Manejo clínico general (GPM) para el trastorno limítrofe de la personalidad: un Modelo generalista para América Latina

Autores/as

  • Marcos Signoretti Croci Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções - ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil https://orcid.org/0000-0002-0743-2565
  • Marcelo José Abduch Adas Brañas Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções. ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil https://orcid.org/0000-0003-3218-7327
  • Carl Fleisher Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA https://orcid.org/0000-0003-3672-3385
  • Teresa Carreño Department of Psychiatry and Behavioral Sciences. University of Miami Miller School of Medicine, Miami, USA https://orcid.org/0000-0001-8898-8938
  • Maria Dayana Jurado Andia Hospital Antonio Lorena, Cusco, Peru https://orcid.org/0000-0003-1608-3616
  • Eduardo Martinho Júnior Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções. ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil https://orcid.org/0000-0002-0092-0881
  • Lois W Choi-Kain Harvard Medical School, Boston, USA. Gunderson Personality Disorders Institute. GPDI. McLean Hospital, Belmont, USA https://orcid.org/0000-0003-4459-0412

DOI:

https://doi.org/10.25118/2763-9037.2022.v12.446

Palabras clave:

trastorno de personalidad limítrofe, salud pública, manejo de caso, psicoterapia, terapéutica

Resumen

Durante muchos años el Trastorno Limítrofe de la Personalidad (TLP) fue considerado una condición intratable. Aun así, diversos tratamientos efectivos basados en la evidencia fueron desarrollados en las últimas décadas, como, Terapia Dialéctica Conductual (DBT), Tratamiento Basado en la Mentalización (MBT) y Psicoterapia Centrada en la Transferencia (TFP), los cuales probaron lo contrario. El problema desde el punto de vista de la salud pública es que la disponibilidad de estas intervenciones es limitada. En este contexto de gran demanda de clínicos entrenados, el Manejo Psiquiátrico General (GPM) y otros abordajes generalistas surgieron. Este artículo revisa la estructura y los principales fundamentos del GPM que orientan a los clínicos no especialistas a planear un tratamiento basado en la medicalización del trastorno, en el gerenciamiento del caso y en intervenciones psicoterapéuticas de apoyo. Nosotros también ilustramos el abordaje con un ejemplo de caso y finalmente, presentamos los desarrollos más recientes, como la integración con el DBT y el GPM para adolescentes (GPM-A).

Descargas

Los datos de descargas todavía no están disponibles.

Métricas

Cargando métricas ...

Biografía del autor/a

Marcos Signoretti Croci, Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções - ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil

Graduada en Medicina por la Facultad de Medicina de la Universidad de São Paulo (FMUSP) en 2011.
Psiquiatra por el Instituto de Psiquiatría del Hospital das Clínicas de la Facultad de Medicina de la
Universidad de São Paulo (IPq-HCFMUSP). Research Fellow en Mclean Hospital, Harvard Medical School, 2015.
Preceptor de la Graduación de Psiquiatría en FMUSP, 2016. Preceptor de la Residencia Médica en
Psiquiatría en IPq-HCMFUSP, 2017. Actualmente trabaja en la Clínica Ambulatoria para el Desarrollo de
las Relaciones y Emociones (ADRE) del IPq-HCFMUSP, donde supervisa y es coordinador general.
Es entrenador oficial de Good Psychiatric Management (GPM) en el Instituto de Entrenamiento para
Trastornos de la Personalidad Límites del Hospital Mclean.

Marcelo José Abduch Adas Brañas, Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções. ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil

Carl Fleisher, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA

https://medschool.ucla.edu/

Médico pela Harvard Medical School. Psiquiatra pela UCLA School of Medicine. Fellowship pela UCLA School of Medicine. Psiquatra da Infância e Adolescência pelo American Board of Psychiatry and Neurology. Professor Clínico Assistente, Departamento de Psiquiatria e Ciências Biocomportamentais, Universidade da California, Los Angeles, California. 

 

Teresa Carreño, Department of Psychiatry and Behavioral Sciences. University of Miami Miller School of Medicine, Miami, USA

https://med.miami.edu/

Médica pela University of Miami Miller School of Medicine, Miami, USA. Psiquiatra e psiquiatra da infância e da adolescência pelo American Board of Psychiatry and Neurology. Professora assistente voluntária no Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA.

