Borderline Personality Disorder is an often misunderstood and frightening diagnosis for both the individual and their loved ones.  It is not the “therapeutic death sentence” that it is often circulated to be!  Much of the information presented is applicable to other “Cluster-B” personality disorders, which are typified by emotional dysregulation, impulsivity, hypersensitivity, identity confusion, and relational challenges; Histrionic Personality Disorder, Narcissistic Personality Disorder, and Anti-Social   This article will explore what constitutes BPD, its prognosis, and effective methods for Borderline Personality Disorder treatment.

What is Borderline Personality Disorder?

The Diagnostic and Statistic Manual-V (DSM-V) lists the features of BPD as “a pervasive pattern of unstable interpersonal relationships, self-image disturbance, affect dysregulation, and marked impulsivity beginning in adolescence and present in a variety of contexts” (APA, 2013).  BPD has a prevalence rate of 1.6%-5%, but persons with BPD account for 20% of those in inpatient facilities, that’s a glaring disproportion and foretells the severity of impact to mental health and well-being (2013).  An independent study found that persons with BPD account for the largest percentage of those with a personality disorder; 20%-25% (Newhill et al, 2009).  Furthermore, 75% of those diagnosed with BPD are female (2013).  However, a study conducted in 2012 found that rates of BPD were congruent between the sexes and attributed this to better diagnostic measures and increased understanding of how BPD behaviors manifest slightly different in men than women (Burke & Stepps).

Symptoms of Borderline Personality Disorder

One of most prominent and destructive features of BPD is the presence of extremely volatile and unstable interpersonal relationships, which often leads to alienation from one’s nuclear family, friends and a great deal of intra-psychic distress (Burke & Stepps, 2012).  Another main feature of BPD is an inability to regulate one’s affect, and subsequently self-harm behaviors such as cutting, substance abuse, sexual promiscuity, violence towards others, and suicide (Newhill et al, 2009).  Suicidal tendencies are a behavior that clinicians must very carefully screen for when assessing a person with other BPD features, it is a very real risk and included in the DSM as diagnostic criterion (APA, 2013) Finally, as the name implies, persons with BPD are unable to form and maintain a stable sense of self-image and identity, which contributes to difficulty regulating emotion and unstable relationships (2009).

BPD’s Connection With Other Disorders

A newly emerging feature that I learned of in my research for this post, and a possible etiological factor, is impulsivity; there is a growing connection between ADHD in children and BPD in adolescents and adults (Burke & Stepps, 2012).  Oppositional Defiant Disorder (ODD) has also been shown to be predictive of possibly developing into BPD (2012). As I conceptualize BPD, these behaviors exist in interdependent feedback loops in a sort of chicken and egg coming first paradox.   No matter the mechanism or point of intervention, emotional dysregulation, interpersonal volatility, intrapersonal suffering, the outcome is most often extreme distress for the person with BPD.  BPD is very challenging for those who struggle with it, and for their family members too; my sister in-law has BPD and it has taken a significant toll on my in-law family’s well-being.  Having a family member or child with BPD takes a tall toll on the entire family system resulting in systemic challenges and crippling despair.  What are we to do?

Treatment Strategies for BPD

An effective treatment strategy used to remediate the symptoms and underlying causes of BPD was devised by University of Washington researcher Marsha Linehan, and is called Dialectic Behavioral Therapy (DBT) (Soler et al, 2008).  DBT’s main tenets are to condition emotional regulation through the use of dialectical exercises and tasks during instances in which there are two seemingly opposing forces and a “middle road” is synthesized to bridge the gap.  Also, conditioning to better manage high levels of stress successfully via mindfulness exercises, healthy emotional coping strategies like journaling and exercising, and helping to develop problem-solving skills (Linehan, 1993b).  There are other modalities with proven effectiveness, but they can be accurately and efficiently summarized as being more general cognitive behavioral strategies (CBT) (Linehan, 1993a).  DBT is a specific form of CBT.  Also, these treatment strategies are more effective when done both in group settings, and in individual counseling sessions (Linehan et al, 2006).  I would posit that the Corrective Emotional Experience, or an experience that corrects one’s emotional response by replacing it with a healthy one as experienced in a real-time group setting that emulates most of our other social associations including the family, as coined by Irvin Yalom as one of the main cruxes to change in group therapy, is also one of the main reasons why group therapy is effective for persons with BPD (2005).  This is why our DBT skills curriculum is taught via therapy and includes a second weekly DBT group to process how well clients are applying their skill based modes of coping.

Relationship Based Treatment for BPD

Something not explicitly mentioned in the literature reviewed for this post, but that would seem to be an integral aspect of successful therapy in treating BPD tendencies, is for a therapist to be unconditionally respectful and warm, consistent, and model appropriate behaviors.  At Sunrise we can respond to clients with BPD tendencies as no one else has been able to in a consistent and sustainable manner, and we can help create the spacing necessary for parents and other loved ones to do the same.  Trust me, I absolutely know that you have given your best for your dear daughter, this is not a criticism in the least but rather an accurate acknowledgment of the limitation of parental roles and family.  The hallmarks of BPD are identity disturbances, emotional dysregulation, and interpersonal instability.  So, by modeling appropriate affect, simply being consistent in general, and providing unconditional positive regard a client can more readily do the same.  The most predictive measure of successful outcomes is the strength of the therapeutic relationship and not the strength of the intervention itself.   The strength of the therapeutic alliance also serves as the gauge for how far we can “push” a BPD client, which is critical when utilizing an intervention like Distress Tolerance training and exercises (Linehan et al, 2006).  These principles are universal to any therapeutic alliance, but they are especially vital when working with those with BPD tendencies.
To conclude this exploration, BPD is a very distressing but not damning disorder for those with it, and for their family and friends, but it can be effectively remediated to a high degree of functioning with which all of the previously mentioned individuals mentioned  are pleased with.  DBT, psychoanalysis, and CBT’s in general have been proven to effectively reduce the intensity and prevalence of negative emotions, which in turn improves identity and interpersonal relationships.  How we treat those with BPD tendencies can create a negative bias that may negatively affect successful therapy and our relationships.  A strong therapeutic alliance is vital to successful treatment, clients, family members, and therapists working as equal team members helps to create this alliance.   Finally, there is hope, please don’t forget or let wither our most precious intervention for ourselves and our loved one struggling with BPD tendencies; hope!
by Allen Richards, CSW, Therapist at Sunrise Residential Treatment Center


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