Treating Borderline Personality Disorder
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Copyright by Harvard University.
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All rights reserved 1/13/2011
What Is It?
Borderline personality disorder is characterized by poor self-image, a feeling of emptiness, and great difficulty coping with being alone. People with this disorder have highly reactive and intense moods, and unstable relationships. Their behavior can be impulsive. They are also more likely than average to attempt or commit suicide. Sometimes, without intending to commit suicide, they harm themselves (for example, cutting or burning) as a form of self-punishment or to combat an empty feeling.
When stressed, people with borderline personality disorder may develop psychotic-like symptoms. They experience a distortion of their perceptions or beliefs rather than a distinct break with reality. Especially in close relationships, they tend to misinterpret or amplify what other people feel about them. For example, they may assume a friend or family member is having extremely hateful feelings toward them, when the person may be only mildly annoyed or angry.
People with borderline personality disorder have a deep fear of abandonment. They compete for social acceptance, are terrified of rejection and often feel lonely even in the context of an intimate relationship. Therefore, it is more difficult for them to manage the normal ups and downs of a romantic partnership. Impulsive, self-destructive behavior may be an attempt to ward off rising anxiety related to the fear of being left alone.
The flip side of the fear is the hope that a relationship will be completely soothing. People with this disorder may idealize a family member, romantic partner or friend, and then become enraged when an inevitable disappointment occurs. They might hold that person responsible for the pain they feel and devalue the relationship.
Most experts believe personality disorders develop as a result of both environmental and biological factors. Early research on this disorder focused on problems in growing up, for example, having gone through abuse or neglect as a child. A significant number of people with symptoms of this disorder have reported such a history in childhood.
Later research has suggested that people with this disorder may have inborn difficulties in regulating their anxiety or moods. They may be more vulnerable to loss or more sensitive to stress than average.
Scientists have begun to see how these characteristics are reflected in the brains of people with borderline personality disorder. Some people with this disorder have an exaggerated startle response to unpleasant stimuli. Brain regions involved in managing fear and controlling aggressive responses function differently in people with borderline personality disorder when compared to people without the disorder. Researchers have also discovered distinctive patterns in hormone levels and the immune system in people with the disorder.
It is quite common for people with borderline personality disorder to also have a mood disorder, eating disorder or substance abuse problem. The person may turn to alcohol or drugs to escape from painful, uncontrollable emotions.
Three times as many women as men are diagnosed with borderline personality disorder. It occurs in about 2% of the population in the United States.
Feeling vulnerable is a common human experience, so many of the symptoms on this list are common. The diagnosis of borderline personality disorder is made only when a person has had many of these symptoms, they are severe in degree, and they are long-lasting.
- Unstable, intense and difficult relationships
- Poor self-image
- Self-destructive, impulsive behavior
- Suicidal threats or attempts
- Extreme mood reactions, including intense, inappropriate anger
- Feeling empty or alone
- Fear of abandonment
- Short-lived psychotic-like distortions of perception or belief, especially under stress
There is no clear line between a personality style and a disorder. Personality patterns are considered to be a disorder when they impair a person’s functioning and cause significant distress.
A diagnosis is usually made on the basis of the history and observations made by a mental health professional during an interview. There are no laboratory tests to determine whether someone has borderline personality disorder. Since there is often an overlap with mood disorder or substance abuse, these possibilities should be considered by the mental health professional in anyone who has the symptoms of borderline personality disorder.
All personality disorders are lifelong patterns, but there is now more optimism about the more distressing aspects of this illness. Research indicates that the symptoms of borderline personality disorder get less intense as people grow older. For example, a study published in 2006 reported that the vast majority of patients studied had recovered within 10 years. With proper treatment, many people see significant improvement.
There is no known way to prevent borderline personality disorder. Once identified, treatment is likely to better the chances of getting relief from the most painful aspects of the disorder.
Psychotherapy is a key part of the treatment of borderline personality disorder.
The problems in this disorder are related to the person’s habitual ways of relating to others and coping with obstacles. People with this disorder tend either to idealize the therapist or to become frustrated easily. They have exaggerated reactions to disappointment. Therefore, it may be difficult for them to sustain a relationship with a mental health professional. This disorder tests the skill of therapists, who have to use a combination of techniques to be effective.
A key challenge in this disorder is that a person may understand interpersonal problems or coping strategies on an intellectual level, but still find it very difficult to tolerate the emotional discomfort that is common in relationships, and to manage intense emotions more successfully.
