Borderline Personality Disorder
Abstract and Keywords
The historical development of the borderline concept is traced up through the development of the diagnosis of borderline personality disorder (BPD). Treatments for BPD during the 1970s and 1980s are discussed, including the object relations theories of Margaret Mahler and James Masterson, as well as trauma theory described by Judith Herman. Three evidence-based treatments (EBTs) that have emerged from the 1990s to the present time are described, as well as findings from brain imaging techniques and how new EBTs and neuroimaging have changed the view of this disorder.
Borderline personality disorder (BPD) is a significant issue for social workers. Individuals diagnosed with BPD make up around 2% of the general population, or approximately 6 million Americans (APA, 2013). Self-mutilating acts are very common; such acts sometimes result in physical handicaps. Recurrent job losses, interrupted education, evictions from their apartments, and broken marriages are also very common, and are associated with high societal costs (APA, 2013).
Individuals with BPD are at a high risk for suicide. Many individuals with BPD report frequent suicidal thoughts (Linehan, 1993a, p. 18). Eight to 10% of individuals who currently have a diagnosis of BPD (480,000 to 600,000 individuals) will eventually commit suicide (APA, 2013; Gunderson, 2006; Oldham, 2006). This suicide mortality rate is 50 times higher than the rate in the general population (Skodol, 2005).
Virtually every setting where social work is practiced includes clients with the BPD diagnosis (Johnson, 1991). Individuals with BPD present themselves for help with problems like substance abuse, suicide attempts, eating disorders, family violence, and issues with self-control (Johnson, 1988). In outpatient mental health clinics, it is estimated that individuals with BPD make up about 10% of the total clientele, while in psychiatric inpatient settings, patients with BPD are estimated to be 20% of the total patient population (Linehan, 2008).
Historical Development of the Borderline Concept
The borderline concept went through a number of significant changes before the diagnosis of borderline personality disorder, as we know it today, was developed.
First Construct: 1880s to 1920s—Borderline (or Borderland) Insanity
During the 1880s to 1920s, the diagnosis of mental conditions consisted mainly of either “psychosis” or “neurosis.” Borderline insanity was considered to be any state of near-insanity that did not clearly fit into either psychosis or neurosis. Prichard (as cited by Stone, 1986) wrote a classic text in 1830 in which he identified a disorder that he called “moral insanity.” He said that individuals with moral insanity were not institutionalized, as most other “insane” individuals were during that time. He wrote that these individuals were “capable of reasoning” but that they were “liable to errors” in judgment and conduct (Prichard, as cited by Stone, 1986, p. 15).
Falret, writing in 1890, described a diagnosis that he called “folie hysterique,” and described individuals suffering from it as having lability of affect, impulsivity, and an extreme contradictoriness of attitude (Falret, as cited by Stone, 1986, p. 6). Also in 1890, Rosse described individuals who were what he called “borderland insane” (in Stone, 1986, p. 32): they were, he said, not so sane as to be able to control themselves, yet not so insane as to require restraint or seclusion (Rosse, as cited by Stone, 1986, p. 32).
Second Construct: 1930s and 1940s—Borderline Personality Organization
The second construct, borderline personality organization, arose out of psychoanalytic observations. The proposed treatment was, accordingly, psychoanalysis. Stern identified a group of patients whose personality organization did not fit into either a psychotic organization or a neurotic organization; therefore, he introduced borderline as a third type of personality organization (Gunderson, 1994).
Third Construct: 1950s to the 1970s—Borderline Syndrome
Borderline syndrome was first considered to be a form of schizophrenia; later it was considered to be a form of affective disorder (Gunderson, 2006).
Fourth Construct: 1970s and 1980s—Borderline Personality Disorder
During the 1970s and 1980s, Gunderson and Singer (1975) examined the professional literature and used the term borderline personality disorder to refer to individuals with unpleasant moods and emotions, impulsive actions, unstable interpersonal relations, psychotic-like thoughts, and social maladaptations (Gunderson & Singer, 1975). Gunderson’s conceptualization of these symptoms led to the inclusion of borderline personality disorder in the Diagnostic and Statistical Manual of Mental Disorders for the first time in 1980, when the third edition (DSM-III) was published (APA, 1980; Gunderson & Singer, 1975; Skodol, 2005). The diagnostic criteria for BPD in the DSM-V have changed very little from those in the DSM-III (APA, 1980, 2013).