Maria Dayana Jurado Andia , Hospital Antonio Lorena, Cusco, Peru

http://hospitalantoniolorena.gob.pe/

Médica formada pela Universidad del Valle, Cochabamba, Bolívia. Psiquiatra pelo Instituto de Psiquiatría do Hospital das Clínicas da Faculdade de Medicina da USP – São Paulo, Brasil. Psiquiatra en el Hospital de Salud Mental, San Juan Pablo II, Cusco Perú

Eduardo Martinho Júnior , Ambulatório para o Desenvolvimento dos Relacionamentos e das Emoções. ADRE, Hospital das Clínicas, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo, USP, São Paulo, SP, Brasil

Lois W Choi-Kain, Harvard Medical School, Boston, USA. Gunderson Personality Disorders Institute. GPDI. McLean Hospital, Belmont, USA

https://hms.harvard.edu/

Bacharelado em Artes pelo Harvard-Radcliffe College. Mestrado pelo Harvard Graduate School of Education. Médica pela Thomas Jefferson University. Psiquiatra pelo Massachusetts General Hospital/McLean Hospital. Fellowship Psicossocial, McLean Hospital. Diretora do Gunderson Personality Disorders Institute, Mclean Hospital, Harvard Medical School. 

Citas

Hastrup LH, Jennum P, Ibsen R, Kjellberg J, Simonsen E. Societal costs of borderline personality disorders: a matched‐controlled nationwide study of patients and spouses. Acta Psychiatr Scand. 2019;140(5):458-67. https://doi.org/10.1111/acps.13094

Paris J, Zweig-Frank H. A 27-year follow-up of patients with borderline personality disorder. Comprehensive Psychiatry. 2001;42(6):482-7. https://doi.org/10.1053/comp.2001.26271

Soeteman DI, Verheul R, Busschbach JJV. The burden of disease in personality disorders: diagnosis-specific quality of life. Journal of Personality Disorders. 2008;22(3):259-68. https://doi.org/10.1521/pedi.2008.22.3.259

Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders. 2010;24(4):412-26. https://doi.org/10.1521/pedi.2010.24.4.412

Linehan MM. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060. https://doi.org/10.1001/archpsyc.1991.01810360024003

Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156(10):1563-9.

https://doi.org/10.1176/ajp.156.10.1563

Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922-8. https://doi.org/10.1176/ajp.2007.164.6.922

Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(4):319. https://doi.org/10.1001/jamapsychiatry.2016.4287

Iliakis EA, Sonley AKI, Ilagan GS, Choi-Kain LW. Treatment of borderline personality disorder: is supply adequate to meet public health needs? PS. 2019;70(9):772-81. https://doi.org/10.1176/appi.ps.201900073

Choi-Kain LW, Albert EB, Gunderson JG. Evidence-based treatments for borderline personality disorder: implementation, integration, and stepped care. Harv Rev Psychiatry. 2016;24(5):342-56. https://doi.org/10.1097/HRP.0000000000000113

Bateman A, Krawitz R. Borderline personality disorder: an evidence-based guide for generalist mental health professionals. Oxford: Oxford University Press; 2013. 231 p. https://doi.org/10.1093/med:psych/9780199644209.001.0001

Chanen AM, Jackson HJ, McCutcheon LK, Jovev M, Dudgeon P, Yuen HP, Germano D, Nistico H, McDougall E, Weinstein C, Clarkson V, McGorry PD. Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial. Br J Psychiatry. 2008;193(6):477-84. https://doi.org/10.1192/bjp.bp.107.048934

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;166(12):1365-74. https://doi.org/10.1176/appi.ajp.2009.09010039

Gunderson JG, Links PS. Borderline personality disorder: a clinical guide. 2nd ed. Washington, DC: American Psychiatric Pub; 2008. 350 p.

Gunderson JG, Links PS. Handbook of good psychiatric management for borderline personality disorder. Washington, DC: American Psychiatric Publishing; 2014. 168 p.

