When Your Loved One Has Borderline Personality Disorder

Escape Plan From a Borderline Woman

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Escape Plan From a Borderline Woman Summary

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Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder characterized by disturbed and unstable interpersonal relationships and self-image, along with impulsive, reckless, and often self-destructive behavior. Individuals with BPD have a history of unstable interpersonal relationships. They have difficulty interpreting reality and view significant people in their lives as either completely flawless or extremely unfair and uncaring (a phenomenon known as splitting). These alternating feelings of idealization and devaluation are the hallmark feature of borderline personality disorder. Because borderline patients set up such excessive and unrealistic expectations for others, they are inevitably disappointed when their expectations aren't realized. The DSM-IV-TR requires that at least five of the following criteria (or symptoms) be present in an individual for a diagnosis of borderline disorder Borderline personality disorder accounts for 30-60 of all personality disorders, and is...

Borderline Personality

Three major factors describe this character disposition. First is the superficiality and lack of depth of any existing relationship. Second, there is an intense reservoir of anger just beneath the surface of ordinary interaction. Finally, instability characterizes self-image, self-esteem, and personal and sexual identity. Along with the store of anger, a complement of tenuous, shifting controls exists. The borderline personality, unlike the schizoid type, may report discomfort with periods of isolation and loneliness. Additional traits include pessimism and impulsivity. Addictive problems or traits reflecting compulsive, obsessional, paranoid, schizoid, and narcissistic tendencies frequently may exist. Additional formulations, with respect to

Borderline Personality Disorder A Critique

We now examine Borderline Personality Disorder as an example of a personality disorder diagnosis that, it could be argued, fails in the intended goals of any diagnosis to clarify etiology, indicate treatment interventions, and determine prognosis. This diagnosis in particular may also have iatrogenic effects on many patients. For instance, one patient commented that other treaters had called her a borderline, and she added that she knew that wasn't good. In fact, she felt they were maligning her and taking an adversarial position with her of distance and guard-edness she felt that under such conditions, she actually was triggered more easily into traumatic disconnections and acting crazy. In short, she felt unsafe. Applying a pathology-based label such as borderline does not contribute to the creation of a healing connection in therapy with people who have been severely harmed in violating interpersonal relationships. The emphasis conveyed by this label on the disturbance, as located...

Cognitive Therapy for Personality Disorders

The 1990s saw several developments of cognitive therapy for personality disorders. Beck, Freeman & Davis (2003) adapted traditional cognitive therapy for each of the DSM-IV personality disorders. Layden et al. (1993) developed a more in depth adaptation for borderline personality disorder, and Linehan (1993) developed a more integrative behavioural-cognitive Zen Buddhist approach for this client group. Meanwhile, Young developed a schema-focussed cognitive therapy for personality disorders, which emphasises the importance of underlying schema change in this group (Young, 1994 Young, Klosko, & Weishaar, 2003). Several preliminary effectiveness studies suggest that these approaches produce significant symptom changes in people diagnosed with personality disorders (Kuyken et al., 2001, Linehan etal., 1999 Linehan, Heard & Armstrong, 1993). It is premature to comment on whether these are evidence-based interventions although several large-scale trials are currently under way.

Neurotransmitters mental disorders and medications

Substantial research evidence also suggests a correlation of neurotransmitter imbalance with disorders such as borderline personality disorders, schizotypal personality disorder, avoidant personality disorder, social phobia, histrionic personality disorder, and somatization disorder.

The Theoretical Basis For

When Marsha Linehan is asked to tell the story of her development of dialectical behaviour therapy (DBT) she says that she did not set out to invent a theoretical orientation for the treatment of borderline personality disorder (BPD). Linehan was treating suicidal clients, attempting to use standard behaviour therapy with them. However, it was not successful for many of the clients. They would present at an individual psychotherapy session with one problem, such as panic disorder and Linehan would choose an empirically supported treatment for that problem. When the clients returned for the next session they would not have completed the prescribed homework because other problems would have surfaced. Linehan realized that standard treatments were not working because the problems of the clients changed from session to session and moment to moment. Her laboratory developed DBT from an attempt to find a means of prioritizing the multiple problems presented by clients who engaged in...

Enhancing Capabilities

The first function of comprehensive DBT is to enhance the capabilities (called skills in DBT) of the clients. This is the function of the skills training mode. Clients often do not engage in skilful behaviours because such behaviours are not in their repertoires In order to engender behavioural change, clients must learn new, functional behaviours while as increasing the generalization of existing functional behaviours. The Skills Training Manual for Treating Borderline Personality Disorder (Linehan, 1993b) is the handbook for skills training. The manual comes complete with lesson plans, and reproducible handouts and homework sheets for patients.

