Borderline Personality Disorder
From Grief to Advocacy: A Mother's Odyssey
by Valerie Porr, M.A.
What do you do when the person you love the most on this earth is stricken
with an illness that so completely changes her behavior it seems as though she
has disappeared, leaving behind only a hollow shell; an illness that you know
nothing about; that your friends don't believe exists; that professionals don't
talk about; for which there is little or no explanatory literature; an illness
which even Oprah doesn't discuss? Borderline Personality Disorder (BPD) is such
an illness and is the diagnosis given to my only child.
At seventeen, my daughter ran away from home for the first time, revealing an
intense hatred for me that she said she had nurtured for years. She accused me
of child abuse. She was aided and abetted in this venture by a wealthy family
who took her in, hired a lawyer for her and took me to court for control of her
trust fund and her child support checks, all the while reciting a litany that
she is still repeating. The court papers implied that I was the sick one and she
was the victim who needed rescuing from me. I, on the other hand, had eight
diagnoses from the various "reputable" therapists who had seen my
daughter over the course of her adolescence. As it turned out, the previous
professional observations were all stepping stones leading to a diagnosis of
BPD. Sadly, this label explained both her history of impulsive behavior and her
letters and diary entries I later found, wherein acts and feelings were revealed
of which I was completely unaware.
Empowered by the court and further enabled by her hippie godfather, my
beloved daughter walked out of my life. I have not seen her for over five years.
She is now twenty three.
Grief has become a permanent part of my daily existence. Unfortunately, for
those of us whose children are thus afflicted, we are denied the solace of the
ordinary rituals and rites of mourning. We must learn to live with our loss and
disappointment as others live with physical disabilities.
This edition of The Journal in some ways represents my personal odyssey over
the past five and one half years in search of information, expertise and an
effective form of therapy that will help to restore some semblance of the child
I've lost-that can lift the gloom that pervades my life. On the pages that
follow you will be introduced to people I have met, lessons I have learned, and
circumstances that account for my evolution as a determined advocate for persons
with BPD and for their families.
Bewildered and deeply saddened when my child left, I read every available
book about BPD trying to understand and although I found the descriptions of the
illness to be accurate, the explanations given did not coincide with my
experiences with my daughter. Confused, feeling completely alone and hopeless, I
started a support group for family members of people with BPD. As family after
family joined our group and shared their histories, I found echoes of my own
pain. It seemed we had all been accused of some sort of child abuse. That was
the common denominator of most of our experiences. All of us had a child who
either loved us or hated us, who had rage attacks and bouts of depression, who
harmed themselves in myriad ways from self mutilation to attempted suicide to
gambling to sexual addiction to eating disorders; who were impulsive, lacked
emotional control or were substance abusers. In addition, these children of ours
rarely perceived themselves as having a problem. To hear them tell it they were
merely the victims of the behavior of others. The pain of seeing our children in
this condition was magnified by the professionals who didn't or couldn't help
them yet never hesitated to blame us for the problem. We, the parents, were made
to feel like destroyers of those we had brought into the world, loved and
At this point, through the efforts of a dedicated fellow advocate, John
Grelek, I had the good fortune to learn about the work of Dr. Marsha Linehan of
the University of Washington in Seattle. She had developed something called
Dialectical Behavioral Therapy (DBT) - a system of cognitive behavioral therapy
for the treatment of BPD with outcome studies showing its efficacy. Suddenly, in
her work, I found some answers to my questions and, for the first time, I felt
there was hope for my child and for others. It became my "mission" to
bring Dr. Linehan's work into the New York City Mental Health System.
With the help of key people in the city and state mental health systems, and
my loyal ally and mentor, Dr. Robert Trestman, in record time we applied for and
got funds to bring Dr. Linehan to NYC for a two day training conference that was
attended by 350 professionals. It was an extraordinary event, and one that Dr.
Trestman and I agreed would require appropriate follow up to insure any real
progress. With that in mind, we created an entity called TARA-APD-an acronym for
Treatment and Research Advancement Association for Personality Disorder. As a
non-profit organization it would be the voice that was needed for the support of
those suffering BPD and contending with the conflicts in today's changing world
of research and health delivery systems. We would no longer tolerate the
indignities that people with BPD and their families had historically been
subjected to by governmental and medical authorities who should know better.
As a child I had seen a film called "Gaslight" in which Ingrid
Bergman, an heiress who is newly married, remarks to Charles Boyer, her
ne'er-do-well husband, that the gaslights in their home seem to be dimming.
"No, they aren't darling," says Boyer, as he fawns over her, "You
are imagining things." Ingrid soon feels that she is going mad when, over
time, what she perceives as reality is not being validated by her doting
husband. The dimming gaslight is the perfect metaphor for the experience of
living with someone with BPD, and advocating for education, appropriate
treatment and research for this painful disorder.
