorder treatment in Victoria.

Spectrum program has the following components:

1. BPD Clinic
2. Dialectical Behaviour Therapy clinic
3. Mentalization Based Treatment clinic
4. Acceptance and Commitment Therapy clinic
5. Psychoanalytic clinic
6. Complex Care Service
7. Secondary consultation program
8. Assessment unit for primary and private sectors
9. Consumer and Carer psycho-education and support groups and
10. Research and Evaluation unit

Spectrum has undergone a change in its model of care in congruence with the National Health and Medical Research Council (NHMRC) guidelines and the requirements of the Victorian Department of Health and Human Services.

Patient profile:

Most of our patients are highly complex and or severely unwell. They have often received multiple treatments without much benefit. They are usually self-harming or highly suicidal. We mostly see women with BPD.

We also provide assessment and consultation to complex patients in other states of Australia.

BORDERLINE PERSONALITY DISORDER IS CONSIDERED AN ENIGMA BY MANY. DO YOU HAVE ANY THOUGHTS ABOUT HOW CLINICIANS SHOULD CONCEPTUALISE THE DISORDER?

BPD is a highly stigmatized and misunderstood disorder.

I think the following analogy may help us to better understand BPD and its treatment. Let’s compare BPD to a car (no disrespect meant to BPD sufferers).

Imagine the car to have hypersensitive accelerators (Amygdala-emotional system of BPD patients) and very poor brakes (cortical control over Amygdala). It is as though BPD patients are driving such a car.

No wonder their driving is erratic (their lives). They may be unsteady in driving (unstable emotions). Even a very mild touching of the accelerator speeds up the car (hyperemotional state) and can make it go off balance (BPD crisis). Because of poor brakes (poor cortical control over Amygdala) they find it hard to control the car especially when the accelerator is very high.

The idea here is that anyone who is made to drive such a car with hypersensitive accelerators and poor brakes will drive erratically and may crash now and then and even go through amber or red lights. It is not the personal weakness or the faulty character of the driver. The problem is the car that has faulty accelerator and brakes.

The task for the clinician is to be a driving instructor for the person driving such a car and teach them to drive that car carefully and learn the skills to handle the accelerator very gently and use the brakes fully and be more careful on the road. 

The demand here is that the clinician is required to sit in the passenger’s seat and play the role of the driving instructor sharing the risks along with the patients.  If the driving instructor (clinician) is fearful and anxious they may become overly critical and careful and not let the driver learn how to drive (e.g. admissions to hospitals, excessive reliance on medication prescriptions). The instructor needs to be very validating and gently guide the driver and teach the skills to drive.

The evidence is that most BPD patients achieve symptomatic remission. Very few patients require lifelong treatment. 10% of the BPD patients remit in 6 months, 45% remission in 2 years and 85% remission in 10 years. At 10 years about 25% are in full-time work and only 40% are receiving disability payments.

AFTER WORKING WITH PATIENTS WITH BPD, WHAT TIPS WOULD YOU GIVE CLINICIANS IN WORKING WITH PATIENT WITH BPD?