Education And Training In

Currently there is no research on minimal or optimal training level to provide DBT although there is evidence that DBT can be applied in community mental health settings (Hawkins & Singha, 1998 Mental Health Center of Great Manchester, New Hampshire, 1998). It is recommended that DBT psychotherapists have graduate training and most non-research oriented programmes have master's level therapists as well as doctoral level therapists. Hawkins & Singha (1998) also found that community clinicians could demonstrate content proficiency regardless of education or behavioural background. The Skills Training Manual for Treating Borderline Personality Disorder (Linehan, 1993b) does not indicate any minimum education or training level required for the provision of the skills training. At this point, there is no research that examines the relationship between the training or educational level of those who are using the workbook as trainers on the one hand and behavioural outcomes on the...

Cognitive Therapy In Practice

A typical cognitive therapy session involves checking how the client has been doing, reviewing the previous session, setting an agenda, working through the agenda items, setting homework, reviewing summarising the session and eliciting feedback. It begins with the therapist and client negotiating an agenda or list of topics that they agree to work on in that session. This involves ensuring the agenda is manageable, prioritising the items and linking them to the therapy goals. The therapist will usually ask the client for a brief synopsis of the time since they last met and as far as possible will try to enable a linking of both positive and negative experiences to thoughts and behaviours. For example, a client who reports feeling less depressed may go on to link this to returning to work and having less time to ruminate. A session would then review the homework from the previous session, again seeking to link progress or lack of progress to the therapy goals. For example, an...

Natural History And Longterm Outcome In Personality Disorder

Data on the natural history of personality disorders are skewed towards the most severe cases and most of these have been identified in psychiatric hospitals and forensic settings. Furthermore, most of the follow-up studies in this area are not really accounts of the natural history of these disorders, but are reports of long-term outcome after variable degrees of widely divergent interventions. Borderline and antisocial personality disorders have attracted particular attention because the impulsive and destructive behaviour of these individuals causes such concern among both carers and society in general. As noted above, borderline patients often make heavy demands on the health service. In contrast, individuals with antisocial

Other Comorbid Psychiatric Conditions

Personality disorders involving impulsivity (including borderline personality disorder) are found more frequently in those with eating disorders involving binge eating than among controls, across the weight spectrum. For example, one study found that obese individuals with binge eating disorder have a 14 prevalence of borderline personality disorder versus only 1 of obese g individuals without binge eating disorder (50). Avoid-ant personality disorder has also been reported to be more prevalent among these subjects with than without binge eating disorder (50,53).

Defenses Forming Character Trait Patterns

Occurs even though disparate values exist in the subject and in the object of identification. Thus, in the borderline personality disorder, another individual can be seen alternately in ideal or devalued terms without awareness of contradiction. Because the nature of splitting is unconscious and the compartmentalizations are self-contained, perceptions of good and bad are reversed without feelings of tension or a recognition of conflict. Consequently, splitting prevents the feelings of ambiguity and distress that would ordinarily be associated with an experience of conflict.

Personality Disorders And Social Sensitivity

Mental disorders whose prevalence changes with time and circumstance can be described as being socially sensitive. Disorders that have a stable prevalence across cultures and time can be described as being socially insensitive. Many of the socially sensitive disorders (e.g., substance abuse, eating disorders, antisocial personality, borderline personality) have externalizing symptoms. Impulsive traits, which tend to be contained by structure and limits and amplified by their absence, are particularly responsive to social context. At the same time, disorders characterized by internalizing symptoms (e.g., unipolar depression, anxiety disorders) are also socially sensitive. Anxious and depressive traits can be either contained or amplified by social supports.

Binge Eating Disorder

Both CBT (100,123) and IPT (100) have been shown to promote reductions in binge eating for up to 12 months following treatment. Treatment is generally similar to that used for bulimia nervosa, with some modifications. It has been hoped that, as these psychotherapies may work through differing mechanisms, patients failing to improve with one form of psychotherapy might respond favorably to another. However, a study using IPT as ''salvage'' therapy for patients who failed to respond to CBT found no additional benefit of IPT in this group (124). Another form of psychotherapy, dialectical behavior therapy (DBT), has recently been adapted for use in binge eating disorder (125). DBT is an empirically validated treatment for individuals with borderline personality disorder, which conceptualizes pathologic behaviors as faulty attempts at affect regulation (126). The treatment attempts to teach clients more functional methods of dealing with negative emotions.

