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Episode 13

Borderline personality disorder

Show notes

Welcome to Generally Speaking, the conversation for all GPs.

Join GPs Dr Gill Singleton and Dr Billy Stoupas as they discuss some of the most pressing topics and issues surrounding the operations of a general practice.

This time, Dr Stoupas and Dr Singleton unpack some of the issues surrounding the diagnosis, treatment and stigma of borderline personality disorder. They are joined by Dr Sathya Rao, the Executive Clinical Director at Spectrum Personality Disorder Service, and Dr Louise Stone, a leading GP and medical educator with clinical, teaching, research and policy interests in mental health.

26 August 2020 - 01:21 PM | 33 min 12 sec

(00:21) Dr Singleton and Dr Stoupas discuss the scope of borderline personality disorder (BPD) issues facing GPs and cite a few statistics.
For example, at least 6% of patients in clinics have the condition, but unfortunately, the majority are not identified. It is a disorder that presents equally in men and women, and thankfully, with early intervention along with the right treatment, recovery is possible.

Introduction of Dr Sathya Rao and Dr Lousie Stone

(02:54) Dr Singleton starts off with Dr Rao and asks about his beginnings in the field of BPD.
He explains that he arrived in rural Australia from India about 27 years ago and his very first patient had severe BPD. He was able to aid in her recovery with the assistance of the then fledgling Spectrum clinic and its clinicians. It was that experience which set him on his path.

(03:44) Dr Stone also had a formative experience in a rural setting where her first job as a qualified GP was one where she was the first female doctor.
As a result, she was swamped with female patients who had experienced trauma. She found the relationship between a history of trauma and the development of BPD compelling, and it set her on her course.

(04:23) Dr Stoupas asks about the issue of nature versus nurture with BPD.
Dr Rao explains that for a long time, it was thought that trauma actually caused BPD, but now it is framed in terms of nature via nurture, or nurture via nature. So, trauma is a very significant risk factor for development of BPD but it doesn’t appear to be causative.

(06:34) Dr Singleton follows up with a question about diagnosing patients before they are adults.
Dr Rao cites research out of Melbourne which suggests that diagnosis can be made from the age of 12.

(07:12) Dr Stone adds that the most difficult patients she sees as a GP are the 15­–18-year-olds because they are still negotiating their way between adolescence and adulthood.
‘A lot of my time is required to reassure parents that when their child is in their early 20s it will be easier because they may be past most of the difficult social, emotional and interpersonal issues of being a teen.’

(09:26) Dr Stoupas raises the issue of the label and stigma attached to the name of BPD.
Dr Rao concurs and suggests that it should be named after John Gunderson, the scientist who contributed greatly to the understanding of the disorder,

(10:47) Dr Stone continues on the topic of diagnosis and suggests that whenever one is made in psychiatry, it is part science, part art and part ethics.
Noting that the goal of a diagnosis is to be helpful, she will sometimes introduce it, but then wait for the right time to actually record it.

(12:04) Dr Stoupas asks for tips on how to identify BPD among other conditions that patients may first present with.

(12:18) Dr Stone says that you don’t make a psychiatric diagnosis, the way you make one of a broken leg.
Psychiatric diagnoses bleed into each other, overlap, and change over time. But an overarching and terrible fear of abandonment is usually the first trigger for her. Following that you look for wild mood swings and personal instability in other aspects of life.

(16:16) Dr Stoupas asks about Spectrum and its funding. Dr Rao explains that it is part of a specialist mental health program funded by the government.
They treat about 200 patients, provide secondary consultations for about 500 patients and train about 1500–2000 clinicians every year.

(17:45) Dr Singleton picks up on the point about the importance of a GP’s self-reflection.
Dr Stone acknowledges that the hardest of the BPD patients are those who question things that a GP may value deeply, which in turn may be taken quite personally, so a GP can feel incredibly alone. This is where peer support and having other clinicians who might see a particular patient every second time can help.

(20:19) Dr Stoupas asks if there are any medications that are safe to use for BPD, given that it commonly occurs with depression and anxiety. Dr Rao concedes that we don’t have medication for the disorder. Psychotherapy is only treatment of choice. Having said that, he suggests there is a place for medications to deal with a patient’s depression or anxiety issues. He suggests using only one psychotropic medication at a time and the lowest possible dosages. If medications prove not to be helpful, avoid the temptation of changing too often.

