Borderline Personality Disorder
(BPD)
PSX_003 Counselling Psychology – PhDr. Pavel Humpolíček, Ph.D
Autumn 2016
Aline Lampertz 464475
Yurena Febles Arteaga 464375
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Contents
1 Definition..................................................................................................................................2
2 Criteria ......................................................................................................................................2
2.1 DSM-5...............................................................................................................................2
2.2 ICD-10...............................................................................................................................3
3 Development and Course..........................................................................................................4
4 Prevalence .................................................................................................................................4
5 Etiology.....................................................................................................................................5
5.1 Genetic and brain factors...................................................................................................5
5.2 Environmental factors .......................................................................................................5
5.3 The Gene-environment interaction model.........................................................................6
6 Diagnosis...................................................................................................................................6
6.1 Differential Diagnosis .......................................................................................................6
7 Impact on functioning...............................................................................................................7
7.1 Psychopathology in the extended families of BPD ...........................................................8
7.2 Psychopathology in the parents of BPD patients ..............................................................8
7.3 Children of mothers with BPD..........................................................................................9
8 Treatment and Therapies...........................................................................................................9
8.1 Medication.......................................................................................................................10
8.2 Psychotherapy..................................................................................................................11
8.2.1 Cognitive Behavioural Therapy (CBT)....................................................................11
8.2.2 Psychodynamic Psychotherapy (PDP).....................................................................13
8.2.3 Group therapy...........................................................................................................14
8.2.4 Therapeutic communities .........................................................................................15
8.2.5 Online spaces – support groups................................................................................15
8.3 Pharmacotherapy with psychotherapy.............................................................................16
8.4 Families and couples .......................................................................................................16
8.5 Transcranial magnetic stimulation ..................................................................................18
9 References...............................................................................................................................19
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1 Definition
Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of
ongoing instability in moods, behavior, self-image, and functioning. These experiences often result
in impulsive actions and unstable relationships. A person with BPD may experience intense
episodes of anger, depression, and anxiety that may last from only a few hours to days (National
Institute of Mental Health, 2016).
2 Criteria
2.1 DSM-5
According to the DSM-5 (American Psychiatric Association, 2013), Borderline Personality
Disorder (BPD) (301.83) is a pervasive pattern of instability of interpersonal relationships, selfimage,
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 behaviour 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 selfmutilating
behaviour covered in Criterion 5).
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
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.
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DSM-5 also gathers associated features that support diagnosis. This features are briefly
described below.
Individuals with BPD may undermine themselves at the moment a goal is about to be achieved
(e.g., dropping out of school just before graduation, destroying a good relationship just when it is
clear that the relationship could last, etc.). Furthermore, individuals with this disorder may feel
more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal
relationships.
Some individuals develop psychotic-like symptoms during times of stress (e.g., hallucinations,
body-image distortions, ideas of reference, hypnagogic phenomena). Besides, premature death
from suicide may occur in these individual, especially in those with co-occurring depressive
disorders or substance use disorders. Physical handicaps may result from self-inflicted abuse
behaviours or failed suicide attempts.
Recurrent job losses, interrupted education, and separation or divorce are also common.
Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in
the childhood histories of those with BPD.
2.2 ICD-10
On the other hand, the ICD-10 (World Health Organization, 1992) defines a disorder
conceptually similar to BPD called Emotionally unstable personality disorder (F60.3). It has the
following two subtypes:
1. F60.30 Impulsive type
At least three of the following must be present, and one of which must be number “2”:
1. Marked tendency to act unexpectedly and without consideration of the consequences.
2. Marked tendency to engage in quarrelsome behaviour and to have conflicts with others,
especially when impulsive acts are thwarted or criticized.
3. Outbursts of anger or violence, with inability to control the resulting behavioural
explosions.
4. Difficulty in maintaining any course of action that offers no immediate reward.
5. Unstable and capricious (impulsive, whimsical) mood.
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2. F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present and, in
addition, at least two of the following:
1. Disturbances in and uncertainty about self-image, aims, and internal preferences.
2. Liability to become involved in intense and unstable relationships, often leading to
emotional crisis.
