Objective: This self study module will present current perspectives on Borderline Personality Disorder.

Objective: This self study module will present current perspectives on Borderline Personality Disorder. The term borderline is an inaccurate term created by psychoanalysts in the 1930s to describe a form of pathology that seemed to be on the border between psychosis and neurosis (Paris, 2002). The first large scale study of Borderline Personality Disorders (BPD) was based on interviews of 35,000 adults by the National Institute on Alcohol Abuse and Alcoholism. They found a lifetime prevalence of 5.6% for men and 6.2% for women (Grant, et al, 2008). This finding was remarkably different than previous studies based on small samples which had estimated a lifetime prevalence of only 1-2% and a 3:1 ratio of women to men (Hunt, 2007). For comparison, the lifetime prevalence of schizophrenia is estimated at 0.4% (Saha et al., 2005). Borderline Personality Disorder (BPD) is the most common personality disorder seen in community Addiction and Mental Health practice. One study also found the diagnosis in 15% of all inpatient psychiatric admissions (Hunt, 2007). Black et al. (2007) found diagnosable BPD in 29.5 percent of their random sample study of male and female offenders who recently entered prison. People with BPD have also been identified as very high users of emergency room and crisis services. People living with Borderline Personality Disorder (BPD) often have intense and highly unstable emotions and relationships, poor impulse control, and an overwhelming, painful sense of emptiness. They may attempt to deal with emotions by engaging in self-mutilatory or other nonfatal self-harm behaviors. About 8-10% of people with BPD will die by suicide which is 50 times the rate for the general population (NIMH, 2009; SAMHSA, 2010). People living with Borderline Personality Disorder often have poor boundaries and may rapidly become involved with peopleand just as quickly become disappointed with them. Even when in a supportive relationship, they tend to feel loneliness and emptiness. When the loss of that relationship is threatened, the idealized caregiver is replaced by an image of a cruel persecutor in a process called splitting. (Hales, et al., 1999). To prevent perceived abandonment, angry accusations and self destructive behavior often occur. When there is no supportive relationship with anyone else, the person with Borderline Personality Disorder may have dissociative experiences, ideas of reference, and desperately impulsive acts. Intense counter-transference reactions are often experienced by staff which may lead them to attempt an inappropriate parental role or to reject the client harshly (Hales, et al., 1999). Despite the severity of symptoms and suicide risk, those living with BPD have a surprisingly high rate of recovery. The evidence suggests that as many as 74% clients may function significantly better by in their middle ages (SAMHSA, 2010). The McLean Study of Adult Development (MSAD) study followed adults with BPD for six years and reported that 73.5% no longer met the criteria for BPD at the end of that time period (Zanarini et al., 2003). They found the greatest decline in impulsive symptoms, with the least improvement in affective symptoms. Suicidal behavior and self-harm, were quickest to resolve and unstable relationships with chronic anger and fear of abandonment were much slower. It is important to note that people who no longer meet the diagnostic criteria may still suffer one or more significant symptoms. 1

The current research indicates that BPD results from interactions between genetic and environmental factors. Neuroimaging and genetic studies suggest that some parts of the brain that regulate emotion and impulsivity are different in people with BPD. For example, one study showed that, when looking at emotionally negative pictures, people with BPD tended to use brain areas related to reflexive actions and alertness. This finding helps explain the tendency to act impulsively on emotional cues (Koenigsberg, 2009). Bradley, et al, (2007) concluded that a biological vulnerability may lead to a cascade of environmental events and what may have begun as an environmental effect may become hard-wired. The multiple contributing factors complicate diagnosis and treatment. Trauma, sexual abuse, and other adverse events can contribute to diagnoses other than BPD so there is no clear relationship between any specific factor and an eventual borderline diagnosis. It should be noted that this interaction of environment and biology is also the explanation of how addictions and some other psychiatric disorders are developed. Neurobiological research has established that being born with a genetic vulnerability does not mean that one necessarily develops any of those conditions. Adding adverse events to the scale is more likely result in an imbalance. However, the addition of effective nurturing and other protective factors may also keep the scale in balance. The burden of living with BPD is often further complicated by a very high rate of co-morbidity with other disorders. New, et al. (2008) reported that people with BPD also have a high prevalence of bipolar disorder (10-20 percent), major depressive disorder (41-83 percent), substance misuse (64-66 percent), panic disorders (31-48 percent), obsessive-compulsive disorder (16-25 percent), social phobia (23-47 percent), and eating disorders (29-53 percent). Furthermore, people with BPD commonly also have avoidant (43-47 percent), dependent (16-51 percent), and paranoid personality disorders (14-30 percent) (New et al., 2008). Men are more likely to have concurrent substance use disorders and women are more likely to also have PTSD (Johnson et al., 2003). The personality traits of affective instability and impulsivity make all of these co-morbid conditions more severe and difficult to treat. In the DSM IV TR, there were 256 possible combinations of criteria that could lead to a diagnosis of BPD which means that there are wide variations in how the disorder is experienced. This module was written before the DSM V was released but the proposed revisions replace the 9 criteria with two dimensional assessments: 1) a personality pathology severity scale, the Levels of Personality Functioning, and 2) a 5 domain/25 facet pathological personality trait assessment. The new DSM V diagnosis is based on the following assessment (APA, 2011): The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. b. Self-direction: Instability in goals, aspirations, values, or career plans. AND 2

