~ Borderline Personality Disorder ~

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What is Borderline Personality Disorder (BPD)?

Borderline personality disorder (BPD) is a devastating psychiatric illness. The diagnosis encompasses patients with a pervasive pattern of affective instability, severe difficulties in interpersonal relationships, problems with behavioral or impulse control (including suicidal behaviors), and disrupted cognitive processes. The estimated prevalence of BPD in the general population is about 2%. It has also been estimated that 11% of outpatients and 20% of psychiatric inpatients presenting for treatment meet the criteria for the disorder.

From http://www.borderlinepersonalitydisorder.com/faqs_.htm

Borderline Personality Disorder Patients Comprise:

	6-10 million Americans
	2% of the general population
	11% of all mental health outpatients
	20% of psychiatric inpatients
	75-90% of those diagnosed are women

Borderline Personality Disorder Resource Center
From http://www.bpdresourcecenter.org/

As summarized from the DSM IV:
(Diagnostic and Statistics Manual of Mental Disorders 4th Edition as used by the American Psychiatric Association):

"A person who suffers from this disorder has labile interpersonal relationships characterized by instability. This pattern of interacting with others has persisted for years and is usually closely related to the person's self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar liability (fluctuating back and forth, sometimes in a quick manner) in a person's affect [mood], or feelings. Relationships and the person's affect may often be characterized as being shallow. A person with this disorder may also exhibit impulsive behaviors and exhibit a majority of the following symptoms:

DSM IV Diagnostic Criteria for BPD:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Anyone with 6 or more of the above traits and symptoms may be diagnosed with Borderline Personality Disorder. However, the traits must be long-standing (pervasive) and there must be no better explanation for them (for example a physical illness, another mental illness or substance misuse).

Treatment:

Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.⁶ Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.⁷

⁶Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67
⁷Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).

^{NIMH National Institute of Mental health
http://www.nimh.nih.gov/publicat/bpd.cfm}

What is Dialectical Behavior Therapy?

Dialectical Behavior Therapy (DBT) is a treatment designed specifically for individuals with self-harm behaviors, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts. Many clients with these behaviors meet criteria for a disorder called borderline personality (BPD). It is unusual for individuals diagnosed with BPD to also struggle with other problems – depression, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety, eating disorders, or alcohol and drug problems. DBT is a modification of cognitive behavioral therapy (CBT). In developing DBT, Marsha Linehan, Ph.D. (1993a) first tried applying standard CBT to people who engaged in self-injury, made suicide attempts, and struggled with out-of-control emotions. When CBT did not work as well as she thought it would, Dr. Linehan and her research team added other types of techniques until they developed a treatment that worked better. It’s important to note that DBT is an “empirically-supported treatment.” That means it has been researched in clinical trials, just as new medications should be researched to determine whether or not they work better than a placebo (sugar pill). While the research on DBT was conducted initially with women who were diagnosed with BPD, DBT is now being used for women who binge-eat, teenagers who are depressed and suicidal, and older clients who become depressed again and again.

Excerpt taken from Dialectical Behavior Therapy Frequently Asked Questions Behavioral Tech, LLC http://www.behavioraltech.com/downloads/dbtFaq_Cons.pdf

DBT my perspective:

DBT - is a cognitive/behavioral therapy - is a treatment designed specifically for individuals with self-harm behaviors, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts. MANY clients with these behaviors meet criteria for borderline personality (BPD). It works around the use of a "Skills Training Manual" - and focuses on 4 Modules called - Core Mindfulness Skills / Interpersonal Effectiveness Skills / Emotion Regulation Skills / Distress Tolerance Skills. Basically you would have a group therapy session for approx 1.5 hours a week and meet with your individual therapist once a week. Your therapist may or may not be a group leader in the group session which has 2 therapists leading the group. 1 of the rules are - If you drop out of group you lose the therapist you have been working with. I HATE this rule as it is a means to "force" you to stay in DBT, in my mind. The therapist and group leaders meet as a "consultation group" along with a Doc once a week. Part of DBT also allows the client to have direct phone contact with their therapist 7 days a week for support to help you get grounded back down with use of a skill. This phone call must happen PRIOR to any self harming behaviors. I have been in a rigid program as exactly laid out by M Linehan and I have been in a modified version. Both were consistent with change of therapists after leaving the group. I had been told once by a group leader that if I do NOT "get" DBT I am most likely going to die from suicide. I did NOT take that as a very positive result and that it was a scare tactic to keep me in DBT. My current treatment team does NOT view DBT as the end all option for me. At this point in my life I refuse to ever do DBT again. Not saying that some of the skills are not used during my therapy as they are useful standing out on their own. For me a strong stance on Behavioral therapies does not work because I just comply to "advance" versus "punishment". Compliance isn't change. For a long time I had the assumption that I was only going to be temporarily be out of group and that's why my therapy with X never ended. I feel the whole No group then new therapist application "plays" on the abandonment fears that I have myself and on others with the Dx of BPD.  I will add that for some persons DBT works wonders from what I have been told and to not be discouraged because it didn't work for me. For me the Dx of BPD fits me like a glove.

Personally I think DBT sucks!

Links:

Borderline Personality Today
This website is built with the highest integrity, compassion for consumers and families, the skills of a mental health professional and experience of a consumer.
http://www.borderlinepersonalitytoday.com/main/

National Mental Health Association
Fact sheet on Borderline personality disorder
http://www.nmha.org/infoctr/factsheets/borderline.cfm