Dual Diagnosis 
and the Borderline Personality Disorder

 

Sharon C. Ekleberry, 2000

Table of Contents

  • The Borderline Personality Disorder

  • Treating the The Borderline Personality Disorder

  • Dual Diagnosis Treatment: Treating the Addicted Borderline Personality Disorder

  •  

    Cluster B:
    The Borderline Personality Disorder (BPD)

    Essential Feature

    The essential feature of the Borderline Personality Disorder is a pervasive pattern of unstable interpersonal relationships, self-image, and affect. There is marked impulsivity that begins by early adulthood (DSM-IV™, 1994, p. 650).

    The ICD-10 refers to BPD as the Emotionally Unstable Personality Disorder which is characterized by impulsivity, unpredictable moods, outbursts of emotion, behavioral explosions, quarrelsome behavior, and conflicts with others. The ICD-10 divides this category into two types: the impulsive type (characterized by emotional instability and lack of impulse control) and the borderline type (characterized by disturbances of self-image, aims, and internal preferences; chronic feelings of emptiness; intense and unstable interpersonal relationships; and self-destructive behavior) (ICD-10, 1994, p. 228).

    Benjamin notes that individuals with BPD often suffer from thought disorders, affective disorders, dissociative disorders, alcohol and substance abuse, eating disorders, and anxiety disorders. She suggests that with BPD, everything that can go wrong has gone wrong. BPD involves disorder in every domain of function: cognition, mood, and behavior (Benjamin, 1993, p. 113).

    Linehan proposes diagnostic criteria for BPD with specific patterns of behavioral, affective, and cognitive instability and dysregulation:

    • Emotional dysregulation:  These individuals are highly reactive and generally experience episodic depression, anxiety, and irritability; they also have problems with anger and anger expression.
       

    • Interpersonal dysregulation:  Relationships are chaotic, intense, but nevertheless, hard to give up. Individuals with BPD engage in intense and frantic efforts to keep significant others from leaving them.
       

    • Behavioral dysregulation:  Individuals with BPD evidence extreme and problematic impulsive and suicidal behaviors. They often attempt to injure, mutilate, or kill themselves.
        

    • Cognitive dysregulation:  There is indication of nonpsychotic forms of thought dysregulation including depersonalization, dissociation, and delusions that can be brought on by stressful situations.
       

    • Self dysregulation:  Individuals with BPD often have little sense of self; they feel empty. BPD is a disorder of both the regulation of and the experience of the self. (Linehan, 1993, p. 11)

    Kroll suggests that borderline pathology is organized around (1) cognitive style (short-circuiting of thoughts with action, selective amnesia, intrusive imagery, cognitive disorganization under stress, rumination focused upon a few unpleasant old memories); and (2) emotional lability (a sense that one's own emotions, whether sadness, anger, joy, or love, are overwhelmingly intense). He describes two central borderline themes: (1) victimization and (2) loneliness/emptiness -- a pervasive sense of isolation and distance from the warmth of the human community (Kroll, 1988, pp. 67-68).

    Theodore Millon would like to see the disorder renamed. He has suggested changing BPD to cycloid personality disorder; other possibilities he has mentioned include: ambivalent personality disorder, erratic personality disorder, impulsive personality disorder, quixotic or labile personality disorder (Millon & Davis, 1996, p. 645). He believes that any of these names would more accurately capture the qualities of the personality syndrome better than the term borderline.

    There is some question as to whether or not BPD is a personality disorder or an affective disorder. Millon suggests the possibility that the clinical characteristics of BPD fall not only into that of a personality disorder but also within the broad spectrum of affective disorders (Millon & Davis, 1996, p. 645). Akiskal has suggested that approximately 50% of individuals with BPD suffer from lifelong affective disorders. He suggests that the bipolar spectrum may merge at one end with schizoaffective states and overlap at the other extreme with character disorders (Millon, 1996, pp. 202-203).

    Family histories of individuals with BPD often reveal a relationship to both manic-depression and alcoholism. There may be an inherited genetic predisposition to poor mood regulation. Many of these individuals come from families with abuse, violence, and traumatic separations (Oldham, 1990, p. 305).

    BPD is rarely the only personality disorder diagnosis for most individuals meeting BPD criteria. The most serious overlap, in 10 observed samples, was with histrionic personality disorder. Three studies found that over 50% of individuals diagnosed with BPD also met the criteria for HPD (Gunderson, et. al., Livesley, ed., 1995, p. 142).

    Beck noted that 60% of individuals diagnosed with BPD meet the criteria for other personality disorders as well, including paranoid, schizotypal, histrionic, narcissistic, avoidant, and dependent personality disorders (Beck, 1990, p. 179). Also of note, in studies of several populations meeting the criteria of BPD, 74% were women (Linehan, 1993, p. 4).

