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Borderline Personality Disorder

  • 1.00 Therapies
    • 1.10 Psychotherapy
      • Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.[1] Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years.
      • Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD[2] although drop-out rates may be problematic.[3]
    • 1.20 Dialectical Behavioral Therapy
      • Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority.
      • The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.
      • DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.[4]
      • Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.[5][6] although whether it has additional efficacy in the overall treatment of BPD appears less clear.[7] Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.[8]
    • 1.30 Schema Therapy
      • Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences.
      • It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than Transference-Focused Psychotherapy, with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement.[9][10] Another very small trial has also suggested efficacy.[11]
    • 1.40 Cognitive Behavioral Therapy
      • Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception, and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[12]
      • Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.
    • 1.50 Marital or Family Therapy
      • Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem-solving, and provide support to family members in dealing with their loved one's illness.
      • Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents.
      • Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.[2]
    • 1.60 Psychoanalysis
      • Traditional psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms[13] although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.[14]
    • 1.70 Transference Focused Psychotherapy
      • Transference-Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In the session, the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear.
      • Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,[15] and that TFP in comparison to Dialectical Behavior Therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style.[16] Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.[17] Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.[9]
    • 1.80 Cognitive Analytic Therapy
      • Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use by individuals with BPD with mixed results.[18]
  • 2.0 Medication
    • 2.1 Antidepressants
    • 2.2 Antipsychotics
      • The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.[20] Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with a borderline personality disorder (BPD).
      • Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably Tardive dyskinesia (TDK).[21] Atypical antipsychotics are also known for often causing considerable weight gain, with associated health complications.[22]
      • Dosage: One meta-analysis of 14 prior studies has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.[23]
  • 3.0 Mental Health Services and Recovery
    • 3.1 Combining Pharmacotherapy and Psychotherapy
      • In practice, psychotherapy and medication may often be combined but there is limited data on clinical practice.[24] Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counseling, medication, and psychotherapy.
      • One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic Olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, although they also experienced weight gain and raised cholesterol.
      • Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.[25]
    • 3.2 Difficulties in Therapy
      • There can be unique challenges in the treatment of BPD, eg. hospital care.[26] In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist may contribute to.[27]
      • Some psychotherapies, for example, DBT, were developed partially to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to adverse effects, with drop-out rates of between 50% and 88% in medication trials.[28] Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.[29]
    • 3.3 Other Strategies
      • Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both. Some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area and that, in some cases, it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.[30]
      • Numerous other strategies may be used, including alternative medicine techniques (see List of branches of alternative medicine), exercise and physical fitness including team sports, occupational therapy techniques including creative arts, having structure and routine, employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.[31]
      • Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialized in the treatment of severe personality disorder.[32]
      • Psychiatric rehabilitation services aimed at helping people with mental health problems to reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion of people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.
      • Data indicates that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two.[33] A longitudinal study found that six years after being diagnosed with BPD, 56% showed good psychosocial function compared to the 26% at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner, at least one parent, good work/school performance, a sustained work/school history, good global functioning, and good psychosocial functioning.[34]
  1. ↑ Aviram, R.B.; D.J. Hellerstein, J. Gerson, et al. (May 2004). "Adapting supportive psychotherapy for individuals with Borderline personality disorder who self-injure or attempt suicide". J Psychiatr Pract 10 (3): 145-55. Retrieved on 2007-09-23.
  2. ↑ 2.0 2.1 Gunderson, J.G. MD (2006-04-10). ""Borderline Personality Disorder - Psychotherapies". American Medical Network. Retrieved on 2007-09-23.
  3. ↑ Hummelen, B.; T. Wilberg, S. Karterud (January 2007). "Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy". Int J Group Psychother 57 (1): 67-91. Retrieved on 2007-09-23.
  4. ↑ Murphy, E. T. PhD; J. Gunderson MD (January 1999). "A Promising TreatmentBorderline Personality Disorder". McLean Hospital Psychiatric Update. Retrieved on 2007-09-23.
  5. ↑ Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "Dialectical behavioral therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands". British Journal of Psychiatry (182): 135-40. Retrieved on 2007-09-23.
  6. ↑ Linehan, M.M.; K.A. Comtois, A.M. Murray, et al. (July 2006). "Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder". Archives of General Psychiatry 63 (7): 757-66. Retrieved on 2007-09-23.
  7. ↑
  8. ↑ Hazelton, M.; R. Rossiter, J. Milner (February - March 2006). "Managing the 'unmanageable': training staff in the use of dialectical behavior therapy for borderline personality disorder". Contemporary Nurse 21 (1): 120-30. Retrieved on 2007-09-23.
