Saturday, September 15, 2012

Borderline Personality Disorder - DBT versus GPM

I just got back from a Mayo Clinic CME course "Clinical Management of Borderline Personality Disorder". I went to see John G. Gunderson, MD.  He and I go way back in a peripheral sort of way to the days before the Internet.  About 20 years ago I sent him a letter and he mailed me a copy of his "Diagnostic Interview for Borderlines." That was about three years after Marsha Linehan mailed me a rough copy of her research protocol for Dialectical Behavior Therapy. I like to see and hear from the experts.

The course was excellent and the logical summation of work done in this field for the past two decades. It was accessible and the faculty that included Dr. Gunderson and Brian Palmer, MD were enthusiastic and optimistic about treatment outcomes. Dr. Gunderson pointed out that sampling bias has led to therapeutic nihilism and stigmatization in the past and that more recent outcome studies show very positive results. The basic tenets of therapy that you learn in psychiatry school can go a long way. Therapeutic neutrality, and active interest in with the patient has to say, the therapeutic alliance, and technical skill with specific interventions are common elements in working with patients across all diagnostic categories.  If the diagnosis is accurate psychopharmacology is a secondary intervention.  The primary focus is psychotherapy and case management.

One of the significant points in the presentation was the concept of General Psychiatric Management (GPM) in the treatment of borderline personality disorder. In the years since I received the DBT manual, in many areas that therapy has become the de facto standard of care for borderline personality disorder. There is research evidence that it is effective.  DBT treatment programs seem to have popped up everywhere in the past decade. My experience in inpatient units led me to observe that many of these patients seem to have been misdiagnosed or DBT was being applied to the wrong diagnosis. There are fairly specific selection criteria for DBT, but it seems that anyone with a difficult problem was being put in a DBT program.

Dr. Gundersen referenced an article in the American Journal of Psychiatry comparing GPM versus DBT.  General Psychiatric Management is a variation of what we used to call supportive psychotherapy and it was defined by the researchers as:

"General psychiatric management was implemented as a comprehensive approach to borderline personality disorder, developed and manualized for this trial, consisting of psychodynamic psychotherapy, case management, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick, J. LeGris, unpublished 2009 manuscript). The psychotherapeutic model in this approach emphasized the relational aspects of the disorder and focused on disturbed attachment patterns and the enhancement of emotion regulation in relationships. Case management strategies were integrated into weekly individual sessions. No restrictions were placed on ancillary pharmacotherapy in either condition; in general, pharmacotherapy was based on a symptom-targeted approach but prioritized mood lability, impulsivity, and aggressiveness as presented in APA guidelines (16)." (see link below to McMain 2012)"
The study showed that the outcomes of both treatment modalities across several outcome measures (suicidal and non-suicidal self injurious behavior, depression, anger, interpersonal functioning) were comparable.  GPM was delivered as once a week hourly psychotherapy with additional case management and coordination of care.  This is important research because the logical extension of this research is to look at ways to improve functional capacity as well as symptomatology.

Take a look at the references and attend the seminar in the future if you have the chance.

George Dawson, MD, DFAPA

John G. Gunderson and Brian A. Palmer.  Clinical Management of Borderline Personality Disorder.  Mayo Clinic CME, September 14, 2012.

McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365-74. Epub 2009 Sep 15.

McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61




2 comments:

  1. George,
    Thanks for your summary. I am forwarding to my stuff so we can discuss our current plans on implementing some "evidence based" therapies and measures. This will help open the discussion to beyond CBT/DBT.
    E

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