3. Excessive efforts to avoid abandonment.
4. Recurrent threats or acts of self-harm.
5. Chronic feelings of emptiness.
6. Demonstrates impulsive behaviour (e.g., speeding, substance abuse).
3 Development and Course
The course of BPD is considerably variable. The most frequent pattern is a chronic instability
in early adulthood, with events of severe affective and impulsive dyscontrol and high levels of use
of health and mental health resources.
The impairment from the disorder and the risk of suicide are greatest in the young-adult years
and gradually decreases with advancing age. Although the tendency toward intense emotions,
impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic
intervention often show improvement beginning sometime during the first year. During their 30s
and 40s, the majority of individuals with this disorder attain greater stability in their relationships
and vocational functioning.
Follow-up studies of individuals identified through outpatient mental health clinics show that
after about 10 years, as many as half of the individuals no longer have a pattern of behaviour that
meets full criteria for BPD. This disorder seems to be less stable over time than expected for
personality disorders (Skodol et al., 2005; Lenzenweger et al., 2007; Gunderson et al., 2003).
4 Prevalence
According to the DSM-5 (American Psychiatric Association, 2013), the average population
prevalence of BPD is around 1.6% but it can be as high as 5.9%, and it is diagnosed predominantly
in females (about 75%).
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In primary care settings, the prevalence is about 6%; among individuals seen in outpatient
mental health clinics it is about 10%; and among psychiatric inpatients, about 20%. Besides, the
prevalence of BPD may decrease in older age groups.
5 Etiology
5.1 Genetic and brain factors
There is significant scientific evidence that BPD is highly heritable. BPD is about five times
more common among first-degree biological relatives of people with the disorder than in the
general population (American Psychiatric Association, 2013).
A systematic review of the heritability of BPD from Amad, Ramoz, Thomas, Jardri &
Gorwood (2014) examined 59 published studies and concluded that BDP has a strong genetic
component. They also state that brain abnormalities of this disorder are a consequence of genes
involved in brain development. BPD must be regarded as a serious disabling brain disorder.
42 published studies found out that, compared with healthy controls, people who have BPD
present extensive cortical and subcortical abnormalities in brain structure and function (McKenzie
& Nasrallah 2013). Those studies have revealed some abnormalities in BPD such as: hypoplasia
of the hippocampus, variations in the CA1 region of the hippocampus and subiculum, a smaller
frontal lobe, a higher glutamate level in the anterior cingulate cortex, greater activation of the
amygdala and prolonged return to baseline, a decrease in inter-hemispheric connectivity between
right and left anterior cingulate cortices.
5.2 Environmental factors
Growing up in an unstable, abusive, or neglectful environment may raise the risk of
developing BPD. Of all environmental factors that place a person at risk for developing borderline
disorder, those associated with poor or uninformed parenting appear to be the most critical.
(Leichsenring, Leibing, Kruse, New, & Leweke, 2011; Judd & McGlashan, 2008; Reich & Zanarini,
2001). Early separation from one or both parents, repeated emotional, physical or sexual abuse by
someone within or outside of the family environment and inconsistent or unsupportive care are
included. Poor parenting can also include failing to protect the child from repeated abuse by the
other parent, another member of the family or an outsider.
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Linehan (1993) also postulates that one of the major causative factors of BPD is an
"invalidating environment," defined as one in which communication of private experiences is met
by erratic, inappropriate, or extreme responses. That environment is usually the family. But of
course, it is important to include that children who have not been exposed to environmental traumas
can still develop borderline disorder.
5.3 The Gene-environment interaction model
The G×E interaction model support that expression of plasticity genes is modified by
childhood experiences and environment, such as physical or sexual abuse. Childhood abuse might,
therefore, disrupt certain neuroplasticity genes, culminating in morphological, neurochemical,
metabolic, and white-matter aberrations—leading to pathological behavioral patterns identified as
BPD (Amad, Ramoz, Thomas, Jardri & Gorwood, 2014)
6 Diagnosis
Unfortunately, BPD is often underdiagnosed or misdiagnosed. In some cases, co-occurring
mental illnesses may have symptoms that overlap with BPD, making it difficult to distinguish BPD
from other mental illnesses. For example, a person may describe feelings of depression but may
not bring other symptoms to the mental health professional's attention (National Institute of Mental
Health, 2016). Diagnosis is often a relief when people with BPD realize that others understand their
experience and treatment options exist.