One popular form of structured psychotherapy is called dialectical behavior therapy (DBT). It tries to take the special problems of borderline personality disorder into account, using a combination of psychotherapy techniques, education, and both individual and group psychotherapy to support the patient’s progress. A second therapy, called schema-focused therapy tries to address maladaptive worldviews believed to originate in childhood and replace those “schemas” with a healthier one through a variety of cognitive therapy techniques.
There have been relatively few controlled studies of psychotherapy for borderline personality disorder. Since the problems in this disorder vary widely, the researchers tend to study a few factors at a time. In some studies, DBT has reduced the frequency of self-harm and the intensity of suicidal thinking. It has also been shown to reduce the intensity of symptoms of depression or anxiety.
Structured forms of psychodynamic psychotherapy have also been used successfully.
In one version, transference-focused psychotherapy, the therapist and patient look closely at the emotional themes that arise between them. People with borderline personality disorder are thought to have great difficulty understanding the difference between their own perspective and that of other people (including the therapist). In one sense, therefore, the goal of therapy is for them to gain perspective on their worldview, and to use what they learn to manage their own feelings and behaviors better. A study of transference-based psychotherapy published in 2007 showed that it worked as well as DBT. It was also more effective than DBT at reducing irritability, impulsivity and assaultiveness.
Another method of psychotherapy is called “mentalization-based therapy” (MBT).
It is based on the idea that people with this disorder have difficulty “mentalizing” or making sense of the emotions, feelings and beliefs of themselves and others. The therapist works to help a person develop more adaptive ways of thinking about emotion and expressing it. They try to help the individual stabilize their sense of self, while managing the ups and downs in the therapy. One focus of attention is the intensity of the patient’s feelings of attachment (or detachment) toward the therapist. MBT makes use of group and individual therapy and has been provided in both outpatient and hospital settings. A small number of controlled studies have shown that, on several measures, MBT was more effective than usual treatment.
Whatever label it carries, treatment aims at helping the person endure feeling isolated, depressed or anxious without resorting to self-destructive behavior or a suicide attempt. Many patients find it difficult to discuss self-destructive impulses with their health care provider, but it can help to do so. Specific plans can be made for how to manage these thoughts or impulses when they arise. Hospitalization sometimes is necessary during periods of crisis.
Outside the hospital, a person with borderline personality disorder may need additional support, such as a day-treatment program, residential treatment, or group, couples or family therapy.
Given the limited amount of research in this area, and the difficulty gaining access to highly specialized treatment programs, it is often wise to employ a combination of psychotherapy techniques.
As with psychotherapy, there is no single medication that is clearly helpful in borderline personality disorder. Instead, medication is usually used to treat symptoms as they emerge or to treat other disorders that may be present (such as a mood or anxiety disorder or a substance abuse problem).
Antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs) can be used for depression and anxiety. There is also some evidence that this group of drugs reduce anger. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). Sometimes, a mood stabilizer is added or used by itself. These include lithium (Lithobid and other brand names), divalproex sodium (Depakote) or topiramate (Topamax). Antipsychotic medication, such as risperidone (Risperdal) or olanzapine (Zyprexa), may be tried if the person’s thinking is distorted.
When To Call a Professional
Because personality styles tend to become more entrenched with age, it is best to seek treatment as soon as significant distress or poor functioning is noticed.
The course of this illness varies and depends on the severity of the symptoms; the amount of stress; the availability of support; the degree of functional impairment; the extent of self-destructive or suicidal behavior; and the presence of other psychiatric disorders, such as depression or substance abuse. It also depends on the person’s ability to stay in treatment. Some people are better able to bear the challenges of treatment. Others, however, find themselves in a cycle of seeking help, then feeling rejected and rejecting the help.
Also, it is sometimes difficult for people with borderline personality disorder to find a therapist they feel comfortable enough with. Given the problems maintaining perspective (see above, under Treatment), it may be difficult for them to distinguish between real and exaggerated disappointment in psychotherapy. One benefit of combining individual therapy with other therapy modes (for example, group therapy) is that it can diffuse some of the intensity and refocus the person on practical goals.
Researchers are now more optimistic about the long-term outcomes in borderline personality disorder. For example, a paper published in 2010 reported on a study that followed hundreds of patients with this disorder over several years. The vast majority of the participants experienced at least some reduction in symptoms with treatment. And half recovered from the disorder, meaning they no longer met the criteria for having borderline personality disorder and they were functioning well. Therefore, at least with continuing treatment, it appears that many people with borderline personality disorder eventually can make significant progress, take some pleasure in their relationships and have satisfying life achievements.
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