Borderline Personality Disorder
According to the DSM-V (American Psychiatric Association, 2013), “the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects” (p.663). To meet the diagnostic criteria for borderline personality disorder (BPD) a person must have at least 5 of the following 9 symptoms:
- Frantic efforts to avoid real or imagined abandonment.
- Unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
- Identity disturbance: unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance misuse, reckless driving, binge eating).
- Recurrent suicidal behaviour or threats, or self-mutilating behaviour.
- Instability of mood and marked reactivity of mood.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
The term borderline comes from an older psychoanalytic term of “borderline personality organisation” that was a patient who was neither psychotic nor neurotic, but on the borderline between these two levels of organisation (Stern, 1938).
Some of the typical characteristics of Borderline Personality Disorder include:
- Seeing things in terms of “black-and-white”, “all-or-nothing”, often polarising their opinion of others and themselves as good or bad with little tolerance for the continuum between these extremes.
- Potentially self-damaging impulsivity such as gambling, spending money irresponsibly, binge eating, abuse of substances, engaging in unsafe sex, or driving recklessly.
- Recurrent suicidal behaviour, or threats, or self-mutilation – usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility.
- Efforts to avoid real or imagined abandonment with intense abandonment fears and exaggerated emotions (such as anger) when faced with separation or unavoidable changes in plans.
- Intense anger or difficulty controlling anger, sarcasm, enduring bitterness, or verbal outbursts associated with feelings of abandonment, often followed by shame and guilt and reinforcing the feeling of being bad or evil.
- A feeling of impending separation or rejection leading to profound changes in self-image, affect, cognition, and behaviour – often interpreting perceived abandonment as validation that they are ‘bad’ or ‘evil’.
- Hypersensitivity to environmental (especially social) circumstances and resorting to impulsive actions such as self-mutilating or suicidal behaviours to cope.
- A pattern of unstable and intense relationships, with the propensity to oscillate between idealizing other people to devaluing them.
- Can have sudden and dramatic shifts in their opinion of others, who may alternately be seen as beneficent supports or as cruelly punitive.
- An unstable self-image or sense of self marked by sudden and dramatic shifts in self-image, characterized by shifting goals, values, aspirations, sudden changes in opinions and plans about career, sexual identity, values, and types of friends. Often self-image is based on being evil or bad, they can have a feeling that they do not exist at all.
- Sudden change from the role of a needy supplicant for help to a righteous avenger of past mistreatment.
- Emotional instability that is due to a marked reactivity of mood that reflect an extreme reactivity to interpersonal stresses.
- Feelings of emptiness, easily bored, may constantly be looking for something to do.
The Neurobiology of BPD (taken from Gregory, 2014)
The aetiology of BPD is controversial, and the following explanation offered by professor Robert Gregory is only one of a number of views. We offer this perspective because of it’s foundation in neuroscience.
- The Emotion Processing Hypothesis postulates that BPD is a disorder of emotion processing, rather than emotion regulation.
- Due to interpersonal stress, BPD does not have the normal processing of emotion that is lateral to medial movement of information through the prefrontal cortex (PFC) and integration with cortical and subcortical networks.
- BPD demonstrates less activation of PFC and greater limbic system activation (ventral striatum, amygdala) and less integration of cortical and subcortical networks.
- BPD may process emotional experiences through subcortical limbic systems rather than then usual verbal/symbolic processing through lateral to medial flow of information through the temporal lobe and PFC.
- Emotional processing regions such as the amygdala, hippocampus, anterior cingulate gyrus and medial prefrontal cortex have shown to be in deficit in BPD.
- BPD display greater activation of limbic structures (amygdala, hippocampus, ventral striatum) when responding to emotional stimuli.
- Deactivation of anterior cingulate gyrus and the medial prefrontal cortex when exposed to strong emotional stimuli, as well as decoupling of limbic and cortical networks – resulting in a difficulty to encode emotional experience into language and identifying, labelling and acknowledging emotions.
- BPD have reportedly low levels of endogenous opioids and are less able to turn off the PANIC system, described by Panksepp, when hyperaroused by emotional stimuli. To alleviate the PANIC system BPD may use self-destructive or hostile actions, or self-soothing coping mechanisms to activate their ventral stratal region (the PLEASURE system according to Panksepp).
- In summary, people with BPD utilise limbic solutions to interpersonal problems.
- More severe cases of BPD may not only have emotion processing network deficits but diminished baseline tonic activity in certain brain regions.