The person suffering from BPD, a severe and persistent mental illness, may
appear completely "normal" and may often have the ability to act
"as if" he or she has no problems. In fact, many people with BPD
become professional actors. This "as if" ability of people with BPD
can be particularly devastating to those who love them.
I remember a night when my daughter locked herself in the bathroom after a
rage attack. I called the police. She kept the police waiting outside the door
for thirty minutes while I escalated to absolutely frantic concern. When she
finally emerged, dissociated from her rage, she acted with regal serenity
"as if" she were Grace Kelly. The police gave me that "raised
eyebrow" look to which I have since become accustomed. It is a look all too
familiar to families of people with BPD who feel foolish and embarrassed when
authorities arrive to assist with a problem that now seems not to be there. It
is "as if..."
If one combines the professional's attitudes toward people with BPD with the
ability of a high functioning person with BPD to act "as if " - one is
having dinner with Boyer and Bergman as the lights dim. The supportive family
member is frustrated and confused by the patient's demonstration of the ability
to effectively act out a denial of the illness, while the doctor minimizes or
avoids it with dismissal comments like, "She's just a teenager. She'll
outgrow it..." and the gaslights seem to dim, again.
The attitude of the psychiatric community towards BPD is very complex. Many
professionals fail to recognize BPD or try to avoid making the diagnosis. It is
a disorder-an illness-that polarizes professionals into non-professional
behavior which can then be called stigma or counter transference or just plain
"I can't stand this patient." The sense of frustration and of failure
which professionals experience when treating people with BPD makes some feel
uncomfortable, inadequate or ineffective. This is usually blamed on the patient
and, of course, on the family - bad patients from dysfunctional families.
NAMI, the National Alliance for the Mentally III, doesn't include BPD in its
advocacy efforts, as if they have decided "it is not a brain disease."
Current research findings in neurobiology and psychopharmacology disagree with
their unsubstantiated position, however, one can see how they justify it by
pointing out that, until now, BPD has been omitted from most epidemiological
studies, and the American Psychiatric Association, the National Institute of
Mental Health, the Center for Mental Health Services, NMHA and NAMI have yet to
produce even a brochure explaining BPD. This seems strange when you consider
that BPD makes up 2% of the general population, 20% of the inpatients and 11% of
the outpatients in the mental health system, has a 10% suicide rate and fills
our prisons, divorce courts and civil courts. Thus I have become Ingrid Bergman,
complaining that the lights are dimming while everyone looks at me with that
"raised eyebrow." Should I tell the emperor he is naked while others
are admiring his invisible new clothes?
The person suffering with BPD has a similar experience. Knowing that their
treatment is inappropriate and their medication (generally thorazine) is not
helping, they often quit treatment. Wouldn't you? They are then stigmatized,
labeled treatment resistant and difficult patients. And so they are. Unless, of
course you question the treatment offered by an antiquated mental health system
that has not yet given up the gaslight for something more illuminating.
Living with the isolation that must accompany the experience of having BPD
requires a great deal of courage and a very strong desire to survive. In 1994
the New York State Office of Mental Health Information Service reported only 297
borderline patients in the State of New York. Knowing these numbers couldn't
possibly be accurate, Dr. Charles Swenson of NY Hospital Cornell Medical Center
and I compiled a provider questionnaire. Out of 39 responses, 997 patients with
BPD were reported. If you question any clinician or substance abuse counselor
they will tell you how prevalent BPD is in their facility and complain about how
hard this population is to treat. Lectures or workshops on BPD are always well
attended. So many patients, families and providers are desperate for any
information at all.
BPD patients are usually admitted to psychiatric hospitals through the
emergency room after a suicide attempt. The patient usually makes four or five;
one out of ten succeeds. These are tough odds. At a recent Suicide Prevention
Conference not one of the presenters ever mentioned BPD. An esteemed researcher
presenting his findings on adolescent suicide also omitted discussion of BPD.
When I asked why he didn't mention an illness which effects so many adolescents,
his response was, "Ah, yes. You're right, but it's a very difficult
subject." Is that the gaslight I see dimming again? Because it is a
difficult disorder, if we avoid discussing it, will it then, perhaps, go away?
This professional avoidance is unacceptable to every parent or loved one of a
person with BPD who lives in fear of that middle-of-the-night telephone call and
to the parent whose child repeatedly tries to commit suicide.
