A Practice Tool for Caring for People with Borderline Personality Disorder in Primary Care

Author: Dr. Micah Peters, PGY3

Halifax Site

Supervisor: Dr. Fred Burge

A Practice Tool for Primary Care Providers

Submitted September 14, 2020

1 ABSTRACT

BACKGROUND: Borderline personality disorder (BPD) is characterized by interpersonal and intrapersonal instability and impulsivity, and associated with neurobiological changes in neuropeptides, hormones, and brain structure. BPD is heavily stigmatized and often deemed untreatable, despite good evidence for decades to the contrary. It is prevalent in primary care, typically associated with patients who are “difficult”, and working with such patients can affect physician satisfaction and wellbeing. There is a paucity of accessible clinical tools to empower primary care providers, like family physicians, to appropriately treat people with BPD with up to date, evidence informed medical practice.

METHODS: PubMed, CINAHL, PsycInfo, Academic Search Premier, and Web of Science were searched for articles relating to BPD management in primary care and for BPD clinical tools.

RESULTS: No full page, appealing tools for BPD management in primary care were found. Articles with principles and recommendations were organized into relevant themes, and consolidated to create an appealing, evidence-informed, treatment focused practice tool.

DISCUSSION: This tool greatly improved past articles’ visual displays of treatment principles for BPD by creating a visually appealing, easily referenced tool for providers in the primary care setting, to be used in print or on smartphones. This tool could potentially be implemented as an interactive website or app, or be quite easily modified for use as a patient self-advocacy tool.

CONCLUSION: Using an extensive search of the literature on caring for people with BPD to create an appealing practice tool, a significant gap in BPD treatment of people in primary care is bridged, empowering primary care providers to better care for people with BPD.

2 INTRODUCTION

Borderline personality disorder (BPD) is a difficult to treat yet fascinating disorder. Most health care providers’ (HCPs) approach BPD in people with caution because of the stigma of difficulty and anxiety attached.¹ Recent research points to this stigma being primarily a function of HCPs attitudes and culture.² Furthermore, research consistently points to people with BPD being perceived as “difficult” and “untreatable”, which many HCPs think are synonymous with BPD.^{3, 4} This is despite clear evidence for years of neurobiological foundations for these “difficulties”.^{5, 6} Pally (2002) makes a case that the environment people with BPD are born into (abusive, neglectful, etc) may be critical in determining their BPD symptoms, function, and thus “difficult-ness” to HCPs.⁵Caring for these patients can challenge a physician’s self-esteem, efficiency, empathy capacity, conflict tolerance, and boundary setting.⁷ A study by An et al.(2009) further correlates the number of difficult patients treated to more burnout and lower job satisfaction among physicians.⁸Positive evidence has been mounting for over two decades that BPD is treatable,^{9, 10} with an overall good long term prognosis.^{11, 12} Kulacaoglu and Kose (2018) review the neurobiology of BPD’s symptoms, and how treatments reverse neurobiological deficits contributing to these symptoms, ⁶ still people with BPD continue to be deemed “morally suspect”, questioned as to their status as patients, and most often perceived as having an incurable, frustrating disorder.³I have seen and even felt these thoughts in my own experience in medicine. Family physicians are well positioned to manage the care of people with BPD since people with BPD have a myriad of complex comorbidities.¹³Yet family physicians can still be successful,^14-16something I have also witnessed firsthand. Thus a large audience of family physicians should be interested in an accessible, succinct, optimistic approach to managing BPD in primary care. The goal is to improve patient care, patient satisfaction, and physician satisfaction. A list of the best clinical principles underlying effective management of BPD should better equip and prepare primary care physicians for less stigmatizing and more satisfying care as they see patients improve. Some principles overlap with psychotherapeutic principles used in the definitive treatment of BPD, but this tool is not intended for instructing providers completely in the definitive treatment of BPD.

3 BACKGROUND

BPD is defined by the DSM 5 as a pervasive instability of relationships, identity, and mood, significant impulsivity, and beginning by young adulthood.,¹⁷ Common symptoms include labile mood, inappropriate and intense anger, continual fear of abandonment, an unstable self-image, and chronic feelings of emptiness.¹⁷ Common behaviours include serial unstable, intense relationships, marked impulsivity, suicidal gestures and self-mutilating acts (ie. self-harm). Many of these BPD manifestations likely relate to deficits in grey matter volume in critical areas for stimulus interpretation and emotional regulation, including the amygdala and prefrontal cortex,⁶as well as higher levels of cortisol and decreased circulating oxytocin.^{18, 19} It is a prevalent disorder, with a point prevalence of 1.6%,²⁰and a lifetime prevalence of 5.9% in the population.²¹The most feared outcome of BPD is suicide, which is attempted by 75-84% of people with BPD, often multiple times,²²with a completion rate much higher than the general population at 6 – 10%.^{23, 24} Its non-suicide premature death rate is two to three times higher than the general population.^11,
24 BPD also often causes recurrent disruptive behaviour in clinics, medical self-sabotage, and is associated with multiple, complex comorbidities (eg. Depression, bipolar disorder, obesity, sexual impulsivity).¹³

BPD is the most studied of the personality disorders, and is often a model PD when exemplifying “difficult” patients.³ This population has been termed “heart sink”, or even “hateful”, patients, by clinicians historically.²⁵ The name of a person with BPD can be all that is required to invoke negative feelings when the person is scheduled for an appointment.²⁶BPD is prevalent in primary care, affecting approximately 6% of patients,²⁷and people with BPD see significantly more physicians in both primary and specialty care,²⁸ than those without personality disorders, so negativity can be significant. Imbeau et al. surveyed 114 Canadian health care providers (a mix of family physicians, family medicine residents, and mental health professionals) in 2014 and found persistent negative attitudes towards people with BPD, within whom the most negative were residents.²⁹Other HCP challenges include strong, often negative, and exhausting emotional reactions in a HCP while seeing a person with BPD (called countertransference),³⁰ and increasing levels of physician burnout.³¹Physician education has fallen short in providing guidance in how to interact with people with BPD.³²This gap in preparedness has an emotional and mental health toll on family physicians as they report it as the most psychologically challenging condition.³³

