Gold-Standard Treatments at Odds:
Complications in Treating Combined Anorexia Nervosa & Borderline Personality Disorder
Any clinician can tell you that treating a life-threatening psychological condition such as an eating disorder or borderline personality disorder is seriously challenging. Treating a person with both an eating disorder and borderline personality disorder, however, is exponentially more difficult than the treatment of either condition alone. This is largely because the gold-standard treatments for these disorders are at odds with one another: treating one life-threatening disorder exacerbates the other. This post discusses how this happens and what to do.
To being to understand this problem, let's start with a discussion of why these disorders are life-threatening. Eating disorders are life-threatening because the bodily impact of eating disordered behaviors such as severe caloric restriction and purging can respectively result in conditions like severe malnutrition and esophageal tears. Borderline personality disorder is also life-threatening because people are at risk of engaging in impulsive behaviors, self-injury, and suicidal behavior when because they lack skills to regulate intense emotions. Clearly, both disorders are life-threatening and must be addressed. But what do you do if someone has both an eating disorder and borderline personality disorder? Just treating both conditions at the same time seems like the obvious answer. Quickly after the implementation of this approach, however, one quickly discovers that the gold-standard treatments of the two life-threatening conditions are at odds.
To further understanding as to why these treatments are at odds, let's first discuss the singular treatment of anorexia nervosa, one type of deadly eating disorder. In anorexia nervosa, a person becomes underweight following a prolonged period of severe caloric restriction. This severe caloric restriction is a behavioral strategy used to temporarily decrease the experience of fearing fatness in a given moment. In the treatment of this condition, the goal must be weight gain to ensure both physical and psychological recovery. Further, from a psychological perspective, a person recovering from anorexia nervosa must endure the following exposures: 1) eating a large quantity of food many times per day (upwards of 4,000 calories), 2) eating a variety of high-fear foods every day such as pizza and burgers, 3) enduring a physical feeling of fullness that the eating disordered mind equates with immediate "fatness," 4) actual weight gain slowly occurring all day, every day for what is more often months, rather than weeks, and 5) not engaging in any "safety" behaviors that result in a respite from fear of fatness such as exercising, purging, and taking laxatives. As such, the treatment of anorexia nervosa involves what can be viewed as a series of multiple, intense, all-day in vivo exposures, that carry on for months. And because the person is in medical crisis, the intensity of this extended exposure cannot be lessened. There is no luxury of spacing out exposures based on psychological readiness in the treatment of anorexia nervosa. A person with anorexia nervosa must be thrown into the metaphorical deep end. As such, I imagine that the series of exposures involved in the treatment of anorexia nervosa are more intense than the treatment of any other disorder.
Now, let's discuss the singular treatment of borderline personality disorder. In the treatment of borderline personality disorder, we are taught early on in graduate school that it is a bad idea to start with underlying trauma, which of course is normally treated with "prolonged exposure." The idea is that if someone does not have skills to cope with intense negative emotions that arise during exposure, they may be at increased risk for impulsive, self-injurious, and suicidal behaviors. So, rather than implementing exposure in the treatment of borderline personality disorder, we are taught the focus in the treatment must be on skill building.* Returning to a deep-end metaphor, learning coping skills is the equivalent of learning how to swim. The skills, of course, are very helpful to know before being thrown into the deep end.
As such, in the treatment of BPD, teaching skills decreases impulsive behaviors, the life-threatening component of the disorder. A person with anorexia nervosa, however, is not immediately saved in the same way with skills. Because the treatment of anorexia nervosa first requires medical & nutritional interventions that are psychologically experienced as exposures, there isn't enough time to teach skills before the interventions begin. Further, even intelligent people with malnourished brains are much more likely to think inflexibly, and therefore, skills such as flexible & dialectical thinking may not be absorbed even if taught well to smart folks.
