Borderline Personality Disorder (BPD)

Kathi Pauncz registered counselling psychologist

RGF Conference Practice Forum

Date: April 2012

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Content

Areas covered in this 1 hour 40 minute forum include:

• What is personality• What is a personality disorder• What is Borderline Personality Disorder (BPD)?• Causes of BPD• Course and prognosis of BPD• Managing some difficult behaviours• Treatment options

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Objectives

The aim of this forum is to:

• Introduce participants to BPD

• Help prevent or minimise problems that can arise from this difficult personality type

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Borderline Personality Disorder (BPD)

Exercise

Discuss your personal objectives for attending this forum.

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What is Personality?

Personality is composed of the enduring individual traits, characteristics, attitudes and habits that are constantly displayed by a person across diverse situations.

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Evolution of the Borderline Syndrome

The concept of the borderline personality has evolved primarily through the theoretical formulations of psychoanalysts who followed Freud.

Adolph Stern (1938) coined the term borderline to describe a group of patients who did not fit into the primary diagnostic classifications of “neuroses” and “psychoses”.

These patients were originally (and sometimes still are) said to be on the borderline between neurosis and psychosis (between mad & bad).

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What is a “Personality Disorder”?

A personality disorder represents an extreme deviation from the way an average person in a particular culture perceives, thinks, feels and relates to others.

The disorder involves deeply ingrained and enduring patterns of behaviour that are manifest as inflexible responses to a wide range of social and personal situations.

The disorder may cause distress to the individual ands create problems in social functioning or performance. (WHO, 1997, p.512)

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What is BPD?

“Trying to define BPD is like staring into a lava lamp: what you see is constantly changing. The illness not only causes instability but symbolises it.” (Mason, P.T. & Kreger, R., 1998, p.25)

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Criteria for BPD(DSM-IV, p. 654)

A pervasive pattern of instability of interpersonal relationships, moods and self image, and marked impulsivity beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Frantic efforts to avoid real or imagined abandonment. • A pattern of unstable or intense interpersonal relationships characterised by

alternating between extremes of idealisation and devaluation. • Identity disturbance: markedly and persistently unstable self image or sense of

self. • Impulsivity in at least two areas that are potentially self damaging (eg spending,

sex, substance abuse, reckless driving, binge eating)• Recurrent suicidal behaviour, gestures or threats, or self mutilating behaviour. • Affective instability due to a marked reactivity of mood (eg intense episodic

dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more that a few days).

• Chronic feelings of emptiness.• Inappropriate, intense anger or difficulty controlling anger (eg frequent displays of

temper, constant anger, recurrent physical fights).• Transient, stress related paranoid ideation or severe dissociate symptoms..

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Borderline Mnemonic (Senger 1997)

ImpulsivenessMoodinessParanoia or dissociation under stressUnstable self ImageLabile intense relationshipsSuicidal gesturesInappropriate angerVulnerability to abandonmentEmptiness

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Additional Traits Common to BPD

• Pervasive shame• Undefined boundaries• Control issues• Lack of Object Constancy• Interpersonal sensitivity• Situational competence• Narcissistic Demands• Feel worthless and unlovable• Come up with facts with no basis in reality• Make decisions based on emotions• Thinking is black and white• Believe they are the victim of everyone else’s behaviour

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BPD

• DVD

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Causes of BPD

• Nature or nurture?

• Developmental theories

• Trauma history

• Attachment issues

• Linehan’s socio biological theory

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Why Single Out BPD? • BPD is the most prevalent PD. These clients are “high

maintenance”.

• “The percentage who eventually commit suicide is estimated at 5-10%.” (cited in Linehan, M.M., 1995)

• Counsellors are often idealised by these clients, however they may switch quickly from idealising to devaluing them.

• Borderlines may experience sudden despair in reaction to a counsellor announcing the end of their session, panic or fury if the counsellor is a few minutes late or must cancel an appointment.