    Self-Image

    Individuals with BPD experience an unstable self-concept that oscillates between feelings of inferiority and superiority. Mostly they feel defective, bad, and victimized (Akhtar, 1995, p. 7). Masterson (1981, p. 100) notes that the self-image in the borderline is that of being deficient. On the superior side of the vacillation is a lack of humility and a core of omnipotence, conceit, and self-righteousness (Akhtar, 1995, p. 7).

    BPD self-image is also described as uncertain. These individuals experience confusion based in an immature, nebulous, and wavering sense of identity, often with underlying feelings of emptiness (Millon & Davis, 1996, p. 664).

    View of Others

    Individuals with BPD are ambivalent toward others as well as themselves. They experience rapidly fluctuating and antithetical perceptions and thoughts concerning persons and events (Millon & Davis, 1996, p. 663).

    For individuals with BPD, childhood abuse appears to impact the perception of threat resulting in a more hostile attributional bias. Past physical abuse results in increased sensitivity to cues of threat, impaired processing of social information, and increased probability of selecting an aggressive response (Spoont, Costello, ed. 1996, p. 73). In other words, they may define neutral behavior from others as threatening and respond with aggression. Their tendency to attribute negative intent to others also allows them to view the interpersonal difficulties they have as being independent of their own behavior (Layden, 1993, p. 2).

    Relationships

    Beck (1990, p. 183) notes that individuals with BPD hold extreme, poorly integrated, and unrealistic expectations of interpersonal relationships. They fluctuate between idealization and devaluation of others (Akhtar, 1995, p. 7). The initial position in BPD relationships is that of friendly dependency on a nurturer (which they believe is desired by those upon whom they depend). This becomes hostile control when, inevitably, the caregiver fails to deliver everything individuals with BPD want (Benjamin, 1993, p. 122). The completely good, nurturing caregiver, with the most minor mistake, becomes the object of BPD hate and contempt (Oldham, 1990, pp. 301-303). Millon (Millon & Davis, 1996, pp. 662-663) describes this quality of BPD behavior within relationships as paradoxical. Even though these individuals need attention and affection, they frequently act in unpredictably contrary, manipulative, and volatile ways that elicit the very rejection they fear. Oldham (1990, pp. 301-303) notes that individuals with BPD destroy the relationships they cannot live without. Benjamin (1993, p. 113) describes this quality as individuals with BPD loving without measure the people they will soon come to hate.

    This interpersonal destructiveness in BPD comes from the unstable self-esteem, internal emptiness, and deficient capacity for autonomy within these individuals. Their dread of abandonment leaves them constantly on edge and vulnerable to anxiety, conflict, and anger. When the explosiveness of their dread and rage is expressed within their relationships, they exhaust or exasperate significant others and the feared abandonment becomes a reality. Stone notes that management of interpersonal hostility is the decisive variable in determining how individuals with BPD do in midlife and beyond. Those whose anger and querulousness continue to smoulder on into middle age eventually find themselves isolated from others. Serious depression, resumption of drug abuse, and suicide are all possible results of having destroyed important relationships through anger (Stone, 1993, p. 226).

    Individuals with BPD also vacillate within relationships between the extremes of distance and closeness (Akhtar, 1995, p. 7). Millon describes the BPD seeking of closeness with caring others as precipitating two contrasting and distressful consequences; these individuals will fear both engulfment and abandonment (Millon & Davis, 1996, p. 664).

    Issues With Authority

    Individuals with BPD are inclined to view authority figures with intensified ambivalence, fear, and rage. Those who have authority are both needed and viewed as dangerous. If the authority figures are service providers, they are seen as replicating parental figures who had access to what was needed but were disinclined to provide it, were potentially abusive and had to be seduced or coerced into being benign and protective. These past parental figures also seemed to have the power, skill, ability, and influence to deal with life's problems, i.e., were autonomous in contrast to BPD self-experience as incompetent and powerless.

    BPD Behavior

    Individuals with BPD evidence readily corruptible ethics, standards, and ideals. Their capacity to experience genuine guilt is weak; their only effective restraints on behavior center around shame, fear, and dread of exposure (Akhtar, 1995, pp. 7-8). They may, after interpersonal difficulties, go into a period of self-criticism and self-blame (Millon, 1996, p. 169). In all likelihood, however, these individuals will vacillate between self-hate and rage toward others without resolution or understanding of their own part in the problems they face. Kantor believes that it is characteristic of all the personality disorders to show a tendency to live in the past, or in fantasy, with too little input from current reality. This produces a type of infantilism and mild memory disturbances that are the result of a diminished ability to pay attention to the here and now (Kantor, 1992, pp. 36-41). Accordingly, individuals with BPD often evidence the following cluster of behaviors: minimal adherence to personal ethics, vulnerability to shame, self-blame, rage toward others, and a diminished capacity to attend to and benefit from environmental or interpersonal feedback.

