Enterovirus Infections

References

• de Crom SC, Rossen JW, van Furth AM ym. Enterovirus and parechovirus infection in children: a brief overview. Eur J Pediatr 2016;175(8):1023-9. [PubMed]

Essentials

• Borderline personality disorder (BPD) is a serious condition that considerably decreases the functional capacity of the patient. The disorder is characterised by emotional instability, difficulties in controlling behaviour, susceptibility to problems with personal relationships, and a tendency to experience intense feelings of shame.
• The prevalence rates are higher among the young, those with a poor education and women.
• The disorder is often associated with self-inflicted cuts, drug overdoses and other acts of deliberate self-harm without serious suicidal intent.
• Differentiation from bipolar disorder and attention deficit disorder may be difficult.
• Psychotherapy is the main form of treatment.

Background

• BPD affects about 0.7% of the population, but the figure may be as high as 6% among those attending primary care centres, 10% among those attending mental health outpatient clinics and 20% among psychiatric patients receiving inpatient care.
• The factors increasing the risk of a person developing the disorder are often the same as those linked to other psychiatric disorders and physical illnesses. An accumulation of several risk factors indicates an increased likelihood of developing BPD.
• Hereditary factors predispose a person to the disorder.
• Recurrent childhood adversities and problems within a child's developmental environment often play a predictive role in the development of the disorder.
• The patient engages repeatedly in self-injuring behaviour, usually in order to bring relief to emotional distress.

Diagnosis

• The main responsibility as regards diagnosis, treatment and the integration of treatment lies with a psychiatric outpatient clinic whose staff works closely with psychiatric inpatient facilities, primary health care, substance abuse clinics, the social sector and facilities providing psychotherapy services.
• Several semi-structured interview methods and self-rating scales have been designed for the diagnosis and clinical examination of personality disorders, and these may be used in specialist health care settings to confirm the diagnosis.
• The differentiation of BPD from bipolar disorder and attention deficit disorder may be difficult.
• BPD may be preceded by attention deficit disorder of childhood which may have been complicated by environmental factors.
• Traumatic experiences in childhood, impulsivity and mood changes alternating between anger and anxiety are more common among patients with BPD than those with bipolar disorder.
• BPD is often seen in conjunction with other psychiatric disorders that need to be addressed. Substance abuse disorders are also common. A complexity of symptoms is characteristic of the disorder.

Treatment

• Treatment should be planned and carried out as far as possible in an outpatient facility. If inpatient care is necessary, day hospitals should be favoured.
• A patient with BPD may become a frequent visitor at health care facilities; the character of the visits may be intense but they often remain short-term as the patient seeks help from several sources at the same time.
• The patient's failure to comply with agreements creates a challenge as far as cooperation and treatment of physical illnesses are concerned.
• It has been observed that up to 50% of primary health care patients with BPD are not receiving appropriate treatment. A significant share of persons with BPD utilise primary health care services annually due to somatic symptoms or diseases.
• When assessing the need for treatment the physician should consider the risk of complications of the disorder: self-injuring behaviour, interruption of treatment, impulsivity and anxiety.
• The patient should be helped to understand the short and long term consequences of his/her behaviour and differentiate between the two; this may activate the patient and improve his/her ability to solve problems.
• The patient should be informed about the diagnosis, in order to promote his/her autonomy and support patient education and cooperation. The patient should be informed about the assumed aetiology of the disorder and about the current understanding of its effective treatment.
• Therapy that addresses the meaning, recognition, perception and regulation of emotions is also important.
• Because there is a risk that the patient's clinical condition may worsen and, in particular, self-injuring behaviour increase, inpatient treatment periods must be as structured as possible. The additional support offered and the patient's ability to experience the predictability of his/her surroundings may improve the condition.
• Day hospital programmes may offer superior treatment results as compared with conventional psychiatric treatment.
• The principal treatment form of the disorder is psychotherapy, such as dialectical behaviour therapy, different cognitive therapies, mentalization-based treatment and transference-focused psychotherapy. Different therapy forms may be applied in the different phases of the disorder according to the patient's needs.
• Educational and skill-oriented family interventions that are offered in a group may improve the family's functioning and the relatives' well-being. Meeting the family may reduce the burden of the relatives and it may reduce possible conflicts between the patient and the relatives, as well as between the relatives and the treatment units. The most common problems with families include communication difficulties, difficulties in relating to hostile reactions and a fear of the patient committing suicide.
• Newer antipsychotic medication, particularly, may be beneficial in modifying symptoms. When planning drug therapy, take into account the increased risk of suicide committed with drugs and the increased risk of less purposeful suicide attempts, susceptibility to addiction to medicines and alcohol or drug abuse, independence in carrying out drug therapy as well as the patient's other illnesses.
• Antidepressants can be beneficial in treating the patient's other disorder. Alternatives in treating anxiety may be buspirone and pregabalin. The use of benzodiazepines is not recommended in treatment of symptoms of borderline personality disorder.
• The intention to alleviate very different kinds of psychiatric symptoms may lead to inappropriate polypharmacy.