Besides difficulties with countertransference ²⁶ and a lack of training around both BPD and its effective treatments,³² Australian general practitioners in Wlodarczyk (2018) described (among others) four more patient factors contributing to the challenging management of people with BPD: 1) various mental and physical comorbidities, 2) difficulties in diagnosis due to symptom overlap with other psychiatric and physical illnesses 3)difficulties with boundaries, and 4) attendance issues.²⁶ These four issues are well known in people with BPD: they have poorer adherence to treatment plans and appointments,³⁴ diagnosis may be difficult even for psychiatrists,^35, ³⁶many of these patients could have boundary issues from comorbid personality disorders or past traumas,¹⁷and complex comorbidities such as somatization, chronic pain, and substance use disorder are frequent in this population.¹³ Thus these difficulties were not surprising. However, they may be approached with more hope! Certain strategies, techniques and treatments adopted by the physician have been shown to be successful,^{23, 37, 38} with an 8 year remission rates of 78% after 16 years,¹² and a full symptomatic remission rate of 92% at 27 years.¹¹

Past reviews on BPD in primary care often speak of both diagnosis and patient management principles.^{14-16,
39, 40} Although diagnosis is difficult, actually managing these patients’ issues in a busy practice seems to be the larger problem for primary care phsyicians.²⁶ Unfortunately, these reviews, as well as other articles, may provide ample text for family physicians managing BPD, but are not easily accessible, engaging tools, though some half-page “boxes” or tables are at least an attempt.^{16, 23, 26, 27, 39, 40}A memorabletool that can be accessed easily (as a poster in an office or an image on a smartphone), specifically targets countertransference and BPD behaviours, outlines the proven treatments available, and addresses psychopharmacology in BPD, may correct some ongoing difficulties physicians have in managing people with BPD. Thus the research questions addressed by this article are: Are there ANY accessible, visually appealing, and more comprehensive practice tools for managing people with BPD in the primary care setting? If not, can such a tool be readily created to address this gap in BPD management in primary care?

4 METHODS

As noted above, this article’s objectives were to create a tool that can rapidly guide primary care physicians to evidence-informed principles for in managing people with BPD (appendix A).

A thorough search for tools relating to the treatment of people with BPD was performed along with a structured and detailed search to identify current evidence for strategies to see improve the symptoms of people with BPD. Using Draw.io online diagramming software,⁴¹ a tool was then created to deliver an appealing, easily-usable practice tool.

4.1 Search for a Tool

First, grey literature was searched using Google and various combinations of the search terms: “borderline personality disorder”, infographic, treatment, algorithm, tool, summary (both images and web), and directly by images found that were about BPD. This search did not identify any current tools to address the specific gap which this paper planned to address. ClinicalKey and Dynamed were also searched for tools. The databases of Pubmed, WebOfScience, CINAHL, PsycInfo, and Academic Search Premier (latter three using EBSCOHost) were searched using similar terms (excluding infographic), along with (and some without) primary care or family physician, to look for primary care tools (see appendix D). These searches were refined with the assistance of a health sciences librarian at Dalhousie University.

4.2 Search For up-to-date Knowledge for Management of BPD

Second, these searches (with and without the term “tool” and like terms) were used to find up-to-date knowledge on the treatment and management of BPD, in order to improve existing tools or create new ones, depending on what was found. Additional articles were collected by hand-searching cited references of some of the review articles retrieved, searching article reference lists, and searching PubMed for BPD reviews. A further method was searching databases with title/abstract filters (but fewer search terms). This increased search results dramatically, so the author elected to only screen the 100 most relevant results. This was due to multiple searches resulting in 375 to 4717 articles found at a time, with relevance sorted automatically according to databases’ algorithms. Ferri’s Clincal Advisor ⁴², via ClinicalKey, and two books^37, ⁴³were also included as guides to knowledge, not just tools. All articles included were limited to online accessibility and English text. The Covidence.org’s systematic review website was used for a methodical approach to screen articles from database searches, as well as remove duplicates.⁴⁴ Articles were included based on significant text, tables, or figures that described clinical principles of managing people with personality disorders (PD) as outpatients (though mostly BPD, BPD is also often a model PD), with a mix of qualitative work, reviews, and original studies. Studies were excluded during screening if they focused on comorbidities of BPD, only the diagnosis of BPD, inpatient settings, only non-treatment aspects of BPD, or if it doesn’t relate to personality disorders at all.

4.3 Creating the Tool

Using the documents collected, major themes were identified, with subthemes under them, and a table constructed with quotations or paraphrases from sources (Appendix B). Draw.io online design software was chosen to create the final product thanks to a trusted colleague’s recommendation, and because of its ease of use, adequate options, zero cost, and quick speed.⁴¹ Data were included in the final product based on an author decision of its likelihood in providing guidance to the primary care physician’s approach to people with BPD.

5 Results

Despite an extensive search of published and grey literature, no engaging or visually appealing summaries with a focus on BPD management were found. There were a few visual overviews of BPD as a whole, directed to patients, found in the grey literature (see last page of appendix D), but none on only management. From research database searches, more than 800 articles were removed as duplicates and a further 954 were screened for inclusion in the tool. Approximately 32 studies of these 954 screened were used, along with books and other sources gathered from reference and citation searches. Many of these articles listed management pearls and principles for treating people with BPD in both primary and secondary care, ^{1, 2, 4, 8,
10-12, 14-16, 23, 25-27, 37-75} (see examples in Appendix D). Table 1 (in Appendix B) was constructed using consistent themes found in the majority of articles surveyed, as well as what was found in tables and boxes from articles. No articles describing the creation of a physician-centered practice tool document were found, so this was done arbitrarily.