Despite wide variability in the description of BPD’s etiology, treatment, and prognosis, the theories dominating the professional literature today tend to agree, more or less, with the description of BPD in DSM-V (APA, 2013). How the conceptualization of BPD in DSM-V defines the symptoms, etiology, and prognosis for individuals with the disorder is described below. The diagnostic criteria are listed here in this excerpt from DSM-V:
Borderline Personality Disorder/Diagnostic criteria 301.83 (F60.3)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, 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. (APA, 2013, p. 663)
It has often been claimed that no two treatment providers can agree on whether a client meets criteria for BPD—that it cannot be reliably diagnosed. However, in two major studies that used standardized interviews based on the symptoms in DSM-IV (APA, 1994) to assess BPD symptoms, the reliability of the BPD diagnosis was “very good” to “excellent” (Zanarini, Frankenburg, & Vujanovic, 2002; Zanarini et al., 2000). The levels of reliability found in these two studies are reportedly as high as or higher than levels of reliability for many other mental disorders (Skodol, 2005, p. 10).
The DSM-V (APA, 2013) notes that there is much variability in the course of the disorder, but that the most common pattern is one where the most severe symptoms occur in early adulthood, with high usage of health and mental health resources (APA, 2013, p. 665). It reports that individuals with BPD who receive psychotherapy “often show improvement sometime during the first year” (p. 665), although many of the symptoms tend to be lifelong. It states that the impairment from the disorder and the risk of suicide are the greatest in early adulthood, and that the impairment and risk tend to decline as the individual ages. It states that during their thirties and forties, individuals with this disorder gain greater stability in their relationships and in their ability to function at a job. According to the DSM-V, follow-up studies of individuals have indicated that about 10 years after first coming to outpatient mental health clinics for treatment, as many as 50% of the individuals no longer met full diagnostic criteria for BPD (APA, 2013, p. 665).
Theories and Treatments during the 1970s and 1980s
Three theories dominated the professional literature about treatments for BPD during the 1970s and 1980s. The section below explains how each of the theories of BPD describes the symptoms, etiology, and treatment. Two of the theories fall under the umbrella of object relations theory. What these two theories have in common is that they posit that BPD is caused by disruptions in a child’s attachment process during the first two to three years of life. They also theorize that, as adults, individuals with BPD have problems in their adult relationships, including their relationship with a significant other. And they postulate that one of the most useful tools for learning about and treating an individual’s attachment problems is the relationship between the client and therapist. Two of the best-known object relations theorists about BPD are Margaret Mahler and James Masterson. The third theory dominating the literature during the 1970s and 1980s was trauma theory, the theory that BPD was caused by traumatic events—especially adverse childhood events.
Object Relations Theory—Margaret Mahler
Description of BPD: What is it?
Margaret Mahler called her developmental theory the process of separation-individuation (Flanagan, 1996). Separation and individuation, in Mahler’s description, are actually two separate but interrelated and interwoven processes that lead to the psychological birth of the human infant (Flanagan, 1996, p. 158). Borderline personality disorder was seen as a result of a disruption in the process of separation and individuation.
Separation was described by Mahler as “the process by which a growing child comes to experience herself as a separate, distinct entity who ‘stands alone,’ so to speak. It is the process of moving away from oneness with the mother” (Flanagan, 1996, p. 159). Individuation, on the other hand, was defined as the process of coming to experience oneself as unique and individual. “[Individuation] includes very specific self-knowledge about the traits, qualities, characteristics, and idiosyncrasies that make one oneself and no one else” (Flanagan, 1996, p. 159).
Mahler’s three main phases in the separation-individuation process were described as: (1) the autistic phase (birth to 12 weeks), an objectless and, in fact, even self-less phase; (2) the symbiotic phase (6 weeks to 10 months), when the caregiver (usually the mother, in Mahler’s view) and the infant seem to have a complete merger and healthy union; (3) the “separation-individuation proper” phase (6 months to 24 months), which was further divided into four subphases of (a) separation and (b) practicing, (c) rapprochement, and (d) “on the way to object constancy” (Flanagan, 1996, pp. 159–164).
Mahler wrote that, optimally, the separation-individuation process takes place very gradually, and that it is crucial that, during the rapprochement subphase, the mother is still very emotionally available to the child (Mahler, 1986, p. 439). If, however, the mother is not emotionally available during this phase, or if separation-individuation is otherwise forced along too rapidly, several things could happen that could lead to the development of BPD.
For one thing, there is greater risk that the “other” becomes a “bad” object in the child’s mind and emotions. There also seems to be the tendency, in this case, for the child to identify the self with the “bad” object (Mahler, 1986, p. 441). This results in the child’s splitting the world of objects into “good” and “bad.” Then the child’s aggression may be unleashed in such a way as to sweep away the “good” object, and with it, the “good” self-representation. This may be indicated by, for example, severe temper tantrums by the child (Mahler, 1986, p. 441).
Mahler wrote that interference in the rapprochement subphase, along with other unresolved conflicts sometime during the entire developmental process, from the symbiotic phase through the end of the separation-individuation phase, could contribute to the development of “borderline pathology” (Mahler, 1986, pp. 441–444). Thus, in Mahler’s view, BPD was due to unresolved conflict(s) during the process of separation-individuation.