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;169(6):650-61. https://doi.org/10.1176/appi.ajp.2012.11091416

Oud M, Arntz A, Hermens ML, Verhoef R, Kendall T. Specialized psychotherapies for adults with borderline personality disorder: a systematic review and meta-analysis. Aust N Z J Psychiatry. 2018;52(10):949-61. https://doi.org/10.1177/0004867418791257

Gunderson J, Masland S, Choi-Kain L. Good psychiatric management: a review. Current Opinion in Psychology. 2018;21:127-31. https://doi.org/10.1016/j.copsyc.2017.12.006

Kolla NJ, Links PS, McMain S, Streiner DL, Cardish R, Cook M. Demonstrating adherence to guidelines for the treatment of patients with borderline personality disorder. Can J Psychiatry. 2009;54(3):181-9. https://doi.org/10.1177/070674370905400306

Unruh BT, Sonley AKI, Choi-Kain LW. Integration with mentalization-based treatment. In: Applications of good psychiatric management for borderline personality disorder: a practical guide. Washington, DC: American Psychiatric Association Publishing; 2019. p. 307-26.

Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2012;169(5):476-83. https://doi.org/10.1176/appi.ajp.2011.11101550

Choi-Kain LW, Gunderson JG, American Psychiatric Association Publishing. [editors]. Applications of good psychiatric management for borderline personality disorder: a practical guide. Washington, D.C: American Psychiatric Association Publishing; 2019.

Finch EF, Brickell CM, Choi-Kain LW. General psychiatric management: an evidence-based treatment for borderline personality disorder in the college setting. Journal of College Student Psychotherapy. 2019;33(2):163-75. https://doi.org/10.1080/87568225.2018.1491361

Hong V. Borderline personality disorder in the emergency department: good psychiatric management. Harv Rev Psychiatry. 2016;24(5):357-66. https://doi.org/10.1097/HRP.0000000000000112

Gunderson JG, Links PS. Manual do bom manejo clínico para transtorno de personalidade borderline. São Paulo: Hogrefe; 2018.

Bernanke J, McCommon B. Training in good psychiatric management for borderline personality disorder in residency: an aide to learning supportive psychotherapy for challenging-to-treat patients. Psychodynamic Psychiatry. 2018;46(2):181-200.

https://doi.org/10.1521/pdps.2018.46.2.181

Unruh BT, Gunderson JG. "Good Enough" psychiatric residency training in borderline personality disorder: challenges, choice points, and a model generalist curriculum. Harv Rev Psychiatry. 2016;24(5):367-77. https://doi.org/10.1097/HRP.0000000000000119

Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry. 2006;14(5):249-56.

https://doi.org/10.1080/10673220600975121

Rüsch N, Hölzer A, Hermann C, Schramm E, Jacob GA, Bohus M, et al. Self-stigma in women with borderline personality disorder and women with social phobia. Journal of Nervous & Mental Disease. 2006;194(10):766-73. https://doi.org/10.1097/01.nmd.0000239898.48701.dc

Chanen AM, McCutcheon L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. Br J Psychiatry. 2013;202(s54):s24-9.

https://doi.org/10.1192/bjp.bp.112.119180

Fineberg SK, Gupta S, Leavitt J. Collaborative deprescribing in borderline personality disorder: a narrative review. Harv Rev Psychiatry. 2019;27(2):75-86. https://doi.org/10.1097/HRP.0000000000000200

Keuroghlian AS, Gunderson JG, Pagano ME, Markowitz JC, Ansell EB, Shea MT, Morey LC, Sanislow C, Grilo CM, Stout RL, Zanarini MC, McGlashan TH, Skodol AE. Interactions of borderline personality disorder and anxiety disorders over 10 years. J Clin Psychiatry. 2015;76(11):1529-34. https://doi.org/10.4088/JCP.14m09748

Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. A Randomized controlled study of a psychoeducation group intervention for patients with borderline personality disorder. J Clin Psychiatry. 2019;81(1). https://doi.org/10.4088/JCP.19m12753