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Managing Some Difficult Behaviours

• Visualisation• Practise mindfulness• Set clear boundaries• BP’s rages• Be a “rock”• Responding to self mutilation• Empathise with the BP• Suicidal threats

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Treatment Approaches

• Dialectical Behaviour Therapy (DBT)• Cognitive Behaviour Therapy (CBT) • Acceptance and Commitment Therapy (ACT)• Interpersonal Therapy (IPT)• Pharmacotherapy• Hospitalisation• Supportive Psychotherapy

The mainstay of treatment of BPD is psychotherapy. However because of their impulsivity, two thirds drop out of treatment within a few months.

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Media Examples Exercise

Borderline characters often fill the roles of boyfriend/girlfriend/room mate from hell or spurned lover who often seek revenge because of rejection, perceived or real.

Exercise

Can you provide examples of media characters with BPD characteristics?

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REFERENCES American Psychiatric Association, (1994), DSM IV, Washington, DC.

Arnold, L. & Magill, A., (1998), The Self Harm Help Book, Abergavenny: The Basement Project.

Arnold, L. & Magill, A., (1996), Working with Self Injury, Bristol: The Basement Project.

Beck, A.T., Freeman, A. and Associates, (1990), Cognitive Therapy of Personality Disorders, Guilford Press, New York.

Bockian, N.R., Porr, V. & Villagran, N.A., (2002), New Hope for People with Borderline Personality Disorder, Prima Publishing, division of Random House, New York.

Chapman, A.L. & Gratz, K.L., (2007), The Personality Disorder Survival Guide. Everything You Need to Know about Living with BPD. New Harbinger Publications, USA.

Davies, J., (2000), A Manual of Mental Health Care in General Practice. Commonwealth Department of Health & Aged Care, ACT.

Herman, J., (1994), Trauma and Recovery. From Domestic Abuse to Political Terror. Harper Collins Publishers, USA.

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REFERENCESKreger, R. & Shirley J.P., (2002), The Stop Walking on Eggshells Workbook. Practical Strategies for

Living with Someone who has Borderline Personality Disorder, New Harbinger Publications Inc., New Jersey.

Kreisman, J.J. & Straus, H., (1989), I Hate You - Don’t Leave Me. Understanding the Borderline Personality, Avon Books, New York.

Krawitz, R. & Watson, C. (2000), Borderline Personality Disorder - Foundations of Treatment, Seaview Press, South Australia.

Linehan, M.M., (1993), Cognitive Behavioural Treatment of Borderline Personality Disorder, Guilford Press, New York.

Linehan, M.M., (1993), Skills Training Manual for Treating Borderline Personality Disorder, Guilford Press, New York.

Linehan, M.M., (1995), Understanding BPD. Guilford Publications, New York, (Video & Program Manual).

Linehan, M.M., (1995), Treating BPD, Guilford Publications, New York, (Video & Program Manual).

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REFERENCESMcCormack, C.C., (2000), Treating Borderline States in Marriage, Jason Aronson Inc., Northvale, New

Jersey.

McGrath, H. & Edwards, H., (2000), Difficult Personalities. A Practical Guide to Managing the Hurtful Behaviour of Others, Choice, Australia.

McKay, M., Wood, J.C. & Brantley, J., (2007), The Dialectical Behaviour Therapy Skills Workbook. Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation and Distress Tolerance, New Harbinger Publications, USA.

Mason, P.T. & Kreger, R., (1998), Stop Walking on Eggshells. Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder, New Harbinger Publications Inc., New Jersey.

Morrison, J., (1995), DSM IV Made Easy. The Clinician’s Guide to Diagnosis, Guilford Press, New York.

Rockland, L.H., (1992), Supportive Therapy for Borderline Patients, Guilford Press, New York.

Santoro, J., (1997), The Angry Heart: Overcoming Borderline and Addictive Disorders, New Harbinger Publications, USA.

Stevens, B.A., (2008), Self-care for the Practising Psychologist: Treating Personality Disordered Patients, 4 hour workshop handout for Australian Psychological Society.