Borderline Personality Disorder PDF

3/27/24, 9:37 PM Print Preview Chapter 12: Personality Disorders: 12-3b Borderline Personality Disorder Book Title: Psychopathology: An Integrative Approach to Mental Disorders Printed By: Wefae Ali ([email protected]) © 2023 Cengage Learning, Inc., Cengage Learning, Inc. 12-3b Borderline Personalit...

3/27/24, 9:37 PM Print Preview Chapter 12: Personality Disorders: 12-3b Borderline Personality Disorder Book Title: Psychopathology: An Integrative Approach to Mental Disorders Printed By: Wefae Ali ([email protected]) © 2023 Cengage Learning, Inc., Cengage Learning, Inc. 12-3b Borderline Personality Disorder People with borderline personality disorder (Cluster B (dramatic, emotional, or erratic) personality disorder involving a pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses.) lead tumultuous lives. Their moods and relationships are unstable, and usually they have a poor self-image. These people often feel empty and are at great risk of dying by their own hands. Consider the case of Claire. Clinical Description Borderline personality disorder is one of the most common personality disorders observed in clinical settings. It is observed in every culture, is seen in about 1% to 2% of the general population (Choi-Kain & Gunderson, 2019), and constitutes 20% to 25% of all psychiatric admissions (Gunderson & Palmer, 2019). Claire’s life illustrates the instability characteristic of people with borderline personality disorder. They tend to have turbulent relationships, fearing abandonment but lacking control over their emotions (Hooley, Cole, & Gironde, 2012). They often engage in behaviors that are suicidal, self-mutilative, or both, cutting, burning, or punching themselves. Claire sometimes used her cigarette to burn her palm or forearm, and she carved her initials in her arm. As mentioned previously, a significant proportion—nearly 10%—die by taking their own lives (Björkenstam, Björkenstam, Holm, Gerdin, & Ekselius, 2015; Gunderson, 2011). Fortunately, the long-term outcome for people with borderline personality disorder is encouraging (Winsper, in press). Approximately nine out of ten patients with borderline personality disorder achieve remission in the decade after seeking treatment (Gunderson et al., 2011; Keuroghlian et al., 2015). People with this personality disorder are often intense, going from anger to deep depression in a short time. Dysfunction in the area of emotion is sometimes considered one of the core features of borderline personality disorder (Choi-Kain & Gunderson, 2019) and is one of the best predictors of suicide in this group (McGirr et al., 2009). The characteristic of instability (in emotion, interpersonal relationships, self-concept, and behavior) is seen as a core feature with some describing this group as being “stably unstable” (Hooley et al., 2012). This instability extends to impulsivity, which can be seen in their drug misuse and selfmutilation. Although not so obvious as to why, the self-injurious behaviors, such as cutting, sometimes are described as tension-reducing by people who engage in these behaviors (McKenzie & Gross, 2014; Nock, 2010). Claire’s empty feeling is also common; these people are sometimes described as chronically bored and have difficulties with their own identities (Linehan & Dexter-Mazza, 2008). The mood disorders discussed in Chapter 7 are common among people with borderline personality disorder. One study of inpatients with this disorder found that more than 80% also had major depression and approximately 10% https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 1/7 3/27/24, 9:37 PM Print Preview had bipolar II disorder (Zanarini et al., 1998). Eating disorders are also common, with approximately 65% having some form of eating and feeding disorder (for example, Khosravi, 2020). Approximately 25% of people with borderline personality disorder also have bulimia (see Chapter 8); while 20% meet criteria for anorexia (Zanarini et al., 1998). Up to 64% of the people with borderline personality disorder are also diagnosed with at least one substance use disorder (Zanarini et al., 1998). Substance use in this population appears to be a way of coping with their unstable emotions (Vest & Tragesser, 2020). As with antisocial personality disorder, people with borderline personality disorder tend to improve during their 30s and 40s, although they may continue to have difficulties into old age (Zanarini et al., 2012). Causes The results from numerous family studies suggest that borderline personality disorder is more prevalent in families with the disorder and somehow linked with mood disorders (Amad, Ramoz, Thomas, Jardri, & Gorwood, 2014). Studies of monozygotic (identical) and dizygotic (fraternal) twins indicated a higher concordance rate among monozygotic twins, further supporting the role of genetics in the expression of borderline personality disorder (Streit, Colodro-Conde, Hall, & Witt, 