6.1 Differential Diagnosis
According to the DSM-5 (American Psychiatric Association, 2013), BPD commonly coexist
with depressive and bipolar disorders, substance use disorders, eating disorders (notably bulimia
nervosa), posttraumatic stress disorder and attention-deficit/hyperactivity disorder, among others.
BPD must be distinguished from personality change due to another medical condition, in
which the traits that emerge are a consequence of the effects of that medical condition on the central
nervous system. Secondly, BPD must also be distinguished from symptoms that may develop in
association with persistent substance use. Thirdly, it should also be distinguished from an identity
problem, which is reserved for identity concerns related to a developmental phase (e.g.,
adolescence) and does not qualify as a mental disorder.
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7 Impact on functioning
People with BPD can feel angry at members of their family and alienated from them. It is hard
for the family members to cope with them, they often feel angry and helpless at how their family
members relate to them. In addition, parents of BDP patient can have a bad behavior, for example,
over-involved and under-involved in family interactions (Allen & Farmer, 1996) Incest, for
example, may be a type of as extreme and inappropriate overinvolvement of, for instance, a father
with his daughter.
High levels of chronic stress and conflict, decreased satisfaction of romantic partners, abuse,
and unwanted pregnancy may result from a romantic relationships with BDP partner. However,
these links may apply to personality disorders in general (Daley, Burge & Hammen, 2000).
Splitting is a major defense mechanism of patients with BPD. This consist on often regarding
self and others as “all good” or “all bad”, without middle ground. Splitting has a significant impact
in borderline person’s life and their relationships. This phenomenon is closely related to what Beck
& Freeman (1990) called “dichotomous thinking” and what Linehan (1993) referred to as “all or
none thinking.” Splitting is described in the American Psychiatric Association’s Diagnostic &
Statistical Manual (DSM-5) as “A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and devaluation.”
People who are regarded as being “all good” (idealization) are sometimes referred to as being
“split white” or “painted white”. People who are regarded as being “all bad” are sometimes referred
to as being “split black” or “painted black” (devaluation). Since there is no middle ground, these
individuals can go from idealization to devaluation in a short period of time. For instance, a mother
may habitually tell her daughter that she is “useless” or “worthless” but when she gets a good grade
at school praise and say things like “we are all so proud of you!”
Psychotherapy must be orientated to help the patient begin to experience the shades of grey
between the extremes and integrate the positive and negative aspects of the self and others. A major
challenge of psychotherapy is to help patients recognize that their perception of others, including
the therapist, is a representation rather than how they really are.
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7.1 Psychopathologyin the extended families of BPD
There are four common associated areas of familial psychopathology: mood disorders;
impulse disorders; substance use disorders; and Axis II disorders including BPD. It seems that the
families of patients with BPD partially mirror the psychopathology encountered in the probands.
Various psychopathological characteristics in the extended of BDP probands in comparison
with the extended families of a control proband have been examined in a number of studies.
Davidson and Siever (1991) made a study where they compared the relatives of: individuals with
BPD; individuals with other personality disorders; and individuals with schizophrenia. They found
out that the relatives of BPD probands presented higher risks for affective and impulse disorders.
Goldman, D’Angelo and De Maso (1993) found that the relatives of BPD individuals had
significantly greater rates of depression, substance abuse and antisocial characteristics as well.
Finally, in a large study by Zanarini (2004), they found that the families of BPD probands
were more likely to have BPD psychopathology compared with the non BPD probands, particularly
subsyndromal symptoms.