Psychoanalytic Model Of Nosology

My classification of personality disorders centers on the dimension of severity (Kernberg, 1976). Severity ranges from (1) psychotic personality organization, to (2) borderline personality organization, to (3) neurotic personality organization. Psychotic personality organization is characterized by lack of integration of the concept of self and significant others, that is, identity diffusion, a predominance of primitive defensive operations centering on splitting and loss of reality testing. The defensive operations of splitting and its derivatives (projective identification, denial, primitive idealization, omnipotence, omnipotent control, devaluation) have as a basic function to maintain separate the idealized and persecutory internalized object relations derived from the early developmental phases predating object constancy that is, when aggressively determined internalizations strongly dominate the internal world of object relations, to prevent the overwhelming control or...

Process Of Therapeutic Change

Jillian had been diagnosed with Bipolar Disorder (aggressiveness without mania) on two previous hospitalizations and presently met criteria for Major Depressive Disorder, severe. Despite the affective volatility and instability that was suggestive of Borderline Personality Disorder (BPD), Jillian was better described by the label Oppositional Disorder a DSM-IV category closely related to the description of Passive Aggressive Personality Disorder (PAG) from the DSM-III-R (APA, 1987). Her patterns that were independent of mood disorder and that supported this label included the following specific DSM-IV items (1) She often lost her temper, (3) she typically refused to comply with rules and requests, (5) she frequently blamed others for her mistakes or misbehavior, (6) she was touchy and easily annoyed by others, (7) she was often angry and resentful. The proper way to define the PAG category has been so controversial that in the DSM-IV, it was moved from Axis II in the DSM-III-R to a...

Transferencefocused Management Of Affect Storms

In initial interviews, borderline patients usually show far better control of affect than they are able to maintain during effective treatment. The likelihood of periods of inordinate violence of the patient's affect and its expression in action and or countertransference requires, however, that patient and therapist agree in advance on the conditions of the treatment that will make management of such episodes possible. These conditions must include the maintenance of a clear and stable boundary of the therapeutic setting. This boundary involves not only the fixed time and space of the psychotherapeutic relationship, but also the extent to which the patient may yell or not, the requirement to avoid any destructive action against the therapist, his or her belongings, the office, and the space in which the treatment takes place, as well as protecting the patient from any dangerously destructive action against the self. The patient must understand that physical contact between patient...

DSMIV and Dsmivtr The Diagnostic and Statistical Manual

A further break in tradition is exemplified by the dropping of the diagnostic category known as inadequate personality disorder from DSM-III and DSM-IV. In contrast to the traditional categories that have been deleted, however, recent interest and research in several areas have resulted in new inclusions. For example, both the borderline personality disorder and the narcissistic personality disorder have been added as discretely recognized diagnostic entities starting with DSM-III and continuing in DSM-IV. Similarly, the section on psychosexual dysfunctions has been greatly expanded in response to current interest and treatment approaches in this area. The diagnosis of minimal brain damage is reclassified in DSM-IV as an attention-deficit hyperactivity disorder based on insufficient evidence of positive underlying neurological trauma.

Clinical Case Example

Georgia, a recently divorced woman in her mid-40s, initially called and left a message asking a psychologist (the author) to call, telling his secretary, I may want to hire him. She started her initial session by saying, I have a bunch of problems and described having recently been diagnosed with a recurrence of skin cancer. She continued, I think I'm borderline and described a history of verbal and physical abuse both during childhood and in her marriage. She reported having recurrent problems in romantic relationships, saying, I keep marrying my father and also reported having had negative experiences with previous therapists. Georgia stated her primary goal for therapy as, I want to live without psychic pain. She was correct in thinking that she met criteria for a diagnosis of Borderline Personality Disorder, and her understandable difficulty coping with the recurrence of her cancer also qualified for a diagnosis of Adjustment Disorder.

Research And Empirical Support

Cognitive conceptualizations of personality disorders are of recent vintage and, consequently, only limited research into the validity of these conceptualizations has been reported. Recent studies have examined the relationships between the sets of beliefs hypothesized to play a role in each of the personality disorders and diagnostic status. These hypotheses have been supported for Borderline Personality Disorder (Arntz, Dietzel, & Dreesen, 1999) and for Avoidant, Dependent, Obsessive-Compulsive, Narcissistic, and Paranoid Personality Disorders (A. T. Beck et al., 2001). The other personality disorders were not studied because of an inadequate number of subjects. These studies show that dysfunctional beliefs are related to personality disorders in ways that are consistent with cognitive theory but do not provide grounds for conclusions about causality and do not provide a comprehensive test of cognitive conceptualizations of personality disorders.