The objectives were achieved by summarizing data into themes and subthemes, with relevant quotes or paraphrases by authors noted for implementation into the tool. The five major themes that emerged from the literature were:

1. Manage countertransference hopefully, reflectively, and collaboratively

2. Ensuring patient-physician relationship and treatment environment have structure and firm boundaries

3. Becoming a safe, consistent place to contain and mentalize dysregulation

4. Develop a thorough, mutually agreeable treatment plan with both short and long term goals and expectations

5. Prescribe conservatively, in limited amounts, for short durations, if at all

5.1 Managing Countertransference Hopefully, Reflectively, and Collaboratively

Countertransference is defined by the American Psychological Association as “the therapist’s unconscious (and often conscious) reactions to the patient and to the patient’s transference (a projection onto the analyst of …. unconscious feelings… directed towards important individuals).”^{45, 46} In practice, this may include over-involvement to “save” a person feeling abandoned or suicidal, or under-involvement with a person who displays intense affects changes and angry, hateful rants that deeply affect the HCP. ⁴ These can affect the patient-physician relationship in a damaging way, especially when the HCP isn’t able to recover and reflect upon the negative countertransference reaction.⁴ This is more likely to worsen the person’s treatment, access to care, and prognosis.^{39, 42}as well as reinforcing the HCP-driven stigma around people with BPD.²This often co-occurs with stigma around BPD within the culture of health care providers. Six subthemes identified within managing counter transference include self care, self reflection, discussing cases with peers and specialists, the clinical response to countertransference, health care provider negativity, and the patient-physician relationship. Self care was both vital to continuing to be the best physician possible for the patient, but also important to role model this for people with BPD.^{47, 48} Self reflection includes understanding biases, emotions, and tolerance of patient behaviours, all of which is essential to limit stigma and hopelessness⁴⁹and create a more empathic and positive therapeutic relationship with the patient.^{50, 4}The physician should be aware that people with BPD may experience symptoms and traits on a continuum of experiences that all of humanity share. ⁵¹However, this results in therapeutic relationships with a person with BPD amplifying, often uncomfortably, our own loneliness, emptiness, and shortcomings as human beings. ⁵¹ Discussing challenging cases with peers and specialists is essential to minimizing negative countertransference,⁵²caring for one’s self, and optimizing care for the patient,^{23, 26, 42}especially if patient’s self destructive behaviour is difficult to manage. ¹⁶If the patient makes a distressing statement, the physician should remain calm, always attempting to enable patients’ competence and control. ³⁸ At this point in an interaction the HCP may desire to control the situation by taking action.³⁸ This can assuage the HCP’s desire for control but, unfortunately, results in escalating the conflict. ^{38, 48}Sansone and Sansone (2013) found that most HCPs were pessimistic, frustrated, and had unempathetic attitudes towards people with BPD, both due to stigma and due to negative experiences.¹ While this may be a typical human reaction to the complexity of a person with BPD,¹ this reaction may be improved by realizing the significantly positive prognosis for people with BPD. ^2, ^11, ¹²For successful outcomes the precious patient – physician relationship must be kept hopeful, patient centered, therapeutic, and not depend entirely on the patients’ behaviour, especially important in people with BPD who fear abandonment. ¹⁴Physicians should be authentic, holding themselves accountable for mistakes, and identifying with (thus normalizing) patients’ experiences and behaviour whenever possible.^23,
43Levinson 1993 found that more than 50% of physicians with “difficult patients” blamed “difficult” behaviour (such as disruptive, abusive, or attention-seeking) on the patients, likely inhibiting patient care and potentially physician self-care. ⁵³This relates to the common myth that a patient-physician relationship can be one-sided. ⁴⁷ In contrast, Pare and Rosenbluth (1999) believe, “Simply tolerating these patients may be the best that can be done and may be better treatment than they have received from anyone else”.⁵⁴The best antidote to countertransference is “self-insight and self-restraint”. ⁴If a HCP has the privilege of watching a patient improve through a long term, caring, patient-centered relationship, it is deeply satisfying, worth the effort.^{14,
16, 38}

5.2 Managing Physician-Patient and Treatment Boundaries

A second theme described in the literature is that people with BPD will get better faster if their primary care physician provides a structured, clinical environment and clearly communicated treatment plan.^{23, 39, 42}This starts with the physician appropriately perceiving the patient as competent, intelligent, and responsible. These traits are often minimalized by the person’s unstable self-image and prior maladaptive dependent habits for help, or inhibited by stigma.³⁸ With this knowledge, a physician can more readily create an empowering contract with the patient regarding the structure, frequency, amount, and length of visits, phone calls per month, physician availability, and even amounts of drugs to be dispensed at a time.^{23, 27,37, 39, 40, 42, 54}Mutual treatment goals should be agreed upon as well, usually long term but short term are reasonable. ^23, ²⁶The goal is to balance empowering the patient’s intelligence, competence, and responsibility, while minimizing the patients’ fears of abandonment.^38, ^{27, 40} A structured interview that includes a clear agenda, time limit, and active effort by the physician to ensure focus on the most urgent, current problem, can provide the patient with security about the encounter while minimizing unnecessary tangents.^23, ³⁹ Flexibility may be required to ensure the patient is well cared for, ⁴³ but unless a true emergency surfaces, lengthening or adding visits, or creating after hours availability will further enable maladapative behaviours and is not recommended.¹⁶ During the clinic visit a chaperone should be present for physical exams ^{27, 39}due to difficulties in interpreting boundaries, and the possibility for manipulation.⁵⁴ Lastly, thorough documentation of the treatment plan and discussed boundaries is vital when the patient is questioning the agreed upon contract during episodes of conflict (especially if firing the patient must be considered).⁵⁴

