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Borderline personality disorder

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Borderline personality disorder (BPD) is often considered to be one of the more challenging forms of psychopathology that a clinician can encounter. The disorder is characterized by a pervasively unstable self-image and dysfunctional interpersonal relationships often as a result of extreme emotional and behavioral dysregulation (American Psychiatric Association [APA], 2013). The term “borderline” was introduced in the early twentieth century to describe individuals who were on the border of psychosis (Gunderson, 2009). That is, individuals who demonstrated some psychotic personality features but also demonstrated intact reality testing and were therefore differentiated from psychosis.

Following its inception in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM–III; APA, 1980), BPD has been characterized as a quasi-psychotic disorder, an affective disorder, and a trauma or stressor-related disorder. However, BPD is best characterized as a disorder of personality with a great deal of heterogeneity. Common symptoms of BPD include frantic efforts to avoid real or imagined abandonment, dysfunctional interpersonal relationships, unstable sense of self, impulsive and self-damaging behaviors, recurrent suicidal or non-suicidal self-injurious behaviors, emotional lability, anger, and paranoia or dissociation (APA, 2013). Perhaps the most pervasive symptom of BPD is a pattern of unstable relationships in which the patient alternates quickly from intense dependency and idealization to devaluation and anger, which is often the result of the patient’s perception of neglect or abandonment. Periods of anger and distress are often transient disruptions from a chronic state of dysphoria and feelings of emptiness.

It is estimated that 75% of individuals with BPD have attempted suicide at some point during their life, with an average of over three attempts per person (Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994). Consequently, it is not surprising that when individuals with BPD seek out health services, it is often during times of crisis and visits are often precipitated by suicidal or other self-injurious behaviors or states of volatility and aggression (Trull, 2015). As a result, individuals with BPD often comprise a challenging and undesirable treatment population for clinicians. Nevertheless, BPD is quite prevalent in clinical settings. With an estimated 75% of individuals with BPD from the general population seeking mental health services (Tomko, Trull, Wood, & Sher, 2014), on average, this population comprises 6% of primary care patients, 10% of outpatients, and 20% of inpatients (APA, 2013). Epidemiologic findings suggest that despite challenges to clinical interventions, treatment utilization among individuals with BPD is relatively high. Therefore, the provision of effective treatments for these individuals is paramount for any mental health setting.

Approaches to Treatment

Psychodynamic Approaches

The first approach developed for the treatment of BPD was the psychoanalytic approach, which informed later psychodynamic approaches. Otto Kernberg (1967) popularized the psychodynamic approach for BPD and originally defined the disorder by its primitive defense mechanisms (e.g., splitting, projection), identity diffusion, and transient breaks with reality. Kernberg developed a psychotherapy, transference-focused psychotherapy (TFP), which emphasized the direct acknowledgement and resolution of intrapsychic and interpersonal conflict through transference analysis between the patient and clinician (Neacsiu & Linehan, 2014). TFP first targets suicidal and self-injurious behaviors and then impulse control, emotion regulation and the ability to tolerate anxiety, and the development and maintenance of stable interpersonal relationships as modeled by patient-clinician interactions. Practitioners of TFP often address treatment targets hierarchically, in order of severity. Of most importance with BPD individuals is managing suicidal and self-injurious behaviors, followed by behaviors that could potentially disrupt the therapeutic relationship, and then the identification of object relations patterns in the therapeutic relationship that can be applied to other interpersonal relationships (Clarkin, Levy, Lenzenweger, & Kernberg, 2007). TFP has been shown to be effective in reducing suicidal ideation and self-injurious behaviors, anger, irritability, and impulsivity (Neacsiu & Linehan, 2014).

With an alternative psychodynamic approach, Bateman and Fonagy (2010) conceptualized BPD as primarily an attachment disorder based on a pattern of maladaptive relationships from one’s early development. Mentalization-based therapy (MBT) was developed with this in mind. Mentalization refers to a process by which people perceive and interpret each other and themselves (Bateman & Fonagy, 2010). Within this framework, individuals with BPD are vulnerable to misinterpretation of interpersonal interactions and therefore have an inadequate capacity for mentalizing (Bateman & Fonagy, 2010; Neacsiu & Linehan, 2014). Therefore, individuals with BPD may attribute erroneous or distorted beliefs or interpretations to their own or others’ behaviors. This may result in the dysfunctional pattern of dependency and devaluation in interpersonal relationships that is so common in BPD individuals. Bateman and Fonagy conceptualized this mentalizing impairment as the core feature of BPD, which would also explain the relationship between disorganized attachment and emotion dysregulation, attentional problems, and impulse control (Bateman & Fonagy, 2010).