And what solace is it for the family whose child has died. Yes, it's
difficult! BPD can be fatal. Should we hush up and politely go away? Or do we go
on till we have changed this professional denial of so serious and life
threatening a problem? Yes, Dr. Esteemed Researcher, we agree "...it's a
very difficult subject!" BPD is co-morbid with anorexia and bulimia. Those
who suffer from lack of impulse control will often use food as a means of acting
out. At lectures on eating disorders it is rare to hear a discussion of how to
deal with the anorexic who has BPD. When I ask my usual questions, the faraway
look wil1 come into the eyes of the presenter as he says, "Yes, we should
be studying that, as it is related." The voice will then trail off as they
quickly take another question. But, I persevere; I send them related research
papers, I ask more questions, and I tell them about TARA -the Association for
Personality Disorder. I pose questions at each and every lecture or workshop I
attend. You can hear some say, "Oh, no...not her again!" Yes, there I
am...somebody's relentless mother, asking researchers the questions
practitioners are desperate to learn about and should be asking themselves. When
I am not there, does anyone else bring up this stigmatized disorder? BPD is
spoken of in hushed tones, with a tinge of embarrassment-like syphilis or TB,
taboo diseases at the turn of the century, or like AIDS when it first came to
the public's attention. If we continue to allow BPD to remain in the psychiatric
closet we will never get our children the treatment they deserve. More
questioners are wanted. More advocates are needed; a chorus of voices demanding
that things change!
Males with BPD are prone to domestic violence and rage attacks. They make up
a large percentage of the prison population and seem to be resistant to
treatment as usual. A leading specialist in schizophrenia who writes on the
conditions of the mentally ill in the forensic system and advises families to be
aggressive advocates and provoke wolf-like - confrontations recently,
unashamedly, described BPD as a "garbage bag diagnosis." I took his
advice and advocated aggressively, with letters to him, and finally a
confrontation with him-eyeball to eyeball, face to face. And what did he do,
this champion I had admired from afar for his courage and knowledge on other
issues? He promised me he would never again describe BPD in those terms. Be
assured we will monitor the keeping of that promise. It appears that to be a
successful advocate one must perfect the role of professional pest. That is what
I have proudly become.
People with BPD can be helped by combining sensitive and up to date
psychopharmacological treatment and effective new methods of cognitive therapy.
This will keep patients out of expensive hospital beds and help them back into
meaningful roles in the community. Why would our society choose to ignore what
can work to help people whose neurobiological disorder causes them to wreak
havoc on themselves, bring despair to their families, create problems in the
work place, fill our prisons and jails, clog our courts with stalkers and
lengthy divorce and child custody battles, and burn out therapists faster than
our schools can turn them out?
Finding the answers to these questions will not be easy. But we are
determined to play a prominent role in putting BPD on the neurobiological
disorders agenda. Some days I feel like Sisyphus pushing a huge rock to the top
of the mountain. But, with TARA-APD and the people whose articles and
experiences you will read in this edition, I know, at last, I am no longer
alone. We are a growing community of mutual interest. To raise money for
research, to create a family data bank and share our insights and information,
and to advocate, advocate, advocate will, some day soon, turn out those
metaphorical gaslights and illuminate the path to better tomorrows.
Valerie Porr, M.A. is a co-editor of this issue of The Journal and Executive
Director of TARA Association for Personality Disorder whose offices are at 23
Greene Street, NY, NY 10013.
See the index from
Volume 8, Issue 1 of The Journal.
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Borderline Personality Disorder
Borderline Personality Disorder (BPD) is one of the most controversial diagnoses
in psychology today. Since it was first introduced in the DSM, psychologists and
psychiatrists have been trying to give the somewhat amorphous concepts behind
BPD a concrete form. Kernberg's explication of what he calls Borderline
Personality Organization is the most general, while Gunderson,
though a psychoanalyst, is considered by many to have taken the most scientific
approach to defining BPD. The Diagnostic Interview for Borderlines and the DIB-Revised
were developed from research done by Gunderson, Kolb, and Zanarini. Finally,
there is the "official" DSM-IV definition.
Some researchers, like Judith Herman, believe that BPD is a name given to a
particular manifestation of post-traumatic stress disorder: in Trauma and
Recovery, she theorizes that when PTSD takes a form that emphasizes heavily
its elements of identity and relationship disturbance, it gets called BPD; when
the somatic (body) elements are emphasized, it gets called hysteria, and when
the dissociative/deformation of consciousness elements are the focus, it gets
called DID/MPD. Others believe that the term "borderline personality"
has been so misunderstood and misused that trying to refine it is pointless and
suggest instead simply scrapping the term.
What causes Borderline Personality Disorder?