    It is difficult for people to be comfortable with individuals with BPD because they so easily become sullen and hurt or obstinate and nasty. These individuals are readily provoked; they are impatient and irritable unless things go their way. While BPD anguish and despair are genuine, they are also often a means of expressing hostility and can be used to frustrate and retaliate against others. However, individuals with BPD may believe that the obstructiveness, pessimism, and immaturity that others see in them is actually a reflection of their sensitivity and the inconsiderateness that others show toward them (Millon, 1996, pp. 168-169).

    Individuals with BPD are behaviorally inconsistent. Their emotional equilibrium seems to be in constant jeopardy; they are unpredictable and impetuous, erratic, and impulsive (Millon & Davis, 1996, pp. 661-662). They appear to share an impulsive, sensation-seeking trait with individuals with antisocial personality disorder (Zuckerman, Costello, ed., 1996, p. 298).

    Both of these personality disorders (BPD and APD) show increased levels of aggressive behavior (defined as behavior intended to inflict discomfort, hurt, harm, injury, or destruction on others). Anger usually precedes the aggressive behavior. This disposition toward anger and aggression is referred to as irritability (Lish, Costello, ed., pp. 24-26). In particular, individuals with BPD who were sexually or physically abused often show inordinate anger and vindictiveness. These individuals must take responsibility for their hostility and vengefulness toward others; they must stop abusing others in the present for the abuse they experienced in the past (Stone, 1993, p. 257). If these individuals do not take responsibility for their querulousness and irritability, with a corresponding willingness to manage hostile behavior, they face increasingly negative interpersonal consequences (Stone, 1993, p. 226). Stone believes that for individuals with BPD, it is often a case of the "e;nice get nicer"e; and the "e;mean get meaner."e; Prognosis in treatment appears to be dependent on the management of hostility more than any other variable (Stone, 1993, pp. 255-256).

    Linehan identifies six behavioral patterns evidenced in BPD:

    1. Emotional vulnerability.  Individuals with BPD have severe difficulty in regulating negative emotions -- including sensitivity to negative emotional stimuli, emotional intensity, and a slow return to an emotional baseline.

    2. Self-invalidation.  Individuals with BPD have unrealistically high standards and expectations for self with a tendency to invalidate or fail to recognize emotional responses, thoughts, beliefs, and behaviors.

    3. Unrelenting crises.  Individuals with BPD often engage in "e;parasuicidal"e; behavior, i.e., nonfatal, intentional self-injurious behavior that results in actual tissue damage, self-mutilation, and self-inflicted burns, with little or no intent to cause death.

    4. Inhibited grieving.

    5. Active passivity.  Individuals with BPD fail to engage actively in solving their own life problems while actively soliciting problem solving from others.

    6. Apparent competence.  Individuals with BPD often appear more competent than can be demonstrated through their behavior or accomplishments (Linehan, 1993, pp. 10-14).

    Affective Issues

    Individuals with BPD have been described as "e;hemophiliacs of emotion"e; (Sperry, 1993, p. 357). Linehan suggests that BPD is primarily a dysfunction of the emotion regulation system; the other characteristics of BPD are secondary to this dysfunction. Emotional dysregulation is due to the emotional vulnerability (defined as high sensitivity to emotional stimuli or a low threshold for emotional reaction), emotional intensity (extreme emotional reactions), and a slow return to emotional baseline, plus the inability to regulate emotions. These difficulties have their roots in biological predispositions which are exacerbated by environmental experiences. The emotional experience of BPD is one of chronic aversive affective experiences. Failure to inhibit maladaptive, mood-dependent actions follow (Linehan, 1993, pp. 42-43).

    Linehan (1993, p. 60) suggests that self-mutilation has an important affect-regulating function. While the exact mechanism is unclear, many individuals with BPD report substantial relief from anxiety and other intense negative feelings after cutting or burning themselves.

    Millon notes that the most salient feature of BPD is the depth and variability of moods (Millon & Davis, 1996, p. 646). This emotional instability can also be called emotional lability or reactivity. Spoont sees emotional instability as primarily a temporal and behavior related trait, i.e., it must be conceptualized as the lack of stable behavior over time. He sees emotional instability expressed behaviorally as a form of impulsivity. He proposes four behavioral characteristics of emotional instability: unpredictability of responses to stimuli; increased lability; unusual intensity of responses, and unusual responses (Spoont, Costello, ed., 1996, pp. 48-49).

    Individuals with BPD struggle with despondency, rage, fury, self-hatred, arrogance, anxiety, uncertainty, emptiness, dependency, stubbornness, and self-damaging impulses. These individuals are desperate, intense, and unstable; they cannot self-comfort. They flee into impulsive sex, food, drugs, shopping (or shoplifting). They may self-mutilate. These activities will temporarily make them feel calmer (Oldham, 1990, p. 303).