7.2 Psychopathologyin the parents of BPD patients
As reported by some studies with both parents, the individuals with BPD described their
parents in a negative way (Guderson, 1997), uncaring and overcontrolling (Zweig-Frank , Paris J.,
1997; Weaver, Clum, 1993; Parker, Roy, Wilhelm, et al, 1999), unempathetic (Guttman, Laporte,
2000), conflictual (Allen, Abramson, Whitson, et al, 2005), invalidating and critical (Fruzzetti,
Shenk, Hoffman, 2005), aversive , less nurturing, and less affectionate (Johnson, Cohen, Chen, et
al, 2006) ,emotionally withholding (Zanarini, Gunderson, Marino, et al., 1989), over-protective
(Torgersen, Alnaes . 1992; Gagnon, 1993), over-involved as well as under involved (Allen ,
Farmer, 1996) and hostile (Hayashi , Suzuki , Yamamoto, 1995).
Nickell et al. (2002) found that BPD features were associated with insecure attachment (i.e.,
anxious or ambivalent attachment) and the perception of a lack of caring from the mother.
Bandelow et al. (2005) found that the BPD subsample described the attitude of their parents toward
them as significantly more unfavorable in all aspects.
Overall, these studies portray the parents of patients with BPD in a very unflattering light.
There is a limitation in this kind of studies since the patients can have distorted perceptions of
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parents because of their inherent difficulties with emotional regulation. Thus, the result may not be
objective.
In addition to studies examining the general impressions of both parents, there are other
studies about the specific relationship between the BDP individual and the mother. In those studies
(Golomb, Ludolph & Westen, 1994; Paris & Frank, 1989; Bezirganian, Cohen & Brook 1993;
Liotti & Pasquini, 2000), those with BPD have described their mothers as egocentric (i.e. using the
child for their own ego-gratifying needs), less caring, inconsistent and overinvolved.
There are not too many studies about the specific relationship of the BPD individuals with
their fathers. Fathers were rated particularly negatively by BPD patients (Baker et al., 1992). The
researchers found that this negative response was related to the age of the BPD individual as well
as if fathers were perpetrators of sexual abuse.
7.3 Children of mothers with BPD
The effects of BPD mothers on their children have been examined by several studies, usually
with a control group. For instance, Hobson and colleagues (2005) found that mothers with BPD
were found to be less available for positive engagement, disorganized and intrusively insensitive.
Barnow and colleagues (2006) compared the children of BPD mothers with those of depressed
mothers, mothers with personality disorders and mothers without psychopathology. They
discovered that the children of BPD mothers had lower self-esteem, exhibited more emotional and
behavioral problems and were more harm avoidant.
Furthermore, the study of Weiss et al. (1996) showed that children of BDP mothers compared
with children of mothers with a non BPD personality disorder were more impulsive and had more
psychiatric diagnoses, including a higher prevalence of BPD. Finally, Newman et al. (2007) saw
that BPD mothers were less sensitive in their interactions with offspring, and likewise, the children
had less desire to interact, were less satisfied, less competent and more distressed.
8 Treatment and Therapies
BPD has historically been viewed as difficult to treat. However, with newer and proper
treatment, many people with BPD experience fewer or less severe symptoms and an improved
quality of life. Many circumstances affect the length that it takes for symptoms to improve once
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treatment begins, so it is important for people with BPD and their relatives, couple, friends and
others to be patient and to receive appropriate support during treatment. (National Institute of
Mental Health, 2016).
Psychotherapy is the primary treatment for BPD, while medications are useful for treating
comorbid disorders, such as depression and anxiety. Besides, short-term hospitalization has not
been found to be more effective than community care for improving outcomes or long-term
prevention of suicidal behavior in those with BPD (Paris, J., 2004).
8.1 Medication
A systematic review and meta-analysis of randomised controlled trials (RCT) by
the Cochrane collaboration (Stoffers et al., 2010) found that there was no fully effective medication
for the core BPD symptoms (chronic feelings of emptiness, identity disturbance and abandonment),
but they did found that some medications could impact isolated symptoms of BPD or the symptoms
of comorbid conditions. They exposed the following results:
Among the habitual antipsychotics used in BPD, they found that haloperidol may reduce
anger and flupenthixol may reduce the likelihood of suicidal behaviour. Of the atypical
antipsychotics studied in relation with BPD, one trial found that aripiprazole may reduce
interpersonal problems and impulsivity. Olanzapine may decrease affective instability, anger,
psychotic paranoid symptoms, and anxiety, but a placebo had a greater ameliorative impact on
suicidal ideation than olanzapine did. They also found that the effect of ziprasidone was not
significant.
