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).     

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.     

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.     

Confronting Myths and Stereotypes About Borderline Personality Disorder

SUMMARY

The clinician treating a patient with borderline personality disorder (BPD) is often faced with complicated challenges, from making and communicating an accurate diagnosis, to implementing an appropriate, informed plan for treatment. Myths and stereotypes about BPD, and the individuals who may carry the diagnosis, likely complicate effective recognition and treatment of the disorder. BPD has been a controversial diagnosis among clinicians since its inception, and it is poorly understood among the general public. Pressures to avoid an explicit exploration of the diagnosis stemming from myths and stereotypes about the disorder can come from a number of sources, including other clinicians, family members and patients themselves. The results of minimizing or ignoring the contribution of borderline pathology may be detrimental. Clinical decisions based on outmoded thinking about diagnosis, prognosis, treatment efficacy, and availability of resources may deny patients optimal care. Integrating current findings into consideration of a BPD diagnosis and design of appropriate treatment, free of misconceptions about the condition, may help limit the untoward effects associated with failure to appreciate elements of borderline personality.     

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.     

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.     

A Review of the Effectiveness and Mechanisms of Change for Three Psychological Interventions for Borderline Personality Disorder

The therapeutic uncertainty common in much of the early literature on borderline personality disorder (BPD) has given way to a growing research base with findings indicating the effectiveness of a number of psychological treatments. This article will review three major evidence-based treatments for BPD: dialectical behavior therapy, schema-focused therapy and mentalization-based treatment. While not a panacea, these treatments have provided, to differing degrees, a reasonable level of evidence indicating therapeutic effectiveness. The evidence base for each of these models is discussed as well as possible mechanisms of change. The article highlights similarities between the differing modalities as well as the features that distinguish the models. The article contends that increasing mentalization skills may be a common underlying factor in all treatments for individual with BPD. The authors conclude by discussing the difficulties and potential benefits of treatment integration.     

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.     

Relationship Quality Among Young Couples from an Economic and Gender Perspective

Less than a third of married couple households in the United States are composed of families with one breadwinner. This is a stark contrast to a mere 40 years ago when men were the primary breadwinner for the majority of households. The goal of this study was to determine how the perception of household chores is related to relationship quality. Specifically we wanted to determine how perception of household chores is related to relationship quality reported by partners from a traditional economic and a gender role theory perspective. Using data from the National Longitudinal Survey of Youth, 1986 cohort, results indicate that perceived unfairness in household division of chores was predictive of women’s relationship quality, but not men’s. Arguments about affection and money were predictive of relationship quality for both genders.     

Economic Factors and Relationship Quality Among Young Couples: Comparing Cohabitation and Marriage

Are economic resources related to relationship quality among young couples, and to what extent does this vary by relationship type? To answer these questions, we estimated regression models predicting respondent reports of conflict and affection in cohabiting and married partner relationships using the National Longitudinal Study of Youth, 1997 (NLSY97, N = 2,841) and the National Longitudinal Study of Adolescent Health (Add Health, N = 1,702). We found that economic factors are an important predictor of conflict for both married and cohabiting couples. Affection was particularly responsive to human capital rather than short‐term economic indicators. Economic hardship was associated with more conflict among married and cohabiting couples.     

Personality Similarity-Dissimilarity and Underlying Psychopathology in Couples Seeking Marital Counseling

Two hypotheses related to the conceptualization of marriage as an interaction relationship and marital dysfunction as interpersonal pathology were tested empirically. Thirty first-married couples asking specifically for marital counseling from a community counseling service were administered Cattell's Sixteen Personality Factor Questionnaire. Husband and wife inter-correlations on each of the 16 first order and 2 second order factors were derived. Male and female mean sten scores on Neuroticism and Psychoticism were also derived. Data analysis revealed support for the second but not the first hypothesis.     

Trajectories of Interracial Heterosexual Couples: A Longitudinal Analysis of Relationship Quality and Separation

Minimal research has examined interracial couples’ relationship satisfaction and dissolution patterns over time. Using dyadic data across 8 years, we examined potential differences in relationship quality trajectories through latent growth curve modeling with 1,336 couples as well as differential risks for relationship dissolution through logistic regression between same‐race and interracial relationships using a different subset of 2,370 couples. Results indicated that women in interracial relationships were significantly lower in initial relationship quality than women in same‐race relationships. Further, interracial couples of Black‐Hispanic partnerings were twice as likely to separate across 8 years than same‐race couples. These results suggest that despite interracial relationships not substantively differing from same‐race couples in trajectories of relationship quality, specific Black‐Hispanic interracial couples are at a higher risk of eventual separation.     

Sexual Satisfaction and Relationship Satisfaction in Dating Couples

Abstract

This study assessed the merits of an amended Interpersonal Exchange Model of Sexual Satisfaction (IEMSS; Lawrance & Byers, 1992, 1995) that includes a measure of relationship communality, a construct not adequately captured by existing exchange models of sexual/relationship satisfaction. A total of 189 undergraduates (102 female) in sexually active dating relationships completed measures of sexual satisfaction, relationship satisfaction, favorability of sexual exchanges, and the extent to which their romantic relationships were characterized by mutually communal behaviors (i.e., relationship communality). Analyses revealed that relationship communality made a small but unique contribution to sexual satisfaction and a large contribution to relationship satisfaction, even after controlling for sexual satisfaction and favorability of sexual exchanges. Implications for understanding the dynamics of sexually active dating relationships are discussed.     