It would be remiss to discuss BPD without including a comment about Linehan's
work. In contrast to the symptom list approaches detailed below, Linehan has
developed a comprehensive sociobiological theory which appears to be borne out
by the successes found in controlled studies of her Dialectical Behavioral
Linehan theorizes that borderlines are born with an innate biological
tendency to react more intensely to lower levels of stress than others and to
take longer to recover. They peak "higher" emotionally on less
provocation and take longer coming down. In addition, they were raised in
environments in which their beliefs about themselves and their environment were
continually devalued and invalidated. These factors combine to create adults who
are uncertain of the truth of their own feelings and who are confronted by three
basic dialectics they have failed to master (and thus rush frantically from pole
to pole of):
DBT tries to teach
clients to balance these by giving them training in skills of mindfulness,
interpersonal effectiveness, distress tolerance, and emotional regulation.
|vulnerability vs invalidation
|active passivity (tendency to be passive when confronted with a problem
and actively seek a rescuer) vs apparent competence (appearing to be capable
when in reality internally things are falling apart)
|unremitting crises vs inhibited grief.|
Kernberg's Borderline Personality Organization
Diagnoses of BPO are based on three categories of criteria. The first, and
most important, category, comprises two signs:
|the absence of psychosis (i.e., the ability to perceive reality
|impaired ego integration - a diffuse and internally contradictory concept
of self. Kernberg is quoted as saying, "Borderlines can describe
themselves for five hours without your getting a realistic picture of what
The second category is termed "nonspecific signs" and includes such
things as low anxiety tolerance, poor impulse control, and an undeveloped or
poor ability to enjoy work or hobbies in a meaningful way.
Kernberg believes that borderlines are distinguished from neurotics by the
presence of "primitive defenses." Chief among these is splitting, in
which a person or thing is seen as all good or all bad. Note that something
which is all good one day can be all bad the next, which is related to another
symptom: borderlines have problems with object constancy in people -- they read
each action of people in their lives as if there were no prior context; they
don't have a sense of continuity and consistency about people and things in
their lives. They have a hard time experiencing an absent loved one as a loving
presence in their minds. They also have difficulty seeing all of the actions
taken by a person over a period of time as part of an integrated whole, and tend
instead to analyze individual actions in an attempt to divine their individual
meanings. People are defined by how they lasted interacted with the borderline.
Other primitive defenses cited include magical thinking (beliefs that
thoughts can cause events), omnipotence, projection of unpleasant
characteristics in the self onto others and projective identification, a process
where the borderline tries to elicit in others the feelings s/he is having.
Kernberg also includes as signs of BPO chaotic, extreme relationships with
others; an inability to retain the soothing memory of a loved one; transient
psychotic episodes; denial; and emotional amnesia. About the last, Linehan says,
"Borderline individuals are so completely in each mood, they have great
difficulty conceptualizing, remembering what it's like to be in another
Gunderson's conception of BPD
Gunderson, a psychoanalyst, is respected by researchers in many diverse
areas of psychology and psychiatry. His focus tends to be on the differential
diagnosis of Borderline Personality Disorder, and Cauwels gives Gunderson's
criteria in order of their importance:
|Intense unstable relationships in which the borderline always ends up
getting hurt. Gunderson admits that this symptom is somewhat general, but
considers it so central to BPD that he says he would hesitate to diagnose a
patient as BPD without its presence.
|Repetitive self-destructive behavior, often designed to prompt rescue.
|Chronic fear of abandonment and panic when forced to be alone.
|Distorted thoughts/perceptions, particularly in terms of relationships and
interactions with others.
|Hypersensitivity, meaning an unusual sensitivity to nonverbal
communication. Gunderson notes that this can be confused with distortion if
practitioners are not careful (somewhat similar to Herman's statement that,
while survivors of intense long-term trauma may have unrealistic notions of
the power realities of the situation they were in, their notions are likely
to be closer to reality than the therapist might think).
|Impulsive behaviors that often embarrass the borderline later.
|Poor social adaptation: in a way, borderlines tend not to know or
understand the rules regarding performance in job and academic settings.|
The Diagnostic Interview for Borderlines, Revised
Gunderson and his colleague, Jonathan Kolb, tried to make the diagnosis of
BPD by constructing a clinical interview to assess borderline characteristics in
patients. The DIB was revised in 1989 to sharpen its ability to differentiate
between BPD and other personality disorders. It considers symptoms that fall
under four main headings:
|anger (including frequent expressions of anger)
Impulse action patterns
|manipulative suicide gestures
|other impulsive behaviors|
|intolerance of aloneness
|abandonment, engulfment, annihilation fears
The DIB-R is the most influential and best-known "test" for diagnosing
BPD. Use of it has led researchers to identify four behavior patterns they
consider peculiar to BPD: abandonment, engulfment, annihilation fears;
demandingness and entitlement; treatment regressions; and ability to arouse
inappropriately close or hostile treatment relationships.
The DSM-IV gives these nine criteria; a diagnosis requires that the subject
present with at least five of these. In I Hate You -- Don't Leave Me!