2. Impairments in interpersonal functioning (a or b): a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal. B. Pathological personality traits in the following domains: 1. Negative Affectivity, characterized by: a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. c. Separation insecurity: Fears of rejection by and/or separation from significant others, associated with fears of excessive dependency and complete loss of autonomy. d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior. 2. Disinhibition, characterized by: a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one s limitations and denial of the reality of personal danger. 3. Antagonism, characterized by: a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults. C. The impairments in personality functioning and the individual s personality trait expression are relatively stable across time and consistent across situations. D. The impairments in personality functioning and the individual s personality trait expression are not better understood as normative for the individual s developmental stage or socio-cultural environment. E. The impairments in personality functioning and the individual s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). 3

Treatment There are many types of evidence based psychotherapies for BPD. Bradley, et al. (2007) listed the following principles that are common to all the successful therapeutic approaches: A clear framework for treatment that outlines expectations and boundaries for both the clinician and the client; Frequent (often biweekly) contact over a period of a year or longer; Close attention to the clinician-client relationship and discussion thereof as central to treatment; Development of skills and coping mechanisms to manage impulsivity and emotional dysregulation; and A progressive approach to treatment that follows essentially a three-step pattern: (1) stabilizing the client, (2) understanding how past experiences inform current behaviors, and (3) reorganizing and reconceptualizing thoughts and behaviors affecting interpersonal relationships. The burden of BPD is also experienced by their families, friends and co-workers. Unstable emotions, difficulty with relationships, and high rates of suicide are extremely stressful to others. Family psychoeducation increases their understanding of BPD, helps them develop appropriate ways to deal with stress and improves the outcomes of people being treated for BPD (SAMHSA, 2010). Consideration of how BPD is successfully treated provides a further understanding of this disorder. The success of treatment has also helped reduce the stigma of BPD among healthcare professionals. Generally, medication is not recommended specifically for BPD although it may be needed for co-morbid conditions (NICE, 2009). Inpatient psychiatric admission should only be a last resort after other forms of crisis resolution and home treatment are unable to provide safety (NICE, 2009). The most widely used and well evaluated therapy is Dialectical Behavior Therapy (DBT). This form of psychotherapy was developed by Marsha Linehan in the 1980s to treat those suffering from Borderline Personality Disorder in a way that is optimistic and preserves the morale of the therapist. The therapy is intense, lengthy and costly but the result is often a life worth living. Linehan (1993) stated that Dialectical Behavior Therapy is based on: (a) bio-social theory of Borderline Personality Disorder combined with elements of (b) mindfulness from Zen philosophy, and (c) a dialectical approach. According to the bio-social theory used in Dialectical Behaviour Therapy (DBT), persons with BPD are born with biologically hard-wired temperament or disposition toward emotion vulnerability. Emotion vulnerability consists of a relatively low threshold for responding to emotional stimuli, intense emotional responses and difficulty returning to a baseline level of emotional arousal. Without very skillful and effective parenting or child-rearing, the child has difficulty learning how to cope with such intense emotional reactions (Chapman 2006). An emotionally vulnerable individual is more at risk of BPD traits when growing up in an environment that invalidates the child s emotional responses by ignoring, dismissing, or punishing them, or by oversimplifying the ease of the coping/problem solving (Kiehn & Swales, 1995). As a result the child is left without the skills needed to regulate emotions, often is afraid of his or her emotions and may resort to quickly executable, self-destructive ways to cope with 4

