Overthinking

"Acclaimed for its wisdom and no-nonsense style, this authoritative guide has now been revised and expanded with 50% new content reflecting a decade of advances in the field. Distinguished psychiatrist Joel Paris distills current knowledge about borderline personality disorder (BPD) and reviews what works in diagnosis and treatment. Rather than advocating a particular therapy, Paris guides therapists to flexibly interweave a range of evidence-based strategies, within a stepped-care framework. The book presents "dos and don'ts" for engaging patients with BPD, building emotion regulation and impulse control skills, working with family members, and managing suicidality and other crises. It is illustrated throughout with rich clinical vignettes. New to This Edition *Up-to-date findings on treatment effectiveness and outcomes. *Chapter on dimensional models of BPD, plus detailed discussion of DSM-5 diagnosis. *Chapter on stepped care, including new findings on the benefits of brief treatment. *Chapter on family psychoeducation and other ways to combat stigma. *New and expanded discussions of cutting-edge topics/m-/BPD in adolescents, childhood risk factors, and neurobiology"-- Provided by publisher Front Matter 1 Copyright 6 About the Author 7 Acknowledgments 9 Preface 11 Contents 13 Introduction 15 The Purpose of this Book 16 How this Book is Organized 17 Part I: Definitions 19 Chapter 1: Making the Diagnosis 21 A Brief History of the BPD Diagnosis 23 BPD in the DSM System 25 BPD in DSM-III and DSM-IV 25 DSM-5's Section II Definition of BPD 27 Trait Domains Underlying BPD and their Implications 28 Emotional Dysregulation (Affective lnstability) 28 lmpulsivity 30 Interpersonal Sensitivity 32 Cognitive Dysfunction 32 How Traits Interact to Produce Disorders 33 Diagnostic Measures 34 Case Example 1: Wilma (Typical BPD) 35 Case Example 2: Samantha (Typical BPD) 35 Case Example 3: Sarah (Typical BPD) 36 Case Example 4: Melissa (BPD According to DSM but not to DIB-R) 36 Case Example 5: Nathalie (Lifetime but Not Current BPD) 37 Case Example 6: Maureen (Personality Disorder but Not BPD) 37 BPD in Practice and in the Community 38 Case Example 7: Steven 42 Why Making a BPD Diagnosis is Important 43 Sources of Resistance to Diagnosing BPD 44 Clinical Implications 45 Chapter 2: Dimensional Models 47 BPD in DSM-5's Section III 48 The ICD-11 Model of Personality Disorders 53 Dimensions Versus Categories in BPD 55 Dimensional Diagnosis for all Mental Disorders? 59 Some Conclusions About Dimensional Models 60 Clinical Implications 61 Chapter 3: Boundaries with Other Mental Disorders 62 Why BPD Remains Controversial 62 Comorbidity and Co-Occurrence 64 BPD and Psychosis 65 Case Example 1 : Bill 66 Case Example 2: Wendy 66 Case Example 3: ]une 67 Case Example 4 67 BPD and Depression 67 Case Example 5: Susan 70 BPD and the Bipolar Spectrum 70 Case Example 6: Lisa 75 Case Example 7: Mona 76 Case Example 8: Helen 76 BPD and PTSD 77 Case Example 9: Lily 77 Case Example 10: Meredith 78 BPD and ADHD 79 BPD and Other Personality Disorders 80 Case Example 11: David 80 Case Example 12: George 81 When Comorbidity is Clinically Important 81 Case Example 13: Caroline 82 Case Example 14: Betty 82 Clinical Implications 83 Part II: Causes 85 Chapter 4: BPD across the Life Cycle 87 Childhood Precursors of BPD 87 Internalizing and Externalizing Features 89 Borderline Pathology of Childhood 90 Case Example 1: Rory 90 Why Adolescence is Crucial for Psychopathology 91 Misconceptions About BPD in Adolescence 93 Adolescent and Adult Symptoms of BPD 94 Case Example 2: Dora 96 Treating BPD in Adolescence 96 Late-Onset BPD 98 Case Example 3: Joan 98 Case Example 4: Lalith 99 Clinical Implications 99 Chapter 5: Risk Factors 101 Lessons from Behavioral Genetics 101 The Nature of Genetic Influence in BPD 103 Neurobiological Correlates of BPD 106 Neurotransmitters 106 Brain lmaging 107 Neuropsychological Testing 109 Neural Connectivity 109 Psychological Theories of BPD 110 Retrospective Studies 112 Prospective Studies 112 High-Risk Studies 113 Parenting, Emotional Neglect, and BPD 115 Child Abuse and Trauma 116 The Ubiquity of