2020). The emotional reactivity that is a central aspect of borderline personality disorder has led researchers to look at this personality trait for clues about inherited influences (endophenotypes). Important genetic studies are investigating genes associated with the neurochemical serotonin because dysfunction in this system has been linked to the emotional instability, suicidal behaviors, and impulsivity seen in people with this disorder (Joyce, Stephenson, Kennedy, Mulder, & McHugh, 2013; Soloff, Chiappetta, Mason, Becker, & Price, 2014). This research is in its early stages, and there are, as yet, no solid answers for how genetic differences lead to the symptoms of borderline personality disorder (Streit et al., 2020). Neuroimaging studies, designed to locate areas in the brain contributing to borderline personality disorder, point to the limbic network (Vandekerckhove, Berens, Wang, Quirin, & De Mey, 2020). Significantly, this area in the brain is involved in emotion regulation and dysfunctional serotonin neurotransmission, linking these findings with genetic research. Low serotonergic activity is involved with the regulation of mood and impulsivity, making it a target for extensive study in this group (Hooley et al., 2012). DSM 5 Table 12.6 Diagnostic Criteria for Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 2/7 3/27/24, 9:37 PM Print Preview 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 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 criterion 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. From American Psychiatric Association, (2022), Diagnostic and statistical manual of mental disorders (5th ed., Text Revision). To further understand the nature of this disorder, it is necessary to refine the concept of emotional reactivity in borderline personality disorder. When asked about their experiences, people with this disorder will report greater emotional fluctuations and greater emotional intensity, primarily in negative emotions such as anger and anxiety (Khosravani, Berk, Sharifi Bastan, Samimi Ardestani, & Wrobel, in press). Some research is looking at how sensitive these individuals are to the emotions of others. Using morphing technology, one study tested how people with and without borderline personality disorder could correctly identify the emotion of a face that was morphing on screen (changing slowly from a neutral expression to an emotional expression such as anger) and found those with borderline personality disorder were more accurate than controls (Fertuck et al., 2009). In one study, the emotion “shame” was explored in people with this disorder (Rusch et al., 2007). For example, people were given the following scenario: “You attend your coworker’s housewarming party, and you spill red wine on a new cream-colored carpet, but you think no https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 3/7 3/27/24, 9:37 PM Print Preview one notices.” Participants were then asked to say which of the following four reactions they would have (Rusch et al., 2007, p. 317): “You would wish you were anywhere but at the party.” (indicating shame proneness) “You would stay late to help clean up the stain after the party.” (guilt proneness) “You think your coworker should have expected some accidents at such a big party.” (detachment) “You would wonder why your coworker chose to serve red wine with the new light carpet.” (externalization) This study found that women with borderline personality disorder (no men were included in this study) were more likely to report shame than healthy women and women with social phobia. The researchers also found that this elevated tendency to experience shame was associated with low self-esteem, low quality of life, and high levels of anger and hostility (Buchman-Wildbaum et al., 2021). Shame has also been found to be related to self-inflicted injury (for example, cutting) in this population (Wiklander et al., 2012). This incorporation of shame in interpreting certain situations has also been observed in children and youth with characteristics of borderline personality disorder (Hawes, Helyer, Herlianto, & Willing, 2013). Cognitive factors in borderline personality disorder are just beginning to be explored. Here, the questions are, how do people with this disorder process information, and does this contribute to their difficulties? One study that looked at the thought processes of these individuals asked people with and without borderline personality disorder to look at words projected on a computer screen and to try to remember some of the words and forget others (Korfine & Hooley, 2000). When the words were not related to the symptoms of borderline personality disorder—for example, “celebrate,” “charming,” and “collect”—both groups performed equally well. However, when they were presented with words that might be relevant to the disorder—for example, “abandon,” “suicidal,” and “emptiness”—individuals with borderline