Dynamic Deconstructive Psychotherapy (DDP) is a 12-month treatment for borderline personality disorder and other complex behavior problems, such as alcohol or drug dependence, self-harm, eating disorders, and recurrent suicide attempts. DDP combines elements of translational neuroscience, object relations theory, and deconstruction philosophy in an effort to help clients heal from a negative self-image and maladaptive processing of emotionally charged experiences. Neuroscience research suggests that individuals having complex behavior problems deactivate the regions of the brain responsible for verbalizing emotional experiences, attaining a sense of self, and differentiating self from other, and instead activate the regions of the brain contributing to hyperarousal and impulsivity.
DDP helps clients connect with their experiences and develop authentic and fulfilling connections with others. During weekly, 1-hour individually adapted sessions, clients discuss recent interpersonal experiences and label their emotions, reflect upon their experiences in increasingly integrative, accepting, and realistic ways, and learn how to develop close relationships with others while maintaining their own sense of self.
In research studies, DDP has been shown to improve symptoms of borderline personality disorder, dissociation, and depression, to lessen complex behavioral problems, such as suicide attempts, self-harm, and substance misuse, to decrease institutional care, and to improve functioning. DDP has been shown to be more effective for the treatment of borderline personality disorder than other common approaches. Approximately 90% of clients who undergo a full year of treatment will achieve clinically meaningful improvement, and recovery usually progresses after treatment ends. Because of these findings, the U.S. federal agency SAMHSA has included DDP on its National Registry of Evidence-Based Programs and Practices.
Dialectical behavior therapy (DBT) is a cognitive behavioural method that focuses on interpersonal skills including the concept of mindfulness as it’s main therapeutic intervention. Research shows this to be an effective approach to helping people with DBT, however is a fundamentally different approach to the above DDP. DBT teaches skills to control intense emotions, reduce self-destructive behavior, manage distress, and improve relationships based on the idea that BPD is an affect regulation problem and therefore enhancement of regulation ability is the answer. It seeks a balance between accepting and changing behaviors. This proactive, problem-solving approach was designed specifically to treat BPD. Treatment includes individual therapy sessions, skills training in a group setting, and phone coaching as needed.
Mentalization Therapy (MBT) is a psychodynamic psychotherapy that is less directive than DBT and focuses on enhancing metallization (the capacity to understand behavior and feelings and how they’re associated with specific mental states in ourselves and others). The therapy is designed to help people with BPD to differentiate and separate their own thoughts and feelings from those around them.
Schema Therapy is a psychotherapy developed by Dr. Jeffrey Young for personality disorders, chronic depression, and other difficult individual and couples problems. It integrates elements of cognitive therapy, behavior therapy, object relations, and gestalt therapy into a unified, systematic approach to treatment. There are four main concepts in the Schema Therapy model: Early Maladaptive Schemas, Core Emotional Needs, Schema Mode, and Maladaptive Coping Styles. For more see schematherapysociety.org
Conversational Model (CM) was developed by Robert Hobson and expanded by Russell Meares. The therapy aims to develop the client’s sense of self through a form of conversational relating. Such therapeutic relatedness helps the client develop the capacity to embody what is described as “aloneness-togetherness”. The development of such a dialectic gives the BPD a unique sense of personal being that was formally deficient and at the root of much of the borderline pathology. The manualised form of CM is psychodynamic interpersonal therapy.
A Malady of Representations: Dysautonomic Aspects of BPD – Russell Meares.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Washington, D.C.: American Psychiatric Publishing.
Gregory, R. J. (2014). Remediation for treatment-resistant borderline personality disorder: Manual of dynamic deconstructive psychotherapy. Syracuse, NY: SUNY Upstate Medical University. Downloaded from http://www.upstate.edu/psych/pdf/education/psychotherapy/ddp_manual.pdf
Stern, A. (1938). Psychoanalytic investigation of and therapy in the border line group of neuroses. Psychoanalytic Quarterly, 7, 467-489.
This is a very useful article for my work with veterans where evidence based practice requires care plans identifying from the history and case formulation, an approach within an episodic care model that will be effective. One of the points I notice symptoms exacerbate in this cohort, is where there is transition. Adjustment moving between different environments for example post military discharge, hospital discharge and relationship breakdown. I do notice however that if the relationship is the focus and attachment is attended to, then the risk can stabilise for harm to self or others.
Great Insight about mental health. May it be PTSD, ADHD, depression and etc. What they need are proper counseling from a Psychiatrist.