Jerold Kriesman and Hal Straus refer to BPD as "emotional hemophilia; [a
borderline] lacks the clotting mechanism needed to moderate his spurts of
feeling. Stimulate a passion, and the borderline emotionally bleeds to
Traits involving emotions:
Quite frequently people with BPD have a very hard time controlling their
emotions. They may feel ruled by them. One researcher (Marsha Linehan) said,
"People with BPD are like people with third degree burns over 90% of their
bodies. Lacking emotional skin, they feel agony at the slightest touch or
1. Shifts in mood lasting only a few hours.
2. Anger that is inappropriate, intense or uncontrollable.
Traits involving behavior:
3. Self-destructive acts, such as self-mutilation or suicidal threats and
gestures that happen more than once
4. Two potentially self-damaging impulsive behaviors. These could include
alcohol and other drug abuse, compulsive spending, gambling, eating disorders,
shoplifting, reckless driving, compulsive sexual behavior.
Traits involving identity
5. Marked, persistent identity disturbance shown by uncertainty in at least two
areas. These areas can include self-image, sexual orientation, career choice or
other long-term goals, friendships, values. People with BPD may not feel like
they know who they are, or what they think, or what their opinions are, or what
religion they should be. Instead, they may try to be what they think other
people want them to be. Someone with BPD said, "I have a hard time figuring
out my personality. I tend to be whomever I'm with."
6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I
remember describing the feeling of having a deep hole in my stomach. An
emptiness that I didn't know how to fill. My therapist told me that was from
almost a "lack of a life". The more things you get into your life, the
more relationships you get involved in, all of that fills that hole. As a
borderline, I had no life. There were times when I couldn't stay in the same
room with other people. It almost felt like what I think a panic attack would
Traits involving relationships
7. Unstable, chaotic intense relationships characterized by splitting (see
8. Frantic efforts to avoid real or imagined abandonment
|Splitting: the self and others are viewed as "all good" or
"all bad." Someone with BPD said, "One day I would think my
doctor was the best and I loved|
Promising Treatment for Borderline Personality Disorder
Behavior Therapy, often referred to as DBT, is an empirically researched
psychotherapeutic treatment developed by Dr. Marsha Linehan, Professor
of Psychology, University of Washington, for patients struggling with
chronic suicidality, intentional self-harm and borderline personality
disorder (BPD). This therapy, employing cognitive and behavioral
principles, is rapidly becoming a standard for treating borderline
patients in both this country and abroad. DBT consists of two primary
components involving individual psychotherapy once a week and a weekly
skills training group. Additionally, patients are offered telephone
consultations with their individual therapist as needed.
Biosocial theory. DBT is based on a biosocial theory of personality
functioning in which BPD is seen as a biological disorder of emotional
regulation. The disorder is characterized by heightened sensitivity to
emotion, increased emotional in-tensity and a slow return to emotional
baseline. Characteristic behaviors and emotional experiences associated
with BPD theoretically result from the expression of this biological
dysfunction in a social environment experienced as invalidating by the
Although there are many examples of invalidating environments, all share
three characteristics: (1) individual behaviors and communications are
rejected as invalid; (2) emotional displays and painful behaviors are
met with punishment that is erratically administered and intermittently
reinforcing; (3) the environment oversimplifies the ease with which
problems may be solved and needs met. Most of us have encountered such
environments at some point in our lives and we commonly deal with them
by changing our behavior to meet expectations, or by changing the
environment so that it is no longer invalidating, or, ultimately, by
simply leaving the environment. The dilemma for the borderline patient
occurs when the individual is unable to meet expectations, cannot change
the environment or cannot leave, thus experiencing what has been called
a "double bind."
Treatment. The primary dialectic that defines the core treatment
strategies in DBT is the tension between acceptance of the patient and
the expectation that the patient needs to change. Acceptance strategies,
drawn from Zen practice, involve emotional, behavioral and cognitive
validation as well as teaching the patient personal strategies for
validation. One example of a validation strategy would be recognizing
how self-mutilation can be adaptive (i.e., useful for regulating
The antithesis of acceptance is the expectation of change. This
expectation is embodied in behavioral therapy with its emphasis on
problem solving, rationality, logic and gaining knowledge by testing
hypotheses. Strategies for promoting change include problem solving,
contingency procedures, skills training, exposure and cognitive
An example of a problem-solving procedure is the use of a "chain
analysis" to diminish cutting (self mutilation) behaviors. A chain
analysis reviews the environmental and personal antecedents and
consequences of the cutting behavior in mi-nute detail. An important
goal of this procedure is to identify points during the chain of events
when the borderline patient has an opportunity to do something
different. This sets the stage for the patient to avoid the problematic
behavior in the future.
DBT is organized along a fourfold hierarchy. The first priorities are
suicidal or parasuicidal behaviors and ideation. The second priorities
are behaviors that interfere with therapy. Third is behavior that
interferes with quality of life. The fourth priority of DBT addresses
skills deficits commonly found in individuals with BPD.
