Dialectical behavioral therapy and the treatment of borderline personality disorder

Borderline Personality Disorder

Definitions and historical foundations

Diagnostic and Statistical Manual of Mental Disorders (DSM

Etiology

DBT

Genetics

Environmental Conditions

Neurological issues

Diagnoses and related issues

Comorbidity

Psychopharmacological approaches

Dialectical Behavioral Therapy

Empirical support

Theoretical aspects of DBT

The dialectical model

Etiology

Praxis

This study is intended to present a clear overview of the characteristics, history, etiology, diagnosis and treatment of Borderline personality Disorder. This disorder has been the subject of much contention and debate over the years and has not only been difficult to define but also to diagnose due to its theoretical and practical proximity to other disorders. The advent of Lineham's Dialectical Behavioral Therapy however has provided a more structured and theoretically integrated approach and means of dealing with and treating Borderline personality Disorder. This study will pay special attention to the emergence and praxis of Dialectical Behavioral Therapy.

The overall intention of the study is to provide an in-depth view of the cardinal aspects relating to a comprehensive understanding of Borderline personality Disorder. To this end only the most important and pertinent aspects have been discussed in an attempt to provide a consecutive and integrate overview, leading to an evaluation of Dialectical Behavioral Therapy. This has also meant that not every aspect or component of Borderline personality Disorder is dealt with. However, the cardinal areas are discussed and analyzed within the space and parameters of the study.

Section one: Overview of Borderline personality Disorder

1. Definitions and historical foundations

Borderline personality disorder (BPD) is defined as pervasive pattern of impulsivity and instability in interpersonal relationships and self-image Its primary diagnostic criteria include extreme efforts to avoid abandonment; instability in relationships, affect, and identity; and reckless impulsivity. (Coker & Widiger, 2005, p. 212)

Another definition summarizes the essence of this complex area as follows:

personality disorder characterized by extreme instability and impulsivity, fear of abandonment and self-injurious behavior." (What is Borderline Personality Disorder?) However these brief definitions do not go very far in exploring or explaining this complex condition. The Diagnostic and Statistical Manual of Mental Disorders summarizes the central aspects of the disorder as follows. "The essential feature of the Borderline Personality Disorder is a pervasive pattern of unstable interpersonal relationships, self-image, and affect. There is marked impulsivity that begins by early adulthood (DSM-IV™, 1994, p. 650).

Furthermore the Internationals Classification of Diseases (ICD-10) refers to BPD as "...the Emotionally Unstable Personality Disorder which is characterized by impulsivity, unpredictable moods, outbursts of emotion, behavioral explosions, quarrelsome behavior, and conflicts with others. " (ICD-10, 1994, p. 228). The ICD-10 divides BPD into two types:

the impulsive type (characterized by emotional instability and lack of impulse control) and the borderline type (characterized by disturbances of self-image, aims, and internal preferences; chronic feelings of emptiness; intense and unstable interpersonal relationships; and self-destructive behavior) (ICD-10, 1994, p. 228).

Borderline personality disorder is a relative newcomer to the arena of diagnosable psychiatric illnesses. Recognition of the complex of Borderline Personality Disorder grew from the original diagnosis of hysteria as a medical condition in the early 1800's. (Hodges, 2003 p 409) The modern origins of the term Borderline stems from an ambiguity and uncertainty in diagnosis; when it was found that a patient manifested a combination of both neurotic and psychotic symptoms. "Many clinicians thought of these clients as being on the border between neurotic and psychotic, and thus the term borderline came into the diagnostic lexicon. "(Hodges, 2003 p 409)

Before the 1970's there were many different terms used to describe a patient exhibiting the symptoms we now describe as Borderline Personality Disorder. In 1938, Stern referred to the borderline between neuroses and psychoses and in 1941 "Zilboorg described a disorder that he considered to be a mild version of schizophrenia; patients with this disorder had disturbances of reality testing, associative thinking, shallowness of affect, and pervasive anger." (Excerpt from Personality Disorder: Borderline) Similarly, Deutch described a group of patients who had symptoms that are now classified as BPD in 1942. These patients had symptoms characterized by a lack of a consistent sense of identity and source of inner direction. Deutch subsequently classified these patients as "as-if personalities" because "...the patients completely identified with those upon whom they were dependent. "(Excerpt from Personality Disorder: Borderline)

Later, Hoch and Polatin were later to create the term pseudoneurotic schizophrenia to describe a disorder characterized by panphobias, pananxiety, and pansexuality. (Excerpt from Personality Disorder: Borderline)

The first description of borderline disorder as a disorder of character was applied in 1959 by Schmideberg. This was followed by Grinker who "...made the first efforts to describe borderline personality through systematic empirical investigation.." (Excerpt from Personality Disorder: Borderline)

In terms of the original Diagnostic and Statistical Manual of Mental Disorders (DSM-I), a patient with the present-day borderline pathology would have been diagnosed as an "emotionally unstable personalities."

At present the DSM-IV reports that the borderline personality has become one of the "...most common of the Axis II presentations in both the public sector and in private practice."(Hodges, 2003 p 409) BPD has throughout its history been considered as a complex that straddled the borders between psychosis and neurosis.

In general terms BPD is characterized by marked instability in functioning; affect; mood; interpersonal relationships; reality testing and manifestation of extreme anger. (Excerpt from Personality Disorder: Borderline) Another general aspect is the dissatisfaction with the projected image of self on others as well as a strong ambivalence as to personal function and purpose. The continuity between BPD from childhood to adulthood is areas that is still unclear and in need off further research.

One of the first and most obvious aspects of Borderline Personality Disorder or BPD is not only the complexity and sometimes seemingly ambiguous nature of the diagnostic criteria, but also the fact that those who suffer for this condition also need to make use of multiple support systems due to the complexities involved in treatment of this disorder.

One of the factors that makes the classification and definition of BDP more complex is that,

The symptoms of borderline patients are similar to those for which most people seek psychiatric help: depression, mood swings, the use and abuse of drugs and alcohol as a means of trying to feel better; obsessions, phobias, feelings of emptiness and loneliness, inability to tolerate being alone, problems about eating.

What is Borderline Personality Disorder?)

However, there are additional aspects that have to be considered in understanding the BDP patient; one of which is the marked difficulty in controlling "ragefulness" and an unusually sharp impulsiveness and ambiguity in relationships.

A they are unusually impulsive, they fall in and out of love suddenly; they tend to idealize other people and then abruptly despise them. A consequence of all this is that they typically look for help from a therapist and then suddenly quit in terrible disappointment and anger. www.bpdresourcecenter.org/what.htm"

What is Borderline Personality Disorder?)

There is also contention and debate as to the exact nature of Borderline Personality Disorder and there are differing perceptions of the disorder from some quarters. There is little doubt that that Borderline Personality Disorder is one of the most controversial diagnoses in psychology today. "Since it was first introduced in the DSM, psychologists and psychiatrists have been trying to give the somewhat amorphous concepts behind BPD a concrete form. "(Borderline Personality Disorder)

One of the most general views of this disorder is Kernberg's explication of what he calls Borderline Personality Organization. (Borderline Personality Disorder) A more scientific approach to the disorder has been taken by Gunderson. An example of the often subtle variations and approach to the meaning and understanding of BDP is clear from the following quotation.

Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder: in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD. Others believe that the term "borderline personality" has been so misunderstood and misused that trying to refine it is pointless and suggest instead simply scrapping the term.

Borderline Personality Disorder)

Notwithstanding this debate, a clear and comprehensive definition and outline of Borderline Personality Disorder is provided by Beck and Freeman (1990). This definition includes four central markers of the disorder; namely, poorly integrated identity, primitive defenses, relatively firm self-object boundaries (compared to those of a psychotic), and reasonably intact reality testing (also compared to a psychotic). (Boucher, 1999, p. 32)

Beck and Freeman then build on these basic starting points and add the most obvious and characteristic features of the disorder. These include: intense emotional reactions, changeable moods, and great variety of symptoms

Specific indictors of the disorder are as follows.

Diverse assortment of problems and symptoms that may shift

Unusual symptoms or unusual combinations of symptoms

Intense emotional reactions out of proportion to situation; poor anger control

Self-punitive or self-destructive behavior

Impulsive, poorly planned behavior that may later be recognized as foolish

Brief periods of psychotic symptoms

Confusion regarding goals, priorities, and feelings

Feelings of emptiness or void

Lack of stable intimate relationships; relationship difficulty

Tendency to either idealize or denigrate others

Tendency to confuse intimacy and sexuality

Affective instability (Boucher, 1999, p. 32)

The overall diagnostic and symptomatic patterns described by these points indicate that BPD is a serious disorder and is "...classified as a major personality disorder involving dramatic, emotional, or erratic behavior; intense, unstable moods and relationships; chronic anger; and substance abuse." (Boucher, 1999, p. 33)

There are a number of criteria which, in line with DSM-IV, are used to identify and characterize this disorder. The first of these criteria refers to "...unstable and intense interpersonal relationships, with marked shifts in attitudes toward others (from idealization to devaluation or from clinging dependency to isolation and avoidance), and prominent patterns of manipulation of others.."(Boucher, 1999, p. 33)

Perception also plays an important role in the identification and understanding of the BDP patient. This refers particularly to social perception. Benjamin and Wonderlich (1994) recognized that BDP patients showed differences in social perception when compared to bipolar and unipolar subjects. In relation to this they found that "...BPDs view relationships with their mothers, hospital staff, and other patients with more hostility than mood disordered patients. BPDs see themselves as attacked by other patients and as part of hostile and noncohesive families. "(Boucher, 1999, p. 33)

Another aspect that identifies the BDP sufferer is "... intense clinging dependency and manipulation..." (Boucher, 1999, p. 33) This is a central characteristic of the BDP patient in terms of social interaction and is an aspect which also makes the treatment of this patient all the more difficult.

Therefore a further cardinal criterion of these patients is that they show major social dysfrucntionality. As Boucher in his study (1999) states,

Hostility enters on the heels of denial of dependency; as part of vehement denial, BPDs devalue the strengths and personal significance of others. Often, this takes the form of extreme anger when others set limits for relationships, or when separations are about to occur. Social perception is pervasively dysfunctional. (Boucher, 1999, p. 33)

Understanding BPD is a precarious and difficult issue in many instances. As stated, one of the issues surrounding BDP is the difficulty in diagnosis and assessment due to the interrelationships and similarities to other disorders and areas of mental concern. This is evidenced by the fact that while BDP is often diagnosed in children and adolescents, one has to must make allowance for other issues including eating disorders, substance abuse, and mood disorders that may be age specific.

BPD is often diagnosed in children and adolescents. However, considerable caution should be used when doing so, as some of the symptoms of BPD (e.g., identity disturbance, hostility, and unstable relationships) could be confused with a normal adolescent rebellion or identity crisis. (Coker & Widiger, 2005, p. 213)

1.2. Diagnostic and Statistical Manual of Mental Disorders (DSM)

As discussed above, the earlier history of the definition, identification and classification of Borderline Personality Disorder was unclear and uncertain - especially with regard to its differentiation from other neurotic conditions.

Due to this fact the Diagnostic and Statistical Manual of Mental Disorders, Second Edition, (DSM-II) contained very little that adequately described or identified the Borderline personality. However, inline with the growing definitions and awareness of BPD as a unique condition with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, (DSM-III), BPD became a diagnostically based on a systematic description of observable clinical characteristics. "This description was carried over to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised, (DSM-III-R) in 1987 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in 1994. "(Excerpt from Personality Disorder: Borderline)

According to the DSM-IV (1994) BPD is a ":...pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of nine criteria." (Boucher, 1999, p. 33) Some of these criteria have been referred to in the above section. The following is a listing of the nine criteria.

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

What is Borderline Personality Disorder?)

The DIB-R is the considered as the most influential method of diagnosing BPD. This had led researcher to identify four central behavior patterns that are particular to BDP. These are "... abandonment, engulfment, annihilation fears; demandingness and entitlement; treatment regressions; and ability to arouse inappropriately close or hostile treatment relationships." (Borderline Personality Disorder)

1.3 Etiology

In terms of prevalence, indication it is estimated that approximately 1% to 2% of the general population would meet the DSM -- IV criteria for BPD (Coker & Widiger, 2005, p. 213)

Furthermore "BPD is the most prevalent personality disorder within most clinical settings (although perhaps not the most prevalent in community settings...)." (Coker & Widiger, 2005, p. 213)

Coker and Winder state in their study Personality Disorders, that about 15% of all inpatients or 51% of inpatients with a personality disorder and 8% of all outpatients or 27% of outpatients with a personality disorder, will meet criteria for borderline personality disorder. Further statistics show that in terms of gender demographics about 75% of persons with BPD will be female (Coker & Widiger, 2005)

In terms of figures relating to mortality and morbidity it was found that the number of premature deaths in patients with BPD may be due to an increased risk of suicide. This is supported by the fact that "... Approximately 70-75% of patients with BPD have a history of at least one deliberate act of self-harm." (Excerpt from Personality Disorder: Borderline)

An important aspect in understanding Borderline Personality Disorder is the significance of comorbid conditions. These can include dysthymia, major depression, psychoactive substance abuse, and psychotic disorders. (Excerpt from Personality Disorder: Borderline) In a 1999 study of 409 patients it was found that patients with BPD were twice as likely to receive a diagnosis of 3 or more current axis-I disorders and that they were nearly 4 times as likely to have a diagnosis of 4 or more axis-I disorders. These included mood disorders, anxiety, substance abuse, eating disorders, and somatoform disorders.

Excerpt from Personality Disorder: Borderline)

An interesting note in terms of the demographics of BPD is that the initial diagnosis of the disorder is rarely found in patients who are older than forty years of age.