Although, according to Mahler, the treatment of people with BPD takes a long time—a number of years—she definitely believed that they could recover. Her writings included many case examples of clients with BPD who did recover and went on to live productive lives (Mahler, 1986, pp. 445–448).
In Mahler’s treatment, the therapist utilizes the client-therapist relationship extensively: (a) to help the client explore his or her early relationship with the caregiver(s), (b) to explore how the client feels about separateness, and (c) to explore how early difficulties in relationship with the caregiver affect their current relationships (Flanagan, 1996, p. 169). Thus, Mahler’s theory of object relations puts the relationship between the therapist and the client at the very heart of psychological development and growth (Flanagan, 1996).
Object Relations Theory—James Masterson
Description of BPD: What is it?
Masterson (1988) wrote that:
The borderline patient … lacks a mature ego with its fully developed capacities. Because of the ego’s arrest in the pre-oedipal stage, the borderline has limited capacities to tolerate anxiety and frustration, to accept certain reality limitations, to distinguish between fantasy and reality, as well as to differentiate the past from the present, all of which are necessary for classical Freudian analysis. He has little basic trust and does not relate to the therapist as a real, whole human being with positive and negative attributes.
(Masterson, 1988, pp. 129–130)
Masterson also wrote that the individual with BPD has never learned basic skills for life, such as how to pursue a career or a hobby or how to develop a mature, healthy relationship (p. 133).
As mentioned above, Masterson attributes BPD to an individual’s ego being “arrested in the pre-oedipal stage”—due to the mother’s unavailability (Masterson, 1988, pp. 130, 133). This means that the person never resolved his/her oedipal conflict, and thus the person is immature, has not developed an internalized set of moral principles, and has a fantasy of a perfect mother who will take care of his/her every need to feel nurtured (Berzoff, 1996).
Masterson (1988) wrote that there are three types of therapy beneficial for the individual with BPD, including two types that are relatively short—“shorter-term therapy” and counseling (p. 135). However, he wrote, the two shorter types of therapy do not truly help to overcome the “impaired real self” (p. 135). In order to truly facilitate the emergence of the “real self,” Masterson believed that individuals with BPD would require “intensive analytic psychotherapy, a longer-term treatment with sessions at least three times a week for three to five years or longer” (Masterson, 1988, p. 136). Thus, Masterson felt that treatment was a long and intensive process for these individuals. On the other hand, his writings show that he was optimistic that recovery could and would happen. Also, he described many of his clients with BPD who became very successful individuals: they returned to college, they developed mature relationships and got married, they had successful careers, etc. (Masterson, 1988).
Because individuals with BPD have very little basic trust and do not relate to the therapist as a separate, complete individual, establishing a therapeutic alliance is a goal of psychotherapy, rather than a prerequisite, as it is in working with healthier individuals, according to Masterson (1988, p. 130).
Masterson believed that individuals with BPD are not able to form a transference relationship with the therapist; instead, they engage in “transference acting out,” in which they see the therapist as literally being the projection of parental figures from the client’s past (p. 130).
The therapist’s first step should be to confront the client and to help the client convert the “transference acting out” into real transference and into an alliance with the therapist (Masterson, 1988, p. 131). This confrontation should take the form of bringing to the client’s attention the maladaptive and self-destructive nature of his/her defenses.
Usually, in response to confrontation, the individual with BPD will perceive the therapist as the disapproving maternal image and will have feelings of abandonment. This then causes the client to resist changing his/her behavior constructively, and instead to resort to a false compliance and submissiveness toward the therapist. The client hopes that this will bring a rewarding response from the therapist, since that is the client’s only strategy for preventing an “abandonment depression” (Masterson, 1988, p. 131). The client has a distorted perception that a true, authentic relationship with the therapist will lead to the client’s being either engulfed or abandoned.
The therapist must instead confront the false compliance and submissiveness, and must again confront the client’s projections of his parents onto the therapist. This will result in a circular process of “resistance, confrontation, working through of the feelings of abandonment, further resistance, and further confrontation, which leads to further working-through” (Masterson, 1988, p. 131). Masterson believed that this process would often continue for several years of treatment.
However, at some point, the client will begin to have insight into his/her projections and maladaptive defenses (i.e., the false self) and will become willing to face and work through the “abandonment depression” (Masterson, 1988, p. 132). This is the second stage of treatment—working through the depression.