emotions, such as deliberate self-harm (Chapman, 2006). One of the primary goals of DBT is to improve patients quality of life by reducing ineffective action tendencies associated with dysregulated emotions. DBT includes behavioral skills that specifically aim to teach patients how to recognize, understand, label, and regulate their emotions (Chapman, 2006). Since therapy is relationship based, people with Borderline Personality Disorder naturally have difficulty in standard treatment approaches One of the valuable techniques of Dialectical Behavior Therapy is mindfulness which comes from Zen philosophy. Zen emphasizes the wisdom inherent in each individual, and the wise mind as a synthesis of information gathered from the emotions with information gathered from facts. To access the wise mind, DBT offers core mindfulness skills; the what skills (observe, describe a situation, just using the facts of here and now, and participate by acting while keeping in contact with the wise mind), and the how skills (non-judgmentally, not describing people or events as good or bad, even if a situation is experienced as highly stressful, a nonjudgmental stance provides access to the wise mind). DBT emphasizes non-judgment of the self and of the behavior of judging. These skills allow the individual to slow down and notice what is, to reduce emotional arousal and accept a situation; it helps the individual adopt a course of action that is in concept with his or her goals and avoids impulsive urges such as being vengeful, righteous or self-sabotaging (Koons, 2008). A Zen parable describes a man riding on a rapidly galloping horse. He passes someone standing on the road who asks, Where are you going in such a hurry? The man replies, Ask the horse. Dialectical philosophy separates DBT from other cognitive-behavioral treatments. Within a dialectical framework, reality consists of opposing, polar forces that are in tension. Each opposing force is incomplete on its own, and these forces continually are balanced and synthesized (Chapman, 2006). The dialectical process is pervasive in the therapy. The central dialectical synthesis is between the need for 'acceptance' being balanced with the need for 'change' (Linehan, 1993). There are specific techniques of acceptance and validation designed to counter the self-invalidation of the patient. These are balanced by techniques of problem solving to help learn more adaptive ways of dealing with difficulties. Extreme and rigid thinking is a characteristic of this disorder and the dialectical approach counters this position (Linehan, 1993). Dialectical The term dialectical refers to a philosophical method of seeking understanding that is fundamental to this form of therapy. It is a surprisingly simple and effective way of thinking. Make a statement expressing your position on some issue. (carrots taste bad) Think of the opposite position on the issue. (carrots are worth eating) Look at both sides of the issue and find what is valuable in each. Look for ways to resolve the contradictions and keep the valuable features. (cook the carrots differently to change the taste but keep the nutrition) In philosophical terms, you have just made a thesis, found the antithesis, and created a synthesis between the two. Of course, this synthesis is a statement that also has an antithesis and the process continues onwards... 5

Five Functions of DBT The program of treatment consisting of individual therapy, group therapy and a therapist consultation team. It is a program of treatment rather than a single method conducted by a practitioner in isolation. This therapy requires specialized training to deliver. Chapman (2006) describes the following five critical and unique elements of DBT: A. Enhancing life skill capabilities with development of: (a) Emotion regulation skills (b) Mindfulness skills: paying attention to the experience of the present moment and regulating attention (c) Interpersonal skills: effectively navigating interpersonal situations (d) Distress tolerance skills: tolerating distress and surviving crisis without making situations worse B. Generalizing capabilities: The patient s gains are practiced in their natural environment; this function is accomplished by providing homework assignments, practicing skills in individual sessions and phone support to help the patient apply skills when they are most needed C. Improving motivation and reducing dysfunctional behaviors: This function is focused on behaviors that are consistent with a life worth living, primarily accomplished in individual therapy. Each week the therapist has the patient complete a diary card on which he or she tracks various treatment targets (e.g. self-harm, suicide attempts, emotional misery). The therapist uses this card to prioritize session time, giving behaviors that threaten the patient s life (e.g. suicidal or self-injurious behaviors) priority, followed by behaviors that interfere with therapy (e.g. absence, lateness, noncollaborative behavior), and behaviors that interfere with the patient s quality of life D. Enhancing and maintaining therapist capabilities and motivation: Working with patients with BPD can tax the coping resources, competencies, and resolve of their treatment providers (i.e. suicide attempts, repeated suicidal gestures, behaviors that interfere with therapy). An essential ingredient is a system of providing support, validation, continued training, skill building, feedback and encouragement to therapists, accomplished in a weekly 1 2 hour therapist consultation meeting. E. Structuring the environment: This involves structuring the environment in a manner that most effectively promotes progress; such as ensuring all of the elements of effective treatment are in place, and the five functions of treatment are met. Other support or boundaries are extended to the patient as each unique situation is evaluated, such as helping the patient avoid social circles that promote drug use, or structuring telephone support to allow a patient to call the therapist prior to self harm, rather than after, to avoid the perception this behavior is rewarded. Manipulative People with Borderline Personality Disorder are commonly described as manipulative. Linehan points out that this implies that they are skilled at managing other people when it is precisely the opposite that is true. Staff may feel manipulated but that does not necessarily imply that this was the intention of the patient. It is more probable that the patient did not have the skills to deal with the situation more effectively (Kiehn & Swales, 1995). 6