The goals of skills training are to change behavioral, emotional and
thinking patterns that cause personal misery and in-terpersonal
distress. Specific goals include reducing dysregulation while increasing
adaptive (i.e., more regulated) behaviors. Patients are taught to attend
to the moment without judgment or impulsivity, a quality Dr. Linehan
describes as "core mindfulness." Newly learned skills enable
patients to improve emotional, cognitive and interpersonal functioning.
Empirical results. DBT was compared to treatment as usual (TAU),
typically consisting of psychopharmacological treatment and intermittent
supportive psychotherapy. In a landmark study, Linehan and colleagues
found the following:
1. Compared with TAU, subjects assigned to DBT had significantly fewer
and less severe parasuicidal behaviors during the treatment year. These
results were obtained even though DBT was no better than TAU at
improving self-reports of hopelessness, suicide ideation or reasons for
2. DBT was dramatically more effective than TAU in limiting treatment
drop out, the most serious behavior interfering with therapy. At the end
of one year, only 16.4 percent of DBT patients had left treatment. In
contrast, approximately 50 percent of TAU patients had dropped out.
3. Subjects assigned to DBT had a tendency to enter psychiatric
inpatient units less often and had fewer inpatient psychiatric days.
Those in DBT had an average of 8.46 inpatient days over the year
compared with 38.86 inpatient days for subjects receiving TAU. This
finding suggests that DBT is cost effective.
4. DBT subjects rated themselves as more successful at changing their
emotions and improving general emotional control. They also had
significantly lower scores on self-reported measures of anger and
In a subsequent study, the standard DBT (DBT individual therapy and the
DBT skills group) was compared to a once weekly individual psychodynamic
therapy and the DBT skills group. This study showed that the DBT skills
group lost its effectiveness when combined with individual psychodynamic
therapy. This study also supported the practice of providing telephone
consultations to patients between sessions when needed. To explain this
point, Linehan likens life to a basketball game — having a therapist
unavailable between sessions would be like a coach being unavailable
during the game.
DBT is usually considered a one-year treatment. In this time, the
therapy targets behaviors involving life and death, behaviors that
impede therapy and activities that affect quality of life. Concurrently,
the patient learns techniques taught in the skills group. This one-year
treatment has been empirically validated and designated as Stage I by
Dr. Linehan; she has developed sequels to this treatment that are
currently being evaluated. Stage II, which is begun only after the
patient has acquired the basic skills of Stage I, is based on the
rationale that patients must be able to cope with the consequences of
trauma and focuses on reducing posttraumatic stress. Stage III
emphasizes increasing self-respect, reducing self-hatred and achieving
individual goals and interpersonal connections.
Linehan, Marsha M. (1993). Cognitive-Behavioral Treatment of Borderline
Personality Disorder. New York:
Linehan, Marsha M. (1993). Skills Training Manual for Treating
Borderline Personality Disorder. New York:
Linehan, M., Asuicidal borderline patients. Archives of General
Psychiatry (1991). 48: 1060-1064.
Shearin, Edward N. and Linehan, Marsha M. Dialectical behavioral therapy
for borderline personality disorder:
theoretical and empirical foundations. Acta Psychiatrica Scandinavica
(1994). 89 (suppl. 379): 61-68.
* * *
This article was contributed by Elizabeth T. Murphy, PhD, and John
Gunderson, MD. Dr. Murphy conducts outpatient DBT individual therapy and
skills groups with patients at McLean Hospital. Dr. Gunderson is
director of McLean’s Ambulatory Personality Disorder Service and
Psychosocial Research Program, and is Professor of Psychiatry at Harvard
Borderline Personality Disorder
Borderline Personality Disorder (BPD) is a distinct disorder in
it's own right. It is not, as many suppose, a 'diagnosis of degree'. To put it
another way someone with a diagnosis of BP is not 'half a psychopath', nor is it
valid to differentiate between the 'borderline' personality disorder and the
In part the confusion over the definition of BPD is a semantic one. The term
borderline has associations with 'halfway' measures and so it is natural to
assume that borderline personality disorder means half a personality disorder.
Actually the term refers to the now outdated but once widely accepted notion
that sufferers exist on the borderline between psychosis and neurosis (Heller L.
M. 1991). It is the BPD's propensity to exhibit both neurosis and
pseudopsychosis which is the chief diagnostic paradigm.