Of the mood stabilizers studied, valproate semisodium may ameliorate depression,
interpersonal problems, and anger. Lamotrigine may reduce impulsivity and anger; topiramate
may ameliorate interpersonal problems, impulsivity, anxiety, anger, and general psychiatric
pathology. The effect of carbamazepine was not significant.
In relation to the antidepressants, they found that amitriptyline may reduce depression,
but mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate showed no effect. Finally, omega-3
fatty acid may ameliorate suicidality and improve depression. From 2010, trials with these
medications have not been replicated and the effect of long-term use have not been assessed.
As can be seen, medication effectiveness evidence is weak. Thus, and because of the potential
for serious side effects from some of these medications, the 2009 UK National Institute for Health
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and Clinical Excellence (NICE) clinical guideline for the treatment and management of BPD
recommends that medication should not be used specifically for BPD and its individual symptoms
or associated behaviour. However, it can be considered in the general treatment of comorbid
conditions. They propose a review of the treatments of those with BPD and a current medication
prescription who do not have a diagnosed comorbid mental or physical disorder. In this way, some
evidence could be found to avoid what they see as an unnecessary drug treatment (Abraham, Kelly,
West & Michie, 2009).
8.2 Psychotherapy
Psychotherapy is the main treatment for people with BPD (Leichsenring et al., 2011).
According to current research, psychotherapy may alleviate some symptoms, but additional studies
are needed to better understand how psychotherapy works (National Institute of Mental Health,
2016).
Psychotherapy can be provided one-on-one or in a group setting. Group sessions may teach
people with BPD how to interact with others and how to effectively express themselves. It is
important that people in therapy get along with and trust their therapist, although this might be
difficult because of the nature of BPD itself. There are several types of psychotherapy used to treat
BPD. Some of them will be mentioned below.
8.2.1 Cognitive Behavioural Therapy (CBT)
The aim of CBT is to help people with BPD identify and change those core beliefs
and/or behaviors that cause inaccurate perceptions of themselves and others as well as
problems interacting with others. Thus, CBT place emphasis on observable behaviours and
on the psychic schemata or “inner scripts” (usual patterns of thought that concern the self
and interpersonal world, built up during developmental years). In the evolution of BPD,
those behaviours and their underlying schemata may have become maladaptive for diverse
causes: hereditary predispositions, humiliations or other psychological hurts by parents, or
even trauma originated from physical or sexual abuse (Beck and Freeman, 1990).
That early maladaptive schemata include basic assumptions as: “I’ll be alone forever”;
“no one will be there for me”; “I’m a bad person”; “I deserve to be punished”; “No one
would love me if they really got to know me”. These assumptions reflect some important
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themes relevant to BPD patients such as fear of abandonment, conviction of unlovability
and exaggerated guilt. The cognitive distortions typical of BPD patients involve polarized
all-or-none attitudes, which Beck & Freeman (1990) refer to as “dichotomous thinking”.
Therapy focuses on decreasing that tendency to dichotomous thinking, helping the
patient develop better control over his emotions and impulses, and strengthening the
patient’s sense of identity (Stone, 2006). According to the National Institute of Mental
Health (2006), CBT may help reduce a range of mood and anxiety symptoms and reduce
the number of suicidal or self-harming behaviours.