Zanarini MC, Conkey LC, Temes CM, Fitzmaurice GM. Randomized Controlled Trial of Web-Based Psychoeducation for Women With Borderline Personality Disorder. J Clin Psychiatry. 2018;79(3). https://doi.org/10.4088/JCP.16m11153

Skoglund C, Tiger A, Rück C, Petrovic P, Asherson P, Hellner C, Mataix-Cols D, Kuja-Halkola R. Familial risk and heritability of diagnosed borderline personality disorder: a register study of the Swedish population. Mol Psychiatry. 2021;26(3):999-1008. https://doi.org/10.1038/s41380-019-0442-0

Gunderson JG, Berkowitz C. Family guidelines: multiple family group program at McLean Hospital. [Adaptado para o português, em 2006, por Brañas MJAA, Croci MS e Martinho Júnior E]. https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2020/02/Family-Guidelines-Final-Portuguese-Version.pdf

Gunderson JG, Bateman A, Kernberg O. Alternative perspectives on psychodynamic psychotherapy of borderline personality disorder: the case of "Ellen". Am J Psychiatry. 2007;164(9):1333-9. https://doi.org/10.1176/appi.ajp.2007.07050727

Weinberg I, Ronningstam E, Goldblatt MJ, Schechter M, Maltsberger JT. Common factors in empirically supported treatments of borderline personality disorder. Curr Psychiatry Rep. 2011;13(1):60-8. https://doi.org/10.1007/s11920-010-0167-x

Conway CC, Boudreaux M, Oltmanns TF. Dynamic associations between borderline personality disorder and stressful life events over five years in older adults. Personality Disorders: Theory, Research, and Treatment. 2018;9(6):521-9. https://doi.org/10.1037/per0000281

Stepp SD, Whalen DJ, Scott LN, Zalewski M, Loeber R, Hipwell AE. Reciprocal effects of parenting and borderline personality disorder symptoms in adolescent girls. Dev Psychopathol. 2014;26(2):361-78. https://doi.org/10.1017/S0954579413001041

Winsper C, Hall J, Strauss VY, Wolke D. Aetiological pathways to borderline personality disorder symptoms in early adolescence: childhood dysregulated behaviour, maladaptive parenting and bully victimisation. Bord Personal Disord Emot Dysregul. 2017;4(1):10.

https://doi.org/10.1186/s40479-017-0060-x

Links PS, Ross J, Gunderson JG. Promoting good psychiatric management for patients with borderline personality disorder: promoting good psychiatric management. J Clin Psychol. 2015;71(8):753-63. https://doi.org/10.1002/jclp.22203

Bach B, First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry. 2018;18(1):351. https://doi.org/10.1186/s12888-018-1908-3

Oldham JM. The alternative DSM-5 model for personality disorders. World Psychiatry. 2015;14(2):234-6. https://doi.org/10.1002/wps.20232

Schiavone FL, Links PS. Common elements for the psychotherapeutic management of patients with self injurious behavior. Child Abuse & Neglect. 2013;37(2-3):133-8.

https://doi.org/10.1016/j.chiabu.2012.09.012

Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. 2003;48(5):301-10. https://doi.org/10.1177/070674370304800505

Vijay NR, Links PS. New frontiers in the role of hospitalization for patients with personality disorders. Curr Psychiatry Rep. 2007;9(1):63-7. https://doi.org/10.1007/s11920-007-0011-0

Palmer BA. Discussion of emotional processing in a ten-session general (good) psychiatric treatment for borderline personality disorder. Personality and Mental Health. 2015;9(1):79-80.

https://doi.org/10.1002/pmh.1288

Bozzatello P, Rocca P, De Rosa ML, Bellino S. Current and emerging medications for borderline personality disorder: is pharmacotherapy alone enough? Expert Opinion on Pharmacotherapy. 2020;21(1):47-61. https://doi.org/10.1080/14656566.2019.1686482

Gunderson JG, Choi-Kain LW. Medication management for patients with borderline personality disorder. AJP. 2018;175(8):709-711. https://doi.org/10.1176/appi.ajp.2018.18050576

Mercer D, Douglass AB, Links PS. Meta-analyses of mood stabilizers, antidepressants and antipsychotics in the treatment of borderline personality disorder: effectiveness for depression and anger symptoms. Journal of Personality Disorders. 2009;23(2):156-174. https://doi.org/10.1521/pedi.2009.23.2.156

