Borderline Personality Disorder

SUMMARY

Our knowledge about borderline personality disorder (BPD) has taken some unexpected turns: BPD is less stable, it is more genetic, and it is more treatable than we would ever have imagined even 15 years ago. These developments have profound implications for understanding and treatment of individuals with BPD.     

Borderline Personality Disorder and Hospitalization

SUMMARY

This chapter reviews and discusses the issues and controversies related to the hospitalization of suicidal patients with a diagnosis of borderline personality disorder. It highlights the challenges faced by both the clinical staff and a prototypical patient during a hospitalization. Included are a discussion of the transference and counter-transference that arise during inpatient treatment, the stressors on the staff as well as on the patients themselves. The chapter offers suggestions for enhanced in-hospital treatment, including increased collaborative decision-making, clear and realistic short- and long-term goals for patient and family, and increased supervision and ongoing education of staff.     

Borderline Personality Disorder and Adolescence

SUMMARY

This chapter addresses many of the potential challenges clinicians face when working with adolescents with BPD. First, we present the diagnostic issues related to an adolescent population. Second, we review issues related to the families, peers, and larger systems (e.g., schools) that reciprocally influence the adolescent and the treatment. Third, we discuss specific treatment concerns and propose solutions, including how to effectively manage therapists' own reactions to working with this population. Many of the clinical vignettes and suggested interventions in this chapter derive from our experience working in an outpatient adolescent Dialectical Behavior Therapy (DBT) program. As described later in this book, DBT is an evidence-based treatment effective for suicidal multi-problem individuals with promising data published with suicidal adolescents diagnosed with borderline features (Rathus & Miller, 2002).     

Biological Underpinnings of Borderline Personality Disorder

SUMMARY

Biological understanding of a personality disorder is best achieved by examining the disorder's component dimensions, which for borderline personality disorder include impulsive aggression and affective instability. Current biological research into BPD aims to identify the neurotransmitters and brain regions implicated in each of these key domains. Because of advancing technologies and analytic strategies, structural and functional neuroimaging are at the forefront of such efforts. Structural neuroimaging, primarily in the form of magnetic resonance imaging (MRI) scans, gives information about the anatomy of the brain, while functional neuroimaging, primarily functional MRI (fMRI) and positron emission tomography (PET) scans, gives information about brain activity and neurotransmitter systems at the molecular level. BPD neuroimaging studies to date have implied the involvement of several neurotransmitter systems, principally serotonin, along with dysfunction of select brain regions, including the prefrontal cortex and amygdala, suggesting a “dualbrain pathology”: “hyperarousal-dyscontrol syndrome.” However, the exact mechanisms of all these putative etiologies remain unknown.     

Family Experience of Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) struggle with unbearable emotions that arise out of interpersonal difficulties. Self‐harm and suicidal behaviours serve to regulate these emotions and to gain a sense of well‐being and control in a treatment context where hospital admissions are avoided by mental health services. Clinician engagement with families may be constrained by their knowing the accepted etiology of the disorder, which includes a causal link with the family environment. Other constraining factors include the negativity of those with BPD toward their family, and their clinicians' diagnostic uncertainty or confusion. This qualitative study explored the experience of families whose close relative with BPD has a long history of self‐harm and/or suicide attempts. Family members were found to have chronic and traumatic stress. Family roles and relationships were strained, as were relationships between the family and the mental health system. The findings of this study indicate that treatment for BPD needs to adopt a systemic approach that considers individuals and their significant family relationships, as well as relationships between the family and treatment providers.     

Supportive Psychotherapy for Borderline Patients

SUMMARY

An imagined conversation between a clinician/teacher and a beginning therapist conveys the concept of a psychoanalytically informed supportive psychotherapy for borderline patients and incorporates the major hypotheses as to the origin of the disorder. Within a basically developmental point of view, the treatment recognizes the contributions of genetics, animal studies, neuroscience, early interpersonal relationships and the object relations that derive from them. The psychodynamics of a typical case are considered from all of these viewpoints, while the student-therapist is encouraged to keep in mind the basic concepts of psychoanalysis. These include: unconscious mental activity, transference, and the internalization of the therapist's attitude of respectful listening, which leads to the capacity to listen in that way to oneself and others.     

Family Systemic Approaches for Borderline Personality Disorder in Acute Adult Mental Health Care Settings

This thematic literature review explores the contribution of family/systemic approaches in the treatment and care of people with borderline personality disorder (BPD) in acute adult mental health care settings. It recognises the importance of early childhood trauma, family dynamics, and relationships in the aetiology of BPD and outlines key benefits and constraints of a family systems approach. The article discusses institutional, cultural, and power structures that influence the diagnosis and treatment process for adult clients with BPD and the value of relational ethics in guiding or mediating care between the family, healthcare system, and community.     

Peer Substance Use Associated With the Co-occurrence of Borderline Personality Disorder Features and Drug Use Problems in College Students

Abstract

Objective: To determine if the substance use patterns of one's close friends and romantic partners would be a significant contributor to the co-occurrence of borderline personality disorder (BPD) features and drug use problems above and beyond impulsivity and negative emotionality. Participants: Participants were 2,202 undergraduates who attended a large southeastern university between 2003 and 2006. Methods: All subjects completed measures assessing the presence of BPD symptoms, drug use problems, general personality traits, and the proportion of their friends and partners who had used illicit drugs within the past 12 months. Results: The illicit drug use patterns of one's friends and romantic partners was a significant contributor to the co-occurrence of BPD features and drug use problems even when controlling for levels of impulsivity and negative emotionality. Conclusions: These findings suggest possible additional avenues for treatment focusing on helping students with BPD and drug use problems modify their social group.     

