Diagnostic criteria and treatment approaches for borderline personality disorder

Borderline Personality Disorder

Individuals with Borderline Personality Disorder are afflicted with a continual state of emotional conflict and chaos, often swinging from one extreme of emotion to another. Patients with BPD are traditionally known to exhibit symptoms of depression, anger and anxiety at varying times, and traditionally demonstrate self-injurious behavior. The road to treatment and recovery is often a different one, as traditional psychotherapeutic approaches often fail treating patients with DSM-IV. There is recent evidence that suggests that an integrative approach for treating BPD is best. This type of approach would combine cognitive behavioral therapy, pharmacological intervention and traditional psychotherapy techniques to find the best possible outcome for BPD patients.

DSM-IV for Borderline Personality Disorder

The DSM-IV identifies symptom and behavior-based criteria for diagnosing this disorder. The diagnostic criteria for identifying borderline personality disorder according to the DSM-IV include: "a pervasive pattern of instability of interpersonal relationships, self-image and affects marked by impulsivity beginning by early adulthood" (APA, 1994). The DSM-IV further suggests that a traditional psychotherapeutic approach be utilized when treating BPD.

This emotional instability present in borderline personality patients may be present in many different forms and contexts, and generally is indicated via the following criteria: (1) "frantic efforts to avoid real or imagined abandonment," (2) pattern of unstable interpersonal relationships that generally "alternate between extremes of idealization and devaluation," (3) "identity disturbance that includes a marked unstable self-image and sense of self," (4) impulsivity that can be self damaging and may including excessive spending, sex or binge eating (5) instability associated with a "marked reactivity or mood" (6) irritability and anxiety that occurs as episodic, (7) frequent anger or tantrums, (8) inappropriate displays of anger and (9) transient or stress related "paranoid ideation" (APA, 1994:654). A person with BPD will exhibit several of the criteria mentioned above. Characteristically a patient with BPD is recognized as having extreme mood swings and a poor sense of self-image that may lead to suicidal tendencies.

Because borderline personality disorder is complex in nature and difficult to label, differential diagnostic criteria and theoretical orientations have been established for assessing the disorder (Cottrell & Jones, 2000). Thus a therapist might encounter differing behavioral, symptomatic and psychodynamic formulations and findings that form the basis of diagnostic categorization of BPD (Cottrell & Jones, 2000). Differential diagnostic criteria may include: identity diffusion, contradictory aspects of self and others, splitting defenses, projective identification, idealization and omnipotence as well as denial and de-valuation of the self (Cottrell & Jones, 2000). The specificity of borderline personality disorder remains in question however because patients vary in symptomology and personality despite fitting into diagnostic criteria (Cottrell & Jones, 2000).

Some researchers have in fact suggested that dimensional rather than diagnostic measures of behavior might be more appropriate for BPD patients, including analysis of differential characteristics and dimensions such as cognition, impulsivity, emotional liability and anxiety (Silk, 2002). Patients with BPD might also meet differential criteria for disorders including anti-social and shizotypal personality disorders (Cottrell & Jones, 2000; Silk, 2002). In fact as many as half of BPD patients exhibit the criteria for these other disorders (Silk, 2002). What differentiates BPD patients include the impulsive feelings, self-deprecating behaviors and suicide attempts common in BPD patients (Cottrell & Jones, 2000). Scales useful for determining the patient include the Gunderson Diagnostic Interview and Perry Borderline Personality Scale (Cottrell & Jones, 2000).

Traditional therapy has focused on pharmacological interventions for treating certain criteria of the disorder including depression and traditionally psychotherapeutic interventions. Psychotherapy while perhaps beneficial is often not backed by empirical data supporting this treatment approach. This is because traditional psychotherapy often fails and patients often drop out of treatment. Psychotherapists have even expressed some resistance toward treating BPD patients.

Conclusions

Traditional modes of therapy includes individual therapy, group skills training and therapist consultation (Linehan, 1993; Osada, 2003). Cognitive behavioral as well as traditional therapies all incorporate these aspects and rely on therapy to be voluntary to be successful.

Because there is no one specific or universal method for treating BPD it is important that all therapy is integrative in its approach. Traditionally psychotherapy has been used to treat BPD as defined by the criteria established by the DSM-IV. New evidence suggests that most patients drop out of therapy after a short period of time, and that a cognitive behavioral approach or DBT based approach which is grounded in cognitive behavioral therapy combine with other approaches including psychotherapy may be the best treatment option for patients suffering from this disorder. The focus of therapy should be providing a strong working relationship in a safe and comfortable environment for the patient.

References:

APA. (1994). "Diagnostic and statistical manual of mental disorders, 4th ed."

Washington D.C., American Psychiatric Association.

Beck, Aaron T. And Freeman, Arthur M. And Associates (1990). Cognitive Therapy of Personality Disorders. New York: Guilford Press.

Appelibaum, A.H.; Diamond, D.; Kernberg, O.F.; Koenigsberg, H.W.; Stone, M.H. &

Yeomans, F.E. (2000). "Borderline patients: Extending the limits of treat ability." New York: Basic Books.

Cottrell, S. & Jones, P. (2000). "Borderline Personality Organisation." 11, November,

2004, from: http://www.clinical-supervision.com/Borderline.htm

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., and Heard, H.L. (1991).

Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.

Linehan, M.M., Kanter, J.W., and Comtois, K.A. (1999). Dialectical behavior therapy for borderline personality disorder. In D. Janowsky (Ed.), Psychotherapy indications and outcomes (pp. 93-118).

Osada, M. (2003). "Using dialectical behavior therapy to treat borderline personality disorder: A broad overview." BPD from the Inside Out. 4, November 2004, from http://www.borderlinepersonality.ca/dbttreatBPD.htm

Silk, K.R. (2002). "Borderline Personality Disorder." Current Psychiatry, 1(11).

Available: http://www.currentpsychiatry.com/2002_11/1102_borderline.asp

Stenhouse, L. & Van Kessel, K. (2002). "Cognitive therapy and dialectical behaviour therapy: An integrative approach to conceptualization of borderline personality disorder." New Zealand Journal of Psychology, 31(2):87