The general symptomatic indicators are that those with BPD can be identified by factors such as emotional instability and impulsive behavior. BPD patients also show signs of hostility when young and abnormal affectivity and impulsivity during adolescence. Gunderson (2001) states that,

As adults, persons with BPD may be repeatedly hospitalized, because of their affect and impulse dyscontrol, psychotic-like and dissociative symptomatology, and risk of suicide and suicide attempts (Gunderson, 2001; Zanarini et al., 1998a). These individuals are at a high risk for developing depressive, substance-related, bulimic, and posttraumatic stress disorders" (Coker & Widiger, 2005, p. 213) RR

One of the defining aspects of BPD is extremely high neuroticism.

In particular, these individuals are at the very highest range of anxiousness, angry hostility, depressiveness, impulsiveness, and vulnerability. Borderline clients will also likely be low in the agreeableness facets of trust and compliance and low on the conscientiousness facet of competence. (Coker & Widiger, 2005, p. 213)

The reasons for this condition are related to many aspect and theories, ranging from biological causative factors to social and environmental factors. The various pathogenic mechanisms are dealt with in numerous, and often very different theoretical stances. Many of the theories as to the origins of BPD are related to social and environmental factors such as abandonment, separation, and/or exploitative abuse. This is one of the reason why "frantic efforts to avoid abandonment" is the first item in the DSM -- IV-TR diagnostic criterion set (Coker & Widiger, 2005, p. 212)

Another theoretical causative factor that is referred to is disturbed, abusive or broken relationships. This often results in "... The development of malevolent perceptions and expectations of other." (Coker & Widiger, 2005, p. 212)

In turn, these perceptions of others, coupled with the inability to control affect, may "...contribute to the perpetuation of intense, hostile, and unstable relationships. Coker & Widiger, 2005, p. 212)

DBT

On of the most persuasive theories of the causative foundations of Borderline Personality Disorder is provided by Linehan, who has developed a comprehensive sociobiological theory which " appears to be borne out by the successes found in controlled studies of her Dialectical Behavioral Therapy." (Borderline Personality Disorder)

While this theory will be dealt with in greater detail in the second section of this stride, a brief overview in the context of the general etiology of BPD may be appropriate at this point,

This influential theory states that the Borderline Personality has an innate tendency which is biologically founded to react more intensely to lower levels of stress than others and to take longer to recover. This is also related to the environment in which they were raised which is, according to Linehan, one in which their experiences and perceptions were continuously devaluated and invalidated. This results in a psychological situation and environment where "These factors combine to create adults who are uncertain of the truth of their own feelings." (Borderline Personality Disorder)

DBT tries to teach clients to balance these dysfunctional aspects by giving them training in skills of mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.

1.3.2. Genetics

There are a number of studies which subscribe to the view that BPD is a disorder"... with a genetic disposition that cannot be accounted for by other comorbid disorders." (Coker & Widiger, 2005, p. 212) There are also studies which suggest a genetic history comorbid with mood and impulse control disorders. Research also states that "... It is generally acknowledged that borderline personality disorder (BPD) has a complex, multifactorial etiology with interacting genetic and environmental substrates..." (Borderline Personality Disorder Etiology)

At present the genetic foundations of BPD are subject to debate and ongoing research - particularly in the light of some of the latest findings and developments in the field of Genetics.

However some studies have claimed a strong genetic disposition in those who exhibit signs of BPD. "An overview of the existing literature suggests that traits similar to BPD are influenced by genes. It is too early to say to what extent BPD is also influenced by genes, but because personality traits generally show a strong genetic influence, this should also be true for BPD" (Torgersen S. 2000)

Researchers are aware of the potential of genetic studies for an understanding of the etiology of BPD, but there is also a concomitant awareness that research into this aspect in terms of any definitive conclusions is still in its infancy. This view is expressed in a 2002 study by LJ, Torgersen et al. entitled The borderline diagnosis III: identifying endophenotypes for genetic studies.

A the specific genetic underpinnings of this disorder have not been extensively investigated. Family aggregation studies suggest the heritability for BPD as a diagnosis, but the genetic basis for this disorder may be stronger for dimensions such as impulsivity/aggression and affective instability than for the diagnostic criteria itself. Family, adoptive, and twin studies also converge to support an underlying genetic component to the disorder.

Borderline Personality Disorder Etiology)

1.3.3. Environmental Conditions

There are numerous studies which indicate that that a childhood history of physical and sexual abuse, or a combination of the two, as well as parental abuse and neglect and conflict within the home, can all be contributing or instigating factors in BDP. (Coker & Widiger, 2005, p. 212) This can also be related to various pathogenic factors such as abandonment and separation. These initial and early abuse or abandonment issues in the child or adolescent's development, especially when it concerns parent ands other important people in the child's life, is one of the constants in those classified as having BDP. This can result in the "...development of aggressive and negative perceptions as well as expectations of others" (Coker & Widiger, 2005, p. 212)

There is a general consensus that environmental factors play a major role in BPD. However there is also proof that environmental and social factors are not always central to the instigation of BPD. "....but not all individuals with BPD report a history of abuse, neglect, or separation as young children." (Causes of Borderline Personality Disorder) However it is generally recognized that factors such as sexual abuse pay a large part in the etiology of BPD. Social and environmental factors are usually seen as co-present in the BPD.

Forty to 71% of BPD patients report having been sexually abused, usually by a non-caregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from harmful environments as well as impulsivity and poor judgment in choosing partners and lifestyles.

Causes of Borderline Personality Disorder)

The severity of negative childhood experiences can have a profound effect on personality development and can therefore be one of the central criteria in BPD.

For individuals with BPD, childhood abuse appears to impact the perception of threat resulting in a more hostile attributional bias. Past physical abuse results in increased sensitivity to cues of threat, impaired processing of social information, and increased probability of selecting an aggressive response. (Spoont, Costello, ed. 1996, p. 73).

This means that the individual interprets neutral behavior from others as threatening and could possibly respond in an aggressive manner. Furthermore, an important point is that." Their tendency to attribute negative intent to others also allows them to view the interpersonal difficulties they have as being independent of their own behavior. "(Layden, 1993, p. 2).

Post traumatic stress is also a related factor mentioned by a number of researchers. This aspect is also linked by some researchers to genetic disposition.

