31 August 2007

Pharmacy fees for methadone and buprenorphine treatments.

Drug Alc Review 2007 26;4:411-416

The impact of community pharmacy dispensing fees on the introduction of buprenorphine - naloxone in Australia. Winstock AR, Lea T, Ritter A.

Dear Colleagues,

These authors have survey responses from over 400 NSW pharmacists about current and proposed prices for methadone and buprenorphine under various regimens including daily, weekly, fortnightly and monthly attendance. A figure of $31 weekly recurs with little variation according to the number of attendances until this reached one per fortnight when the lowest response was $19 per week.

These authors do not examine these fees in relation to other commercial aspects of community pharmacy, nor are we given an international comparison. Ideally, as with other medical treatments, those who are unemployed or indigent should be looked after in the public system. In many areas there is simply no alternative to pharmacy treatment since most hospital pharmacies steadfastly refuse to become involved. In the 1980s, the published recommended price in NSW was $5 daily �including counselling� ($35 per week). Pharmacists still charge approximately the same price which is a philanthropy without parallel in health care in my experience.

The authors state that the introduction of the bup-naloxone combination product: �permitted the revision of takeaway policies � and � the possibility of unsupervised treatment.� Only one of the 24 references refers to the combination product which hardly supports the contention that this constitutes a �new treatment paradigm�. They suggest a need for: �early dissemination of unambiguous information regarding the introduction of a new medication, especially where supervised dispensing through community pharmacies is essential to the provision of treatment. The potential impact upon the successful rollout of a new treatment paradigm that was developed to benefit stable patients in the community may be jeopardised when such processes are not followed.�

I would suggest that the only thing jeopardising this new treatment paradigm being rolled-out (hate those terms!) is a lack of evidence that it actually works in practice. There is a dearth of research on both the combination product itself and on (completely) non-supervised treatment such as is commonly used in France and England. This all makes the tone of the paper somewhat confusing since the benefits proposed for buprenorphine-naloxone are still theoretical.

These authors appear to believe that long term dispensing or administration of buprenorphine should be cheaper than traditional short term maintenance treatments and they seem disappointed with outcomes showing otherwise, at least for less than fortnightly attendance.

It is hard to be �unambiguous� about a new and untried treatment, and pharmacists of all people, know that dealing with addictions can be tough and unpredictable. Also, the new proposal assumes that doctors are able to distinguish which patient is going to be stable long term, yet there is no simple way I know of doing that. The best protection for patients may be the innate conservatism of Australian health care workers, sceptical of claims made for new drugs until proven in practice. It is indeed a �brave new world�, giving addicted patients medication without the continuing supervision of a pharmacist, nurse, psychologist or even a self-help or group therapy session. In fact, this �paradigm� flies in the face of the DSM definition of addiction, involving some degree of loss of control over drug use at certain times.

Another concern was borne out in a paper from Melbourne recently (Neilsen 2007) where administering buprenorphine as a sub-lingual tablet was associated with numerous reported practical problems compared with the use of liquid methadone. I wonder how many Australian doctors are prescribing unsupervised buprenorphine.

Comments by Andrew Byrne ..

References: Nielsen S, Dietze P, Dunlop A, Muhleisen P, Lee N, Taylor D. Buprenorphine supply by community pharmacists in Victoria, Australia: perceptions, experiences and key issues identified. Drug Alc Review 2007 26;2:143-152

30 August 2007

Perceptive correction on some mythology around alcoholism and addictions

This is a perceptive �correction� on some mythology around alcoholism and addictions by a man with decades of experience in the field.

Wall Street Journal

Bad Advice for Lindsay Lohan

By STANTON PEELE August 7, 2007; Page A11

People have been offering advice to Lindsay Lohan since she relapsed soon after leaving her last stint of rehab. Now that she's entering another clinic, it's time to reevaluate many of these recommendations. Following are the four main mistaken pieces of advice:

1) Ms. Lohan should never, ever drink again. Her father, Michael Lohan, agrees with the treatment programs his daughter has tried and believes that she should never, ever drink again. The elder Lohan swore off alcohol himself not long ago, after a serious car accident led to a drunk-driving conviction. Although this advice is well-intended, it is implausible. What are the chances Ms. Lohan will abstain for the rest of her life? After her second stint in rehab, wearing an alcohol monitor, she lasted about a week before partying all night.