personality disorder remembered more of these words despite being instructed to forget them. This preliminary evidence for a memory bias may hold clues to the nature of this disorder and may someday be helpful in designing more effective treatment (Baer, Peters, Eisenlohr-Moul, Geiger, & Sauer, 2012; Winter, Elzinga, & Schmahl, 2013). An important environmental risk factor in a gene–environment interaction explanation for borderline personality disorder is the possible contribution of early trauma, especially sexual and physical abuse. Numerous studies show that people with this disorder are more likely to report abuse than are healthy individuals or those with other psychiatric conditions (see, for example, Bandelow et al., 2005; Kuo, Khoury, Metcalf, Fitzpatrick, & Goodwill, 2015; Zanarini et al., 2014). Unfortunately, these types of studies (based on recollection and a correlation between the two phenomena) do not tell us directly whether abuse and neglect cause later borderline personality disorder. In an important study, researchers followed 500 children who had documented cases of childhood physical and sexual abuse and neglect and compared them in adulthood with a control group (no history of reported abuse or https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 4/7 3/27/24, 9:37 PM Print Preview neglect) (Widom, Czaja, & Paris, 2009). Significantly, more abused and neglected children went on to develop borderline personality disorder compared with controls. This finding is particularly significant for girls and women because girls are two or three times more likely to be sexually abused than boys (Bebbington et al., 2009). It is clear that a majority of people who receive the diagnosis of borderline personality disorder have suffered terrible abuse or neglect from parents, sexual abuse, physical abuse by others, or a combination of these (Kleindienst, Löffler, Herzig, Bertsch, & BekraterBodmann, 2020; Mainali, Rai, & Rutkofsky, 2020; Temes et al., 2020). For those who have not reported such histories, some research is examining just how they could develop borderline personality disorder. For example, factors such as temperament (emotional nature, such as being impulsive, irritable, or hypersensitive) or neurological impairments (being exposed prenatally to alcohol or drugs) and the ways they interact with parental styles may account for some cases of borderline personality disorder (Graybar & Boutilier, 2002). Symptoms of borderline personality disorder have been observed among people who have gone through rapid cultural changes. The problems of identity, emptiness, fears of abandonment, and low anxiety threshold have been found in child and adult immigrants (Laxenaire, Ganne-Vevonec, & Streiff, 1982; Skhiri, Annabi, Bi, & Allani, 1982). These observations further support the possibility that prior trauma may, in some individuals, lead to borderline personality disorder. Remember, however, that a history of childhood trauma, including sexual and physical abuse, occurs in people with other disorders, such as schizoid personality disorder, somatic symptom disorder (see Chapter 6), panic disorder (see Chapter 5), and dissociative identity disorder (see Chapter 6). In addition, a portion of individuals with borderline personality disorder have no apparent history of such abuse (Cloninger & Svakic, 2009). Although childhood sexual abuse and physical abuse and neglect seem to play an important role in the etiology of borderline personality disorder (Kleindienst et al., 2020; Mainali et al., 2020; Temes et al., 2020), neither appears to be necessary or sufficient to produce the syndrome. An Integrative Model Although there is no currently accepted integrative model for this disorder, it is tempting to borrow from the work on anxiety disorders to outline a possible view. In Chapter 5, we describe the triple vulnerability theory (Barlow, 2002; Suárez, Bennett, Goldstein, & Barlow, 2008). The first vulnerability (or diathesis) is a generalized biological vulnerability. We can see the genetic vulnerability to emotional reactivity in people with borderline personality disorder and the ways this affects specific brain function. The second vulnerability is a generalized psychological vulnerability. People with this personality disorder tend to view the world as threatening and to react strongly to real and perceived threats. The third vulnerability is a specific psychological vulnerability learned from early environmental experiences; this is where early trauma, abuse, or both may advance this sensitivity to threats. When a person is stressed, their biological tendency to be overly reactive interacts with the psychological tendency to feel threatened. This may result in the outbursts and https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 5/7 3/27/24, 9:37 PM Print Preview suicidal behaviors commonly observed in this group. This preliminary model awaits validation and further