21 Apr Cognitive Behavioral Therapy (CBT)
Borderline Personality Disorder and Treatments
By Farnoush Termeforoosh, LMFT
Personalities are what sets us apart from each other, and it’s how we define ourselves and relate to others. We may describe others as “having a great personality” or “their personality is what sets them apart”. What about those individuals with certain personalities that responding with sudden and intense emotions changing very frequently based on their interpretation? These individuals have a certain personality that confuses even the closest family members and creates distance and disconnect. These individuals misinterpret their interactions with others, often invoking feelings of hurt, sadness, anger and anxiety, depression, loneliness, and emptiness. These individuals demonstrate high, intense level of emotions and take a longer time returning to baseline due to inability to regulate their emotions. They have a hard time taking responsibility for their behaviors and feeling, often blaming others. These individuals usually had an unstable, chaotic family system, where one or both parental figures are absent (physically, mentally, emotionally) and/or they are raised in an abusive environment.
These individuals may have what is called Borderline Personality Disorders (BPD), a disorder that mainly impacts relationships and is one of the hardest disorders to treat. According to National Alliance for Mental Health (NAMI), almost 2% of the US population are diagnosed with Borderline Personality Disorders. Nearly 75% of individuals diagnosed with BPD are women. BPD is a pervasive pattern of instability of emotions, self-image and interpersonal relationship beginning by early adulthood. These are the following symptoms that are prevalent throughout this individual’s life and causes impairment in their functioning.
- Fear of abandonment: This fear is developed in early childhood due to having a poor attachment with one or both parental figures. When a child does not have a nurturing parent to contain them emotionally and provide a stable family system, this child develops a poor sense of self-image. This individual has an emotional need for constant reassurance and connection that plays out throughout their life. Therefore, this individual may demonstrate high intense emotions and reactions to “hold on” to the relationship for fear of losing the relationship. As a result, they end up exhausting others, or pushing others away. Their fear of abandonment has come true, so to speak, and therefore the fear intensifies and becomes a vicarious cycle of self-fulfilling prophecy.
- Unstable relationships: Individuals with BPD tend to get close to people quickly, spending most of their time with that person, and then may end this relationship suddenly when they perceive feelings hurt, rejected, ashamed or abandoned. This individual has no middle ground in relationships where things are negotiated or discussed to resolve misunderstandings or issues. This individual usually responds with extreme emotions of loving someone and without a moment’s notice, hates that person to the core. These reactions tend to confuse others including family members, partners and friends, and as a result, this and may create distance in the relationship.
- Unstable sense of self: This individual has a hard time identifying their sense of self and therefore engages in frequent changes in relationships, jobs, values and goals.
- Impulsive, self-destructive behaviors: Individuals with BPD tend to engage in impulsive behaviors that are due to seeking an emotional need that has been unmet, or the need for more emotional stimulation that can lead to self -destructive behaviors. For example, this individual may perceive feeling rejected by someone they care about, and they may harm themselves or go on an impulsive shopping spree (at times putting themselves in debt) or wanting to feel loved and have intercourse with many people they do not know well on order to fill the emotional void. Suicidal behavior or self-injury may occur in these individuals due to their poor self-regulation skills and misinterpretation of others’ responses. Sometimes they may threaten others for self-harm or make suicidal gestures to gain their own emotional goals.
- Emotional dysregulation or instability in emotions: Individuals with BPD often display varied or random emotions based on their interpretation at that moment, despite their reaction with the same person and the same situation on another day being smooth. For example, this individual may misinterpret their partner as talking to someone else as their partner being interested in another person, fearing this partner does not love them anymore or may leave them. Therefore, they exhibit a strong reaction such as yelling, crying, anger outbursts, being sad or nervous with no evidence or proof, despite the partner’s responses of reassurance. These extreme emotions usually last for a few hours and only rarely continue more than a few days.
The treatment of BPD is mainly therapy and the most effective therapy to address this disorder is Dialectic Behavioral Therapy (DBT). Marsha Linehan PhD created Dialectic Behavioral Therapy (DBT) in the 1970s with her colleagues after discovering that Cognitive Behavior Therapy (focus is on changing perceptions) was not as useful in treating BPD. Marsha Linehan has BPD and had struggled with these symptoms herself. DBT is an evidence-based treatment that consists of 4 elements: Distress Tolerance, Emotion Regulation, Mindfulness and Interpersonal Effectiveness. DBT consists of weekly individual and group therapy that is very structured. This type of treatment focuses initially on gaining control over emotion, then moves on to teach how to express emotions effectively. This individual learns problem solving and eventually gains a sense of completeness and sense of wellbeing.
In conjunction with DBT, psychotropic medications might assist in treating aggression, anxiety, impulsivity, substance use and depression. According to the American Psychiatric Association, SSRI’s (Selective Serotonin Reuptake Inhibitors), mood stabilizers, and antipsychotic medications might be used to treat symptoms of this disorder or other mental health disorders that often occur along with BPD.
We recommend reading these book for learning about Borderline Personality Disorder:
1. DBT Skills Training: Handouts and Worksheets by Marsha M. Linehan
2. The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, Jeffrey C Wood, Jeffrey Brantley
Picture is adopted from Scientist Animation website.