Borderline Personality Disorder

Borderline Personality Disorder (BPD) may result from numerous factors, but it is generally believed to result from an interaction between an individual’s innate predisposition, and the social and family environment within which they grow up. Not everyone with an initial temperamental vulnerability to emotional dysregulation (an inability to organise and manage feelings) will develop BPD, but growing up in a family context where feelings tend to be trivialised or ignored, and where emotional expressiveness is discouraged, for example, can create fertile ground for this condition to surface. In other words, a dysfunctional environment can bring about disorder in a vulnerable individual.

A person with BPD will tend to be highly sensitive to emotional events (particularly those involving other people), have intense responses to these events, and have difficulty returning to an emotional baseline following the event. Such an individual, having failed to learn how to label and regulate emotional arousal, has a low tolerance to emotional distress, and develops a distrust in their ability to accurately interpret events; they often do not know how to act, think, or feel in different situations. They therefore rely on others to see how they should behave, and thus fail to develop a coherent sense of self. The expressive style (or behaviour) of the borderline adult often swings between the opposite poles of complete suppression and inhibition of emotion on the one hand, and extreme behavioural displays on the other. Acts such as cutting and overdosing, for example, may be carried out in an attempt to release the intense painful emotions that are felt, as well as to gain help from others. Difficulties with anger and anger expression are not uncommon.

The emotional dysfunction central to BPD often interferes with the ability to develop and maintain stable relationships, as this depends on both a stable sense of self, and a capacity to self-regulate mood. Social and occupational functioning therefore will often be significantly impaired for sufferers of this condition. There is a high incidence of suicidal behaviour and other forms of self-harm among people with BPD.

Symptoms

  • suicide threats and crises, self-destructive behaviour
  • difficulties with anger and anger expression
  • episodes of anxiety, depression and irritability
  • instability of thoughts and feelings
  • extreme and impulsive behaviour
  • suppression of thoughts and behaviour
  • dissociation and delusions
  • loss of sense of self, feelings of emptiness
  • chaotic, intense relationships, that are marked with difficulties

Diagnosis

Assessment has two main aims: that of making a diagnosis, and that of treatment planning for an individual. A diagnostic interview will be conducted to establish criteria for Borderline Personality Disorder. To be diagnosed as suffering from BPD, the individual will suffer from dysregulation and instability in the realms of their emotions; their cognitions (thoughts); their behaviours, and in their interpersonal relationships. Symptoms will be assessed for both severity and frequency. Suicide risk will also be assessed and monitored, as suicidal behaviours are not uncommon among sufferers of this disorder. Assessment may be ongoing for a period of time, to determine the effectiveness of treatment.

Medication

Different types of medication may be used to target different aspects of this mental health disorder. For example, minor tranquilizers and/or antidepressants may be used to help with emotional symptoms such as anxiety, depression and impulsive-aggressive behaviour. Lithium carbonate may be used to treat transient psychotic episodes. The effectiveness of medication with respect to symptom alleviation will be carefully monitored, and it is likely that it will be used in conjunction with psychological treatment.

Psychological Treatment

Psychological therapy tends to blend psychodynamic, interpersonal and cognitive behavioural approaches. Treatment goals will include increasing control over impulsive behaviour, increasing ability to tolerate anxiety and other emotions, strengthening the client’s sense of identity, and the development of stable interpersonal relationships.

Cognitive-behavioural treatment will be particularly targeted at correcting the errors in thinking that are typical for sufferers of BPD, such as the assumption that the world is dangerous, and that the sufferer is powerless and vulnerable. Such beliefs will be challenged, with the aim that behaviour in turn will become more adaptive. Strategies which might be adopted include an emphasis on learning tolerance, acceptance and increased mindfulness. The development of skilful behaviour is encouraged in such areas as mood management, coping with stress, interpersonal effectiveness, and learning to respond with awareness without being judgmental. The client will be encouraged to shift from extreme, rigid, black-or-white thinking and behaviour towards more balanced responses and an open-minded attitude. Learning to bear pain skilfully will be key, such as allowing thoughts and feelings to be fully experienced, without the need to change or control them.