Range Of Psychopathology And Personality Disorders Within The Scope Of Treatment

At the level of the personality disorders, the negative sides of the adaptations are used as a chronic maladaptive style. Pure types of adaptations are seen along with various degrees and combinations of the adaptations. For example, Schizoid, Antisocial, Paranoid, Passive-Aggressive, Obsessive-Compulsive, and Histrionic Personality Disorders are seen as the pure types of the adaptations. As to the Schizoid adaptation, three levels of personality disorders are apparent (1) Avoidant, which is the mildest version, (2) Schizoid, which is in the middle, and (3) Schizotypal, which is the most severe. The other personality disorders represent different combinations of the adaptations. For example, Dependent Personality Disorder involves a combination of the Schizoid and Passive-Aggressive adaptations. Avoidant Personality Disorder represents a combination of the Paranoid and Schizoid adaptations. Borderline Personality Disorder has aspects of both the Antisocial and Passive-Aggressive...

How Therapeutic Challenges Are Conceptualized And Managed

Linehan (1993) has emphasized the importance of what she calls therapy-interfering behaviors in the treatment of Borderline Personality Disorder, and the same point applies in the treatment of other personality disorders as well. A variety of interpersonal behaviors such as inconsistent attendance, angry outbursts during therapy sessions, and recurrent crises can greatly interfere with the effectiveness of therapy. Although we do not presume that the client's intent is to undercut the effectiveness of therapy, that is the effect these behaviors have if they are not addressed effectively. Cognitive therapists endeavor to recognize therapy-interfering behaviors as soon as they are manifested and to work with the client to address them promptly. sometimes all the therapist needs to do is to call the client's attention to the consequences of his or her behavior (i.e., I know it seems reasonable to come in to see me when you are feeling bad and to cancel sessions when you are feeling okay,...

Zyprexa see Olanzapine

Alzheimer's disease antisocial personality disorder borderline personality disorder conduct disorder intermittent explosive disorder may occur with tic disorders may occur with vascular dementia oppositional defiant disorder paranoid personality disorder substance intoxication Agitation borderline personality disorder generalized anxiety disorder may occur with tic disorders dependent personality disorder Depersonalization acute stress disorder borderline personality disorder depersonalization disorder dissociative identity disorder panic disorder Alzheimer's disease bipolar disorder borderline personality disorder cyclothymic disorder dysthymic disorder major depressive disorder may occur with pyromania may occur with sexual dysfunctions pain disorder postpartum depression seasonal affective disorder substance abuse substance dependence Derealization acute stress disorder borderline personality disorder Dissociative amnesia

Is the Anxiety Consciously Experienced

In writing this section in a way that presents diagnostic implications, the psychologist may be able to distinguish between characterological or personality disorder problems and neurotic problems. When the behavior is ego-syntonic, that is, when the patient's problematic behavior does not cause personal distress, the diagnostic impression of a character or personality disorder can be considered. On the other hand, when the problematic behavior is ego-alien, the resulting intense anxiety is consistent with a diagnosis within the neurotic range. When anxiety develops out of fears related to loss of ego-intactness, this ego-alien experience can suggest the possibility of an emerging psychotic fragmentation. When anxiety appears in the self disorders of narcissistic and borderline personalities, the ego-alien experience suggests failures in respective defense patterns. In the narcissistic type, anxiety is generated by the frustration of entitlements. In the borderline personality,...

Borderline Histrionic and Narcissistic Personality Disorders

In the case of Borderline Personality Disorder, the DSM-IV suggests that this disorder might not represent a culture-specific disorder because behaviors associated with it have been seen in many cultures around the world (DSM-IV, 1994, p. 652). In the case of the second disorder (Histrionic), norms for personal appearance, emotional expressiveness, and interpersonal behavior vary widely across cultures. Symptoms associated with this disorder (e.g., emotionality, seductiveness, impressionability) may be culturally accepted by the community,

Contemporary Theories Of Personality Disorders And Treatment

The cognitive-behavioral treatment of personality disorders is one of the newer treatments for personality disorders (Sperry, 1999). The dialectical behavior therapy (DBT) model of Marsha Linehan (1993) was developed specifically for Borderline Personality Disorder. Her approach, although based on behavioral principles, blends aspects of Eastern philosophy and many elements of the major schools. Because there are numerous integrative models, only some of those applicable to personality disorders are mentioned. A major advance is Wachtel's (1977) cyclical psychodynamic model, an integrative approach applicable to the treatment of personality dysfunction. Johnson (1985) developed one of the earliest innovative integrative approaches to transforming character. Magnavita (2000, 2002c) presented an integrative relational model that blends psychodynamic, cognitive, and systems theory and is the precursor to the unified model presented in this volume (chapter 24). Sperry (1995) offered an...