    Defensive Structure

    The BPD defensive regulatory mechanism is regression. Individuals with BPD show a tendency under stress to retreat to developmentally earlier levels of anxiety tolerance, impulse control and social adaptation (Millon & Davis, 1996, pp. 664-665). For these individuals, the capacity to tolerate anxiety, depression, or frustration is limited. They have minimal capacity to perceive or accept reality limitations. They have difficulty differentiating past and present, reality and fantasy, and mature and infantile aspects of their mental life (Masterson, 1981, pp. 147-148).

    Individuals with BPD are characterized by a predominance of primitive defensive operations: splitting, dissociation, primitive idealization, primitive projection, denial, and omnipotence. There is a defensive capacity to keep contradictory experiences of the self and others out of awareness. BPD is further characterized by the absence of anxiety tolerance, impulse control, or developed channels of sublimation. The limited ability of individuals with BPD to tolerate anxiety refers to the tendency to develop increased symptoms or regressive behavior with increased tension. Impulse control addresses the inability of these individuals to experience instinctual urges or strong emotions without having to act on them against their own better judgement. Sublimatory ineffectiveness refers to the degree to which individuals with BPD are unable to invest themselves in values beyond their immediate self-interest or self-preservation (Kernberg, 1984, pp. 15-19).

    Table of Contents

    Treating the Borderline Personality Disorder

    The Borderline Personality Disorder Coming Into Treatment

    Individuals with BPD may enter treatment in either mental health or substance abuse facilities. They may self-refer or be referred via the criminal justice system. If self-referred, these individuals may have an extensive history with mental health treatment. They are inclined to work their way through large systems by being treatment demanding and simultaneously treatment resistant. They are inclined to be drug-seeking and volatile when displeased with either the treatment or the service providers.

    A prominent BPD motivation for treatment is to receive the support these individuals were deprived of in childhood (Masterson, 1981, p. 152). Individuals with BPD typically come to treatment with an erratic, inconsistent, and unpredictable pattern of problems including unstable relationships, labile mood, impulsivity, and identity confusion. Variability is the hallmark of BPD; no single feature or pattern is invariably present (Beck, 1990, pp. 178-180).

    Medication Issues

    Psychotropic medication may be useful for individuals with BPD depending on presenting symptoms. However, over time, medication often proves less than helpful as personality issues confound the medication issues. Problems in medicating BPD include non-compliance, demands for frequent changes in the dose or type of medication, overdosing, and failure to accurately report change, e.g., reporting feeling worse when apparently doing better (Sperry, 1995, p. 75). The BPD propensity for alcohol and drug abuse and addictive behavior is also a concern in using medication. Alcohol and others drugs can potentiate prescribed medication and heighten chances for an accidental overdose. Or individuals with BPD may decide to use prescribed medications in combination with alcohol and other drugs to attempt suicide (Layden, 1993, pp. 111-112).

    The general guidelines for use of medication with BPD emphasize that the medication must be matched to specific target symptoms such as affective instability, transient psychotic phenomena, ragefulness, irritability, aggression, impulsivity, anxiety, and depression.

    • Mood or affective instability is a core or fundamental feature of several personality disorders and is defined as excessive vulnerability of mood to environmental and interpersonal stressors; when referring to perceived interpersonal criticism or abandonment, mood instability has been called rejection sensitivity. Mood instability is prominent in histrionic, narcissistic, borderline, and avoidant personality disorders. MAOIs and lithium have been helpful. Currently, Depakote is frequently utilized for mood instability. Fluoxetine may also decrease mood lability (Ellison & Adler, Adler, ed., 1990, p. 52).
       

    • The transient psychotic phenomena experienced by some individuals with BPD have been treated with antipsychotic medication. Low dosages for short periods of time can improve BPD reality testing, attention span, and reduce pervasive anxiety. Neuroleptic medication has also been found to be effective in counteracting aggressivity and impulsivity (Layden, 1994, p. 104).
       

    • Ragefulness, irritability, and aggression have been treated by a number of medication. Lithium carbonate, carbamazepine, antidepressants, beta-noradrenergic receptor antagonists, buspirone, and antipsychotic medication all appear to have some usefulness in reducing aggression. SSRIs are promising for treating paranoia, interpersonal sensitivity, and hostility -- however, low doses may not be effective for BPD; Prozac doses can be as high as 80 mg. per day (Gunderson & Links, Gabbard & Atkinson, eds., 1996, pp. 974-976).
       

    • Even though antidepressants and antianxiety medications have been used to treat aggression, there are studies that suggest tricyclic antidepressants and alprazolam are both associated with increased impulse and behavior dyscontrol (Lish, Costello, ed., 1996, pp. 37-38). Amitriptyline seems to cause BPD symptoms to get worse: MAOIs seem more promising (Ellison & Adler, ed., 1990, p. 46). However, MAOIs require stringent controls on food intake that individuals with BPD, particularly those vulnerable to suicidal ideation or behavior, may not be able to meet.
       