In the last 20 years, the Dialectical Behaviour Therapy (DBT) developed by Marsha
Linehan (1993) has increased its popularity and respectability as a method specially for
minimizing the tendency among BPD patients to make suicide attempts of self-harm
behaviours. It combines standard CBT techniques for emotion regulation with concepts of
mindfulness, distress tolerance, acceptance, and interpersonal effectiveness. It includes the
use of one individual session per week with a therapist, along with a weekly group session
oriented toward skills training. Phone calls to the therapist are allowed (whereas they are
discouraged in Transference-Focused Psychotherapy –which we will be mentioning
below–), but with the condition that the therapist will speak with the patient who is about
to self-cut or make a suicide gesture, with the expectation that their conversation will lead
to the abstention in the patient from self-damaging and the ability to acquire self-control. If
the patient calls after having self-damaging, the call must cut short to avoid the possible
“secondary gain” that the patient might obtain from being listened by other, in this case the
the therapist.
The term "dialectical" means a synthesis or integration of opposites, those polarized
opposite feelings and attitudes of the patient. It includes the need for acceptance and the
need for change. Thus, DBT therapists accept clients as they are while also acknowledging
that they need to change in order to reach their goals. For instance, many BPD patients have
been abused in childhood, hence the validation during the therapy becomes crucial to
reassure the patient that certain negative experiences such as neglect, unjustified
punishment or incest really happened and that the patient was not “crazy” for having
thought, e.g. “I am a bad person”. What is more, all of the skills and strategies taught in
DBT are balanced in terms of acceptance and change (mindfulness and distress tolerance
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in acceptance-oriented skills and emotion regulation and interpersonal effectiveness in
change-oriented skills).
The first randomized clinical trial of DBT showed reduced rates of suicidal gestures,
psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual
(Dimeff & Linehan, 2001). Besides, a meta-analysis found that DBT reached moderate
effects in individuals with borderline personality disorder (Kliem, Kröger & Kosfelder,
2010). Nonetheless, a 2006 systematic review from the Cochrane collaboration showed no
differences between DBT and treatment as usual in individuals meeting criteria for BPD at
6 months, or in hospital admissions in the previous 3 months (Binks et al., 2006)
8.2.2 Psychodynamic Psychotherapy (PDP)
The psychoanalytically-oriented or “psychodynamic” methods are rooted on the
assumption that unconscious forces and conflicts are buffeting the borderline patient and
that is the cause of the polarized attitudes and oscillating behavioural patterns seen in BPD
individuals. For example, they usually swing from adoration to contempt toward key
figures in their lives (manifesting the defense mechanisms of idealization and devaluation).
The psychodynamic approach tries to promote psychic integration through the careful
examination of the polarized attitudes in hopes this will lead to more appropriate attitudes
toward other people and to more modulated behaviours in everyday life. In this therapy, the
client-therapist relationship must be strong; therapists want their clients to be as open and
honest as possible with them. For this to happen, clients must trust their therapist.
As reported by the APA Practice Guideline (American Psychiatric Association, 2001),
most psychotherapists and psychoanalysts agree that psychoanalytic psychotherapy, at a
frequency of one to three times a week face-to-face with the patient, is a more suitable
treatment than psychoanalysis.
Transference-Focused Psychotherapy (TFP) is a psychodynamic treatment rooted
in the patient’s confused and contradictory sense of identity associated with emotionally
intense mental images of themselves and others. The defense against these contradictions
leads to disturbed relationships with others and with self. For instance, splitting or
dichotomous thinking are defense mechanisms. The distorted perceptions of self and others
are the focus of treatment as they emerge in the relationship with the therapist (transference).
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The therapist helps the patient unconsciously reassign extreme positive or negative images
associated with one person to another person, such as the therapist. In that moment, the
therapist talks with the patient to interpret and understand why the patient distorts his or her
sense of self and images of other people. The consistent interpretation of these distorted
perceptions is considered the mechanism of change. Intense changes in emotions occur as
patients learn to reflect and verbalize what they are feeling, rather than acting out these
emotions impulsively.
In early research from Clarkin, Foelsch & Levy (2001) studying the efficacy of a yearlong
TFP, suicide attempts were significantly reduced during treatment. Moreover, the
physical condition of the patients was significantly improved. When the treatment year was
compared to the prior year, they found that there was a significant decrease in psychiatric
hospitalizations and days spent as inpatients in psychiatric hospitals. Finally, the dropout
rate for the 1-year study was 19.1%, which was a comparable rate to previous studies
assessing the treatment of borderline individuals, including DBT research. In another study
from Clarkin, Levy & Schiavi (2005) comparing TFP with treatment as usual, TFP group
experienced significant decreases in psychiatric visits and hospitalizations during treatment
year, as well as significant increases in global functioning when compared to treatment as
usual.
