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"Psych 101 -
What you didn't learn in nursing school."


by Kathi Stringer
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Borderline Personality Disorder
Pathology and Treatment

Written by Kathi Stringer

Revision A. 8/25/03

As a cavort, I would like to suggest that borderline pathology is not the fault of the client because she has not fully reached certain developmental levels. Instead, she has relied on a maze of mental structures and primitive defense mechanisms that contributed to her cognitive dissonance. Yet, I firmly believe that a treater working with a multidisciplinary team conducting a carefully selected treatment plan that could, validate, modify, limit, empathize and provide a holding environment, might reverse what others criticize as the chronic personality disorder. By employing methods of genuine concern and strong countertransference management, the unattainable may be attained.

The indented purpose of this work is to discuss Borderline Personality Disorder (BPD) and its vicissitudes within its respective spectrum. Borderline has long been a controversial label. It was once thought to be denoted some where between psychosis and neurosis (Stern, 1938; Kernberg, 1975). Because of the inconsistency of BPD, professionals have had a hard time setting the criteria for this personality disorder. At one time, BPD was informally used, a catch-all, garbage-can diagnosis for individuals who did not fit into more characteristic diagnostic slots. It wasn’t until 1980 that BPD was included into the DSM III. Five of the eight must be present to meet the criteria for BPD, although, the risk of suicide increases with each inclusion. Note* DSM IV [2] added an extra criteria, #9.

1. Frantic efforts to avoid real or imagined abandonment.

2. Unstable and intense interpersonal relationships. One moment they may idealize their partner, the next, completely devaluate them. (example of splitting)

3. Identity is always in question. Unstable self-image and sense of self. Borderlines have even been know to change their gender in search of self.

4. Impulsiveness. At least in two areas and are self damaging. Such areas include; gambling, sex, reckless driving, spending sprees, binge eating,

5. Suicidal ideation. Self-mutilating, gestures, threats and behavior. Starvation. (in some cases, this is not to die, but to feel something, anything, to feel alive.) drugs & etc.

6. Severe mood shifts. Depressed and lost one moment and euphoric the next.

7. Chronic feelings of emptiness and boredom. Life is generally uninteresting and holds no meaning.

8. Inappropriate display of anger, or difficulty controlling anger, temper tantrums.

9. Stress-related paranoid ideation. Severe dissociate symptoms.

Inclusive, there is empirical evidence pointing to a high comorbidity of transient major depression and axis two Borderline Personality Disorder. Also, 1.8% to 4% of the general population have Borderline Personality Disorder and the female to male ratio is 3:1. The percentage rises with inpatient at 23% and outpatient at 11%.

The preferred treatment modality used by professionals include three components; individual psychotherapy, group therapy and medication. Medication plays an significant role in recovery since 90% of the time medication is used during treatment. It is important that the psychiatrist and psychotherapist keep the lines of communication open to stifle the common countertransference problems in the area.

Two major forms of psychotherapies are used with treatment of the borderline. One is Dialectal Behavior Therapy or DBT (Linehan, 1993) [3] and Psychodymanic Psychotherapy (Kernberg, 1989). First, lets enumerate the principles of psychodymanic therapy and then elaborate further. Stability of the framework of treatment.

Borderline clients do very well with structure.

Minimize Silence

The treater would do well to facilitate the session to minimize silence since it does not go over well with the client. For example (Gabbard ) [1], the treater might say, "You are quiet, would you share with me what you are thinking?" or, "I have a feeling that something is troubling you, and you seem to be sorting it out." or "I noticed with my last remark, you became quiet." This is important to help decrease the risk of the client interpreting the silence as uncaring, callus and cold.

Primary Effect, Anger

The clear and constant hallmark of the borderline is the ubiquitous anger and rage, the primary effect. It would be advantages for the treater to tolerate the project anger, then identify and contain it, rather then retaliating or withdrawing which would impede the therapeutic environment. Working with the borderline triggers countless countertransference problems. The emergence of countertransference stems from the debilitating behavior of the borderline who is unable to function, evoking intense feelings of anger from the therapist.

Link Consequence to Event

The treater should identify the sympathetic elements of self-destructive action that transmutes to consequences. Some of these destructive behaviors are bingeing, self-mutation, self-destructive behavior in interpersonal relationships, suicide gestures to self-bullying. For example, a client may not realize self-mutation is not recognized in society as normal, and has a direct consequence. In the borderline, it is not uncommon for them to have split-off the interpsychic process of "action equals consequence."

Impulsiveness

The unequivocal identification of the borderline is their impulsiveness. They have a tendency to react, rather then to respond. They compartmentalize their unintegrated thoughts, preventing them from making the connection of rational choices. They are completely unaware that events-feelings-behavior are interrelated. For example, Jim told his therapist that he went out and got drunk last night for no apparent reason. He didn’t know why. Exploring this further, earlier that day, Jim had won a class award for which he did not feel worthy. His low self esteem turned to guilt which led to his impulse to drink. Linking these intrinsic factors (events-feelings-behavior) will provide a cathexis to ameliorate cognitive correction, the ability to respond.

