BPD Treatment: How To Navigate The Disorder
Medically Reviewed By Laura Angers, NCC, LPCBorderline Personality Disorder (BPD) is a mental health disorder that often begins in early adulthood. It is characterized by an unstable or poorly developed self-image, rapidly changing personal goals, intense but unstable relationships colored with neediness due to real or imagined fear of abandonment, and an impaired ability to recognize the needs and feelings of others.
Signs and Symptoms of BPD
When five (5) or more of the following symptoms are present in an individual in different environments, the individual might have Borderline Personality Disorder:
- Frantic efforts to keep away from true or imagined abandonment.
- Patterns of unstable and very strong interpersonal bonds described as alternating from extreme idealization to devaluation.
- Identity interruption: significantly and persistently unstable image of self or sense of self.
- Impulsive behavior in at least two aspects that are possibly self-damaging (e.g., spending, substance abuse, sex, binge eating, reckless driving).
- Recurrent suicidal patterns, threats, or self-destructing behavior.
- Affective instability resulting from a distinct reactivity of moods (e.g., extreme episodic dysphoria, anxiety that lasts for hours and more than a day, although seldom), or irritability.
- long-standing feelings of emptiness.
- Trouble controlling anger (e.g., persistent anger, recurring physical fights, frequent displays of temper).
- short-term, stress-related paranoid ideations or extreme dissociative symptoms.
As an individual with Borderline Personality Disorder gets older, some of the symptoms begin to wane; for example, suicidal attempts. They may retain some other symptoms such as intense emotional response, impulsivity, and intensity in relationships.
People with BPD who opt for treatments often show marked improvement in their lifestyle, vocation, and relationships.
Treating BPD
The mainstay of Borderline Personality Disorder treatment is psychotherapy. Studies have shown that treatment with medications might be ineffective. Medications are, however, used to treat co-morbid conditions such as depression.
Psychotherapy
Psychotherapy, as a means of treatment, has been around for a long time as it has been compared to the ritual healings practiced in ancient Greece. Over the years, it has evolved from a form of pseudoscience to what we have now. As such, there are several types of psychotherapy.
The types of psychotherapy related to Borderline Personality Disorder can be discussed under three broad groups:
- Cognitive-behavioral therapy
- Dynamic psychotherapy and
- Other forms of psychotherapy
Cognitive Behavioral Therapy and BPD
Cognitive Behavioral Therapy focuses on what is currently causing the symptoms of the disorder to cause changes in both cognition and behavior directly.
Features of Cognitive Behavioral Therapy include:
- The patient is an active partner in treatment.
- Socratic questioning, i.e., thoughts, are challenged with gentle questions.
- Attention to provoking and maintaining factors, e.g., the patient records in a journal what happens before the symptoms begin, what happened after the symptom and how both might relate to the disease
- Attention to patient’s way of thinking
There are several kinds of Cognitive Behavioral Therapy. Those with relevance to BPD are
This is an expanded form of cognitive-behavioral therapy, which was designed by Marsha Linehan for people with BPD who repeatedly harm themselves.
Dialectic Behavior Therapy has three major components.
- Individual sessions,
- Skills training sessions, and
- Communication with a therapist in between sessions
Individual Sessions
The focus in these sessions include
- Cognitive-behavioral techniques
- Dialectical methods of thinking, i.e., showing that the world is not binary and there can be more than one side or solution to a problem.
- Mindfulness; a person is taught to view problems in a detached manner.
- Aphorisms; word-groups or phrases that remind a person of what is going on. An example of an aphorism that can be used is, ‘Although I may not have caused all my problems, I still have to solve them.’
Skills training sessions
These sessions typically last about 2 hours or more. They are usually scheduled weekly, and they are done in groups. People diagnosed with BPD are taught how to control their anger and other strong emotions, how to deal with distress, interpersonal skills, and mindfulness.
Communication with Therapists in between sessions
This is designed to help patients get through a crisis by using the skills learned during the individual and skills training sessions. It is usually done by telephone.
Dialectic Behavior therapy can last for up to a year. It has well documented beneficial effects on the behaviors of people with BPD. It reduces self- harming and suicide attempts.
