BPD and the Need for Community

SUMMARY

This chapter emphasizes the importance of a community/systems approach in managing the treatment of individuals with borderline personality disorder. The natural systems existing around patient, clinician and family are recognized, and we examine how working teams are built from these systems. The Borderline Center at McLean Hospital is used as an illustration of an organizational model that utilizes the concept of the “holding environment” (Winnicott, 1965) to provide comprehensive services to borderline patients and their families. As patients move through various levels of care and exhibit typical borderline symptomatology, the importance of communication and coordination on the part of the treatment team is highlighted. This chapter also will illustrate the essential ways in which patients, clinicians and families are able to join together in the treatment of this disorder, with special emphasis on the necessity of family involvement. We also will examine how the treatment teams provide the foundation for larger communities, which are critical to sustaining the ongoing work of its members.     

(Mis) Representations of the Long-Term Effects of Childhood Sexual Abuse in the Courts

SUMMARY

This study addresses the (mis) representations made by pro-false memory attorneys and expert witnesses in court regarding the long-term effects of childhood sexual abuse (CSA). Five pro-false memory positions were identified: (1) there is no causal connection between CSA and adult psychopathology; (2) the evidence is insufficient; (3) CSA does not cause specific trauma-related outcomes like borderline and dissociative identity disorder; (4) other variables than CSA explain the variance of adult psychopathology; and (5) the long-term effects of CSA are general and non-specific. Examining the testimony revealed that such pro-false memory testimony was based solely on a partial understanding of retrospective data and that pro-false memory experts do not cite the more recent prospective data. Reviewing the totality of the scientific evidence demonstrates that such pro-false memory testimony is inaccurate and has the potential of misleading the jury. Prospective studies provide sufficient evidence to causally link CSA to a number of areas of adult psychopathology including multiple, co-morbid psychiatric conditions, and possibly to link early parent-infant attachment pathology to the development of borderline and dissociative identity disorder.     

(Mis) representations of the long-term effects of childhood sexual abuse in the courts

This study addresses the (mis) representations made by pro-false memory attorneys and expert witnesses in court regarding the long-term effects of childhood sexual abuse (CSA). Five pro-false memory positions were identified: (1) there is no causal connection between CSA and adult psychopathology; (2) the evidence is insufficient; (3) CSA does not cause specific trauma-related outcomes like borderline and dissociative identity disorder; (4) other variables than CSA explain the variance of adult psychopathology; and (5) the long-term effects of CSA are general and non-specific. Examining the testimony revealed that such pro-false memory testimony was based solely on a partial understanding of retrospective data and that pro-false memory experts do not cite the more recent prospective data. Reviewing the totality of the scientific evidence demonstrates that such pro-false memory testimony is inaccurate and has the potential of misleading the jury. Prospective studies provide sufficient evidence to causally link CSA to a number of areas of adult psychopathology including multiple, co-morbid psychiatric conditions, and possibly to link early parent-infant attachment pathology to the development of borderline and dissociative identity disorder.     

Examining the relationship between childhood sexual abuse and borderline personality disorder: does social support matter?

The relationship between childhood sexual abuse and borderline personality disorder is a prominent issue in the etiological research on borderline personality disorder. This study further explored the relationship between childhood sexual abuse and the development of borderline personality features while evaluating the moderating role of a primary social support source in a sample of 290 female undergraduate students enrolled at a major southeastern university. Consistent with previous research, retrospective self-reports of childhood sexual abuse and low social support were both positively correlated with current borderline personality features. It was hypothesized that the presence of a supportive relationship at the time the childhood sexual abuse occurred would moderate the relationship between childhood sexual abuse and borderline personality features. This moderation hypothesis was not supported in the current study, but post-hoc analyses reveal the need to further examine how we define social support following childhood sexual abuse. This research is a stepping stone toward the prevention of borderline personality disorder following childhood sexual abuse.     

Examining the Relationship between Childhood Sexual Abuse and Borderline Personality Disorder: Does Social Support Matter?

