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Samenvatting Thema 3 Personality Disorders (Master Clinical Psychology)
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Thema 3 Blok 4.2 Forensic Psychology (Master Clinical Psychology)
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Thema 3Is het mogelijk PD te behandelen en treed er echt verandering op? Model van Gunderson.
Gunderson, J.G. (2016). The Emergence of a Generalist Model to Meet Public Health Needs for
Patients With Borderline Personality Disorder.
Casus
Casus van een jongen met een borderline PD en ook zelfdestructief gedrag met suïcidale gedachtes.
Behandeling duurde lang omdat psycholoog dacht dat alleen DBT evidence-based was en daarom
alleen zocht naar iemand die dat kon uitvoeren. Uiteindelijk niet iemand officieel gevonden maar wel
die iets kon. Manier van behandelen is meer vader-achtig en niet zoals een normale behandeling. Er
worden ook wat meer directieve aanwijzingen gegeven. Na een lang traject van ups en downs lijkt de
jongen zijn leven aardig op de rails te hebben. Vraag is of het zo blijft en of de borderline gedachtes nu
echt weg zijn of dat hij alleen geleerd heeft zijn gedrag aan te passen.
Inleiding
This patient group accounts for about 2% of the population, 15%-20% of psychiatric hospital and
clinic admissions, 10%-15% of emergency department visits, and about 6% of primary care visits. The
far higher indirect costs associated with the disorder include high rates of failed work, marriages, and
child-rearing, as well as high rates of medical problems. Eerste behandelingen gebaseerd op
psychoanalytische theorieën van Kernberg, maar weinig bewijs voor. Dit artikel focust zich op de 3
behandelingen met het meeste bewijs, the problems they exposed, and how, after a second generation
of outcome research, a generalist treatment model emerged. This model shows that nonspecialist
psychiatrists and other professionals can provide effective care, which helps address the need for more
clinicians to treat patients with the disorder.
Evidence based treatments: The Big Three
Samenvatting staat in de afbeelding.
1. Dialectical Behavioural Therapy (Linehan, 1993):
DBT was a radically different model of therapy, whose effectiveness was demonstrated by dramatic
improvements compared with usual care. This model combines once-weekly individual with weekly
group therapy. It was far more supportive and didactic than the psychoanalytic model. In the recent
revision of her manual, Linehan now details applications of DBT for a number of other disorders as
well. Her revelation of having spent a significant portion of her adolescence hospitalized for severe
self-harm has generated increased credibility for her model and even more devotion to it by patients.
2. Mentalization-Based Treatment (Bateman & Fonagy, 1999):
Like dialectical behaviour therapy, it combined a weekly individual session with group therapy.
Mentalization-based treatment was based on observations of troubled parent-child interactions, which
were thought to cause the borderline patients’ impairments in self/other awareness. The mentalization-
based treatment interactions themselves are psychoanalytic-like by emphasizing inquiry (“not
knowing”) and focusing on the patients’ interactions with their clinicians or with other group
members. Unlike psychoanalysis, mentalization-based treatment is more supportive and discourages
interpretation. Mentalization-based interventions are dialectical behaviour therapy-like in being
supportive and dyadic (i.e., clinicians are more “real” in showing emotions and self-disclosures), but
unlike dialectical behaviour therapy, mentalization-based treatment discourages directives and lacks
homework. Wel effectief maar heeft zeker niet DBT vervangen.
3. Transference-Focused Psychotherapy (Kernberg, 1999):
A study compared an investigator-developed treatment against two controlled manualized alternatives;
specifically, twice-weekly transference-focused psychotherapy was compared with dialectical
behaviour therapy and with once-weekly individual supportive psychotherapy. Although there were
some advantages for the transference-focused psychotherapy in diminishing hostility and improving
reflectiveness (related to the mentalization concept), the three treatments performed quite similarly in
most outcome domains. The study offered evidence that an identifiably psychoanalytic form of
therapy could be manualized, and the results were interpreted as an affirmation of the efficacy of
transference-focused psychotherapy.
, Nadelen
Because of the time and costs required for specialized training in these evidence-based treatments,
they have not offered—and cannot be expected to offer—a meaningful response to the public health
need for clinicians to treat patients with borderline personality disorder. Another issue is that all three
models primarily target the psychological problems of the disorder, giving relatively little attention to
its biogenetic sources and social adaptational failures. The significant heritability of borderline
personality disorder was not discussed, family interventions were not included, medication
management had an unintegrated role provided by an independent clinician, and vocational
rehabilitative needs were not addressed. Ook de rol van medicatie is bij deze modellen niet
meegenomen. Daarom nu gekeken naar een meer algemeen Generalist Model.
Emerge of a generalist model
Alle modellen hebben uiteindelijk hetzelfde doel: verbeteren van Borderline (PD) patiënten. Daarom
gekeken naar de onderliggende factoren. The nonspecific characteristics they shared included the
presence of a primary clinician, the establishment of goals, active responsiveness, a therapeutic
relationship, safety planning, and at least as-needed use of other clinicians to discuss problems. Er zijn
hier 3 studies naar gedaan:
1. The first such study compared TFT, DBT, and supportive psychotherapy. When that study was
completed, transference-focused psychotherapy’s success was so heralded that relatively little
attention was paid to the fact that the considerably less intensive once-weekly supportive
psychotherapy did nearly as well.
2. The second study to use a manualized comparison treatment tested the value of DBT compared
with general psychiatric management. The general psychiatric management arm of this study has
been characterized by Kernberg as being like supportive psychotherapy. General psychiatric
management was a once-weekly treatment mostly offered by general (nonspecialist) psychiatrists
with 5 or more years’ experience. General psychiatric management is openly psychoeducational,
medicalizes the disorder, focuses more on life outside the office than on in-office interactions, and
integrates medication management. Here too, the results from the generalist arm were very
similar to the index treatment, that is, what Linehan herself recognized as high-quality DBT.
3. The third relevant RCT used primarily registered nurses to test the value of MBT against a
treatment called structured clinical management. Like general psychiatric management, structured
clinical management is a weekly supportive case management that focuses more on life outside
the treatment than on the interactions within the sessions. In this trial, patients in the
mentalization-based treatment arm improved more rapidly, but both conditions led to significant
gains on all outcome variables. It was the subgroup with more comorbidity that benefited more
from MBT. In an independent trial in which MBT (individual and group) was compared with
biweekly supportive group therapy, few differences were observed in their effects, although again
patients receiving mentalization-based treatment improved more rapidly.
Discussion
Altogether, these studies have now established that treatments that require less training and that are
less intensive than the major evidence-based therapies can be relatively efficacious for patients with
BPD. The generalist model supported by this research centers on once-weekly sessions with a case
manager/psychotherapist who is supportive, directive, and pragmatic. As illustrated in the vignette, the
general psychiatric management model of treatment is initiated by unapologetically disclosing the
borderline personality disorder diagnosis, which is clearly identifiable by excessive anger,
interpersonal reactivity, selfharm, and impulsivity. This diagnostic disclosure is then accompanied by
psychoeducation, including explicit statements about the handicaps imposed by genetic makeup. The
clinician then keeps the borderline patients’ focus on their problems in daily living, while flexibly
integrating family interventions, group therapies, and medications.
Implicaties
Less intensive interventions should become a first line of treatment.
The treatment of borderline personality disorder need not be reserved for specialists with
extensive training.
The negative stigma that has surrounded BPD since its introduction into the diagnostic system.
Even now, BP patients have a reputation for being untreatable and even treatment resistant.
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