(21:41) Dr Stone adds that patients will often go to multiple psychiatrists, multiple GPs, and may be on a dangerous combination of medications.
So as a GP, if you’ve got a 15-year-old who’s on the classic triple of a mood stabiliser, an antidepressant and an antipsychotic, that should be questioned.

(24:57) Dr Stoupas raises the issue of those with BPD who chronically have thoughts of self-harm or suicide, and asks what a GP should be looking out for.
Dr Rao explains that it is difficult to differentiate between a suicide risk and the risk of non-suicidal self-injury, as there is no science to guide us. He suggests that many patients often follow a particular pattern of self-harm behaviours, so if there’s a change in the pattern then that’s when we need to be alerted. Also, if a BPD patient has suffered severe trauma during childhood, particularly sexual abuse, or is using substances or is feeling abandoned, these factors can increase the risk quite significantly.

(27:51) Dr Singleton asks about the future of BPD treatment. Dr Stone highlights the limitations of the system and the difficulty of getting patients who need care, the treatment and access to psychologists and psychiatrists that they need.
She cites her own home of Canberra, and the near impossibility of direct access to a psychiatrist. She also describes the issue of the vicarious trauma of the carers of BPD patients. She has often ended up having to treat them for post-traumatic stress disorder because they are the ones who are face to face with the suicide risk of their loved ones on a daily basis.

(30:10) Dr Rao continues with his vision of the future care of BPD and mental health which involves a step-care approach and a national plan.
The step-care approach would include the primary sector, the private sector, the public sector and the specialty sector. With easy access and flow of patients across all of these sectors. He feels that with a national approach and training, appropriate care could be delivered to the vast majority of patients with GPs managing some psychological work within their 20 minute consultations.

(31:53) Dr Stoupas and Dr Singleton sign off with a final note of the importance of GPs looking after themselves so that they can continue to provide the best possible care to patients.

  • Borderline personality disorder (BPD) affects approximately 6% of patients in GP clinics. It’s the most common personality disorder in Australia, affecting about 1–4% of the population at some time in their lives.
  • BPD is treatable – the most effective treatment combines support and psychological therapy. Medication may help in some cases, but is not the main treatment for BPD.
  • Dialectical behaviour therapy (DBT) is a type of talking therapy, designed for the specific needs of people who experience very strong emotions such as those with BPD. More information is available here.
  • Important resources for GPs and patient information sheets from The Royal Australian & New Zealand College of Psychiatrists (RANZCP) can be found here.
  • The BPD Foundation has plenty of lived experience stories which patients may find useful, available here.

‘In my community in Canberra, it’s almost impossible for me to talk to a psychiatrist directly. I have to go through layers of allied health in layers of triage. These patients are difficult to manage and there comes a point with a GP where the GP needs support. And that support is very difficult to get.’

‘It’s very hard when you have no money, you’re unemployed, you’re living in your car, as an adolescent to actually do much in terms of your general health. And we also have to acknowledge that it’s more common amongst more disadvantaged groups. And by definition, those more disadvantaged groups have the highest mental health load and the lowest access to services, which is a travesty.’
– Dr Louise Stone
 

‘For a long time, we thought that trauma actually caused borderline personality disorder, but we have now moved away from the debate of nature versus nurture. Now we talk in terms of nature via nurture, or nurture via nature. So what we now know is that trauma is a very significant risk factor for development of borderline personality disorder, but it doesn’t appear to be causative.’

‘I would set up a step-care approach which would have a national plan. And the step-care approach would include the primary sector, the private sector, the public sector and the specialty sector. And there should be very easy access and flow of patients across all the sectors.’
– Dr Sathya Rao

  • If you would like to learn more about Dr Sathya Rao’s experience and insights, or would like to connect, visit his LinkedIn here
  • If you would like to learn more about Dr Louise Stone’s experience and insights, or would like to connect, visit her LinkedIn here
  • If you would like to learn more about Dr Gill Singleton’s achievements and insights, or would like to connect, please visit here.
  • If you would like to learn more about Dr Billy Stoupas’ achievements and insights, or would like to connect, please visit here.
Resources referred to in the Generally Speaking podcast and on the https://www.racgp.org.au/generallyspeaking/home website are views of the hosts and not necessarily endorsed by RACGP.

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