5.3 Be a Safe, Consistent Place for Containment and Mentalization

The third concept maintains that every person with BPD needs a “holding” environment where they can be safely heard (especially if intensely angry or markedly labile in mood) with empathy and calm, neutral attention^{43, 47}Often HCPs who distance themselves from people with BPD are protecting themselves, perhaps unconsciously, but this may worsen the person’s symptoms of abandonment, thus increasing maladaptive and harmful behaviours that will reinforce HCPs distance^50,
55In the face of aggression or dysregulation, a physician must attend to the emotion more than the content.⁵² This can be done by labelling patients’ chosen style of maladaptive behaviour. ^{16, 47} Attending to and labelling emotion will de-escalate the behaviour as long as the HCP maintains a neutral, empathic attitude. ^{26, 37}It is important to tolerate, within limits, certain actions and anger while firmly requesting appropriate conduct never giving into demands. ^{27, 37, 56,}If ineffective, conclude the visit and reschedule if possible to minimize a fear of abandonment.¹⁶As with any patient, people with BPD must be held accountable for unacceptable behaviour, ³⁷and they must actively participate in their treatment. ^{23, 43}Continue to reinforce that behaviours are learned responses and are ineffective, and thus they have the potential and the ability to change, but it is entirely their responsibility. ^16, ²³Maintaining a positive, hopeful perspective, in light of any situation described or conflict that occurs, is important for both the physician and the patient. ⁴⁷

When a person discloses thoughts of self harm or suicide, attend to their concerns genuinely and with concern, listening and exploring thoroughly, especially trying to distinguish if a self-punishment desire, or a truly suicidal impulse. ²³If truly suicidal, be judicious in sending to the emergency department for admission; if unsure, first speak with a specialist, peer, or other HCP involved in the person’s care, as outpatient treatment is often the best treatment.²³

Mentalizing is “the ability to understand one’s own and others’ mental states” ⁵⁷, and is another essential component of managing people with BPD.⁴⁸Simply labeling their emotions can create crucial, mental separation from the emotion, physiologically enabling the pre-frontal cortex (underactive in people with BPD⁴²to exert control over a hyperactive amygdala.⁴Mentalizing enables people to anticipate crises, inhibit their impulses, and regulate their affect.⁴⁸ This is reinforced by HCPs explicitly giving them “permission to feel”, speak those feelings, and reinforcing the differences between feelings, thoughts, and actions.^16, ⁴⁸Dialectical behavioural therapy, the most studied and well known therapy for BPD, is an intensive individual and group therapy that empowers people with BPD with the skills needed to regulate labile emotions and manage relationships effectively. ^{Choi Kain 2017 (61?)} Using MRI technology, Mancke et al (2018) showed that “DBT increased grey matter volume of brain regions… critically implicated in emotion regulation and higher-order functions, such as mentalizing”,which correlated with these patients’ therapy responses.⁵⁸

5.4 Treatment Planning: Goals, Expectations, and Options

DBT may still be a gold standard of treatment (though it’s controversial), but no longer must its long wait list prevent people with BPD from getting effective treatment.⁵⁹ The evidence, most recently reviewed by Storebø et al in a Cochrane review (2020), suggests that BPD-specific psychotherapies are all quite equivalent, including specialized therapies (DBT, mentalization-based therapy [MBT], transference-focused psychotherapy [TFP], and schema-focused therapy [SFT]) and generalized therapies (general psychiatric management [GPM] and structural clinical management [SCM]).⁶⁰ Whether the therapy has significant training and is high intensity, or neither, and whether it is an individual, group, or combined therapy, does not matter.^{10, 61}Patients may need constant support to stay in therapy for fear of abandonment by the primary care physician,³⁹but if the patient is participating,physicians should expect positive changes over thecourse of months, and eventually improve substantially ^12, ^{14, 43}Thesechanges seem to include central neurological changes: Schmitt et al (2016) found that DBT reversed some of the neurobiology likely underlying core BPD symptoms of markedly labile emotions, including anger, specifically finding, “reduced activity and increased connectivity in neural networks related to salience processing [attributing importance to new stimuli] and emotion regulation”. ⁶²Setting SMART, small goals can also significantly help, even if it’s scheduling lifestyle changes like exercise and sleep, or focusing on attending helpful groups (AA, NA).^{23, 63, 64} Interventions the physician can try include motivational interviewing or step-wise problem solving ^{40, 65}, the “5 A’s” ^66, ⁶⁷, or the “BATHE” technique.^{67, 68} Lastly, unity via ongoing, clear communication between HCPs is essential to minimize a frequent defence mechanism among people with BPD called “splitting”, ^{23, 27,} ^{40, 69} or creating extreme dichotomies to defend oneself from conflict. ⁷⁰

5.5 Prescribe conservatively, in limited amounts, for short durations, if at all

Medications are only to be used as off-label adjuncts to quality psychotherapy in the treatment of BPD symptoms.^{23, 61, 71, 72} The only time they are first line is for comorbidities, which are harder to remit and require specific symptom targeting due to overlap^{52, 73, 74}The only evidence for medications are from small trials showing benefit for specific symptoms like anger, anxiety, and depression, using atypical antipsychotics (aripiprazole and olanzapine), omega 3 fatty acids, and two anticonvulsants (topiramate and valproate);⁷⁵ lamotrigine was recently shown to be of no significant benefit.⁷² Yet literature reviews, including a recent Cochrane review (2020) by Stoffers-Winterling, continue to show no convincing evidence of long term benefit, nor benefit for core symptoms.⁷²If physicians and patients mutually agree to try medications, investing in psychoeducation and a referral for psychotherapy should be the first step.⁷³ Medications should only be started at low doses, titrated slowly, and have a pre-specified date to taper or stop the medication if it’s not efficacious, limiting the symbolic nature of treating BPD with medication (which is simply not the definitive treatment).^{23, 52, 73} Limit amounts of potentially toxic medications (sedatives, cardiac medications) dispensed by pharmacies due to potential for impulsive, self-destructive behaviour,⁴⁰ and remember the high co-occurrence of substance use disorder with BPD (up to 80%).⁵² Benzodiazapenes are contraindicated, and other controlled substances should only be used as a last resort.³⁷ Attempt deprescribing any medication with unclear benefit to the patient;^{23, 73} There is no evidence for polypharmacy,^40,
52 and we know it can cause harmful dependence and side effects.^{37, 74}

6 DISCUSSION

6.1 Summary of “tools” and review of evidence found in the literature

Boxes and tables found in articles may have been intended to become daily tools for physicians, but were not overtly labelled or explained as such. They were not explicitly reviewed and explained in detail here, but rather their contents were used to create this tool (Appendix A).