The alternative view is that the 21-year-old Ms. Lohan will almost surely drink again and she needs a fallback position to be safe. This might include having her "people" shut her off from drinking too much, or setting a departure time for leaving clubs or parties. Failing this, someone -- if not Ms. Lohan herself -- needs to keep her from driving after she's been drinking. That way, she can at least survive to try to do better down the road.

2) Ms. Lohan needs to learn that she is a lifetime alcoholic-addict. She inherited the alcoholism-addict gene from her father, right? The alternative position is: Who knows that is true?

Another young Hollywood star who was branded an addict was Drew Barrymore. Remember when she appeared on the cover of People magazine at age 13 as America's youngest addict? Ms. Barrymore had many substance abusing relatives, including her parents, and so experts concluded she would be addicted her entire life.

But, almost 20 years later, in 2007, Ms. Barrymore was on the cover of People again -- this time as the world's most beautiful person! No one thinks of her as an addict any longer. Young people often ultimately outgrow youthful problems, sometimes quite serious ones, including drinking and drug addiction.

3) Ms. Lohan needs to remain locked in treatment for a long time, with no day passes. Critics note that Ms. Lohan was permitted out of her treatment program to go to her gym. Other addicts, such as Daniel Baldwin, tut-tut that this is too permissive. Mr. Baldwin should know -- he's been in treatment nine times. In his 40s when last treated, he now claims to be off cocaine for good.

On the other hand, maybe it is no wonder Ms. Lohan and so many others relapse after being restricted in residential programs for months. The minute the doors of the center shut behind them, they are out on the street facing the same old playmates and playgrounds.

An alternative approach would be to treat Ms. Lohan as an outpatient. This offers her the opportunity to expose herself to the world under supervision. She could then practice how to deal with her freedom while maintaining her sobriety. For example, she could be guided towards new friends and ways of spending her free time. Of course neither the hospital nor the outpatient setting can work miracles right away -- it took Drew Barrymore years to reform her life.

4) Ms. Lohan should avoid show business. The problem obviously is her involvement in movies, coupled with all of Tinsel Town's temptations. If she just stays away from Hollywood and the glitterati, she'll be fine.

But Ms. Barrymore didn't need to leave Hollywood to change. The alternative view is that Ms. Lohan is a talented person who can achieve success in movies and music, and that work is therapeutic. Not all her films are great. But she has done good work with the likes of legendary director Robert Altman and co-stars Kevin Kline, Meryl Streep and Lily Tomlin. More opportunities like these could help her to learn professionalism, discipline and self-respect.

Ms. Lohan needs to grow up, realize her talents and find ways to fill her time that aren't self-destructive. Coming to see herself as an adult, accepting responsibility, and developing pride in her skills are difficult but time-tested therapeutic techniques. These are things Ms. Lohan won't learn in standard treatment programs.

Mr. Peele is a psychologist and therapist who has written nine books on addiction. His new book is "Addiction-Proof Your Child" (Three Rivers Press).

8 August 2007

Implants of naltrexone: information sought on outcomes

Dear Readers,

Like many of my colleagues, I am concerned at the use of naltrexone implants for addiction purposes in Australia without the normal safeguards of a new medication. As an alternative to post-marketing surveillance I propose a survey to seek first hand reports of experiences, both positive and negative, with these devices. Some have been used in patients who have travelled long distances and may lack sufficient local medical support.

Readers who have consulted with patients who have been prescribed naltrexone implants are invited to write to report their findings, including individual case reports. Age and sex of patients and dependency diagnosis would be useful, along with any other relevant clinical details (type of implant, number of implants, etc).

I undertake to collate these and report back to the appropriate parties, including health authorities, manufacturers (where these are known), informants and patient groups for their information.

In medicine, �proof of effectiveness� means that a sufficient number of positive research trials of high quality have been published by reputable authors in peer reviewed, respected journals.

In my view we have not yet reached this situation by general consensus with naltrexone implants.

With best regards,

Andrew Byrne ..

Potential conflict of interest: In my practice I prescribe and dispense methadone, buprenorphine and other drugs in the treatment of addictions. I have published on methadone to abstinence experience in my own medical practice (ref on request).

1 August 2007

Personality Disorders (Supplement)

Concord Dependency Seminar 31 July 2007.