• Believe that people with BPD have a genuine mental illness. It is not “just a behaviour” (NHMRC clinical practice guidelines for BPD refers to BPD as a mental illness).
• BPD is a condition of the brain and the mind and it is not the person’s fault, weakness or a failing on their part.
• Patients with BPD have a hyperactive and hyper-responsive emotional system (Amygdala). The cortical control over Amygdala is inadequate.
• Take a developmental perspective and understand the patient’s illness from a theoretical perspective.
• While working with BPD patients, if you make mistakes, apologise. Be transparent and totally honest with BPD patients. They have very sensitive interpersonal radar and see through defensiveness.
• Develop a treatment plan and a crisis management plan along with the patient. Encourage patients to author the development of such plans under clinicians’ guidance.
• Have a clear structure and boundaries to your treatment plan.
• Be aware of emotions in the therapeutic relationship (yours and patients) and manage them with care.
• BPD patients are chronically suicidal. Learn to differentiate chronic risks from acute risks.
• Teach patients skills to manage their painful emotions, interpersonal relationships and self-harm and suicidal urges.
• Remain calm when patients are in crisis. A crisis may not always mean imminent suicide risk.
• Take a long term perspective. Patient’s illness may fluctuate in the short term.
• People with BPD get well. Clinical remission is the norm, not an exception. Many people with BPD achieve recovery and very few people require lifelong treatment.
• It is not always necessarily to have specialist BPD-specific psychotherapy (e.g. DBT, MBT) training and skills. Knowledge of common psychotherapeutic factors and principles may be sufficient to treat very many patients.
• Clinicians who are active, enthusiastic, interested, hopeful, validating and willing to treat seem to be able to get good results with BPD patients.
• Seek supervision or at least informal discussions with your peers or colleagues.
• Take second opinions.
• Keep medication prescriptions to a minimum. Do not admit them frequently. 

 

THE DIAGNOSIS OF BPD IS STIGMATISED IN SERVICES. WOULD YOU AGREE WITH THIS? SOME EXPERTS HAVE PROPOSED A RECLASSIFICATION TO COMPLEX TRAUMA DISORDER. WHAT ARE YOUR VIEWS ON THE TERMINOLOGY AS A WHOLE?

I agree with you that BPD is a highly stigmatised disorder. Gunderson has famously stated that “BPD is to psychiatry what psychiatry is to medicine”. Unfortunately, mental health clinicians are the biggest stigmatisers of BPD.

The name BPD is unhelpful, confusing and invalidating. It adds to the incorrect perception that it is not a legitimate mental illness.

Prof Jayashri Kulkarni and I have considered Complex Trauma Disorder (CTD) as an alternative name to BPD. This conceptualization is very validating for BPD patients who have experienced significant trauma. However, this does not take into account those who have not suffered childhood trauma.

While there is a good deal of research that links childhood abuse to BPD, there is also evidence that about a third of people with BPD report no abuse at all.

Even if we broadly conceptualise attachment difficulties as a traumatic experience, we still see up to 10% of people with BPD who report no significant traumatic childhood experiences or attachment difficulties.

Further, there are many people who have experienced child abuse who do not develop BPD and many people with BPD who were not abused or maltreated as children.

In summary, although there is a strong link between Trauma and BPD, what is clear is that childhood trauma is a significant risk factor for BPD but trauma in itself does not seem to cause BPD. Trauma in the presence of biological predisposition is likely to cause BPD.

Therefore, the conceptualisation of BPD as a Complex Trauma Disorder or Complex PTSD, while a useful way of reducing stigma, does not seem to be completely helpful in understanding the full range of BPD presentations. Similarly, Emotion Regulation Disorder is also unsatisfactory as not all BPD patients have significant emotion dysregulation.

I believe we have three options:

1. We don’t waste time debating the name and get on with the task of treating and further researching the disorder OR
2. We reconceptualise BPD as a heterogeneous disorder and think of subtypes of BPD (Complex PTSD, Complex Trauma Disorder, Emotion regulation disorder, Complex attachment disorder, etc.) OR
3. We name it after a clinician- e.g. Gunderson’s disorder.

It is interesting to note that when we study the history of psychiatric nosology, we see that BPD originally came from Hysteria. Hysteria was split into Conversion Disorders, Dissociative Disorders, Somatoform disorders, Somatization disorders, BPD and Histrionic Personality Disorder. The nosological confusion surrounding BPD reminds us of the confusion we had with Hysteria in the past.

CAN YOU GIVE US ONE EXAMPLE (I'M SURE THERE ARE MANY) WHERE YOUR EXPERTISE IN PERSONALITY DISORDERS ASSISTED IN IMPROVING PATIENT OUTCOME?

I distinctly recall a patient with BPD I once saw. She was imprisoned for a crime she had committed in relation to her illness and was severely aggressive towards herself and others.