An Exploration of Common Elements in Dialectical Behavior Therapy,Mentalization Based Treatment and Transference Focused Psychotherapy in the Treatment of Borderline Personality Disorder

A number of leading practice models have been found to be effective in the treatment of Borderline Personality Disorder (BPD). These include Dialectical Behavior Therapy, Transference Focused Psychotherapy and Mentalization Based Treatment. This article reviews the current evidence for these dominant practice models, and concludes that no single treatment has been found to be consistently superior in the treatment of BPD. Given the lack of evidence priviledging one single model of treatment, and the fact that it is not always feasible or desirable for social workers to practice using pure manualized treatment models, there is a need to develop more integrative approaches to treatment with this vulnerable population. By highlighting specific similarities and differences between practice techniques, this paper attempts to pave the way toward developing a more integrative treatment approach to working with individuals with BPD, an approach where interventions are selected based on appraisal of the evidence, clinical expertise, and client need.     

The Association Between Partner Enhancement and Self‐Enhancement and Relationship Quality Outcomes

The purpose of this research was to understand in greater detail, using 2 samples (Study 1 N = 4,881 heterosexual couples; Study 2 N = 335 heterosexual couples who completed the Relationship Evaluation Questionnaire), how partner or self‐enhancement patterns differentially influence relationship outcomes. A multivariate analysis of covariance was conducted comparing 4 outcome measures for different couple types in which individuals rated the partner higher, the same, or lower than they rated themselves on affability. Couples in which both individuals perceived themselves as more affable than the partner experienced poorer results on the relationship outcome measures, whereas couples in which both individuals perceived the partner's personality as more affable than their own experienced more positive relationship outcomes. Additional analyses with structural equation models demonstrated the consistent influence of enhancement measures on relationship outcomes for cross‐sectional and longitudinal samples.     

Perceptions of Emotional Closeness and Commitment Among African American Couples: Implications for Promoting Relationship Stability

This study investigated how married and cohabiting African Americans define and experience emotional closeness and commitment because these processes have been shown to be directly linked to relationship stability. Thirty married and 30 cohabiting African American couples participated. Couples were between the ages of 21 and 45 years and had been in their relationship between 3 and 15 years. Interviews were conducted with the couples in their homes and were aimed at yielding a co-construction of couples’ views of these constructs. Specifically, this co-construction involved an examination of the ways men and women in married and cohabiting relationships define and experience emotional closeness and commitment. Special attention was devoted to examining the themes elicited from these interviews and illuminate the specific ways in which married and cohabiting African American couples consider emotional closeness and commitment. In general, few differences were apparent in their perceptions of emotional closeness. However, married couples were more likely to report that commitment played a large role in their decision to be together. Conversely, cohabiting couples expressed different views of commitment, often stating that commitment played a minimal role in their relationship or that they experienced commitment in ways that were not linked to the legal affirmation of their relationship. Implications for future research and practice include the importance of pinpointing the individual and cultural deterrents that affect the relationship stability of low income African American couples.     

Marital Conflict in Older Couples: Positivity,Personality, and Health

The authors examine the implications of health and personality characteristics for late‐life marital conflict using data from the 2010–2011 wave of the National Social Life Health and Aging Project, a nationally representative study with data on both partners in 955 marital and cohabitational dyads. Using these data, they relate characteristics of husbands to characteristics of their wives and vice versa. Wives with husbands in fair or poor physical health were more likely to report high levels of marital conflict, but the reverse was not true. Similarly, wives reported more conflict when their husbands were high on Neuroticism, high on Extraversion, and low on a new measure the authors call Positivity. The findings suggest noteworthy gender differences between men and women in the associations between individual characteristics and levels of marital conflict. The authors point to differences between husbands' and wives' marital roles as a contributor to these differences.     

Cohabitation,Relationship Quality,and Desistance From Crime

Although the empirical links between marriage and desistance are well established, very little is known about the degree to which cohabitation is associated with changes in criminal behavior. This is a significant oversight given that, among some segments of the population, cohabitation has become more common than marriage. In this article, the author investigated the links between cohabitation and desistance from crime. In doing so, particular attention was paid to the possibility that similarities between the apparent effects of marriage and cohabitation are obscured by variations in relationship quality and the increasing tendency for cohabitation to precede marriage. Analyses based on the National Longitudinal Survey of Youth 1997 (N = 3,232) indicate that cohabitation is associated with reductions in the rate of property and drug offending, but not the termination of violent, property, or drug offending. By contrast, marriage is consistently associated with large reductions in the rate of offending across the 3 crime categories as well as the abandonment of those crimes. These results provide greater insight into the links between adult family relationships, such as cohabitation and marriage, and desistance from crime.