Borderline personality disorder

Borderline personality disorder has stirred up a lot of controversy not only about its name and symptoms, but especially about its causes.

It is a biological disorder related to an instability of the brain?

Or is it generated by psychological factors, frequently associated with childhood trauma?

Borderline personality disorder has primarily psychological causes, linked to major childhood traumas. Verbal abuse, physical abuse, neglect, abandonment, sexual abuse. People with borderline personality disorder often (more than 90% of cases) have an extremely traumatic life history. With exposure to abuse, often in multiple ways and difficult to accept (e.g. children whose parents die prematurely or are killed, are abandoned, who are orphaned, go through multiple families. Who are beaten and humiliated horribly, with violent, aggressive or psychotic parents. They are tied up, locked up, neglected or sexually abused, sometimes even by siblings or parents).

One of the leading theories about the origins of borderline personality disorder is that it is a post-traumatic stress disorder that has become a personality mode. Trauma is particularly caused by or linked to trusted people, often with ambivalent behaviors that alternate between being violent and close. Example: parents, siblings, relatives, psychologically affecting the person’s ability to discern between “good and bad”, between “close, trusted, and enemy”.

Trauma is not mandatory.

Borderline disorder may also be caused by exposure to ambivalent parenting. With a mother who comes and goes, is close and then suddenly becomes cold or angry. It is said that mothers with borderline disorder raise children with borderline disorder.

Psychoanalytic theories believe that all people naturally go through a borderline period around the age of 18 months, in which the child alternates between being close to the mother and moving away from her to explore the world. Mother is perceived as either good or bad and not as a complete person with good and bad.

Biology also plays a causative role, as emotional instability and impulsiveness are not only learned but also inherited.

Treatment for borderline personality disorder is almost exclusively psychotherapeutic.

Drug treatment is recommended only when combined with other disorders.

Psychotherapy is generally a long-term therapy of 5 to 7 years. Psychotherapy is marked by many interruptions and changes of psychotherapists. Therefore, before deciding to stop treatment or change therapist, an analysis of the therapeutic relationship is necessary.

There are therapies specifically designed for borderline personality disorder whose effectiveness is supported by long-term studies:

1. Dialectical Behavioral Psychotherapy (DBT).

Developed by Marsha Linehan in the late 1970s, DBT became the gold standard for the treatment of borderline personality disorder. Recommended by all international guidelines and the World Health Organization.
It has proven effective in reducing suicidal behavior, self-harm, psychiatric hospitalization, and depression. It reduced treatment dropouts, reduced substance use symptoms, impulsiveness and anger. The quality of life and overall level of functioning has increased.

The DBT shall consist of:

individual therapy
psychoeducation group
intervention group for psychotherapists

Psycho-education groups are group therapies designed to train behavioral skills. The group is run as a class in which the group leader teaches skills and assigns homework for clients to practice in their daily lives.

The groups meet weekly for approximately 2.5 hours and it takes 24 weeks to achieve full competencies through the curriculum. It being often repeated to create a year-long program.

DBT includes four sets of behavioral skills:

Mindfulness: the practice of being fully aware and present in the moment.

Stress tolerance: how to tolerate pain and stress in difficult situations without changing them.

Interpersonal effectiveness: how to ask for what you want and say “no” while maintaining self-respect and relationships with others.

Emotion regulation: how to change the emotions you want to change.

2. Schema Therapy

It was developed by Dr. Jeffrey E. Young for use in the treatment of DSM Axis I personality disorders and chronic disorders when patients do not respond or relapse after undergoing other therapies. Schema Therapy is an integrative psychotherapy, combining theory and previously existing therapy techniques. Including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory and Gestalt therapy.

3. Mindfulness Based Treatment (MBT)

MBT is a form of psychodynamic psychotherapy, developed and manualized by Peter Fonagy and Anthony Bateman. MBT was designed for people suffering from borderline personality disorder, who suffer from disorganised attachment. And who, because of this, have failed to develop a capacity for mindfulness in the context of a secure attachment relationship.

The goal of treatment is for patients with borderline personality disorder to increase their ability to think. This should improve emotional regulation and stabilize interpersonal relationships.

4. Transfer Focused Psychotherapy (TFP)

It is a modified psychodynamic treatment, very structured, twice a week. It is based on the borderline personality disorder model of Otto Kernberg.

It sees the individual with borderline personality organization as holding representations of self and significant others. They are unreconciled and internalized contradictorily, representations with a great emotional charge and significance. Defending against these contradictory internalized object relations leads to disturbed relationships with others and with oneself.

Distorted perceptions of self or others and associated emotions are at the heart of treatment, as they arise in the relationship with the therapist (transference). The treatment focuses on integrating these separate parts of the self and representations of others. This is because consistent interpretation of these distorted perceptions is considered the main mechanism for change.

TFP is one of a number of treatments that can be useful in the treatment of borderline personality disorder. However, TFP alone has been shown to change the way patients think about themselves in relationships.

Treatment for borderline personality disorder at Hope Clinic is based on the theory of dialectical-behavioral therapy!

The treatment combines elements of our training in transactional analysis, psychoanalysis and cognitive behavioral therapy, in accordance with at least some of all the above theories.

DBT is itself a combination of elements from all types of psychotherapy, with an important focus on the therapeutic relationship. The significant factor being the phasing of therapy, considering that psychoanalytic interpretations are intended for the later stages of therapy.

1. Mindfulness

Techniques for being fully aware of all aspects of life. It teaches content skills – “what mindfulness is” (observing, describing, participating) and process skills – “how to do mindfulness” (non-judgmental, one thing at a time, effectiveness.

2.Stress tolerance

How to tolerate pain and stress in difficult situations, crisis management strategies

3. Interpersonal effectiveness

3. Interpersonal effectiveness

4. Emotion regulation

How to change the emotions you want to change in order to decrease negative vulnerabilities, reduce distress and increase “positive” emotions.
These skills will be reinforced through repetition, homework and repeated sessions between sessions. They are not specific to borderline personality disorder.

They can also be adapted for bipolar disorder or adolescents. They build a set of psychological skills for a healthy and balanced lifestyle.