After working with her for a few months, supervising her clinicians, and providing secondary consultations, she was able to be released from the prison safely. Given my experience treating personality disorders, I was able to assist in reconceptualising her as a patient rather than a solely a criminal.

After a series of assessments, the patient and I were together able to formulate the reasons for and triggers of her aggression. Having done this, the triggers in her environment were able to be modified along with the help of her clinicians and the prison staff. This reduced her aggression.

In addition, she was reconnected with her family, and this provided her with a sense of human connection. Working together with the clinicians and prison staff, in this case, was hugely satisfying as there was a positive outcome for the patient.

YOU HAVE BEEN IN PSYCHIATRIC PRACTICE FOR MANY YEARS NOW. WHICH CASE HAS HAD THE GREATEST IMPACT ON YOU AND WHAT HAVE YOU LEARNT?

When I migrated to Australia, my very first patient happened to be someone with severe BPD. I had very limited skills to manage the patient as she was highly suicidal and self-injured repeatedly.

I needed help. My colleagues also did not know how to treat her. I took a number of second opinions which all suggested different diagnoses and treatment plans. I pursued many of them without much help.

Around the same time Spectrum was being set up and my senior colleagues advised me to seek help from the newly set up Spectrum service. It so happens that the first patient to seek treatment from Spectrum was my first BPD patient.

The patient got well and I was very impressed by the work done by Spectrum staff. I learned that people with BPD do get well with treatment. This inspired me to specialise and pursue a career in personality disorders.

WHICH PERSON DO YOU ADMIRE THE MOST PROFESSIONALLY AND WHY?

I most admire my teacher Prof Channapatna Shamsundar. He is a professor of psychiatry at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India. I think he is way ahead of his time. He is one of the most evolved psychiatrists I have met.

What he taught me 30 years ago still holds true. He taught me psychodynamic psychotherapy and inspired me to pursue psychotherapy.  He also taught me not to take personal credit when patients recovered and also not to take it personally if they didn’t.

He believed and published scientific papers which concluded that characteristics of an ideal therapist matched closely with the characteristics of ideal human behaviour. He practised a non-judgemental stance and mindfulness in his day to day dealings.

He believed strongly that a therapist’s intention to get the patient well played a powerful role in the actual outcome. He taught his students by example. He practised what he preached.

He intuitively practised principles of Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT) and Mentalization-Based Treatment (MBT) even before those treatments were formally conceptualised. He has inspired me the most.

WHAT ARE YOU WORKING ON OR READING AT THE MOMENT?

• My colleagues and I have developed a Brief Intensive Group Treatment for BPD that can be delivered in 10 weeks offering a psychotherapy dose of 80 hours (as you are aware standard individual therapy with weekly one-hour consults would take 2 years to deliver 80 hours of therapy dosing). Our public mental health services are under-resourced, and long-term care is often inaccessible. A 10-week intensive intervention offers an attractive option. Group treatment makes it even more efficient. This is based on both common factors in BPD psychotherapy and Spectrum treatment principles.
• We are researching BPD presentations in emergency departments.
• We are also looking at BPD presentations associated with ambulance use.
• I am finding an interesting link between Polycystic Ovarian Syndrome (PCOS) and BPD with 25% of BPD patients reporting co-occurring PCOS in our clinics. (Read more about PCOS and neuropsychiatric issues)
  

HOW DO YOU SEE PSYCHIATRY DEVELOP IN THE NEXT 10 YEARS?

• I think we will see pharmaco-genetics play a very important role in how we prescribe medications.
• We will understand personality disorders a lot more, and I won’t be surprised if BPD is reclassified as not a personality disorder.
• Hopefully, we will find a medication that can reduce the emotional overdrive and make it relatively easier for our BPD patients to cope.
• We are likely to learn more about the application of genetic engineering in psychiatry.
• I wonder if robotics will start taking up psychotherapy!

ANY FINAL WORDS OF WISDOM FOR THE READERS OF THE HUB?

Professionally, it is very gratifying to work with people experiencing BPD. Give it a go.