Secondary Autonomous Ego Function

The secondary autonomous ego function relates specifically to the capacity for directed thought. In evaluating this ego function, the tester is interested in determining if any impediments are interfering with directed thought. The presence of directed thought, even if impaired, differentiates the secondary autonomous function from the primary autonomous function. Patients demonstrating processes of decompensation or depersonalization, persons who are ambulatory schizophrenics, borderline patients, individuals in profound general crisis, or incipiently schizophrenic or prepsychotic patients are likely to show impairment of this ego function. Secondary autonomous ego impairment may also be visible in the borderline personality. Here, the intrusion of primary process impulses appears in the form of abundant themes and percepts reflecting anger and hostile impulses and, perhaps, sexual identity confusion as well. This kind of response pattern reflects the strain on the patient's ego...

Bias and Base Rates

As for epidemiological notions, examiners may be consciously or inadvertently influenced in the conclusions they draw by how they view the nature and incidence of various conditions. Those who believe that borderline personality disorder is widespread are likely to diagnose this condition more frequently than those who think this diagnostic category lacks precision and is used too frequently. Those who believe that attention-deficit hyperactivity disorder (ADHD) occurs mainly in boys, and adolescent anorexia mainly in girls, are relatively unlikely to diagnose ADHD in girls and anorexia in boys.

Other Applications

The success of IPT in treating unipolar mood disorders has led to its expansion to treat other psychiatric disorders. Frank and colleagues in Pittsburgh have been assessing a be-haviourally modified version of IPT as a treatment adjunctive to pharmacotherapy for bipolar disorder. Further, IPT is increasingly being applied for a range of non-mood disorders. There are intriguing applications of IPT as treatment for bulimia (Agras et al., 2000 Fairburn et al., 1993 Wilfley et al., 1993, 2000) and anorexia nervosa social phobia (Lipsitz et al., 1999), posttraumatic stress disorder, borderline personality disorder and other conditions. Life events, the substrate of IPT, are ubiquitous, but how useful it is to focus on them may vary from disorder to disorder. There have been two negative trials of interpersonal therapy for substance disorders (Carroll, Rounsaville & Gawin, 1991 Rounsaville et al., 1983), and it seems unlikely that an outwardly focused treatment such as IPT would be...

Crisis housing

The course of most serious mental illness (such as schizophrenia, bipolar disorder, severe depression, and borderline personality disorder) is cyclical, typically characterized by periods of relative well-being, interrupted by periods of deterioration or relapse. When relapse occurs, the individual generally exhibits florid symptoms that require immediate psychiatric attention and treatment. More often than not, relapse is caused by

Therapeutic Strategy

The psychodynamic psychotherapy for borderline personality organization just outlined derives from psychoanalytic technique, using essential concepts and techniques derived from psychoanalysis, but modifying them in specific ways that make this treatment clearly different from psychoanalysis proper. In fact, one of the origins of this treatment was the failure of standard psychoanalysis to help many patients with severe personality disorders and the need to modify the psychoanalytic treatment in the light of that experience (captured particularly in the psychotherapy research project of the Menninger Foundation Kernberg et al., 1972). The essential techniques taken from psychoanalysis that, in their respective modification, characterize the technique of this psychodynamic psychotherapy, are (1) interpretation, (2) transference analysis, and (3) technical neutrality. In the psychodynamic psychotherapy of borderline patients, tendencies toward expression in action rather than through...

Prevalence

Epidemiological surveys using a variety of diagnostic criteria estimate a prevalence of 10 to 15 of at least one personality disorder within the general population (Mattia & Zimmerman, 2001). The diagnosis is more commonly made in younger people (25 to 44 years). The sex ratio varies according to the specific disorder for example, women are more likely to be diagnosed with borderline personality disorder (BPD) whereas most individuals diagnosed with antisocial personality disorder are men. Unsurprisingly, both prisons and psychiatric hospitals have a particularly high prevalence of personality disorder. Within the former this has been estimated to be as high as 78 Singleton, Meltzer & Gatward (1998), while figures for the latter range from one-third to two-thirds. The role of personality disorder in psychological morbidity is also significant in general practice. In a one-year prevalence study of 'conspicuous psychiatric morbidity' in patients attending two general practices in...

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