Dr Glenys Dore, Senior Staff Specialist Psychiatrist, NSCCAHS

Summary Supplement

Paranoid personality disorder: SUSPECT (four criteria)

S (1) Suspicious of others

U (5) Unforgiving (bears grudges)

S (7) Spouse fidelity suspected

P (6) Perceives attacks (and reacts quickly)

E (2) "Enemy or friend" (suspects associates &friends)

C (3) Confiding in others feared

T (4) Threats perceived in benign events

Mrs F complained that people at work disliked her and she contemplated seeking legal advice as she thought they wanted her to leave. She had prolonged disagreements with the pay office about salary and conditions. When she requested a change of appointment with her doctor she "knew" it would be rejected despite it being offered, and complained bitterly about inflexible health professionals" Harari &Meares 2001

Schizoid personality disorder: DISTANT (four criteria)

D (7) Detached or (flattened) affect

I (6) Indifferent to criticism and praise

S (3) Sexual experiences of little interest

T (2) Tasks (activities) done solitary

A (5) Absence of close friends

N (1) Neither desires nor enjoys close relations

T (4) Takes pleasure in few activities

Schizoid personality disorder

Marjorie, a nurse, worked in the night shift in a small hospital. She lived alone with her 6 cats and saw her family only on Christmas Day, an event which she found most anxiety-provoking. Born of elderly parents, she had always been quiet and remote, a compliant child who seemed to need no company. In adult life she found it difficult to understand other people's need for friends and believed that an emotional life was 'unnecessary'. Harari &Meares 2001

Schizotypal personality disorder: ME PECULIAR (five criteria)

M (2) Magical thinking or odd beliefs

E (3) Experiences unusual perceptions

P (5) Paranoid ideation

E (7) Eccentric behaviour or appearance

C (6) Constricted (or inappropriate) affect

U (4) Unusual (odd) thinking and speech

L (8) Lacks close friends

I (1) Ideas of reference

A (9) Anxiety in social situations

R (10) Rule out psychotic disorders and pervasive developmental disorder

Avoidant personality disorder: CRINGES (four criteria)

C (2) Certainty (of being liked required before willing to get involved with others)

R (4) Rejection (or criticism) preoccupies one's thoughts in social situations

I (3) Intimate r'ships (restraint in intimate relationships for fear of being shamed)

N (5) New interpersonal relationships (is inhibited in)

G (1) Gets around occupational activity (involving significant interpersonal contact)

E (7) Embarrassment (potential) prevents new activity or taking personal risks

S (6) Self viewed (as unappealing, inept or inferior)

Dependent personality disorder: RELIANCE (five criteria)

R (1) Reassurance (required for decisions)

E (3) Expressing disagreement difficult (due to fear of loss of support or approval)

L (2) Life responsibilities (needs to have these assumed by others)

I (4) Initiating projects difficult (due to lack pf self confidence)

A (6) Alone (feels helpless and discomfort when alone)

N (5) Nurturance (goes to excessive lengths to obtain nurturance and support)

C (7) Companionship (another relationship is sought urgently when close relationship ends)

E (8) Exaggerated fears of being left to care for self

Obsessive-compulsive personality disorder: LAW FIRMS (four criteria)

L (1) Loses point of activity (due to preoccupation with detail)

A (2) Ability to complete tasks (compromised by perfectionism)

W (5) Worthless objects (unable to discard)

F (3) Friendships (and leisure activities) excluded (due to a preoccupation with work)

I (4) Inflexible, scrupulous, overconscientious (on ethics, values, or morality, not accounted for by religion or culture)

R (6) Reluctant to delegate (unless others submit to exact guidelines)

M (7) Miserly towards self and others

S (8) Stubbornness (and rigidity)

Histrionic personality disorder: PRAISE ME (five criteria)

P (2) Provocative (or sexually seductive) behaviour

R (8) Relationships (considered more intimate than they are)

A (1) Attention (uncomfortable when not the centre of attention)

I (7) Influenced easily

S (5) Style of speech (impressionistic, lacks detail)

E (3) Emotions (rapidly shifting and shallow)

M (4) Made up (physical appearance used to draw attention to self)

E (6) Emotions exaggerated (theatrical)

Narcissistic personality disorder: SPEEECIAL (five criteria)

S (3) Special (believes he or she is special and unique)

P (2) Preoccupied with fantasies (of unlimited success, power, brilliance, beauty or ideal love)

E (8) Envious (of others, or believes others are envious of him/her)

E (5) Entitlement

E (4) Excess admiration required

C (2) Conceited (grandiose sense of self importance)

I (6) Interpersonal exploitation

A (9) Arrogant (haughty)

L (7) Lacks empathy

Antisocial personality disorder: CORRUPT (Three criteria)

C (1) Conformity to law lacking

O (6) Obligations ignored

R (5) Reckless disregard for safety of self or others

R (7) Remorse lacking

U (2) Underhanded (deceitful, lies, cons others)

P (3) Planning insufficient (impulsive)

T (4) Temper (irritable and aggressive)

A Quick Guide to the Personality Disorders (adapted from "DSM Made Easy", an excellent reference tool for the busy clinician!)