Within this paradigm a number of clear diagnostic features are evident. The
American diagnostic manual, DSM-IV, (American Psychiatric Association 1994)
lists nine discrete features and requires five of these to be present over time
before a diagnosis of BPD can be made. The nine features (reproduced in brief)
are as follows:
1 Frantic efforts to avoid real or imagined abandonment.
2 A pattern of unstable and intense personal relationships.
3 Identity disturbance
4 Impulsivity in at least two areas that are potentially self damaging
5 Recurrent suicidal behavior, gestures, threats or self-mutilating behavior.
6 Affective instability due to a marked reactivity of mood.
7 Chronic feelings of emptiness.
8 Inappropriate, intense anger.
9 Transient, stress related paranoid ideation or severe dissociative symptoms.
The European version, ICD-10 (WHO - 1992) is largely in agreement with these
criteria although less comprehensive in its' description of BPD.
Common features of Borderline Personality Disorder
Borderlines tend to experience chronic emotional lability and employ a range of
endorphin releasing behaviours to compensate for their marked dysphoria.
One of the major features of Borderline Behavior is self-injury. Somewhat
surprisingly for most people the act of cutting the flesh results in euphoria
via the release of endorphins which not only prevents the sensation of pain but
also anaesthetises the BP against their chronic emotional distress. This is a
major cause of self-harming behavior among Borderlines.
Emotional lability is a classic feature of BPD. Moods can shift rapidly - even
minute to minute - with no obvious reason which the onlooker can understand.
Possibly due to limbic system malfunction borderlines can experience a steadily
intensifying combination of a range of distressing emotions leading to a range
of anaesthetising behaviors as noted above.
Progressive dysphoria, along with other stressors can give rise to psychotic or
psuedopsychotic symptoms which are generally cognitive in nature (thought
disorders) but can also include hallucinations, derealisation and
During development it is normal for children to categorize things as either 'all
good' or 'all bad'. It is impossible for them to appreciate the 'grey areas' of
life in the same way that adults can. This immature cognitive strategy persists
in BPDs leading to rapidly changing and diametrically opposed opinions about
life events and significant others.
Because of their measurable brain dysfunction borderlines are also at increased
risk of depression, anxiety disorders, other personality disorders and a range
of behavioural and addictive disorders. The latter are secondary to the practice
of self-anaesthetizing via impulsive or self-destructive behaviours. They are
also prone to eating disorders, possibly as an attempt to assert control over
themselves and their moods in much the same way as other eating disorder
sufferers can. Bear in mind that eating disorders have also been related to
sexual issues in development (Lyttle J. 1986 pp. 334 - 335). Incidentally,
despite the psychotic features already outlined there is no correlation between
BPD and schizophrenia.
Although there is general agreement concerning the diagnostic features of BPD
its' aetiology and treatment have become the focus of considerable debate over
In terms of aetiology the arguments can loosely be divided into the two familiar
categories of 'nature' and 'nurture' and each argument has a lot to support it.
A review of the relevant literature reveals, not unexpectedly, the traditional
demarcation between psychiatry and psychoanalysis - a professional division
which we as nurses are fortunate enough to be able to avoid in favor of a more
eclectic understanding of the condition.
Regarding the 'nurture' argument statistical research has revealed a number of
indicators of borderline development including:
1 "history of extreme frustrations and intense aggression during the first
few years of life." (Kernberg O. 1975)
2 A history of 'invalidating environments' (Linehan M. 1993 2)
3 Sexual or physical abuse - particularly before age 15 (Herman et al 1989).
The concept of the invalidating environment is that of a situation fraught with
erratic and inappropriate responses from significant others to the private
experiences (thoughts, beliefs, emotions) of the developing BPD. In addition the
rule of thumb in environments such as these is to oversimplify the ease with
which problems can be solved, thus apportioning blame to the BPD who is criticized
for their inability to easily overcome their difficulties. Over time
this can result in a chronic and classical 'double bind' scenario.
The significance of physical and sexual abuse in childhood is emphasized by a
number of separate studies: (Goldman S.J. et al 1992;Weaver T.L. et al 1993;
Stone J. 1990). It should be remembered, however, that a history of Child Sexual
Abuse is not a firm diagnostic criteria and there are many cases of BP who do
not report such a history. Nevertheless it remains a remarkably common factor in
the development of both male and female BPs.
These have led to some very relevant observations concerning the conditions'
correlation with Post Traumatic Stress Disorder. Kroll J. (1988) suggested that
the brief psychotic or psuedopsychotic interludes experienced by BP sufferers
are no different from those of PTSD sufferers. It is also significant that
research into PTSD using the Trauma Symptom Inventory (Briere J. 1997) correctly
identified 89% of inpatients independently diagnosed as BP. Wether or not PTSD
is a major component in the development of BP it is clear that many BPDs have
significant psychological trauma in their histories.
Of course any discussion on the aetiology of BPD would not be complete without
consideration of the other side of the argument - the 'nature' theory. Briefly,
this area of research focuses upon the genetic or biological component of BPD.
