Borderline patients, many of whom also have somatization disorders, frequently become dependent on their physicians in an extremely demanding, clinging, helpless, or self-destructive manner. Physicians may feel manipulated, angry, depleted, exhausted, or self-doubting. They may want to end the patient relationship or rescue the patient from herself, or they can be drawn into a cycle of extensive medical testing to try and explain many somatic complaints. These patients fear separation or abandonment and may react to potential losses with panic, emotional instability, anger, or impulsive (suicidal or self-destructive) actions. They may seek care and utilize defenses, which appears as a somatization disorder. These somatic symptoms and borderline personality structure often represent the sequelae of childhood abuse, sexual abuse, or other trauma (Kernberg, 1975; Sansone et al., 2001).
Use of parallel inquiry to uncover a history of trauma is often most helpful for the patient complaining of multiple somatic complaints. Borderline patients often react to medical care with an aggressive or dependent clinging to their physician and other caretakers. They may angrily devalue the physician who does not adequately explain their symptoms and may make entitled demands for special treatment when they become worried or frustrated. They tend to relate to others as "all good or all bad," which significantly contributes to their poor life functioning.
Typically, reality testing is intact. However, under stress, borderline patients may temporarily lose reality testing and manifest severe distortions in perceptions or sense of reality. They may misunderstand the physician's intentions or instructions. They may also experience episodes of derealiza-tion, depersonalization, or brief psychotic episodes. Borderline patients have identity diffusion, extreme fluctuations in self-perception from the grandiose to an excessively harsh underestimation of their abilities. They also have stormy and chaotic relationships with others. They rely heavily on splitting, projective identification, projection, and devaluing.
Office management of borderline patients involves an empathic understanding of their fears. These fears revolve around the threat to their security or fears of separation or abandonment and, secondarily, sensitivity to rejection, or fears of humiliation. They require firm limit setting (e.g., what physician can realistically offer). Attempts to satisfy these patients' intense needs often result in an exhausted or angry physician. This can be avoided by setting realistic limits while offering the patient different ideas or options for medical care, and suggestions of more adaptive behaviors. Initial interventions should attempt to establish reality testing or correct reality distortions. If reality testing is intact, the most helpful interventions can be aimed at attending to medical care while decreasing the pathologic splitting defenses by using confrontation, clarification, and interpretations of the problematic situation.
The primary treatment for borderline personality disorder is psychotherapy complemented by symptom-targeted pharmacotherapy. Certain types of psychotherapy and medications are effective in the treatment of borderline patients. Most will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning. Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior (APA, 2001; Soloff, 2008).
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