"DSM-IV lists 10 personality disorders.... divided into three clusters, A, B, and C........ Five of the 10 have been studied reasonably well and therefore have greater validity than the rest: antisocial, borderline, obsessive-compulsive, schizoid, schizotypal."

Cluster A: "withdrawn, cold, suspicious, or irrational."

Paranoid Personality Disorder:....."distrustful and suspicious of others, whose motives are seen as malevolent."

Schizoid Personality Disorder:..... "isolated from social relationships and shows a restricted emotional range in interpersonal settings."

Schizotypal Personality Disorder:....... "isolation and discomfort with social relationships, as well as perceptual or cognitive distortions and peculiar behaviour."

Cluster B: "dramatic, emotional, and attention-seeking.....moods are labile and often shallow.......often have intense interpersonal conflicts."

Antisocial Personality Disorder:..... "Before age 15, for 12 months or more the patient [satisfied criteria for Conduct Disorder]...repeatedly violated rules, age appropriate societal norms, or the rights of others.... Since age 15, the patient has shown disregard for the rights of others in a variety of situations."

Borderline Personality Disorder: ......"unstable impulse control, interpersonal relationships, moods, and self-image."

Histrionic Personality Disorder: ...... "emotional excess and attention-seeking behaviors are present in a variety of situations"

Cluster C: "anxious and tense, ......... often overcontrolled."

Narcissistic Personality Disorder:...... "grandiosity (fantasized or actual), lack of empathy, and need for admiration"

Avoidant Personality Disorder:........."social inhibition, hypersensitivity to criticism, and feelings of inadequacy are present in a variety of situations"

Dependent Personality Disorder:..... "a need to be taken care of leads to clinging, submissive behaviour and fears of separation that are present in a variety of situations"

Obsessive-Compulsive Personality Disorder:....... "a preoccupation with control, orderliness, and perfection overshadow qualities of efficiency, flexibility, and candour."

Generic Criteria for Personality Disorders

1. A lasting pattern of behaviour and inner experience that markedly deviates from norms of the patient's culture..... evident in at least two of these areas:

. Affect

. Cognition

. Impulse control

. Interpersonal functioning

2. This pattern is fixed and affects many personal and social situations ....[and] causes clinically important distress or impairs work, social, or personal functioning.

3. This pattern has lasted a long time.......with roots in adolescence or young adulthood.

4. It isn't better explained by another mental disorder ......[and] isn't directly caused by a general medical condition or by the use of substances, including medications.

Full Diagnostic Criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

. Frantic efforts to avoid real or imagined abandonment (do not include suicidal or self-mutilating behaviour covered in criterion 5).

. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and evaluation.

. Identify disturbance: persistent and markedly disturbed, distorted, or unstable self-image or sense of self (eg. feeling like one does not exist or embodies evil).

. Impulsiveness in at least two areas that are potentially self damaging (eg. Spending, sex, substance abuse, shoplifting, reckless driving, binge eating - do not include suicide or self -mutilating behaviour covered in criterion 5).

. Recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour.

. Affective instability: marked reactivity of mood (eg. intense episodic dysphoria, irritability, or anxiety) usually lasting a few hours and only rarely more than a few days.

. Chronic feelings of emptiness.

. Inappropriate, intense anger or lack of control of anger (eg. Frequent displays of temper, constant anger, recurrent physical fights).

. Transient, stress-related severe dissociative symptoms or paranoid ideation.

Full Diagnostic criteria for 301.7 Antisocial Personality Disorder

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

. failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest

. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

. impulsivity or failure to plan ahead

. irritability and aggressiveness, as indicated by repeated physical fights or assaults

. reckless disregard for safety of self or others

. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations

. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behaviour is not exclusively during the course of Schizophrenia or a Manic Episode.

Personality Disorders

Concord Dependency Seminar July 2007

Dr Glenys Dore, Senior Staff Specialist Psychiatrist, NSCCAHS

In this seminar Dr Dore introduced us to what is sometimes a "no go zone" for health professionals involved in addiction treatment: Personality Disorders (PDs).