When the client reaches the “bottom” of the depression, and when this depression is worked through, a dramatic change occurs and “the real self starts to flower” according to Masterson (1988, p. 133). This is the third and last stage of treatment. In this stage, the client must work through, in transference, the expectation that the therapist will be the mother that he/she had always wished for (p. 133). In this stage, the client begins to explore new interests and new activities in order to give expression to the “real self” (p. 133). In response, the therapist provides the support and encouragement that the client never received from the parents whenever the client attempted to express the real self. Clients experience this support from the therapist as an acknowledgment and refueling of their real selves. They will also work through their transference fantasy, and will realize that the therapist is not a substitute parent (p. 135). In this way, the real self of the client will be allowed to come to life. “Self-activation and self-expression [begin] to flower and, with it, creativity … A true, loving, intimate relationship [becomes] possible” (p. 147). This is the completion of the work of therapy (Masterson, 1988).
Description of BPD: What is it?
Judith Herman, M.D., Associate Professor of Psychiatry at Harvard Medical School, considered one of the foremost experts on trauma (Linehan, 1993a; van der Kolk, 1994), proposed what she felt was a more descriptive name for the syndrome that results from “prolonged, repeated trauma” (and which includes BPD and several other diagnoses). The name she proposed was “complex post-traumatic stress disorder” (Herman, 1992).
Herman reported that “a pattern of intense, unstable relationships is one of the major criteria” for BPD (1992, p. 124). She wrote that disturbances in identity formation are also characteristic of clients with both BPD and multiple personality disorders. An unstable view of self, she wrote, is one of the major diagnostic criteria for BPD, “and the ‘splitting’ or inner representations of self and others is considered by some theorists to be the central underlying pathology of the disorder” (Herman, 1992, p. 125).
As described above, Herman theorized that BPD results from childhood physical and sexual abuse. Herman wrote that,
My investigations have also documented histories of severe childhood trauma in the great majority (81 percent) of cases … The earlier the onset of abuse, and the greater its severity, the greater the likelihood the survivor would develop symptoms of borderline personality disorder. The specific relationship between symptoms of borderline personality disorder and a history of childhood trauma has now been confirmed in numerous studies.
(Herman, 1992, pp. 125–126)
Herman’s description of the recovery process implies that it is long, usually taking a number of years (Herman, 1992, p. 213). She also wrote that, even after a client has “recovered” and has withdrawn from treatment, the client may again experience some symptoms at times in his or her life when under stress. She said, “Recovery of the trauma is never final …”(Herman, 1992, pp. 211–212).
Still, she said, clients with complex post-traumatic stress disorder (which includes clients with BPD) do recover to the point where they have a new capacity to take pleasure in life, where they engage fully in relationships with others, … and where they have constructed a coherent system of meaning in all their life experiences (Herman, 1992, pp. 212–213).
Thus, Herman describes the prognosis for BPD as somewhat guarded. These individuals, she said, do improve with treatment, but recovery is rarely a permanent state (Herman, 1992).
Herman described three stages for the recovery of someone with BPD (and anyone with the proposed complex post-traumatic stress disorder). During Stage One, the central therapeutic task is to help the client establish a sense of safety for him/herself. Herman said that for survivors of chronic childhood abuse, establishing safety can become an “extremely complex and time-consuming task” (p. 166) because of the client’s own danger to self, in the forms of suicidal ideation, self-mutilation, eating disorders, substance abuse, impulsive risk-taking, and repetitive involvement in abusive relationships (p. 166).
Gradually, the survivors gain some basic sense of safety in life and have some confidence that they can find a place of safety when they need to. Also, they begin to feel some trust and safety with the therapist. These changes mark the end of Stage One (p. 174).
In the Second Stage, remembrance and mourning, the survivor must tell the story of the trauma in order to make progress in recovery. “Traumatic memory,” said Herman, “is wordless and static” (Herman, 1992, p. 175). Usually, the survivor has divorced his/her emotions entirely from the telling of the story. The therapist must not push the survivor, but must let the survivor confront the horrors of the past in their own way and in their own time. The therapist, Herman said, plays the role of a “witness and ally, in whose presence the survivor can speak of the unspeakable” (p. 175). This point marks the end of Stage Two of recovery.
During Stage Three, the central task is reconnection with other individuals and with society as a whole. For survivors of childhood abuse, this stage feels like they are refugees entering a whole new country. They have to learn, from the beginning, what is typical, average, wholesome, and normal for ordinary people, because their early environments have so skewed their perspective on society as a whole (p. 198).
Stage Three will draw to an end, said Herman, when the survivor meets some of the following criteria: the physiological symptoms of PTSD are within manageable limits, the survivor is able to experience the full range of emotions without falling apart, the survivor has new self-esteem, the survivor has a support system, and the client has found new meaning and hope, to replace their former confusion and despair. After most of these things are accomplished, the survivor is ready to withdraw from therapy (p. 213).
Evidence-Based Treatments from 1990s through the Present
The 1990s marked the beginning of publication of scientific studies that sought to demonstrate effectiveness of treatments for BPD. Three types of psychotherapy stand out as having more support from scientific research than the others: dialectical behavior therapy, transference-focused psychotherapy, and mentalization-based treatment (Bateman & Fonagy, 2006; Clarkin et al., 2007; Linehan, 1993a). Thus, these three forms of psychotherapy, along with medical treatments, are discussed in this section on evidence-based treatments (EBT).