This is another form of expanded cognitive behavioral therapy that was developed by Jeffrey Young.
It is based on the assumptions that people with BPD may have four basic maladaptive schemas:
- Abandoned/abused child
- Angry/ impulsive child
- Detached protector
- Punitive parent
Schemas are the ways we think of and categorize the world. They are thought to arise in childhood.
Schema focused therapy aims to replace the maladaptive schemas with adaptive new ones.
The therapist aims to do this by using techniques such as guided imagery, assertiveness training, and role-playing to help the patient to face and confront past traumatic events. The therapist might also directly target the emotions associated with the events.
Schema focused therapy usually takes about two years for it to become effective.
- Cognitive Behavioral Therapy
Regular cognitive behavioral therapy can also be used to treat patients with BPD with positive results.
Dynamic Psychotherapy
This is a type of psychotherapy based on psychoanalysis. Unlike CBT, it focuses on the origin of a mental disorder rather than what is currently maintaining it.
The premise of dynamic psychotherapy is that unconscious mental processes that begin in childhood influences the way we function in adulthood.
The forms of dynamic psychotherapy relevant to BPD include:
- Mentalization-based treatment,
- Transference Focused Psychotherapy, and
- Cognitive Analytic Therapy
Mentalization is the ability to understand intuitively how the thoughts, feelings, and motivations of others relate to one’s thoughts, feelings, and emotions.
The Mentalization-based treatment, which was developed by Peter Fonagy and Antony Bateman, is based on the assumption that people with BPD have a problem of parental attachment which developed in early childhood. This attachment problem may then lead to deficits in Mentalization.
The treatment aims to resolve the problem of Mentalization by developing self-regulation capacity through a dynamic psychoanalytical approach which involves –
- Group psychotherapy
- Individual psychotherapy
- Community therapy
- Partial Hospitalization and
- Outpatient treatment.
Otto Kernberg developed this method of dynamic psychotherapy for people with BPD. It is based on the idea that BPD develops as a result of identity diffusion, i.e., an inability to notice that people are not wholly good or bad. According to Kernberg, people with BPD might be unable to realize from childhood that people can be both good and bad at the same time.
Transference focused therapy aims to correct this identity diffusion by focusing on the past relationships of the person with BPD and see how they are currently affecting the life of the individual.
Tony Ryle developed cognitive analytic therapy.
A therapist asks the person with BPD to record in a diary a list of problems, moods, and maladaptive behaviors. Some of the behaviors are then taken as specific examples to work with and correct. The origins of these behaviors are also probed with the view that they began in early childhood.
There is some evidence that cognitive analytical theory works with people who have BPD. The evidence is, however, not conclusive.
Other forms of psychotherapy which could be used to treat BPD are supportive therapy, group therapy, and family therapy.
Medications
Medications are sometimes used as adjuncts to psychotherapy. Studies have, however, called into question their effectiveness. Despite these facts, some medications could be used to treat co-morbidities that arise with BPD. Please consult with a medical professional before making any medically related decisions.
Examples include
Antidepressants especially SSRIs for depression,
Mood stabilizers such as lithium for bipolar disorder, and
Antipsychotics, especially atypical antipsychotics, for reality distorting disorders.
Hospitalization
Individuals with BPD may sometimes have to be hospitalized, especially if severe crises arise. The hospitalization is usually not long term, especially if there are no other medical problems.
They may also have to be hospitalized for certain treatment modalities.
Self Care
Although this is not a mode of treatment, it can add to the general wellbeing of anyone with BPD. Self-care habits should be practiced. Examples of self-care habits include good sleeping habits, regular exercise, nutritious diet intake, proper stress management, and so on.
Conclusion
Borderline Personality Disorder can be treated. Treatment often relieves the effects of BPD, especially self-harm and suicide. If you are concerned that you or someone you care about might have a borderline personality disorder, you should reach out to a competent mental health professional and get more detailed information about treatment for the disorder. You could get further information from highly qualified mental health professionals at BetterHelp.
References
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5) American Psychiatric Association, Washington, DC.
Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (2018). Shorter Oxford Textbook of Psychiatry, Seventh Edition Oxford University Press, Oxford, United Kingdom.