As seen from Appendix C, there are overlapping themes in the tables and boxes arranged. The main themes of these tables along with other literature used in the tool (see results, Appendix C) align with the six themes chosen. Significantly, major guidelines for BPD from the USA and the UK agree with the majority of these findings.^{76, 77} Also, in reference to treating “difficult patients” (many of whom have BPD), most management themes were similar in the literature on BPD compared to Lorenzetti’s 2013 review of treating “difficult patients”. ^{7, 23, 26, 27 40}

6.2 Moving from Literature to Tool

Taking the themes and major points above, these were shortened for artistic power and changed into active tense for reader impact, chosen carefully, and succinctly added to a template on Draw.io. As expected, there were some disagreements in the literature. First, it was unclear if silent empathy and prompting in response to a distressing statement was more appropriate, ³⁸ or actively engaging continually with a person with BPD.^{23, 43} However, it seemed that only in these specific situations, in order to prevent the physician from a “rescue” or “distancing” reaction, would silence be appropriate. ³⁸ Second, Cristea et al (2017)’s metanalysis disagrees with the idea that all therapies are equivalent, believing that most specialized therapies, including mentalization based therapy, dialectical behavioural therapy, and transference focused psychotherapy are more effective than generalized therapies.⁷⁸ Storebø’s 2020 Cochrane review is more thorough, and Finch et al. (2019) further disagree, asserting generalized therapies don’t have significant risks or downsides.¹⁰ Paris and Laporte (2018) further assert a welcome point, that a stepped approach, starting with short term or generalized therapies to start, and then moving to specialized therapies, may be the most accessible and still effective system regardless. ⁷⁹Third, medications are controversial. The American guidelines from 2001 (surprisingly not updated since) speak to specific domains of symptoms in which medications may help, such as anger, anxiety, or micropsychoses. ⁷⁶ Parker (2019) summarizes more updated data, saying still considering second generation antipsychotics, omega 3 fatty acids, and anticonvulsants (not lamotrigine) for these areas may be reasonable.⁷⁵ However, this is in contrast to the UK guidelines published in 2009, stating medications should not be used except for true emergencies.⁷⁷ Finally, a Cochrane update of pharmacotherapy in 2020 (a full review is pending) found no conclusive evidence for pharmacotherapy for BPD.⁷² Yet medications are routinely prescribed, often in pressure from patients seeking something to help symptoms, and this may result in potentially dangerous polypharmacy, lead to substance abuse, or suicide attempts.⁶¹

Due to slight conflicts in the evidence on psychotherapies, the latest Cochrane review was taken as best evidence, along with the other articles supporting Storebø’s point. ^10, ^{60, 59,}Regarding pharmacotherapy, a middle ground, compared to the UK and USA guidelines, was taken, as evidence is still inconclusive⁷²but some physicians believe medications, used correctly, can help some symptoms as well as improving the patient-physician relationship. ²³

6.3 What it might be missing:

Most objectives outlined in the background were met, but it could have done better connecting symptoms and behaviour to clinical principles. Counter-transference can involve realizing that symptoms manifesting and expressed in BPD may reflect a continuum that can include HCP’s own experiences and humanity.⁵¹ This may be unnerving , but it is crucial to an empathetic patient-physician relationship. ⁵¹ It is crucial to respond to disruptive or uncomfortable behaviour as you would to symptoms of other diseases: with an evidence based treatment plan, in this case being a calm, neutral, empathic attitude, labelling the dysfunctional behaviour while maximizing patient’s capacity for competence, control, and reminding them of responsibility for choices. ^16, ^{26, 39}This is only implicitly reflected in the tool.

This tool was not created to aid in diagnosis, which alone is controversial, especially with DSM 5’s multiple classifications for personality disorders and the increased chances of comorbid personality disorders with BPD.¹⁷ Still, diagnosis has an important relationship to stigma.⁸¹ Appropriate, timely diagnosis can decrease stigma and mistrust in the health care system, and should improve treatment, prognosis, relief at a diagnosis, and greater access to care. ^2, ^{37, 42, 49, 69, 74 80, 81} While there is concern that a diagnosis increases stigma, and the label itself worsens some patients’ experiences, overall the longterm benefits of giving a diagnosis seem to outweigh the harms. ^{2, 81, 82}

Another way to decrease stigma will be increasing HCPs awareness of the fairly good prognosis for people with BPD, although the data can be complex. Patients in Zanarini’s study (2012) were inpatients, taken from before many therapies were available, and had non-intensive outpatient therapy, ¹²andonly 50% fully recovered their employment and social lives at 10 years; 60% at 16 years.¹² As inpatients, likely they were more severe than community patients, and that people with less severe BPD may do much better, with more treatments available now.

Lastly, a surprising finding in the tables, boxes, and even literature of BPD management, especially in primary care, was the lack of details on crisis management or suicidal intention; only two tables/boxes mentioning it.^{23, 26} A reason for this may be the lack of evidence behind any screening tools for suicidal intent in stopping completed suicides,⁸³hospitalization (the default management pathway for most concerned physicians) is not significantly effective either.⁸³ Gunderson (2014) believes the best approach is to explore the threats thoroughly, to determine if the person is truly suicidal, or seeking self punishment after a recent significant stressor or behaviour.⁴³ Some warning signs that may help are changes in mood, stressors, activity, losses, or substance use.⁴In the end, always call a specialist if unsure, and it’s important to remember that most patients have managed crises before on their own and competent.⁴³ Ultimately, maximizing their own responsibility is crucial for long term recovery.⁴³

6.4 Implementation

Initial implementation and use of the tool should be as a poster in a physician office, ideally shared with HCPs, or as an electronic document, to be downloaded onto primary care providers’ smartphones or computers for quick access. The best way to distribute it to doctors may be getting it printed and mailed, or emailed, to them through the local Canadian Family Physician Chapter, Doctors Nova Scotia, the Nova Scotia Family Physician Facebook page, or through the Nova Scotia health Authority. As this will require buy in, it will be first emailed to physicians and family residents well known to the author, and presented to fellow family medicine residents and family physicians in a powerpoint session, with distribution to those interested. Hopefully this will acquire enough of a following to advocate for its inclusion in broader family physician organizations that can increase its distribution.