Past traumatic events are present in many (if not most) cases of BPD, contributing to the comorbidity with posttraumatic stress and dissociative disorders (Brodsky, Cloitre, & Dulit, 1995; Gunderson, 2001; Hefferman & Cloitre, 2000), but the nature of these events and the age at which they occurred appear to vary. BPD may involve the interaction of a genetic disposition toward an emotionally unstable temperament with a cumulative and evolving series of intensely pathogenic relationships (Gunderson, 2001; Morey & Zanarini, 2000). (Coker & Widiger, 2005, p. 212)

Neurological issues

The Neurological aspect is also another contentious area in BPD etiology and there is no definite consensus in terms of seeing this aspect as a ubiquitous factor - although there is certainly consensus to the fact that neurological aspects influence and impact on the understanding of BPD. "Neurochemical dysregulation is evident in individuals with BPD, but whether this dysregulation is a result, cause, or correlate of prior interpersonal traumas is unclear." (Coker & Widiger, 2005, p. 212)

Studies have shown that that patients with BPD might have" increased rates of soft neurologic signs, as well as, learning disabilities, attention deficit disorder, and abnormal electroencephalograms." (Excerpt from Personality Disorder: Borderline.) There are also various other foundational pathological issues that are associated with the proclivity for BPD. These include possible frontal lobe dysfunction which can manifest itself in increased impulsivity, cognitive inflexibility, and poor self-monitoring and perseveration. (Excerpt from Personality Disorder: Borderline.) However, there is considerable conjecture and debate surrounding this issue and "...as basis for BPD, this hypothesis is limited by unclear definitions and lack of standardized neuropsychological measures." (Excerpt from Personality Disorder: Borderline.)

BPD has also been associated with neurodevelopmental delays and various other organic impairments, as well as unusual nervous system sensitivities. While Neurochemical dysregulation is evident in individuals with BPD, it is still a moot point whether this form of dysregulation is "....a result, cause, or correlate of prior interpersonal traumas (Gunderson, 2001; Silk, 2000) remains unclear. (Coker & Widiger, 2005, p. 212)

Diagnoses and related issues

The primary diagnostic criteria for Borderline Personality Disorder includes central aspects such as extreme efforts to avoid abandonment; instability in relationships, affect, and identity; and reckless impulsivity"(Coker & Widiger, 2005, p. 212) The sensitivity to environmental circumstances can also lead to intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans. The feeling of abandonment is often associated with feelings of a lack of self-worth and the assumptions that they are "bad."

Criteria for Borderline Personality Disorder)

This in turn can result in self - harming and self - mutilation actions such as suicidal behavior

The medical diagnosis of Borderline Personality Disorder, or from the point-of-view of other theorists, Borderline Personality Organization, is often based on various categories of criteria. The first category comprises two essential indicators, these are:

The absence of psychosis (i.e., the ability to perceive reality accurately)

Impaired ego integration ? A diffuse and internally contradictory concept of self.

Borderline Personality Disorder)

Interestingly Kernberg is quoted as saying, "Borderlines can describe themselves for five hours without your getting a realistic picture of what they're like." (Borderline Personality Disorder) The second category is referred to as "nonspecific signs." This includes indications of "... low anxiety tolerance, poor impulse control, and an undeveloped or poor ability to enjoy work or hobbies in a meaningful way." (Borderline Personality Disorder)

The aspect of impulsivity has been recognized as a particularly determining factor in diagnosis. BPD patients may for example, "gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly." (Criteria for Borderline Personality Disorder)

Suicide and attempted suicide also falls into this category and "...completed suicide occurs in 8%?10% of such individuals"... while self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common." (Criteria for Borderline Personality Disorder)

Patients with Borderline Personality Disorder may also display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)... The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction.

Criteria for Borderline Personality Disorder)

Identity disturbance is another essential diagnostic trait. This is usually characterized by a persistent and sometimes ambiguous sense of self.

There might also be rapid changes in self-image which is often accompanied by changes in goals, values and even choice of friends. An interesting point is that,

Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations.

Criteria for Borderline Personality Disorder)

An important aspect that theorists have emphasized is that in the diagnosis of Borderline Personality Disorder, patients can be distinguished from other neurotics by, what Kernberg terms as "primitive defenses." One of these defenses found in BDP patients is "splitting" or intensive dissociation from context. This is often seen when a BPD patient views people or objects as all bad or all good. (Borderline Personality Disorder) What is important to note in this regard is that this sharp judgment process in BPD patients can be disassociated form time and context.

In other words, someone who is considered "bad" by the BDP patient on one day might be perceived as all good on the following day.

This above aspect is related to the problems of "object constancy" in BDP sufferers.

A they read each action of people in their lives as if there were no prior context; they don't have a sense of continuity and consistency about people and things in their lives. They have a hard time experiencing an absent loved one as a loving presence in their minds. They also have difficulty seeing all of the actions taken by a person over a period of time as part of an integrated whole, and tend instead to analyze individual actions in an attempt to divine their individual meanings. People are defined by how they lasted interacted with the borderline.

Borderline Personality Disorder)

Among other differences that characterize the BDP patient are beliefs that thoughts can actually cause events to occur as well as the "...projection of unpleasant characteristics in the self onto others and projective identification, a process where the borderline tries to elicit in others the feelings s/he is having.." (Borderline Personality Disorder) This process of projection of feelings is possibility one of the most complex areas in the therapeutic remedying of the disorder.

Other characteristics that are determining factors in diagnosis include fluctuating relationships as well as "...an inability to retain the soothing memory of a loved one; transient psychotic episodes; denial; and emotional amnesia." (Borderline Personality Disorder) Linehan's comments are appropriate in this context. She says that, "Borderline individuals are so completely in each mood; they have great difficulty conceptualizing, remembering what it's like to be in another mood." (Borderline Personality Disorder)

Linehan proposed various diagnostic criteria for BPD with specific patterns of behavioral, affective, and cognitive instability and dysregulation:

Emotional dysregulation: These individuals are highly reactive and generally experience episodic depression, anxiety, and irritability; they also have problems with anger and anger expression.

Interpersonal dysregulation: Relationships are chaotic, intense, but nevertheless, hard to give up. Individuals with BPD engage in intense and frantic efforts to keep significant others from leaving them.

Behavioral dysregulation: Individuals with BPD evidence extreme and problematic impulsive and suicidal behaviors. They often attempt to injure, mutilate, or kill themselves.

Cognitive dysregulation: There is indication of nonpsychotic forms of thought dysregulation including depersonalization, dissociation, and delusions that can be brought on by stressful situations.

Self dysregulation: Individuals with BPD often have little sense of self; they feel empty. BPD is a disorder of both the regulation of and the experience of the self. (Linehan, 1993, p. 11)

There are also other views from various theorists that need to be taken into account. As will become evident, the diagnosis of BPD is determined to a large extent by what is seen to constitute the disorder and how it is perceived. Kroll for example suggests there are two central Borderline themes or characteristics. These are "1) victimization and (2) loneliness/emptiness -- a pervasive sense of isolation and distance from the warmth of the human community." (Kroll, 1988, pp. 67-68).

Kroll works on the assumption that the pathology of Borderline cases is organized around " cognitive style" - which refers to "short-circuiting of thoughts with action, selective amnesia, intrusive imagery, cognitive disorganization under stress, " and emotional lability, which refers to an intensity of emotional sensitivity which is almost overwhelming. (Kroll, 1988, pp. 67-68).

Another view is that of Theodore Millon who suggests that BPD is a" cycloid personality disorder." He believes that the following terms are more correctly indicative of the nature of BPD:

ambivalent personality disorder, erratic personality disorder, impulsive personality disorder, quixotic or labile personality disorder. (Millon & Davis, 1996, p. 645). Millon also emphasizes the ambivalence in BPD patients towards themselves and others. "Individuals with BPD are ambivalent toward others as well as themselves. They experience rapidly fluctuating and antithetical perceptions and thoughts concerning persons and events." (Millon & Davis, 1996, p. 663).