Resilience 119 Social Factors 124 BPD: A Socially Sensitive Disorder 127 Clinical Implications 129 Chapter 6: A General Model 130 The Biological-Psychological Interface 132 The Biological-Social Interface 135 The Psychological-Social Interface 136 A Multidimensional View of BPD 137 Implications of the Model for Treatment 138 Clinical Implications 139 Part III: Treatment 141 Chapter 7: Outcome 143 Early Studies 144 Outcome Studies from the 1980's 144 Predictors of Outcome 148 Long-Term Outcome and Suicide 149 Prospective Studies of BPD Outcome 151 Mechanism of Recovery 155 Treatment and Recovery 158 Clinical Implications 159 Chapter 8: Psychopharmacology 160 Are Drugs Always Necessary in the Treatment of BPD? 160 Antipsychotics 162 Selective Serotonin Reuptake lnhibitors 165 Mood Stabilizers 167 Other Options 168 Polypharmacy 169 Clinical Implications 169 Chapter 9: Psychotherapy 171 Dialectical Behavior Therapy 171 Other Forms of Cognitive Therapy and CBT 176 Mentalization-Based Therapy 177 Psychodynamic Therapies 178 General Psychiatric Management 180 Other Therapies 180 Psychotherapy for Adolescents with BPD 182 Group Therapy and Psychoeducation 182 Integrative Psychotherapy and Common Factors in the Therapy of BPD 183 Clinical Implications 186 Chapter 10: Brief Treatment and Stepped Care 187 Access to Treatment and Public Health 187 Brief and Long-Term Psychotherapies 188 Costing Psychotherapy 189 How Psychotherapy Became Lengthy 190 Stepped Care in Medicine and Psychiatry 193 Stepped Care in BPD 194 Origins of a Stepped-Care Program 195 Results of the Stepped-Care Program 196 Clinical Implications 197 Chapter 11: Guidelines for Management 198 Psychotherapy: What to Do and What Not to Do 199 "Getting a Life" 203 Work and Relationships 205 Easy Cases 207 Case Example 1: Brenda 208 Case Example 2: Cathy 208 Case Example 3: Fiona 209 Middling Cases 210 Case Example 4: Chloe 210 Case Example 5: Oriana 210 Case Example 6: Laura 211 Hard Cases 212 Case Example 7: Rachel 212 Case Example 8: Mary 213 Case Example 9: Norma 214 Case Example 10: Doris 214 Brief Interventions and Extended Care 214 Case Example 11: Paula 216 Clinical Implications 216 Chapter 12: Stigma and Families 217 Stigma and BPD 217 Psychoeducation for Patients with BPD 219 Psychoeducation for the Families of Patients with BPD 219 Clinical Implications 222 Chapter 13: Therapeutic Interventions 223 The General and the Specific 224 How to Talk to a Patient with BPD 225 Building an Alliance 226 Case Example 1: Marilyn 227 Case Example 2: Nora 227 Targeting the Core Dimensions of BPD 228 Case Example 3: Patricia 228 Case Example 4: Rachel 229 Case Example 5: Soraya 230 Case Example 6: Vanessa 230 Case Example 7: Chloe 231 Work and Relationships 231 Case Example 8: Zara 232 Case Example 9: Rita 232 Case Example 10: Abigail 233 Case Example 11 : Barbara 233 Group and Individual Therapy 234 Case Example 12: Tania 235 Clinical Implications 236 Chapter 14: Problems in Therapy 237 Frequency of Sessions 238 Case Example 1: Frances 239 Attendance 239 Telephone Calls 241 Case Example 2: Cora 242 Therapist-Patient Boundaries 243 Case Example 3: Ellen 244 Sharing the BPD Diagnosis with Patients 245 Case Example 4: Gloria 245 Involving the Family 246 Case Example 5: Leila 248 Case Example 6: Olivia 248 Split Treatments 249 Case Example 7: Tara 250 Length of Therapy 250 Intermittent Therapy for BPD 252 Case Example 8: Greta 253 Termination Issues 254 Case Example 9: Melanie 255 Case Example 10: Kate 255 Case Example 11: Anne 256 Clinical Implications 257 Chapter 15: Suicidality and Hospitalization 258 Suicidal Thoughts 258 Case Example 1: Tania 260 Self-Harm 260 Case Example 2: Helen 261 Suicide Attempts 262 Case Example 3: Brigitte 263 Case Example 4: Elaine 264 Death by Suicide 264 Case Example 5: Florence 265 Case Example 6: Harold 266 Chronic Suicidality 266 Case Example 7: Moira 267 Managing Chronic Suicidality 267 "Will I Be Sued?" 269 Hospitalization 270 Case Example 8: Yael 271 Clinical Implications 274 Chapter 16: Research Directions 275 Resolving Issues of Diagnosis and Boundaries 275 Etiology 278 Treatment 279 References 281 Index 319