Dialectical Behavior Therapy (DBT)—Linehan
Description of BPD: What is it?
DBT, which was developed by Marsha Linehan, a psychologist at University of Washington, is based on a “biosocial” theory of BPD (Linehan, 1993b). The main tenet of this theory is that the core disorder in BPD is emotion dysregulation.
Emotion dysregulation is seen as a joint outcome of biological predisposition and an invalidating environment during childhood. The biological predisposition consists of emotional vulnerability, defined as: (a) very high sensitivity to emotional stimuli, (b) extremely intense response to emotional stimuli, and (c) a slow return to emotional baseline once emotional arousal has occurred (Linehan, 1993b, p. 2). Because of this emotional vulnerability, borderline individuals find it difficult to inhibit inappropriate behavior rising from strong emotion, to organize themselves for action toward an external goal, to self-soothe any physiological arousal that the strong emotion has induced, and to refocus their attention in the presence of strong emotion (Linehan, 1993b, p. 2).
The major premise is that BPD is primarily a dysfunction of the emotion regulation system; it results from biological irregularities combined with certain dysfunctional environments, as well as from their interaction and transaction over time. The characteristics associated with BPD … are sequelae of, and thus secondary to, this fundamental emotional dysregulation.
(Linehan, 1993a, p. 42)
Linehan recommends one year of treatment for individuals with BPD at the DBT clinic at the University of Washington. However, she admitted that, “Our data do not support a claim that one year of treatment is sufficient for these patients. Our subjects were still scoring in the clinical range on almost all measures” (Linehan, 1993a, p. 24). Thus, in DBT as well, the prognosis is somewhat guarded.
DBT combines the basic strategies of behavior therapy with Eastern Zen and Western contemplation practices within a dialectical worldview that emphasizes the synthesis of opposites (Linehan, 1993a). In the client exercises, Linehan has referred to the mindfulness practices as “activating Wise Mind” (Linehan, 1993a, pp. 214–216).
The primary dialectical tension in DBT is between accepting the clients as they are, while simultaneously helping them change. Linehan recommends communicating to the client something like this: It’s not your fault that you [have certain behavior traits]. However, you are the only one who can do something about changing them. No one else can do it for you (Linehan, 1993a, pp. 98–99).
Skills training groups make up the second most important mode of treatment in DBT and were established to address the skills deficits of borderline individuals. Besides their motivational issues, borderline individuals also exhibit maladaptive behaviors. They are not able to inhibit maladaptive behaviors that flow out of strong negative emotions nor are they able to continue adaptive behaviors that are … necessary to meet long-range goals (Linehan, 1993b, p. 6).
The skills training groups teach four sets of skills: (1) emotion-regulation skills, to help clients minimize emotional liability, (2) interpersonal effectiveness skills, to help clients prevent the relationship chaos that they tend to create, (3) distress-tolerance skills, to help clients refrain from maladaptive, impulsive behaviors in response to their mood swings, and (4) mindfulness skills, to help clients control cognitive dysregulation and confusion about their self-identity (Linehan, 1993b, pp. 6–7, 107). Linehan has written a point-by-point manual, complete with handouts for clients, to be used in the skills training groups.
Short-Term Object Relations Theory—Yeomans, Clarkin, and Kernberg
Transference-focused psychotherapy, developed by Clarkin, Kernberg, and several other colleagues, was the first treatment based on object relations theory that was able to scientifically demonstrate effectiveness (Clarkin et al., 2001). Kernberg had been very influential among treatment providers and other theorists on the topic of BPD and was widely quoted in the professional literature. Clarkin and his colleagues developed a shorter-term form (12 months) of Kernberg’s object relations therapy, called transference-focused psychotherapy (TFP), which showed effectiveness for treating individuals with BPD in a randomized controlled trial (Clarkin et al., 2001; Clarkin, Levi, Lenzenweger & Kernberg, 2007). In a managed care environment, any type of shorter-term, evidence-based treatment attracts a lot of attention.
Description of BPD: What is it?
Kernberg (1967) had earlier developed a concept that he called “borderline personality organization,” or BPO, to refer to all “severe” personality disorders, because he believed that they all presented with similar problems in psychological functioning (Yeomans, Clarkin, & Kernberg, 2002, p. 5). He believed that BPO is “situated between the higher level neurotic personality organization and the lower level psychotic personality organization” (p. 5) and includes the following personality disorders: schizoid, schizotypal, paranoid, histrionic, narcissistic, antisocial, and dependent (Yeomans et al., 2002, p. 5). He stated that individuals with BPO will present with problems in five areas: “(1) nonspecific ego weakness, (2) disturbed interpersonal relations, (3) difficulty with commitment to love and work, (4) some degree of pathology in sexual relations, and (5) superego pathology” (Yeomans et al., 2002, p. 7).