Teicher et al (1994) identified dysfunction in the limbic system, particularly
relating to the hippocampus and amygdala although the research was unclear as to
weather this dysfunction was the result of neurological changes secondary to
"The Hippocampus .. is essential for the laying down of long term memory.
The amygdala, in front of the Hippocampus, is the place where fear is registered
and generated." (Carter R. 1998 p.42)
Given the essential functions of these two areas of the brain we can begin to
understand the possible neuro-biological origins of certain Borderline traits
such as emotional lability, splitting (the tendency to characterize things as
'all good' or 'all bad'), and the condition's dissociative traits.
It is interesting to note that many researchers have identified serotonergic
dysfunction in the brains of BPDs. This may have marked implications for the
maintenance of mood and also go some way towards explaining the frustration and
rage routinely exhibited by sufferers (Siever L.J. 1997).
The equifinality model postulates that both the 'nature' and 'nurture' paradigms
are equally valid. In brief it suggests that a biological vulnerability, perhaps
inherited in BPDs with a family history of neurological disorder or created as a
result of neurological changes secondary to PTSD in childhood is a necessary
element of Borderline Personality disorder. The biological sequelae of childhood
trauma is an area which we are only just beginning to understand. New studies
suggest a wide range of neurobiological changes as a result of childhood sexual
abuse (Siever L. J. 1997).
In addition to the biological factor, however it may arise, trauma of one kind
or another does appear to be vital. This may be sporadic as is often the case in
physical or sexual abuse or more chronic as already noted via the mechanism of
Linehan's 'invalidating environment'.
It is no secret that this particular client group can be something of a
nightmare when it comes to finding effective therapeutic interventions. The
treatment of BPD is fraught with difficulty, particularly in an in-patient
setting where many borderline behaviors result in discord among the staff or
where the demands made upon an individual nurse can become extremely
Treatment of BPD falls into two main categories - pharmacology, incorporating a
range of medication options and psychotherapeutic techniques ranging from
supportive counseling to psychoanalysis. Although many of the treatments
available fall firmly outside the remit of the RMN it does no harm for nurses to
understand the options available.
Pharmacological treatments include:
SSRIs to combat the deficiencies in serotonin absorption.
Neuroleptics to treat psychotic symptoms as well as dysphoria .
Carbamazepine has been used in the treatment of behavioural and affective
problems (Cowdry R.; Gardner D. 1988).
Thyroxin as many BPDs have symptoms of hypothyroidism
It has been reported that alprazolam can decrease behavioural control and that
amitriptyline increases paranoia, assault and suicide threats (Cowdry R.;
Gardner D. 1988).
Psychotherapeutic approaches to Borderline Personality Disorder are dogged with
the same problems of compliance as pharmacological approaches are. This is in no
small measure due to the difficulty Borderline patients have in forming the
stable relationships generally seen as a pre-requisite for therapy.
Nevertheless 'talking cures' are effective in conjunction with medication and it
seems that both types of intervention are necessary. If counseling is designed
to help people think through their difficulties and learn to take control of and
responsibility for their emotions it makes sense to give the brain a fighting
chance to work properly at the same time.
The most effective form of therapy for BPDs seems to be 'Dialectic Behavior Therapy' (Linehan M. 1993 2). This is at first glance a very strange
juxtaposition of traditions drawing as it does from 'cognitive behavior therapy', 'supportive
counseling' and 'Zen Buddhism'. The term Dialectic refers
to the inherent dichotomy of BPDs experience in which everything is polarized into extremes such as rejection/acceptance; good/bad; active; passive and
crisis/calm. The term Dialectic refers to the scenario of opposing viewpoints characterized
by thesis and antithesis in classical philosophy.
In essence the technique is designed to promote insight and change via skills
training, introspection and validation. This in itself is seen as dichotomous as
validation and acceptance in the mind of the BPD (black and white thinkers) is
not conducive to encouragement to change.
The downfall for acute psychiatric wards is that the procedure typically takes 1
- 3 years and requires a consistent approach from two separate therapists who
will (in certain circumstances) make themselves available to the BPD round the
clock. Needless to say this is not a realistic option for ward based RMNs.
However many of the techniques of DBT are extremely valid and can be used in
acute. In particular the principles of validation and skills training are very
But herein lies the rub. If such an approach is to work it requires firm
boundaries and a consistency of approach which is historically very difficult to
maintain on acute. This is particularly true in the treatment of BPDs who can be
adept at eliciting a range of responses from staff via the mechanisms of
transference and counter-transference.
What we do have is the opportunity to promote self-acceptance and, in
conjunction with medication prescribed by our medical colleagues, the chance to
promote a range of skills from problem solving to anger management. It seems
that BPD is less of a lifestyle choice than many of us, myself included,
previously thought. There are very real psychological and biological/organic
deficits which can be addressed and treated effectively.
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