    • Anticonvulsant medication such as carbamazepine (Tegretol) may be effective in controlling rage outbursts, identity confusion, and depersonalization. Unfortunately, Tegretol does not improve BPD subjective mood; it may actually precipitate a depressive episode. However, it is possible that combining Tegretol with Prozac, Zoloft, or Welbutrin could be effective (Layden, 1993, pp. 105-106).
       

    • Impulsivity is defined as a decreased threshold for motor disinhibition with or without associated hyperactivity. Impulsivity is most typical with BPD, NPD, and APD. This behavior may represent a failure to integrate and respond to environmental cues that should be inhibitory. SSRIs have been accumulating positive anecdotal evidence in the treatment of impulsivity. Lithium also enhances serotonergic activity and has been shown to reduce aggressive and impulsive behavior in individuals with a variety of personality disorders (Ellison & Adler, Adler, ed., 1990, pp. 50-51).
        

    • Anxiety in BPD is often reflected in low tolerance to stimulation and a high anticipation of harm. While BPD anxiety is responsive to benzodiazepines; these medications are addictive and have been associated with disinhibition of impulse control and the release of violent behavior (Gunderson & Links, Gabbard & Atkinson, eds., 1996, pp. 974-976). Layden (1993, p. 103) also encourages caution in the use of benzodiazepines with individuals with BPD because of the potential for dangerous disinhibition of behavior. This could be manifested in increased physical aggression, angry outbursts, self-harmful behavior, and suicidal behavior.
        

    • Depression often accompanies mood instability; it is marked by low energy and leaden fatigue. Individuals with BPD are among the most vulnerable of the personality disorders to dysphoria and depression. Standard antidepressant medication can be helpful (Ellison & Adler, Adler, ed., 1990, p. 53).

    General guidelines when considering medication for BPDs:

    • If possible, medicating individuals with BPD should wait until rapport has been developed with the primary service provider.
       

    • Service providers should maintain a positive attitude toward medication without presenting it as a cure all (or a substitute for therapy).
       

    • Medication should not be introduced, overtly or covertly, as an expression of service provider exasperation or frustration with treatment.
       

    • Individuals with BPD may respond with anger and criticism to the suggestion of medication (or conversely, they may demand medication immediately upon entering treatment). Service providers need to be prepared for either.
       

    • Medication should be suggested in the spirit of a collaboration exploration.
       

    • The service provider must combat their own negative expectations about medicating individuals with BPD.
        

    • When introducing medication to individuals with BPD, the roles and responsibility the treatment provider, patient, and medical personnel should be calmly and respectfully clarified.
       

    • Risks and benefits of medication should be openly discussed with clients with BPD (Layden, 1994, pp. 106-107).

    Treatment Provider Guidelines

    Remember that individuals with BPD have a high level of interpersonal skill (they can disrupt entire systems), but they use their abilities in destructive ways. It is vital that support be given in the service of positive functioning rather than in the service of chaos, misery, and regression (Benjamin, 1993, pp. 132-133).

    Individuals with BPD bring rage, intense moods, extraordinary demands for attention, testing behavior, and self-damaging behavior to the treatment process. They can provoke feelings of helplessness and anger in service providers. It is, therefore, vital to set and enforce limits so that the treatment provider can remain involved, compassionate, reliable, and consistent (Oldham, 1990, p. 306). Sperry (1995, pp. 65-66) noted five points of consensus in treating individuals with BPD: the service provider must be active in identifying, confronting, and directing client behaviors; there must be a stable treatment environment; BPD clients must learn to connect actions and feelings; self-destructive behavior must be made ungratifying; and countertransference feelings must receive careful attention.

    Linehan (1993, pp. 106-108) suggests basic assumptions needed by service providers regarding individuals with BPD:

    • They are doing the best they can.
       

    • They want to improve.
       

    • They need to do better, try harder, and be more motivated to change.
       

    • They did not cause all of their problems but they have to solve them anyway.
       

    • The lives of of individuals with BPD who are suicidal are unbearable as they are currently being lived.
       

    • Individuals with BPD must learn new behaviors that are not mood-dependent.
       

    • Service providers working with these individuals need support.

    It is important to remember that the secondary gain from BPD self-mutilation, which can evoke service provider feelings of anxiety and rage at being manipulated, does not reduce the danger involved in the behavior. The behavior is reinforced by the relief from internal pressure it provides through de-focusing from affective pain. Individuals with BPD are often able to dissociate from the physical pain and cannot modulate the behavior via an aversive reaction to that pain. Crisis management and a direct treatment focus on self-damage is essential.