Object relations theory emphasizes that the innate drives described by Freud (libido and aggression) are not experienced in the abstract but in relation to an object, a specific other (Yeomans et al., 2002, p. 12). The infant has periods of high affective intensity when he/she experiences needs for survival or for pleasure. For a normal infant’s development, when the infant is hungry, the mother responds and the infant experiences pleasure and satisfaction. However, for some infants, the caregiver either does not respond at all, or responds in an abusive manner; this causes the infant to experience hate and rage. During these periods of peak affective intensity, the psyche lays down “affect-laden memory structures,” in relation to how the “other” responds to his/her needs. During these peak affect states, the infant memorizes what seems important for survival, for attaining pleasure, and for avoiding pain.
Most infants who have a nurturing caregiver are able to develop a concept of the “other” who has some good and some bad characteristics, which allows for flexibility, and is adaptable to the complexities of the real world. In contrast, infants with an abusive or neglectful caregiver will have an excess of aggression that they cannot successfully integrate into their psyche. They handle this excess aggression by keeping it split off. This is the “most important single etiological force in the development of BPO” according to Kernberg, Clarkin, and Yeomans (Yeomans et al., 2002, p. 34).
Thus, TFP theorists view abuse and neglect by the caregiver as central to the etiology of BPO. They suggest that development of BPO may also be related to chronic physical illness, early, prolonged separation, or a severely frustrating life situation (Yeomans et al., 2002).
Yeomans, Clarkin, and Kernberg have noted that, partly because of the high rate of suicide among individuals with BPO, many treatment providers are reluctant to accept these individuals into treatment (Yeomans et al., 2002). But these authors assert that, rather than avoid treating these individuals, treatment providers should simply be realistic about the possibility that some of the individuals may, indeed, commit suicide. Even excellent treatment (such as TFP) cannot guarantee that suicide will not occur. Such a realistic attitude will protect the treatment providers from self-blame or excessive disappointment in the event of a suicide. Further, individuals with BPD or BPO should not be denied treatment simply because they are high risk for suicide; many of them will respond well to treatment.
Yeomans, Clarkin, and Kernberg maintain that BPO is treatable, though it may take a long time to see progress (2002). They assert that TFP will usually produce a decrease in the client’s most serious impulsive behaviors within 12 months, but significant structural change (in the client’s psyche) “usually requires a minimum of two years and often many more years of treatment” (Yeomans et al., 2002, p. 45).
In summary, although proponents of TFP consider BPO to be treatable, and they consider TFP to be one of the best evidence-based treatments, overall they view the prognosis for individuals with BPO to be from fair to poor (Yeomans et al., 2002).
Unlike cognitive-behavioral treatments, and similar to the more psychoanalytically oriented object relations therapies, TFP aims to change underlying personality structure in addition to changing clients’ behaviors.
The treatment attempts to identify the underlying object relations dyads that are in effect at the current time and are affecting the client’s perceptions of self and others. The therapist works with the material that emerges in the therapy relationship (transference) and discusses with the client what is occurring in order to shed light on the client’s psyche (Gunderson & Hoffman, 2005, p. 31). The therapist seeks to provide the client with the opportunity to integrate the split parts of the self, so that the parts do not have to be at war with each other, or to be disowned (p. 31).
TFP has modified traditional psychodynamic psychotherapy in order to maximize effectiveness in BPO and BPD. TFP relies more on the nonverbal channels of communication; the TFP therapist is more active in intervening than in traditional therapy; TFP often requires more deviation from therapeutic neutrality; and the TFP therapist must absorb and deal with more intense levels of affect than the levels of affect encountered in traditional therapy with healthier clients (Yeomans et al., 2002, p. 47). The therapist invites the client affects to emerge in a safe but controlled environment (p. 47). Components of TFP include weekly meetings with the individual therapist, one or more weekly group therapy sessions, and meetings of therapists for consultation and/or supervision (Yeomans et al., 2002).
Mentalization-Based Therapy—Bateman and Fonagy
Bateman and Fonagy developed a psychoanalytically oriented day hospital therapy that they later manualized and named mentalization-based therapy (MBT) (2003). Mentalization is the mind’s ability to perceive and interpret human behavior in terms of people’s mental states, such as needs, feelings, beliefs, goals, or reasons.
Description of BPD: What is it?
MBT is based on the theory that borderline personality symptoms, such as impulsivity and inability to regulate one’s emotions, result from the individual’s inability to mentalize (Bateman & Fonagy, 2003). It is theorized that gaining the ability to mentalize will enable individuals to regulate their emotions, as well as enabling them to build relationship skills (Bateman & Fonagy, 2003).