During MBT, the clinician emphasizes stabilizing the patient’s sense of self and the regulation of emotions in the context of a healthy attachment in the therapeutic relationship. As opposed to many other empirically supported treatments, MBT allows for a number of various techniques, so long as the primary treatment goal is unitary: increase the individual’s capacity for mentalizing and facilitate awareness of the individual’s thoughts and feelings surrounding situations (Bateman & Fonagy, 2010). In this sense, the clinician is more concerned with the treatment outcome than the treatment itself. To begin, the clinician helps the patient regulate their emotional expression and impulsivity so that it is then possible to intimately examine one’s internal representations and sense of self. Empirical support for MBT is less common than for other psychotherapies for BPD; however, following an 18-month treatment period, BPD individuals showed reductions in suicidal and self-injurious behavior, inpatient hospitalization admissions, depression, anxiety, and improvements in social functioning (Bateman & Fonagy, 2001).

Cognitive-Behavioral and Linehan’s Biosocial Approach

Alternatively, Marsha Linehan (1987) utilized a cognitive-behavioral approach to propose that emotion dysregulation was the primary mechanism of BPD. Within her biosocial model, individuals with BPD are emotionally vulnerable as the result of biological predispositions and an invalidating environment (Crowell, Beauchaine, & Linehan, 2009). Further study has indicated that it is the BPD individual’s high baseline for negative emotion intensity rather than high emotional reactivity that distinguishes the biosocial vulnerability of BPD (Kuo & Linehan, 2009). That is, BPD individuals may be predisposed to automatically start off at a higher level of negative emotional intensity when compared to those without BPD, which contributes to an already dysfunctional emotion regulation system.

Based on Linehan’s biosocial model, dialectical behavior therapy (DBT), a cognitive-behavioral therapy, is the most empirically-supported treatment for BPD (Kuo & Linehan, 2009). The term “dialectic” in DBT refers to a treatment approach used to enact change by methods of persuasion and reliance on transference and modeling in the therapeutic relationship (Neacsiu & Linehan, 2014). Through this lens, many self-injurious behaviors of those with BPD are impulses that are strengthened over time by immediate and transient reductions in negative emotions. In DBT treatment, individuals are taught various behavioral skills to replace previous maladaptive and impulsive behaviors. DBT interventions also focus on the tolerance of negative emotions and nourishment of more positive interpersonal relationships.

In a study comparing the efficacy of TFP and DBT as compared to treatment as usual in an outpatient setting, researchers found that both therapies produced positive change and improvement in suicidality (Clarkin et al., 2007). However, TFP was generally associated with more improvements than DBT and was uniquely associated with improvements in impulsivity, irritability, and physical and verbal assault. Alternatively, following DBT, individuals with BPD were less likely to attempt suicide or have self-injurious behaviors, had lower treatment drop-out rates, and noted reductions in anger, hopelessness, and depression (Linehan et al., 2006). Therefore, although DBT is the most empirically supported treatment for BPD, there is also a lot more information on DBT when compared to TFP. More information is needed on TFP to adequately compare the efficacy of these two prominent therapies for BPD.

Given the inherent role of the clinician in TFP and MBT in focusing on the transference relationship, there are bound to be some cultural difficulties. Although TFP and MBT have proven effective in treating BPD, there is heavy reliance on the clinician’s interpretation of the client’s motives, unconscious, defenses, personality, and thought processes. These interpretations are inherently heavily influenced by gender, sexual orientation, race, ethnicity, culture, and other social values to name a few. This invariably opens the door for bias and demands the clinician be culturally competent. Although TFP and MBT are rather simple psychodynamic therapies, as far as required training, they become increasingly complex when incorporating cultural factors. Alternatively, DBT offers skills training, which can be highly useful and tailored to the individual based on a variety of cultural contexts. DBT skills are thought to be the most important mechanisms for change in individuals with BPD (Neasciu, Rizvi, & Linehan, 2010), and thus provide an effective tool for a variety of clients. This, in addition to generally requiring fewer sessions than MBT in particular, make DBT more appealing and contribute to why DBT is the most studied and empirically supported treatment for BPD.