The relationship between childhood sexual abuse and borderline personality disorder is a prominent issue in the etiological research on borderline personality disorder. This study further explored the relationship between childhood sexual abuse and the development of borderline personality features while evaluating the moderating role of a primary social support source in a sample of 290 female undergraduate students enrolled at a major southeastern university. Consistent with previous research, retrospective self-reports of childhood sexual abuse and low social support were both positively correlated with current borderline personality features. It was hypothesized that the presence of a supportive relationship at the time the childhood sexual abuse occurred would moderate the relationship between childhood sexual abuse and borderline personality features. This moderation hypothesis was not supported in the current study, but post-hoc analyses reveal the need to further examine how we define social support following childhood sexual abuse. This research is a stepping stone toward the prevention of borderline personality disorder following childhood sexual abuse.     

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.     

Body-Related Emotions in Posttraumatic Stress Disorder Following Childhood Sexual Abuse

Traumatic experiences are associated with emotions such as anxiety, shame, guilt, disgust, and anger. For patients who have experienced child sexual abuse, these emotions might be triggered by perceptions of their own body. The aim of this study was to investigate the extent of the association of the body to traumatic experiences and to discern the emotions linked to trauma-associated body areas. Ninety-seven female participants were assigned to four groups: post-traumatic stress disorder following child sexual abuse with co-occurring borderline personality disorder, post-traumatic stress disorder following child sexual abuse without co-occurring borderline personality disorder, borderline personality disorder without post-traumatic stress disorder, and healthy controls. Participants rated 26 body areas regarding their association with trauma and 7 emotions. Emotions were assessed by questionnaires. Results suggest that specific areas of the body are associated with trauma and linked to highly aversive emotions. In post-traumatic stress disorder patients, the areas associated with highly negative emotions were the pubic region and inner thighs. Thus, the patient’s body may act as a trigger for traumatic memories.     

Severe borderlines and self psychology

This paper will discuss work with a woman diagnosed as having borderline personality disorder because of classic symptoms of intense unstable affect, recurrent suicidality, self-mutilation, and primitive defensive organization. Once a selfobject transference tie was established, the borderline symptoms remitted. Discussion of this case will focus on the clinical application of concepts from the field of psychoanalytic self psychology, particularly the concepts of self-object functions and intersubjectivity, in work with patients diagnosed as borderline.     

Where is the border? Current issues in the diagnosis and treatment of the borderline

Differential diagnosis of subtypes of individuals meeting criteria for borderline personality disorder has received only limited attention in the recent social work literature on the borderline. Whether the borderline disturbance is moderate or severe, the condition may overlap with several borders, suggesting that borderline personality disorders are a heterogeneous group of conditions. Discrimination between different subtypes is necessary in order to help clients obtain the optimum combination of treatments.     

The borderline/schizoid marriage: the holding environment as an essential treatment construct

The borderline/schizoid marital constellation is the prominent constellation among borderline patients on a long-term inpatient unit. Treatment of this marital constellation, in which each spouse has a severe personality disorder, requires application of the concept of the holding environment as an essential treatment construct, with the therapist as manager of the holding environment. This paper explicates the means of management. With the proposed treatment approach and a long-term treatment orientation, seemingly hopeless cases can improve.     

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.     

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.     

Critical review of the concept of the borderline child

The concept of the borderline child is reviewed in this paper. Questions are raised about the generally held assumption that a similarity exists between the dynamics of borderline children and those of borderline adults. It is suggested that no data is currently available to substantiate such a view. Further questions are raised about the assumption that the etiology of the disorder in childhood is based on poor or improper nurturance. A working definition of the concept of the borderline child is proposed that is free of preconceptions as to the etiology of the dysfunction. A hypothesis is presented for further investigation that at least some borderline children's etiology may be found in the presence of a minimal brain dysfunction or a severe learning disability.     