One of the more obvious determinants of the BPD individual can be ascertained by the quality of the relationships that he or she is involved in. Studies show that interpersonal relationship in BPD is usually very poor and troubled. Researchers note that "... individuals with BPD hold extreme, poorly integrated, and unrealistic expectations of interpersonal relationships. They fluctuate between idealization and devaluation of others (Akhtar, 1995, p. 7). It has also been found that the BPD patient can be extremely demanding, making reciprocal relationships almost impossible at times. Therapists have pointed out that patient can be unreasonable in their demands and even become hostile when the "... caregiver fails to deliver everything individuals with BPD want (Benjamin, 1993, p. 122) The establishment of cordial relationships with others is therefore severely hampered by unpredictable mood swings and an ambiguous and unrealistic approach to the feelings of others. There is a paradoxical conflict between the desire for care and affection on the part of the individual with BPD and their often hostile and aggressive approach in relationships. Oldham states that individuals with BPD destroy the relationships they cannot live without." (Oldham, J.M.1990, p. 301)

This destructive polarity in interpersonal destructiveness in BPD is essentially derived form a lack of self-esteem and a sense of internal emptiness and loss of worth. This sense of 'existential anxiety' is a cardinal diagnostic factor that in many instances has not been researched and documented in - depth in the literature. The management of interpersonal relationships is one the prime objectives in therapy as it can have a devastating effect on the life, and recovery potential, of the BPD sufferer. (Stone, 1993, p. 226).

Comorbidity

The presence of comorbid disorders is a fact or which complicates the diagnostic processes in BPD. "BPD rarely stands alone and commonly occurs simultaneously with other disorders, often preventing an accurate diagnosis. These can include eating disorders, substance abuse, major depression and bipolar disorder." (Borderline Personality Disorder) Many other personality disorders overlap in the diagnosis of BPD. In one documented study of ten observed samples there was an overlap with histrionic personality disorder "...studies found that over 50% of individuals diagnosed with BPD also met the criteria for HPD." (Gunderson, et. al., Livesley, ed., 1995, p. 142). Beck for example has noted that approximately sixty percent of those diagnosed with BPD also met the criteria for various other personality disorders. These included paranoid, schizotypal, histrionic, narcissistic, avoidant, and dependent personality disorders (Beck, 1990, p. 179).

Various aspects of comorbidity have already been mentioned. "The high comorbidity rate among the different personality disorders has been of particular concern to researchers, "and "... comorbidity in the diagnosis of narcissistic personality disorder has continuously been a source of debate." (Rivas, 2001, p. 22) particular concern in this regard is the relationship the narcissistic personality disorder and other Axis II diagnoses as it "...puts in question the validity of the diagnosis." (Rivas, 2001, p. 22) Rivas states in a study that this problem is evidenced by the fact that 21% of the participants also met criteria for narcissistic personality disorder. He further points out that An important point is that Kernberg's original research was based on a population with a primary diagnosis of borderline personality disorder (Kernberg, 1975). The DSM-III (1980) adopted much of its criteria for the original narcissistic personality disorder diagnosis from Kernberg's behavioral descriptions (Ronningstam, 1999). As such, the high comorbidity rate previously reported in the literature seems plausible. (Rivas, 2001, p. 22)

The high comorbidity rate that has been reported in the literature on BPD has also complicated the treatment process, as well as creating a certain amount of uncertainty. Researchers therefore suggest that a more holistic approach to the diagnoses and treatment of this disorder.

A it is important to take a holistic approach to individuals who exhibit narcissistic personality traits. Individuals do not often seek treatment specifically for their narcissistic qualities, but rather for other conditions that may have been facilitated in part by these same qualities. As the disorder often coexists with other conditions, it is important to assess the extent to which narcissistic traits are impacting (e.g., interacting with, maintaining, escalating, etc.) other diagnoses and adjust treatment accordingly. Employing different assessment techniques and information gathering instruments will help achieve a clearer clinical picture. (Rivas, 2001, p. 22)

In other words, Rivas suggests that different techniques and tests should be done in order to account for the various comorbid factors that may be present in the patient; and also so as not to miss elements which may lead to a positive diagnosis of BPD.

Another suggestion takes into account the cultural and social context of the disorder. This suggests that like many narcissistic disorders, BPD is also "culture-bound" and therefore "....clinicians must assess and diagnose individuals from different cultural backgrounds accordingly. Integrating cultural sensitivity and dimensional conceptualization [which] may help the clinician better understand how a client's narcissistic trait fits with their background experience. (Rivas, 2001, p. 22)

Section 2: Treatment

3.1. Treatment Overview

Many studies continually make reference to the fact that Borderline Personality Disorder is extremely difficult to treat. "....very few client populations are as challenging for mental health professionals as people with borderline personality disorder (BPD; Linehan, Cochran, & Kehrer, 2001). " (Smith & Peck, 2004 p.25) The reason given is that the BPD patient is usually extremely demanding "...stretching the boundaries of most mental health clinicians. "(Smith & Peck, 2004 p.25)

The BPD patent often has continual crises and is prone to suicide attempts.

A cardinal aspect is that, until the advent of Dialectical Behavior Therapy (DBT), there were very few treatments found to be effective with these patients. Another factor that is mentioned is that training to deal with BPD is often insufficient and therapist may not have the necessary experience to deal with demands involved in dealing with a BDP patient. As one therapist states,"They can be very manipulative...They test the therapist a lot. One day they are idealizing you and the next day they can storm out of a session and slander you in front of the community. I've had this happen to me." (Umrigar, Thrity. 2002.) Another therapist attests that "It's draining to work with borderlines. It hurts to make emotional contact with them because their inner world is so painful." (Umrigar, Thrity. 2002.)

The most common form of treatment for this disorder is a combination of medication and therapy." Often patients are treated with antidepressants as well as mood stabilizers such as lithium. In addition, they must have three to five years of therapy. "(Umrigar, Thrity. 2002.)

Psychotherapy which is empathic and non-judgmental is usually seen as the most effective form of treatment. However, in order to be effective the therapy should be "...structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. " (Corelli, Richard J.)

Periods of hospitalization are also sometimes required to alleviate times of extreme stress in the patient's treatment. The general goals of any treatment of BPD patients include "...increased self-awareness with greater impulse control and increased stability of relationships. A positive result would be in one's increased tolerance of anxiety. "(Corelli, Richard J.)

Personality integration and the reduction of the various symptoms such as mood disturbance are also part of the overall therapeutic strategy when dealing with BPD.