    Countertransference Issues

    The potential range of treatment provider responses to individuals with BPD go from over-involvement with excessive emotional investment to detachment with excessive self-protective distancing. The over-involved position manifests in service provider certainty of being able to rescue individuals with BPD from their psychological problems. The self-protective responses show up in the service providers' eagerness to limit or terminate the therapeutic relationship in response to outbursts and irrational demands. There is a mid-range on this continuum that is characterized by sedate caring, interest, supportiveness, and objective understanding (Layden, 1993. pp. 122-123). The therapeutic relationship with individuals with BPD can be so unstable that service providers bounce back and forth between the excessively distant and excessively involved extremes -- mirroring the clients' pathology (Layden, 1993, p. 124).

    In the worst of circumstances, Gabbard & Wilkinson (1994, p. xi - 6) believe that countertransference with clients with BPD can compel clinicians to engage in ill-advised behavior that results in unethical boundary transgressions. Service providers may come to believe that they are responsible for BPD clients and that love or friendship within the therapeutic relationship will be healing, i.e., that the problem is how these individuals have been treated by others. Clinicians may respond to the BPD form of entitlement that is manifested through demands to be treated as exceptions to usual treatment and program procedures. To ward off BPD anger at being denied special consideration, treatment providers may extend sessions, engage in inappropriate self-disclosure, defer payment or not charge any fee, and engage in physical or sexual behavior.

    The difficulty in working with individuals with BPD is that they will actively coerce nurturance until the service providers burn out. During treatment with these individuals, treatment providers are at risk for an ever increasing sense of loss of control. Also, whether there is or is not any progress in treatment, clients with BPD will eventually feel abandoned and engage in rageful and self-destructive behavior. Countertransference may then tend toward hostile dominance as the treatment providers directly experience that clients with BPD are victims who have learned the tactics of abuse and are willing to use them (Benjamin, 1993, pp. 130-131).

    In the productive therapeutic relationship, service providers maintain benign objectivity; show genuine concern for well-being of these clients; are "e;real people"e; who are consistently positive and supportive; maintain a firm grounding in reality, an even temperament, and an unthreatened willingness to address acting out and distortions from clients with BPD. Willingness to consult with a colleague is also an good indication of a healthy approach to working with these individuals (Layden, 1993, p. 124).

    Treatment Techniques

    Assessment of individuals with BPD should include:

    • a history of self-harm and unsafe behaviors;
       

    • a history of previous treatment;
       

    • a list of potential means for self-harm;
       

    • a history of dissociative experiences (identify what is lost: behavior, affect sensation, or knowledge);
       

    • a psychosocial history and history of sexual abuse;
       

    • a neurological workup of individuals who have a history of self-mutilating behavior that could have resulted in head injury;
       

    • presence of psychotic thinking;
       

    • and a history of suicidal behavior (Ries, TIP #9, 1994, pp. 57-58).

    It is also imperative that BPD assessment address substance use and compulsive behaviors.

    Basic treatment principles in working with individuals with borderline personality disorder:

    • Identify, confront, and treat comorbid substance abuse disorders and depression. Follow-up studies suggest that treatment of comorbid substance abuse disorder greatly improves the outcome of BPD treatment.
       

    • Learn to differentiate nonlethal self-harm from true suicidal intent. Lifetime risk of suicide in individuals with BPD is 10%. With untreated alcoholism, dually diagnosed individuals with BPD have a 5-year survival rate as low as 58%.
       

    • Stress that treatment is a collaborative enterprise; service providers are neither omnipotent nor omniscient.
       

    • Manage countertransference. Learn to assist clients with BPD to work through projections rather than responding with old and familiar forms of interaction.
       

    • Set a "e;low threshold for seeking consultation."e; Do not provide service in isolation (Gunderson & Links, Gabbard & Atkinson, eds, 1996, pp. 969-970).

    A major issue in BPD treatment is learning emotional modulation. Linehan (1993, p. 59) suggests that most borderline behaviors are either attempts to regulate intense affect or are the outcomes of emotional dysregulation. Emotional dysregulation is both the problem being solved and the source of additional problems. Impulsive and suicidal behaviors can be seen as maladaptive solution behaviors to the problem of overwhelming, uncontrollable, intensely painful negative affect.

    There are basic skills for effective emotional modulation that can be learned by individuals with BPD. They need the ability to reduce maladaptive mood-dependent behaviors; they must learn to trust and validate themselves as well as their emotions, thoughts, and activities. Four major emotional modulation abilities are: a) inhibiting inappropriate behavior related to strong negative or positive affect; b) self-regulating physiological arousal associated with emotions; c) refocusing attention in the presence of strong emotions; and d) organizing self for action in the service of an external, non-mood-dependent goal (Linehan, 1993, p. 46). General skills that assist in emotional modulation for individuals with BPD are: 1) skills that increase interpersonal effectiveness in conflict situations; 2) skills that increase self-regulation of unwanted emotions; 3) skills for tolerating emotional distress; and 4) skills that increase the ability to experience emotions and avoid emotional inhibition (Linehan, 1993, p. 62).

