Treating borderline personality disorder is complex for the therapist and often challenging for the patient. This article discuss the goals of therapy and some of the therapeutic approaches used, as well as a few insights into the diagnostic criteria for the disorder.
Although some progress has been made in borderline personality disorder treatments it remains the case that treatment is a complex and delicate process. The fact that the person is prone to impulsive behavior, self-harm and possibly aggression are significant issues. Personality disorders affect the person for much of their life and the evidence to date suggests that there is variation in the level of success that might be attained from treatments, including periods of remission.
What Does it Mean to be Borderline?
The criteria for borderline personality disorder were not established until the first major revision of the Diagnostic and Statistical Manual (DSM) in the 1980s. The DSM is basically a manual of symptoms and is used by clinicians to diagnose psychiatric illnesses. The most notable features of the disorder are unregulated states of emotion, outrageous behavior, erratic social interactions and unstable emotions. Despite these features the person never quite tips over into a state of psychosis, which has prompted the phrase ‘stable in their instability’.
The DSM-IV-TR defines borderline personality disorder as a pervasive pattern of instability of interpersonal relationships, self-image and affect, and marked impulsivity. Estimates suggest that roughly two percent of the US population have this disorder. It is thought to be more common in women and nearly 10 percent of people with borderline personality disorder go on to commit suicide. It begins in childhood and its key characteristics include five of the following:
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense personal relationships characterized by alternating between idealization and devaluation.
- Identity disturbance: marked and persistently unstable self-image.
- Impulsivity in at least two areas that are potentially self-damaging (such as substance abuse, reckless driving).
- Recurrent suicidal behavior or self-mutilating behavior which may include repeated threats or gestures.
- Chronic feelings of emptiness.
- Inappropriate intense anger or difficulty controlling anger.
- Transient stress-related paranoid ideation or severe dissociative symptoms.
Diagnostic Criteria - Neglect and Sexual Abuse
Two areas of research tend to stand out. The first relates to comorbidity, that is, the extent to which borderline or other personality disorders are associated with other psychological disorders. The second is the role of sexual abuse. In relation to comorbidity, the most obvious candidates are depression, bulimic-type eating disorders and drug misuse. Sexual abuse meanwhile has been the focus of a great deal of research and there is evidence to suggest it plays a significant role in the development of borderline personality disorder. However, sexual abuse very often occurs within a more general context of neglect and this is a further consideration.
It is probably fair to say that the criteria for borderline personality disorder are based more around description than hard science. The central characteristics of the disorder involve intense fears of abandonment and the use of self-harm as a means of coping with strong emotions. It also appears that childhood rejection and trauma influence the development of a negative sense of self. In turn, this increases the risk of the disorder developing.
The development of borderline personality disorder may stem from biological, psychological and social interactions. Potential borderlines are very often highly sociable, spontaneous, active and emotionally expressive, although they may be considered a little pushy and demanding at times. Stress is a key factor in amplifying these characteristics. The loss of a loved one or involvement in some form of trauma for example, can result in low moods or mood swings. The person may turn to alcohol or other substances in order to cope and may find themselves in unstable personal relationships. This vicious cycle provides the fuel for the development of the disorder.
Relatively few controlled studies have been undertaken that compare and evaluate the effectiveness of treatment methods. Goals for treatment1 however include:
- Psychotherapy: generally regarded as more effective for less severe personality disorders.
- Prevention: where suicide risk appears high, the main aim of therapy might just be to prevent suicide.
- Limit-setting: where people who are prone to impulsive behaviors are set achievable goals to help cope with uncontrollable impulses.
- Commitment: where the patient-therapist relationship is viewed as paramount in attaining therapy goals. If the patient and therapist cannot relate, the goals of therapy are unlikely to be achieved.
In general, people with borderline personality disorder appear to gain most from talking therapies if they are open to the idea of psychological therapies, have low levels of impulsivity, and have a good level of social and emotional support from close family and friends.
One of the more effective borderline personality disorder treatments is cognitive therapy (CBT). One form of CBT, specifically developed for the treatment of borderline personality disorder, is dialectical behavior therapy (DBT).
The main purpose of CBT is to identify and then modify core beliefs and patterns of thought that drive behavior. This is achieved through the development of problem-solving plans and homework tasks. However, for some people with high levels of emotional sensitivity the focus on change appears to cause distress and this can lead to drop out from therapy.
DBT was developed by Marsha Linehan as a way of responding and acknowledging the difficulty of change in people with borderline personality disorder. Issues of self-harm or drug taking, for example, whilst considered not in the best interests of the person are accepted as valid ways of coping. The therapist tries to achieve the goals of therapy by accepting that drugs or alcohol makes perfect sense as a way of dealing with a moment of crisis or a mood of depression, but they offer alternative, less harmful and more effective solutions to those problems.
DBT is increasingly viewed as the treatment of choice for borderline personality disorder as it reduces self-harm, suicide attempts and bulimic eating disorders associated with the disorder.
Medication for BPD
Drugs therapies have a relatively limited remit with personality disorders and tend to be viewed as a way of supplementing or supporting psychological therapies. Antidepressants, for example, might be prescribed during a period of depression.
Bennett, Paul. Abnormal and Clinical Psychology. Open University Press (2003).
Claridge, Gordon and Davis, Caroline. Personality and Psychological Disorders. Arnold Publishers (2003).
Linehan. M, Schmidt. H, Dimeff. L. A, et al. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. American Journal on Addiction 8: 279-92.
Roth, A et al (1998) What Works for Whom? New York: Guilford. In Bennett, Paul. Abnormal and Clinical Psychology. Open University Press.