Experts state that a starting point for the treatment of BPD patients is accurate and extensive assessment. This is particularly pertinent when the proclivity for suicide among these patients is taken into account. Ries provides a listing of aspects that should be considered in terms of assessing the individual with BP. These include:

history of self-harm and unsafe behaviors;

history of previous treatment;

list of potential means for self-harm;

history of dissociative experiences (identify what is lost: behavior, affect sensation, or knowledge);

psychosocial history and history of sexual abuse;

neurological workup of individuals who have a history of self-mutilating behavior that could have resulted in head injury;

presence of psychotic thinking;

and a history of suicidal behavior (Ries, TIP #9, 1994, pp. 57-58).

A further consideration that should be taken into account in preparation for treatment is that the BPD patient often forges an intense relationship with the therapist. This of course is a positive factor in relation to the positive outcome of treatment, but bearing in mind the mercurial and intense nature of the disorder, the therapist should be aware of potential complications. "Borderline patients are often highly motivated for treatment, but their relationship with the therapist might become as intense as his or her relationships with other significant persons." (Coker & Widiger, 2005, p. 214) Therapy should also be as intensive and open and confiding as possible.

Immediate and historical issues should be addressed in therapy, and the client should feel safe expressing and addressing anger, bitterness, and depression. Weekly meetings should be provided. Sessions should emphasize the building of a strong therapeutic alliance, monitoring self-destructive and suicidal behaviors, validation of suffering and abusive experience (but also help the client take responsibility for actions), promotion of self-reflection rather than impulsive action, and setting limits on self-destructive behavior (APA, 2001). (Coker & Widiger, 2005, p. 214)

Furthermore, studies state that the tendency for polarization in emotional response in BPD patients should be monitored in the therapy process and continually addressed.

A further aspect that has become clear in the treatment of this disorder is, as Rivas states, "It seems evident that this type of personality structure cannot be completely changed through several weeks of brief or closed-ended therapy." (Rivas, 2001, p. 22) Rivas also states that working with a BPD patient may also require self -questioning and certain flexibility on the part of the therapist as to the understood by the ordered or disordered personality. By this he means that working with BPD patients also requires a large degree of self-critical awareness on the part of the therapist so that presumptions and social assumptions do not interfere with the therapeutic process.. "Working with an individual with a narcissistic personality disorder is therefore not only challenging therapeutically but also developmentally as a clinician and as a person. (Rivas, 2001, p. 22) This also relates to an awareness of important aspects such as transference.

3.3. Dialectical Behavioral Therapy

Dialectical Behavioral Therapy or DBT is a type of cognitive-behavioral therapy for sufferers of BPD that in simplistic terms "...teaches them skills to reverse their negative thoughts and behaviors." (What is Borderline Personality Disorder?) more formal definition of DBT is: "...a systematic and integrative orientation to treating borderline personality disorder, or BPD," (Smith & Peck, 2004) The general emphasis in DBT is on the balance between acceptance and change in aiding the patient with relief of the symptoms of BPD and the improvement the quality of life.

The foundations of the therapy were developed by Dr. Marsha Lineham. Another more explicit view of Dialectical Behavioral Therapy is that it is "... A treatment that blends cognitive - behavioural interventions with Eastern meditation practices and shares elements in common with psychodynamic, client-centred, Gestalt, paradoxical, and strategic approaches " (Stenhouse & Van Kessel, 2002 p 87)

Lineham developed DBT as essentially a treatment for women with a history of parasuicide who met criteria for BPD. (Stenhouse & Van Kessel, 2002 p 87)

The foundational assumption that formed the basis of DBT was that the behavior of the Borderline individuals was formed by and as a consequence of "failed emotional regulation." Lineham's view was that failed emotional regulation or dys-regulation was the result of biological dysfunction in the emotion regulation system and an invalidating environment." (Stenhouse & Van Kessel, 2002 p 87)

Lineham pioneered this treatment of BPD in 1991. Her ideas were based on the concept and praxis that psychological treatment was just as important in dealing with Borderline patients as was the more traditional psycho? And pharmacotherapy.

Lineham also emphasized a hierarchical structure in treatment goals.

This structure began with the reduction of parasuicidal and life - threatening behaviors. This was followed by a reduction of behaviors which may interfere in the therapy process. Thirdly, reducing behaviors were introduced that improved the individual's quality of life.

Lineman published results of her work which attested to the practical success of her work and approach. The difference of DBT to other approaches in therapy for BPD is that is combines a dialectical perspective with cognitive- behavioral therapy. This has resulted in a particular procedure of interventions which has been shown to produce positive results in the reduction of the symptoms of BPD.

Empirical support

There are a number of approaches and therapeutic strategies that have met with some success in the past in the treatment of Borderline Personality Disorder. These include psychodynamic or interpersonal therapies. However the success of these therapies has been limited, whereas the work by Linehan has resulted in empirical support to justify the claim to success of DBT.

One of the successful aspects of this approach has been the integrative approach of Dialectical Behavioral Therapy. (Smith & Peck, 2004 p.25)

However it is in the actual results that the proof of the effectiveness of this approach lies. These results show that With women who inflict self-harm, DBT has significantly reduced hopelessness, depression, anger, suicidal acts, dissociation, and frequency of parasuicidal behavior....Studies also found that women were less angry, had better self-reported social adjustment, had fewer inpatient days in the hospital at 4, 8, and 12 months post treatment (Linehan et al.; Linehan, Tutek, Heard, & Armstrong, 1994), and maintained higher global functioning (Linehan, Heard, and Armstrong, 1993) after undergoing DBT. (Smith & Peck, 2004 p.25)

The results have shown particular efficacy in terms of the reduction of suicide and the related motivational symptoms.

In another study with clients who inflicted harm on themselves, DBT decreased self-harm, dissociative experiences, depressive symptoms, suicidal ideation, and impulsivity (Low, Jones, Duggan, Power, & MacLeod, 2001), while another study's suicidal adolescent participants showed fewer psychiatric symptoms, less suicidal ideation, and fewer symptoms of BPD after 12 weeks (Rathus & Miller, 2002). (Smith & Peck, 2004 p.25)

In a study by Turner (2000) which compared DBT to client-centered therapy in individuals, it was found that "...the DBT group had fewer self-harm incidents, suicide attempts, and inpatient days than did the client-centered group, and the therapeutic alliance had a significant influence on outcomes." (Smith & Peck, 2004 p.25)

However in patients with a dual diagnosis of BPD and drug dependence, DBT treatment has met with mixed and uncertain results. "... A clinical trial compared the effectiveness of DBT with women who have BPD and substance abuse and found that DBT was useful for treating BPD, but was not more effective than the treatment as usual group in reducing substance abuse problems." (Smith & Peck, 2004 p.25) This has resulted in the recommendation that although DBT is an effective approach additional research is needed and that "...findings should be evaluated with a conceptual understanding of the treatment." (Smith & Peck, 2004 p.25)

3.3.2. Theoretical aspects of DBT

Cognitive theory provides the substructure and underpinnings of DBT and has become a mainstay of clinical psychology. At the centre of all cognitive therapy is the view that "dysfunctional thinking is the core, if not the cause, of symptoms of psychopathology." (Shean, Glenn D.2003) In other words dysfunctional thinking causes the individual to ".... misperceive situations" and therefore to react inappropriately in ways that can lead to the symptoms of BPD.