Another way will be to publish it in a journal, such as the Canadian Family Physician journal. While difficult, it certainly would help distribution. The last, but not a difficult method, is to email it to major authors in the BPD treatment field for feedback and potential distribution. These would include: Dr. Paris, Dr. Storebø, Dr. Sulzer, Dr. Searight, Dr. Moran, Dr. Finch, Dr. Bateman, Dr. Sansone, and Dr. Choi-Kain (Sadly Dr. Gunderson passed away last year).

Hopefully this tool could be studied in the future for its effect on providers’ knowledge of treatment for BPD, their confidence and satisfaction in caring for people with BPD, and ultimately see if it improves the satisfaction and care perceived by people with BPD.

Even if this research never happens, there are not many primary studies looking at people with BPD in primary care. Truly a great outcome from this tool is to invigorate the research in this area and then be bested by other tools, in order to give people with BPD the best care they can get.

7 STRENGTHS / LIMITATIONS

The strengths of this study is that it was pseudo-systematic, using 5 databases with multiple search methods, a host of search terms, and even Google, to cast a wide net for relevant literature. Using covidence.org’s tools for removing duplicates, screening articles was efficient and less likely to miss relevant data.⁴⁴

Some important improvements on prior tables and “boxes” found in prior literature are:

1) It’s visually appealing; 2) It’s more detailed in order to explain why these principles are important; 3) It clarifies prognosis, providing hope; 4) It is a reminds providers that DBT is no longer the only treatment, and that goal-setting and lifestyle approaches may help;^{23, 63, 64} 5) it implies a real disease as well as truly effective treatment in stating the neurobiological deficits involved in BPD symptoms reversed with treatment; 6) It is clearer and more detailed about medication use due to chronic overprescribing in people with BPD. ^{23, 61, 74}

There were a number of limitations to this study. Adolescent BPD management was not specifically described due to the need for a narrower search in such a broad subject. However, on a quick search of Pubmed (see appendix C), none of the 57 articles found described primary care management for adolescent BPD, and only two focused on management of adolescent BPD.^{84, 85} Neither article mentioned how primary care management might differ, thus the same clinical principles likely apply.^84,
85 Also, searching in English and only those with online availability (though this included getting many documents delivered online via library services if not available locally) may have limited results. There were no exclusion/inclusion criteria prespecified, so it was semi-systematic, as this search was iterative. However, articles were consistently relevant to personality disorder management (BPD is the most studied of personality disorder after all)⁷⁷and had to have principles or ideas that could be implemented in primary care settings. Lastly, no guidelines for the creation of a practice tool for physicians, or even health care providers, could be found. Thus approximate comparisons with other educational tools⁸⁶, templates,⁸⁷ and using basic guidelines from grey literature⁸⁸ were used to roughly guide the creation of the final product. While the tool does not fit nicely onto standard size printer paper, it would be best if printed at twice the size seen in this document, which could be done at a university printer or likely through a health organization. It also excels on a smartphone screen, but it must be recognized as a potential barrier to implementation still.

In future, an interactive tool on a website or app that linked statements and themes with references, quotes, and sample conversations may be more clinically applicable. It also may be reasonable to add a second page that fills in details on symptoms in connections with treatment principles, describes all types of psychotherapy and medications that have been studied, as well as discussing stigma, diagnosis, and crisis management further. While not considered during the research phase nor the creation of this tool, there may be enough of a gap in patient self-advocacy tools available that, with slight modifications, this could become a helpful self-advocacy tool for people with BPD when visiting their physicians.

8 CONCLUSION

BPD is a complex disorder that is highly stigmatized with patients not getting necessary treatments, despite BPD having a relatively good prognosis long term. Primary care physicians are often involved in their care, but feel ill-equipped to handle people with BPD, and there are no easily accessible tools to help. This study searched relevant literature extensively and created a one page, visually appealing tool to help primary care providers manage BPD. It included five main themes:

1. Manage countertransference hopefully, reflectively, and collaboratively

2. Ensuring patient-physician relationship and treatment environment have structure and firm boundaries

3. Becoming a safe, consistent place to contain and mentalize dysregulation

4. Develop a thorough, mutually agreeable treatment plan with both short and long term goals and expectations

5. Prescribe conservatively, in limited amounts, for short durations, if at all

This tool has many similarities to tables from past reviews of BPD management in primary and secondary care, but has more details on treatments, more visuals, and distinctions between major themes and smaller subthemes. It will be implemented proportional to the interest primary care providers show in it, as well as sent to experts in the field in case they have recommendations for improvement or implementation. It is designed for now as a paper or electronic document, but could easily have a page added, be turned into an interactive website or app, and potentially be modified to be used as a patient-advocacy tool to discuss with their primary care providers’ office.

9 Acknowledgements

Robin Parker and Jackie Phinney, both librarians at Dalhousie Library, who helped MP refine his library searches.

Dr. Fred Burge, supervisor and facilitator of MP’s growth and learning through the process of making this article.

Dr. Emily Murphy and Dr. Jock Murray, for empowering MP with the time required to complete this article

My wife Jill Peters, BScN, MPH, who edited this paper, helped design the tool, and was incredibly supportive throughout the process.