Now with a greater understanding of the individual disorders, let's return to the problem: focusing on treatment of an eating disorder in which intense exposure is needed can exacerbate the emotion dysregualtion inherent in borderline personality disorder, increasing the odds for impulsive behavior, self-injurious behavior, and suicide; alternatively, focusing primarily on skill building to treat the borderline personality disorder would does not allow for the rapid weight gain needed to ensure medical stability in the treatment of anorexia nervosa.
To increase understanding of this problem even further, let's combine the above concepts with understanding a bit about how the brain is impacted by both disorders. A patient with anorexia nervosa has a malnourished brain that will result in inflexible thinking, further obsessionally, increased irritability, and other cognitive deficits. If this person also has borderline personality disorder, not only is the brain malnourished, but the system in the brain in charge of emotion regulation is malfunctioning. As such, the brain is malnourished - and needs nourishment to function properly - but the process by which re-nourishment occurs involves intense, all-day, multiple exposures that predictably result in rather severe emotion dysregulation, which is efficiently calmed by the immediate escape of negative emotion through the sabotage of the re-nourishment process (e.g. purging). Big problem.
The problem is so big, in fact, that I do not think that simply treating someone with both outpatient gold standards of treatment - Family Based Therapy for anorexia nervosa and Dialectical Behavior Therapy for borderline personality disorder - will be helpful. I do, however, have some strategies for fighting the two-headed monster that is comorbid anorexia nervosa and borderline personality disorder.
When clinicians finally see a patient with anorexia nervosa and borderline personality disorder in treatment, the complex interplay of psychological and physical pathology has already seriously compromised the patient's overall health. Without any time for fostering full understanding of our rationale, the only thing to do in the moment is push the person into the deep end of the pool. As clinicians we must also, however, dive in after them. In the pool, we can hold them up until they learn how to swim.
I don't believe there is much hope of recovering from comorbid anorexia nervosa and borderline personality disorder without massive amounts of support. Inherent in the disorder of anorexia nervosa, the person with this diagnosis cannot reach the conclusion that consuming large volumes of food and gaining weight will result in recovery. We have to show them this. As such, an outpatient level of care is very rarely enough. It makes sense to me that most people who are severely underweight with anorexia nervosa and borderline personality disorder must be hospitalized on a psychiatric unit with staff and structure that can limit dangerous behaviors. Because re-nourishment will inevitably be an awfully triggering experience, we must be as emotionally supportive as possible We must also must be practically supportive and help the person learn as many coping skills as possible. When someone is very underweight, we don't have the medical luxury of spending time focusing on skills, nor is it likely that most people can effectively learn the skills with a malnourished brain and body. I think we must focus on re-nourishment while mitigating as many destructive behaviors as possible and teaching skills. Once the person is stabilized, going to a structured program, likely makes the most sense.
Unfortunately, in 2017 America, people with anorexia nervosa do not stay on inpatient units until they are 100% weight restored, even without the added complications that borderline personality disorder brings. On a larger scale, I intend to advocate for a return to a time when patients stay until they have truly weight restored, especially if there is co-morbid borderline personality disorder. In short, a presentation of both anorexia nervosa and borderline personality disorder really seems to call for the highest levels of care that you can get for the longest amount of time that you can get. Whether you are a provider, patient, or loved one: I urge you to convey the information in this post to foster an understanding of the serious problem the comorbidity that anorexia nervosa & borderline personality disorder presents to advocate for more time in higher levels of care.
*Please note: there is evidence that PTSD & BPD can be treated simultaneously (Harned and colleagues; for more info: http://bit.ly/2cCrbiy). But let's think about the treatment of borderline personality disorder and co-morbid PTSD v.s. anorexia nervosa a bit more. In the treatment of PTSD, "prolonged exposure" typically refers to about an hour of exposure once per week, the intensity of which is selected based on the psychological readiness of the patient. From the perspective of someone who has undergone treatment for anorexia nervosa, the term "prolonged" is likely to seem sarcastically adorable. I can imagine my patients saying "Wait, that is considered prolonged? Ha!" Although PTSD might be able to be treated in the context of BPD with careful consideration, the challenge of treatment anorexia nervosa is much greater.