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New therapy designed to treat borderline teenagers with eating disorders
The approach expands access to psychiatric treatment within the public healthcare system, as non-specialist physicians, once trained, can deliver the interventions
Researchers from USP, in partnership with McLean Hospital in the United States, have developed a new therapeutic approach aimed at treating teenagers with borderline personality disorder associated with eating disorders. The initiative seeks to fill a gap in the public health system, which currently offers few treatment options for this combination of psychiatric conditions, characterized by high complexity, overlapping symptoms, and common risk factors. Existing interventions are scarce, highly specialized, long-lasting, and not very accessible to the population. Adolescence is considered a crucial phase for achieving better prognoses, preventing symptom escalation, and reducing the risk of the disorder becoming chronic.
The approach, entitled Good Psychiatric Management for Adolescents with Borderline Personality Disorder and Eating Disorders (GPM-AED), is multidisciplinary and includes early diagnosis, patient support, psychoeducation, management of self-destructive behaviors, active family involvement, and medication when needed.
“The clinical condition of these patients is marked by emotional instability, impulsivity, intense interpersonal relationships, and a high risk of suicide, which is aggravated by a dysfunctional relationship with food, often used as a form of emotional regulation,” psychiatrist Marcos Signoretti Croci describes.
The researcher is one of the coordinators of the Outpatient Department for the Development of Relationships and Emotions (Adre) at the Institute of Psychiatry (IPq) of Hospital das Clinicas (HC) of the USP Medical School (FMUSP), where the new therapeutic proposal is being implemented.
Since its creation in 2017, Adre has treated more than 100 patients aged 13 to 18 with severe emotional dysregulation, referred by the Psychosocial Care Center (CAPS), the Basic Health Units (UBS), and other internal IPq services. “Treatment lasts an average of six months, and although there is no definitive cure for the disorders, most patients are discharged after this period, with significant remission of symptoms, such as greater emotional regulation and a reduction in risk behaviors – self-harm and suicidal ideation,” Croci says.
As a way of disseminating the proposals of the new management and training professionals, Adre also promotes workshops aimed at physicians, psychologists, nurses, and other mental health professionals every year, when free registration is available for professionals working at CAPS.
Physician Yasmin Nascimento Ávila completed her specialization in Psychiatry at Adre, where she worked directly with teenagers. She is currently working as a volunteer researcher, but has decided to take the experience, which she considers a success, to her hometown of Belém, in Pará. Excited by the new clinical management model’s results, she plans to implement a similar care center in the region soon. Yasmin says that “it was an encouragement to realize that it is possible to treat patients with these disorders. There is a stigma towards borderline patients. During medical training, we often lose hope of effective therapies for these cases. The new evidence-based management represents a light at the end of the tunnel,” she says.
Overlapping symptoms and risk factors
According to the psychiatrist, personality disorders usually appear in adolescence and early adulthood. It is estimated that between 30% and 50% of adolescents with borderline personality disorder in outpatient treatment also show symptoms of eating disorders, such as anorexia nervosa, bulimia, and binge eating — conditions whose diagnoses can overlap over time.
Although there are effective treatments for both conditions separately, such as Dialectical Behavior Therapy, Cognitive Analytic Therapy and mentalization-based approaches for the disorder — in addition to Cognitive Behavioral Therapy and family interventions for eating disorders — Croci explains that these approaches are highly specialized, long-term and limited in supply, which makes them not very accessible to the public primary health care system. “Only patients who don’t show improvement with GPM-AED interventions [Good Clinical Management for Adolescents with Borderline Personality Disorder and Eating Disorders] are referred for these therapies, which are also indicated for adults living with the disorders,” she says.
According to Croci, the new therapeutic proposal focuses specifically on adolescents because it is understood that both disorders, in this age group, have symptomatic overlaps because they share similar risk factors and clinical characteristics: history of childhood trauma or abuse; insecure attachment (unstable relationships); negative affectivity (intense emotions that are difficult to control); difficulty regulating emotions; impulsivity; unstable self-image and low self-esteem; and self-destructive behaviors (self-injurious behaviors such as cutting or self-induced vomiting).
The GPM-AED was an adaptation of the General Psychiatric Management model, originally aimed at adults with borderline personality disorder, developed by psychiatrist John Gunderson, a professor at Harvard Medical School and researcher at McLean Hospital in the United States, a world benchmark institution for borderline.
Therapeutic alliance
Croci considers it difficult to identify which specific interventions of the new approach are most significant on their own, as is often the case with other complex treatments. However, he emphasizes that building a collaborative therapeutic alliance with the patient is fundamental to treatment progress, as it encourages active learning and supports the implementation of changes.
According to the physician, for this alliance to be effective, various procedures are applied, such as diagnostic communication — which enables the clinician to understand and explain mental health problems to the patient —, psychoeducation, emotional validation, and commitment strategies. Croci also stresses the significance of family involvement, which is considered an essential component in treatment. Family participation contributes to patient engagement, improves relationship dynamics, and strengthens support throughout therapy.
The management was described in the article General Psychiatric Management for Adolescents With Borderline Personality Disorder and Eating Disorders, published in the American Journal of Psychotherapy, with Marcos Signoretti Croci as first author.
Professors Eduardo Martinho Jr. and Marcelo Brañas, both from FMUSP, are also coordinating Adre along with Croci.
More information: Marcos S. Croci, by email marcos.croci@fm.usp.br or adre.ipq@hc.fm.usp.br
English version: Nexus Traduções, edited by Denis Pacheco
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A reprodução de matérias e fotografias é livre mediante a citação do Jornal da USP e do autor. No caso dos arquivos de áudio, deverão constar dos créditos a Rádio USP e, em sendo explicitados, os autores. Para uso de arquivos de vídeo, esses créditos deverão mencionar a TV USP e, caso estejam explicitados, os autores. Fotos devem ser creditadas como USP Imagens e o nome do fotógrafo.