Receiving a diagnosis of borderline personality disorder (BPD) may seem devastating. There’s a lot of confusion about what BPD really means and how it’s actually treated. Along with misunderstanding, there’s also stigma. This can make a person feel even more alone. However, BPD actually affects about two percent of the population. That’s more people than have bipolar disorder or schizophrenia. And there’s good news: Borderline personality disorder is treatable and recovery is possible. Here’s a closer look at everything from what BPD really looks like to how it’s treated to what loved ones can do.
- Individuals with BPD are manipulative. BPD is the result of a combination of causes, including biological factors and a history of being invalidated, which may result in an inability to regulate emotions, according to Michael Baugh, LCSW, an expert in dialectical behavior therapy (DBT) and mindfulness at Third Wave Behavioral Center, his private practice in Seattle. Picture a bell curve of emotionality, Baugh suggested. “Individuals at the more emotional end of the spectrum (like people with BPD and many good therapists) are more easily and strongly triggered by events in their environment, and it takes longer for them to return to baseline — but they can learn the skills to manage these more intense emotions,” he said.
Baugh gave the following example: An emotional child grows up in a stoic family, where he’s constantly told to calm down. He tries to follow the family’s rules by suppressing the awareness of his emotions. As the intensity of his emotions ramps up, however, it eventually bursts out of the zone where it can be ignored. When this happens, the emotions appear to go from zero to 60 on the emotions speedway, and their intensity can’t be controlled. “At that point everybody in the family has to deal with it, and because people need to have emotions responded to, this only reinforces the person getting to emotional extremes,” Baugh said. Consequently, this becomes the only way the person knows how to manage emotional situations.
In other words, a person with borderline personality disorder rarely makes a conscious decision to manipulate anyone. When a person isn’t having their needs met, they resort to extreme behaviors, according to Neil Bockian, Ph.D, founder and president of Behavioral Health Associates and co-author of New Hope For People with Borderline Personality Disorder. These behaviors then get reinforced when family members or people who don’t normally pay attention to them rush in, he said. When loved ones get burned out, the person with BPD starts escalating the behaviors.
- It’s untreatable. “The research shows convincingly that some treatments for BPD are remarkably effective,” said Kristalyn Salters-Pedneault, Ph.D, a clinical psychologist who specializes in BPD and writes a blog on About.com on the disorder.
- BPD is a life sentence. According to Alexander Chapman, Ph.D, president of the DBT Centre of Vancouver and co-author of The Borderline Personality Disorder Survival Guide: “In a recent study of patients with BPD who were hospitalized and then released, up to 70 percent no longer met criteria for the disorder at some point in a six-year follow-up period. Of those people who stopped meeting criteria for the disorder, 94 percent of them never met criteria again across the six years.”
- People with BPD aren’t trying hard enough. According to Joan Wheelis, M.D., director of the Two Brattle Center in Cambridge, Mass., “it isn’t that clients aren’t motivated, but that there is significant emotional, cognitive and behavioral dysregulation associated with the disorder.” People don’t realize just how considerable their deficits are. Many are very intelligent, talented and productive so it’s hard to believe, she said. “The person is doing the best they can given their current mental state,” Bockian said.
According to Salters-Pedneault, “BPD is best treated with a multi-method team approach,” which might include an individual and group therapist and a psychopharmacologist to manage medication. It’s this team who then “can determine the treatment of choice for an individual patient,” said S. Charles Schulz, M.D., head of the department of psychiatry at the University of Minnesota Medical School.
However, too many treatments can result in a “non-treatment treatment,” where the client isn’t fully engaged effectively in therapy, Dr. Wheelis said. She noted the importance of having “a primary clinician who’s responsible for the architecture of the whole treatment.”
Psychotherapy is the central treatment for borderline personality disorder. “To date, the gold-standard treatment for BPD is DBT (dialectical behavioral therapy),” Salters-Pedneault said. While there’s no way to say that DBT is superior — to date, no studies have compared all treatments in a “horse race” — judging by the quantity and quality of the studies that support DBT, it’s currently the best form of treatment, she said. Other promising psychosocial treatments include schema-focused, mentalization-based and transference-focused therapy.
Medications are sometimes prescribed to reduce symptoms of BPD or to treat a co-occurring disorder (such as bipolar disorder) and may help in conjunction with psychosocial treatments. According to Dr. Schulz, while studies haven’t been conclusive, some research has found that individuals who participated in DBT and took olanzapine (Zyprexa) experienced a reduction in symptoms when compared with individuals who attended treatment but took a placebo.
Dr. Wheelis, who advocates the use of medication, worries that “medication may be prescribed too frequently, leading to polypharmacy.” Additionally, “medication for symptoms of BPD can sometimes interfere in teaching the client that they can tolerate and cope with their emotions head-on,” she said.
