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.     

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).     

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.     

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.     

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.     

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.     

A specific therapeutic approach to suicide risk in borderline clients

One of the most difficult clinical challenges facing social workers today is suicidal behavior in clients with borderline personality disorder. This article reviews the various types of suicidal behavior exhibited by these clients, including self-destructive behavior and overt suicide attempts. Management of these behaviors is essential if treatment is to be successful. Frameworks are offered for understanding and managing both kinds of behavior.     

A Pilot Study to Explore the Influence of the ‘Safety First Assessment Intervention’ on the Family Environment

The family environment is considered an important influence on a young person's well‐being. The ‘Safety First Assessment Intervention’ is a model of care that considers and incorporates the importance of family environment when assessing and managing distressed young people. This pilot study explores the influence of the ‘Safety First Assessment Intervention’ on the family environment of young people referred to Child and Adolescent Mental Health Services. A pre‐ and post‐design was used, with families completing the Family Survey before and after their assessment/intervention. The Family Survey was correlated with a validated measure of family function, the APGAR, and pre‐intervention. Significant changes in multiple dimensions of family environment, including reduced level of distress for the adult, increased level of distress for the young person, improved sense of how the family felt the adult was managing currently, and improved confidence in family communication were found. There was no significant change in how the adult understood their role in helping the young person manage their distress. A thematic analysis showed trends in the current concerns for young people and adults as well as the difficulty young people in distress have in identifying their strengths. This pilot study demonstrates that the ‘Safety First Assessment Intervention’ can influence the family environment in a positive way and highlights the importance of using a family‐based approach for distressed young people.     

Kernberg Versus Kohut: A (Case) Study in Contrasts

In this paper, the main concepts of Otto Kernberg and Heinz Kohut—two theorists who have greatly influenced clinical social work practice with severely disturbed patients—are presented, and then compared by using a case from the practice of the author. The case illustrates the value of utilizing some of the treatment principles put forward by Kernberg and Kohut without becoming too wedded to either of the overall treatment approaches they have formulated. Some aspects of the manner in which the practitioner determines when the treatment approach needs to be modified—to avoid the pitfalls of either being too wedded to an approach or too eclectic—are discussed as well.     

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.     

Boundary Ambiguity and Borderline Personality Traits: Implications for Treatment for Adolescent Girls in Foster Care

This article explores the relationship between boundary ambiguity and borderline personality traits in adolescent girls in foster care. Boundary ambiguity is a family systems concept: family members are uncertain about who is in or out of the family—in either psychological or physical presence or absence. In foster care, it can be assumed that an adolescent girl has experienced trauma significant enough to be removed from her family. The connection between early childhood trauma and attachment disruption in addition to the connection between insecure/disorganized attachment and borderline personality disorder leads to the conclusion that these same adolescents are at high risk for developing borderline personality traits. The sample consists of 40 caseworkers from New England’s child protection departments and therapists from residential programs working with adolescent girls. They completed the Shedler-Westen Assessment Procedure for Adolescents to determine the presence of personality disruption as well as a variation of Pauline Boss’s Boundary Ambiguity Scale #1, and demographic questionnaires. The results find a significant correlation between boundary ambiguity and borderline personality traits. These findings provide directions for future research in clinical treatment and child welfare policy making.     

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.     

An Evidence-Based Approach to Managing Suicidal Behavior in Patients with BPD

SUMMARY

This review will suggest an evidence-based approach to managing suicidal patients with borderline personality disorder (BPD). Many principles currently used in practice have little basis in empirical data. And some approaches used to manage chronic suicidality, particularly the emphasis on “safety,” may actually be counter-productive.     

Identifying Mental Disorder from the Faces of Women with Borderline Personality Disorder

Although appearance-based cues can help to diagnose physical illness, visual manifestations of mental disorder may be more elusive. Here, we investigated whether individuals could distinguish women with a serious mental disorder (borderline personality disorder) from demographically- and IQ-matched non-psychiatric controls. Participants rated mentally ill targets as more likely to have a mental disorder from photos more accurately than chance, despite not believing that such judgments were possible. The configuration of facial cues played an important role in these judgments, as interfering with the spatial relationships between facial features reduced participants’ accuracy to chance guessing. Further investigation showed similar results when participants rated the targets for specific mental disorders (borderline personality disorder, major depressive disorder) and rated the mentally ill targets as more depressed, angry, anxious, disgusted, emotionally unstable, distressed, and less happy. Moreover, the depression ratings significantly correlated with the targets’ actual depressive symptoms. Thus, individuals may be able to infer aspects of mental disorder from minimal facial cues.     

Choosing Family: Meaning and Membership in the Lesbian Family of Choice

SUMMARY

This conceptual/theoretical article uses the psychodynamic Self Psychology model for the development of a vital, harmonious, and cohesive self to describe and understand the psychological importance of family for lesbian women. How can a healthy lesbian self be developed, nurtured, and maintained in an oppressive sexist and homophobic world? Family relationships are shown to fulfill the three fundamental psychological functions that sustain the lesbian self. In the absence of genetic and/or legal criteria, the basis on which someone is considered “family” is explored.     

Family Medicine Research:

No abstract available for this article.