Abraham PF, Calabrese JR. Evidenced-based pharmacologic treatment of borderline personality disorder: a shift from SSRIs to anticonvulsants and atypical antipsychotics? Journal of Affective Disorders. 2008;111(1):21-30. https://doi.org/10.1016/j.jad.2008.01.024

Bridler R, Häberle A, Müller ST, Cattapan K, Grohmann R, Toto S, Kasper S, Greil W. Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: a comparison with other psychiatric disorders. European Neuropsychopharmacology. 2015;25(6):763-772. https://doi.org/10.1016/j.euroneuro.2015.03.017

Nosè M, Cipriani A, Biancosino B, Grassi L, Barbui C. Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials: International Clinical Psychopharmacology. 2006;21(6):345-53. https://doi.org/10.1097/01.yic.0000224784.90911.66

Grilo CM, Stout RL, Markowitz JC, Sanislow CA, Ansell EB, Skodol AE, et al. Personality disorders predict relapse after remission from an episode of major depressive disorder: a 6-year prospective study. J Clin Psychiatry. 2010;71(12):1629-35. https://doi.org/10.4088/JCP.08m04200gre

Fruzzetti AE, Shenk C, Hoffman PD. Family interaction and the development of borderline personality disorder: a transactional model. Develop Psychopathol. 2005;17(4).

https://doi.org/10.1017/S0954579405050479

Lawn S, McMahon J. Experiences of family carers of people diagnosed with borderline personality disorder. J Psychiatr Ment Health Nurs. 2015;22(4):234-43.

https://doi.org/10.1111/jpm.12193

Bo S, Vilmar JW, Jensen SL, Jørgensen MS, Kongerslev M, Lind M, Fonagy P. What works for adolescents with borderline personality disorder: towards a developmentally informed understanding and structured treatment model. Curr Opin Psychol. 2021;37:7-12. https://doi.org/10.1016/j.copsyc.2020.06.008

Fonagy P, Luyten P, Allison E. Epistemic petrification and the restoration of epistemic trust: a new conceptualization of borderline personality disorder and its psychosocial treatment. J Pers Disord. 2015;29(5):575-609. https://doi.org/10.1521/pedi.2015.29.5.575

Driessens CMEF. Extracurricular activity participation moderates impact of family and school factors on adolescents' disruptive behavioural problems. BMC Public Health. 2015;15(1):1110. https://doi.org/10.1186/s12889-015-2464-0

Oberle E, Ji XR, Guhn M, Schonert-Reichl KA, Gadermann AM. Benefits of extracurricular participation in early adolescence: associations with peer belonging and mental health. J Youth Adolescence. 2019;48(11):2255-70. https://doi.org/10.1007/s10964-019-01110-2

Hooley JM, Franklin JC. Why do people hurt themselves? A new conceptual model of nonsuicidal self-injury. Clin Psychol Sci. 2018;6(3):428-51. https://doi.org/10.1177/2167702617745641

Sonley AKI, Choi-Kain LW, American Psychiatric Association Publishing. [editors]. Good psychiatric management and dialectical behavior therapy: a clinician's guide to integration and stepped care. Washington, D.C: American Psychatric Association Publishing; 2021. 173 p.

Choi-Kain LW, Sharp C, American Psychiatric Association Publishing [editors]. Handbook of good psychiatric management for adolescents with borderline personality disorder. Washington, DC: American Psychiatric Association Publishing; 2021.

Publicado

2022-12-19

Cómo citar

1.
Croci MS, Brañas MJAA, Fleisher C, Carreño T, Jurado Andia MD, Martinho Júnior E, Choi-Kain LW. Manejo clínico general (GPM) para el trastorno limítrofe de la personalidad: un Modelo generalista para América Latina. Debates em Psiquiatria [Internet]. 19 de diciembre de 2022 [citado 22 de diciembre de 2024];12:1-26. Disponible en: https://revistardp.org.br/revista/article/view/446

Número

Sección

Artículo de revisión

Plaudit