Alternative Conceptualizations

Rather than using symptoms to categorize BPD, some researchers have relied on dimensional personality traits. Utilizing this approach, personality disorders can be conceptualized as uncommon extremities in common personality traits. Using the five-factor model of personality, individuals with BPD are often high in neuroticism (i.e., anxious, angry, hostile, depressive, impulsive, vulnerable), high in openness (i.e., feelings and actions), low in agreeableness (i.e., antagonistic, non-compliant), and low in conscientiousness (i.e., impulsive; Lynam & Widiger, 2001). As alternative criteria for BPD, the DSM-5 (APA, 2013) lists unstable self-image or identity, lack of self-direction, lack of empathy, and interpersonal/intimacy problems in addition to several maladaptive personality traits. BPD individuals must have personality traits of disinhibition (i.e., impulsivity, risk taking) and antagonism (i.e., hostility), in addition to the possibility of negative affectivity (i.e., emotional lability, anxiousness, separation insecurity, depressivity).

The dimensional model of BPD and personality disorders in general may have clinical utility in providing an assessment of multiple areas of functioning. Rather than focusing on select symptoms that patients present to the clinician, the clinician can assess all areas of personality functioning. Further, when conceptualizing patients, clinicians can often develop “tunnel vision” as far as how to categorize a patient into particular symptoms or a particular disorder. This approach would help eliminate that categorical thinking to view patients on a spectrum of healthy traits and behaviors versus less healthy traits and behaviors. In addition, given the large amount of culturally relevant normative data on personality traits, the clinician could then determine if a specific trait is elevated based both on empirical data and clinical judgment, providing a more justifiable and reliable approach to psychodiagnostic assessment.

Diagnostic symptoms of the DSM are mostly bound in United States’ culture, deciding what is pathological and what is not. This marriage of culture and disorder makes cross-cultural comparisons difficult and makes parsing culture from psychology a difficult if not impossible task. Given the cross-cultural applicability of the five-factor model, this constellation of traits may be more culturally relevant particularly in the context of specific behaviors (Carlo, Knight, Roesch, Opal, & Davis, 2014). For example, in a culture where collectivism is highly valued, an individual’s sense of self may be highly dependent on others. Through an individualistic and Western lens, this may be reflective of a distorted self-image when this is likely not the case. Using a continuum of behavior-specific personality traits may be more efficacious than potentially over-pathologizing categorical DSM-5 symptoms in these instances.

However, the same problem could develop when utilizing the dimensional model of personality traits. Particular traits could become associated with always being maladaptive or undesirable, or particular traits could be repeatedly associated with certain social groups. Therefore, although personality traits have been shown to be cross-culturally valid for the most part, the desirability of specific traits likely varies across different contexts (e.g., situations, gender, culture, sexuality). This could lead to pathologizing particular traits, which already exists to a lesser degree. The five-factor model is defined by traits of openness, conscientiousness, extraversion, agreeableness, and neuroticism, which are for the most part, desirable traits in the United States. By using these labels as the bases of personality, we are setting this as a template for defining healthy individuals. Already, any deviation from these traits or the inverse of these traits, may be considered abnormal or undesirable.

An additional complication with this dimensional model is that just because individuals display or report certain traits and characteristics does not mean that they have maladaptive outcomes, which is often one of the most important criteria for a psychological disorder. Similar to Linehan’s biosocial model, having these traits may just make individuals more likely or vulnerable to develop a personality disorder. There are a number of potential factors that may affect the expression of these underlying traits and may have more influence on behaviors than the personality traits alone. To name a few, biological, socioeconomic, political, religious, historical, geographical, and other cultural factors have been shown to have a great deal of influence in shaping behaviors and the expression of personality traits (Terracciano & McCrae, 2006). In addition, conflict with one’s environment and stressors may be the most decisive factors in whether a personality trait will be displayed and to what degree it is determined problematic. For example, discriminatory or oppressive experiences may provoke aggression or anger in many marginalized individuals. This may be perceived as an extreme trait by some and pathologized; however, by others, most likely of the individual’s ingroup or by culturally competent clinicians that understand the marginalized experiences of others, this may be deemed a culturally-relevant response and a momentary reaction, not truly reflective of one’s personality. Although personality is a component of behavior, it is not a determinant of behavioral expression. As we have seen, there are a number of factors that affect this relationship.

Further, the problem of over-pathologizing and cultural applicability may not depend on the classification system but rather who is doing the classifying. Unfortunately, implicit bias is unavoidable. It is the duty of the clinician to be cognizant of their own biases so that when they arise, they can be examined and incorporated in the clinical decision process. Conceptualizations of personality disorders based on either categorical symptoms or dimensional personality traits are both the subject of cultural biases. One is bound by cultural values and definitions of pathology behavior. The other is bound by expression based on a multitude of biological and social factors. It is the duty of the clinician to incorporate these factors when making a diagnosis and treating the individual. 

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