Dialectical Behavior Therapy (DBT)
Developed by Marsha Linehan, Ph.D, DBT is based on cognitive-behavioral therapy and helps individuals with BPD manage their emotions, develop healthy relationships and lead a meaningful life. “DBT helps people to come to regulate their emotions and be able to truly enjoy life,” according to Baugh.
DBT consists of individual therapy, group skills training and phone coaching. Each week, individuals spend one hour with a therapist and two hours in a group session and complete assignments between sessions. Because symptoms affect every part of a person’s life, “one hour of therapy a week is just not going to cut it,” Salters-Pedneault said.
DBT requires at least a six-month to a year-long commitment, because it’s highly structured, and it takes six months to go through all the modules in a skills group once, Baugh said. It’s often more effective for clients to practice these stages a second time to cement skills and start chipping away at any trauma.
The first stage addresses suicide and self-harming behavior. Stage two involves treating emotional trauma from the past. Stages three and four help clients work on “problems of living and develop their capacity for joy and a sense of being comfortably at home in the universe,” Baugh said.
Challenges & Strengthening Recovery
To get the most benefit out of therapy, and common to DBT practice, Dr. Wheelis asks her clients to tape-record their sessions. “By listening to the session during the week a client can learn more about their struggles.” This can be especially useful for emotionally challenging sessions. Her clients are required to spend a minimum of 20 hours each week participating in meaningful activities outside of therapy (e.g., church, charity, work). The goal is to help individuals develop a life worth living.
Keep in mind that therapy is a process, so “it’s important to be patient, work hard and give therapy a chance to work,” Chapman said. Approach each new skill or lesson with an open mind. For instance, people may doubt the usefulness of mindfulness skills, but with practice and time, many say it’s “the most helpful skill they’ve learned.”
“Sometimes therapy can be like being on a long hike and staying the course despite thunderstorms, blizzards and so on,” Chapman said. If you find yourself losing motivation or wanting to skip sessions or homework, Chapman recommended asking your therapist for help. He helps his clients “come up with at least three critically, life-and-death-important reasons for sticking with therapy, and remind themselves of these reasons when things get rough.”
Ultimately, “Try your best to be kind, compassionate, nonjudgmental and understanding toward yourself… accept yourself for who you are right in this moment, and at the same time, find ways to help improve your life. Remember that you are not to blame for your problems, but you can do something about them,” he said.
“Treatment for BPD is available and it is effective, but it may take time and effort to find the right provider,” Salters-Pedneault said. Look for a provider who specializes in BPD. Behavioral Tech has a list of DBT specialists, and the non-profit organization TARA has more information. If there isn’t a specialist in your area, Chapman suggested checking your local college for psychologists or a psychological association, which may have referral directories.
You also can contact mental health professionals at a local hospital or medical center for a referral to programs or clinicians who specialize in BPD. Some areas have mental health directories. For instance, Vancouver has the “Red Book,” which lists mental health services in your community.
Typically, selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment. SSRIs reduce depression, anxiety, anger, impulsivity and self-injurious and suicidal behavior (Bockian, Porr & Villagran, 2002).
Paul Soloff, M.D., a psychiatrist at the Western Psychiatric Institute and Clinic at the University of Pittsburgh and an expert on BPD, has written extensively about matching medication with symptoms, and has developed these categories.
- Cognitive-perceptual: problems with thought and perception, such as paranoid thinking, suspiciousness and hallucinations.
- Impulsive-behavioral dyscontrol: impulsivity, aggressive behavior, suicidal threats, substance abuse.
- Affective-dysregulation: mood instability, intense and inappropriate anger, feelings of sadness.
According to a recent meta-analysis, which looked at medication efficacy for various personality disorders, antipsychotics were effective in treating cognitive-perceptual symptoms, while mood stabilizers were effective in treating anger and the impulsive-behavioral dyscontrol (Ingenhoven, Lafay, Rinne, Passchier & Duivenvoorden, 2010). Some research also has shown that olanzapine, an atypical antipsychotic, can reduce BPD symptoms, but not all studies have found this, Dr. Schulz said.
In general, a major drawback is that few studies have compared “medications in head-to-head trials,” Dr. Schulz said. Still, there’s been considerable research and many studies do show encouraging results, he concluded.
According to Dr. Schulz, these are some of the ways to maximize the effectiveness of your medication.
- Discuss possible side effects with the prescribing physician. “The physician and patient need to always candidly review the benefits of the prescribed medication in comparison to side effects and move on to other medications or see if the patient still needs medication if side effects outweigh benefits,” he said.
- Take medication as prescribed, and be open with your doctor. “If a patient doesn’t discuss taking medication irregularly, the psychiatrist may think the medication isn’t working and either increase the dose or change medications when such a plan isn’t necessary.”
- Be patient. “Medications generally show best effects over time,” so you won’t experience “immediate or miraculous results.”
- Avoid alcohol and drugs.
Self-harm is common in BPD. People usually self-harm to dull or deal with their emotional pain or to stop feeling numb, Salters-Pedneault said. They also might self-harm to punish themselves, according to Chapman, co-author of Freedom from Self-Harm.
