(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.