Address the Here-and-Now

Given the complex ideology, fifty to seventy percent of borderlines experienced childhood abuse, neglect and trauma. All to often the borderline tends to drudge up the past, exposing buried relics in preference of dealing with the problems of the here-and-now. I am not suggesting their childhood should not be reexamined for relevance to current behaviors, by all means it should be, but rather held in abeyance while dangerous, current inappropriate behaviors are dealt with. For example, Ricky is constantly getting into fights at school and destroying school property. The immediate situation calls for improved coping skills and a plan to advert his reactions to negative stimuli. Now lets turn to:

General principles of Dialectical Behavior Therapy (Linehan) [3]

Once weekly group and once weekly individual therapy

Primary impairment is reviewed as a constitutional dysregulation of control of emotion and effect

A number of behavioral outcomes are identified that result from this underlying difficulty.

Group therapy teaches patients behavioral coping skills.

Individual therapy focuses on 6 goals

Suicidal behaviors

Therapy - Interfering behaviors

Behaviors that interfere with the quality of life.

Behavioral skill acquisition

Posttraumatic stress behaviors

Self-respect behaviors

Suicidal Ideation

According to Linehan [3], parasuicide or suicide crisis behaviors should be taken seriously and I must agree. According to research, seven to ten percent of borderlines kill themselves. When in session a treater might determine when the thought entered the client's mind. For example, the treater could ask what set off the feelings of suicide. At times, a borderline will want to make an impact and erroneously think that her death would severely disrupt the therapist’s life. The treater should acknowledge the patient would be missed but her life would continue as usual. Clients at high suicide risk should not be given lethal drugs and reassessed for the degree or measure of succeeding. Next we have:

Modifications of Psychotherapy with BPD (Gabbard, The Menninger Project) [1] in light of new trauma data.

Aggression is understood in terms of an infantile self, rightly full of rage at parents.

Therapist must established a sense of safety for the patient.

Therapist needs to acknowledge and empathize with the patient’s experience of being victimized (a very helpful validating strategy).

The patient’s anger and manipulative behaviors need to be reframed as understandable, given the patient’s early life experience (creates countertransference).

The therapeutic alliance in patients with BPD was correlated with the therapist interventions.

The client with early trauma, transference interpretation of the patient’s aggression caused the alliance to deteriorate because the client experienced it as a lack of recognition that real tormentors were involved.

Empathic validation and affirmation of the client's perception improved the alliance.

Rightly Full of Rage at Parents

Given what borderlines have been though, they harbor anger, unable to contain it, they seek the all good object that they cannot destroy. Therapy should teach them emotional deregulation management.

Safety for the Patient

Boundaries must be established with clear consequences (Gabbard ) [1]. The borderline incessantly will test limits hoping unconsciously to find immoveable lines of demarcation. It should be understood if the client needs evaluation and poses a danger to herself, the decision for hospitalization will be made by the emergency doctor. This modality will lift the responsibility from the treater and placing it in the hands of others, an applicable therapeutic measure to prevent manipulation or power struggles. Using this agency, a treater will impede countertransference feelings arising out of guilt. This is not to imply that all suicide ideation is borderline pathology, it could very well be a dysthymia depression advancing to major depression.

Interpretation of the Patient’s Aggression

In other words, if the treater rejects the projected anger and interprets that the patient has wrongfully directed the anger toward the treater, then this will usually backfire since the client will feel that the treater has minimized his trauma.

Acknowledge and Empathize with the Patient’s Experience

Typically, the borderline's past is riddled with chaotic battlefields of abuse and neglect amalgamated with an invalidating environment. The treater would do well not to re-victimize the client by continuing the act of the invalidating authoritarian. Survivors have a desire to be seen, heard and believed.

Manipulative Behaviors

Manipulative behaviors should be analyzed and dealt with according. On the other hand, what may look like manipulation to the treater may very well be the unconscious pathological signature of the borderline. Suppose for a moment (Linehan) [3], that a catastrophic earthquake nearly leveled a major city. The police, fireman and emergency crews are severely taxed. No one is able to help you. Trapped in the rubble within a small opening your child you love most in the world cries for help. The opening is too small for you to crawl through; if only she could move a couple of feet. You find a stick hoping that she is able to grasp it, but to no avail. Time is of the essence. Crews are asking people to clear the area. At any moment an aftershock is likely happen. The child is crying. She can’t move because every bone in her body is broken! Do you suppose that she is manipulating you or just being difficult? Are you thinking that she will get out when she is ready? What would you do? Cheerlead, yell, plead, sweet-talk, suggest, threaten, distract and direct!

Therapeutic Alliance

Psychotherapy will not progress if the treater and client are at odds with each other. The treater should declare an armistice and construct common goals with the alliance of the client. A self proclaimed perennial omnipotent treater will find them self working with an severely un-pliable patient, which of course circumvents improvement.

Clinical Manifestations of Splitting in Adults

Alternating expression of contradictory behaviors.

Selected lack of impulse control.

The compartmentalization of individuals into, "all good" & "all bad" camps.

A coexistence of contradictory of self-representations that alternate with one another.

Alternating Expression

Part of a borderlines symptomatology is alternate expression. One moment the client will idealize a person and then completely devaluate them the next. They can experience severe mood shifts from high elation to despairingly low valleys. It’s no wonder they often think they are losing their mind (Kreisman) [4].

References

1. Integrated Treatment of Borderline Personality Disorder - Glen O. Gabbard, M. D. - Video Lecture / APA Series

2. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR - American Psychiatric Association (APA)

3. Cognitive-Behavioral Treatment of Borderline Personality Disorder - Linehan

4. I Hate You, Don't Leave Me - Jerold Kreisman, M.D., Hal Straus