Fonagy, who first developed the concept of mentalization, found that individuals with BPD had often grown up in families that inhibited mentalization skills (Bateman & Fonagy, 2006). For example, in abusive families, children are often not allowed to express negative emotions, such as sadness or anger, nor were they allowed to talk with the parents about the parents’ intentions or behaviors. Fonagy believed that this type of family environment led to the development of BPD (Bateman & Fonagy, 2006).
Bateman and Fonagy said that, based on at least one study, improvement in symptoms began after six months of treatment and continued until the end of treatment at 18 months, when clients no longer met criteria for BPD (Bateman & Fonagy, 2006). At an 8-year follow-up of the original treatment, the authors found that only 13% of the MBT group met criteria for BPD, compared to 87% of the treatment-as-usual group (2006).
In MBT, the therapist models a nonjudgmental attitude of curiosity and open-mindedness toward what the client describes of his or her own experiences. In this way, the therapist encourages the client to think about his/her experience and to step back and get perspective on that experience (Bateman & Fonagy, 2006). This process enables us to understand ourselves—to know what our own states of mind and body mean. The process also enables us to empathize with, and effectively communicate with, others, and thus to build relationships with others.
Therefore, the client and the therapist work together to build the client’s ability to mentalize by exploring alternative perspectives to the client’s subjective experience of self and others. The initial task is to help the client regulate emotion through this process of learning to mentalize (Bateman & Fonagy, 2006).
The traditional view of BPD in the psychiatric community since its inclusion in the DSM-III has been that BPD has a largely environmental etiology, but that pharmacotherapy can be a useful adjunct to psychotherapy and other psychosocial treatments (APA, 1980; Sadock, Sadock, & Ruiz, 2014). The view has been that psychotropic medications cannot treat the core disorder, but rather should be aimed at treating specific symptoms of BPD (Sadock et al., 2014). A similar view has been that BPD tends to coexist with other Axis I and Axis II disorders and that psychotropic medications can be used to treat the other Axis I disorders, but not to treat BPD per se. However, new technologies have led to a new conception of the disorder.
Description of BPD: What is it?
Due to new types of technology, especially advances in neuroimaging, a growing number of researchers have observed some evidence of brain dysfunction specific to individuals with BPD. This has resulted in a relatively new conception of BPD that explicitly identifies the core of the disorder as a “neurobehavioral developmental brain dysfunction” (Rosenberg, 1994, p. 59).
Oldham suggested that that BPD is a personality disorder emerging from the interaction of underlying genetically based traits with environmental stressors (2007, p. 11). Several studies have suggested that BPD is heritable, especially the twin study by Torgersen et al., which found a concordance for BPD of 35% in monozygotic twins, compared with 7% in dizygotic twins (Torgersen et al., 2000). A genetic model demonstrated a heritability effect of 0.69 (1.0 would indicate complete heritability). This suggests that there is a strong genetic component in the etiology of BPD (Skodol, 2005; Torgersen et al., 2000).
Rosenberg (1994) stated that many symptoms of BPD, including lack of impulse control, affective dysregulation, cognitive disability, and predisposition to psychotic decompensation suggest orbitofrontal or limbic areas as the center of the brain dysfunction in BPD. If it is true, he said, that BPD is essentially a brain dysfunction, then it could be primarily treated by pharmacological means. Rosenberg has predicted a day when medication will, indeed, be the primary treatment for BPD (Rosenberg, 1994, p. 59).
MRI studies of individuals with BPD have reported smaller volumes, compared to a healthy control group, in various parts of the brain, including the frontal lobe, left orbitofrontal cortex, anterior cingulate, hippocampus, amygdale, and parietal lobe (Vollm et al., 2009). Vollm et al. noted that, up until that point, most of the brain abnormalities identified in the research had been in the parts of the brain related to expression and regulation of affect (2009, p. 65).
Proponents of the neurobiological theory foresee a time in the future when medications will become the primary treatment for the neurobiological symptoms. Currently, however, most or all of the proponents of the neurobiological theory recommend that medications be used in combination with other psychosocial treatments (Oldham, 2010). However, as stated above, some researchers expect that more effective medications for BPD will be found that will help improve the client’s quality of life in a much shorter period of time (Rosenberg, 1994).
Proponents of the neurobiological theory vary in their views of the prognosis for BPD. Four studies have published findings on the long-term outcome of BPD (Paris, 1993). All four studies examined patients with BPD for 14 to 16 years after being discharged from an inpatient hospital. The first finding was that, in three out of the four studies, nearly 10% of the subjects committed suicide, and that the low suicide rate reported in one of the studies was likely the result of sample bias (Paris, 1993). On the other hand, the four studies reported on by Paris all showed a high degree of recovery from BPD after 15 years.