People who are depressed, for example, are thought to prolong and exacerbate their problems because they are disposed to think of themselves as defective, to view their circumstances as defeating, and to view the future as holding little promise... Negative expectations about the likelihood of the occurrence of valued outcomes (hopelessness) and perceptions of helplessness to change outcomes are cognitive beliefs that are thought to trigger and maintain depressive reactions (Abramson, Metaisky, & Alloy, 1989).

Shean, Glenn D.2003)

In cognitive therapy the therapist attempts to create a relationship or alliance with the patient and then proceeds by identifying the patient's dysfunctional thoughts. The process enables the patient to monitor and redefine the relationship between his or her thoughts, actions, attitudes and emotions. The aim is to identify dysfunctional core beliefs and to unravel their origin. The goals of cognitive therapy are therefore to alter and change dysfunctional thinking and replace it with function and positive thought. A major aspect of this process is to enable the patient to identify the thought processes that trigger various symptomatic responses.

In a theoretical sense, cognitive therapy is based on an objectivist approach to epistemology that equates adjustment with accuracy of beliefs.

Therapeutic strategies are targeted at goals that are concrete and symptom focused. These characteristics are conducive to the development of individualized treatment approaches to specific problems and provide a framework that is compatible with normative outcome studies."

(Shean, Glenn D.2003)

The dialectical model

DBT is based on a cognitive model which is transactional and dialectical.

It relates to the diathesis-stress model in that it recognizes the importance of "...both the individual and the environment in which he or she lives." (SWENSON, CHARLES R. 1999) This model places emphasis on the interaction between certain characteristics of the individual and the conditions or context and environment. In these terms, Lineham's theoretical stance maintains that there is a 'dialectical' relationship between the behavior and functioning of the individual and the environment which are continuously impacting and affecting each other. Theoretically, the two aspects of the individual and the environment are considered as a reciprocal relationship which results in a transactional rather than an interactional process. (SWENSON, CHARLES R. 1999)

As mentioned, the theory of DBT states that the foundation of the disorder of emotions in BPD is one of 'dysregulation'.

This results in an imbalance between the individual and the environment and the "...individual dispositions to emotion vulnerability and dysregulation put demands on an already invalidating environment, and vice versa. Thus, these factors reciprocally influence each other, exacerbating both. "(SWENSON, CHARLES R. 1999)

Another important theoretical concept in understanding DBT is the concept of the "invalidating environment." This refers to an environment which 'deligitimizes' the behaviors, emotions and thoughts of the individual.

The dialectical worldview in DBT has three main principles. These are described as: interrelatedness and wholeness, polarity, and continuous change. It is the concept of interrelatedness and wholeness that forms the fulcrum of praxis in DBT. The second principle of the dialectical approach is polarity. "This construct suggests that a natural and inescapable tension exists between these polar, and thereby contradictory, forces. Examples of opposing forces include life and death, good and bad, or trust and mistrust." (Smith & Peck, 2004 p.25)

This leads to the third principle of the dialectical worldview which is continuous change. This constant change is produced essentially by the polarity between two extremes. In this model or theory, balance and homeostasis when achieved "...is subjected to the same polarity and change pressures, and thus the cycle continues." (Smith & Peck, 2004 p.25)

In terms of its underlying philosophy, DBT is aligned to a relativistic view of reality. In other words there is no absolute truth "... rather, truth is situational, subject to change, and continually constructed over time." (Smith & Peck, 2004 p.25) This view can be related to thought in Zen Buddhism which places emphasis on the natural instability and uncertainty of reality and the preeminence of change and balance. This also relates to the Buddhist view of mindfulness.

Clients are encouraged to walk the middle path by using such principles as mindfulness. Mindfulness is the integration of a person's emotional mind with his or her logical mind, resulting in a "wise mind [which] adds intuitive knowing to emotional experiencing and logical analysis" (Linehan, 1993b, p. 63).

Smith & Peck, 2004

Cognitive behavioral therapy therefore forms an important second component of DBT after the primary emphasis on dialectical thinking. Each stage of the treatment is informed by the principles of cognitive behavioral therapy.

During each of the stages of treatment, the mental health practitioner utilizes cognitive behavioral techniques -- keeping a thought diary, behavioral analyses, exposure techniques, flooding, contingency management, and shaping -- in order to meet the treatment target goals (Linehan, 1993a). In addition, clients in DBT are required to participate in a weekly, manualized skills training, complete with homework assignments and a structure for each session (Linehan, 1993b).

In terms of etiology, the environs that characterize the DBT patient usually generate a sense of inferiority and loss of self-esteem. This is particularly the case with children and adolescents.

Such environments are characterized by a parent's inappropriate, unpredictable, or extreme responses when a child communicates his or her experience. The child is told that he or she is wrong in his or her assessment of this situation and is, consequently, wrong about his or her emotional response, or understanding (both positive or negative). The child then attributes his or her internal experiences to unacceptable personality traits. (Smith & Peck, 2004 p.25)

Etiology

The development of BPD is also, terms of DBT theory, dependent on biological predisposition. However, an invalidating environment may change or alter biological aspects, particularly in the child. "....an invalidating environment may change the biology in a young person, similar to the way sexual abuse, found commonly in the history of someone with BPD, can create changes in physiological/biological responses." (Smith & Peck, 2004 p.25) The reason that underlies this sort of biological change or a change in an individual's physiology means that the person may move towards a state of dysregulation.

Linehan refers to five stages or areas of dysregulation that form the characteristic symptoms of BPD. The first is referred to as emotional dysregualtion. This is characterized by emotional instability and is associated with anger and domestic violence. Secondly, interpersonal dysregulation refers to a pattern of unstable relationships and efforts to avoid loss. An example is:"... A woman may enter a relationship with the expectation of immediate emotional intimacy and when that is not forthcoming right away, she may accuse the other person of not letting her in and break off the relationship." (Smith & Peck, 2004 p.25) third area is termed behavioral dysregulation. This refers to self-damaging and self-inflicted harm such as suicide attempts. The fourth area of DBT is cognitive deregulation which "...consists of cognitive disturbances such as ruminating thoughts or dichotomous thinking." (Smith & Peck, 2004 p.25) The fifth are is self-dysregulation; which refers to an unstable self-image and a feeling of chronic emptiness and meaninglessness. These five areas are also related to and consistent with six behavioral patterns. (Smith & Peck, 2004 p.25)

These behavioral patterns include the following.

Emotional vulnerability. This is prime characteristic of a person with BPD and is identifiable by a very high sensitivity to emotional stimuli. This can also be accompanied by extreme emotional reactions which do not return to a normal baseline emotion for long periods.

Self-invalidation. This is explained as a tendency to "...invalidate one's own experiences and includes self-hate, shame, anger at the self, and unrealistic expectations for the self." (Smith & Peck, 2004 p.25)

Unrelenting crises are a pattern of frequent, negative events that take precedence over everything else in the person's life. (Smith & Peck, 2004 p.25)

The restriction of emotions such as inhibited grieving.

