Boston Counseling Therapy

What is Borderline Personality Disorder? How is BPD Treated?

The following article provides an overview of the diagnosis and symptoms of Borderline Personality Disorder

DSM IV-TR Definition
A pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 

(3) identity disturbance: markedly and persistently unstable self-image or sense of self 

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating). 
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 

(7) chronic feelings of emptiness 

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 

(9) transient, stress-related paranoid ideation or severe dissociative symptoms
The facts

Eleven percent of all psychiatric outpatients and 19% of psychiatric inpatients are estimated to meet criteria for BPD; of patients with some form of a personality disorder, 33% of outpatients and 63% of inpatients appear to meet BPD criteria.

Behavioral Patterns in BPD

Emotional vulnerability: A pattern of pervasive difficulties in regulating negative emotions, including high sensitivity to negative emotional stimuli, high emotional intensity, and slow return to emotional baseline, as well as awareness and experience of emotional vulnerability.

Self-invalidation:Tendency to invalidate or fail to recognize one’s own emotional responses, thoughts, beliefs, and behaviors. Unrealistically high standards and expectations for self.

Unrelenting crises: Pattern of frequent, stressful, negative environmental events, disruptions, and roadblocks-some caused by the individual’s dysfunctional lifestyle, others by an inadequate social milieu, and many by fate or chance.

Inhibited grieving: Tendency to inhibit and overcontrol negative emotional responses, especially those associated with grief and loss, including sadness, anger, guilt, shame, anxiety, and panic.

Active passivity: Tendency to passive interpersonal problem-solving style, involving failure to engage actively in solving of own life problems, often together with active attempts to solicit problem solving from others in the environment; learned helplessness, hopelessness.

Apparent competence: Tendency for the individual to appear deceptively more competent that she actually is: usually due to failure of competencies to generalize across expected moods, situations, and time, and to failure to display adequate nonverbal cues of emotional distress.

Borderline individuals generally experience:
Emotional dysregulation
Interpersonal dysregulation
Behavioral dysregulation
Cognitive dysregulation
Self dysregulation

Psychopharmacology

BPD involves dysregulation in too many domains for a single drug to serve as a panacea.
Several agents may be useful for improving measures of global functioning, depression, schizotypal symptoms, and impulsive behavior.

Antipsychotic medications demonstrated reductions in irritability, though effects in other domains of functioning have been inconsistent. They are generally considered most effective for severely disordered patients with BPD.

Newer antipsychotics, although not yet tested for patients with BPD, may be effective in targeting irritability and psychotic symptoms without the pervasive side effects of traditional antipsychotics.

Patients with BPD are notoriously noncompliant with treatment regimens, may abuse the prescribed drugs or overdose, and may experience unintended effects of the drug.

Cognitive-Behavioral Treatments

Beck’s approach of treating BPD has the focus of is on restructuring thoughts and on developing a collaborative relationship through which more adaptive ways of viewing the world are developed.

R.M. Turner hypothesizes that maladaptive schemas are reinforced over time to produce the difficulties characteristic of the disorder. His structured, multimodal treatment consists of pharmocotherapy combined with concurrent individual and psychoeducational group therapy in which specific strategies target interpersonal and anxiety management skills deficits.

Dialectical Behavior Therapy (DBT)
The theoretical orientation to treatment is a blending of three theoretical positions: Behavioral science, dialectical philosophy, and Zen practice.

Behavioral science, the technology of behavior change, is countered by acceptance and tolerance of the patient (with techniques drawn both from Zen and from Western contemplative practice); the poles are balanced within the framework of a dialectical position.

Philosophical Basis: Dialectics

The term ”dialectics” as applied to behavior therapy refers both to a fundamental nature of reality and to a method of persuasive dialogue and relationship.

Dialectics guides the clinician in developing theoretical hypotheses relevant to the client’s problems and to the treatment. As dialogue and relationship, dialectics refers to the treatment approach or strategies used by the therapist to effect change.

Dialectical Case Conceptualization

Dialectics suggests that a psychological disorder is best conceptualized as a system.
The systematic dysfunction is characterized by:

Defining the disorder with respect to normal functioning
Assuming continuity between health and the disorder
Assuming that the disorder results from multiple rather than single causes.

A second dialectical assumption that underlies Linehan’s biosocial theory of BPD is that the relationship between the individual and the environment is a process of reciprocal influence, and that the outcome at any given moment is due to the transaction between the person and the environment.

Stages of treatment

A pretreatment stage prepares the client for therapy and elicits a commitment to work toward the various treatment goals.

It is important to provide an orientation to specific goals and treatment strategies, and to make the commitment to work toward the goals since this will be an aspect of each of the following stages of treatment.

Stage I
During this stage the primary focus is on stabilizing the patient and achieving behavioral control.
Criteria for putting a patient on this stage are based on level of current functioning, together with the inability of the patient to work on any other goals before behavior and functioning come under better control.

Subsequent stages

Stage 2:
the treatment goals are to replace “quiet desperation” with nontraumatic emotional experiencing.
Stage 3:
to achieve “ordinary” happiness and unhappiness, and reduce ongoing disorders and problems in living.
Stage 4:
to resolve a sense of incompleteness and achieve joy.
Functions of treatment
Enhancing behavioral capabilities by expanding the individual’s repertoire of skillful behavioral patterns.

Improve the patient’s motivation to change by reducing reinforcement for dysfunctional behaviors and high-probability responses (cognitions, emotions, actions) that interfere with effective behaviors
Functions of treatment

Ensure that new behaviors generalize from the therapeutic to the natural environment.
Enhance the motivation and capabilities of the therapist so that effective treatment is rendered
Structure the environment so that effective behaviors, rather than dysfunctional behaviors, are reinforced.

Target behaviors
Suicidal behaviors
Therapy interfering behaviors
Quality of life behaviors
Behavioral skills
Post traumatic stress reduction
Resolving problems in living and increasing self respect
Attaining the capacity for sustained joy

DBT treatment models Individual therapy
Each patient has an individual psychotherapist who is also the primary therapist for the patient on the treatment team.
All other modes of therapy revolve around the individual therapy.
The individual therapist is responsible for helping the patient inhibit maladaptive, borderline behaviors and replace them with adaptive, skillful responses.

Skills Training

All patients must be in structured skills training during the first year of therapy.
DBT skills training is conducted in a psychoeducational format and is generally conducted in open groups that meet weekly for 2 to 2 1/2 hours.

Areas addressed are:
Dialectical strategies Problem-Solving strategies
Validation strategies Change procedures

Telephone Consultation

Phone consultation with the individual outpatient therapist between psychotherapy sessions is an important part of DBT.

Many suicidal and borderline individuals have enormous difficulty asking for help effectively.
Patients often need help in generalizing DBT behaviors skills to their everyday lives.
Following conflict or misunderstandings, phone consultation offers an avenue for patients to repair their sense of an intimate therapeutic relationship without having to wait until the next session.

Case consultation meetings for therapists

This is a very difficult population to treat. All therapists (individual and group) currently using DBT with Borderline patients are expected to attend weekly case consultation meetings, preferably in a group setting.

All DBT therapists are required to be in a consultation or supervisors relationship.

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