8.2.3 Group therapy
In consonance with the APA Practice Guideline (American Psychiatric Association,
2001), the sparse literature on group therapy for BPD patients points that group treatment
is not harmful and may be helpful, but it does not provide evidence of any clear advantage
over individual psychotherapy. In general, group therapy is usually used in combination
with individual therapy and other types of treatment, evidencing the clinical wisdom that
the combination is more effective than solely group therapy. Studies of combined individual
Dynamic Therapy plus group therapy suggest that unknown components of combined
interventions may have the greatest therapeutic power (McGlashan, 1986).
Clinical experience suggests that a reasonably homogeneous group of BPD patients is
generally recommended for group therapy, although patients with dependent, schizoid, and
narcissistic personality disorders or chronic depression also mix well with BPD individuals
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(Gunderson, J. G., 2009). Conversely, it is generally recommended not to include patients
with antisocial personality disorder, untreated substance abuse, or psychosis.
8.2.4 Therapeutic communities
Therapeutic communities are structured environments where people with a range of
complex psychological conditions and needs come together to interact and take part in the
therapy in order to help them with their emotional and self-harming problems teaching them
social interaction skills. Most TCs are residential, such as in large houses, where people
stay for around one to four days a week (National Health Service, 2016).
As well as taking part in individual and group therapy, you would be expected to do
other activities designed to improve social skills and self-confidence, such as household
chores, meal preparation, games, sports and other recreational activities and regular
community meetings where people discuss issues that have arisen in the community.
This TCs usually set guidelines on what is considered an acceptable behaviour within
the community, such as not drinking alcohol, no violence to other residents or staff, and no
attempts at self-harming. Those who break these guidelines are usually told to leave the TC.
While some people with BPD have reported that the time spent in a TC helped their
symptoms, there's not yet enough evidence to tell whether TCs would help everyone with
BPD.
8.2.5 Online spaces – support groups
Nowadays, some organizations offer online support groups, discussion boards, blogs
and online communities as additional ways to connect with others in similar situations. This
can be an additional support for in-person groups and may be especially helpful if there are
no groups in the area where the patient lives. Thus, in these groups, fellow members offer
validation and give tips and techniques that have worked for others.
Mental Health America is an example of community that has its own online support
community through the webpage ‘www.inspire.com’, enabling individuals to connect on a
variety of issues and topics related to mental health.
Other types of psychotherapy may be helpful for some people with BPD, such as Supportive
Psychotherapy, Dynamic Deconstructive Therapy (DDT), Schema-Focused Therapy (SFT)
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or Mentalization-Based Therapy (MBT). Therapists often adapt psychotherapy to better meet a
person's needs, and may also switch from one type of psychotherapy to another, mix techniques
from different therapies, or use a combination of psychotherapies.
As we have seen, psychotherapy is beneficial for some clinically relevant problems of
patients with BPD. However, further research is needed to also improve other core features of this
disorder (Skodol et al., 2005).
8.3 Pharmacotherapywith psychotherapy
The advantages of combining pharmacotherapy and psychotherapy in BPD are still unclear.
Fluoxetine (antidepressant) combined with Dialectical Behaviour Therapy (DBT) did not produce
any additional benefit compared with DBT plus placebo (Simpson and colleagues, 2004).
However, in a double-blind study of Soler et al. (2005), olanzapine (antipsychotic) added to DBT
provided an additional benefit compared with DBT plus placebo, although no differences were
reported in another study made on BPD women with high irritability in favour of the DBT plus
olanzapine combined treatment (Linehan, McDavid, Brown, Sayrs & Gallop, 2008). Otherwise,
the combination of fluoxetine and interpersonal therapy was superior to fluoxetine plus clinical
management.