    In treating BPD aggression, it is important to identify aggressive motives that exist in the here and now and to make the accompanying inappropriate behavior visible and dystonic. BPD aggression may be understood in terms of an immature self full of rage at parents who failed to provide for survival and developmental needs -- and who may have been directly involved in abuse (Gunderson & Links, Gabbard & Atkinson, eds., 1996, p. 970). However, current aggression elicits counteraggression and must be managed. Individuals with BPD must learn to recognize their own inclination toward and skills in being abusive toward others.

    Supportive treatment for individuals with BPD has a focus on the reality problems of daily life. The goals of supportive therapy are improving these clients' adaptation to their life circumstances and diminishing the likelihood of self-destructive behavior (Gunderson & Links, Gabbard & Atkinson, eds., 1996, p. 970). In group therapy, peers are more able than treatment providers to confront maladaptive and impulsive behaviors. They can be very effective in identifying dependent or manipulative gratifications and making them less acceptable as behaviors to individuals with BPD (Gunderson & Links, Gabbard & Atkinson, eds., 1996, p. 973).

    Linehan's (1993, p. 19) dialectical behavior therapy includes active education about emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self-management skills. It also involves the core treatment techniques of: problem solving, skill training, contingency management, and cognitive modification. Linehan's DBT approach uses supportive acceptance balanced with confrontation and change strategies.

    Finally, the TIP #9 (Ries, 1994, pp. 57-59) suggests that BPD treatment include the use of written and verbal contracts for safety. These contracts should be limited to clear behavioral responses for managing unsafe feelings and behaviors. They should be simple and direct, e.g. If I want to get drunk, I will call my sponsor. Also effective in BPD treatment is the use of mini-contracts for each session to stay focused. Here the service provider states the purpose of each session, uses a checklist, encourages the client with BPD to keep mood and dream journals, limits survivor work to a time after daily living skills are demonstrated, and keeps and dates all correspondence and notes from telephone conversations.

    Treatment Goals

    Personality disorders derive in part from patterns of behavior and thought that would appear to be hard-wired into the central nervous system during the first six years of life. It is understandable that PDs are hard to modify and slow to change. However, studies suggest that positive changes can occur. The treatment goal in working with all of the personality disorders is the same: the gradual development of new, more adaptive habits of thought and behavior that prevail over the preexisting, maladaptive patterns (Stone, 1993, p. 152).

    Treatment goals for individuals with BPD must include management of unsafe behaviors, affect management, and reduction of substance abuse. Linehan (1993, pp. 126-127) suggests that a central BPD treatment goal is management of self-mutilating behavior. The rate of completed suicides for individuals with BPD who cut or burn themselves is twice that of those who do not. This behavior can also damage the body irrevocably and presents the possibility of accidental death. The effectiveness of treatment will be based, at least in part, on the development of an intent in these individuals to help rather than harm themselves.

    Table of Contents

    Dual Diagnosis Treatment: Treating The Addicted Borderline Personality Disorder

    Cluster B: Incidence of Co-Occurring Substance Abuse Disorders

    Cluster B has the highest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, O'Connell, ed., 1990, p. 184).

    Stone (1993, p. 222) suggests that a complicated reciprocal relationship exists between BPD and illicit drugs. Abuse of alcohol and certain drugs, e.g., amphetamines, can intensify the symptomatology of BPD by making impulsivity worse. However, it is also possible that abuse of amphetamines, marijuana, or psychedelics sets in motion a deterioration of habits and self-control that leads to a clinical picture resembling BPD.

    Millon (1996, p. 200) notes that individuals with BPD are characterized by drug-seeking behavior. Individuals with BPD will be particularly vulnerable to the escape offered by drugs and alcohol. Real world interaction triggers multiple interpersonal crises and overwhelming negative affect. Drugs can, ostensibly, offer relief from BPD turmoil and emptiness.

    Khantzian, et. al. (1990, p. 3) view the treatment of any character disorder as the road to recovery from addiction. However, this approach demands a continued attention to and concern about maintaining abstinence and avoiding relapse. Addiction becomes a disorder in its own right and must be addressed directly. However, the treatment of personality disorders can lead to profound change in the personality disordered individual's experience of self and the world, which, in turn, can positively affect recovery from addiction.

    Drugs of Choice for the Borderline Personality Disorder

    Individuals with BPD experience extraordinary affective discomfort. They are frequently agitated, labile, and overwhelmed. They do not define themselves as able or effective in managing their own lives. Their defenses are regressive; under stress they become more childlike. Drugs and alcohol can offer these individuals a way of coping; drugs can block out sensations of pain, discomfort, or negative affect. The appeal of drugs and other compulsive behaviors in soothing, distracting, and escaping is apparent and powerful. Richards (1993, pp. 280-281) states that individuals with BPD, over any of the other personality disorders, are the "e;best candidates"e; for developing addictive disorders. These individuals will use almost any drug or route of administration to their own worst advantage, They often abuse prescribed medications and may hoard these medications for suicide attempts.

