Hot items in management in addiction and borderline personality disorders

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Hot items in management in addiction and borderline personality disorders

  1. 1. Hot items in management of Borderline Personality Disorder with Alc./Drug Dependence By Ahmed Albehairy, M.D Psych. Consultant MOHP
  2. 2. IntroductionWithin literature, co morbidity with BPD ranges; from 5.2% to 32%. Among opiate addicts, 12% of cocaine-dependent inpatients. 17% Within a polysubstance abuse. 32% met criteria for BPD during periods of both drug use and abstinence. Addiction. 102(7):1140-1146, July 2007. Darke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, Maree
  3. 3. IntroductionAddiction. 102(7):1140-1146, July 2007.Darke, Shane; Ross, Joanne; Williamson, Anna; Mills, Katherine L.; Havard, Alys; Teesson, Maree
  4. 4. Assessment1- The scope of brain disease: in addiction (1997,2006) reward systems, (hedonic responses and the reinforcement of use ,diminishing cognitive control (choice)). , stress systems involving, for example, CRF. ( stress-induced 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; 101s1:23-30John oldman, borderline personality comes of age, editorial,2009, : 166,509-511Torgen S,Lygren S, et al : a twin study of personality disorder, comp psych 2000: 41: 416-425
  5. 5. Assessment1- The scope of brain disease: in BPD - Torgeson and colleagues found that 68% of BPD are heriditary.2000 - hyperactivity to –ve stimuli / inc. –ve affect ,---- hyperactive amygdala and limbic system. - lack of capacity for cognitive context and affect control ---- dec. activity of preorbitofrontal and ant.cingulate. - though long term psychotherapy is used in intervention , it is considered as long term learning and memory change in the brain.
  6. 6. Assessment2- Diagnosis :- Categorical vs Dimensional. ( traits, grouping that combines the present dependence and abuse criteria and a second group that constitutes hazardous drinking). Descriptive vs psychodynamic . ( neurobiological disposition and psychological development) Dependence & abuse vs BPD. ( source of behavioral dyscontrol & affective dysregulation ) DSM-V underway, BPD ( retained as borderline disorder, axis I, and given to adolescents).
  7. 7. Assessment Pathogenesis of BPD Insecure attachment Developmental derailmentInadequate parental support Unstable Interpersonal Relationships -Excessive intensity. -Overvalued expectation. -Unfounded anxieties. - Cognitive perceptual symptoms Endophenotype Impulsive aggression. Affect instability.
  8. 8. Assessment3- Risk, should be assessed in every session in BPD- suicidality, idea, gesture, plan, trial. overdose- Self harm. - harm to others.- impulsivity.- Aggression.- Relapse.
  9. 9. Assessment4- Differential diagnosis: ADHD, PTSD, Dissociative Identity Disorder, Major depression, Bipolar Disorder, schizophrenia.5- Co-morbities.6- family.
  10. 10. Assessment7- cognitive errors in drug dependence Cues Drug Urge Internal & related believes Automatic And external Anticipatory and thoughts craving Drug oriented Continued use Instrumental and Or relapse Behavioral strategy and Facilitating actions believes
  11. 11. Assessment7- cognitive errors in BPD Use of drug to cope with stress. Hopelessness. Negative beliefs about self. Poor impulse control, difficulty in using thoughts Doubling sense of emptiness. Drug is the only source of friends. Dichotomous vision.
  12. 12. Assessment8- skills deficits:- Mindfulness. is the capacity to pay attention, nonjudgmental, to the present moment- Interpersonal effectiveness. Emotion regulation . Stress tolerance .
  13. 13. Assessment9- Decisional capacity “ WHAT”, principal of partial incompetence10- transference.Louis C. Charland Ph.D.Departments of Philosophy and Psychiatry & Faculty of Health SciencesUniversity of Western OntarioLondon Ontario Canada N6A 3K7Email: charland@uwo.ca
  14. 14. Tools of interventionPsychotherapyCrisis interventionCBTDBT- Interpersonal effectiveness , Emotion regulation, Stress tolerance, MindfulnessMentalization- based therapy.
  15. 15. Tools of interventionDBT Mindfulness and interpersonal effectiveness :Describe, express, assert, reinforce, mindful, appear confident, negotiate, gentle, interested, validate, easy manner. Distress tolerance: distraction, self sooth the five senses, improve the moment, pros cons thinking Emotion regulation: describe, interpretation, interfere
  16. 16. Tools of interventionPsychopharmacologyBPDSuicidality---- lithium , AED, clozapineImpulsivity, affective unstability --- SSRI,AED, atypical APSelf Harm--------- opiate antagonist up to 300 naltrexone /dayEvident depression or psychosis, lapse in reality testing. Identity diffusion---- APALC/Drug dependenceImpulsivity , craving , anhedonia, sense of emptiness.Disclosures–2007– Ross J. Baldessarini, M.D. Alkermes, Auritec, Biotrofix, IFI, Janssen, JDS, Lilly, Merck,
  17. 17. Questionnaire for a guideline consensus for treatingBPD & ALC/Drug dependence
  18. 18. Thank you

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