How TFP Addresses Depression and Suicidality

1	How TFP Addresses Depression and Suicidality Sonia Kulchycky, MD
2	Sources of Depression in BPD Patients Comorbid Affective Disorder Borderline Mechanisms Personality Predispositions Narcissistic Histrionic and Borderline Sadomasochistic Environmental Factors Depression Accompanying Improvement
3	Diagnosing Depression in Course of Treatment Diagnose Source of Depression, considering: - Biological Factors/Phenomenology - Characterological Factors - Transference Issues - Current Life Circumstances
4	Tactical Approaches to Depression - I 1 - If comorbid affective disorder: Major Depression SSRI (see relevant algorithm) If Dysthymia Use clinical judgment re med trial or not 2 – If life events are contributing, assess whether the feelings are appropriate, even a sign of progress
5	Tactical Approaches to Depression II If neither comorbid affective disorder or life circumstances: Diagnose the dyads of self and other representation activated since the depression may be an affect linking a particular dyad The dyads are examined by exploring the transference and interpersonal vignettes of the patient Is the depression related to emerging awareness of internal conflicts and/or aggression?
6	Case example of depressed patient Indifferent powerful self who wants nothing Self who longs for loving caretaking Impotent, devalued other Abandoning, disappointing other
7	Managing Suicidality in BPD - I Assess Level of Risk Diagnose its sources - Implement Appropriate Interventions
8	Assessing Level of Suicide Risk - Consider the Following Factors: 1 - Comorbid conditions 2 – Social and Occupational Factors 3 – Family and Developmental Factors 4 – Characterological Factors 5 – Demographic Factors
9	Diagnosing Sources of Suicidality Comorbid Axis I disorders Character pathology The two may occur together; decide which is primary at the moment
10	Tactical Approaches to Suicidality -If comorbid conditions, diagnose and treat -Decide if outpatient is safe No hospitalize Yes 1)refer to contract setting, 2)As above, clarify, confront, and interpret the self-object dyad driving the suicidality 3)Consider if the suicidality is part of a defensive response to a dyad 4)Transform the suicidality into an understanding of the underlying dynamic (motivations)
11	Case Example of Suicidal Pt. Sick, “crazy” self Healthy, “sane” self Healthy, “sane” other “Crazy”, sick other who abandons TFP out of fear
12	Case example – 2^nd Interpretation “Failure”, devalued, worthless self Successful, superior persecutor Successful, employed other “Failure”, controlled, devalued victim