Arrangement of treatment

• The principal role of the primary health care is to screen and refer patients to specialist health care.
• If BPD is associated with half-hearted attempts at self-harm associated with chronic self-injuring behaviour, a referral of the patient to psychiatric inpatient care after a suicide attempt may do more harm than good. Inpatient care may be indicated if a suicide attempt is associated with a serious wish to die or a serious mood disorder, or if the patient presents with psychotic symptoms or severe dissociation symptoms.
• The assessment of the need for medication in personality disorders is the responsibility of a specialist physician.
• Polypharmacy is often common with these patients, and a specialist physician should be consulted if medication is considered necessary.

Treatment in primary health care

• The treatment of a patient with BPD is very challenging even for an experienced doctor and can be at times somewhat overwhelming.
• It is likely that the patient has experienced, during his/her life, feelings of being neglected and labelled and has not often experienced feelings of being understood.
• Take the patient's experience seriously and understand that he/she has his/her reasons for experiencing things in the way he/she does.
• Avoid being provoked by the patient's disruptive behaviour.
• Give the patient regular, time-limited appointments that are not dependent on a new disease.
• Set limits regarding clinging and oppressive behaviour without judging the patient and his/her behaviour.
• The patient is always him-/herself responsible for his/her behaviour.
• Discuss the various treatment options openly with the patient, remember the importance of keeping hope alive and aim to provide a confidential therapeutic relationship. Drawing out an open treatment agreement that outlines the responsibilities of both the doctor and patient may assist in gaining the patient's trust.
• The initial aim when treating a patient with poor treatment compliance is to improve his/her motivation for treatment.
• Patients who display features of somatisation and those with a multitude of physical illnesses should mainly be managed in the primary health care, as should hypochondriac patients.
• Psychiatric consultation is particularly important if
  • the patient becomes a heavy user of various health care and social welfare services
  • the symptoms are difficult to control but the patient is not willing to be referred to specialist care
  • the patient does not commit himself/herself to the treatment of a physical illness
  • differential diagnosis proves problematic; for example, in order to confirm diagnosis
  • adequate results are not achieved with the treatment prescribed by the primary care physician, or if there is uncertainty about the adequacy of the results.

Prognosis

• According to follow-up studies, the prognosis is usually good. The symptoms also usually alleviate as the patient grows older, but some patients may even then fulfil the diagnostic criteria of some other personality disorder. Depressive symptoms also alleviate and functional capacity recovers clinically significantly in a few years.
• Appropriate treatment will hasten symptomatic improvement, reduce self-injurious behaviour and improve functional capacity.
• More than every other patient suffering from borderline personality disorder will no longer meet the diagnostic criteria for the disorder after more than 5 years. Similarly, depressive symptoms alleviate and functional capacity recovers clinically significantly in a few years.
• Completed suicide occurs in 3%-9% of individuals with the disorder. Suicide is more likely to be successful when the patient is aged over 30 years.
• Chronic depression may persist in some patients as a residual symptom.

Emotionally unstable personality disorder ICD-10

Type of disorder	Diagnostic criteria
Impulsive F60.30	A. The general criteria for personality disorder (F60) must be met.
	B. Criterion A and at least two of the following must be present: tendency to act impulsively and without consideration of the consequences tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized liability to outbursts of anger and violence, with inability to control the behaviour difficulty in maintaining any course of action that offers no immediate reward unstable and capricious mood.
	Note The impulsive type is characterised predominantly by emotional instability and lack of impulse control. Outbursts of violence and threatening behaviour are common, particularly in response to criticism by others.
Borderline type F60.31	A. The general criteria for personality disorder (F60) must be met.
	B. At least three of the symptoms mentioned in criterion B for F60.30 must be present with at least two of the following in addition: disturbances in and uncertainty about self-image, internal preferences and sexual orientation liability to become involved in intense and unstable relationships, often leading to emotional crisis excessive efforts to avoid abandonment recurrent threats or acts of self-harm chronic feelings of emptiness.
	Note Several of the characteristics of emotional instability are present in the borderline type. Disturbances in the patient's own self-image, aims and internal preferences as well as chronic feelings of emptiness are characteristic. Intense and unstable relationships may cause repeated emotional crises. They may be associated with excessive efforts to avoid abandonment. These crises may lead to recurrent suicide threats or attempts, or acts of self-harm.