Finley-Belgrad reported that an initial diagnosis of BPD is rarely made in clients more than 40 years old (2002, p. 14). These findings may suggest that individuals with BPD improve with age.
Oldham reported a 6-year follow-up study of individuals with BPD in which 74% of the individuals met criteria for BPD during the entire course of the follow-up (Oldham, 2010).
Thus, proponents of the neurobiology theory of BPD vary in their estimates of the length of time needed for treatment and recovery, and they report a need for caution because of the high risk for suicide among individuals with BPD.
As stated above, most proponents of the neurobiological theory recommend several types of psychotherapy as the first line of treatment for individuals with BPD—they agree that current medications do not treat the core disorder, but they believe that, for best results, medications should also be added to psychotherapy. Sadock et al. (2014) recommend dialectical behavior therapy, mentalization-based therapy, and transference-focused psychotherapy as useful psychotherapeutic approaches for individuals with BPD. Oldham (2010) recommended psychotherapy as the primary treatment for BPD.
Proponents of the neurobiological theory recommend medications to deal with specific symptoms in individuals with BPD, in order to improve overall functioning. Sadock et al. (2014) recommend use of the following: antipsychotics to control anger, hostility, and brief psychotic episodes; antidepressants to improve depressed mood; MAO inhibitors to modulate impulsive behavior; benzodiazepines to help with anxiety and depression; and anticonvulsants to improve global functioning in some individuals. Furthermore, while the proponents of the neurobiological theory believe that medications will be found that will treat the core disorder of BPD, they admit that, currently, no such medications exist.
However, as shown above, recent studies using neuroimaging techniques have discovered a number of differences in brain structure and function between individuals with BPD and individuals in control groups. It is possible that, in the not-too-distant future, neuroimaging will provide clues to improved treatments.
Global Relevance of BPD
As a quick look at the reference list below reveals, until very recently, most research concerning personality disorders was conducted in North America, Europe, and Australia (Paris, 1993; Rosenberg, 1994; Zanarini et al., 2000). However, a number of relatively recent developments in the field of personality disorders have made research in this field more feasible, and have suggested that personality disorders, similar to mental illnesses, are just as prevalent in other parts of the world as they are in North America, Europe, and Australia (Tyrer et al., 2010).
The first development was the inclusion of personality disorders in the DSM-III (APA, 1980). The DSM-III demonstrated that personality disorders can be reliably diagnosed, and that personality disorders have a significant influence on the prognoses for comorbid mental disorders.
A second development was the expansion of the codes for personality disorders in the ICD-10 (WHO, 1993). While there had only been one code for personality disorder in the ICD-9, the ICD-10 included codes and diagnostic criteria for nine specific personality disorders, plus two subtypes under one of the personality disorders (WHO, 1993). The ICD-10 included “borderline type” under “emotionally unstable personality disorder” (WHO, 1993), which, although it has certain differences from BPD in the DSM-V, is mostly quite similar (APA, 2013).
A third development was the development and the increasing use of short screening instruments for personality disorders (Tyrer et al., 2010). The development of these instruments has made it possible for lay interviewers in many different countries to collect data for research studies on personality disorders.
The largest such study was conducted in ten different countries, six of which were low- or middle-income countries: Colombia, Lebanon, Mexico, Nigeria, China, and South Africa (Huang et al., 2009). The study reached across five continents as well. The study showed that personality disorders make up between 3 and 10% of community samples, regardless of the country.
Thus, personality disorder has “achieved a level of understanding and … respectability that allows it to be considered as an equal partner with other mental disorders” (Tyrer et al., 2010). This level of acceptance has opened the way to further research into personality disorders. For example, researchers have looked at the impact of a personality disorder on comorbid mental disorders and have found that having a personality disorder correlates with a poorer prognosis for the comorbid mental illness (Tyrer et al., 2010).
The level of acceptance of personality disorder(s) has also led to: (a) studies calculating the negative impact of personality disorders on a country’s economy, (b) research studies testing the effectiveness of various treatments, as discussed above, and (c) examination of new ways of classifying personality disorders—ways that would result in less overlap between the specific disorders, and that would be more useful for identifying appropriate treatments (Tyrer et al., 2010).
Personality disorders are now almost as widely accepted as other mental disorders, and are recognized as having roughly the same prevalence—from 3% to 10%—in community samples across many different countries and different continents. This has led to an increase in research into personality disorders, which in turn has increased society’s understanding of them.
There are now a number of evidence-based psychotherapies for individuals with BPD. Historically, BPD was usually seen as a lifelong disorder, but research since the 1990s has challenged this assumption. Evidence-based treatments have restored many individuals with BPD to a significantly higher level of functioning. On the other hand, even the evidence-based treatments take a minimum of 18 months to effect significant improvement in symptoms, and the various authors concede that, for many individuals with BPD, it will take years of treatment to reach the point where they no longer meet diagnostic criteria.
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