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.
Cognitive Behavioral Perspective
There are other ways to view borderline personality disorder including from a cognitive behavioral perspective. Beck & Freeman (1990) suggest that borderline personality disorder may be addressed via cognitive behavioral techniques that address the expressions "of early maladaptive schemas" (p. 185). They suggest that the cognitive effects of the disorder cause a patient to believe that other people are responsible for satisfying their needs, and represent themselves as helpless in "a hostile world without security" (Beck & Freeman, 1990).
Cognitive behavioral therapy may be useful in treating and preparing patients for transference focused psychotherapy (Appelibaum, et. al, 2000). The CBT treatment approach aims to reduce behaviors that are harmful and life threatening first and foremost and those that interfere with the quality of life (Beck & Freeman, 2000). A cognitive behavioral approach requires that patients are taught to be aware of how their thinking is fundamentally instable, as well as recognize their emotional responses and interpersonal behavior. The goal of therapy is to help the patient develop coping mechanisms that will assist them in dealing with thoughts and feelings (Appelibaum, et. al, 2000).
A critical component of cognitive therapy involves individualized case conceptualization, which may help therapists organize information about a patient (Stenhouse & Van Kessel, 2002). The components of a cognitive treatment model will include analysis of core beliefs, intermediate beliefs and automatic beliefs (cognitive content) with information processing structures that are responsible for psychological responses (Stenhouse & Van Kessel, 2002). The therapist works to mobilize the patient toward achieving a particular goal or aim (Stenhouse & Van Kessel, 2002).
Social workers and psychologists are increasingly seeking out new methods for treating BPD. The latest approach is termed dialectical behavior therapy which is a form of cognitive behavior therapy (Linehan, 1993). This form of therapy combines cognitive and behavioral techniques in a highly structured treatment protocol that has been shown as an effective form of intervention (Osada, 2003).
The treatment described by Linehan defines the pathology of BPD according to the criteria established by the DSM-IV, thus generally patients are considered as having emotional dys-regulation and instability characterized with episodic depression, irritability and anger (Osada, 2003). Impulsive behavior is another characteristic trait with frequent attempts at suicide or self-injury (Linehan, 1993).
Traditionally treating borderline personality disorder has proven difficult in a clinical setting because patients don't often respond to therapeutic efforts and generally drop out of treatment frequently (Osada, 2003). Therapists sometimes avoid treating patients because they are typically resistant and may demonstrate angry characteristics (Osada, 2003). DBT however is an effective treatment tool that combines individual psychotherapy, the traditional approach to BPD with DSM-IV criteria with psychosocial skills training (Osada, 2003).
Few psychosocial treatments for BPD have been shown to be effective when utilized alone as a treatment method for BPD (Osada, 2003; Linehan et. al, 1999). Pharmacotherapy is often commonly utilized as a secondary treatment method to address depressive symptoms however the effects of medication are also somewhat limited in patients with BPD (Osada, 2003). DBT however has shown to effectively treat BPD particularly in patients who demonstrate self-injurious behavior (Osada, 2003; Linehan, 1993).
A study conducted of 44 patients with BPD who met the criteria for BPD and had a chronic tendency of parasuicide demonstrated that DBT is more effective that traditional or treatment as usual therapies (Osada, 2003). Cognitive behavioral therapy generally results in a "reduction of parsuicidal attempts in patients, a higher attrition rate in subjects and fewer inpatient psychiatric hospitalization days" (Osada, 2003; Linehan et. al, 1991).
The research suggests that DBT works like standard cognitive behavioral therapy techniques by emphasizing ongoing assessment and data collection with regard to typical patient behaviors, and requires a clear and precise definition of treatment targets and a collaborative working relationship between patients and therapists (Osada, 2003). The key features are the same as cognitive behavior therapy and include problem solving, skills training and cognitive modification (Linehan, 1993; Osada, 2003).
Cognitive behavioral therapy assumes that borderline personality patients have "early maladaptive schemas or patterns of thinking that develop during childhood" and it is these patterns that result in…