The Making of Multiple Personality Disorder: A Social Constructionist View

This article explores the social construction of multiple personality disorder by analyzing professional agreements about the nature of the diagnosis, while locating these within their historical and cultural context. First, a historical review of the disorder traces various overlapping streams of discourse that have shaped the construction of the diagnosis. This is followed by a cross-cultural comparison of MPD and dissociative phenomena in several non-Western societies. The article concludes with some reflections on the cultural meanings of MPD in contemporary America.     

Schizotypal Personality Disorder: A Clinical Social Work Perspective

Schizotypal personality disorder (SPD) is considered to be a “schizophrenia spectrum disorder” as evidenced in part by its cross-listing in that chapter of the DSM-5. SPD is considered to be a condition with limited potential for positive change because one of its major features is the presence of a biologically based cognitive deficit. This assumption, however, is an example of the medical model’s creating a bias against psychosocial features that are always involved in character development. The social work profession’s bio-psycho-social perspectives focus more comprehensively on all features of the condition and promote a more optimistic view of clients’ change potentials. The purposes of this paper are to examine SPD from a social work perspective and to demonstrate, with a case example, how effective intervention can be organized and delivered.     

Borderline Personality Disorder: Foundations of Treatment

The move from social work practitioner to supervisor can cause a crisis in identity for some social workers, a point at which professional values, roles and commitment are questioned and re-analysed. Yet it is an area in which there appears to be little written to assist the worker to normalise their fears and anxieties, or to assist with making the process smoother for both supervisor and supervisee. Drawing on practice experience in a range of health and community service settings, the present study will examine some of the feelings, issues, challenges and dilemmas faced by new social work supervisors. It will also explore the preparation of supervisors, the use of power in the supervisory relationship and the need for training. It will then discuss tips and conditions for improving the supervisory relationship.     

Borderline Personality Disorder and Access to Services: A Crucial Social Justice Issue

A diagnosis of Borderline Personality Disorder (BPD) can significantly affect access to services. Two Australian approaches to addressing this crucial social justice issue are compared: Project AIR (Affect Integration and Recovery), exemplifying changes within the existing psychiatric paradigm; and Adults Surviving Child Abuse's Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Changes within the existing paradigm do not address stigma and fragmented services that create barriers to service. By comparison, the Guidelines represent a trauma informed perspective that recognises underlying complex trauma for most with the BPD diagnosis. Implications for services are discussed.     

Relationship Between Childhood Sexual Abuse and Borderline Personality Disorder in Women Psychiatric Inpatients

The rclationshp between childhood sexual abuse (CSA) and borderline personality disorder (BPD) in 50 women psychiauic inpatients was examined. Inpatienfs were inletviewed using he Diagnostic Interview for Borderlines (Revised) (DIB-R). Women sexually abused as children (n = 30) scored significantly higher than those who were not (n = 20) on the total DIB-R and three of its four section scores. Women sexually abused as children were significantly more likely to have a definite diagnosis of BPD than women not sexually abused as children. who largely exhibited symptom patterns indicative of diagnoses other than BPD. An unexpected finding was that women sexually abused as children were more likely to have eating disorders than those who were not. Treatment for borderlines should explicilly address and validate the tremendous consequences of CSA on etiology and course of symptoms.     

Relationship Quality and Stability in Couples When One Partner Suffers From Borderline Personality Disorder

The main goal of the present study was to examine and compare the psychosocial functioning of 35 couples including a woman diagnosed with borderline personality disorder (BPD) to that of a nonclinical control sample of 35 couples. The BPD status of women from the clinical group and the prevalence of personality disorder in their partner were ascertained through the SCID-II. Participants completed self-report measures of couple functioning. A majority of couples in which the woman suffered from BPD (68.7%) evidenced frequent episodes of breakups and reconciliations and, over an 18-month period, nearly 30% of these couples dissolved their relationship. Nearly half of the men involved in a romantic relationship with a woman suffering from BPD met criteria for one personality disorder or more. As compared with nonclinical couples, clinical couples showed lower marital satisfaction, higher attachment insecurity, more demand/withdraw communication problems, and higher levels of violence.     

Dangerous and severe parenting disorder? Personality disorder,parenting and new legal proposals

The Government has proposed new legal measures for the management of people with personality disorders who are dangerous to others. In this paper, it is argued that there is no reason why these proposed measures should not apply to those individuals with personality disorders who are parents and present a severe risk of harm to their own children. New measures that provided a legal and clinical framework for the provision of assessment and possible therapy for personality disordered parents who pose a risk to their children would ful?l a real need which is not being met. Copyright © 2003 John Wiley & Sons, Ltd.     

Schizoid Personality Traits Among the Homeless Mentally Ill: A Quantitative and Qualitative Report

This paper examines the interplay among schizoid personality traits, chronicity of homelessness, and engagement in treatment in a homeless mentally ill population. Both qualitative and quantitative information will be provided about a sample of 125 homeless mentally ill individuals receiving psychiatric treatment in a comprehensive services drop-in clinic. Naturalistic observations and a case vignette suggested that schizoid traits were prevalent and may have been playing a role in treatment engagement and chronicity of homelessness. This hypothesis was tested using quantitative research methods. The results showed that schizoid personality disorder and schizoid personality traits were prevalent in the sample. The presence of schizoid traits was positively correlated with chronicity of homelessness. Further, two schizoid traits (being content without sexual involvement with others, and lacking close friends or confidants) were positively correlated with remaining in treatment at 3 months. Implications of these findings for future research and treatment design will be discussed.