People with Personality Disorders are "The Patients Psychiatrists Dislike" (Lewis & Appleby Br J Psych 1988), and workers in drug and alcohol will recognise these feelings: these patients are seen as difficult to manage, unlikely to arouse sympathy, annoying, not deserving of health resources, noncompliant, not accepting advice, having poor prognosis, their suicide attempts as "attention-seeking' rather than genuine, their requests for admission as manipulative.

Therefore, a Personality Disorder diagnosis may be seen as derogatory, pejorative and stigmatising. "What is conveyed.. is that the patient is difficult and probably unpleasant" (Gunn &Robertson Psychological Medicine 1976), with their symptoms seen as less genuine (Slavney &McHugh 1974; Thompson &Goldberg 1987).

Before focusing on Antisocial PD and Borderline PD, the most common diagnoses in substance using populations, Dr Dore traced some of the development of ideas about what we now call personality.

Hippocrates identified four elements in nature with four corresponding substances in human beings: Air, with Blood; Water, with Phlegm; Fire, with Yellow bile; Earth with Black bile. Galen later identified four corresponding "temperaments": from blood, the Sanguine (confident, hopeful); from Phlegm, the phlegmatic (dull, sluggish); from bile, the Choleric (passionate) and from Black bile, Melancholic.

Eysenck neatly resolved Galen's four temperaments into two dimensions: introversion-extroversion along one axis and stable-unstable along the other. In this model, the "sanguine" person was extroverted and stable; the "phlegmatic" person stable but introverted; the "choleric" person extraverted and unstable; the "melancholic" person introverted and unstable (the psychotic person emerged out of this combination).

Others have suggested a three or four dimensional approach. Cloninger's model of personality, has four distinct "traits" of Temperament (Harm avoidance, Novelty seeking, Reward dependence and Persistence) and three "traits" of Character (Self-directedness, Cooperativeness, Self-transcendence). Temperament comprises basic emotions, the emotional core of personality, early emotional and behavioural dispositions whereas Character "mental self government", "what a person makes of himself or herself intentionally".

For example, one of your correspondents is by temperament harm avoiding, novelty shy, aloof (not needing cuddles) and persistent..another almost the opposite. Both, of course, have Self-directed, Cooperative and Self-transcendent characters!

DSM-IV is concerned less with theories and more with practical empirical descriptions. Thus, it uses a categorical rather than Dimensional approach, with 3 clusters - Cluster A, Odd or Eccentric; Cluster B, Dramatic, Erratic or Emotional and Cluster C, Anxious or Fearful - comprising a total of ten personality disorders (and a rag-bag category, as always in DSM, "not otherwise specified").

Personality Disorders are common in the general population (Antisocial PD = ASPD 4%, Borderline PD = BPD ~ 2%), and especially so in psychiatric populations and people with substance use disorders. Among people with a current alcohol use disorder: 30% have at least 1 PD; people with a current drug use disorder, 50% at least 1 PD. The ATOS study reported 80% of current heroin users with a PD, 33% Antisocial PD, 7% Borderline PD, 38% ASPD + BPD. In this study BPD was strongly related to suicide attempts, needle sharing, overdose risk, polydrug use, depression, psychological distress and poorer treatment outcomes (Darke et al. Drug &Alcohol Dependence 2004). Antisocial PD is associated with earlier onset drug use &IDU, more polydrug use, higher levels HIV risk-taking and poorer social functioning in patients on MMT (Henderson et al 2002 NDARC Monograph No. 49).

Before labelling someone with a personality disorder (like "narcissistic" or "borderline") it is essential to be sure that they meet the general criteria of a personality disorder. Under the mnemonic PPAIIN, the pattern of inner experience &behaviour must be Persistent, Pervasive (with a broad range of personal &social impacts), from Adolescence onwards, causing Impairment, be Inflexible &maladaptive and Not due to mental disorder, medical condition, or substance use.

Before concentrating on ASPD and BPD, Dr Dore introduced us to all the DSM PDs, for which ingenious psychiatry candidates have developed helpful mnemonics (listed in the Supplement to this summary on the Redfern Clinic Website, with some case examples).

In Cluster A, the Odd or Eccentric group, are the Paranoid (Suspicious, Jealous, but not Psychotic or Unlawful); the Schizoid (Unemotional, Cold, Indifferent) and Schizotypal (Odd + Magical Beliefs, Behaviors, not Paranoid) types.