Active passivity. This is essentially a form of acceptance of helplessness or "learned" helplessness. This is an important aspect in therapy as it means that the patient has leant a process of negative response to situation as well as a reliance on others to solve problems which inhibits the reliance on his or her own judgment.

Another characteristic symptom is apparent competence; which refers to the appearance and not the reality of competence in certain areas. This can be seen in the example of a person appearing to be more competent than he or she really is. "Competence is inhibited by the inability to transfer skills or knowledge across mood states." (Smith & Peck, 2004 p.25)

Praxis

In summary DBT asserts that due to an invalidating environment and biological factors, some people are prone to react in an abnormal way to emotional stimulation. In essence their "level of arousal" increases more rapidly than the context would normally require. This results in lives of crisis and misunderstandings. This is further exacerbated by the fact that these individuals do not have any methods for coping with these emotional states and the confusing reciprocal self-image that is projected. Dialectical Behavioral Therapy claims to be a method that helps develop these methods of coping for the BPD sufferer.

Basically the praxis of DBT revolves around work in individual therapy sessions. The therapist teaches or leads the patient in methods and procedures that enable him or her to cope with, adapt, and even change, states of emotional trauma. This leads to further therapy sessions where the therapist teaches the patient how to "... manage interpersonal relationships, tolerate distress, accept reality and regulate their emotional outbursts. "(Umrigar, Thrity. 2002.)

In this process there is a strong emphasis on the relationship between the therapist and the patient. (Umrigar, Thrity. 2002.)

In practice Dialectical Behavioral Therapy consists of two basic parts or elements. The first part consist of weekly psychotherapy sessions in which particular problematic behavior or event from the past week is explored in detail, beginning with the chain of events leading up to it, going through alternative solutions that might have been used, and examining what kept the client from using more adaptive solutions to the problem:" (Borderline Personality Disorder)

Part of the process during and between sessions is to reinforce various adaptive behaviors. The therapist focuses on teaching and leading the patient in dealing and with emotional trauma. The central emphasis in this process is on teaching adaptation and modes of coping with emotional stress and not on avoidance or on taking the patient out of trauma.

In DBT the therapist therefore deals with behaviors in a descending hierarchy:

decreasing high-risk suicidal behaviors decreasing responses or behaviors (by either therapist or patient) that interfere with therapy decreasing behaviors that interfere with/reduce quality of life decreasing and dealing with post-traumatic stress responses enhancing respect for self acquisition of the behavioral skills

Borderline Personality Disorder)

The second phase of the treatment involves weekly 2.5?hour group therapy sessions in which "...interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught." (Borderline Personality Disorder)

Other theorists claim that the DBT treatment process actually takes place in four different stages. The first stage is the preparatory stage where "...the client's commitment and agreement to the requirements of the DBT process is secured. (Smith & Peck, 2004 p.25) They clam that this preparatory phase essential to the success of the treatment. (Smith & Peck, 2004 p.25)

The next stage the treatment is very similar to the first stage discussed above. It is intended to "... facilitate the client's attainment of basic capacities...." "(Smith & Peck, 2004 p.25)

This is aimed at the decease of life-threatening behaviors such as ideation related to harming oneself. The focus is also on therapy- interfering behaviors. Examples of this aspect are a failure to establish a therapeutic relationship, pushing the therapist's limits (i.e., showing up at the therapist's home or staff splitting), and openly hostile attacks on other clients during group skills training. (Smith & Peck, 2004 p.25

In stage two of DBT, the mental health professional focuses on reducing posttraumatic stress. "Because almost 75% of the women diagnosed with BPD are victims of childhood sexual abuse," (Linehan et al., 2001) and because most clients have symptoms consistent with post-traumatic stress. An important aspect of the process is that each stage must be accomplished before the initiation of the following stage as the skills and behaviors learnt lead to the next level.

In stage three the "... The mental health counselor shifts the therapeutic focus to increasing the client's self-respect and achieving individual goals. (Smith & Peck, 2004 p.25). This stage focuses on the synthesis of the elements already taught and increasing self-respect and self-worth, as well as positive self-perception.

Stage four is "...designed to increase the capacity for sustained joy, the client continues to generalize his or her behaviors and skills, and works to integrate an identity as someone who has overcome BPD." (Smith & Peck, 2004 p.25) This is an integrative stage where the patient learns to accept the reality and context in which he or she lives and to iterate the present self with the past. When the therapy is completed "...this work provides the client with a more integrated self, more adaptive coping mechanisms, and an acceptance for the self." (Smith & Peck, 2004 p.25)

In conclusion, the process suggested by DBT allows for an integrated and principle - driven behavioral treatment The central aim to replace maladaptive and dysfunctional behavior patterns with effective and positive ones. Lineham has produced a number of replication studies since her paper in 1991. She has also written a training manual concerning the implementation of DBT. The result for her studies show a consistent pattern which indicates that DBT does reduce the symptoms and trauma of BPD. One example of these findings is that in one randomized controlled trial (n=39) [Hawton 2001] it was demonstrated that "...DBT was more effective than routine care in the repetition of deliberate self-harm in women with borderline personality disorder (ARR=0.34-95%CI 0.63 to 0.05; NNT 2.9-95%CI 2 to 23). (Dialectical Behaviour Therapy: HNS) This implies that the implementation of DBT can significantly increase a positive prognosis.

As it is based on a dialectical foundation it takes account of biosocial as well as individual aspects in the treatment. It therefore provides the best treatment ands methodology for dealing with BPD to date.

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What is Borderline Personality Disorder? Retrieved November 1, 2005 form Borderline Personality Disorder Resource Center. Web site: http://www.bpdresourcecenter.org/what_glossary.htm

World Health Organization. (1994) Pocket Guide to the ICD-10 Classification of Mental and Behavioural Disorders. Washington, D.C.: American Psychiatric Press Inc.

This debate also involves the close linkage of BPD with post-traumatic stress. Recently the debate about the definition of BPD has been extended. Due to the fact that the majority of those diagnosed with BPD are female, this has resulted in the suggestion that "... The increase in such BPD diagnoses in women has its genesis in the revisions of the diagnostic code. Specifically, in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) category, the definition of the term borderline has been resculpted to resemble that of the affective disorders, which has resulted in a diffusion of the "border" between psychosis and neurosis from which the disorder is named (Kroll, 1993)." (Hodges, 2003 p 409)

This will be treated in more depth in the second section.

It should be note that the effort to avoid abandonment is the initial item in the DSM -- IV-TR diagnostic criterion.

However, as has been suggested, there is an opposing point-of-view which views psychopharmacological agents as a viable first line of treatment. This is a perspective that has to be kept in mind in the assessment of the various dimensions of BPD.

In this respect it might be interesting to compare and contrast various Eastern therapeutic philosophies with the ideas of thought and thinking in BPD. Zen Buddhism is very accessible on this aspect through the work of T.D. Suzuki.