Linehan (1993) outlines a hierarchy of targets for individual therapy. Each stage is approached with a validation-problem solving orientation but a wide variety of therapeutic modes, including medication, may also be used. An important part of the treatment is the requirement that the client record all instances of targeted behaviors on weekly diary cards. Each stage must be completed before moving on to the next. It may take a year, or more, to complete the sequence. 1) Decreasing suicidal behaviors 2) Decreasing therapy interfering behaviors 3) Decreasing behaviors that interfere with the quality of life 4) Increasing behavioral skills 5) Decreasing behavior related to post-traumatic stress 6) Improving self esteem 7) Individual goals Conclusion People with Borderline Personality Disorder are suffering from a serious illness. The condition is frequently concurrent with other disorders, including addiction, and is seen in all Addiction and Mental Health services. The unregulated emotion and high risk behaviours make life difficult for those living with the disorder and everyone else in their social world. In the past, this condition has often resulted in rejection, avoidance and a pervasive stigma in the healthcare system. Treatment is now available that is effective, respectful of the clients and preserves staff morale. Recovery is possible and many people with BPD will attain a stable and satisfying life. References American Psychiatric Association (2011) DSM-5 Development: Borderline Personality Disorder Retrieved from: http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=17 Black, D. W., Gunter, T., Allen, J., Blum, N., Arndt, S., Wenman, G., et al. (2007). Borderline personality disorder in male and female offenders newly committed to prison. Comprehensive Psychiatry, 48, 400-405. Bradley, R., Conklin, C. Z., & Westen, D. (2007). Borderline personality disorder. In W. O Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality disorders: Toward the DSM-V (pp. 167-201). Thousand Oaks, CA: Sage Publications. Chapman, A. L. (2006). Dialectical behavior therapy: Current indications and unique elements. Psychiatry MMC. 3(9) pp. 62-68. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F. & Kernberg, O. F.. (2007). Evaluating three treatments for borderline personality disorder: a mulitwave study. American Journal of Psychiatry, 164(6), pp. 922-928. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69, 533-545. Hales, R., Yudofsky, S. & Talbott, J. (1999). Textbook of psychiatry, 3 rd Edition. American Psychiatric Press: Washington, DC. 7

Hunt, M. (2007). Borderline personality disorder across the lifespan. Mental health issues of older women: A comprehensive review for health care professionals. V. J. Malatesta (Ed.). The Howorth Press, Inc. 2007. pp. 173-191. Available online at http://swmh.howorthpress.com Johnson, D. M., Shea, M. T., Yen, S., Battle, C. L., Zlotnick, C., Sanislow, C. A., et al. (2003). Gender differences in borderline personality disorder: Findings from the Collaborative Longitudinal Personality Disorders Study. Comprehensive Psychiatry, 44, 284-292. Kiehn, B. & Swales, M. (1995). Dialectical Behavior Therapy in the treatment of borderline personality disorder. Psychiatry On-Line November. Koons, C. R. (2008). Dialectical behavior therapy. Borderline personality disorder: Meeting the challenges to successful treatment. P. D. Hoffman & P. Steiner-Grossman (Eds.). The Haworth Press, 2008. pp. 109-132. Available online at http://swmh.howorthpress.com Koenigsberg HW, Siever LJ, Lee H, Pizzarello S, New AS, Goodman M, Cheng H, Flory J, Prohovnik I. (2009) Neural correlates of emotion processing in borderline personality disorder. Psychiatry Research. 172(3):192 9. Linehan, M. (1993) Skills training manual for treating borderline personality disorder. The Guilford Press: New York. National Institute of Mental Health. (2009). Suicide in the U.S.: Statistics and prevention. Retrieved from http://www.nimh.nih.gov/health/publications/suicide-in-the- us-statistics-and-prevention/index.shtml National Collaborating Centre for Mental health Borderline Personality Disorder: The NICE Guideline on Treatment and Management (2009) The British Psychological Society and The Royal College of Psychiatrists New, A. S., Triebwasser, J., & Charney, D. S. (2008). The case for shifting borderline personality disorder to Axis I. Biological Psychiatry, 64, 653-659. Paris, J. (2002). Chronic suicidality among patients with borderline personality disorder. Psychiatric Services, 53(6), pp.738-742. Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A systematic review of the prevalence of schizophrenia. PLoS Medicine, 2, e141. SAMHSA (2010) Report to Congress on Borderline Personality Disorder, US Department of Health and Human Services. Schulz, S. C. & Rafferty, M. P. (2008). Combined medication and dialectical behavior therapy for borderline personality disorder. Borderline personality disorder: Meeting the challenges to successful treatment. P. D. Hoffman & P. Steiner-Grossman (Eds.). The Haworth Press, 133-144. Available online at http://swmh.howorthpress.com Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160, 274-283. 8