10 REFERENCES

10.1 Introduction references

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29. Imbeau D, Bouchard S, Terradas MM, Simard V. Attitudes des médecins omnipraticiens et des résidents en médecine familiale à l'endroit des personnes souffrant d'un trouble de personnalité limite [Attitudes of general physicians and family medicine residents towards patients with borderline personality disorder]. Sante Ment Que. 2014;39(1):273-289. Accessed online August 25, 2020, at: https://www.erudit.org/en/journals/smq/2014-v39-n1-smq01474/1025917ar/

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10.2 Methods References

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10.3 Results references

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Top of Form

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10.4 Discussion References:

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11 Appendices

11.1 Appendix A – TOOL

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Description automatically generated

11.2 Appendix B– Tabulated Form of Results

Table 1:Themes and Subthemes with Evidence

Theme	Sub theme	Evidence in literature
Counter-transference :	Self care	Must take care of self to care for patients’ sake, and model it, directly helpful to BPD, maintain positive perspective ^{16 47} Ok to refer to other physicians who can better handle pts with BPD esp if not coping with +++SI, SH ¹⁶ Counter-transference is unavoidable, self reflection often helpful in discovering more about patient ⁷⁴
	Self reflection	Essential for functional, optimal pt-doctor relationship ⁵⁰ Be aware of emotions before and during interaction, as stigma may limit HCPs’ tx, appropriate dx, and pt’s access to care ^{39, 42} Need unbiased attitude, Otherwise will increase pt stigma, hopelessness ^{49, 71}
	Discuss with peers / specialists	Need team and supervision due to negative countertransference ⁵² Need for specialty support or other PCPs’ support - ^{16, 23, 26 42}
	Clinical Response –	Often feel we have to “do something”, give advice in the face of conflict, but this actually increases conflict while worsening the patient’s and our situation both short term and long term – ⁴⁸ Respond to dysregulation as you would any other symptom because it’s part of psychiatric condition (not necessarily an intrinsically difficult patient) – ³⁹ Silence in the face of a patient’s distressing statement may be just what they need to show their competence and responsibility – ³⁸ “4 options in bad situation: leave it, accept it, change it, or reframe it” ¹⁶
	Negativity	HCPs overwhelmingly feel: Fear, anxiety, frustration, decreased empathy, fear their patient may manipulate them or be violent, thus increasing focus on physical symptoms and may create anger and defensiveness in the physician, compromising the essential dr-patient relationship (and this may not be atypical as a response to a person with BPD) – ¹ >50% Drs blame pts as source of frustration in interactions with “difficult patients”, which inhibits patient care – ⁵³ NO patient-physician relationship is one-sided, ⁴⁷ Prognosis is actually quite good ^{3, 12}
	Patient-Physician relationship	Tolerating the patient may be the best treatment – ⁵⁴ Ensure patient aware that high quality care is not dependent upon their symptoms or behaviour (within the limits set down)– ¹⁴ Physicians must also be active and accountable participants – ²³ ⁴³
Managing Boundaries and structure –	Structured clinical environment crucial	Limit length of visits, Rx amounts prescribed, # visits / month and physician availability, ensure crisis plan –⁵⁴ Ensure treatment goals defined as well – ²⁶ No more than 1-2 physicians primarily caring for patient ²³ Outline contract for availability ²³ Brief, consistent, freq, structured ^{23, 27} ^{37, 39, 40} (esp for needy, demanding pts) ⁴² Structure interview with intro, agenda, and rationale, to give pt security about encounter, to contain typical diffusion of hx, and to focus on the most urgent, current problem only ²³ ³⁹ Contract must find balance of minimizing pt fear of abandonment (w/ regular visits) and creating boundaries to empower pt – ²⁷ ^{38 40} Leniency in these conditions (except in a TRUE emergency) will maintain maladaptive behaviours, such as lengthening visits, additional visits, or after-hours availability ^{16, 26, 37, 39, 40, 54} Try to Label why pt seeking more visist, as may be due to a fear of abandonment) – ³⁹ Boundaries enable pt to develop own sense of competence, control, but depend on dr perceiving pt as intelligent, responsible, competent, and that “not all is as it appears to be” ³⁸
	Set clear Professional boundaries	Ensure chaperones available for physical exams ^{54, 39} Document, document, document ^{69, 54}
Contain and be a safe place	Contain dysregulation	Become a safe place where the patient is heard with empathy and a calm, neutral attention. ^{43, 47} Calm, concerned empathic attention will de-escalate behaviour ²⁶ ³⁷ Attend the emotions more than the content – ⁵² If expressing suicidal intent, explore thoroughly to better understand if simply self-punishment for recent behvaiour, or if truly suicidal intent. If clearly the latter, act judiciously in arranging for urgent follow up or referral for potential admission, though always worth asking for help from peer or specialist if unsure ²³ Patients’ suicidality is usually acute on chronic, so maximizing responsibility, with awareness that they have coped with crises in the past, but also aware of the higher suicide rate, is important – ^{4, 23}
	Responding to anger or aggression	Reframe anger as chosen style of behaviour (an ineffective, maladaptive choice), and thus can be changed, so label and address such behaviour; Label and model that self-destructive acts are ineffective, learned responses to strong emotion, or a learned cry for help, – ¹⁶ ⁴⁷ Tolerate anger, with limits, not giving into demands – ^{27 37 56} Explicitly and firmly request appropriate behaviour; if patient is not responding, conclude visit and reschedule – ¹⁶ Hold patient accountable for behaviours, do not tolerate unacceptable behaviours: same standard for all patients – ³⁷ Expect active participation and responsibility, with accountability and reinforcing potential for change, in person’s treatment. ²³ Maintain positive perspective and frame things as positively as possible in response– ⁴⁷
	Mentalization : Labelling and validating emotions	Help them label their emotions, creating separation from emotion and enabling the pre-frontal cortex (less active in people with BPD – ⁴²) to exert control over a hyperactive amygdala ⁴ ³⁷ Give them permission to feel by reinforcing that feelings / impulses don’t have to act out, THUS giving pt ability to anticipate crisis, inhibit impulses, and regulate affect –⁴⁸ ¹⁶ (helped with Collaboratively examine issues from all sides)
Treatment options, goals, and plan	Psychotherapeutics	Most common types include: dialectical behaviour therapy (DBT), mentalization-based therapy (MBT), transference-focused therapy, Schema-based therapy, general psychiatric management, structured clinical management, and systems training for emotional predictability and problem solving (STEPPS). MBT / DBT are most studied – ⁶⁰ Low quality evidence (small effect sizes, unstable followup outcomes, and likely bias) shows no clear differences in effect between psychotherapies, and there were a large variety of treatments that all showed some effect, with amount of patient time, treatment intensity, and individual versus group settings. Even treatment as usual is at least somewhat effective, without having significantly worse outcomes – ^{10, 60, 78} Stepped care approach helpful for increasing access to care ⁷⁹ Constant support for person to stay in this therapy is key ,and reassure that it’s not abandonment, but additional care as definitive treatment (³⁹)
	Short term goals	Small, feasible goals can make a real difference, like Regular exercise or sleep, attend groups like AA, try to call for help before crisis, etc. ²³ Brief counselling interventions like motivational interviewing, step-wise problem solving techniques, the “5 A’s” or the “BATHE” technique may all empower patients create and achieve their own SMART goals – ^{65, 26, 47, 67}
	Expectations	Expect positive changes – ^{14, 43, 12}.
	Provider Splitting	Ensure active, clear, ongoing communication with all HCPs to avoid splitting between HCPs and ensure coordinated care ^{23, 26, 40, 27}
Pharmaco-therapy must be used conservatively as adjuncts and only one at a time.	Medications are only adjuncts to quality psychotherapy	Emphasize meds are not first line, but adjuncts to psychotherapy, because no medications are able to cure the core symptoms of BPD - ^71, ^23, ⁷² Prescribe conservatively; no medication ahs been approved for BPD and none are uniformly or dramatically helpful – ⁸
	Polypharmacy not worth for symptoms of BPD - ^{40, 52}	Creates dependence and increased risk side effects ³⁷ No evidence for it - ⁷⁴ Desperate cocktails in crisis aren’t worth the risk – ⁷³
	Limit amounts of medications dispensed for people with BPD	Given impulsivity and SH predilection, limit Rx amounts of toxic medications (eg. TCAs, cardiac meds, Benzos) - ⁴⁰ Be very conservative using potentially addictive or abusable medications – ^{40, 52} 25% of pts with BPD may consider suicide by overdosing – ⁵² esp given high proportion SUD in pts with BPD (20-80%; 65% SUD have BPD)– ⁵² Consider tapering both effective and ineffective medications – ⁷³
	Medications are important in treating comorbidities	If treating Comorbid conditions, which may benefit from pharmacotherapy, be very clear what symptoms are being targeted. Remission often more difficult due to BPD – ^{52, 73, 74}
	Medications that may help with specific symptoms of BPD	Benzos contraindicated, may worsen BPD, incr inhibition - ³⁷ Small studies did show benefit for specific BPD symptoms 1. olanzapine - anger, anxiety 2. Aripiprazole – anger, anxiety, impulsivity, depression 3. Omega 3 fatty acids reduced depression 4. Anticonvulsants (Topiramate, Valproate) improved anxiety and anger As results not easily pooled and few studies, no general recommendations appropriate, no medications proven for core sx of BPD – ⁷⁵ Lamotrigine and fluoxetine no longer recommended due to recent studies showing no sig benefit - ⁷²
	Prescribing medications	Stop medications with unclear benefit before starting new medication ²³ Invest in shared decision making, psychoeducation, and psychotherapy – ⁷³ Be aware medication is powerful symbol of BPD treatment, may undermine pt’s self-improvement, thus hard to stop if no sig SEs unless thorough psychoeducation around effective tx for BPD ^{23 73} If medication started, do specific trial of one medication through single pharmacy with agreed upon end time if medication not effective - ⁵² Start low, go slow,monitor compliance, SEs, SI – ⁷³