Self-harm is different from suicide. In fact, “Many people engage in self-harm in order to reduce suicidal thoughts and urges,” said Salters-Pedneault, who’s had many clients worry that if they stopped self-harming, they’d become suicidal.
To help clients reduce self-harming behaviors, Chapman first explores their purpose. Next, he works with the client to find healthy but similarly beneficial substitutes for the self-injury. As part of DBT, Chapman also conducts a “chain analysis” to learn “what led to the self-harm, what the consequences were and how to break up this chain of events in the future.”
In addition, clients learn how to “identify their emotions early on before they become overwhelming,” Salters-Pedneault said. Emotions, she tells clients, are helpful because they provide valuable information.
Suicide is also common in BPD. “About 75 percent of people with BPD have attempted suicide at least once in their lives,” Chapman said. About 10 percent will complete suicide.
At Chapman’s treatment center, to prevent suicide, they take a detailed history of the suicidal behavior (and continue to regularly assess risk) and remove anything that can be used to commit suicide. They ask their clients to fill out a “diary card” to keep track of suicidal urges.
If a person is currently suicidal, Chapman helps the client better understand why suicide seems like the best option. If a person has tried to commit suicide, Chapman and the client map out the chain of events, and work on what would fix these issues.
Hospitalization for suicidal borderline patients is frequently very problematic. It may reinforce the very behaviors you’re trying to reduce in treatment, such as turning to suicide instead of using new coping skills to deal with painful emotions, Dr. Wheelis said. If a person “feels attended to, heard and comforted [when hospitalized], it’s likely to reinforce the behavior that led to the hospitalization.” Suicide attempts aren’t manipulative; people with BPD are responding to “contingencies which can be reinforcing or punishing, she said. “If being in the hospital is aversive to a patient, it’s likely that the suicidal behavior which led to the hospitalization may diminish the behavior.”
Suicide is also treated by helping people with BPD “create a life that feels more valuable…so that life stops feeling so meaningless,” Salters-Pedneault said. “We help clients get in contact with their reasons to stay alive and build a life worth living,” Chapman said.
Focusing on suicide makes a person think they’re out of options, which is simply untrue. As Chapman said, “it’s like being locked in a dark room and only seeing the door with the light under it [the suicide door], when in fact, there are several doors; the client just has to turn away from the suicide door to see them.”
For Loved Ones
It’s “important for family members and people in the patient’s social network to be as supportive as possible,” Chapman said. Support your family member while he or she is trying out new skills and then reward the changes. Know what to do in a crisis, and tell your loved one that you’ll work as a team and learn about DBT.
Most often, people with BPD feel misunderstood. You can help by remembering that your loved one is “doing the best they know how,” and “try to validate the part of their experiences and behaviors that make sense to you,” Baugh said. “One thing you can always validate is on the basis of people’s history and brain chemistry,” he said. For instance, you might say, “If I had been through what you have this week, I’d probably feel just like you do.”
But “Don’t validate the invalid,” Baugh said. Instead, find something that you believe is appropriate. “You can validate a person’s intention to do the right thing and focus on whatever positive actions they did during the day,” even as simple as getting out of bed.
Unfortunately, it’s not uncommon for people with BPD to refuse treatment. Many don’t think they have a problem. They may believe that this is who they are, and that everything would be fixed if others reacted to them the way they’d like, Bockian said. “But I’ll work with whoever is motivated,” he said. He works with loved ones, such as parents, to help improve their lives and learn to interact more effectively with the person with BPD.
Bockian helped one client interact with his wife and better understand her behavior, which seemed wildly unpredictable. Before therapy, the client would attribute her anger to an immediate cause. But there were deeper issues. Beneath complaints about his driving simmered feelings of rejection, which really precipitated many spats. His client started talking to his wife about these feelings instead of waiting until an argument exploded. This gave him a greater sense of control, helped him take her behavior less personally and alleviated a lot of his anxiety.
Here are just some of the helpful resources on the web.
- BPD Central: maintained by BPD expert and author Randi Kreger.
- BPD Family: Salters-Pedneault cautioned that though she highly recommends this source for loved ones, readers should keep in mind that some people have been hurt by their family member with BPD and are speaking from this perspective.
- TARA: the largest non-profit organization for BPD. It also offers a national resource and referral center.
- BPD on About.com: includes tons of information on BPD.
Bockian, N.R., Porr, V., & Villagran, N.E. (2002). New Hope For People With Borderline Personality Disorder. New York: Three Rivers Press.
Ingenhoven, T., Lafay P., Rinne, T, Passchier, J., & Duivenvoorden, H. (2010). Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials. Journal of Clinical Psychiatry, 71, 14-25.
Tartakovsky, M. (2010). Living with Borderline Personality Disorder. Psych Central. Retrieved on May 18, 2013, from http://psychcentral.com/lib/2010/living-with-borderline-personality-disorder/
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
Published on PsychCentral.com. All rights reserved.