research. Treatment In stark contrast to individuals with antisocial personality disorder, who rarely acknowledge requiring help, those with borderline personality disorder appear quite distressed and are more likely to seek treatment even than people with anxiety and mood disorders (Ansell, Sanislow, McGlashan, & Grilo, 2007; Bender et al., 2014). Reviews of research on the use of medical treatment for people with this disorder suggest that symptomatic treatment may not be helpful (Stoffers-Winterling, Storebø, & Lieb, in press). Efforts to provide successful treatment are complicated by problems with drug misuse, noncompliance with treatment, and attempts to take their own lives. As a result, many clinicians are reluctant to work with people who have borderline personality disorder. One of the most thoroughly researched cognitive-behavioral treatments was developed by Marsha Linehan (Linehan et al., 2006; Linehan et al., 1999; Linehan & Dexter-Mazza, 2008). This approach—called dialectical behavior therapy (DBT) (Promising treatment for borderline personality disorder that involves exposing the client to stressors in a controlled situation, as well as helping the client regulate emotions and cope with stressors that might trigger suicidal behavior.) —involves helping people cope with the stressors that seem to trigger suicidal behaviors and other maladaptive responses. Priority in treatment is first given to those behaviors that may result in harm (suicidal behaviors), then those behaviors that interfere with therapy, and, finally, those that interfere with the patient’s quality of life. Weekly individual sessions provide support, and patients are taught how to identify and regulate their emotions. Problem solving is emphasized so that patients can handle difficulties more effectively. In addition, they receive treatment similar to that used for people with PTSD, in which prior traumatic events are reexperienced to help extinguish the fear associated with them (see Chapter 5). In the final stage of therapy, clients learn to trust their own responses rather than depend on the validation of others, sometimes by visualizing themselves not reacting to criticism (Lynch & Cuper, 2012). Results from a number of studies suggest that DBT may help reduce suicide attempts, dropouts from treatment, and hospitalizations (Linehan et al., 2015; Linehan & DexterMazza, 2008; McMain, Guimond, Streiner, Cardish, & Links, 2013). A follow up of 39 women who received either dialectical behavior therapy or general therapeutic support (called “treatment as usual”) for 1 year showed that, during the first 6 months of follow up, the women in the DBT group were less suicidal, less angry, and better adjusted socially (Linehan & Kehrer, 1993). Another study examined how treating these individuals with DBT in an inpatient setting (a psychiatric hospital) for approximately 5 days would improve their outcomes (Yen, Johnson, Costello, & Simpson, 2009). The participants improved in a number of areas, such as with a reduction in depression, hopelessness, anger expression, and dissociation. A growing body of evidence is now available to document the effectiveness of this approach to aid many individuals with this debilitating disorder (Linehan, 2014). https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 6/7 3/27/24, 9:37 PM Print Preview Unfortunately, longitudinal studies provide substantial evidence for a high rate of symptomatic remission in borderline personality disorder (BPD) (Zeitler et al., 2020). Probably some of the most intriguing research we describe in this book involves using the techniques in brain imaging to see how psychological treatments influence brain function. One pilot study examined emotional reactions to upsetting photos (for example, pictures of women being attacked) in controls and in women with borderline personality disorder (Schnell & Herpertz, 2007). This study found that among the women who benefited from treatment, arousal (in the amygdala and hippocampus) to the upsetting photos improved over time as a function of treatment. No changes occurred in controls or in women who did not have positive treatment experiences. This type of integrative research holds enormous promise for our understanding of borderline personality disorder and the mechanisms underlying successful treatment. Chapter 12: Personality Disorders: 12-3b Borderline Personality Disorder Book Title: Psychopathology: An Integrative Approach to Mental Disorders Printed By: Wefae Ali ([email protected]) © 2023 Cengage Learning, Inc., Cengage Learning, Inc. © 2024 Cengage Learning Inc. All rights reserved. No part of this work may by reproduced or used in any form or by any means graphic, electronic, or mechanical, or in any other manner - without the written permission of the copyright holder. https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=607607251305910651374883797&eISBN=9780357657881&id=1993194890&snap… 7/7