Cluster A PDs have a higher incidence in families of schizophrenia patients, and are often antecedent for Psychotic disorders, including schizophrenia, delusional disorders and schizophreniform disorder. In these people, stress may trigger Brief Reactive Psychosis.

Treatment options for cluster A include low dose antipsychotics and supportive psychotherapy, with openness, consistency, emphasising reality (paranoid), and social skills development (schizoid), and education on the interaction between substance use & psychiatric vulnerability.

In Cluster C, the Anxious or Fearful group, are the Avoidant (Needs People But Fears Relationships); Dependent (Needs Relationships, Indecisive, Fears Abandonment) and Obsessive-Compulsive (Rigid, Perfectionist + Inefficient) types. The Passive-Aggressive PD (Negative Attitudes with Passive Resistance to Demands) was dropped from DSM-IV.

Remember that Cluster C PD are not the same as anxiety disorders, although these may co-exist. Anxiety disorders may respond to specific therapies.

In Cluster B, the Dramatic, Erratic or Emotional group, are the ASPD (Aggressive, Unlawful, Impulsive); Borderline (Unstable, Chaotic, Impulsive, not Aggressive or Unlawful), Narcissistic (Self-Centered, Entitled, Lacks Empathy But Not Unlawful or Chaotic), and Histrionic (Dramatic, Seductive But not Chaotic) types.

Many people will recognise the "narcissistic rage" of a person typically fragile at their core, the demands of specialness and entitlement belying a sense of inner inferiority. It was asked without irony how common Narcissistic PD is among CEOs. Sadly few people with Narcissistic PD go into psychotherapy, few improve over time. Histrionic PD might present as almost hypomanic.

Briefly the DSM criteria for ASPD are: the individual is at least age 18 years, with evidence of Conduct Disorder with onset before age 15 years, and a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, not exclusively during the course of Schizophrenia or a Manic Episode.

As a general exclusion, the behaviours should not be better explained by another disorder, including a substance use disorder. ASPD may be over-diagnosed in SUD populations, because drug seeking behaviours, especially for illegal drugs, are likely to be considered "antisocial".

ASPD is more common in 1st-degree relatives of ASPD individuals, is associated with ADHD; the related Conduct Disorder is associated with erratic or inconsistent parenting and neglect. After 30 years of age there tends to be reduced antisocial behaviour (crime, promiscuity) and reduced substance use.

Dr Dore gave the example of a man who had a history of fights, truancy, theft, near expulsion from school, drug use and dealing, addiction to heroin, benzodiazepines, cannabis, with alcohol use, and by age 19, three counts of murder. When seen at age 36 yrs, he was married, with a child, and much settled.

Heroin users with ASPD respond as well as other heroin users to opioid pharmacotherapy (similar retention in treatment, methadone dosage, improvement in heroin use) however with poorer social functioning (Darke et al 1996; Darke et al 1994; Gill et al 1992; Rouser et al 1994)

Spot the diagnosis: "On return from your last holiday, your patient informed you that she smashed up her goldfish bowl and flushed her much-loved goldfish down the toilet, killing them. She has since replaced them."

Marsha Linehan (1993), the guru of Dialectical Behavior Therapy, gives us an unforgettable image:

"Borderline individuals are the psychological equivalent of the 3rd-degree burn patient. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.."

Briefly the DSM criteria for Borderline PD are: A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood, which may include: frantic efforts to avoid real or imagined abandonment; unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation; impulsiveness in spending, sex, substance abuse, shoplifting, reckless driving, binge eating ; recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour; intense episodic dysphoria, irritability, or anxiety; chronic feelings of emptiness; inappropriate, intense anger or lack of control of anger; transient, stress-related severe dissociative symptoms or paranoid ideation. (see supplement for full criteria).

People with BPD may suffer from an almost murderous rage. Does "cutting" serve as emotional release or self punishment? Their feelings may swing pendulum like between love and hate, the pedestal and resentment. There is a poor sense of identity, of who/what they are.

BPD is characterised by recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour, and although 90% improve despite multiple suicidal episodes, the stark reality is that 10% will complete suicide. Like ASPD, BPD tends to improve with age: by age 35 - 40 years: 75% have close to normal function, with less impulsivity (suicidality, self mutilation), better interpersonal relationships (less stormy relationships, less devaluation/sadism/manipulation) and people learn how to avoid emotional triggers. (Paris J. Canadian Medical Association Journal 2005)

In managing patients with PDs, especially BPD, it is important to bear in mind the concept of Transference, whereby unresolved feelings about important figures from the patient's past are revealed in the patient's transference towards the therapist.