  9. ↑ 9.0 9.1 Giesen-Bloo, J.; R. van Dyck, P. Spinhoven, et al. (June 2005). "Outpatient psychotherapy for borderline personality disorder: a randomized trial of schema-focused therapy vs transference-focused psychotherapy". Archives of General Psychiatry 63 (6): 649-58. Retrieved on 2007-09-23.
  10. ↑ Darden, M. (2006-10-10). "New hope for an 'untreatable' mental illness". EurekAlert! Retrieved on 2007-09-23.
  11. ↑ Nordahl, H.M., T.E. Nysaeter (September 2005). "Schema therapy for patients with borderline personality disorder: a single case series". J Behav Ther Exp Psychiatry 36 (3): 254-64. Retrieved on 2007-09-23.
  12. ↑ Davidson, K.; J. Norrie, P. Tyrer, et al. (October 2006). "The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial". Journal of Personality Disorders 20 (5): 450-65. Retrieved on 2007-09-23.
  13. ↑ "Borderline Personality Disorder". Retrieved on 2007-09-23.
  14. ↑ Bateman, A.; P. Fonagy (January 2001). "Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up". American Journal of Psychiatry 158 (1): 36-42. Retrieved on 2007-09-23.
  15. ↑ Levy, K.N.; J.F. Clarkin, L.N. Scott, et al. (2006). "The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy". Journal of Clinical Psychology (62): 481-501. Retrieved on 2007-09-23.
  16. ↑ Levy, K.N.; K.B. Meehan, K.M. Kelly, et al. (2006). "Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder". Journal of Consulting and Clinical Psychology (74): 1027-1040.
  17. ↑ Clarkin, J.F. Ph.D.; K.N. Levy, Ph.D., M. F. Lenzenweger, Ph.D., et al. (June 2007). "Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study". The American Journal of Psychiatry (164): 922-928. doi:10.1176/appi.ajp.164.6.922. Retrieved on 2007-09-23.
  18. ↑ Ryle, A. (February 2004). "The contribution of cognitive analytic therapy to the treatment of borderline personality disorder". J Personal Disord 18 (1): 3-35. Retrieved on 2007-09-23.
  19. ↑
  20. ↑ Siever, L.J.; H.W. Koenigsberg (2000). "The frustrating no-man's-land of borderline personality disorder" (PDF). Cerebrum, The Dana Forum on Brain Science 2 (4). Retrieved on 2007-09-23.
  21. ↑ Casey, D.E. (1985). "Tardive dyskinesia: reversible and irreversible". Psychopharmacology Suppl (2): 88-97. Retrieved on 2007-09-23.
  22. ↑ Ruetsch, O.; A. Viola, H. Bardou, et al. (July - August 2005). "Psychotropic drugs induced weight gain: a review of the literature concerning epidemiological data, mechanisms and management". Encephale (4 Pt 1): 507-16. Retrieved on 2007-09-23.
  23. ↑ Grootens, K.P.; R.J. Verkes (January 2005). "Emerging evidence for the use of atypical antipsychotics in borderline personality disorder". Pharmacopsychiatry 38 (1): 20-3. Retrieved on 2007-09-23.
  24. ↑
  25. ↑ Simpson, E.B.; S. Yen, E. Costello, et al. (March 2004). "Combined dialectical behavior therapy and fluoxetine". Journal of Clinical Psychiatry 65 (3): 379-85. Retrieved on 2007-09-23.
  26. ↑ Kaplan, C.A. (September 1986). "The challenge of working with patients diagnosed as having a borderline personality disorder". Nurs Clin North Am 21 (3): 429-38. Retrieved on 2007-09-23.
  27. ↑ Aviram, R.B.; B.S. Brodsky, B. Stanley (October 2006). "Borderline Personality Disorder, Stigma, and Treatment Implications". Harvard Review of Psychiatry 14 (5). Retrieved on 2007-09-23.
  28. ↑ American Psychiatric Association (October 2001). "Practice Guideline for the Treatment of Patients With Borderline Personality Disorder". Am J Psychiatry.
  29. ↑ Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (2004). "Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission". Am J Psychiatry 161 (11): 2108-14. Retrieved on 2007-09-23.
  30. ↑ Warner, S.; T. Wilkins (2004). "Between Subjugation and Survival: Women, Borderline Personality Disorder and High-Security Mental Hospitals". Journal of Contemporary Psychotherapy 34 (3): 1573-3564. Retrieved on 2007-09-2].
  31. ↑ Flory, L. (2004). Understanding borderline personality disorder. London: Mind. Retrieved on 2007-09-23.
  32. ↑ Campling, P. (2001). "Therapeutic communities". Advances in Psychiatric Treatment (7): 365-372. Retrieved on 2007-09-23.
  33. ↑
  34. ↑ Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (February 2005). "Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years". J Personal Disord 19 (1): 19-29. Retrieved on 2007-09-23.
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