11.3 Appendix C – Search Strategy

Table 2: search terms used in searching databases

Concept 1	Concept 2	Concept 3	Concept 4	Concept 5
Borderline personality disorder	Treatment	Doctor’s office	Principle	clinical decision aid
Personality disorder	Psychoeducation	Primary care	Algorithm	clinical guide
	Therapy	Family doctor	Flow chart	clinical decision aid
	Pearls	Family physician	Protocol	clinical principles
	Quotes	General practitioner	Guideline	clinical essentials
	Counsel	Family practitioner	Chart	clinical theory
	Recommendation	Primary care provider	Formulation	clinical management
	Management		Schema	clinical attitude
	Advice		Blueprint	clinical procedure
			Outline	clinical guideline
			Diagram	framework
				treatment essentials
				treatment principles
				approach

These included Ebscohost (PsychInfo, Academic Search Premier, PsycBooks, PsycExtra), Web of Science, PubMed. These were always combined together once in each database, as well as in 3 or 4 concept combinations, but searching by title/abstract only, and screening first hundred results only (as results were often in hundreds to thousands). EMBASE was not able to be searched via Dalhousie library due to technical difficulties, so it wasn’t searched.

Table 3: Search terms in Google for possible clinical tools.

Google: algorithm principle OR flow-chart OR chart OR formulation OR schema OR blueprint OR outline OR diagram OR doctor's OR office OR primary OR care OR family OR doctor OR family OR physician OR general OR practitioner OR family OR practitioner OR primary OR care OR provider OR treatment OR management AND "borderline personality disorder" -: No clear flowchart, protocol was found.

Later search terms: "principle OR algorithm OR flow chart OR protocol OR guideline OR chart OR formulation OR schema OR blueprint OR outline OR diagram" to above searches, again none found by title screening.

Searches on Google Images, looked through first hundred results each time:

· borderline personality disorder treatment

· borderline personality disorder infographic

· treatment, "borderline personality disorder", and any of: algorithm OR protocol OR chart OR guide OR clinical OR decision OR tool OR management OR summary OR physician; (NOT) ncbi.nlm.nih.gov

Also searched Dynamed and ClincialKey for physician tools, found only additional synthesis of management pearls, no tools.

Searches for differences in management with adolescent BPD: (via PubMed):

(Borderline personality disorder) AND ((doctor's office) OR (primary care) OR (family doctor) OR (family physician) OR (general practitioner) OR (family practitioner) OR (primary care provider)) AND (treatment OR management OR pearls) AND (adolescent OR teenager OR adolescence or pediatric))