Borderline Personality Disorder (BPD) is an often misunderstood & highly stigmatised mental health disorder. Treatment options have traditionally been ineffective, however Dialectical Behavioural Therapy (DBT) offers the best outcomes for people struggling with this disorder.
A personality disorder is defined in DSM 5 (Diagnostic & Statistical Manual of Mental Disorders, 2013), as, '...an enduring pattern of inner experience & behaviours that deviates markedly from the expectations of the individual's culture, is pervasive & inflexible, has an onset in adolescence or early adulthood, is stable over time, & leads to distress or impairment.', (DSM 5, 2013; pp. 645). In other words, it's part of somebody's personality.
The term 'borderline', in the context of BPD, comes from old ideas about neurosis & psychosis. The 'borderline' refers to a condition that lies somewhere between what psychiatry used to view as neurosis- but not all the way towards psychosis. In recent times there has been discussions within the mental health community about changing this name, which some believe is misleading. Some have suggested that 'Affect Regulation Disorder', may be a more accurate description of this condition, however in the latest publishing of the DSM 5 in 2013, the name Borderline Personality Disorder remains.
A diagnosis of BPD can only be made on adults, however traits of the disorder can be seen emerging in adolescence & early adulthood. To meet the criteria for the diagnosis, traits must be seen over time as a regular & a stable (as in enduring, not without emotional instability) part of the person's personality.
The diagnosis criteria for BPD demands that 5 or more of the following apply for the person;
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable & intense interpersonal relationships, characterised by alternating between extremes of idealisation & devaluation.
3. Identity disturbance: markedly & persistently unstable self-image or sense of self.
4. Impulsivity in at least 2 areas that are potentially damaging (e.g. substance abuse, reckless driving etc).
5. Recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour.
6. Affective instability due to marked reactivity of mood.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
(DSM 5, 2013; pp. 663)
As you can see, BPD may have many different combinations of these symptoms, with some people experiencing most of these criteria, whilst others maybe only 5.
A diagnosis of BPD is often a diagnosis of exclusion- that is, it is made when other diagnosis have been dismissed. It is common for people diagnosed with BPD to have had previous diagnoses of depression, anxiety, or other mental health conditions. People with BPD can also have other mental health diagnosis, as well as BPD. For example, it is not uncommon for people to have a valid diagnosis of depression, as well as BPD. These people may benefit from treatment for both conditions.
The most widely accepted theory of what causes BPD is a bio-social explanation. This outlines a person having a biological disposition towards the disorder (so they are born with a biological or genetic disposition), plus experience of an 'invalidating environment'. An invalidating environment is defined as any experiences that result in emotional invalidation. This can be severe, such in the case of childhood abuse. An invalidating environment could also mean something less obvious, such as parents who dismiss & invalidate the display or expression of emotions in a child.
People with BPD often try lots of different forms of mental health treatment in their journey towards wellness, but often have limited effectiveness from these treatment. Common forms of therapy, such as CBT, are often ineffective for BPD. It is not uncommon for people with BPD to have had lots of contact with mental health services & professionals in the past.
Trauma-related mental health conditions, such as complex PTSD, can often display very similar symptoms to BPD. Many people with BPD have a history of trauma, but not all. The results of childhood trauma are especially close in presentation to BPD symptoms, Difficulties regulating emotions & affect, difficulties with attachment & relationships, & an unstable sense of identity are very common for people who have experienced childhood trauma, particularly childhood sexual abuse. It is important to recognise the role of trauma in anyone diagnosed with BPD, however it may not change the recommended treatment plan for recovery.
There is significant stigma associated with BPD, even within health services. BPD behaviours are often misunderstood as 'attention-seeking', or 'behavioural' in nature. These labels are not only incorrect, they are harmful to the people they are made against, & can stand in the way of effective treatment.
There is however, signifiant research to indicate that people with BPD benefit from a specialised treatment approach, & that risk issues be managed slightly differently from other diagnostic groups. Issues such as chronic suicidality should be managed differently for people with BPD, due to research suggesting long-term hospitalisation may be counterproductive.
So what is the recommended treatment, & is there hope for people struggling with BPD? The good news is yes! Research into BPD has demonstrated significantly better results for people who engage in Dialectical Behavioural Therapy (DBT). DBT has been extensively researched, & shown to be the best form of treatment for BPD. Research has also shown DBT can be highly beneficial for other conditions, such as drug & alcohol addiction, eating disorders, & any condition resulting in difficulties regulating emotional states.
DBT targets emotion regulation & distress tolerance as core components of the therapy. Interpersonal effectiveness skills & mindfulness are also core aspects. Identification of extremes in a person's life & thinking patterns are targeted, & 'middle ground' is where we are aiming to move towards.
DBT is traditionally offered in a group + individual therapy framework. The group is usually weekly, & involves teaching of specific psychological skills. The individual therapy sessions are focused on more individual issues, monitoring of mood & skill usage, as well as forming a therapeutic relationship.
At Mindful Recovery Services (MRS) we have several ways people can do DBT therapy. We run an intensive group program twice per year, which involves weekly skills training groups, individual therapy sessions & phone coaching.
We also have our Emotion Mastery Program: DBT Done Differently, which involves online skills training & 1:1 sessions. This allows anyone with a busy schedule, or isn't keen on an intensive group, access to the same amazing DBT resources & support.
If you or someone you know is struggling with BPD, give us a call at MRS. Treatment works & can provide long-term relief from the chaotic nature of BPD. There is hope!
Wishing you all good mental health:) Alex.
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