Results are very diverse, hence future studies on the combination of pharmacotherapy and
psychotherapy are needed to improve the empirical support for its use in BPD patients
(Leichsenring et al., 2011).
8.4 Families and couples
Families of people with BPD may also benefit from therapy. The challenges of dealing with
a loved one with BPD on a daily basis can be very stressful, and family members may
unconsciously act in ways to aggravate their relative's symptoms. Some therapies include family
members in treatment sessions to help them understand and support BPD individuals (National
Institute of Mental Health, 2016). Although more research is needed to determine the effectiveness
of family therapy in BPD, studies on other mental disorders suggest that including family members
can help in a person's treatment. There are different levels of possible psychopathology in multiple
members, it is the reason why the family intervention must be undertaken with care. Programs for
17
family members are few in number and most authors seem to recommend psychoeducation
(Sansone & Sansone, 2009).
Blum and colleagues (2008) developed an intervention called Systems Training for
Emotional Predictability and Problem Solving (STEPPS). It is a group treatment program
during 20 weeks. The aim is to educate family members, significant others, and health care
professionals about BPD. It gives them guidance on how to interact consistently with the person
with the disorder. STEPPS is designed to supplement other treatments the patient may be receiving,
such as medication or individual psychotherapy. This program includes cognitive behavioral
elements and skills training and also encourages the participation of family members and other
significant persons.
On the other hand we have psychoeducation, which refers to the education that is offered to
individuals with a mental health condition and their families to help to empower them and deal
with their condition in an optimal way.
As reported by the APA Practice Guideline (2001), there is only one published study of
family therapy for patients with BPD (Gunderson, 2009) which found that a psychoeducational
approach could greatly improve communication and diminish conflict in the family. Published
clinical reports differ about their family treatment recommendations. Some clinicians recommend
removing the patient’s treatment from the family setting and not attempting family therapy
(Gunderson, 2009), while others recommend working with the patient and involve the family too
(Shapiro, 1992).
Clinical experience suggests that family work is most apt to be effectiveness and can be of
critical importance when patients with BPD have significant involvement with the family. Failure
to enlist family support is a common reason to stop the treatment. However, there may be some
unexpected risks with psychoeducation, even if it is the predominant theme in the treatment
approach to families with a BDP member. Specifically, Hoffman et al. (2003) explored family
members’ knowledge about BPD. In this study, greater knowledge about BPD was associated with
greater family member distress, burden, depression, and hostility toward the patient.
Finally, in accordance with APA Practice Guideline (American Psychiatric Association,
2001), only clinical experience and case reports can give us some information about couples
therapy. This clinical literature suggests that couples therapy may be an useful and, sometimes,
essential adjunctive treatment modality. However, couples therapy is not recommended as the only
18
form of treatment for patients with borderline personality disorder. Clinical experience suggests
that it is relatively contraindicated when either partner is unable to listen to the other’s criticisms
or complaints without becoming too enraged, terrified, or despairing (Seeman, & Edwardes-Evans,
1979).
According to the the APA Practice Guideline (American Psychiatric Association, 2001), the
usual goal of couples therapy is to settle and strengthen the relationship between the partners or to
clarify the nonviability of the relationship. Other goal for some is to educate and clarify for the
partner of the BPD patient the process that is taking place within the relationship. Partners of BPD
patients may struggle to accommodate the patient’s alternating patterns of idealization and
depreciation as well as other interpersonal behaviours. Thus, spouses may become dysphoric and
self-doubting, as well as too attentive and exhibit reaction formation (a defense mechanism from
the psychoanalytic theory in which emotions and impulses which are anxiety-producing or
perceived to be unacceptable are mastered by exaggeration). The goal of treatment is to explore
and change these maladaptive reactions and problematic interactions between partners.
8.5 Transcranialmagnetic stimulation
Using neurostimulation techniques such as repetitive transcranial magnetic stimulation and
deep brain stimulation to modulate the activity of a given region of the brain seems to have
effectiveness in the improvement of impulsivity, suicidality and aggression, as McKenzie &
Nasrallah (2003) found correlations between those symptoms and structural brain abnormalities.
19
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