Common defense mechanisms allow the person to defend against threatening or anxiety-provoking situations: splitting, idealisation, denigration, externalisation, projection, denial, acting out, repression.

If this seems too high falutin, we can at least identify the tactics. The person may stone- wall (allows no choice other than his/her position), attack ("You're not the caring doctor I thought"...."I'll take you to HCCC"...."I'll kill myself") or trick (manipulating the facts, making surprise demands) (from Ury William. Getting Past No: Negotiating With Difficult People).

The therapist's counterpart to transference is "Countertransference". They may themselves fall into the role of victim (feeling helpless, worthless, distant, withdrawn), of abuser (getting angry, retaliating, rejecting, cancelling appointments, "throw off program") or the role of rescuer ("only I understand"; unfair criticism of colleagues, extra appointments, late night calls, inappropriate prescribing, even sexual relationship).

In balancing Countertransference, remember there is a "zone of helpfulness" between overinvolvement and underinvolvement.

In managing your reactions, remember people are often trying to provoke reaction - they know your hot buttons. It is tempting to strike back, to break off the relationship, or to give in - the latter rewards bad behaviour, encourages same tactics in future, damages your reputation (weak, soft touch) and may compromise safety

Some tips:

. Try not to react, remain empathic and nonjudgmental,

. "Go to the balcony", either actually or mentally.

. "Step to their side" (you can't reason with a non-receptive patient, give a full respectful hearing

. Acknowledge (don't dismiss patient as irrational, acknowledge his/her point &feelings, if appropriate offer an apology)

. Use active listening (eye contact, empathic, reflective listening, paraphrase, seek clarification

. Buy time to think (pause &say nothing, "rewind the tape, ask for clarification, take time out, delay the decision)

. Try to understand transference-countertransference issues.

. Debrief with colleagues

Some rules for yourself:

. Acknowledge their position, even if don't agree with it (agree wherever you can)

. Express your views clearly without provoking (acknowledge negative impacts of your decision, acknowledge your differences, speak about your responsibilities, mention duty of care, Guidelines, Dept of Health etc)

. Negotiate a way forward (treatment contracts can help)

The focus of treatment for BPD may be the BPD itself, or comorbid Axis I, II disorders, and should include safety assessment and risk management.

A suicide/violence risk assessment distinguishes between plan and intention. Watch out for a recent mental state change. Management includes a crisis plan in collaboration with other (clinicians and family), increasing patient responsibility (exploring alternatives to self harm, self soothing techniques), consulting with colleagues if high risk, with medication and/or hospitalisation if needed. It is crucial to document your assessment and plan: remember the pain of writing a "Dear Coroner" letter.

Pharmacotherapies for BPD may be used with the aim of symptomatic relief: for affective dysregulation, impulsive-behavioural dyscontrol, or cognitive perceptual symptoms (suspiciousness, referential thinking, paranoid ideation, illusions, derealisation, depersonalisation, hallucinations). Treatments may include SSRIs or venlafaxine, low dose antipsychotics (higher doses if psychotic), Mood Stabilisers. ECT may be used if there is comorbid severe axis I depression.

Dialectical Behaviour Therapy is a three pronged approach

. Accepting patients just as they are within a context of trying to teach them to change

. Supportive acceptance; validation

. Confrontation &change strategies (individual or group work towards emotion regulation, improved interpersonal effectiveness, distress tolerance, core mindfulness, self-management skills) (Linehan M. CBT of Borderline PD 1993)

Principles of work with BPD (After Gabard 1994) are

. Establish a stable framework/structure predictable (eg frequency, length sessions)

. Take an active stance: validate, affirm

. Contain the anger &self destructing behaviours (soothe, validate, risk assessment, limit behaviour; problem solve)

. Establish the connection between feeling &actions

. Set limits on problem behaviours

. Maintain a "here &now" focus

. Monitor countertransference feelings

. Risk Management

Dr Dore highly recommended "Getting Past No: Negotiating With Difficult People", a book by Ury William.

Summary by Richard Hallinan based on the Concord presentation by Dr Glenys Dore.

Note there is also a supplement to this seminar available.