    Individuals with BPD often use alcohol and other drugs in a chaotic and unpredictable pattern; they may engage in a polydrug pattern involving alcohol and other sedative-hypnotics for self-medication. Clients with BPD often abuse benzodiazepines that have been prescribed for anxiety -- which can lead to a relapse to their actual primary drug of choice (Ries, TIP #9, 1994, p. 55).

    The issue of prescribed medication for individuals with BPD is complex and difficult. These individuals often demand medication for anxiety and become quite angry when denied. They are noncompliant with medication -- either using too much or too little. They are inclined to misreport the impact of the medication, saying they feel better when they do not or worse when they feel better. The intensity of their discomfort can make prescribing of addictive medication seem more reasonable than it should. Their propensity for crises often brings them into contact with an array of service providers and medical personnel. They are quite frequently successful in obtaining the medication they seek, usually benzodiazepines, from at least one doctor from whom they receive services. Then it becomes difficult to withdraw a drug to which they may have already developed physical adaptation and tolerance. Many individuals with BPD are informed enough to tell medical personnel that if they do not receive a prescription for Zanax, for example, they will probably have a seizure.

    Another issue regarding drug of choice for individuals with BPD has to do with their intolerance for being alone and the intensity of their relationships. These individuals will often use drugs and alcohol as part of their contact with needed others. The drug of choice will then be incidental to that used by their social contacts. Recovery in these situations will be dependent upon linking addicted clients with BPD to a strong support network that fosters abstinence such as AA or NA.

    Dual Diagnosis Treatment for the Borderline Personality Disorder

    Richards (1993, p. 278) suggests that treatment failures for the dually diagnosed are often a result of failure to consider the function of the addiction, including the drug of choice, within the context of the psychopathology dominant in the individual. Salzman (Mule, ed., 1981, pp. 346-347) believes that the inner forces that initiate and sustain addiction are immaturity and inappropriate, magical coping techniques. Dual diagnosis treatment must involve recognition of these tendencies that foster addictive behavior, i.e., immaturity, escapism, and grandiosity. New ways must be learned for dealing with feelings of powerlessness and helplessness other than compulsivity.

    When individuals with BPD cannot self-comfort, they flee into impulsive sex, food, drugs, shopping (or shoplifting). Impulsive and self-destructive behaviors will temporarily allow them to feel calmer (Oldham, 1990, p. 303). Conversely, panic is a frequent and significant reaction to confrontation of drug use or compulsive behaviors. The drug/behavior may have become so important to individuals with BPD that it is perceived as necessary for survival. This panic can be the cause of lying, avoidance, or treatment withdrawal. Life without the drug of choice appears impossible and incomprehensible.

    When individuals with BPD, who have not previously reported other compulsive behaviors, are able to achieve abstinence from their drug of choice, service providers must address the possibility of or check for alternative addictive involvement, e.g., shopping, shoplifting, impulsive and unsafe sexual behavior, or gambling. Recovery programs must cover all addictive patterns.

    Dual diagnosis treatment for addicted individuals with BPD must address the function of the addictive substance and/or compulsive behaviors while developing strong substitutes that can sustain recovery behaviors and abstinence, e.g., involvement in AA or NA, affect management (particularly anger), medication compliance, cognitive self-calming techniques, identified recovery behaviors, e.g., daily contact with sponsors, and therapy for issues related to a family history of physical or sexual abuse. The treatment modality of choice is rarely long-term individual therapy. Group more effectively addresses transference issues and is compatible with fostering affective management techniques, life management skills, and recovery community involvement

    Twelve-step group participation may be a more successful process for individuals with BPD with pre-12-step practice sessions. These individuals should be helped to organize their thoughts and to practice saying "e;pass"e; when feeling unsafe. They should be encouraged to join same sex groups when possible and use same sex sponsors. If appropriate, sponsors can be brought into a treatment session to learn why individuals with BPD are taking medication and to discuss setting boundaries. Further, individuals with BPD need to learn the difference between powerlessness and helplessness (Ries, TIP #9, 1994, p. 60).

    Relapse for individuals with BPD is defined as engaging in any unsafe behavior such as AOD use, self-harm, and noncompliance with medications. Relapse prevention must focus on both preventing AOD use and recurrence of psychiatric symptoms (Ries, TIP #9, 1994, p. 60).

    Confrontation usual to substance abuse treatment may be useful with high-functioning individuals with BPD. It will overwhelm lower-functioning individuals. Service providers must be aware of the severity of pathology in each individual with BPD when deciding on the use of confrontation techniques. Abstinence can be a prerequisite to treatment only with very high-functioning individuals with BPD; otherwise, it needs to be a goal of treatment. Use should be confronted but not result in termination from treatment.