Psychological assessment through performance-based techniques and self-reports: a case study of a sexually abused girl at preschool age

We investigated the implicit psychological and behavioral consequences of sexual abuse in an adolescent girl who suffered child sexual abuse at preschool age in this case report. We report the manifestations of this abuse on her personality and psychological functioning using a structured clinical interview and a comprehensive psychological battery including the Beck Anxiety Inventory, the Beck Depression Inventory, the Standard Progressive Matrices, Rorschach Ink Blots, and the Schema Mode Inventory. These investigations were useful in formulating both a diagnosis and a management plan. The girl fulfilled diagnostic criteria for a major depressive episode and borderline personality disorder. This combination of psychological testing may be useful in establishing an accurate multiaxial diagnosis and for understanding the behavioral and psychological sequelae of child sexual abuse in similar cases. The study further suggests that schema-focused therapy is a useful therapeutic tool for individuals who have suffered child sexual abuse at an early age and who have borderline personality disorder.     

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.     

Psychological Assessment through Performance-Based Techniques and Self-Reports: A Case Study of a Sexually Abused Girl at Preschool Age

We investigated the implicit psychological and behavioral consequences of sexual abuse in an adolescent girl who suffered child sexual abuse at preschool age in this case report. We report the manifestations of this abuse on her personality and psychological functioning using a structured clinical interview and a comprehensive psychological battery including the Beck Anxiety Inventory, the Beck Depression Inventory, the Standard Progressive Matrices, Rorschach Ink Blots, and the Schema Mode Inventory. These investigations were useful in formulating both a diagnosis and a management plan. The girl fulfilled diagnostic criteria for a major depressive episode and borderline personality disorder. This combination of psychological testing may be useful in establishing an accurate multiaxial diagnosis and for understanding the behavioral and psychological sequelae of child sexual abuse in similar cases. The study further suggests that schema-focused therapy is a useful therapeutic tool for individuals who have suffered child sexual abuse at an early age and who have borderline personality disorder.     

Borderline personality disorder: Psychosocial considerations and rehabilitation implications

The article describes the medical and psychosocial aspects of borderline personality disorder, a common and sometimes severe psychiatric condition marked by emotional instability and problems with interpersonal relationships. Medication, psychosocial and other treatment issues are discussed within the context of the rehabilitation counselor's role in providing vocational services for people with borderline personality disorder.     

Eating Disorders and Additional Psychopathology in Women

Eating disordered individuals are often found to exhibit additional psychopathology such as depression, anxiety, substance abuse, and "borderline symptoms" such as self-injury and suicidality. This pilot study examined 535 female subjects with eating disorders to determine the relationship between such additional psychopathology and a prior history of sexual abuse. While few differences were found on general psychiatric/psychological symptoms as measured by the SCL-90-R, subjects that reported a history of sexual abuse were found to have more prior suicide attempts and hospitalizations, and more frequent self-injury and alcohol problems. These findings suggest that symptoms seen in some eating disorder patients that are frequently described as "borderline" may be indicators for a history of sexual abuse.     

Book reviews

Conclusion The Narcissistic and Borderline Disorder is an unusually thought provoking and useful book because it encourages the reader to compare and evaluate the work of several major theorists who have attempted to conceptualize narcissistic and borderline pathology. In spite of my disagreement with some specific formulations, I think that for the most part Masterson's choice of separation-individuation theory as an organizing framework for describing these disorders is quite effective in providing a logically consistent developmental context in which clinical phenomena can be studied and understood. Regardless of one's theoretical orientation, this book, is notable for its large measure of clinical wisdom, especially Masterson's observations about: (1) The Tallionic Impulse, in which he discusses how borderline patients attempt to injure the object by attacking the self; (2) The False Self, in which he outlines how the patient's compliance with the therapist's unspoken expectations may become a major resistance to treatment; (3) the hopelessness helplessness, and despair that narcissistic and borderline patients predictably experience as they begin to separate and thereby confront the existential loneliness of forging an autonomous identity; and (4) the confusion and discouragement that therapists experience when faced with the patient's despair at the very moment when the patient has initiated some constructive change.